Focusing on Quality Performance: NCQA

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Focusing on Quality PerformanceNCQAs
Activities in the US Health Care System

• Joachim Roski, PhD MPH
• Vice President, Performance Measurement
• July 12, 2006

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Overview

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

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The US System - Simplified
Specialized providers e.g. DM


Patient
Employers/ Public Sector
Health Plans


Provider MD/MD group Hospital

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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.
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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.
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About NCQA
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NCQAs Mission and Vision

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

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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

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NCQAs Constituency Councils
Board of Directors
Standards Committee Committee on Performance
Measurement
Health Care Practitioner Advisory Council
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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

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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

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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

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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

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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
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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
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Standardizing Performance Measurement
Data collection
Consenus
Implementation policies
Development of Performance measures
Data transmission
Verification
Data analysis
Public Reporting
Maintenance of Measure specs
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Performance Msmt in Accreditation
Care Experience
In Future
Standards
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Public Sector relies on NCQA
Accreditation and HEDIS meet Public
oversight requirements
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Communicating with Consumers
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Prototype for chronic care reports
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Documented Performance Results
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Performance results heart disease, hypertension,
asthma
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Results in Diabetes Care
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Results in preventive care
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Problem Quality Gap
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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

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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

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Evaluation of clinical performance
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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

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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

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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

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Featuring Results
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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 [phone]