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A DECADE OF HEDIS®:CELEBRATING SUCCESS, SHAPING THE
FUTURE
MARGARET E. O’KANEPRESIDENT
2A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
TODAY’S DISCUSSION
• NCQA: A Brief Introduction• Defining the Stakes• A Decade of Improvement:
Quantifying the Impact• Assessing Special Needs Plans• The Quality Agenda At a
Crossroads:Shaping the Future
3A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
NCQA: A BRIEF INTRODUCTION
• Private, independent non-profit health care quality oversight organization founded in 1990
• Mission: To improve the quality of health care
• Committed to measurement, transparency and accountability
• Unites diverse groups around common goal: improving health care quality
4A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
NCQA ASSESSES HEALTH PLAN SYSTEMS & PROVIDERS
• NCQA Accreditation– 2/3 of HMOs in U.S. are NCQA-Accredited
• Covering 75% of HMO lives
– Only Accreditation program that scores programs on quality of care
• Physician Recognition Programs– Assesses for diabetes, heart/stroke, back
pain care, office care systems– Recently recognized 10,000th physician– New program identifies “medical homes”
5A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
WHAT DO WE MEASURE?
• HEDIS®
– Cancer screening, diabetes, cardiac care– Measures of effective, appropriate care– HEDIS measure criteria: valid, relevant,
feasible– Specifications vetted by committee of health
care stakeholders, thought leaders– Results are rigorously audited
• CAHPS®
– Access, timeliness, satisfaction– Independently collected
6A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
THE WAY OUR SYSTEM OUGHT TO WORK
A value-based health care system
20% of peoplegenerate
80% of costs
Healthy/Low Risk
At-Risk
HighRisk
ActiveDisease
Health care spending
Early Symptoms
Source: HealthPartners
7A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
DEFINING THE STAKES
8A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
KATHLEEN CASEY-KIRSCHLING
Photo: USA Today
9A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
KATHLEEN CASEY-KIRSCHLING:THE FIRST BABY BOOMER
• By 2030, 1 in 5 Americans will be 65 or over
• An estimated 80 million Americans will sign up for Medicare over the next 20 years – That works out to one new Medicare
beneficiary every ten seconds of every day
10A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
MEDICARE HOSPITAL INSURANCE TRUST FUND
ASSETS AS A PERCENTAGE OF OF EXPENSES, 1970-2025 (PROJ.)
Source: “Status of the Social Security and Medicare Programs,” ssa.gov
0%
20%
40%
60%
80%
100%
120%
140%
160%
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
2018
2020
2022
2024
Projected Medicare Hospital Insurance Trust Fund Assets
11A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
A DECADE OF MEASUREMENT:QUANTIFYING THE IMPACT
12A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
IN THE BEGINNING...• Quality widely assumed to be high• Measurement regarded as a novelty• Health plans went first
– Purchaser demand, threat of regulation were key
– CMS was a key supporter
• Strong provider resistance• Performance gaps revealed, quality
improvement efforts launched• Patient safety story unfolded• Notion of ‘cost/quality tradeoff’
exploded
13A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006
Cholesterol Screening
MEASUREMENT DRIVES IMPROVEMENT:
CHOLESTEROL SCREENING, MA PLANS, 2000-06
NO
DA
TA
/ S
PEC
. C
HA
NG
E
14A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006
Hypertension
MEASUREMENT DRIVES IMPROVEMENT:
BLOOD PRESSURE CONTROL, MA PLANS, 2000-06
SPECIFICATIONCHANGE
15A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006
Beta-Blockers After a Heart Attack
MEASUREMENT DRIVES IMPROVEMENT:
POST-MI BETA-BLOCKER TREATMENT, 2000-06
16A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006
HbA1c control (<9.0)
MEASUREMENT IDENTIFIES OPPORTUNITIES
FOR IMPROVEMENT:HbA1c CONTROL (<9.0 mg/dL), 2000-06
17A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
IMPROVEMENTS SAVE LIVES
Cumulative Lives Saved Due to Commercial and Medicare Quality Improvement, 2000-2006
Measure Lives Saved
Beta-Blocker Treatment 4,400 – 5,600
Cholesterol Management 10,100 – 17,000
Controlling High BP 56,800 – 98,600
Poor HbA1c Control 2,000 – 3,400
TOTAL 73,300 – 124,600
18A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
BUT WE STILL HAVE FURTHER TO GO
HEDIS Performance, 2005-2006: • Commercial plans improve in 30 of 44 measures• Medicaid plans improve in 34 of 43 measures• Medicare plans improve in 8 of 21 measures
– Partly attributable to high number of first-time reporters
– 64 MA plans reported HEDIS for the first time in 2006– Plans reporting in ’05 and ’06 improve on 13 of 21
measures
• We must stay focused on advancing quality
19A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
EVALUATING SPECIAL NEEDS PLANS (SNPs)
• Created by MMA legislation of 2003• SNPs serve vulnerable groups of
beneficiaries– Institutionalized– Those with severe or disabling chronic
conditions– Dual eligibles (Medicare and Medicaid)
• NCQA evaluation requirements build on existing Accreditation standards
20A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
EVALUATING SPECIAL NEEDS PLANS (SNPs):
A PHASED APPROACH• 2008: Review 477 SNPs
– Evaluate performance on 13 HEDIS measures of care– Assess structure and process, case management,
member experience, quality improvement
• 2009: Review 787 SNPs– Expand suite of HEDIS measures, with focus on
measures of care for older adults; integrate CAHPS, HOS
– Expand structure and process measures to include care transitions, plan design, caregiver experience
– Test benchmark measures
• 2010: Review 787+ SNPs– Refine benchmark measures for collection; expand set
of applicable HEDIS measures
21A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
THE QUALITY AGENDA AT A CROSSROADS
22A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
ONLY 1 IN 5 MEDICARE BENEFICIARIES ARE ENROLLED IN ACCOUNTABLE
SYSTEMS
Traditional Medicare:74.4%
MA HMO plans: 15.4%
MA PPO plans: 2.4%
MA PFFS plans: 5.1%
SNPs: 2.7%
23A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
PRIVATE FEE-FOR-SERVICE PLANS: THE FASTEST- GROWING SEGMENT OF MEDICARE
ADVANTAGEEnrollment in Medicare Advantage as a Percentage of Part A Enrollment
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016
0
5
10
15
20
25
30
PFFS Plans
HMOs and PPOs
Source: Congressional Budget Office
24A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
WE MUST ASSESS THE VALUE WE’RE GETTING FOR THE TAXPAYER DOLLAR
• Growth in unaccountable PFFS plans is troubling, yet it’s the fastest-growing MA segment– PFFS is reimbursed at a higher rate
than other plan types• MSAs remain small (<250)• Accountability must cut across
plan, payment types– Support in Congress, MedPAC for PFFS
accountability
25A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
WHAT’S NEXT?
• Develop and test accountable health care models such as the medical home
• Implement a comprehensive strategy for stewardship of medical evidence
• Develop more bundled, severity-adjusted payment models
• Develop a public-private strategic plan for improving population health
26A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
THE AVERAGE MEDICARE BENEFICIARY SEES SEVEN DOCTORS
Dx
Tx
RxTx Rx
DxDx
Dx
Rx
Rx
Dx
Tx
Rx
Tx
Tx
Rx
Dx
Tx
RxDx
Tx
…confusing, dangerous gaps in care often result.
27A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
EVIDENCE STEWARDSHIP
• We don’t have evidence to support much of the medical care we deliver
Current model:• Investigator-initiated research• Fragmented by specialty, organ
systems• Repetitive trials in some areas, no
evidence in others
28A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
PAYMENT REFORM: TIE IT TO OUTCOMES
• Bundling of payments (partial capitation) desirable to allow integrated systems to gain from their efficiencies
• Performance benchmarking also plays an important role – Facilitates performance comparison– Transparency critical to trust– Allows differential rewarding for superior
care
29A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
THE HEALTH OF AMERICANS IS A PRECIOUS NATIONAL ASSET
• We need to treat our collective health as an asset and zealously protect it (e.g., “Gross National Health”)– A comprehensive strategy for population
health stewardship is needed– Stakeholders are preoccupied with rising
costs• Warning signs are there: growing
numbers of uninsured, rising rates of diabetes, obesity
30A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
CHALLENGES IN POPULATION HEALTH MANAGEMENT
• Keeping healthy people healthy (e.g., promoting wellness)
• Finding disease early in its course to optimize outcomes
• Keeping the chronically ill as well as possible
• Improving care coordination for patients with complex conditions
• Providing compassionate, coherent end-of-life care
• Identifying, eliminating medical errors
31A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
THE THREE DIMENSIONS OF STRONGPOPULATION HEALTH MANAGEMENT
QUALITY
AFFORDABILITYACCESS
32A DECADE OF HEDIS: SHAPING THE FUTURE
MARGARET E. O’KANE
For more information:www.ncqa.org
SNP Assessment:www.ncqa.org/snp.aspx
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