NCQA PPCPCMH

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NCQA PPC-PCMH

• Elizabeth Kraft, MD MHS

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Objectives

• Background NCQA
• Outcomes of accountability and transparency
• Evolution of PPC-PCMH (Physician Practice
  Connections-Patient Centered Medical Home)

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Healthcare Landscape

• Broken System
• Our health insurance system is failing
• Only 61 of employers offer benefits
• Only 50 of small employers offer benefits
• 47 million Americans are uninsured
• Payment incentives favor bad care
• Costs are too high
• Quality is unreliable

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Need to Respond

• Response to IOM reports
• To Err is Human and Crossing the Quality Chasm
  both provide evidence on critical importance of
  systems
• Change from blaming individual clinicians for
  mistakes and shortfalls to improving systems so
  clinicians can succeed
• Raise awareness of physicians of importance of
  systems in enhancing quality
• Link health services research on systems and
  clinical outcomes to practice

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Quality Mantra

• What gets measured gets monitored
• What gets monitored improves
• What gets measured will be rewarded.

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Quality Standards Organizations

• Key Organizations in Quality 1995
• NCQA, CMS, JCAHO, IHI, health plans, FAACT
• Key Organizations in Quality 2008
• CCGC
• NCQA, CMS, JCAHO, ABMS, AMA/Phys Consortium on
  Performance Measurement, Leapfrog, State and
  Regional Programs, AQA-HQA-PQA, IOM, IHA, Benefit
  consultants, health plans, researchers, medical
  specialty groups, researchers, measurement
  software vendors, NQF, foundations, employer
  coalitions, URAC, HealthGrades, Subimo, eValu8,
  PCPCC, NQCB, eValu8
• State regulations

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What is NCQA?

• The National Committee for Quality Assurance is a
  private, 501(c)(3) not-for-profit organization
  dedicated to improving health care quality.
  Since its founding in 1990, NCQA has been a
  central figure in driving improvement throughout
  the health care system, helping to elevate the
  issue of health care quality to the top of the
  national agenda.
• www.ncqa.org

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NCQAs Mission and Vision

• Mission
• To improve the quality of health care
• Vision
• To transform health care quality through
  measurement, transparency and accountability

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NCQA The Trinity of Healthcare
QUALITY
COST/AFFORDABILITY
ACCESS
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NCQAs Primary Products

• Accreditation Certification Programs
• Performance Measurement HEDIS

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Accreditation Certification Programs

• Health Plan Accreditation (HPA)
• Managed Behavioral Health Organizations
• New Health Plans (NHP)
• Disease Management (DM)
• Wellness and Health Promotion (WHP)
• Credentials Verification Organizations (CVO)
• Physician Organizations (PO)
• Utilization Management (UM)
• Credentialing (CR)
• Disease Management (DM)
• Physician and Hospital Quality (PHQ)
• Medicare Advantage (MA) Deeming
• Special Needs Plans (SNP)
• New York Ratings Examiner Reviews

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38 States Use or Recognize NCQA Accreditation
Commercial (35)
Medicaid (22)
Both
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Public Reporting

• Report Cards on the NCQA Web site
• Health Plan Report Card HPA, MCOA. PPOA, MBHO,
  CVO, DM, NHP, PO, OC, HIP
• Recognized Physician Directory for the physician
  recognition programs
• Quality Compass

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Health Plan Report Card
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Colorado Use of NCQA Results
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Results

• Quality of care for members enrolled in
  accountable health plans has improved
  significantly!
• Accredited plans outperform unaccredited plans
  when HEDIS results are compared
• Public reporting drives performance

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Public Reporting Drives PerformanceSelected
Commercial Averages, 2006
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Success (Requiem for a Quality Metric)
Beta-Blocker Rates After a Heart Attack
2007 CO 98.5 U.S. 98.6 MCD 86.1
Commercial HEDIS Averages, 1996 - 2003
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Quality Improvement Saves Lives!
Gross estimate of lives saved does not take
comorbities or expected mortality over time into
account.
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Wagner Model for Effective Prevention and Chronic
Illness Care
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Overlap in Content of PPC-PCMH/CCM
Delivery System Design
Patient Centered Medical Home
ClinicalInformationSystems
P P C
DecisionSupport
Self-ManagementSupport
Community Support
Wagner Chronic CareModel
Whats Included?(Infrastructure)
How Much Used?(Extent)
What Functions?(Implementation)
Evidenceand Scoring(Verification)
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Development of PPC-PCMH

• Document evidence base linking specific system to
  clinical performance
• Medline Review
• Cochrane Collaborative
• Manuscripts in press
• Convene expert panel to review evidence and
  suggest standards/measures
• Conduct analysis of practice defects using six
  sigma process (with GE in BTE project)
• Create standards
• Test survey tool incorporating standards
  developed related to chronic care model

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Members of Advisory Panels

• Bruce Bagley
• Michael Barr
• John Blair
• Gifford Boyce-Smith
• Carolyn Clancy
• Francois DeBrantes
• Suzanne Delbanco
• Daniel Duffy
• Barbara Fleming
• Shelly Greenfield
• Amy Helwig
• Sherry Kaplan
• Charles Kilo
• Tom Knight

• Elizabeth McGlynn
• Alan Muney
• Eugene Nelson
• Marc Overhage
• Jonathan Perlin
• Gaile Povar
• David Reuben
• Douglas Roblin
• Margaret See
• Steven Shortell
• Leif Solberg
• David Stevens
• Edward Wagner

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Overall Recognition Process

• Recognition is based on
• Each element specifies type of documentation
• Reports
• Documented processes
• Records or files

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PPC-PCMH Content and Scoring
Must Pass Elements
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PCMH Must Pass Elements

• PPC1A Written standards for patient access and
  patient
  communication
• PPC1B Use of data to show meeting this standard
• PPC2D Use of paper or electronic-based charting
  tools to organize clinical information
• PPC2E Use of data to identify important
  diagnoses and conditions in practice
• PPC3A Adoption and implementation of
  evidence-based guidelines for three conditions
• PPC4B Active support of patient self-management
• PPC6A Tracking system to test and identify
  abnormal results
• PPC7A Tracking referrals with paper-based or
  electronic system
• PPC8A Measurement of clinical and/or service
  performance
• PPC8C Performance reporting by physician or
  across the practice

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PCMH Beta Testing Results

• Preliminary results from Minnesota and
  Massachusetts
• Overall PPC score, and sub-scores have positive
  correlation with higher clinical performance on
  most measures (diabetes, CV, asthma)
• Overall PPC score does NOT appear to correlate
  with patient experiences of care
• Presence or absence of EMR per se, correlates
  ONLY WEAKLY with clinical measures
• However, practices with fully functional EMRs
  achieve highest scores on PPC

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PCMH Beta Test Conclusions

• Assessment of systems is feasible though
  challenging
• In pay-for-performance applications, review of
  documentation or on-site audit needed to verify
  some systems as well as implementation across
  practice sites
• Educating physicians and practice staff about
  systems is high priority
• More research on relationship of systems to
  quality and patient experiences is needed

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Key to Sustained Payment Reform for PCMH
Demonstrated Benefits

• Evaluation should focus on multiple endpoints
  process and outcomes, patient experiences, and
  efficiency
• Standardized set of tools and metrics will allow
  for comparing results across settings and
  populations
• Evaluation design to focus on outcomes/care for
  patients served in PCMH vs. those not in PCMH
  unlikely to have sufficient information at
  physician level to draw conclusions, particularly
  for resource use

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Physician Recognition

• Recognizes physicians who provide high quality
  care to patients with specific conditions
• Low back pain
• DPRP (Diabetes)
• CPRP (Heart Stroke)
• PPC (Physician Practice Connections)
• PPC-PCMH (Patient Centered Medical Home
  Recognition)

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Future of Physician Recognition??? How Patients
Will Choose Their Doctor

• Professional Qualifications
• Board certification
• Technology
• Clinical Quality
• Preventive measures
• Mammograms
• Immunization rates
• Clinical Outcomes
• Beta Blocker after MI
• Diabetes measures
• Satisfaction
• Patient survey
• Resource Efficiency
• Formulary compliance
• NCQA RECOGNITION

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• YOU can be the difference in changing healthcare
  quality in Colorado
• Use your knowledge about quality improvement to
  make informed choices as a patient, as a consumer
  and as a citizen