A DECADE OF HEDIS ® : CELEBRATING SUCCESS, SHAPING THE FUTURE MARGARET E. O’KANE PRESIDENT

2 A 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

3 A 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

4 A 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”

5 A 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

6 A 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 people generate 80% of costs Healthy/ Low Risk At- Risk High Risk Active Disease Health care spending Early Symptoms Source: HealthPartners

7 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE DEFINING THE STAKES

8 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE KATHLEEN CASEY-KIRSCHLING Photo: USA Today

9 A 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

10 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE MEDICARE HOSPITAL INSURANCE TRUST FUND ASSETS AS A PERCENTAGE OF OF EXPENSES, (PROJ.) Source: “Status of the Social Security and Medicare Programs,” ssa.gov

11 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE A DECADE OF MEASUREMENT: QUANTIFYING THE IMPACT

12 A 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

13 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE MEASUREMENT DRIVES IMPROVEMENT: CHOLESTEROL SCREENING, MA PLANS, NO DATA / SPEC. CHANGE

14 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE MEASUREMENT DRIVES IMPROVEMENT: BLOOD PRESSURE CONTROL, MA PLANS, SPECIFICATION CHANGE

15 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE MEASUREMENT DRIVES IMPROVEMENT: POST-MI BETA-BLOCKER TREATMENT,

16 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE MEASUREMENT IDENTIFIES OPPORTUNITIES FOR IMPROVEMENT: HbA1c CONTROL (<9.0 mg/dL),

17 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE IMPROVEMENTS SAVE LIVES Cumulative Lives Saved Due to Commercial and Medicare Quality Improvement, MeasureLives Saved Beta-Blocker Treatment 4,400 – 5,600 Cholesterol Management10,100 – 17,000 Controlling High BP 56,800 – 98,600 Poor HbA1c Control 2,000 – 3,400 TOTAL73,300 – 124,600

18 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE BUT WE STILL HAVE FURTHER TO GO HEDIS Performance, : 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

19 A 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

20 A 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

21 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE THE QUALITY AGENDA AT A CROSSROADS

22 A 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%

23 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE PRIVATE FEE-FOR-SERVICE PLANS: THE FASTEST- GROWING SEGMENT OF MEDICARE ADVANTAGE Enrollment in Medicare Advantage as a Percentage of Part A Enrollment Source: Congressional Budget Office

24 A 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

25 A 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

26 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE THE AVERAGE MEDICARE BENEFICIARY SEES SEVEN DOCTORS Dx Tx Rx Tx Rx Dx Rx Dx Tx Rx Tx Rx Dx Tx Rx Dx Tx …confusing, dangerous gaps in care often result.

27 A 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

28 A 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

29 A 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

30 A 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

31 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE THE THREE DIMENSIONS OF STRONG POPULATION HEALTH MANAGEMENT QUALITY AFFORDABILITYACCESS

32 A DECADE OF HEDIS: SHAPING THE FUTURE MARGARET E. O’KANE For more information: SNP Assessment: