Upload
nathan-evans
View
222
Download
4
Tags:
Embed Size (px)
Citation preview
Introduction to NCQA & SNP Assessment
Brett KayDirector, SNP Assessment
Casandra MonroeAssistant Director, SNP Assessment
2SNP Training – Intro to NCQA & SNP Assessment Program
Purpose of Training
• Provide brief overview of NCQA• Describe the SNP assessment
program NCQA is executing on behalf of CMS
• Give a general understanding of main components of SNP assessment– HEDIS® measures– Structure & Process measures
3SNP Training – Intro to NCQA & SNP Assessment Program
A Brief Introduction to NCQA
• Private, independent non-profit health care quality oversight organization founded in 1990
• Committed to measurement, transparency and accountability
• Unites diverse groups around common goal: improving health care quality
4SNP Training – Intro to NCQA & SNP Assessment Program
NCQA: Mission and Vision
• Mission– To improve the quality of health
care • Vision
– To transform health care through measurement, transparency and accountability
5SNP Training – Intro to NCQA & SNP Assessment Program
NCQA: COMMITTED TO MEASUREMENT, TRANSPARENCY,
ACCOUNTABILITYQuality measurement
means:• Use of objective measures
based on evidence• Results that are comparable
across organizations• Impartial third-party
evaluation and audit• Public Reporting
NCQA’s quality programs include:
• Accreditation of health plans using performance data
• HEDIS clinical measures• CAHPS consumer survey• Measurement of quality in
provider groups• Physician Recognition
6SNP Training – Intro to NCQA & SNP Assessment Program
Achieving the Mission
• 3 out of 4 Americans enrolled in an HMO are in an HMO accredited by NCQA
• More than 90 percent of managed care organizations report HEDIS® quality data
• 38 states and the federal government rely on NCQA Accreditation and HEDIS
• More than 12,000 physicians have earned NCQA Recognition; programs form the basis of quality improvement programs and P4P nationwide
7SNP Training – Intro to NCQA & SNP Assessment Program
SNP Assessment: How did we get here?
• Existing contract with CMS to develop measures focusing on vulnerable elderly
• Revised contract to address SNP assessment– 1st year—rapid turnaround, adapted
existing NCQA measures and processes from voluntary Accreditation programs
– 2nd year—focus on SNP-specific measures– 3rd year—Refine measures; identify new
SNP-specific measures, where appropriate
8SNP Training – Intro to NCQA & SNP Assessment Program
Objectives of SNP Assessment Program
• Develop a robust and comprehensive assessment strategy
• Evaluate the quality of care SNPs provide
• Evaluate how SNPs address the special needs of their beneficiaries
• Provide data to CMS to allow plan-plan and year-year comparisons
9SNP Training – Intro to NCQA & SNP Assessment Program
Three-Year StrategyPhase 1 - FY
2008 Phase 2 - FY 2009 Phase 3 - FY 2010
SNPs Effective as of January 2007
SNPs Effective as of January 2008
SNPs Effective as of January 2008
HEDIS 2008(13 measures)
HEDIS 2009(15 measures)•Addition of two 1st year measures: Care for Older Adults; Medication Reconciliation Post-Discharge
HEDIS 2010 • Measure development:
–Potentially Avoidable Hospitalizations–Inpatient Readmissions–MDS measures (I-SNPs)–Disease-specific measures (C-SNPs)
Structure & Process Measures
• SNP 1: Complex Case Management
• SNP 2: Improving Member Satisfaction
• SNP 3: Clinical Quality Improvements
Structure & Process Measures
• SNP1 – 3• SNP 4: Care Transitions• SNP 5: Institutional SNP
Relationship with Facility• SNP6:Coordination of
Medicare & Medicaid
Structure & Process Measures
•Refinement of existing S&P measures, includes the potential development of new elements
•Potential development of new measures
10SNP Training – Intro to NCQA & SNP Assessment Program
SNP Assessment: Phase I • 2008 SNP Data Collection Successfully
Completed – 340 HEDIS submissions – 432 Structure & Process submissions
• Draft SNP Report sent to CMS September 30– Final Report to CMS—April 2009
• Reassessment – Plans with 50% or less on any element– 72 plans requested reassessment– Revised scores sent to CMS
• SNP specific HEDIS measures released in HEDIS 2009 Volume 2
11SNP Training – Intro to NCQA & SNP Assessment Program
Project Time Line – Phase II
• March - Release final S&P measures• March 30 - Release ISS Data
Collection Tool– S & P Measures
• April - Release IDSS Data Collection Tool– HEDIS Measures
• June 30 - HEDIS submissions and S&P measures submissions due to NCQA
• October 30 - NCQA delivers SNP Assessment Report to CMS
12SNP Training – Intro to NCQA & SNP Assessment Program
Training & Education
• Five training topic areas, focus is on content and data submission– Introduction to NCQA & SNP Assessment
Program– SNP Subset of HEDIS Measures– Interactive Data Submission System
(IDSS)– Structure & Process Measures
• Phase I (SNP 1-3)• Phase II (SNP 4-6)
– Interactive Survey System (ISS)
HEDIS 101
14SNP Training – Intro to NCQA & SNP Assessment Program
What Is HEDIS?
HealthcareEffectivenessData &InformationSet
HEDIS is an evolving set of standard specifications for measuring health plan performance
15SNP Training – Intro to NCQA & SNP Assessment Program
Where Did HEDIS Come From?
•Originally developed by employers and the HMO group in 1991; NCQA took charge of HEDIS in 1992
•Expanded in 1996 to cover all three product lines: commercial, Medicare and Medicaid
•Addresses the leading causesof death
•Includes information on quality, utilization and cost
16SNP Training – Intro to NCQA & SNP Assessment Program
How Are HEDIS Data Used?•Federal, state and other regulatory requirements
•State of Health Care Quality report•Performance-based accreditation•Health plans use for RFP/RFI preparation
•Quality improvement activities and health plan operations
•Quality Compass, Quality Dividend Calculator
•US News and World Report - Ranking of Health Plans
17SNP Training – Intro to NCQA & SNP Assessment Program
Data Reporting
•Data are reported to NCQA in June of the reporting year
•Data reflect events that occurred during themeasurement year(calendar year)
18SNP Training – Intro to NCQA & SNP Assessment Program
Data Reporting
•Example:– HEDIS 2009 data are reported in
June 2009– Data reflects events that occurred
January–December 2008 (per specs)
– HEDIS 2009 = 2008 data
19SNP Training – Intro to NCQA & SNP Assessment Program
Effectiveness of Care Measures
•Clinical quality of care •Focus
– Preventive care– Up-to-date treatments for acute
episodes of illness– Chronic disease care– Appropriate medication
treatment
Collecting HEDIS Data
21SNP Training – Intro to NCQA & SNP Assessment Program
Three HEDIS Data Sources
Administrative
Medical records
Surveys
Claims Encounter Eligibility Provider
22SNP Training – Intro to NCQA & SNP Assessment Program
Data Sources
•Administrative– Membership data– Provider data– Claims/encounter data
– Hospital discharge data
– Pharmacy data– Carve-out data
23SNP Training – Intro to NCQA & SNP Assessment Program
Selecting an Eligible Population
• Member ID
• Age (DOB)
• Enrollment date and type
• Dates of service
• Diagnosis and procedure codes
• Provider specialty
• Pharmacy
24SNP Training – Intro to NCQA & SNP Assessment Program
• Defining the denominator is critical
• Administrative: Claims and encounter data– Denominator: Based on all eligible
members of the population
Clinical MeasuresData Collection
Clinical MeasuresData Collection
HEDIS Compliance Audit
26SNP Training – Intro to NCQA & SNP Assessment Program
•A standardized audit methodology for verifying the reliability of HEDIS data collection and rate calculation processes
•Outcome is whether or not a measure is reportable
NCQA HEDIS Compliance Audit
NCQA HEDIS Compliance Audit
27SNP Training – Intro to NCQA & SNP Assessment Program
•Data collection and calculation methods can vary across plans
•A standardized audit identifies, quantifies and converts errors
•The audit reduces bias
Why a Standardized HEDIS Audit?
Why a Standardized HEDIS Audit?
Structure & Process Measures
29SNP Training – Intro to NCQA & SNP Assessment Program
What is a S&P Measure?
• A statement about acceptable performance or results
• Assesses a plan’s ability to comply with specific requirements
• Focus on systems necessary for quality care– Policies & procedures, reports,
materials
30SNP Training – Intro to NCQA & SNP Assessment Program
How are S&P Measures Developed
• Similar to HEDIS measures development• Initial literature review and evidence• Measurement Advisory Panel (GMAP)
– Diverse set of expert stakeholders– Technical expert panels also formed, if
necessary
• Pilot tests to determine feasibility, burden
• Public comment• Final Approval from GMAP and CMS
31SNP Training – Intro to NCQA & SNP Assessment Program
32SNP Training – Intro to NCQA & SNP Assessment Program
Components of the S&P Measures
• Standard statement: a statement about acceptable performance or results
• Intent statement: A sentence that describes the importance of the S&P measure
• Element: The component of the measure that is scored and provides details about performance expectations. NCQA evaluates each element within the measure to determine the degree to which the SNP has met the requirements within the S&P measure.
33SNP Training – Intro to NCQA & SNP Assessment Program
Components of an S&P Measure
• Factor: An item within an element that is scored (e.g., an element may require an organization to demonstrate that a specific document includes 4 items. Each item is a factor).
• Scoring: The level of performance the organization must demonstrate to receive a specific percentage on each element (100%, 80%, 50%, 20%, 0%)
• Data source: Types of documentation or evidence that the organization uses to demonstrate performance on an element. NCQA requires 3 types of data sources for S&P assessment:
34SNP Training – Intro to NCQA & SNP Assessment Program
Data Source Types
• Documented Processes: Policies and procedures, process flow charts, protocols and other mechanisms that describe an actual process used by the organization
• Reports: Aggregated sources of evidence of action or compliance with an element, including management reports; key indicator reports; summary reports of analysis; system output giving information; minutes; and other documentation of actions that the organization has taken
• Materials: Prepared materials or content that the organization provides to its members and practitioners, including written communication, Web sites, scripts, brochures, review and clinical guidelines
35SNP Training – Intro to NCQA & SNP Assessment Program
Components of an S&P Measure
• Scope of Review: The extent of the organization’s services evaluated during an NCQA survey. Scope of review may vary
• Look-back period: The period of time for which NCQA evaluates an organization’s documentation to assess performance against an element
• Explanation: Guidance for demonstrating performance against the element
• Example: Descriptive information illustrating performance against an element’s requirements. Examples are for guidance and are not intended to be all-inclusive
36SNP Training – Intro to NCQA & SNP Assessment Program
Look-Back Period FAQs
• Could you clarify the look-back period and whether a SNP must develop or review all of its documentation within that this timeframe?– The look-back period is the three-month period
prior to survey submission—March 31, 2009 to June 30, 2009. All documentation must be current as of the look-back period but it could have been developed before that time.
– For evidence consisting of a policy, an organization that did not have one in place can develop and incorporate it into its operations during the look-back period.
2009 SNP Measures Requirements
38SNP Training – Intro to NCQA & SNP Assessment Program
SNP Assessment Process
• Phased Approach– Defining and assessing desirable
structural characteristics– Assessing processes– Assessing outcomes
• Two main components – HEDIS Measures-focus on clinical
performance– Structure & Process measures-focus on
structural characteristics and systems
39SNP Training – Intro to NCQA & SNP Assessment Program
SNP Assessment Process
• S&P Measures assessment– Data collection through Web-based
Interactive Survey System (ISS) data collection tool.
• Several levels of review:– Off-site Review (Level 1)– Executive Review (Level 2)– Final Eyes (Level 3)
40SNP Training – Intro to NCQA & SNP Assessment Program
S&P Assessment: What’s New for 2009
• Plan Comment Period– b/w level 2 & 3 review– Plans will have an opportunity to provide
additional information to clarify issues from original submission materials
– Quick turnaround: plans will have to respond to NCQA requests for more information rapidly
– One-time opportunity: Only chance plans have before data is finalized and sent to CMS. There will not be a reassessment like Phase I.
41SNP Training – Intro to NCQA & SNP Assessment Program
S&P measures: What’s New for 2009
• SNP 1-3: Added 2 new elements– SNP 2C: Improving member satisfaction
•Focus on implementing interventions to address member satisfaction issues
– SNP 3B: Clinical measurement activities•Focus on collecting, analyzing relevant
clinical data• Identifying opportunities for improvement
based on data analysis
– Existing elements: added more examples and clarified explanations
42SNP Training – Intro to NCQA & SNP Assessment Program
S&P measures: What’s New for 2009
• SNP 4: Care Transitions– All SNP Types– Focus on how SNPs manage planned and
unplanned transitions of care for members
• SNP 5: Institutional SNP Relationship with Facility– (I-SNPs only)– Focus on ensuring SNP members in Institutional
facilities receive comprehensive quality care
• SNP 6: Coordination of Medicare and Medicaid– Different requirements for Duals and I&C SNPs– Focus on helping members obtain benefits/services
regardless of payer.
43SNP Training – Intro to NCQA & SNP Assessment Program
New Phase II HEDIS Measures
• Measures– Care for Older Adults (COA)– Medication Reconciliation Post-
Discharge (MRP)
• Hybrid Method Collection
SNP Data & Reporting
45SNP Training – Intro to NCQA & SNP Assessment Program
Data Submissions
• HEDIS measures– Submission date: June 30, 2009– IDSS data collection tool– All data must be audited by NCQA certified
HEDIS auditor
• S&P measures– Submission date: June 30, 2009– ISS data collection tool
• No Fees required to submit
46SNP Training – Intro to NCQA & SNP Assessment Program
Who Reports
• HEDIS measures– All SNP plan benefit packages with 30+
members as of February 2008 Comprehensive Report (CMS website)
• S&P measures– All SNP plan benefit packages– Plans with no enrollment exempt from
certain elements
47SNP Training – Intro to NCQA & SNP Assessment Program
What to Report
• S&P measures• Cohort I—All SNPs operational as of
January 1, 2007 and renewed in 2009.– S&P measures 4-7 (SNP 2:C & 3:B)
• Cohort II—All SNPs operational as of January 1, 2008 and renewed in 2009– All S&P measures (SNP 1-6)
•Do not report SNP 7 (SNP 2:C & 3:B)
48SNP Training – Intro to NCQA & SNP Assessment Program
What happens after submission?
• NCQA Analysis of HEDIS and S&P measures– Comparison to MA plans (HEDIS) and
to other SNPs– Demographic (size, type, region)– Statistical significance
• Deliver report to CMS– CMS will make all decisions about how
to use the data– NCQA will not publicly report any of
the SNP data
49SNP Training – Intro to NCQA & SNP Assessment Program
And now…
Questions?
50SNP Training – Intro to NCQA & SNP Assessment Program
Contacts
Brett KayDirector, SNP [email protected]
Casandra MonroeAssistant Director, SNP [email protected]
51SNP Training – Intro to NCQA & SNP Assessment Program
Additional Resources
• NCQA SNP Webpage: www.ncqa.org/snp.aspx– FAQs (HEDIS)– Training descriptions & schedule– Final HEDIS and S&P measures (March 14)
• NCQA Policy Clarification Support (PCS)http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp
• HEDIS Audit informationhttp://www.ncqa.org/tabid/204/Default.aspx
52SNP Training – Intro to NCQA & SNP Assessment Program
Additional Information
• HEDIS 2008 Volume 2 Publication Purchase
http://www.ncqa.org/tabid/78/Default.aspx
• October Specifications Updatehttp://www.ncqa.org/Portals/0/PolicyUpdates/HEDIS%20Technical%20Updates/2008_Vol2_Technical_Update.pdf
53SNP Training – Intro to NCQA & SNP Assessment Program
Additional SNP Trainings
• Introduction to NCQA & SNP Assessment– March 5th 1:00 – 3:00 pm– March 10th 1:00 – 300 pm
54SNP Training – Intro to NCQA & SNP Assessment Program
Additional SNP Trainings
• SNP Subset of HEDIS Measures– March 3rd 11:30 – 1:00 pm– March 11th 11:30 – 1:00 pm – March 16th 1:00 - 2:30 pm– March 26th 1:00 - 2:30 pm– April 1st 12:30 - 2:00 pm
• Structure and Process Measures (S&P 1-3)– March 12th 1:00 – 2:30 pm– March 19th 1:00 - 2:30 pm– March 25th 12:30 - 2:00 pm– April 23rd 2:00 – 3:30 pm
55SNP Training – Intro to NCQA & SNP Assessment Program
Additional SNP Seminars
• Structure and Process Measures (S&P 4-6)– March 17th 2:00 - 3:30 pm– March 24th 2:00 - 3:30 pm– March 31st 2:00 - 3:30 pm– April 2nd 12:30 – 2:00 pm– April 7th 2:00 - 3:30 pm– April 15th 1:00 – 2:30 pm
• Interactive Survey System (ISS)– April 8th 1:00 – 2:30 pm– April 14th 1:00 - 2:30 pm– April 17th 1:00 – 2:30 pm – April 21st 1:00 - 2:30 pm– April 28th 1:00 – 2:30 pm– May 7th 1:00 – 2:30 pm