Introduction to NCQA - PowerPoint PPT Presentation


PPT – Introduction to NCQA PowerPoint presentation | free to download - id: a72da-NTY0Z


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Introduction to NCQA


1st year rapid turnaround, adapted existing NCQA measures and processes from ... 3rd year Refine measures; identify new SNP-specific measures, where appropriate. 8 ... – PowerPoint PPT presentation

Number of Views:757
Avg rating:3.0/5.0
Slides: 56
Provided by: geralds2
Learn more at:


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Introduction to NCQA

Introduction to NCQA SNP Assessment Brett
Kay Director, SNP Assessment Casandra
Monroe Assistant Director, SNP Assessment
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

A Brief Introduction to NCQA
  • Private, independent non-profit health care
    quality oversight organization founded in 1990
  • Committed to measurement, transparency and
  • Unites diverse groups around common goal
    improving health care quality

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

  • NCQAs quality programs include
  • Accreditation of health plans using performance
  • HEDIS clinical measures
  • CAHPS consumer survey
  • Measurement of quality in provider groups
  • Physician Recognition
  • Quality measurement means
  • Use of objective measures based on evidence
  • Results that are comparable across organizations
  • Impartial third-party evaluation and audit
  • Public Reporting

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

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 yearrapid turnaround, adapted existing NCQA
    measures and processes from voluntary
    Accreditation programs
  • 2nd yearfocus on SNP-specific measures
  • 3rd yearRefine measures identify new
    SNP-specific measures, where appropriate

Objectives of SNP Assessment Program
  • Develop a robust and comprehensive assessment
  • 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

Three-Year Strategy
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 CMSApril 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

Project Time Line Phase II
  • March - Release final SP measures
  • March 30 - Release ISS Data Collection Tool
  • S P Measures
  • April - Release IDSS Data Collection Tool
  • HEDIS Measures
  • June 30 - HEDIS submissions and SP measures
    submissions due to NCQA
  • October 30 - NCQA delivers SNP Assessment Report
    to CMS

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)

What Is HEDIS?
  • Healthcare
  • Effectiveness
  • Data
  • Information
  • Set

HEDIS is an evolving set of standard
specifications for measuring health plan
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 causes of death
  • Includes information on quality, utilization and

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
  • Quality Compass, Quality Dividend Calculator
  • US News and World Report - Ranking of Health Plans

Data Reporting
  • Data are reported to NCQA in June of the
    reporting year
  • Data reflect events that occurred during
    the measurement year (calendar year)

Data Reporting
  • Example
  • HEDIS 2009 data are reported in June 2009
  • Data reflects events that occurred
    JanuaryDecember 2008 (per specs)
  • HEDIS 2009 2008 data

Effectiveness of Care Measures
  • Clinical quality of care
  • Focus
  • Preventive care
  • Up-to-date treatments for acute episodes of
  • Chronic disease care
  • Appropriate medication treatment

Collecting HEDIS Data
Three HEDIS Data Sources
Claims Encounter Eligibility Provider
Medical records
Data Sources
  • Administrative
  • Membership data
  • Provider data
  • Claims/encounter data
  • Hospital discharge data
  • Pharmacy data
  • Carve-out data

Selecting an Eligible Population
  • Member ID
  • Age (DOB)
  • Enrollment date and type
  • Dates of service
  • Diagnosis and procedure codes
  • Provider specialty
  • Pharmacy

Clinical Measures Data Collection
  • Defining the denominator is critical
  • Administrative Claims and encounter data
  • Denominator Based on all eligible members of the

HEDIS Compliance Audit
NCQA HEDIS Compliance Audit
  • 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

Why a Standardized HEDIS Audit?
  • Data collection and calculation methods can vary
    across plans
  • A standardized audit identifies, quantifies and
    converts errors
  • The audit reduces bias

  • Structure Process Measures

What is a SP Measure?
  • A statement about acceptable performance or
  • Assesses a plans ability to comply with specific
  • Focus on systems necessary for quality care
  • Policies procedures, reports, materials

How are SP 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

(No Transcript)
Components of the SP Measures
  • Standard statement a statement about acceptable
    performance or results
  • Intent statement A sentence that describes the
    importance of the SP 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 SP

Components of an SP 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 SP assessment

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

Components of an SP Measure
  • Scope of Review The extent of the organizations
    services evaluated during an NCQA survey. Scope
    of review may vary
  • Look-back period The period of time for which
    NCQA evaluates an organizations documentation to
    assess performance against an element
  • Explanation Guidance for demonstrating
    performance against the element
  • Example Descriptive information illustrating
    performance against an elements requirements.
    Examples are for guidance and are not intended to
    be all-inclusive

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 submissionMarch 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

SNP Assessment Process
  • Phased Approach
  • Defining and assessing desirable structural
  • Assessing processes
  • Assessing outcomes
  • Two main components
  • HEDIS Measures-focus on clinical performance
  • Structure Process measures-focus on structural
    characteristics and systems

SNP Assessment Process
  • SP 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)

SP Assessment Whats 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.

SP measures Whats 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
  • Identifying opportunities for improvement based
    on data analysis
  • Existing elements added more examples and
    clarified explanations

SP measures Whats 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
  • (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 IC SNPs
  • Focus on helping members obtain benefits/services
    regardless of payer.

New Phase II HEDIS Measures
  • Measures
  • Care for Older Adults (COA)
  • Medication Reconciliation Post-Discharge (MRP)
  • Hybrid Method Collection

  • SNP Data Reporting

Data Submissions
  • HEDIS measures
  • Submission date June 30, 2009
  • IDSS data collection tool
  • All data must be audited by NCQA certified HEDIS
  • SP measures
  • Submission date June 30, 2009
  • ISS data collection tool
  • No Fees required to submit

Who Reports
  • HEDIS measures
  • All SNP plan benefit packages with 30 members as
    of February 2008 Comprehensive Report (CMS
  • SP measures
  • All SNP plan benefit packages
  • Plans with no enrollment exempt from certain

What to Report
  • SP measures
  • Cohort IAll SNPs operational as of January 1,
    2007 and renewed in 2009.
  • SP measures 4-7 (SNP 2C 3B)
  • Cohort IIAll SNPs operational as of January 1,
    2008 and renewed in 2009
  • All SP measures (SNP 1-6)
  • Do not report SNP 7 (SNP 2C 3B)

What happens after submission?
  • NCQA Analysis of HEDIS and SP 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
  • NCQA will not publicly report any of the SNP data

And now…
  • Questions?

  • Brett Kay Director, SNP Assessment 202-955-1722 k Casandra Monroe Assistant Director,
    SNP Assessment 202-955-5136

Additional Resources
  • NCQA SNP Webpage
  • FAQs (HEDIS)
  • Training descriptions schedule
  • Final HEDIS and SP measures (March 14)
  • NCQA Policy Clarification Support (PCS)
  • http//
  • Login.asp
  • HEDIS Audit information
  • http//

Additional Information
  • HEDIS 2008 Volume 2 Publication Purchase
  • http//
  • October Specifications Update
  • http//

Additional SNP Trainings
  • Introduction to NCQA SNP Assessment
  • March 5th 100 300 pm
  • March 10th 100 300 pm

Additional SNP Trainings
  • SNP Subset of HEDIS Measures
  • March 3rd 1130 100 pm
  • March 11th 1130 100 pm
  • March 16th 100 - 230 pm
  • March 26th 100 - 230 pm
  • April 1st 1230 - 200 pm
  • Structure and Process Measures (SP 1-3)
  • March 12th 100 230 pm
  • March 19th 100 - 230 pm
  • March 25th 1230 - 200 pm
  • April 23rd 200 330 pm

Additional SNP Seminars
  • Structure and Process Measures (SP 4-6)
  • March 17th 200 - 330 pm
  • March 24th 200 - 330 pm
  • March 31st 200 - 330 pm
  • April 2nd 1230 200 pm
  • April 7th 200 - 330 pm
  • April 15th 100 230 pm
  • Interactive Survey System (ISS)
  • April 8th 100 230 pm
  • April 14th 100 - 230 pm
  • April 17th 100 230 pm
  • April 21st 100 - 230 pm
  • April 28th 100 230 pm
  • May 7th 100 230 pm