HEALTH PLAN QUALITY IMPROVEMENT STRATEGY REPORTING UNDER THE AFFORDABLE CARE ACT: IMPLEMENTATION CONSIDERATIONS Emma Hoo, David Lansky, Joachim Roski, and Lisa Simpson April 2012 ABSTRACT: The Affordable Care Act calls for the U.S. Secretary of Health and Human Services to issue quality improvement reporting requirements for employer group health plans, including self-insured plans, and individual plans, as well as for qualifying plans in health insurance exchanges. Health plans will need to report on their quality improvement activities regarding plan or coverage benefits and provider reimbursement structures that: improve health outcomes, prevent hospital readmissions, improve patient safety and reduce medical errors, and implement wellness and health promotion activities. Mindful of the opportunity to leverage existing plan reporting tools and achieve administrative efficiencies, this report summarizes key features of the eValue8 Health Plan Request for Information, National Committee for Quality Assurance accreditation, and Medicaid’s external quality review process. The authors offer the National Quality Strategy as a framework for quality improvement reporting requirements to align efforts among health plans, health care providers, and health care purchasers. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn about new Commonwealth Fund publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1592. CONTENTS About the Authors .............................................................................................................. iv Executive Summary........................................................................................................... vii Introduction ......................................................................................................................... 1 Framing Assumptions .......................................................................................................... 2 Health Plans’ Benefit Design and Provider Reimbursement Strategies .............................. 3 Developing a Framework for Quality Improvement Reporting Requirements ................... 5 Measuring Health Plan Efforts to Improve Quality Through Benefit Design and Provider Reimbursement Strategies ..................................................................... 13 Uses of Reported Information from Health Plans ............................................................. 17 Key Recommendations ...................................................................................................... 21 Appendix A. Participants at Roundtable Discussion ......................................................... 25 Appendix B. Section 2717 and 1311 of the Affordable Care Act ..................................... 27 Appendix C. Comparison of Existing Health Plan Quality Improvement Reporting Tools ........................................................................................................... 30 Appendix D. Reportable Indicators of Quality Improvement Strategies, Measures, and Program Operations ............................................................................. 34 LIST OF EXHIBITS Exhibit 1. National Quality Strategy Measurement Domains Exhibit 2. eValue8 Key Processes and Methodologies Exhibit 3. NCQA Health Plan Report Card Exhibit 4. Illustrative Hierarchy of Measures and Reporting Indicators for Hospital Readmissions Exhibit 5. Member Support: Health Plan Services Information Used iii ABOUT THE AUTHORS Emma Hoo is a director at the Pacific Business Group on Health (PBGH), a national coalition of 50 large public and private purchasers. Her work has focused on payment reform and care redesign, including pilot programs with PBGH members to test health improvement and primary care initiatives that seek to optimize care for people with multiple chronic conditions. Previously, she managed the operations of PacAdvantage, a small group health insurance exchange that was transitioned to private management from the State of California. Ms. Hoo has managed value-purchasing initiatives, including health plan and vendor assessments, value-based benefit design research, and group purchasing programs on behalf of PBGH members. She also participated in the National Committee for Quality Assurance’s Disease Management Measurement Advisory Panel and the National Quality Forum Multiple Chronic Conditions Framework Committee. She is a graduate of Harvard University. David Lansky, Ph.D., is president and chief executive officer of the Pacific Business Group on Health (PBGH) and directs its efforts to improve the affordability and availability of high-quality health care. Since 2008, Dr. Lansky has led the coalition of 50 large employers and health care purchasers representing more than 3 million Californians and 12 million beneficiaries nationally, including CalPERS, Wells Fargo, Intel, Boeing, Safeway, Chevron, Walmart, and the University of California. PBGH also collaborates with diverse stakeholders on national health care policy issues. A nationally recognized expert in accountability, quality measurement and health information technology, Dr. Lansky has served as a board member or advisor to numerous health care programs and is now the purchaser representative on the federal Health IT Policy Committee, serves on its Meaningful Use Workgroup, and chairs its Quality Measures Workgroups. Previously, he was senior director of the health program at the Markle Foundation and was founding president of the Foundation for Accountability (FACCT), which develops quality measures and Web-based health care assessment tools for consumers and purchasers. He holds a doctoral degree from the University of California, Berkeley. Joachim Roski, Ph.D., M.P.H., recently joined Booz Allen Hamilton as an executive advisor in the Division of Advanced Healthcare Analytics. In his role, he works with public-sector clients, including the Centers for Medicare and Medicaid Services and Veterans Administration, and with private-sector providers and payers in support of health care reform implementation efforts. Prior to joining Booz Allen Hamilton, he served as fellow and managing director at the Engelberg Center for Health Care Reform at The Brookings Institution, where he focused on implementation of demonstration and iv pilot efforts to develop nationally consistent ways to collect and aggregate administrative and clinical data in support of payment reform. Previously, Dr. Roski served as vice president for performance measurement, research, and analysis for the National Committee for Quality Assurance, director of quality and performance effectiveness at Allina Health System, and research director in the School of Public Health at the University of Minnesota. Dr. Roski earned a master’s degree in public health from the Division of Epidemiology at the University of Minnesota’s School of Public Health and his doctorate degree in health psychology from the University Trier, Germany. Lisa Simpson, M.B., B.Ch., M.P.H., FAAP, is president and CEO of AcademyHealth. A nationally recognized health policy researcher and pediatrician, Dr. Simpson’s research has focused on improving the performance of the health care system and includes studies of the quality and safety of care, the role of health information technology in improving the quality of care, and health care disparities. Before joining AcademyHealth, Dr. Simpson was director of the Child Policy Research Center at Cincinnati Children’s Hospital Medical Center and professor of pediatrics in the Division of Health Policy and Clinical Effectiveness, Department of Pediatrics, University of Cincinnati. She served as the deputy director of the Agency for Healthcare Research and Quality (AHRQ) from 1996 to 2002. Dr. Simpson earned her undergraduate and medical degrees at Trinity College (Dublin, Ireland) and a master’s degree in public health at the University of Hawaii. She completed a postdoctoral fellowship in health services research and health policy at the University of California, San Francisco. Additional input for this report was provided through a stakeholder roundtable held on July 8, 2011. Roundtable participants are listed in Appendix A. Editorial support was provided by Martha Hostetter. v EXECUTIVE SUMMARY A provision of the Patient Protection and Affordable Care Act (Affordable Care Act) requires health plans to submit reports each year demonstrating how they reward health care quality through market-based incentives in benefit design and provider reimbursement structures. By spring 2012, the U.S. Secretary of Health and Human Services (HHS) is expected to develop requirements for health plans to report on their efforts to: improve health outcomes, prevent hospital readmissions, ensure patient safety and reduce medical errors, and implement wellness and health promotion activities. Both employer group health plans, including self-insured plans, individual market plans, and qualified health plans sold through the insurance exchanges are required to submit such reports (Appendix B). This report outlines key considerations for implementing these provisions of the health reform law. After reviewing health plan strategies that may positively affect health and health care quality, we propose a framework that can be used to identify and develop measures and reporting requirements. Next, we review current health plan assessment methods that may inform specifications to be developed by the HHS secretary. Finally, we offer a set of recommendations for the design of health plan reporting requirements. Many health plans implement benefit designs that aim to improve health care outcomes, quality, and value. By benefit design, we mean the use of cost-sharing and incentives across a range of product options; these are distinct from coverage rules, which are determined by federal guidance on the definition of essential health benefits. Examples of innovative benefit practices include the selection of high-performing physicians, physician groups, and hospitals based on various quality and efficiency metrics; the use of decision support to guide preference-sensitive treatment choices; and the use of patient reminders and incentives to encourage enrollees to receive preventive screenings. In addition, some health plans use their contracts with providers to encourage high-quality, high-value care. Such payment models include performance-based contracts that link payment to the achievement of certain quality and/or efficiency thresholds. A limited number of purchasers attempt to bundle payments for episodes of care. Some primary care medical home or accountable care contracts augment a primary care case management fee with prospective gain-sharing for achieving reductions in the total cost of health care or achieving other performance targets. Among hospitals, the Premier vii program, Medicare Advantage STARS program, and the Centers for Medicare and Medicaid Services’ (CMS) hospital value-based purchasing program have accelerated adoption of quality- and outcomes-based contracts with payments linked to performance, public reporting, or participation in regional and multistate collaboratives. Framework for Quality Improvement Reporting Requirements In considering a framework to meet reporting requirements outlined in the Affordable Care Act, there are significant opportunities to align with the National Quality Strategy (NQS) in pursuit of improving population health, improving care experiences, and controlling per capita costs. Common domains across these initiatives and the NQS priorities reflect a broad view of quality improvement: • making care safer by reducing harm; • engaging patients and family as partners in their care; • promoting effective communication and care coordination; • promoting the most effective prevention and treatment practices; • working with communities to enable healthy living; and • making care more affordable through new health care delivery models. As illustrated below, there are relevant benefit design and provider reimbursement features that could be grouped under each priority area as a way to reinforce and implement a health plan’s quality improvement strategies. To guide the selection of quality improvement reporting requirements for health plans’ benefit design and provider reimbursement strategies, the following criteria should be considered: 1. conforms to statutory requirements; 2. consistent with the National Quality Strategy and other federal programs; 3. likelihood that measured activities and/or reporting will contribute to improvement of health outcomes; 4. builds upon existing documentation and reporting systems where possible in order to limit additional burden on plan reporting or provider data collection; 5. has face validity to consumers, plans, providers, and policymakers; and 6. submitted information can be verified. viii Measuring Health Plan Efforts to Improve Quality Health plan performance is measured through an increasing array of standardized performance measures assessing preventive care, clinical processes, and intermediate outcomes (e.g., blood pressure or cholesterol levels) as well as care experiences and outcomes (e.g., functional status). CMS requires health plans participating in Medicare Advantage to report many such performance measures. In addition, many of these measures are required by states for Medicaid managed care programs or under regulatory requirements promulgated through states’ health departments or insurance commissioners. Many health plans attempt to improve performance by rewarding and reimbursing providers for a range of activities including care coordination, care and case management, medication reconciliation and compliance, or development of primary care medical homes. In addition, health plans may seek to improve value through benefit designs that provide incentives for members to choose evidence-based treatments (e.g., by waiving copayments) or select providers with higher performance ratings. Health plans may also offer decision-support tools to help members make informed treatment choices. There are a variety of approaches to assessing health plan performance. An employer-sponsored tool developed and maintained by the National Business Coalition on Health (NBCH), eValue8 gathers information through a standard, annual, request-for- information survey. It gathers information about health plan performance in critical areas such as prevention and health promotion, adoption of health information technology, member and provider support, disease management, provider performance measurement and rewards, patient safety, pharmaceutical management, and behavioral health. The National Committee for Quality Assurance (NCQA) and URAC accredit health plans, with NCQA accreditation more commonly required by large employers. NCQA-accredited health plans are reviewed against more than 60 standards and must report on their performance in more than 40 areas in order to earn accreditation. NCQA uses a unified set of standards for health maintenance organizations (HMOs), managed care organizations (MCOs), preferred provider organizations (PPOs), and point of service (POS) plans, relies extensively on performance measures in accreditation decisions, and publishes a health plan report card on its Web site. Medicaid managed care’s external quality review is another health plan assessment approach, although it does not directly report on benefit and provider reimbursement strategies. Furthermore, the structure and content of this assessment may ix vary considerably, depending on the review organization. While reporting standardized performance measures is common and routine for most HMO and POS plans, and for many PPO plans, detailed assessment and reporting of health plan activities related to provider payment and benefit design strategies are not. Uses of Reported Information from Health Plans The various audiences for health plan quality information have unique needs, which should be taken into account in the design and implementation of reporting requirements. These requirements should also address various applications of the information, such as oversight and monitoring, quality improvement, public reporting, and decision support. The audiences for health plan quality information include: 1. state oversight and health information exchange boards, as well as governance and operational entities; 2. health plans; 3. consumers; 4. employers; and 5. physicians, hospitals, and provider organizations. Purchasers rely on both NCQA accreditation and eValue8 to collect program and service operations data and, to varying degrees, to assess the effectiveness of a health plan’s quality improvement programs. Consumers might use quality information to make decisions about choice of provider, choice of treatment, and potential out-of-pocket costs. The quality reporting system should assess whether health plans make information about the performance of individual physicians and hospital service lines available to their members; such information is becoming more widely available, and research has shown that consumers prefer it to performance information aggregated at physician group or hospitalwide levels. Key Considerations At a roundtable meeting supported by The Commonwealth Fund and convened by AcademyHealth, experts, stakeholders, and government officials discussed current approaches to health plan quality improvement reporting and generated recommendations for implementing reporting requirements under the Affordable Care Act (Appendix A). • Recommendation 1. Move ahead strategically, balancing parsimony, standardization, and innovation by emphasizing dimensions of care delivery and x payment reform that align with the National Quality Strategy and hold the greatest promise for delivering significant improvements in health outcomes and value. Use standardized outcome measures to set performance expectations, but do not overly prescribe interventions that could have the unintended consequence of stifling innovation. Support the development and use of metrics that may fill NQS measurement gaps, such as those assessing care coordination, patient-reported outcomes, and affordability. • Recommendation 2. Focus on outcomes, when they are available; report on improvement strategies only when outcomes reporting is not yet feasible. Consider the evidence base for health plans’ improvement strategies as well as the current state of performance measurement. Balance consistency and reporting burden with opportunities to refine the underlying measures for broad domains that are delineated in the statute, such as wellness and prevention. Use process measures and indicators of improvement programs’ results, effectiveness, and reach when outcomes are not available and in cases where they may be helpful in illuminating issues such as incentive design, disparities in care, or risk segmentation. • Recommendation 3. Recognize and address the information needs of diverse users of quality reporting, including state oversight and exchange boards, governance and operational entities, health plans, consumers, employers, and providers. The information and detail required for oversight and quality improvement are different than those for public reporting and accountability. Likewise, consumers want actionable information and tools to support decisions about their choice of health plans, doctors, hospitals, and treatment. In addition, consumers may have different expectations about transparency than do other users. • Recommendation 4. Support consistent implementation across health plans and health insurance exchanges to foster administrative efficiency and ensure benchmarking capabilities across states. Offer templates and reporting formats to promote standardization across states as well as across the public and private sectors. Promote consistency in the information available to consumers and the requirements for multistate health plans. • Recommendation 5. Balance value against the resources required to implement quality reporting by aligning efforts with other federal programs and leveraging existing accreditation and reporting tools. Align with other measurement and reporting requirements of the Affordable Care Act and other federal initiatives such as the incentives for “meaningful use” of electronic medical records and the Medicare Shared Savings Program. xi • Recommendation 6. Invest in initial testing and develop a learning infrastructure for evaluation and improvement of reporting over time, while keeping an eye on unintended consequences. Align public and private value-based purchasing initiatives to facilitate knowledge transfer and adoption of best practices. Integrate qualitative feedback from regulators, health plans, providers, and consumers; in particular, elicit feedback from consumers on how they are using the available information and what other information they want. Monitor the potential for unintended consequences and the implications for future policy. • Recommendation 7. Review and update quality reporting requirements on a regular basis to ensure their relevance and alignment with emerging federal requirements. Provide criteria for the frequency and scope of such reviews to capture new evidence and spread innovative practices. Over time, more robust measures of health care outcomes may emerge from electronic health records, new coding requirements, and health information exchange. xii HEALTH PLAN QUALITY IMPROVEMENT STRATEGY REPORTING UNDER THE AFFORDABLE CARE ACT: IMPLEMENTATION CONSIDERATIONS INTRODUCTION Section 2717 of the Affordable Care Act includes a set of reporting requirements for employer group health plans, including self-insured plans, as well as individual market plans. By March 2012, the Secretary of the U.S. Department of Health and Human Services (HHS), in consultation with experts in health care quality and other stakeholders, is to develop requirements for all health plans to report on their quality improvement activities with respect to benefits and provider reimbursement structures that: (A) improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model as defined for purposes of section 3602 of the Patient Protection and Affordable Care Act, for treatment or services under the plan or coverage; (B) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; (C) implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; and (D) implement wellness and health promotion activities. All group health plans and health insurance issuers offering group or individual coverage must submit an annual report to the secretary and their enrollees on whether the plans satisfy the elements described above. Section 1311 of the reform law also calls for rewarding quality through market-based incentives. The secretary is to develop a similar set of reporting requirements for qualified health plans sold through the insurance exchanges. Further, as a condition of certification in a health insurance exchange, qualified health plans are required to demonstrate they have implemented a quality improvement strategy, which is described similarly in terms of the plan’s reimbursement and incentive structures. In addition, plans in the exchanges will have to report on their activities aimed at reducing health and health care disparities. (See excerpts of Sections 2717 and 1311 in Appendix B.) 1 Other statutes and regulations require the secretary to establish quality reporting requirements for various programs, including the National Quality Strategy, Medicare Shared Savings Program for accountable care organizations, the Physician Compare public reporting Web site, hospital value-based purchasing, and the incentive program to encourage meaningful use of electronic medical records. HHS seeks to have a coherent and consistent framework for capturing and reporting quality information wherever possible, while conforming to the specific requirements of relevant statutes and prior regulations. There are significant opportunities to align measurement requirements across these programs to focus health plan and provider activities in quality and population health improvement while minimizing administrative burdens. This report examines current practices in reporting health plan quality improvement strategies, the types of such quality improvement programs, and health plan assessment methods. The authors first present assumptions that frame the interpretation of Sections 2717 and 1311 of the Affordable Care Act and then describe benefit designs and provider reimbursement strategies that may positively affect health and health care quality. Finally, the report concludes with recommendations for health plan reporting, which were substantially informed by discussions among stakeholders and experts at a meeting on July 8, 2011. These recommendations are the opinions of the authors and do not represent any consensus from the attendees at that meeting. FRAMING ASSUMPTIONS The Affordable Care Act called for the development of a National Quality Strategy and includes many provisions for activities to measure, report on, and promote the quality and outcomes of care. The provisions discussed here (Sections 2717 and 1311) represent only a small part of overall activities in the public and private sectors to advance health care quality. Therefore, we narrowly interpreted the provisions as focusing only on the specific strategies and domains articulated in the legislative language. Strategies for educating consumers and public reporting on quality and outcomes were considered largely out of scope for this report. A second framing assumption addressed the scope of the quality improvement strategies covered by the terms “coverage benefits” and “provider reimbursement strategies.” While benefit design is the most obvious interpretation of the first term, health plans also often provide covered individuals with other important benefits and services, which may be relevant and appropriate for reporting. For example, member risk stratification and engagement through health management programs that improve care coordination and reduce readmissions (one of the domains called for in the legislation) can also serve to differentiate plan performance. 2 A third framing assumption is how these requirements affect Employee Retirement Income Security Act (ERISA) plans. For the purposes of this report, it is assumed that self-insured employers would not be subject to the reporting requirements; however, the insurance entities that they contract with to implement their insurance products would be included in the reporting requirement. HEALTH PLANS’ BENEFIT DESIGN AND PROVIDER REIMBURSEMENT STRATEGIES Many health plans have implemented benefit design and provider reimbursement strategies that may significantly improve health care quality, outcomes, and value. The following illustrative examples provide context for a quality improvement reporting framework. There are varying amounts of evidence on the effectiveness of these strategies. By benefit design, we mean the use of cost-sharing and other incentives across a range of health plan options, distinct from coverage rules, which are determined by the definition of essential benefits. The cost-sharing levels among health plan product designs offered through the exchanges will be established through defined actuarial values for each of four levels (platinum, gold, silver, and bronze). Current benefit designs seek to influence members’ provider selection, treatment choice, engagement in care management or coaching, use of preventive and health promotion services, and prescription drug adherence. Examples of such benefit designs include: • Incentives to choose high-performing physicians, physician groups, and hospitals based on various quality and efficiency metrics. These may focus on primary care and/or specialty physicians, as well as certain high-cost hospital services such as cardiac or orthopedic care. • Reference pricing, or fixed-dollar coverage for specific procedures or narrowly defined episodes of care. This approach has garnered interest among large purchasers as a vehicle to drive price transparency and differentiate among provider networks based on value. • Use of decision support to guide a member’s choice of an elective service among evidence-based options, linked to a patient’s risk tolerance, preference, outcomes expectation, and disease state or stage of illness. Copayment waivers or coinsurance reductions may accompany a patient’s engagement in using decision tools, independent of the actual course of treatment. • Employers and health plans commonly offer financial incentives to promote participation in care management or coaching to reduce health risks. 3 • Patient reminders and incentives promote use of preventive screenings. Point accumulators, reduced out-of-pocket costs, or other rules may reward adherence or achievement of biometric goals such as a healthy body mass index or appropriate lipid levels, or enrollment in a smoking cessation program. • Incentives are also commonly used to engage members in completing health risk appraisals or using online self-care tools (e.g., educational courses, weight management, or stress reduction). • Condition-specific incentives may be targeted to reduce financial barriers to obtaining medications for chronic conditions or diagnostic screenings. These may be triggered by diagnosis alone or be tied to participation in a health management program. Health plans also use provider reimbursement strategies to attempt to improve care. Most private plans use fee-for-service reimbursement, typically based on the Medicare resource-based relative value scale. Select services such as maternity care are commonly reimbursed as case rates. To a lesser degree, but with growing interest, health plans are contracting with providers for episode payments that are intended to promote care coordination and management of a course of treatment for a defined condition. Managed care plan payments may include capitation, either for primary care or, less commonly, specialty contact capitation, whereby an organized multispecialty group or independent practice association accepts full or partial risk for managing the cost of services within the budgeted capitation. Such payments may also be risk-adjusted. The capitated entity may in turn pay its providers through a per member per month schedule, discounted fee-for-service with a withhold, or some combination. Payments may be augmented by a modest pay-for-performance bonus linked to clinical quality, patient experience, adoption of heath information technology, practice certification, or other participatory recognition programs. To varying degrees, organized medical groups may accept shared or full risk for inpatient care. Emerging models include quality- or performance-based contracts that link bonuses or payment levels to quality and/or efficiency thresholds. Other structures include a primary care case management fee paid on a per member per month basis. Some primary care medical home or accountable care contracts also include prospective gain-sharing for achieving total cost of health care targets, or may also include progress payments for milestones such as volume of patients enrolled. 4 Hospital payment structures are varied, with per diem and case rates more prevalent among commercial plans than Medicare diagnosis-related group (DRG) case rates. The Premier/CMS Pay-for-Performance program, Medicare STARS performance rating program, and the CMS hospital value-based purchasing strategy have accelerated adoption of quality- and outcomes-based contracts among private plans, with payments linked to performance, participation in public reporting initiatives, or participation in regional and multistate collaboratives. Medicare policies have also created significant interest among private payers in nonpayment for health care–acquired conditions and serious reportable events. There are limited efforts to introduce episode contracting, but these have not been widely adopted because of administrative challenges around claims processing and patient identification and qualification. Global budgeting and quantifying potentially avoidable complications have also been tested on a limited basis as a way to promote improvement and establish a shared savings objective between payers and hospitals. Federal initiatives to provide financial incentives to use health information technology may also carry over into private payments for physicians and hospitals. The Medicare Shared Savings Program for accountable care organizations has reinvigorated dialogue on managing total risk. Such organizations could enhance regional competition within health insurance exchanges, but patient attribution to a primary care physician remains a key issue in defining the terms of shared risk. DEVELOPING A FRAMEWORK FOR QUALITY IMPROVEMENT REPORTING REQUIREMENTS Section 2717 of the Affordable Care Act specifies that health plans shall report on benefit designs and provider reimbursement structures that aim to improve health outcomes, prevent hospital readmissions, improve patient safety, and promote health and wellness activities. Similarly, Section 1311 requires health plans participating in health insurance exchanges to provide information to the exchange and enrollees on the same activities. A Potential Quality Improvement Framework In considering a framework to meet these reporting requirements, there are significant opportunities to align health plan quality improvement and measurement efforts across other national initiatives to focus health plan and provider improvement activities. The National Quality Strategy (NQS) pursues the “Triple Aim” of improving population health, improving care experiences, and controlling per capita costs (Exhibit 1). Other relevant examples include elements of the National Prevention Strategy, federal 5 requirements for providers to make “meaningful use” of electronic medical records, and the measures for accountable care organizations defined in the Medicare Shared Savings Program regulations. Common domains across these initiatives and the NQS priorities reflect a broad view of quality improvement: • making care safer by reducing harm; • engaging patients and family as partners in their care; • promoting effective communication and care coordination; • promoting the most effective prevention and treatment practices; • working with communities to enable healthy living; and • making high-quality care more affordable through new health care delivery models. Exhibit 1. National Quality Strategy Measurement Domains Promoting effective Making care safer communication and by reducing harm care coordination Promoting the Triple Aim: Engaging patients most effective Quality care and family as prevention and partners in treatment practices Population health their care Affordability Working with Making quality care communities to enable more affordable healthy living Source: Adapted from Meaningful Use Quality Measurement Workgroup presentation. 6 National Quality Strategy   The  National  Quality  Strategy  articulates  a  set  of  six  priorities  to  achieve  the  “Triple  Aim”  of   improving  population  health  and  patients’  care  experiences,  while  controlling  costs:     1. Making  care  safer  by  reducing  harm  caused  in  the  delivery  of  care.   2. Ensuring  that  each  person  and  family  is  engaged  as  partners  in  their  care.   3. Promoting  effective  communication  and  coordination  of  care.   4. Promoting  the  most  effective  prevention  and  treatment  practices  for  the  leading  causes   of  mortality,  starting  with  cardiovascular  disease.   5. Working  with  communities  to  promote  wide  use  of  best  practices  to  enable  healthy   living.   6. Making  quality  care  more  affordable  for  individuals,  families,  employers,  and   governments  by  developing  and  spreading  new  health  care  delivery  models.     The  National  Quality  Strategy  further  articulates  10  principles  for  designing  specific  initiatives  to   achieve  the  Triple  Aim.  Many  of  the  approaches  to  addressing  the  health  plan  reporting   requirements  can  reinforce  these  principles:     1. Payment  incentives  that  foster  better  health,  quality  improvement,  innovation,  and   greater  value.   2. Public  reporting  initiatives  offer  consumers  and  payers  vehicles  to  compare  costs,   review  treatment  outcomes,  assess  patient  satisfaction,  and  hold  providers  accountable.   3. Public  and  private  collaborative  efforts.   4. State  and  federal  regulations  create  public  standards  for  safe,  reliable  care,  monitor   providers,  ensure  feedback  and  accountability,  and  strengthen  patient  safety  and   quality  improvement.   5. Consumer  incentives  and  value-­‐based  insurance.   6. Measurement  of  care  processes  and  outcomes  using  consistent,  nationally  endorsed   measures  in  order  to  provide  information  that  is  timely,  actionable,  and  meaningful  to   both  providers  and  patients.   7. Adoption  of  health  information  technology.   8. Timely  and  actionable  feedback  for  clinicians  and  other  providers.   9. Training,  professional  certification,  and  workforce  and  capacity  development.   10. Innovation  and  rapid-­‐cycle  learning.   7 As described below, health plans might structure their benefit design and provider reimbursement strategies according to these priority areas. The examples are intended to be illustrative only—aimed at fostering dialogue about health plans’ improvement strategies and potential approaches to assessing their effectiveness. Making Care Safer by Reducing Harm The Centers for Disease Control and Prevention estimates that at least 1.7 million health care–associated infections occur each year, leading to 99,000 deaths. Adverse medication events cause more than 770,000 injuries and deaths each year—and the cost of treating patients who are harmed by these events is estimated to be as high as $5 billion annually. (See National Strategy for Quality Improvement in Health Care, Report to Congress, March 2011, http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf.) Benefit designs targeting patient safety may include incentives to choose higher- performing providers with demonstrated outcomes such as fewer patient complications due to serious reportable events or health care–acquired conditions (HACs). Reimbursement mechanisms may include performance-based payments, as well as nonpayment for HACs. In addition to reduced complications, measures could include reduced frequency of adverse drug interactions, medical errors, and avoidable readmissions, and their associated costs. Engaging Patients and Family as Partners in Care Health care delivery is often organized around specific conditions and focused on whether clinical symptoms are resolved, rather than whether patients achieve their desired outcomes. But engaging patients and their families is critical to improving health outcomes and delivering patient-centered care. To encourage patients to get involved, many health plans offer member education and health coaching services, along with Web-based decision-support tools that can be distinguished by their content, functionality, and if they can be customized to a patient’s circumstances. Increasingly, plans are using motivational interviewing and similar techniques to help patients set goals and improve their self-care skills, as well as consumer segmentation strategies to deliver targeted outreach. There are few tools with which to measure the effectiveness of such efforts. Most pay-for-performance programs rely on surveys, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS), that assess patient satisfaction, rather than patient activation or self-efficacy. Traditional CAHPS-based measures may not provide comparable results among health plans, unless steps are taken to control for the differences among the plans’ benefit designs and cost-sharing levels. Individuals with 8 high levels of cost-sharing tend to be less satisfied with their health plans than those with lower out-of-pocket expenses. Because health plans may need to have high levels of cost- sharing to achieve an affordable premium, there is the question of whether exchange plan performance and patient experience should be measured separately from the health plan’s overall book of business. Metrics assessing plans’ efforts to promote shared decision- making could document patients’ understanding of their treatment choices, or assess decision quality that tests patients’ knowledge and whether their values and preferences have been taken into account. Measures should also assess whether health plans provide tools to support caregivers. Health information technology may facilitate the use of patients’ reports in outcomes-based performance metrics. For example, clinical registries or electronic health records could make it easier to assess health status and patient-reported outcomes for certain services, such as knee replacement or cardiac surgery, that are sensitive to functional or symptom improvement. Promoting Effective Communication and Care Coordination Health plans seek to ensure that their contracted providers coordinate care to reduce gaps and duplication in services. Plan-based care management programs often target chronically ill and high-risk patients, but such efforts often are not linked to providers’ own care management programs or hospital-based discharge planning. Benefit design incentives are occasionally used to encourage members to participate in such programs. Health plans may encourage care coordination by promoting medical homes and accountable care organizations. Reimbursement structures for these delivery models vary considerably, with per member per month management fees, payment for enhanced patient access such as through telehealth tools or e-mail, and in some cases, global budgets as an incentive to manage an entire population. Assessments of health plans’ activities in this area have focused on the percentage of members engaged in care management programs, the frequency of outbound and inbound member outreach, and evidence of patient outreach and reminder messages to address gaps in care. In some cases, purchasers maintain performance guarantees to ensure a positive return on investment, or to ensure that select indicators are met such as reductions in ambulatory care–sensitive admissions, emergency department utilization, and avoidable hospital readmissions. Hospital pay-for-performance programs could take into account care coordination measures such as documentation of an advance care plan in the electronic medical record, 9 tracking of care gaps, use of a patient self-care plan, and medication reconciliation after hospital discharge. Health plans’ care coordination programs might be rated on the turnaround time for a “welcome home” call post-hospital discharge or evidence of a follow-up visit with the patient’s primary care physician within a week. Promoting the Most Effective Prevention and Treatment Practices The NQS advocates targeting improvement efforts on high-priority conditions such as cardiovascular disease. Health plans offer a wide range of primary and secondary interventions to address high-cost and high-frequency conditions. Benefit design tactics are frequently used to promote preventive care services and manage chronic conditions. Even before cost-sharing elements for preventive services were eliminated in the Affordable Care Act, many benefit designs reduced or waived member out-of-pocket costs for routine preventive and diagnostic screenings. Value-based benefit design strategies have provided an additional impetus to pursue recommended care by reducing or waiving copayments and coinsurance in conjunction with adherence to recommended treatment and achievement of biometric goals. Various public reporting and performance- based payment initiatives also reward providers for improving clinical processes and outcomes. Working with Communities to Enable Healthy Living The NQS seeks to increase the use of evidence-based interventions to improve population health. Benefit designs may include incentives to participate in smoking cessation or weight loss programs. Assessment of health plan capabilities may include process metrics such as the number of members’ completing health risk appraisals or use of such survey tools to engage at-risk individuals. Importantly, purchasers may also look for evidence of tailored communications to identify familial health risk factors and/or risk factors associated with race or ethnicity. Consideration may also be given to a plan’s strategy to address underdiagnosed and undertreated conditions, or to identify and address disparities in care and cultural competency, for example by stratifying clinical quality measures by demographic factors pertinent to health equity. Making High-Quality Care More Affordable Affordability is a critical issue in attracting enrollment and sustaining the health plan offerings within the health insurance exchanges. Both health plans and providers should be held responsible for ensuring high-value care. While employers’ benefit design strategies may reward higher-value plans by lowering the employee premium contributions, deductibles and point-of-service costs may be increased to lower overall premium to achieve a budget target. In addition to the price of a health plan, a wide range 10 of factors can indicate how efficiently a health plan delivers its services, ranging from its medical loss ratio and administrative costs to risk-adjusted utilization markers, such as hospital length of stay and emergency room use. Plans may in turn link their provider reimbursement structures to measures of appropriateness and efficiency, as well as transparency to make cost and quality information available to consumers. In promoting affordability and value, the NQS seeks to establish common measures that will help assess the cost of new programs and payment systems for families, employers, and the public sector, along with how well these programs support innovation and effective care. It also seeks to: integrate measurement of cost and resource use, together with patient experience and outcomes, into the full range of public and private sector efforts to reform payment; reduce waste from undue administrative burdens; and make information about health care costs and quality available to consumers and providers. Criteria for Selection of Quality Elements To advance this discussion, the following criteria may be useful to guide the selection of quality improvement reporting requirements for health plans’ benefit design and provider reimbursement strategies: 1. conforms to statutory requirements; 2. consistent with National Quality Strategy and other federal programs; 3. likelihood that “measured” activities and/or reporting will contribute to improvement of health outcomes; 4. builds upon existing documentation and reporting systems where possible and limits additional administrative burdens; 5. has face validity to consumers, health plans, providers, and policymakers; and 6. submitted information can be verified. During the roundtable meeting, some participants expressed the view that measures should not be constrained by the strength of evidence available to document their effect, particularly for new measures designed to fill gaps in existing domains such as member engagement and care transitions. Participants also discussed when it was sufficient to report population-wide outcomes (in cases where outcomes measures are available) and when it would be better to assess the processes and programs that show how a plan achieves those results. Additionally, participants noted that it might be sufficient to report certain measures and processes across an entire commercial 11 population, while some data should be reported for just the population enrolled in exchanges, who may have unique characteristics because they are a newly insured population and/or because of the benefit designs offered through the exchanges. Key Considerations for Developing and Aligning Quality Reporting Requirements This report reviews several approaches the HHS secretary could take into account in developing the quality reporting requirements. The final approach should consider issues such as: • How can the requirements under Section 2717 be aligned with those under Section 1311 and those under other federal programs, particularly the overarching National Quality Strategy? • How can the federal reporting requirements be aligned with existing or emerging private sector requirements, such as health plan accreditation and the eValue8 Request for Information? • How can reporting requirements for quality improvement strategies be closely aligned with health plan performance reporting requirements, both within Section 1311 and elsewhere (as well as with the quality rating system for qualified health plans and the enrollee satisfaction survey)? • To what extent is the type of information desired by consumers to make choices about their health plans and health care providers the same or different? • Should the reporting requirements on “plan or coverage benefits and health care provider reimbursement structures” be interpreted broadly to align with emerging measures and measurement frameworks or narrowly based on statute? • Are the quality reporting requirements clearly defined relative to what a plan may include or exclude as “activities that improve health care quality” under the medical loss ratio regulations? These are defined as activities designed to increase the likelihood of desired health outcomes in ways that can be objectively measured. The activities must be primarily designed to: 1) improve health outcomes; 2) prevent hospital readmissions; 3) improve patient safety; 4) implement, promote, and increase wellness and health activities; and 5) enhance the use of health care data to improve quality, transparency, and outcomes. Insurers are also allowed to include health information technology expenses needed to accomplish activities that improve health care quality. 12 Potential unintended consequences are another important consideration. For example, a focus on acquiring more information on health disparities, including racial and ethnic disparities, could influence insurers to use this information to avoid subgroups of the population who might be of higher need and/or higher cost. Conversely, explicitly recognizing that minorities and other vulnerable populations often have higher disease burdens could be a path to creating incentives (for both providers and health plan members) that recognize the “heavier lift” required to achieve comparable outcomes for these groups. Such payment incentives could have a significant effect on the market and safety-net providers and could encourage providers and insurers to reach out to these populations, if the incentives were sufficient. Similarly, creating bundled or episode payments with the goal of driving efficiency may create a disincentive for providers to treat high-risk patients, absent some mechanism for severity adjustment. MEASURING HEALTH PLAN EFFORTS TO IMPROVE QUALITY THROUGH BENEFIT DESIGN AND PROVIDER REIMBURSEMENT STRATEGIES Today, health plan performance is measured through a growing array of standardized measures assessing preventive care and clinical processes, intermediate outcomes (e.g., blood pressure or cholesterol levels), as well as care experiences and outcomes (e.g., functional status) for some populations. These measures encompass those included in the Healthcare Effectiveness Data and Information Set (HEDIS), developed and maintained by the National Committee for Quality Assurance (NCQA), as well as other measures developed and maintained by entities including the Centers for Medicare and Medicaid Services (CMS). CMS requires many of these performance measures to be reported by health plans participating in Medicare Advantage. In addition, many of these measures are required by states for reporting associated with Medicaid managed care programs or regulatory requirements promulgated through states’ health departments or insurance commissioners. These performance measures are specified, collected, and calculated in a manner allowing for easy comparison of health plans’ performance. Measures are designed to demonstrate the proportion of an eligible health plan population that received an indicated service or achieved desired outcomes. In addition to HMO/POS health plans, preferred provider organizations also have recently begun to calculate such performance results. It should be noted that new plan- and provider-level measures are continually reviewed and endorsed through the National Quality Forum and its Measure Applications Partnership. There may also be opportunities to align with new quality measures that are incorporated into the CMS Physician Quality Reporting System and the meaningful use 13 requirements for providers’ use of electronic health records. Moreover, performance measurements should consider emerging sources of information through the transition to CPT-II codes for medical claims, more widespread adoption of electronic health records, and proliferation of clinical registries to monitor and improve quality. Health plans pursue multiple strategies to improve their performance results, including approaches to address population health, care and case management, promotion of evidence-based medicine and guidelines through provider outreach and other means, as well as community and member engagement strategies. Many health plans seek to achieve measureable improvement by rewarding providers for care coordination, care and case management, medication reconciliation and compliance, or acting as a medical home. In addition, health plans may seek to improve value through benefit designs that provide incentives for members to choose evidence-based treatments (e.g., by waiving copayments) or select providers with higher performance ratings. Health plans may also offer decision-support tools to help members make informed choices. This section focuses on the activities that are currently undertaken to assess or measure health plans’ provider reimbursement or benefit design strategies that may favorably affect plans’ performance and members’ health. We characterize three different and common assessment approaches implemented in the marketplace today: the eValue8 health plan request for information (RFI), health plan accreditation or certification, and Medicaid’s external quality review process. Appendix C provides a more detailed comparison of these approaches. Developed and maintained by the National Business Coalition on Health (NBCH), eValue8 is an organization of about 60 employer-based health care coalitions representing over 7,000 employers and 25 million individuals. The eValue8 tool is a standard, annual Request for Information (RFI) survey to gather benchmarks in critical areas such as prevention and health promotion, adoption of health information technology, member and provider support, disease management, provider performance measurement and rewards, patient safety, pharmaceutical management, and behavioral health. NBCH’s eValue8 strives to work in concert with accrediting bodies, including the National Committee on Quality Assurance, URAC, and the Joint Commission, to prevent redundancy and build on existing standards. In addition to this RFI, health plans may also complete additional RFI instruments to support the procurement decisions of employers who have secured different benefit consultants to aid in the compiling and analyzing of relevant health plan data and information. Exhibit 2, from eValue8’s 2010 annual report, illustrates the RFI’s driving processes and methodologies. 14 Exhibit 2. eValue8 Key Processes and Methodologies nse Sco po rin s NB ga d Re lan ete e p pl . sc CH o an n it m wi re p d t nv co CH dV an n s i nts NB th la rai pla n r ne ali tio de om ion ali pon r t fr ns esp d s da Co es po to on cor tat d en ses ers tion an n. R sup su , i ve Invi re nte ri CH tio &A ac ra fy a NB icipa th Q cu cti nd r t wi ra ng cy. pa RFI Better health Better health care Lower costs Sp an tista t pra on d p ke ct tio rio rs ith so la ho ice ac s p ase s w n rit to mu be rin ns lde s an scus urch ting g C on r c ha l s n. s, pla ie oa qu oll ring lop di p ee A ct lit al ab , a ve ts, nd m ion ity or nd de ul a e ack d es aff niz s e im atio m io n an ew r n st orga ng pro n p ore ag ve ro . db e p me je re y p ons an e ur nts cts, ke aliti Fe ch , dC oll vi la as Co an er ab d s ora ts ti o n Re s ul Source: National Business Coalition on Health eValue8 tool. Health plan accreditation is commonly offered through the National Committee for Quality Assurance (NCQA) and URAC. For example, NCQA-accredited health plans are reviewed against more than 60 standards and must report on their performance in more than 40 areas in order to earn accreditation. As of 2009, CAHPS and HEDIS results represented 43 percent of the overall accreditation score, with a relatively small subset based on clinical outcomes. Many carriers have also completed the voluntary Physician Hospital Quality module. Additionally, NCQA offers Primary Care Medical Home certification and physician recognition programs that are currently used by many carriers. NCQA relies on a unified set of standards for HMOs, MCOs, PPOs, and POS plans. NCQA’s Review Oversight Committee, a national panel of physicians, analyzes the survey team’s findings and assigns an accreditation status based on the plan’s compliance with NCQA standards and its performance on selected HEDIS measures, relative to other plans. Exhibit 3 illustrates NCQA’s health plan report card, a publicly available consumer information tool available on its Web site. 15 Exhibit 3. NCQA Health Plan Report Card   Source:  National  Committee  for  Quality  Assurance.   Medicaid managed care’s external quality review (EQR) is another common plan assessment approach. While it focuses on quality measurement and improvement activities, it does not directly report on benefit and provider reimbursement strategies. The Balanced Budget Act of 1997 directed the Department of Health and Human Services to develop protocols for an annual external independent review of the quality outcomes, timeliness of, and access to services provided by Medicaid managed care organizations and prepaid inpatient health plans. This approach follows a different assessment methodology, compared with eValue8 and accreditation. A 2008 Office of the Inspector General report highlighted challenges with variation in reporting and inconsistent completion of deliverables by EQR organizations, as well as inconsistent use of deeming, whereby a state or regulatory agency accepts accreditation in lieu of performing direct audit or oversight functions. A 2009 NCQA Medicaid Managed Care Toolkit identified approximately 75 percent overlap between NCQA standards and federal requirements for quality measurement and improvement, a 67 percent overlap for those related to structure and operations, and a 67 percent overlap for those related to access to care. 16 While the reporting of results for standardized performance measures is common and routine for most HMO/POS and many PPO plans, detailed assessment and reporting of health plan activities pertaining to their provider reimbursement or benefit design strategies are not. NBCH’s eValue8 covers health plans’ provider reimbursement and benefit design strategies more thoroughly than other approaches in use today. Both eValue8 and NCQA have developed promising self-assessment methodologies and validation approaches leveraging online tools. These approaches can provide significant guidance for assessment strategies that can support reporting requirements associated with the Affordable Care Act. USES OF REPORTED INFORMATION FROM HEALTH PLANS The collection of information about health plans’ quality improvement activities should be undertaken with the intended users in mind. Reporting requirements should also address various uses of the information, such as oversight and monitoring, quality improvement, public reporting, and decision support. The audiences for health plan quality information include: 1. state oversight and health insurance exchange boards, as well as governance and operational entities; 2. health plans; 3. consumers; 4. employers; and 5. physicians, hospitals, and provider organizations. Both qualitative and quantitative information can be collected about the extent to which health plans seek to accelerate and reward quality improvement through provider reimbursement and benefit design strategies. A central question regarding the health insurance exchange reporting requirements is the depth and breadth of the information required to assess the adequacy of their quality improvement strategies and oversee the effectiveness of their implementation. Purchasers have relied on both NCQA accreditation and eValue8 to collect program and service operations data and, to varying degrees, to assess the effectiveness of a plan’s programs. Beyond descriptive measures of quality strategies such as how provider performance is measured, purchasers have sought information on the strength and effect of the quality effort, such as total dollars allocated and actually paid based on performance criteria. While these are important indicators, they are not the same as measures of health outcomes. 17 Reporting requirements should consider the availability, credibility, and specificity of outcomes measures, process measures, and operational indicators or survey results where outcomes are not available. For example, if diabetes outcomes measures reflecting effective management of clinical goals are available, there may be less need to know what portion of performance payments is allocated to diabetes measures or the percentage of providers meeting a performance threshold. Similarly, a risk-adjusted hospital ICU mortality rate or all-cause readmission rate may be sufficient to differentiate plan performance, rather than information about the structure of a plan’s case management and discharge planning support. However, if the results of such measures are heavily influenced by a Medicare population, they may have less relevance for a privately insured population or an exchange population with uncertain turnover. Absent population-specific outcomes data, it may be relevant to consider indicators with a shorter time horizon for reports from health plans in the exchanges. For example, with respect to care management programs, it may be desirable to obtain exchange-specific data about the risk stratification of enrolled members, targeted members, engagement results, types of interventions, and the effect of those interventions, such as reduced gaps in care or improved medication adherence. There also may be unintended consequences in the selection of measures and other performance indicators for quality reporting. If the metrics follow the NQS recommendation to target leading causes of mortality such as cardiovascular disease, this should not supplant investments in other preventive care strategies and risk reduction. Provider reimbursement strategies should consider access for underserved populations. Exhibit 4 uses hospital readmissions, one of the quality improvement categories specified in statute, to illustrate the continuum of process indicators to outcomes measures, supported by varied benefit design and provider reimbursement tactics that could be adopted to enhance quality and improve value. Arguably, the hospital readmission outcomes measures are sufficient, but it may also be important to identify clinical processes and benefit or payment indicators used to effect reductions in readmission rates (e.g., pay-for-performance or gain-sharing contracts). Some of the reporting indicators and process measures may inform best practices, while enhancement of patient experience measures may identify additional opportunities for quality improvement. Appendix D includes a more detailed description of reportable performance indicators for each measurement domain specified in Section 2717 of the Affordable Care Act. 18 Exhibit 4. Illustrative Hierarchy of Measures and Reporting Indicators for Hospital Readmissions Outcomes Clinical processes and patient experience Reporting indicators o All-cause readmission rate o 30-day readmission measures by condition o Ambulatory care– sensitive admissions o American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) outcome measures o Use of NQF-endorsed measures o % of members receiving Welcome Home call within 24 hours o % of members with primary care visit within seven (7) days of discharge o Patient and family experience of care coordination across a care transition o Receipt by both care team members and the patient/caregiver of a comprehensive clinical summary after a transition Benefit design Provider reimbursement o % enrollment in premium- o % of payment based on performance differentiated hospital networks incentives linked to readmission rates based on performance in avoidable o Payment for care transitions management readmissions or ambulatory care–sensitive admissions o Gain-sharing or risk-sharing based on targeted reduction in readmission rates, o % enrollment with copay waiver potentially avoidable complications, or for selection of high-performance avoidable emergency department visits hospital o Evidence of provider contracts stipulating nonpayment for health care–acquired conditions and serious reportable events The regulations could establish multiyear goals for quality improvement and measure progress toward fulfilling targets. By establishing reporting strategies on effective provider reimbursement strategies, health plans and providers may accelerate adoption of evidence-based approaches to promote value. Notably, the types of clinical measures and program indicators that are relevant for oversight of plans in the health insurance exchanges may be different than information that is useful for purchasers or consumer decision support. 19 Information reporting should also consider the types of decisions made by consumers about choice of provider, choice of treatment, and potential out-of-pocket costs. While the latter is outside the scope of Section 1311 requirements, there are nevertheless quality indicators that can be correlated with better value, efficiency of care delivery, and reduced waste. The quality rating system should also assess whether plans are making information about the performance of individual physicians and hospital service lines (such as cardiac, orthopedic, or maternity) available to their members; public reporting in both areas is rapidly evolving. Research has shown that physician- level measures are what consumers need and want. Additionally, it is critical to educate those who will use the information on its potential uses for decision-making purposes. Other information to be reported includes plan features and services such as disease management, health coaching, or wellness programs. Exhibit 5 displays plan information from the University of California Plan Chooser tool. Exhibit 5. Member Support: Health Plan Services Information Used   20 An additional issue is the extent to which information reported on quality improvement activities should be for all health plan members or for certain populations. While the exchange health plans may be similar to plans currently available for individual and small-group markets, consideration should be given to potential differences in population demographics and availability of information. Further, high turnover among these market segments may limit the ability to measure the longitudinal effects of plan services for these populations. KEY RECOMMENDATIONS The July 8, 2011, roundtable provided a rich discussion of current approaches to quality improvement reporting and generated some key recommendations for implementing reporting requirements for health plans. Recommendation 1. Move ahead strategically, balancing parsimony, standardization, and innovation. In light of the many existing quality-related initiatives and new requirements called for in other portions of the Affordable Care Act, federal implementation of the provisions in Sections 2717 and 1311 should emphasize dimensions of care delivery and payment reform that align with the National Quality Strategy and hold the greatest promise for delivering significant improvement in health outcomes and value. Attention also should be given to fill gaps in the NQS framework, particularly those related to care coordination, patient-reported outcomes, and affordability, including both efficiency and resource use. A forward-looking strategy can also foster new and effective care redesign while leveraging emerging sources for clinical outcomes data. For any new measures, HHS may want to consider a phase-in of the reporting requirements, allowing for initial experiences to guide fuller implementation. Overly prescriptive reporting requirements could have the unintended consequence of reinforcing current programs and processes geared toward maximizing performance for existing measures, and serve as a disincentive to try new approaches that might achieve better outcomes. Use of standardized outcomes measures can set market expectations, while allowing plans to promote innovative care processes to improve health. There is an opportunity to learn from how employers have been using this type of information and to stimulate market innovation, value gains, quality improvement, and coverage expansion. 21 Recommendation 2. Focus on health outcomes, where available, and supplement by reporting on improvement strategies only in cases where outcomes reporting is not yet feasible. Reporting requirements could prioritize outcomes measures, where available, and incorporate process measures and reportable indicators of quality, effectiveness, and reach when they are not. The approach should take into account the evidence base for the improvement strategies as well as the current state of performance measurement in each area. For example, there are adequate outcomes measures for patient safety and hospital readmission, so that reporting on the reimbursement and benefit strategies aimed at these areas may not add much value. For other domains, additional effort is needed to define the areas of “improving outcomes” and “wellness and prevention” delineated in statute. Reporting on the uptake of a given benefit or participation in innovative payment models may be indicative of the appropriateness and effectiveness of that particular plan strategy, though these factors also could be influenced by the characteristics of the plan’s provider network or covered population. At the same time, such reporting may help disseminate best practices and illuminate such issues as risk segmentation. Recommendation 3. Recognize and address the information needs of diverse users of public reporting on quality improvement strategies. While the development of consumer reporting and a health plan performance dashboard is not in the scope of this report, it is important to recognize the varied uses of quality reporting and the level of information that is of interest and relevant to various stakeholders. Consumers want easy-to-use, actionable information. While alignment of reporting requirements is desirable, the types of information and detail required for oversight and quality improvement are different than those needed for public reporting and to inform consumers’ decision-making. Recommendation 4. Support consistent implementation across health plans and exchanges. In light of the substantial variation in population, provider, and market characteristics across the country, and the likely variation that will occur at the state level in the design and implementation of health insurance exchanges, clear federal guidance and implementation tools for public and private sectors will be critical to ensuring benchmarking capabilities across states. At the same time, promoting standardization across states and the public and private sectors will foster simplicity and consistency in the information available for consumer decision support. 22 CMS could help smooth implementation and minimize burden by issuing clear guidance and a suite of tools. These tools may include templates, instructions, and reporting formats for state exchanges, employers, plans, and those responsible for developing public reports and Web sites. This federal effort could continue over time, collecting lessons learned and best practices and making them broadly available. Recommendation 5. Balance value and judicious use of resources in the implementation of reporting. As demonstrated in this report, there is much knowledge and practical experience to draw on while implementing the reporting requirements. Thus, CMS could adapt existing reporting processes to fulfill the requirements. Given that multiple organizations currently focus on performance measurement and reporting, quality improvement, and accreditation, clear guidance from the federal government would permit these efforts to be adapted to satisfy reporting needs. Reporting enhancements should also focus on areas where there are gaps in measurement, such as consumer engagement and care coordination. Attention should be paid to the needs of the newly insured enrollees in the exchanges, taking into account their health literacy, disparities in care, and the cultural competency of plan and provider services. This guidance and support also should be integrated with other new requirements stemming from the Affordable Care Act. Recommendation 6. Invest in initial testing and develop a learning infrastructure for evaluation and improvement of reporting over time. To date, there have been few efforts to report health plans’ quality improvement strategies to consumers and others. Initial testing with the intended users of these new reports, including state regulators, employers, and consumers, is warranted. In particular, focus groups that assess how consumers use the information will be important. Consumers’ understanding of the disconnect between the costs and quality of care may be more relevant to their decision-making than what they may know about the effect of provider payments on the care they receive (e.g., that the volume of diagnostic procedures might be different if a provider received a bundled payment instead of fee- for-service). However, the latter may be relevant for federal and state oversight of health plans’ provider reimbursement strategies aimed at improving health outcomes and ensuring affordability. As reporting requirements are implemented, it will be important to monitor whether there are any unintended consequences and consider implications for future policy considerations. It also will be important to align public and private value-based 23 purchasing initiatives to facilitate knowledge transfer and accelerate adoption of best practices. Recommendation 7. Provide criteria to guide periodic review and updates to the quality reporting requirements. The quality reporting requirements need to include a process for regular review and updates to reflect new evidence and innovation that delivers improved outcomes or better value. Broader adoption of electronic health records and health information exchange will likely enhance the ability to report health outcomes that can replace multiple clinical process measures. However, new or refreshed quality reporting that accelerates innovation, better care, and better value must be balanced with its ability to be expanded and replicated in various market settings. 24 Appendix A. Participants at Roundtable Discussion   On  July  8,  2011,  The  Commonwealth  Fund  sponsored  a  meeting  of  experts,   stakeholders,  and  government  officials  to  discuss  issues  and  options  for  quality  improvement   reporting  by  qualified  health  plans  under  the  Affordable  Care  Act,  specifically  addressing   Sections  2717  and  1311.  This  report  provides  an  overview  of  several  existing  approaches  to   quality  reporting  and  provides  a  set  of  recommendations  informed  by  the  discussion  at  the   meeting.  Participants  in  the  meeting  included:     Alexis  Ahlstrom,  M.P.H.,  Center  for  Consumer  Information  and  Insurance  Oversight   Tanya  Alteras,  M.P.P.,  Consumer-­‐Purchaser  Disclosure  Project/National  Partnership  for  Women   and  Families   Richard  Baron,  M.D.,  Seamless  Care  Models  Group,  Center  for  Medicare  and  Medicaid  Innovation   Andrew  Baskin,  M.D.,  Aetna   Anne  Beal,  M.D.,  M.P.H.,  Patient-­‐Centered  Outcomes  Research  Institute  (formerly  Aetna  Foundation)   Robert  Berenson,  M.D.,  The  Urban  Institute   Carmella  Bocchino,  R.N.,  M.B.A.,  America’s  Health  Insurance  Plans   Amy  Boutwell,  M.D.,  M.P.P.,  STAAR  Initiative/Harvard  Medical  School   Marshall  Chin,  M.D.,  University  of  Chicago  Medical  Center   Jon  Christianson,  Ph.D.,  University  of  Minnesota  School  of  Public  Health   Carolyn  Clancy,  M.D.,  Agency  for  Healthcare  Research  and  Quality   Helen  Darling,  M.A.,  National  Business  Group  on  Health   Joyce  Dubow,  Ph.D.,  AARP  Office  of  Policy  and  Strategy   A.  Mark  Fendrick,  M.D.,  University  of  Michigan  School  of  Public  Health   Steven  D.  Findlay,  M.P.H.,  Consumers  Union   Anne  Gauthier,  M.S.,  National  Academy  for  State  Health  Policy   Robert  Greene,  M.D.,  UnitedHealthcare   Aparna  Higgins,  America’s  Health  Insurance  Plans   Emma  Hoo,  Pacific  Business  Group  on  Health   George  Isham,  M.D.,  HealthPartners   Marcia  Guida  James,  M.S.,  M.B.A.,  Humana,  Inc.   Craig  Jones,  M.D.,  Vermont  Blueprint  for  Health   Minyoung  (Min)  Kim,  M.P.H.,  Beacon  Communities/Office  of  the  National  Coordinator  for  Health   Information  Technology   David  Lansky,  Ph.D.,  Pacific  Business  Group  on  Health   Tricia  Leddy,  M.S.,  Rhode  Island  Department  of  Health   Cara  Lesser,  M.P.P.,  Office  of  Health  Insurance  Exchanges,  Center  for  Consumer  Information  and   Insurance  Oversight   Jerry  Lindrew,  J.D.,  M.S.,  Employee  Benefits  Security  Administration,  Department  of  Labor   William  B.  Munier,  M.D.,  Center  for  Quality  Improvement  and  Patient  Safety,  Agency  for   Healthcare  Research  and  Quality   Margaret  O’Kane,  M.H.S.,  National  Committee  for  Quality  Assurance   L.  Gregory  Pawlson  M.D.,  M.P.H.,  F.A.C.P.,  Blue  Cross  Blue  Shield  Association   25 Kerri  Petrin,  The  Brookings  Institution   Chris  Queram,  M.A.,  President  and  Chief  Executive  Officer,  Wisconsin  Collaborative  for   Healthcare  Quality   Barbra  Rabson,  M.P.H.,  Massachusetts  Health  Quality  Partners   Joachim  Roski,  Ph.D.,  M.P.H.,  Booz  Allen  Hamilton  (formerly  Engelberg  Center  for  Health  Care   Reform,  The  Brookings  Institution)   Dana  Gelb  Safran,  Sc.D.,  Blue  Cross  Blue  Shield  of  Massachusetts   Richard  Salmon,  M.D.,  Ph.D.,  CIGNA  HealthCare   Joshua  Seidman,  Ph.D.,  Office  of  the  National  Coordinator  for  Health  Information  Technology   Joel  Slackman,  M.S.,  Blue  Cross  Blue  Shield  Association   Paul  Wallace,  M.D.,  Center  for  Comparative  Effectiveness  Research,  The  Lewin  Group   Rebecca  Zimmermann,  Office  of  Health  Insurance  Exchanges,  Center  for  Consumer  Information   and  Insurance  Oversight   ✦✦✦✦✦ Sara  Collins,  Ph.D.,  vice  president,  Affordable  Health  Insurance,  The  Commonwealth  Fund   Karen  Davis,  Ph.D.,  president,  The  Commonwealth  Fund   Stu  Guterman,  Ph.D.,  vice  president,  Payment  and  System  Reform;  executive  director,   Commission  on  a  High  Performance  Health  System,  The  Commonwealth  Fund   Rachel  Nuzum,  M.P.H.,  assistant  vice  president,  Federal  and  State  Health  Policy,     The  Commonwealth  Fund   Cathy  Schoen,  M.S.,  senior  vice  president,  Policy,  Research  and  Evaluation,     The  Commonwealth  Fund   Anthony  Shih,  M.D.,  M.P.H.,  vice  president  for  programs,  The  Commonwealth  Fund   Gerry  Fairbrother,  Ph.D.,  senior  fellow,  AcademyHealth   Hilary  Kennedy,  M.P.A.,  M.Sc.,  senior  associate,  AcademyHealth   Enrique  Martinez-­‐Vidal,  M.P.P.,  vice  president,  AcademyHealth   Lisa  Simpson,  M.B.,  B.Ch.,  M.P.H.,  F.A.A.P.,  president  and  chief  executive  officer,  AcademyHealth   26 Appendix B. Section 2717 and 1311 of the Affordable Care Act   Section  2717:  Ensuring  the  Quality  of  Care.     (a)  QUALITY  REPORTING.  –   (1)  IN  GENERAL.  –  Not  later  than  2  years  after  the  date  of  enactment  of  the  Patient   Protection  and  Affordable  Care  Act,  the  Secretary,  in  consultation  with  experts  in   health  care  quality  and  stakeholders,  shall  develop  reporting  requirements  for  use   by  a  group  health  plan,  and  a  health  insurance  issuer  offering  group  or  individual   health  insurance  coverage,  with  respect  to  plan  or  coverage  benefits  and  health   care  provider  reimbursement  structures  that  –   (A)  improve  health  outcomes  through  the  implementation  of  activities  such  as   quality  reporting,  effective  case  management,  care  coordination,  chronic   disease  management,  and  medication  and  care  compliance  initiatives,   including  through  the  use  of  the  medical  homes  model  as  defined  for  purposes   of  section  3602  of  the  Patient  Protection  and  Affordable  Care  Act,  for   treatment  or  services  under  the  plan  or  coverage;   (B)  implement  activities  to  prevent  hospital  readmissions  through  a   comprehensive  program  for  hospital  discharge  that  includes  patient-­‐centered   education  and  counseling,  comprehensive  discharge  planning,  and  post   discharge  reinforcement  by  an  appropriate  health  care  professional;   (C)  implement  activities  to  improve  patient  safety  and  reduce  medical  errors   through  the  appropriate  use  of  best  clinical  practices,  evidence  based   medicine,  and  health  information  technology  under  the  plan  or  coverage;  and   (D)  implement  wellness  and  health  promotion  activities.     (2)  REPORTING  REQUIREMENTS.  –   (A)  IN  GENERAL.  –  A  group  health  plan  and  a  health  insurance  issuer  offering   group  or  individual  health  insurance  coverage  shall  annually  submit  to  the   Secretary,  and  to  enrollees  under  the  plan  or  coverage,  a  report  on  whether   the  benefits  under  the  plan  or  coverage  satisfy  the  elements  described  in   subparagraphs  (A)  through  (D)  of  paragraph  (1).   (B)  TIMING  OF  REPORTS.  –  A  report  under  subparagraph  (A)  shall  be  made   available  to  an  enrollee  under  the  plan  or  coverage  during  each  open   enrollment  period.   (C)  AVAILABILITY  OF  REPORTS.  –  The  Secretary  shall  make  reports  submitted   under  subparagraph  (A)  available  to  the  public  through  an  Internet  website.   (D)  PENALTIES.  –  In  developing  the  reporting  requirements  under  paragraph   (1),  the  Secretary  may  develop  and  impose  appropriate  penalties  for  non-­‐ compliance  with  such  requirements.   (E)  EXCEPTIONS.  –  In  developing  the  reporting  requirements  under  paragraph   (1),  the  Secretary  may  provide  for  exceptions  to  such  requirements  for  group   27 health  plans  and  health  insurance  issuers  that  substantially  meet  the  goals  of   this  section.   (2)  LIMITATION  ON  DATA  COLLECTION.-­‐None  of  the  authorities  provided  to  the   Secretary  under  the  Patient  Protection  and  Affordable  Care  Act  or  an  amendment   made  by  that  Act  shall  be  construed  to  authorize  or  may  be  used  for  the  collection   of  any  information  relating  to  –   (A)  the  lawful  ownership  or  possession  of  a  firearm  or  ammunition;   (B)  the  lawful  use  of  a  firearm  or  ammunition;  or   (C)  the  lawful  storage  of  a  firearm  or  ammunition.   (3)  LIMITATION  ON  DATABASES  OR  DATA  BANKS.  –  None  of  the  authorities   provided  to  the  Secretary  under  the  Patient  Protection  and  Affordable  Care  Act  or   an  amendment  made  by  that  Act  shall  be  construed  to  authorize  or  may  be  used  to   maintain  records  of  individual  ownership  or  possession  of  a  firearm  or   ammunition.   (4)  LIMITATION  ON  DETERMINATION  OF  PREMIUM  RATES  OR  ELIGIBILITY  FOR   HEALTH  INSURANCE.  –  A  premium  rate  may  not  be  increased,  health  insurance   coverage  may  not  be  denied,  and  a  discount,  rebate,  or  reward  offered  for   participation  in  a  wellness  program  may  not  be  reduced  or  withheld  under  any   health  benefit  plan  issued  pursuant  to  or  in  accordance  with  the  Patient  Protection   and  Affordable  Care  Act  or  an  amendment  made  by  that  Act  on  the  basis  of,  or  on   reliance  upon  –   (A)  the  lawful  ownership  or  possession  of  a  firearm  or  ammunition;  or   (B)  the  lawful  use  or  storage  of  a  firearm  or  ammunition.   (5)  LIMITATION  ON  DATA  COLLECTION  REQUIREMENTS  FOR  INDIVIDUALS.  –  No   individual  shall  be  required  to  disclose  any  information  under  any  data  collection   activity  authorized  under  the  Patient  Protection  and  Affordable  Care  Act  or  an   amendment  made  by  that  Act  relating  to  –   (A)  the  lawful  ownership  or  possession  of  a  firearm  or  ammunition;  or   (B)  the  lawful  use,  possession,  or  storage  of  a  firearm  or  ammunition.   (d)  REGULATIONS.  –  Not  later  than  2  years  after  the  date  of  enactment  of  the  Patient   Protection  and  Affordable  Care  Act,  the  Secretary  shall  promulgate  regulations  that   provide  criteria  for  determining  whether  a  reimbursement  structure  is  described  in   subsection  (a).   (e)  STUDY  AND  REPORT.  –  Not  later  than  180  days  after  the  date  on  which  regulations   are  promulgated  under  subsection  (c),  the  Government  Accountability  Office  shall   review  such  regulations  and  conduct  a  study  and  submit  to  the  Committee  on  Health,   Education,  Labor,  and  Pensions  of  the  Senate  and  the  Committee  on  Energy  and   Commerce  of  the  House  of  Representatives  a  report  regarding  the  impact  the  activities   under  this  section  have  had  on  the  quality  and  cost  of  health  care.       28 Section  1311:  Affordable  Choices  of  Health  Benefit  Plans.     (g)  REWARDING  QUALITY  THROUGH  MARKET-­‐BASED  INCENTIVES.  –   (1)  STRATEGY  DESCRIBED.  –  A  strategy  described  in  this  paragraph  is  a  payment   structure  that  provides  increased  reimbursement  or  other  incentives  for  –   (A)  improving  health  outcomes  through  the  implementation  of  activities  that   shall  include  quality  reporting,  effective  case  management,  care  coordination,   chronic  disease  management,  medication  and  care  compliance  initiatives,   including  through  the  use  of  the  medical  home  model,  for  treatment  or   services  under  the  plan  or  coverage;   (B)  the  implementation  of  activities  to  prevent  hospital  readmissions   through  a  comprehensive  program  for  hospital  discharge  that  includes   patient-­‐centered  education  and  counseling,  comprehensive  discharge   planning,  and  post  discharge  reinforcement  by  an  appropriate  health  care   professional;   (C)  the  implementation  of  activities  to  improve  patient  safety  and  reduce   medical  errors  through  the  appropriate  use  of  best  clinical  practices,  evidence   based  medicine,  and  health  information  technology  under  the  plan  or   coverage;   (D)  the  implementation  of  wellness  and  health  promotion  activities;  and   (E)  As  added  by  section  10104(g).  the  implementation  of  activities  to  reduce   health  and  health  care  disparities,  including  through  the  use  of  language   services,  community  outreach,  and  cultural  competency  trainings.   (2)  GUIDELINES.  –  The  Secretary,  in  consultation  with  experts  in  health  care  quality   and  stakeholders,  shall  develop  guidelines  concerning  the  matters  described  in   paragraph  (1).   (3)  REQUIREMENTS.  –  The  guidelines  developed  under  paragraph  (2)  shall  require   the  periodic  reporting  to  the  applicable  Exchange  of  the  activities  that  a  qualified   health  plan  has  conducted  to  implement  a  strategy  described  in  paragraph  (1).   29 Appendix C. Comparison of Existing Health Plan Quality Improvement Reporting Tools Assessment  Area   eValue8  Health  Plan  Request  for  Information   NCQA  Health  Plan  Accreditation   Medicaid  Managed  Care  Monitoring  (EQR)   What  aspects  about  health   • Administrative  functions  and  services,  including   • Quality  management  and  improvement,   The  External  Quality  Review  assesses  how   plans’  benefit  design  and   accreditation  and  value-­‐based  benefit  design,   • Utilization  management,   state  Medicaid  agencies  develop  and   provider  payment  strategies   • Consumer  engagement,  as  measured  by  price  and   • Provider  credentialing,   implement  a  mandated  quality  assessment   are  assessed?  What  content   performance  transparency,  decision-­‐support   • Members’  rights  and  responsibilities,   and  improvement  strategy  that  includes:   or  concepts  are  assessed?     tools,  and  CAHPS  results,   • Member  engagement  (member  connections),   • standards  for  access  to  care;  structure   • Provider  measurement  and  rewards,  including   • Results  of  HEDIS/CAHPS  Performance   and  operations;  and  quality   community  collaboration  and  network   Measures,   measurement  and  improvement;   differentiation   • Medicaid  benefits  and  services.   • examination  of  other  aspects  of  care   • Pharmaceutical  management,   • Optional  NCQA’s  Physician  and  Hospital   and  services  related  to  improving   • Health  promotion  and  prevention,  including   Quality  certification  program  evaluates  how   quality;  and   smoking  cessation,  maternity  care   well  health  plans  measure  and  report  the   • regular  and  periodic  review  of  the   • Chronic  disease  management,   quality  and  cost  of  physicians  and  hospitals.   improvement  strategy.   • Behavioral  health,   • Health  plans’  benefit  design  programs  or     • Clinical  areas  supported  by  HEDIS  data.     provider  reimbursement  strategies  are  not   Compliance  review  includes:   directly  assessed.   • Enrollee  rights  and  protections,     • Quality  assessment  and  performance   improvement,   • Grievance  systems,   • Fraud  and  abuse,   • Administrative  systems,   • Provider  networks  and  management,   and   • Data  management.     EQR  has  the  option  of  reporting  on   validation  of  encounter  data,  validation  of   consumer  and  provider  surveys  on  quality   of  care,  calculation  of  additional   performance  measures,  and  conduct  of   additional  performance  improvement  and   quality  projects.   30 Assessment  Area   eValue8  Health  Plan  Request  for  Information   NCQA  Health  Plan  Accreditation   Medicaid  Managed  Care  Monitoring  (EQR)   What  evidence  or  criteria   • Evidence  is  directly  referenced  in  the  annual   • Research  evidence  is  used  to  develop  and   • EQR  does  not  select  content  but   are  used  to  select  content   Request  for  Information  tool.   maintain  HEDIS  measures.   validates  performance  improvement   areas  and  concepts  for   • Use  of  nationally  standardized  measures   • Survey  questions  are  field-­‐tested  prior  to  use   projects  undertaken  by  an  MCO/PIHP.   assessment?   endorsed  by  the  National  Quality  Forum   and  inclusion  as  optional  CAHPS  supplemental   • How  a  plan  conducted  its  specific   • Multiple  assessment  areas  represent  new  and   items   improvement  initiatives  (indicators   innovative  policy  areas  for  which  systematic   • Quality  standards  seek  to  reflect  health  plan   monitored,  population  selection,  and   evidence  may  not  be  currently  available.   best  practices.     data  collected  and  analyzed)   • Measure  the  achieved  results  and   ability  for  the  MCO’s  performance   improvement  project  to  sustain  any   achieved  improvements.   Who  is  involved  in  the   • Business  coalition  staff,   • Multiple  ad  hoc  committees  with  subject   • Subject  to  regulatory  requirements.   determination  of  selecting   • Employer  advisory  councils,   matter  experts  and  stakeholder   content  areas  for  selection?   • Health  plan  advisory  council,   representation,   • Experts  and  policymakers  from  the  CDC,  AHRQ,   • Standards  Committee,   the  American  Board  of  Internal  Medicine  and   • Committee  on  Performance  Measures,  and   other  organizations,   • Board  of  Directors.   • Academic  researchers,     • Draft  tool  are  made  available  to  health  plans,   employers,  and  others  for  comment  and   refinement  prior  to  release,   • Collaborators  include  accreditation  agencies  and   consumer  and  purchaser  organizations  such  as   Leapfrog  Group,  Consumer-­‐Purchaser  Disclosure   Project,  and  Catalyst  for  Payment  Reform.     How  is  information   • Online  survey  with  free-­‐form  questions,  tables   • Interactive  Survey  System  (ISS),  a  Web-­‐based   • Data  collection  vehicle  varies.   collected  and  disseminated?   with  embedded  options,  and  data  fields.   tool.   • Information  release  varies  by  state.   • Information  is  uploaded  by  health  plans  to  the   • Health  plans  complete  a  self-­‐assessment   tool  and  transmitted  to  the  requesting  entity   document  as  to  how  they  meet  all  published   (e.g.,  a  business  coalition  or  employer).     standards.   • Detailed  scoring  is  reported  to  the  plan   • HEDIS  and  CAHPS  results  are  reported  online   through  Quality  Compass  (subscription   required  for  detailed  reporting)   31 Assessment  Area   eValue8  Health  Plan  Request  for  Information   NCQA  Health  Plan  Accreditation   Medicaid  Managed  Care  Monitoring  (EQR)   How  is  the  content   • Scoring  algorithm  is  updated  regularly  to  weigh   • Onsite  and  offsite  evaluations  conducted  by  a   • Onsite  and  offsite  evaluations   assessed?   content/assessment  areas  relative  to  their   survey  team  of  physicians  and  managed  care   conducted  by  EQRO  staff.   perceived  differential  contribution  to  value,   experts.   • EQRO  may  benchmark  performance  to   health  improvement,  or  member  utility  (e.g.,   • Points  assigned  to  each  standard.   national  and  statewide  Medicaid   health  outcomes  results  weighted  more  heavily   • Typically  standards  are  not  assessed  in  a  binary   results,  or  may  review  year-­‐over-­‐year   than  process  indicators;  user-­‐customizable  and   fashion  (met/not  met);  most  standards  are   trends  for  individual  MCOs.   interactive  Web  content  weighted  more  than   assessed  gradually  (e.g.,  met  fully,  met  80%,   • Compliance  is  assessed  relative  to   static  data).   met  50%,  etc.).   federal  Medicaid  managed  care   • When  available,  research  evidence  is  used  for   • Points  across  different  standards  areas  are   regulations.   weighting  of  concepts;  often  expert  judgment  is   combined  with  the  results  of  performance     relied  on  to  determine  specific  weights.   report  submitted  by  health  plans  to  determine     • Typically,  values  are  scored  on  an  absolute  and   a  five-­‐level  accreditation  status  (excellent,   not  relative  scale.   commendable,  accredited,  provisional,   • Some  elements  collected  as  information  only.   denied).     • Percentage  performance  results  are  reported  for   each  module.   How  is  information  verified   • Corroborating  descriptive  information  is  required   • Pre-­‐specified,  specific  electronically     as  comprehensive  and   to  support  specific  answers,  such  as  copies  of   transmitted  documents  corroborating  the  self-­‐ accurate?   health  plan  documents  detailing  certain  aspects   assessment  of  specific  standards,  such  as   (e.g.,  screenshots  of  online  consumer   meeting  minutes  and  program  policies.   engagement  tools).   • NCQA  staff  ensures  the  relevance  of  submitted   • Coalition  staff  and  consultants  analyze  the   information.   submitted  information  with  respect  to     congruence.   How  many  health  plans   • Between  30-­‐50  national  and  regional  health   • NCQA-­‐accredited  health  plans  represent  71   • Medicaid  managed  care  organizations.   currently  submit   plans  provide  responses.   percent  of  the  enrolled  population.   • Prepaid  inpatient  health  plans.   information  under  this   • Volume  fluctuates  depending  on  employers’   • 500  health  plan  products  are  included  in   assessment  approach?   procurement  strategies  and  regional  coalition   NCQA’s  QualityCompass,  a  benchmarking  tool   sponsorship.     containing  time-­‐trended  performance  results   for  participating  health  plans.   32 Assessment  Area   eValue8  Health  Plan  Request  for  Information   NCQA  Health  Plan  Accreditation   Medicaid  Managed  Care  Monitoring  (EQR)   Resource  requirements   • Compilation  of  data,  responses,  and  written   • Compilation  of  all  relevant  documentation,   • States  may  perform  EQR  tasks  directly   narrative  from  subject  matter  experts.   performance  measure  results,   or  subcontract  to  EQR  organization(s).   • Documentation  of  specific  areas  required  for   • Preparation  for  on-­‐site  visits,   • EQRO  aggregates  the  information  on  all   verification.   • Full  accreditation  review  is  generally  only   required  activities,  analyzes  data,  and   • HEDIS  and  CAHPS  data  are  auto-­‐populated  from   required  every  three  years,  but  a  portion  of   produces  a  technical  report  and   NCQA  Quality  Compass  reports.   the  score  is  recalculated  every  year  based  on   recommendations.   • Annual  rotation  of  select  modules,  auto-­‐ HEDIS  performance.     population  of  regional  responses  based  on   • Data  aggregation,  including  chart  review  for   national  results  and  optional  use  of  a  “short-­‐ select  measures,  and  analysis  for  HEDIS   form”  mitigate  some  resource  investment.   reporting.   • Organizational  resources  required  to  submit  and   • CAHPS  sampling,  follow-­‐up,  and  analysis.   analyze  the  requested  data  vary  significantly   • Web-­‐based  tool  available.   between  health  plans  and  the  requesting     entities.   • Web-­‐based  response.   Use  of  the  collected   • Information  about  health  plan  program  features   • Accreditation  and  HEDIS  performance  results   • States  use  results  from  EQR  assessment   information   and  relevant  benchmarks  are  used  by  purchasers   are  used  by  health  plans  to  improve  internal   to  direct  how  plans  document  and   for  procurement  decisions  and  vendor   processes  and  provider  performance,  and  by   conduct  performance  improvement   management.   employers  and  brokers/consultants  to  evaluate   projects  and  how  plans  meet  federal   • Several  business  coalitions  including  the  Pacific   procurement  decisions  and  manage  suppliers.   and  state  standards  regarding   Business  Group  on  Health  incorporate   • State  agencies  and  regional  collaboratives   members’  access  to  care.   information  collected  through  eValue8  into  an   publish  accreditation  and  HEDIS  performance   • States  use  EQRO  reports  to  target   online  health  plan  chooser  tool  aimed  at   results  for  consumer  information   technical  assistance  to  the  plans  with   consumers/employees.   • Federal  and  state  agencies  may  require  all  or   identified  deficits  and  sharing  best   • Other  organizations  such  as  Minnesota’s  Buyers’   parts  of  the  NCQA  accreditation  and   practices  across  plans.   Healthcare  Action  Group  or  Pitney  Bowes  may   performance  measurement  efforts  to  meet   • States  amend  plan  contracts  and  set   publish  online  reports  aimed  at  consumers  to  aid   regulatory  or  purchasing  requirements.     new  performance  standards  based  on   health  plan  selection  during  the  annual   EQRO  reports.     enrollment  process.   • Some  plans  use  detailed  Strength  and   Opportunity  report  for  quality  and  process   improvement  initiatives   • Other  plans  use  purchaser  feedback  to  prioritize   new  initiatives  and  program  development.   Notes:  NCQA  is  the  National  Committee  for  Quality  Assurance;  CAHPS  is  the  Consumer  Assessment  of  Healthcare  Providers  and  Systems;  HEDIS  is  the  Healthcare  Effectiveness  Data  and  Information   Set;  MCO  is  managed  care  organization;  CDC  is  the  Centers  for  Disease  Control  and  Prevention;  and  AHRQ  is  the  Agency  for  Healthcare  Research  and  Quality.   33 Appendix D. Reportable Indicators of Quality Improvement Strategies, Measures, and Program Operations   The  table  below  illustrates  a  sample  of  the  wide  range  of  benefit  design  and  provider   reimbursement  tactics  that  could  be  adopted  to  enhance  quality  and  improve  value.  Within   strategies  to  improve  quality,  there  may  be  various  approaches  to  measure  their  impact,  as  well   as  their  scope  and  depth  with  respect  to  health  plans  participating  in  the  exchanges.  For   example,  with  respect  to  health  and  care  management  programs,  it  may  be  desirable  to  obtain   exchange-­‐specific  data  about  the  risk  stratification  of  enrolled  members,  targeted  members,   engagement  results,  types  of  interventions,  and  effect  of  those  interventions,  such  as  reduced   gaps  in  care,  improved  medication  adherence  or  possession  rates,  and  other  factors.     Reporting   Domains   Benefit  Design   Provider  Reimbursement   Health   • Premium-­‐differentiated  provider  networks   • Physician  pay  for  performance  based  on   Outcomes   based  on  quality  performance  with  reported   clinical  outcomes,  HEDIS  results,  CAHPS   • Quality   enrollment,  percentage  of  providers  meeting   results,  evidence  of  reduced  gaps  in  care  or   reporting   criteria  and  quality/cost  results   improved  adherence  to  evidence-­‐based   • Effective  case   • Inclusion  of  performance  information  or   guidelines   management   designation  programs  in  provider  directories   • Facility  pay  for  performance  based  on  clinical   • Care   • Incentives  for  participation  in  care   outcomes,  quality,  CAHPS  results,  or  mortality   coordination   management  programs   rates  (severity-­‐adjusted)   • Chronic   • Value-­‐based  benefit  designs  to  incent   • Percentage  of  payments  (bonus,  fee-­‐for-­‐ disease   engagement  in  treatment  option  decision   service,  etc.)  linked  to  performance   management   support,  adherence  to  recommended   • Support  and  payment  for  accountable  care   • Medication   preventive  and  diagnostic  services,  adherence   structures  or  primary  care  medical  home   and  care   to  maintenance  medications   services   compliance   • Patient  experience  &  CAHPS-­‐type  survey   initiatives   • Transparency  of  cost  and  quality  information   for  consumers   • Evidence  of  patient  engagement  metrics  such   as  Patient  Activation  Measure  (PAM)   Hospital   • Premium-­‐differentiated  hospital  networks   • Payment  for  care  transitions  management   Readmissions   based  on  performance  in  avoidable   • Gainsharing  or  risk-­‐sharing  based  on  targeted   readmissions  or  ambulatory  care–sensitive   reduction  in  readmission  rates,  potentially   admissions   avoidable  complications,  or  avoidable   • Percentage  of  members  receiving  welcome   emergency  department  visits   home  calls  upon  hospital  discharge   • Evidence  of  provider  contracts  stipulating  non-­‐ • Percentage  of  members  who  have  follow-­‐up   payment  for  preventable  hospital   primary  care  appointment  within  7  days   readmissions   34 Reporting   Domains   Benefit  Design   Provider  Reimbursement   Patient  Safety   • Premium-­‐differentiated  provider  networks   • Differentiated  payment  based  on  Health  IT   and  Medical   based  on  patient  safety  management   adoption  (e-­‐prescribing,  computerized   Errors   • Use  of  reference  pricing  in  conjunction  with   physician  order  entry,  HITECH  Meaningful  Use   quality  indicators  to  encourage  selection  of   requirements)   higher-­‐performing  providers  or  use  of  Centers   • Frequency  and  disposition  of  health  care– of  Excellence   acquired  conditions  (HACs)  and  serious   • Coverage  for  medication  reconciliation  review,   reportable  events  (SREs)   with  polypharmacy  management  and   • Evidence  of  provider  contract  requirements   frequency  of  drug–drug  conflicts  identified   for  root  cause  analysis  of  medical  errors   • Demonstration  of  evidence-­‐based  practices   (e.g.,  pre-­‐39  week  C-­‐sections  or  elective   inductions)   Wellness  and   • Value-­‐based  benefit  designs  to  incent   • Preventive  HEDIS  measures   Health   engagement  in  treatment  option  decision   • Percentage  of  providers  using  standard  PHQ-­‐9   Promotion   support,  adherence  to  recommended   depression  screening  tool  with  validation   Activities   preventive  and  diagnostic  services,  adherence   through  sample  chart  audit   • Smoking   to  maintenance  medications,  as  measured  by   • Percentage  of  members  for  whom  smoking   cessation   reduced  gaps  in  care  and  medication   status  and  BMI  are  captured   • Weight   possession  rates,  respectively   • Evidence  of  tailored  communications  to   management   • Availability  and  use  of  incentives  for  health  risk   identify  familial  health  risk  factors  and/or  risk   • Stress   reduction   factors  associated  with  race  or  ethnicity   management   • Availability  and  use  of  incentives  for   • Physical  fitness   completing  Health  Risk  Appraisal  and  related   • Nutrition   screening  tools   • Heart  disease   • Incentives  to  use  consumer  tools  and   prevention   complete  consumer  education,  treatment   • Healthy   decision  support,  and  self-­‐care  sessions   lifestyle   • Percentage  of  members  engaged  in  condition   support   management  programs  or  health  risk   • Diabetes   reduction  programs   prevention   • Evidence  of  patient  reminder  programs  using   various  media  and  response  tracking   Health  and   • Evidence  of  targeted  risk  identification  based   • Percentage  of  members  for  whom   Health  Care   on  familial  risk  factors   race/ethnicity  information  is  captured   Disparities   • Evidence  of  tailored  member  communication   • Strategies  to  improve  provider  cultural   strategies   competency   • Inclusion  of  self-­‐reported  race/ethnicity   • Reporting  and  payment  for  reduced  gaps  in   information  in  member  registration  processes   care   or  surveys   • Language  translation  support   • Caregiver  support   35