4/18/2013. Why Quality Matters. Overview. Discussion

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Bartholomew Doyle
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1 Why Quality Matters Margaret E. O Kane, NCQA President April 18, 2013 Overview Who is NCQA? How do we help brokers? Employers views and quality and value About high-deductible plans Discussion 2 My Presentation, in a Nutshell NCQA s information helps you and your clients find high-value health care 1

Security Check to Middle-Income Worker Needed to Pay for Medicare Part B & Part D Premiums and Co-Pays 50.00% 45.00% 40.00% 35.

2 The Problem Quality Can Help Fix We spend huge sums on health care The Problem Quality Can Help Fix Opportunity costs are huge Consumers Feel the Cost Crunch George Carlin was right: They re coming for your Social Security Percentage of Average Social Security Check to Middle-Income Worker Needed to Pay for Medicare Part B & Part D Premiums and Co-Pays 50.00% 45.00% 40.00% 35.00% 40.00% 46.00% 30.00% 27.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 6.20% Source: Gibson, Medicare Trustees Report

The triple aim: better population health, better experience of care, lower costs About This Event s

(e.g., #6, 8,10 commercial plans, #1 Medicare plan) 8 About this Event s Hosts Kaiser is strong on

3 The triple aim: better population health, better experience of care, lower costs About This Event s Hosts Kaiser is strong on quality 22 plans accredited by NCQA (21 at highest status level: Excellent ) Strong results in NCQA Health Insurance Plan Rankings (e.g., #6, 8,10 commercial plans, #1 Medicare plan) 8 About this Event s Hosts Kaiser is strong on quality Consumer Reports has mentioned Kaiser in articles about NCQA s Health Insurance Plan Rankings Consumer Reports, November 2011 Excerpt shown by special permission from Consumer Reports to NCQA. Not available for further distribution. 3

4 Who is NCQA and how do we help brokers? Tell Me, Please Had you heard of NCQA before today? A. True B. False 92% 8% A. B. 11 About NCQA Our mission To improve the quality of health care Our method Measurement We can t improve what we don t measure Transparency We show how we measure so measurement will be accepted Accountability Once we measure, we can expect and track progress 12 4

Capitated HMOs that consumers worried would withhold care We emphasized Creating measures that focused on patients getting care they needed

5 We work toward high-value health care. Brokers can add value in that world, too. VALUE Measurement, transparency and accountability move health care toward greater value NCQA s early days ( ) We were reacting to Capitated HMOs that consumers worried would withhold care We emphasized Creating measures that focused on patients getting care they needed Striving for better, not legitimizing what is 14 Where NCQA focuses today Population health (e.g., accountable care organizations, patient-centered medical homes) Accountability for resource use and quality Standardized metrics 5

6 What s a PCMH? Patient- Centered Medical Home Emphasizes care coordination and whole-person care to transform primary care into what patients want it to be Prizes ongoing clinician-patient relationships (not disjointed visits) to keep patients healthy Teamwork frees providers to work to their level of training Information technology helps providers improve population health 16 What s an ACO? Accountable Care Organization Provider-based organization Takes responsibility for realizing the triple aim for a group of at least 5,000 patients Emphasizes patient-centered primary care, coordination of care across care continuum Keeps part of savings when it improves care and costs are lower than payers planned 17 Tell Me, Please How often do you use quality information? A. Always B. Sometimes C. Never 57% 27% 16% A. B. C. 18 6

7 What is HEDIS? Healthcare Effectiveness Data & Information Set HEDIS is a registered trademark of NCQA. Health care s most-used tool for improving performance Asks how often insurers provide scientifically recommended tests and treatments to support more than 70 aspects of health 19 What HEDIS measures two highlights Effectiveness of care Do women receive breast cancer screenings? Is diabetics blood sugar controlled? Patient experience (Consumer Assessment of Healthcare Providers & Systems) Was it easy to get appointments? Did your doctor listen carefully to you? 20 A record 125 million Americans (2 in 5) are in health plans that report HEDIS results 7

You can show your clients that what gets measured gets improved 95% 85% Changes in Select HEDIS Measures, 2001-2011 Accredited (solid) vs.

8 You can show your clients that what gets measured gets improved 95% 85% Changes in Select HEDIS Measures, Accredited (solid) vs. Non-Accredited (dotted) Commercial HMOs Children Chicken Pox Vaccination 75% 65% Controlling High Blood Pressure 55% 45% 35% 25% Colorectal Cancer Screening Hba1c control (lower is better) Tell Me, Please Do your clients think that less expensive plans have lower quality? A. Yes B. No C. They re not sure D. I don t know what they think 28% 39% 26% 6% A. B. C. D. 23 How value-focused purchasers think about value varies Employers and Shareholders Definition of Value = Improved Clinical Outcomes + Lower Safety Risk + Reduced Total Medical and Pharmacy Spending + Less Time Away from Work + Faster Return to Function/Return to Work + Improved Work Capacity + Improved Work Safety + Increased Employee Satisfaction Price Government, Plans & Price-Focused Employees Definition of Value = Improved Clinical Outcomes + Lower Safety Risk (+ Reduced Total Medical and Pharmacy Spending) Price Source: Benfield 24 8

Quality Dividend Calculator Makes business case for quality Is the foundation of tools Kaiser uses Shows productivity and absenteeism gains of using NCQA-Accredited health plans 25 Accreditation

9 Quality Dividend Calculator Makes business case for quality Is the foundation of tools Kaiser uses Shows productivity and absenteeism gains of using NCQA-Accredited health plans 25 Accreditation Programs Health Plan Accreditation NCQA s flagship product Covers 70% of Americans in HMOs and PPOs Other Programs Wellness & health promotion Managed behavioral healthcare organizations New health plans Disease management 26 What health plan accreditation looks at Access & service Example: Is there an appeals process for denied claims? Qualified providers Example: Are physicians credentials current? Staying healthy Example: Do people get cancer screenings, flu shots? Getting better Example: What advice does the plan give smokers? Living with illness Example: Does the plan offer disease management programs? 27 9

NCQA Accreditation is performance based Health Plan Structure & Process

0H (Patient Experience) 50% of Score Performance-Based Accreditation

evidence-based care Often linked to pay-forperformance programs 40,000+

10 NCQA Accreditation is performance based Health Plan Structure & Process 50% of Score HEDIS Performance Measures (Clinical Quality) + CAHPS 4.0H (Patient Experience) 50% of Score Performance-Based Accreditation Clinician Recognition Programs Identifies providers delivering timely, evidence-based care Often linked to pay-forperformance programs 40,000+ clinicians at 5,500+ practice sites 29 Employers views on quality and value 10

31 What employers tell us they want A healthy workforce and high-quality health care they can afford Quality affects employers because they pay for about 2/3 of insured population 69 MILLION ACTIVE

11 Tell Me, Please How interested in quality are your clients? A. Very B. Somewhat C. Not at all D. I don t know 49% 43% 7% 0% A. B. C. D. 31 What employers tell us they want A healthy workforce and high-quality health care they can afford Quality affects employers because they pay for about 2/3 of insured population 69 MILLION ACTIVE EMPLOYEES 81 MILLION DEPENDENTS 150 MILLION ACTIVE LIVES COVERED BY EMPLOYERS SMALL EMPLOYERS Employees MEDIUM EMPLOYERS Employees LARGE EMPLOYERS 1,000-4,999 Employees JUMBO EMPLOYERS 5,000+ Employees 5.88 Million Employers 40,476 Employers 7,415 Employers 1,956 Employers 23.5 Million Employees 10 Million Employees 10 Million Employees 25.5 Million Employees 48 Million Lives 22 Million Lives 22 Million Lives 58 Million Lives Total Employers = 5.93 Million*. Adding 13 million retiree lives to the covered lives, employers insure 163 million (64%) of the 256 million total insured lives in the U.S. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, U.S. Census Bureau, Current Population Survey, 2011 Annual Social and Economic Supplement. *Source for Number of Employers: Small Business Administration (SBA), Source: Benfield 33 11

12 Average Rating on 7-Point Scale by All Respondents 4/18/2013 Quality made easy is how NCQA can add value for employers On a 7-point scale, where 1= not at all valuable, and 7 = extremely valuable, how valuable would NCQA rating of the following vendors, programs or providers be to your company (or your members)? 7 6 Top-rated concepts help employers identify and choose quality PBM AccredPrivate Exch PCMH Dffn'* ACO Dffn* COE Desig Plan Diffn* Obesity Depresssion Complex Pt Consumer Accred Process Recog Recog Recog Info Vendors Source: Benfield 34 Tell Me, Please How many employees do most of your clients have? A B C. 1,000-4,999 D. 5, % 38% 9% 4% A. B. C. D. 35 Skepticism and confusion undermine adoption of new care and payment models Employers are interested Coordination, integration and driving patients to high-quality providers makes sense But the signal employers send to the market is weak, because Employers are skeptical Consolidation can lead to higher costs, not savings ( land grab ) Economic players will protect their interests, block real change Coordination, integration and quality are hard to do Employers are confused What does it take to earn the title of PCMH/ACO/COE? Quality can vary within brands St. Mary s is a Hip Replacement COE for Plan A, but not for Plan B? Source: Benfield 36 12

Relative proportion of large and jumbo employers in each segment* 4/18/2013 Employers views and strategies on quality fall along a spectrum Price Shoppers Candidly, we only care about price.

Trust but Verify I have to rely on my plans, but I need to see proof that they re doing things right that Show Me I m not paying for the Data bad quality. I don't trust the plans to do this.

13 Relative proportion of large and jumbo employers in each segment* 4/18/2013 Employers views and strategies on quality fall along a spectrum Price Shoppers Candidly, we only care about price. Blind Faith Quality? That s our plan s job. I trust they ll take care of it. Trust but Verify I have to rely on my plans, but I need to see proof that they re doing things right that Show Me I m not paying for the Data bad quality. I don't trust the plans to do this. I need to get in the game, get the data, steer the traffic. Estimated distribution of employer segments, based on interviews with 21 large companies Source: Benfield 37 Aspiration Reality Value-based decision-making is not where employers would like it to be What Many Employers Aspire To Health management strategies focused on value, informed by data on cost and quality, as well as access. Employees making value-driven health care choices, equipped with credible information about total costs, out-of-pocket costs and quality. Benefit design that tilts the table toward value through network structure and aligned incentives. The Current Reality for Most Employers Quality information needed doesn t exist, is weak or is not credible. Cost information has gotten better. Quality information is limited. Some taking action, but broader movement constrained in part by lack of confidence in data. Source: Benfield 38 About high-deductible plans 13

14 Tell Me, Please How much are you using high-deductible plans as a cost containment strategy? A. A lot B. Somewhat C. Not at all 59% 39% 1% A. B. C. 40 Quality health care and high-deductible plans are at cross-purposes The next frontier: patient engagement 14

Let s align the interests of patients, payers and providers We

own health Other benefits of patient engagement Crucial to

make informed choices and get better results Supports use of

15 Let s align the interests of patients, payers and providers We need to motivate and reward patients for taking care of their own health Other benefits of patient engagement Crucial to success of medical homes Promotes shared decisions, so patients make informed choices and get better results Supports use of decision aids that help patients become informed partners in their care 45 15

16 Discussion 46 16

Note: Accredited is the highest rating an exchange product can have for 2015.

Quality Overview Accreditation Exchange Product Accrediting Organization: NCQA HMO (Exchange) Accreditation Status: Accredited Note: Accredited is the highest rating an exchange product can have for 215.