REPORTING ON EALTH LANS QUALITY IMPROVEMENT ...ACA 2717 & 1311: ENSURING QUALITY By March 2012, the Secretary of Health and Human Services in consultation with experts in health care

REPORTING ON HEALTH PLANS’ QUALITY IMPROVEMENTSTRATEGIES

Adapted from a joint presentation of Joachim Roski, Lisa Simpson, David Lansky and Emma HooAcademy Health/Commonwealth Foundationhttp://www.commonwealthfund.org/Publications/Fund-Reports/2012/Apr/Health-Plan-Quality-Improvement-Strategy.aspx?page=all

ACA 2717 & 1311: ENSURING QUALITYBy March 2012, the Secretary of Health and Human Services in consultation with

experts in health care quality and other stakeholders is to develop requirements for health plans to report on quality improvement activities with respect to plan or coverage 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 activitiesAnd Section 1311: …the implementation of activities to reduce health and health care disparities,

including through the use of language services, community outreach, and cultural competency trainings

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OPPORTUNITIES FOR ALIGNMENT

Triple Aim Better Care Healthy People/Healthy Communities Affordable Care

HHS National Quality Strategy Medicare Shared Savings Program/Accountable

Care Organization measures Physician Quality Reporting System/Physician

Compare public website Hospital value based purchasing “Meaningful Use” EHR incentive program

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BENEFIT DESIGN STRATEGIES

Selection or steerage to high-performing physicians and hospitals.

Reference pricing for specific procedures Incentives for treatment option decision support Employer- and plan-based financial incentives to

promote engagement in condition management or coaching to reduce health risks.

Incentives for preventive screenings Reduced cost-sharing to optimize prescription

drug adherence Incentives to use online tools

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PROVIDER REIMBURSEMENT STRATEGIES

Steerage/increased volume to high-performing physicians and hospitals

Pay-for-performance Bonus payments Higher fee schedule

Performance-based contracting Risk-sharing or gain-sharing based on total cost

of healthcare Primary care or case management fees Non-payment policies for healthcare-acquired

conditions, avoidable readmissions, etc.

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STRAWMAN CRITERIA FOR SELECTION OFQUALITY ELEMENTS

Conforms to statutory requirements Consistent with National Quality Strategy and

other federal programs Evidence (when available) that “measured”

activities and/or reporting will likely contribute to improvement of health outcomes

Builds upon existing documentation and reporting systems where possible; limits additional burden

Has face validity to consumers, plans, providers, policy makers

Submitted information can be verified

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COMMON APPROACHES TO QUALITYASSESSMENT eValue8 Health Plan Request for Information (Public and

Private Purchasers) Health plans administrative functions and services, (e.g. health

promotion and prevention, chronic disease management, and behavioral health)

Consumer engagement (information resources and connectivity) Provider engagement, measurement and rewards

Accreditation (NCQA and URAC) Quality management and improvement, utilization management,

provider credentialing HEDIS/CAHPS, NCQA Member Connections, Physician and Hospital

Quality Health plans’ benefit design programs or provider reimbursement

strategies are not directly assessed External Quality Review (Medi-Cal Managed Care)

Quality measurement and improvement No direct assessment of benefit and provider reimbursement

strategies

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USES FOR QUALITY REPORTING

Plan qualification Oversight and monitoring Quality improvement Public reporting Consumer information

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“EVALUE8” HEALTH PLAN RFI USES

RFI COMPONENTS• Plan Accreditation/Organization• Consumer Engagement and Support• Provider Measurement & Incentives • Pharmacy Management• Prevention and Health Promotion• Chronic Disease Management• Behavioral Health

PLAN FEEDBACK• Purchaser Expectations• Program Development• Quality Improvement

PURCHASER SUPPORT• Procurement• Performance Benchmarking• Vendor Management

MEMBER SUPPORT• Plan Features• Information Tools

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PUBLIC PERFORMANCE REPORTINGNCQA HEALTH PLAN REPORT CARD

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CONSUMER DECISION SUPPORT: PLAN CHOICE

CRITICAL AREAS FOR DISCUSSION

Who are the key audiences for quality reporting? When should reporting be plan-wide vs.

Exchange-specific (population has much higher turnover)?

What considerations should be made for health plan reporting burden?

How do we avoid creating barriers to new entrants (e.g., regional carriers, accountable care organizations?)

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RECOMMENDATIONS Move ahead strategically, balancing parsimony,

standardization, and innovation Focus on outcomes where available and supplement with

reporting on improvement strategies only where reporting on outcomes is not yet feasible.

Recognize and address the information needs of diverse users of quality reporting.

Support consistent implementation across health plans and exchanges

Balance value and judicious use of resources in the implementation of reporting

Invest in initial testing and develop a learning infrastructure for evaluation and improvement of reporting over time.

Provide criteria to guide periodic review and updates to the quality reporting requirements.

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Health Insurance Exchange Summit West Mini-Summit XII

Health Plan Quality Improvement Strategy

Reporting Under the ACA

Presented by

Patty Jones, RN, MBA

Principal and Healthcare Management Consultant

November 6, 2013

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Milliman Background

Actuarial and healthcare management consulting, helping clients since 1947

50%+ of health plans, 24 of top 25

1,500+ healthcare clients including health plans, providers, employers, ACOs and government entities

Working with 135 ACOs including 9 Pioneer ACOs

Healthcare data for 65+ million members and $10M spent on health data research

Independent, known for credibility

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Milliman - Health Reform Analytics

Consulting – States (including CA), Health Plans, Employers, Hospitals and ACOs

Milliman supports the All Payer Databases and analytics in three states

Milliman produces over 300 clinical measures for clients

Consulting/analytics to 33% of registered ACOs, 50% of Pioneer ACOs, and over 30 private ACOs

Working with 11 MSSP analytic clients

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=bP4hbOjwCLys3M&tbnid=oKtt9lgwPkGqLM:&ved=0CAUQjRw&url=http://www.hcwreview.com/henry-ford-health-system-appoints-senior-director-of-planned-giving/&ei=QaJVUZj0FIfrygHW2IDgBA&bvm=bv.44442042,d.aWc&psig=AFQjCNE3VVwlyC9zkS5AfCtwhL0rROfzmQ&ust=1364652988557030

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Health Exchange Quality

Measurement Federal quality measures must be defined and in production by 2016

Exchanges must collect and display quality information by 2016

Plans must submit an annual report to the Secretary of HHS(and info

will be provided to the public) on whether plan structures, benefits, and

reimbursement do the following:

– Improve health outcomes through use of quality reporting, case

management, care coordination, and chronic disease management;

– Implement activities to prevent hospitalization readmissions;

– Implement activities to improve patient safety and reduce medical errors

through the use of best practices, evidence based medicine, and health

information technology; and

– Implement wellness and health promotion activities.

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State Response - Health Exchange Initiatives

to Publish Quality Measures in 2014

Source: Implementing the Affordable Care Act: Key Design Decisions for State-Based Exchanges, Georgetown University

State States to Publish Quality Data Earlier than 2016

FFE

California

Colorado X

Connecticut X

D.C. -

Hawaii -

Idaho -

Kentucky -

Maryland X

Massachusetts X

Minnesota X

Nevada -

New Mexico -

New York X

Oregon X

Rhode Island X

Utah -

Vermont -

Washington -

- -

EHoo

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*California revised

EHoo

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, October 22, 2013

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State Measurement Approaches Vary

Generally, innovative approaches based on standardized measures

Some link to existing quality measurement initiatives and results

Tend to focus on HEDIS-based existing preventive care, condition-

specific and CAHPS survey results

Some developing new measures based on national standards

Information being presented in different ways and with different levels of

detail

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Oregon – Quality Rating Display

Partnering with Air Wisconsin: Recordkeeping and Administration Outsourcing Solution

October 21, 2013

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Rhode Island – Satisfaction Rating Display


October 21, 2013

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Colorado – Quality Rating Display


October 21, 2013

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California – Quality Rating Display


October 21, 2013

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Shift Towards Measuring and Paying for

Quality

Medicare Advantage (MA) Plan Star Ratings

Starting in 2012, Medicare pays bonuses to plans with strong performance on

clinical quality, service measures and patient experience of care measures

The Medicare Advantage five-star rating system is comprised of: – Health Effectiveness Data Information Set (HEDIS)

– Consumer Assessment of Health Plans (CAHPS)

– Health Outcomes Survey (HOS)

– CMS administrative data on plan quality and member satisfaction

Sliding scale bonuses to plans with 4-5 stars – Smaller bonuses promised to plans with 3 or more stars through 2014

– 5 star plans may enroll members all year long

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Impact of Measuring and Paying for Quality

Performance Improvements on HEDIS Measures for MA Plans

Measure HMO

(2010)

HMO

(2011)

PPO

(2010)

PPO

(2011)

Smoking Cessation 77.9 81.5 78.3 79.3

Adult BMI Assessment 50.4 68.2 36.6 62.2

Colorectal Cancer Screening 57.6 60.0 41.0 55.2

Controlling High Blood Pressure 61.9 64.0 55.7 60.6

Source: Early Evidence Suggests Medicare Advantage Pay for Performance May Be Getting Results, Health Affairs Blog October 29, 2012

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Challenges and Opportunities with

Exchange Quality Measurement Variability across states encourages innovation but makes

standardization and comparison challenging

Health plan level measurement may not address quality improvement

opportunities that are important and more actionable at different levels –

geography, populations, providers

Some national measures need more clarification and require risk

adjustment methods that are challenging and are not completely

defined

Measures tend to focus on physician-based services with limited

oversight of inpatient, outpatient and facility-based services

Requiring a high volume of measures can deplete the resources

available to focus on intervention and improvement

What about…consumers

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Is Information Useful to Consumers?


October 21, 2013

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Summary and Discussion

1) Some states have led in creating and publishing quality measures on

Exchanges pending final direction from the federal government. This

helps with early innovation and testing of approaches.

2) Publishing quality measures and rewarding performance can have a

positive impact in improved processes (e.g. documentation of

services) and increased access to needed care.

3) There are opportunities to develop measures that address other

quality measurement areas where significant quality improvement

opportunities exist, such as inpatient care.

4) There is an opportunity to evaluate whether there is a potential role for

all-payer databases to augment health plan quality measurement with

analysis of geographic, population and provider specific variation.

5) Going forward it will be important to understand what information has

meaning and value to consumers.

National Health Insurance Exchange Summit

Covered CaliforniaActive Purchasing for Value

Emma HooNovember 6, 2013

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AgendaCovered California Active Purchasing• Alignment of large group purchasers

and Exchanges• Qualified Health Plan (QHP) selection• QHP contracting• Quality oversight

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The Foundation of PBGH’s WorkOur Purpose To improve the quality and availability of health

care while moderating costs.

Our Vision A health care system accountable for the quality, cost and outcomes of care, where consumers are motivated to seek the right care at the right price and providers are motivated to offer higher quality, affordable care.

Our Mission PBGH is an influential change agent demanding increased value in the health care system. Through collaborative purchaser action and support for systemic change initiatives, we drive improvement in affordability, quality and service.

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PBGH Members

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Embed Value Purchasing in the Exchange Markets

Components of a value‐based Exchange market

1. QHP standards to recognize high value plans• Payment models – fees linked to performance• Benefit designs/member incentives• Performance dashboard: plan and provider metrics• Consumer decision support• Transparency: no provider prohibitions against

cost/quality disclosure2. Care system innovation and competition

• Care systems for sicker patients• Patient centered care• Prices and consumer shopping at care system/provider

level

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Promoting Alignment with Large Purchasers through Covered California QHP Contract Terms

• Participation in collaborative quality initiatives• Provision and use of data and information for

quality measurement and improvement• Advancing claims, cost and quality transparency• Promoting care redesign through IOCP, ACO, PCMH,

telemedicine, etc.• Aligning in purchaser expectations

• eValue8 submission for QHP selection and recertification

• Reporting for Catalyst for Payment Reform Scorecard and Compendium

California Health Benefit Exchange8

Qualified Health Plan Solicitation: Content

Incorporates Some Modules of 2012 eValue8 Request for Information

Robust data collection tool used nationally by large employers

o Permits Exchange evaluators to compare QHP bids easily using electronic tool

o Allows generation of custom reports that facilitate and streamline comparison of QHP bidders’ responses

o Lays foundation for ongoing plan monitoring of quality and other data

o Plans who currently use eValue8 can import data already reported

Presentation by Andrea Rosen, California Health Benefit Exchange Board Meeting, September 18, 2012http://www.healthexchange.ca.gov/BoardMeetings/Documents/September%2018,%202012/IX_CHBE_HealthPlanSolicitationPresentation_9-18-12.pdf



Selected Modules of 2012 eValue8 Request for Information Include

• Enrollment data by HMO and PPO (1.3)• Accreditation Status by NCQA or URAC (1.4)• Provider Management and Health Management of Chronic Conditions (1.5)• Data on Racial, Cultural and Language Competency (1.7)• Alignment of Plan Design: Value- Based Benefit Features such as Patient-

Centered Medical Homes, High Performance Provider Networks, Health Assessments, Shared Decision Making, Consumer Tools, Web Consultation (2.2)

• Practitioner Connectivity and Health Literacy Tools (2.3): Use of EMRs, ePrescribing, Consumer tools to assist in Provider Selection

• Hospital Choice Support (2.4)• Shared Decision-Making and Treatment Option Support (2.5) • Electronic Personal Health Record (2.6) • Claims Management and Transparency to Consumers and Providers (2.7)




Selected Modules of 2012 eValue8 Request for Information

• Performance Measurement: Select CAHPS ratings including health plan, member communications (2.8)

• Provider measurement including Community Collaboration, Use of Leapfrog Hospital Data (3.2)

• Physician Performance Measurement and Reporting (3.4) • Physician/Practice Site and Medical Group/IPA Value Differentiation and

Incentives: payment rewards and payment structures other than fee for service ACO data, PCMH doctors (3.5)

• Hospital Performance Measurement and Feedback (3.6) • Hospital Value Differentiation and Incentives (3.8)• Centers of Excellence and High Performance Hospital Networks (3.9) • Value-Based Formularies and other pharmaceutical management (4.2, 4.3,

4.4, 4.5) • Worksite Wellness and Health Promotion Programs (5.2)• Health Assessments (5.3)




Selected Modules of 2012 eValue8 Request for Information

• Cancer Screening Program and Results (5.4)• Immunization Programs (5.5) • Prevention and Treatment of Tobacco Use (5.6) • Obesity (5.7 partial) • Obstetrics and Maternity and Child (5.8) • Chronic Disease Management and Performance Measurements (6) • Member Identification and Support for Chronic Disease Management (6.3) • Behavioral Health (7)


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Plan Selection Results• Of 32 plans expressing interest in offering health care through

Covered California, 13 plans initially approved (contract negotiations not completed for one plan; commercial product regulatory approval not obtained by another)

•

• Covered California has physicians and hospitals affiliated with:• Many of the state’s leading academic health systems• Six of the 17 Centers for Medicare and Medicaid Services Shared

Savings Accountable Care Organizations• Five of the six Centers for Medicare and Medicaid Services Pioneer

Accountable Care Organizations

Covered California Geographic Rating Regions

• Some regions as few as 2 carriers• Los Angeles and San Diego have 6 carriers

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Quality Contracting Strategy• Participation in quality collaboratives• Promote care redesign through medical homes, accountable

care and new care delivery models• Payment reform and provider payment rewards• Provision and use of data and information for quality of care

• 3.01 HEDIS and CAHPS Reporting

• Alignment with Medicare value‐purchasing• Hospital Quality Oversight

• Deaths and readmissions;• Serious complications related to specific conditions;• Hospital acquired conditions; and• Healthcare associated infections

• Performance transparency: claims/cost data submission • eValue8 submission for QHP recertification• Health and wellness services

• Necessary preventive services;• Tobacco cessation intervention; and• Obesity management

©PBGH 2013 15

Exchange Oversight through Quality Reporting–Getting the Right Care - HEDIS/CAHPS

Appropriate Care Behavioral Health CareAppropriate Testing for Children With Pharyngitis AntidepressantMedicationManagement (Both Rates)Appropriate Treatment for Children With Upper RespiratoryInfection

Follow‐Up After Hospitalization for Mental Illness (7‐Day RateOnly)

Avoidance of Antibiotic Treatment in Adults With AcuteBronchitis

Follow‐Up for Children Prescribed ADHDMedication (Both Rates)

Use of Imaging Studies for Low Back Pain Initiation & Engagement of Alcohol & Other Drug DependenceTreatment ‐ Engagement (13‐17 Yrs and 18+ Yrs)

All‐CauseReadmissions Other Chronic CareAnnual Monitoring for Patients with PersistentMedications MedicationManagement for PeopleWith Asthma (50%/75%

remained on controller medications)Plan All‐Cause Readmission (average adjusted probability ofreadmission)

Use of Spirometry Testing in the Assessment and Diagnosis ofCOPD

Diabetes Care Drug Therapy for Rheumatoid ArthritisCDC: Medical Attention for Nephropathy Pharmacotherapymanagement of COPD Exacerbation

(bronchodilator and systemic corticosteroid)CDC: Hemoglobin‐A1c Testing Doctor and Care RatingsCDC: LDL‐C Screening Global Rating of Care (CAHPS)CDC: Eye Exam (Retinal) Performed Global Rating of Personal Doctor (CAHPS)CDC: LCL‐C Control (<100 mg/DI) Global Rating of Specialist (CAHPS)CDC: HbA1c Control (<8.0%)CDC: Blood Pressure Control (140/90 mmHg)CDC: HbA1c Poorly Control (>9.0%)

Cardiovascular CareControlling High Blood PressureCholesterol Management for Patients with CardiovascularConditions: LDL‐C Control (<100 mg/dL)Cholesterol Management for PatientsWith CardiovascularConditions (LDL‐C Screening Only)Persistence of beta blocker treatment after a heart attack

Measures leverage existing California public performance reporting for HMOs, PPOs and Medi‐Cal Managed Care, as well as Integrated Healthcare Association Pay for Performance measures.

©PBGH 2013 16

Covered California Quality Performance StandardsQuality, NetworkManagement and Delivery System Standards 0.0% of Performance Penalty or Credit for

Measurement Year 2014/ 50% of Performance Penalty or Credit Thereafter

Quality, NetworkManagement and Delivery Systems Standards

Covered California and Contractor shall work with the Covered California Advisory group toperiodically review and adjust the specific measures within each of the measure sets [below]consistent with any applicable Federal regulations. In addition, Covered California will work withcontractors as appropriate to adjust measure sets where a contractor does not have all of the specific HEDISmeasures.

3.1 Quality Reporting System(QRS)‐ Getting the Right Care;.

Expectation: Getting the Right Care‐HEDIS/CAHPS Clinical Effectiveness measure set summary(Product type reporting)‐ 5% of total performance requirement expected.Performance Level: <50th PCT:5% penalty;51‐75th PCT: no penalty; >75th PCT: 5% performance credit(vs. national HMO benchmark).

3.2 Quality Reporting System (QRS)‐Access to Care;

Expectation: Access to Care‐ HEDIS/CAHPS measure set summary (Product type reporting): 5% oftotal performance requirementexpected.Performance Level: <50th PCT:5% penalty;51‐75th PCT: no penalty; >75th PCT: 5% performance credit(vs. national HMO benchmark).

3.3 Quality Reporting System(QRS) ‐ Staying Healthy/Prevention;

Expectation: Staying Healthy/Prevention‐HEDIS/CAHPSmeasure set summary‐(Product type reporting)‐ 5% of total performance requirement expected.Performance Level: <50th PCT: 5% penalty;51‐75th PCT: no penalty; >75th PCT: 5% performance credit(vs. national HMO benchmark).

3.4 Quality Reporting System (QRS‐Plan Service);

Expectation: Plan Service‐ CAHPS measure set summary (Product type reporting) 5% of totalperformance requirement expected.Performance Level: <50th PCT:5% penalty;51‐75th PCT: no penalty; >75th PCT: 5% performance credit(vs. national HMO benchmark).

3.5 eValue8 Expectation: Total Covered California eValue8 performance,795.5 points total. 10% of total performance penalty at risk.Performance Level: < 40% of total points: 10% performance penalty. 40‐74% of total points‐nopenalty. 75% or greater of total points: 10% performance credit.

3.6 Quality and NetworkManagement‐Health Status Assessment;

Performance expectation to be determined

3.7 Quality and NetworkManagement‐Preventive HealthandWellness;


3.8 Quality and NetworkManagement ‐New Care Models;


3.9 Quality and NetworkManagement‐ At Risk Enrollees


Additional administrative and operational performance standards in Attachment 14 of the Covered California model QHP Contract http://www.healthexchange.ca.gov/Solicitations/Documents/130521%20CoveredCA%20QHP%20Model%20Contract‐%20Attachments%20clean%20for%20posting%205‐22‐13.pdf

©PBGH 2013 17

Consideration of scoring and reporting health plan performance using 3 information tiers Global Rating Four Summary Ratings

1. Getting the Right Care (clinical effectiveness)2. Access to Care3. Staying Healthy/Prevention4. Plan Service

Topic/Composite Ratings Organize information in ways that best serve consumer choice Align with major quality accountability programs by CMS/others

Potential Quality Information Structure3 Tiers of Quality Ratings

©PBGH 2013 18

Information Structure 3 Quality Ratings Tiers

©PBGH 2013 19

Elements of Health Plan Choice

EligibilityUser and household eligibility requirements for exchange programs.

Doctor ChoiceSearchable physician, hospital and pharmacy directories by plan. Plan rules to see a doctor.

QualityMember ratings of plan; provider network clinical quality results; systems to ensure patient safety, get health promotion services & engage in self‐care.

Plan Features and RulesWellness resources, health coach, or other services for your health problem(s). Services to save money. Rules about designated providers and programs for select services.

Covered ServicesUser payments when getting care – deductibles, coinsurance or other fees for office visits, hospital stays, medications and other services.

Premium CostTotal premium; premium tax credit or other subsidies, and net premium to consumer

Cost When Getting CareUser’s expected medical services use for upcoming year yields an annual out‐of‐pocket cost estimate.

www.ux2014.orgThe Enroll UX 2014 design offers a new standard for public and private health insurance enrollment, and serves as a reference model for a first‐class user experience (UX) design for health insurance exchanges

©PBGH 2012 20

Global Ratings

Illustration of consumer plan choice experience

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Summary Ratings

Illustration of consumer plan choice experience

©PBGH 2013 22

Alignment of Medi-Cal Managed Care Plans, Regional Plans, and Statewide Quality Ratings• Seek to create a common quality information

experience for consumers choosing among plans historically serving primarily Medi‐Cal Managed Care Plan enrollees and traditional commercial QHPs, statewide and regional, etc.

• Desire for aligned Quality Ratings Systems for QHPs sponsored by Medi‐Cal Managed Care plans and commercial plans

• Issues:• Medi‐Cal and commercial quality measures overlap but differences• Medi‐Cal performance lower than commercial plans• Potential additional offerings of Medi‐Cal Bridge Plan & other QHPs

©PBGH 2013 23

California Experience

Los Angeles Medi‐Cal

Modified CAHPS

Limited HEDIS set

o Covered California QHP Solicitation http://www.healthexchange.ca.gov/Solicitations/Documents/FINAL%20SOLICITATION%2011‐16‐12%20updated%2012‐28‐12.pdf

o Covered California Standard Contract (see Attachment 7) http://www.healthexchange.ca.gov/Solicitations/Pages/QHPSolicitation.aspx

o The Exchanges as Value Purchasers http://www.pbgh.org/storage/documents/PBGH_exchangeasvaluepurchaser_04.pdf

o Health Plan Quality Strategy Under the ACA‐Commonwealth Fund paper http://www.pbgh.org/storage/documents/1592_Hoo_hlt_plan_qual_improve_strategy_report_v2.pdf

o Building a Successful Shop Exchange http://www.pbgh.org/storage/documents/PBGH_SHOP_05.pdf

o Webinar: Plan Choice Decision Support Rules for Health Insurance Exchanges http://www.statecoverage.org/node/4097

o Consumer Decision Support Rules for the Exchanges: http://www.pbgh.org/storage/documents/plan_choice_rules_consumer_decision_support_installments_i_ii_and_iii_120312.pdf

o Helping Consumers Choose the Right Health Plan for Their Needs http://www.pbgh.org/storage/documents/PBGHIssueBriefChooser.pdf

o Covered California QHP Solicitation http://www.healthexchange.ca.gov/Solicitations/Documents/FINAL%20SOLICITATION%2011‐16‐12%20updated%2012‐28‐12.pdf

o Covered California Standard Contract (see Attachment 7) http://www.healthexchange.ca.gov/Solicitations/Pages/QHPSolicitation.aspx

o The Exchanges as Value Purchasers http://www.pbgh.org/storage/documents/PBGH_exchangeasvaluepurchaser_04.pdf

o Health Plan Quality Strategy Under the ACA‐Commonwealth Fund paper http://www.pbgh.org/storage/documents/1592_Hoo_hlt_plan_qual_improve_strategy_report_v2.pdf

o Building a Successful Shop Exchange http://www.pbgh.org/storage/documents/PBGH_SHOP_05.pdf

o Webinar: Plan Choice Decision Support Rules for Health Insurance Exchanges http://www.statecoverage.org/node/4097

o Consumer Decision Support Rules for the Exchanges: http://www.pbgh.org/storage/documents/plan_choice_rules_consumer_decision_support_installments_i_ii_and_iii_120312.pdf

o Helping Consumers Choose the Right Health Plan for Their Needs http://www.pbgh.org/storage/documents/PBGHIssueBriefChooser.pdf

For More Information

AppendixExcerpts from Covered California QHP Contract

©PBGH 2013 26

QHP Contract Terms: Promoting QualityParticipation in Collaborative Quality Initiatives. Contractor shall participate in one or more established statewide and national collaborative initiatives for quality improvement. Specific collaborative initiatives may include, but are not limited to:(a) Leapfrog(b) California Maternal Data Center (sponsored by the California Maternal Quality Care Collaborative (CMQCC)(c) California Joint Replacement Registry developed by the CHCF, California Orthopedic Society and Pacific Business Group on Health (PBGH)(d) NCDR® (National Cardiovascular Data Registry that currently includes seven specific registry programs)(e) Society of Thoracic Surgeons National Database for the collection of general thoracic surgery clinical data(f) National Neurosurgery Quality and Outcomes Database (N2QOD)(g) Integrated Healthcare Association’s (IHA) Pay for Performance Program(h) IHA Payment Bundling demonstration(i) Centers for Medicare and Medicaid Innovation (CMMI) Bundled Payments for Care Improvement initiative (BPCI)(j) CMMI Comprehensive Primary Care initiative (CPC)(k) CMMI Shared Savings Program (including Pioneer, Advanced Payment and other models)(l) Contractor‐sponsored accountable care programs(m) California Perinatal Quality Care Collaborative(n) California Quality Collaborative

©PBGH 2013 27

QHP Contract Terms: Care RedesignContractor is encouraged to actively promote the development and use of care models that promote access, care coordination and early identification of at risk enrollees. Such models may include, but are not limited to:(a) Accountable Care Organizations (ACO);(b) Patient Centered Medical Homes (PCMH);(c) The use of a patient‐centered, team‐based approach to care delivery and member engagement;(d) A focus on additional primary care recruitment, use of mid‐level practitioners and development of new primary care and specialty clinics;(e) A focus on expanding primary care access through payment systems and strategies;(f) The use of an intensive outpatient care programs (“Ambulatory ICU”) for enrollees with complex chronic conditions;(g) The use of qualified health professionals to deliver coordinated patient education and health maintenance support, with a proven approach for improving care for high‐risk and vulnerable populations;(h) Support of physician and patient engagement in shared decision‐making;(i) Providing patient access to their health information;(j) Promoting team care;(k) The use of telemedicine; and(l) Promoting the use of remote patient monitoring.

©PBGH 2013 28

Other QHP Contract Terms: Promoting Higher Value Care

• Reward‐based Consumer Incentive Programs.• Value Based Reimbursement Inventory and Performance (eValue8/CPR).

• % of total valued based reimbursement to providers, by provider and provider type.

• # of Contractor Plan Enrollees accessing participating providers reimbursed under value based payment methodologies.

• % of total Contractor Network Providers participating in value based provider payment programs.

• An evaluation of the overall performance of Contractor network providers, by geographic region, participating in value based provider payment programs.

• For 2015, Contractor and the Exchange shall agree on the targeted percentage of providers to be reimbursed under value based provider reimbursement methodologies.

• Value Based Reimbursement and Adherence to Clinical Guidelines ‐ demonstrate and design approaches to payment that reduce waste and inappropriate care, while not diminishing quality.

• Value‐Pricing Programs such as payment bundling pilots for specific procedures where wide cost variations exist.

• Payment Reform and Data Submission to the Catalyst for Payment Reform’s (CPR) National Scorecard on Payment Reform and National Compendium on Payment Reform.

COVERED CALIFORNIA BOARD OF

DIRECTORS RECOMMENDATION REGARDING

THE QUALITY RATING SYSTEM (QRS)

Jeff Rideout, Senior Medical Advisor

0

CONTEXT FOR CONSIDERING QUALITY REPORTING

OPTIONS

Since physicians and other providers are the most essential factor in

determining quality, Covered California in the past month performed an

assessment of “network similarity,” which measured whether the scores

currently available in the public domain are a good way to compare

insurance companies in the exchange.

Only four of the 12 insurers were found to have highly similar or identical

networks, or 80 percent similarity or above, a threshold for scoring. Only

one of those issuers offered products in both Northern and Southern

California and only two of those insurers offered products in more than

one region.

1

CONTEXT FOR CONSIDERING QUALITY REPORTING

OPTIONS (continued)

From participating health plans, strong arguments have been made both

for and against using historical information and reporting on some plans

for 2014 enrollment.

From a consumer perspective:

o It could be argued that’s not a fair, useful or reliable “quality” indicator

of performance of carriers in the exchange when more than 70

percent of the issuers wouldn’t have a rating. Consumers would be

asked to compare scores from just three plans and potentially

presume that other plans are “poor quality.” In many regions, there

would be only one score available. (See Map)

o It could also be argued that “some information is better than no

information,” even at the risk of mistakenly implying some plans are

of poor quality.

2

WHAT WOULD CALIFORNIA LOOK LIKE FOR CONSUMERS

USING HISTORICAL DATA FOR SOME PLANS?

3

Covered California Plans with QRS: • Contra Costa: Rating Region 5

• Kaiser: All Rating Regions, except 9

• Western Health Advantage: Rating Region 2 and 3

• SHARP: Rating Region 19

EXCHANGES NATIONWIDE: QUALITY RATINGS

• Federal Exchange does not provide quality ratings

• Among the states that provide meaningful quality ratings are:

Oregon, Maryland, Colorado, Connecticut, and Massachusetts

• Among the states that do not provide meaningful quality ratings

for 2014 are: Minnesota, Washington, Rhode Island, Vermont,

Nevada, Kentucky, Idaho*, Hawaii, and Washington DC

• Status of quality ratings for other state exchanges is unknown

today: New York and New Mexico

* Idaho is a different composition of a state-based exchange

4

COLORADO EXCHANGE QUALITY RATINGS

• Rates 5 of 8 health plans – those with historical data

• A single, member experience with plan global rating only o Member overall rating of health plan (CAHPS) is sole measure

• Global member experience rating represented 1-5 stars

• Presents global member experience rating as part of content in the online, side-by-side plan comparison

5

MARYLAND EXCHANGE QUALITY RATINGS

• Rates 3 of 6 health plans – those with historical data*

• Combines a large number of HEDIS and CAHPS quality measures to produce a single, global rating of the plan

• Global plan rating represented 1-5 stars

• Presents plan global rating in PDFs available via links (unclear if also presented in the online, side-by-side plan comparison)

*SHOP plan mix differs

6

OREGON EXCHANGE QUALITY RATINGS

• Rates 11 of 11 health plans

• Combines a small number of HEDIS and CAHPS quality measures to produce a single, global rating of the plan

• Global plan rating represented 1-4 stars

• Presents plan global rating as part of content in the online, side-by-side plan comparison

7

8

Staff recommend that Covered California implement a Quality Rating System (QRS) as soon as it can be

done using HEDIS and CAHPS performance information for Exchange members. The earliest anticipated

presentation of QRS information is open enrollment of 2015 and will include all plans offered on the

Exchange. The implications of this decision on the “Group 3” plan performance assessment of attachment

14 of the model contract have not been determined.

Other options considered but not recommended:

Report QRS scores for those plans that meet the network similarity criteria using historical HEDIS/CAHPS

performance

• Only 5/17 plans offered meet the network similarity threshold (4 of 12 issuers)

• The absence of 70% of the plans creates a challenge for enrollees in their efforts to use quality information and may create an

unintended perception of poor quality or lack of commitment to quality transparency

Voluntary reporting of QRS results based on historic HEDIS/CAHPs scores

• Plans and Stakeholders strongly encouraged Covered California to make a policy decision

• Does not alter the absence of scores for most plans

Administer CAHPS (only) in time for 2014 open enrollment

• Would largely measure only the enrollment experience and not access or clinical care

• Continuous enrollment and sampling requirements would mean information available no sooner than Dec 2014

• Would require a single cross plan vendor contract and commitment

NOTE: Plan CAHPS process to begin in 2014 with results available for open enrollment 2015

Administer a non-CAHPS/HEDIS measure set for 2014 open enrollment

• No such survey exists or would likely be acceptable to the Federal government

• Would largely measure only the enrollment experience and not access or clinical care

RECOMMENDATION ON QUALITY RATING SYSTEM (QRS)