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Focusing on Quality Performance: NCQA

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Title: Focusing on Quality Performance: NCQA


1
Focusing on Quality PerformanceNCQAs
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 26348(26)2635-45.
6
About NCQA
7
NCQAs Mission and Vision
  • Mission
  • To improve the quality of health care
  • Vision
  • To transform health care through measurement,
    transparency and accountability

8
Basic Facts
  • 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
  • NCQAs BOD
  • 1-year terms
  • Provides strategic direction
  • 16 expert members from
  • Clinical practice/Medicine
  • Health care organizations
  • Law
  • Economy/Employer
  • Consumers/Patients

9
NCQAs Constituency Councils
Board of Directors
Standards Committee Committee on Performance
Measurement
Health Care Practitioner Advisory Council
10
NCQAs 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
NCQAs 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
HEDIS - Effectiveness of Care Measures
  • 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

14
CAHPSTM in HEDIS - Care Experience
  • Composite results
  • Care (overall)
  • Health plan
  • Primary Care Physician
  • Specialty Physician
  • Care Experience
  • Access to needed care
  • Timely care
  • Communication with physicians
  • Clinic personnel
  • Payment concerns

Gathers care experience information about adults
and adolescents/children accessing the health
care system
15
Desirable Measure Attributes
Relevance Soundness Feasibility
Meaningfulness Health importance Financial import. Cost-effectiveness Strategic import. Controllability Variance Improvability Evidence Reliability Validity Accuracy Case-mix adjustment Data source comparability Precise specs Reasonable cost Confidentiality Data availability Auditability
16
Standardizing Performance Measurement
Data collection
Consenus
Implementation policies
Development of Performance measures
Data transmission
Verification
Data analysis
Public Reporting
Maintenance of Measure specs
17
Performance Msmt in Accreditation
Care Experience
In Future
Standards
18
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 CareHbA1c 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 CareHbA1c 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
Benefits Data Collection
  • 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

31
Diabetes Recognition Program Measures
Performance Standards
  • Measures Performance Threshold
  • HbA1c control lt 7.0 40
  • HbA1c gt9.0 (poor control) ? 20
  • Blood pressure control lt140/90 mm Hg 65
  • Blood pressure control lt130/80 mm Hg 35
  • Complete lipid panel 85
  • LDL control lt100 mg/dl 50
  • LDL control lt130 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_at_ncqa.org
  • Phone 001 202.955.5139
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