How to Implement Quality in Exchanges Webinar sponsored by AcademyHealth

How to Implement Quality
in Exchanges
Webinar sponsored by AcademyHealth
and the National Committee for Quality
Assistance (NCQA)
April 9, 2012
AcademyHealth seeks to improve health and health
care by generating new knowledge and moving
knowledge into action.
AcademyHealth collaborates with the health services
research community and other key stakeholders to:
– Support the development of health services
– Facilitate the use of the best available research
and information
– Assist health policy and practice leaders in
addressing major health challenges
National Committee for
Quality Assurance (NCQA)
The NCQA is a not-for-profit organization dedicated to
elevating the issue of health care quality to the top of
the national agenda and transforming health care
quality through measurement, transparency and
New Report
E. Hoo, D. Lansky, J. Roski et al., Health Plan
Quality Improvement Strategy Reporting Under
the Affordable Care Act: Implementation
Considerations, The Commonwealth Fund, April
Available at
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Exchanges & Health Plan
Quality Reporting
Today’s event will:
– Examine the Affordable Care Act’s quality
reporting requirements for plans participating in
the health insurance exchanges;
– Highlight examples of how state purchasers have
already integrated health plan quality reporting
and improvement strategies in their existing
programs; and
– Review some concrete ways to implement the
ACA requirements in phases and by strategically
building for the future.
What are the quality requirements for
Exchanges? (Sarah Thomas, MS – NCQA)
How have state purchasers integrated quality
at the plan level into their existing programs?
– Wendy Long, MD, MPH - TennCare
– Richard KP Sun, MD, MPH - CalPERS
How can Exchanges implement the quality
requirements? (Ledia Tabor, MPH – NCQA)
What are the Quality Requirements
for Exchanges?
Sarah Thomas, MS
Certification of Qualified Health Plans
• The Exchange will certify qualified health plans
(QHPs) who meet the following requirements:
– Are accredited within a specific timeframe
– Meet marketing requirements
– Ensure a sufficient choice of providers (network
adequacy) and provide information on providers
– Include essential community providers where
– Implement a quality improvement strategy
– Report health plan quality measures
– Utilize uniform enrollment form
– Utilize standard format for presenting benefit options
NCQA and AcademyHealth
April 9, 2012
Health Plan Accreditation
• Health plans (issuers) must be accredited in the
following categories by an accrediting entity
recognized by HHS (timing determined by state)
Clinical quality measures, such as HEDIS
Patient experience ratings, such as CAHPS
Consumer access
Utilization management
Quality assurance
Provider credentialing
Complaints and appeals
Network adequacy and access
Patient information programs
NCQA and AcademyHealth
April 9, 2012
Network Adequacy Requirements
• Health plans must ensure a sufficient choice of
providers and provide information to enrollees
and prospective enrollees on the availability of
in-network and out-of-network providers
• Must include essential community providers in
health insurance plan networks, where
available, that serve predominantly lowincome, medically-underserved individuals
NCQA and AcademyHealth
April 9, 2012
Quality Rating
• Secretary to develop a rating system for
Exchange health plans in each benefits level on
quality and price
• Secretary to develop an enrollee satisfaction
survey system and make information available
through the portal to allow enrollees to
compare plans
• Exchanges to maintain Internet websites and
assign a rating to each qualified health plan
offered through such Exchange in accordance
with the criteria developed by the Secretary
NCQA and AcademyHealth
April 9, 2012
Quality Improvement Strategy
• Implementation of a quality improvement
strategy that rewards quality through the use of
market-based incentives
– Improves health outcomes
– Reduces readmissions
– Improves patient safety
– Promotes wellness and health
– Reduces disparities
NCQA and AcademyHealth
April 9, 2012
Federal Guidance to States –
Operational Capabilities
• Consider strategy for using quality information to
certify QHPs
• Determine what quality information or metrics
the Exchange will display to consumers
• Build capacity for Exchange system to accept
this quality data and report on website
• Consider how Exchange will monitor QHP
quality during the plan year (monitoring of
complaints, appeals and network adequacy)
NCQA and AcademyHealth
April 9, 2012
Quality Improvement Strategies in Medicaid Managed Care
Lessons Learned from the TennCare Experience
AcademyHealth & NCQA Webinar
April 9, 2012
Wendy Long, MD, MPH, Chief Medical Officer
Bureau of TennCare
TennCare, the Beginning
• In 1994, Tennessee restructured its Medicaid program and became the first state in the nation to enroll its entire Medicaid population
into managed care, as well as being the only state to offer Medicaid to all uninsured and uninsurable citizens – regardless of income.
• This restructured and expanded Medicaid program was renamed “TennCare”.
• At inception, the thought was the cost‐savings from a managed care model would allow the state to cover an expanded population (individuals who would not qualify under traditional Medicaid eligibility standards) and additional benefits.
• As a revolutionary model, this approach brought about some challenges which prompted the program to change and evolve to become the program it is today.
TennCare 1994
1994 Overview
At TennCare’s inception, there were 12 different community service areas (CSAs) and a dozen health plans ‐ only two were statewide. TennCare did not restrict the number of health plans; nor did it require a procurement process for plan selection. Prior to TennCare, Tennessee Medicaid was entirely fee‐for‐
• 12 Plans total – 8 HMOs; 4 PPOs
• Risk Model – All plans were “at‐risk”
• Total Enrollment – 1.1 million
Carved In
Routine Mental Health Services
Carved Out
• Long‐Term Care
• Specialized Mental Health Services
Quality Monitoring
1994 Service Areas
TennCare outlined basic quality management requirements in the contracts with the health plans and contracted with an External Quality Review Organization (EQRO) to review and report on MCO quality. Out of necessity, the EQRO’s primary focus was on getting health plans to a point where they had appropriate policies in place. Quality of encounter data – poor
Network monitoring focused on Geoaccess mapping of MCO reported primary care providers
Appeals were handled by MCOs
TennCare Satisfaction Survey: 1994 – 61% 18
TennCare 2003
2003 Overview
Carved In
By 2003, TennCare required all health plans to be HMOs and serve all areas within each Grand Region in which they participate, resulting in three Service Areas (West, Middle and East). At this time, health plans had begun to experience problems, and some were at risk of becoming insolvent which caused the state to bring them into an Administrative Service Organization (ASO) arrangement. Contributing factors included the impact of lawsuits/consent decrees and a lack of experience and capital on the part of some MCOs. • 9 plans – all HMOs
• Risk Model – All plans were brought into an ASO arrangement (no risk)
• Total Enrollment – 1.35 million
• Physical
Carved Out
• Behavioral Health
• Dental
• Pharmacy
• Long‐Term Care
Quality Monitoring
By now the EQRO was able to focus on adherence to policies. 2003 Service Areas
Encounter data quality had improved. By the late 90’s, TennCare had commissioned several studies on quality including delivery of preventative services, prenatal care and ER utilization. In addition, an annual Women’s Health report was now being produced. Network requirements were expanded to include specialty standards
Management of appeals shifted to TennCare
TennCare Satisfaction Survey : 2003 – 83%
TennCare 2006
2006 Overview
Carved In
By 2006, TennCare reform was nearly complete and relief had been obtained from a particularly burdensome consent decree. After the release of a study by McKinsey & Company in 2004 showing that the growth of TennCare was projected to require every new state dollar in just a few short years, the state had to make some difficult decisions to keep the program operating. The most difficult decision was reducing enrollment, but children and mandatory Medicaid enrollees were protected from these reductions. Program reductions included imposing a limit on prescription drugs for most adults and eliminating adult dental coverage. These steps were challenging but necessary and allowed TennCare to return to firm financial footing.
• 7 plans – all HMOs
• Risk Model – ASOs (no risk) • However, TennCare was in the process of restructuring the program and request for proposals were made for at‐risk plans in 1 of the 3 regions. • Total Enrollment – 1.2 million
2006 Service Areas
• Physical
Carved Out
• Behavioral Health
• Dental
• Pharmacy
• Long‐Term Care
Quality Monitoring
In 2006, TennCare became the first Medicaid agency in the country to require all MCOs be NCQA accredited. In addition, TennCare began requiring that all MCOs report annually on the full set of HEDIS measures. EQRO role shifted to focus on Tennessee specific concerns and to assure annual on‐site monitoring
Provider network monitoring was enhanced to include validation of MCO reported data and confirmation of time to appointment
Medical necessity rules were promulgated to assure evidence‐based decision making
TennCare Satisfaction Survey: 2006 – 87%
TennCare 2009
2009 Overview
Carved In
By 2009, TennCare had secured contracts with two well-capitalized and
experienced MCOs in each region. The plans were operating at full risk. These
MCOS were selected through a competitive bid process. In addition, one health
plan contracted to operate statewide to serve a select population of members and to
function as a back-up health plan should another plan falter. Rates were determined
by an outside actuary to ensure the rates were sufficient for the plans to provide
necessary care and maintain stability. TennCare had also begun implementation
planning for the new TennCare CHOICES in Long-Term Care program that would
eventually bring LTC services for the elderly and adults with physical disabilities into
managed care.
• 3 plans – all HMOs
• Risk Model – At-risk
• Total Enrollment – 1.2 million
2009 Service Areas
• Physical
• Behavioral Health
Carved Out
• Dental
• Pharmacy
• Long‐Term Care
Quality Monitoring
By 2009, all MCOs were NCQA accredited and
HEDIS scores were improving, particularly in the
area of child health. Integration of behavioral
health allowed for reporting of behavioral health
HEDIS measures for the first time. Quality
initiatives targeting emergency department overutilization, comprehensive diabetes care and
adolescent well care were underway.
EQRO tasked with producing annual summary of
HEDIS results that includes statewide weighted
averages as well as comparisons across MCOs
and to national benchmarks. Reports published on
TennCare website.
P4P program in place relative to selected HEDIS
TennCare Satisfaction Survey: 2009 – 92%
TennCare 2012
2012 Overview
Today, TennCare is in the process of extending contracts with its MCOs in
order to maintain stability throughout health reform planning. The CHOICES
program was fully implemented in August of 2010, bringing LTC for the elderly
and adults with physical disabilities into the managed care model and
increasing HCBS options for members. Integration of physical health,
behavioral health and LTC services promotes improved coordination of care for
the “whole person.”
• 3 plans – all HMOs
• Risk Model – At-risk
• Total Enrollment – 1.2 million
Carved In
Carved Out
• Physical
• Behavioral Health
• Long‐Term Care (for E/D)
• Dental
• Pharmacy
• Long‐Term Care (for ID)
Quality Monitoring
2011 Service Areas
Today, TennCare rates above the national Medicaid average in many quality measures and continues to demonstrate improvement . With the integration of LTC into the managed care model, efforts to monitor quality of care in the elderly and disabled population are a new focus of attention. We continue to enhance quality standards – recently added contractual requirement for all plans to utilize hybrid methodology in HEDIS reporting in cases where either hybrid or administrative is acceptable to NCQA
TennCare Satisfaction Survey: 2011 – 95%
Examples of Improvements Over Time
U.S. Expenditure on Health Care Per Capita Vs. Comparable TennCare Per Member Cost Well‐Child Screening Rates
TennCare Unadjusted Rate
TennCare Adjusted Rate
U.S. (OECD Health Data 2011)
TennCare (Cost of Comparable Services/Enrollment)
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Member Satisfaction Rates
2010 HEDIS Results
Improvement in 6 of 8 adult diabetes measures from 2006 to 2010.
Improvement in 5 of 6 women’s health measures from 2006 to 2010.
Improvement in 12 of 12 child health measures from 2006 to 2010.
10 of 12 child health measures exceed national Medicaid average in 2010.
Lessons Learned
On Quality
1. Access to reliable encounter data as quickly as possible is extremely important. Hard data is needed to dispel misinformation and anecdotes. 2. Quality requirements should be spelled out for health plans – e.g. accreditation requirements and timelines, performance measure
reporting requirements. Accreditation takes time so clear milestones should be established to assess progress toward the goal. Consider P4P arrangement to reward plans for accreditation level received. 3. Independent, external review (EQRO, accrediting body like NCQA) goes a long way to quelling stakeholder concerns. 4. MCO required reporting of standardized, evidenced‐based performance measures allows for tracking trends over time and for comparison to national norms (e.g. HEDIS). 5. Consider developing a state level survey that will allow you to track issues of interest to the state over time. This would be in addition to MCO level surveys like CAHPS. 6. Pay for Performance incentives tied to specific performance measures can be used effectively to target attention to your highest
priorities. 7. Network monitoring should include three components:
• Establishment of network standards for various provider types (e.g. geographic, appointment time
• Tracking compliance with standards based on network information self‐reported by MCOs
• An audit process to validate MCO self‐reported information
8. Tracking and analysis of enrollee appeals can be an important quality monitoring tool
CalPERS Health Plan Quality
Data: Sources and Uses
Richard KP Sun, MD, MPH
California Public Employees' Retirement System
 CalPERS and Health Benefits
 Sources of Quality Data
 Uses of Quality Data
Health Plan Chooser
Public Presentations to Board
Contract Requirements
NCQA and AcademyHealth
April 9, 2012
CalPERS and Health Benefits
• Vision statement (excerpt): “, costeffective, quality, and sustainable health
options for our members and employers”
• Will spend about $7 billion in 2012 on health
benefits for >1.3 million active and retired state
& local employees and their family members
• Major plans ("Basic" and "Medicare"): 6
self funded PPO plans administered by Anthem
Blue Cross, 6 HMO plans (with Blue Shield of
California and Kaiser Permanente)
Source: “Facts at a Glance: Health” at
NCQA and AcademyHealth
April 9, 2012
Sources of Quality Data
• HEDIS (CalPERS-specific for PPO plans)
• CAHPS – "Health Plan Member Survey" –
random sample of 1,100 eligible members
from each Basic and Medicare plan with
2,000 members
• Health Care Decision Support System
(HCDSS, "data warehouse") with claims &
other data 2003-present
NCQA and AcademyHealth
April 9, 2012
Use of Data in CalPERS Publications
Example: 2012 Health Benefit Summary
NCQA and AcademyHealth
April 9, 2012
Use of Data in Health Plan Chooser (I)
• Web-based tool allowing members to
compare CalPERS plans on costs, doctors,
plan performance ratings, etc.
• Includes CAHPS data in bar graphs
(excerpt below), HEDIS data for Basic
plans in table (excerpt next slide)
NCQA and AcademyHealth
April 9, 2012
Use of Data in Health Plan Chooser (II)
Asterisks indicate HEDIS measures collected via hybrid (as opposed to administrative) method.
NCQA and AcademyHealth
April 9, 2012
Use of Data in Board Presentations (I)
Selected HEDIS Scores for CalPERS Plans: Number
Above or Below National HMO or PPO Averages
for Reporting Years 2008, 2009, & 2010
Above National Average
Below National Average
Number of HEDIS Measures
Above Or Below National Average
2008 2009 2010 2008 2009 2010 2008 2009 2010 2008 2009 2010
Health Plan and Reporting Year
Source: Attachment to December 14, 2010, CalPERS Health Benefits Committee Agenda Item 3b at
NCQA and AcademyHealth
April 9, 2012
Use of Data in Board Presentations (II)
Percent of Expenditures on
Potentially Avoidable Complications,
By Episode Type – CalPERS PPO
Plans vs. US Benchmarks
Note: CalPERS HCDSS data for these analyses were from 2008-2009. Source: Attachment 2 to February 14, 2012,
CalPERS Pension and Health Benefits Committee Agenda Item 7 at
NCQA and AcademyHealth
April 9, 2012
Use of Data for Contract Requirements
• Incentives for performance related to
HEDIS and CAHPS measures have been
included in contractual performance
guarantees and pay for performance
objectives with CalPERS health plan
• Efforts continue to more closely align the
incentive structures across the plans.
Sources: December 14, 2010, CalPERS Health Benefits Committee Agenda Items 3b and 3c at and
NCQA and AcademyHealth
April 9, 2012
Other Uses of HCDSS Data: Examples
• To support creation of Value Based
Purchasing Design (e.g., analysis of
hospital charges for hip and knee joint
replacement in PPO plans, leading to
$30,000 limit for these surgeries)
• Stanford/NYU study of how introduction
of high-performance networks affects
healthcare costs
Sources: Attachments 1 and 2 to October 18, 2011, CalPERS Health Benefits Committee Agenda Item 3 at and
NCQA and AcademyHealth
April 9, 2012
Contact Information
Richard KP Sun, MD, MPH, Medical Consultant
Health Plan Administration Division
California Public Employees' Retirement System
P.O. Box 1953, Sacramento, CA 95812-1953
[email protected]
NCQA and AcademyHealth
April 9, 2012
How Can Exchanges Implement the
Quality Requirements?
Ledia Tabor, MPH
• Discuss NCQA-recommended phase-in
approach for Exchanges to meet quality
• Discuss how NCQA’s work in quality can be
used in state Exchanges
• Provide design principles for implementing
decision-support tools
• Identify principles to help build Exchanges that
promote value
NCQA and AcademyHealth
April 9, 2012
Two Phases of Policies to Move Towards
Value in Exchanges
Phase 1 - (2013 - 2015)
Phase 2 - (2016 and Beyond)
• Require accreditation
• Require performance-based accreditation
Quality Measures
• Collect quality measures (CAHPS)
Quality Measures
• Create meaningful benchmarks, ratings,
& rankings using HEDIS/CAHPS
• Report measures at plan & provider level
Quality Improvement and Reporting
• Provide evidence of quality
improvement activities
• Consider using past plan results to
report to consumers for plans that have
similar products in the Commercial or
Medicaid market
Web Portal/Decision-Support
• Display quality information together with
cost sharing and premiums
• Create a process for mandatory training
of navigators and brokers on value
Quality Improvement and Reporting
• Develop reward/incentive system
• Create incentives for plans to engage
with consumers
• Push aggressively for quality
improvement through public reporting of
standardized measures, benchmarking
against targets and public education
Web Portal/Decision-Support
• Evolve web portals
NCQA and AcademyHealth
April 9, 2012
Principles for Accreditation
• Simple to understand, administer
• Level playing field among products
• Must include clinical quality measures and
patient experience measures
• Key challenge is transition –
– In 2014 plans will have no quality measures to
report for Exchange enrollees
– Need a transition strategy until 2015 when first
measures, benchmarks can be calculated
NCQA and AcademyHealth
April 9, 2012
Possible Accreditation Timelines
1. Require Accreditation the first year of the Exchange
Accredited Plan
Non-Accredited Plan
(should start process)
State Qualifies Plans
2. Allow a year for plans to be Accredited
(should start process)
• About 18 months to
go through
• No matter what report
Accreditation status
in 2013
State Qualifies Plans
NCQA and AcademyHealth
April 9, 2012
Quality Measures: A National Starter Set
• Use the same quality standards nationally
• Start with a feasible set of measures; can add over time
• Select measures using defined principles
– Aligned with national health improvement goals, Medicaid,
Medicare and commercial strategies
– Widely used by health plans and national quality reporting
initiatives (e.g., HEDIS®)
– The same measures for all types of health plans – HMOs and PPOs
– Phase in more outcomes measures over time
– Require auditing to ensure reliability, validity of results
• Require CAHPS, a proven method of gathering patient
experience; may need new items
NCQA and AcademyHealth
April 9, 2012
Quality Measures for Exchanges
• Various levels of requirements
• Waiting for federal and state rules
• Quality measure reporting options
– Separate Exchange population
• Start with high prevalence measures
• Phase in more with time
– Combine Medicaid or Commercial with
Exchange populations
• NCQA will align its data collection,
reporting, Accreditation with
– Could include non-HEDIS measures
NCQA and AcademyHealth
April 9, 2012
Quality Data Collection
Why do Exchanges
need quality data?
•Qualify plans for
•Monitor quality
improvement goals
and strategies
•Create ratings and
report cards
•Report to consumers
How do Exchanges
obtain quality data?
•Through an efficient
and uniform data
collection process
•Analysis-ready files
•Data submission
process that health
plans already use for
NCQA, CMS, and
other purchasers
NCQA and AcademyHealth
April 9, 2012
Design Principles for Decision-Support Tools
(Refer to NCQA White Paper, Ratings and Decision-Support Tools, for more information)
• Explain how quality information is meaningful in
selection of a high value plan
• Provide short definition & example of concept
• Use filtering to allow consumers to customize
the decision process
Ease of Use
• Data displays should summarize and interpret
data for consumers
• Comfortably and quickly navigate through
NCQA and AcademyHealth
April 9, 2012
Build Exchanges to Promote Value
(Refer to NCQA White Paper, Building State Exchanges to Get Better Value, for more information)
• Ensure that Web portals, report cards,
navigators, brokers and other resources make
total cost and quality information easy to see,
understand and use
– Present information as simply as possible
– Build from existing measures and data collection
– Limit data collection to data that have clear use
– Add more information, new measures and quality
improvement over time
NCQA and AcademyHealth
April 9, 2012
For more information, please contact
Ledia Tabor ([email protected]) or
Kristine Thurston Toppe ([email protected]),
or visit NCQA Exchange Quality Solutions at
NCQA and AcademyHealth
April 9, 2012