Focusing on Quality Performance: NCQA‘s Activities in the US Health Care System

1. Focusing on Quality Performance:NCQA‘s Activities in the US Health Care System Joachim Roski, PhD MPH Vice President, Performance Measurement July 12, 2006

2. Overview • Quality assurance and the US health care system • About NCQA • Documented performance results • Evaluation of physician performance

3. The US System - Simplified Specialized providers e.g. DM $$$ $$$ Patient Employers/ Public Sector $$$ Health Plans $$$ Provider: MD/MD group Hospital $$$

4. Premium Growth Slows as Economy Grows 65.3% increase, 2001-05 Sources: Kaiser Foundation, Employer Health Benefits, 2004 Survey; Bureau of Labor Statistics; Bureau of Economic Analysis.

5. Significant Quality Problems • Only 55% receive evidence-based medical care • Similar for acute, chronic and preventive services • Best results for processes requiring an MD visit (73.4% for annual visit for patients with hypertension); lowest for Education (18.3% smoking cessation advice for patients with COPD) Source: McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003 Jun 26;348(26):2635-45.

6. About NCQA

7. NCQA’s Mission and Vision Mission: To improve the quality of health care Vision: To transform health care through measurement, transparency and accountability

8. Since 1990 private, non-profit health care quality oversight organization Measures and reports on health care quality Unites diverse groups around common goal: improving health care quality NCQA’s BOD 1-year terms Provides strategic direction 16 expert members from: Clinical practice/Medicine Health care organizations Law Economy/Employer Consumers/Patients Basic Facts

9. Consumer Advisory Council Practicing Physicians Advisory Council Public Sector Advisory Council MCO Advisory Council Purchaser Advisory Council NCQA’s Constituency Councils Board of Directors Standards Committee & Committee on Performance Measurement Health Care Practitioner Advisory Council

10. NCQA’s Role in the US Healthcare System • Creates transparency for healthcare market • Allows purchasers and users of health care services to compare results and costs • Facilitates cooperation between the public sector and private sector • Stimulating innovation among private sector and public sector (e.g., rewarding results) • Drives efficiency by aligning objectives and processes • “Deeming” – if health care organizations demonstrate that they meet NCQA requirements often no additional oversight through public sector needed

11. NCQA’s Oversight Methodologies • Accreditation: A rigorous review of the clinical and administrative systems necessary for quality care and service • Performance Measurement (HEDIS®) • Clinical care effectiveness • Access • Care Experience (CAHPS®) • Utilization

12. Accreditation/Evaluation criteria • Client data submission using Web-based, interactive tool with onsite and offsite review • General areas of review (differs by program) • Quality improvement activities • Performance results • Patients’ rights • Confidentiality • Customer service • Data systems

13. Prevention Cancer Screening Breast cancer Cervical cancer Colon cancer Immunizations (Children & Adolescents) Chlamydia screen Antibiotic prescribing Elderly Care Pneumonia vaccination Influenza vaccination Urinary incontinence tx Vision Screening Advice for physical activity Chronic Care Conditions Hypertension Diabetes (6) Cardiovascular Disease Cholesterol test & results Betablocker after AMI Betablocker long-term compliance Smoking cessation Osteoporosis Arthritis Asthma COPD Depression (3) Substance Use (3) Coordination of care psychiatry ADHD Low back pain Safe Medication Management Never medications Appropriate testing HEDIS® - Effectiveness of Care Measures

14. Care Experience Access to needed care Timely care Communication with physicians Clinic personnel Payment concerns Composite results Care (overall) Health plan Primary Care Physician Specialty Physician CAHPSTM in HEDIS® - Care Experience Gathers care experience information about adults and adolescents/children accessing the health care system

15. Desirable Measure Attributes

16. Standardizing Performance Measurement Data collection Implementation policies Consenus Development of Performance measures Data transmission Verification Data analysis Public Reporting Maintenance of Measure spec’s

17. Clinical Effectiveness + = 40% = 60% Accreditation requires performance results Performance Msmt in Accreditation Care Experience In Future Standards

18. NCQA meets public sector reqs (30) Public Sector relies on NCQA Accreditation and HEDIS® meet Public oversight requirements

19. Communicating with Consumers

20. Prototype for chronic care reports

21. Documented Performance Results

22. Performance results heart disease, hypertension, asthma

23. Results in Diabetes Care

24. Results in preventive care

25. Problem: Quality Gap

26. The Quality Gap Toll: Avoidable Deaths Measure Avoidable Deaths per Year Blood Pressure Control 15,000 - 26,000 Cholesterol Control 6,900 - 17,000 Diabetes Care–HbA1c Control 4,300 - 9,600 Smoking Cessation 5,400 - 8,100 Flu Shots for Adults 3,500 - 7,300 Colorectal Cancer Screening 4,200 - 6,300 Beta-Blocker Treatment 900 - 1,900 Prenatal Care 600 - 1,400 Breast Cancer Screening 600 - 900 Cervical Cancer Screening 600 - 800 TOTAL 42,000 - 79,400

27. The Quality Gap Toll: Avoidable Medical Costs Condition Costs/Year Diabetes Care–HbA1c Control $573 million Smoking Cessation $441 million Blood Pressure Control $463 million Colorectal Cancer Screening $191 million Cholesterol Control $87 million Breast Cancer Screening $48 million Osteoporosis Treatment $7 million Beta-Blocker Treatment $6 million TOTAL $1.8 billion

28. Evaluation of clinical performance

29. Physician Recognition Programs • Developed in partnership with leading national health organizations • Current programs • Diabetes Care Excellence • Heart/Stroke Care Excellence • “Office Systems” Excellence • Based on valid, reliable and agreed upon process and outcome measures • New areas: HIV/AIDS, primary care, oncology, musculoskeletal conditions

30. Voluntary and non-punitive Physician-level data encourages self-improvement among physicians Health systems can use physician-level data to manage quality and costs The public can become more informed about physicians Physician abstracts patient record data and self-assesses against criteria using worksheets or Web-based tool (ISS) Physician submits documentation NCQA evaluates & scores submission against benchmarks or thresholds NCQA audits sample (5%) of practices Benefits & Data Collection

31. Diabetes Recognition Program Measures & Performance Standards Measures Performance Threshold • HbA1c control < 7.0% 40% • HbA1c >9.0 % (poor control)  20% • Blood pressure control <140/90 mm Hg 65% • Blood pressure control <130/80 mm Hg 35% • Complete lipid panel 85% • LDL control <100 mg/dl 50% • LDL control <130 mg/dl 63% • Eye exam (dilated) 60% • Foot exam 80% • Nephropathy 80% • Smoking status and 80% cessation advice and treatment

32. Featuring Results

33. Contact Joachim Roski, PhD MPH Vice President, Performance Measurement National Committee for Quality Assurance 2000 L Street NW, Suite 500 Washington, DC 20036 United States of America Email: roski@ncqa.org Phone: 001 202.955.5139