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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
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A Brief Introduction to NCQA
• Private, independent non-profit
health care quality oversight organization
founded in 1990
• Committed to measurement,
transparency and accountability
• Unites diverse groups around common
goal: improving health care quality
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NCQA: 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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NCQA: COMMITTED TO MEASUREMENT,
TRANSPARENCY, ACCOUNTABILITY
Quality measurement NCQA’s quality programs
means: include:
• Use of objective measures based • Accreditation of health plans
on evidence using performance data
• Results that are comparable
across organizations • HEDIS clinical measures
• Impartial third-party evaluation • CAHPS consumer survey
and audit • Measurement of quality in
• Public Reporting provider groups
• Physician Recognition
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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
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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 year—rapid turnaround, adapted existing
NCQA measures and processes from
voluntary Accreditation programs
– 2nd year—focus on SNP-specific measures
– 3rd year—Refine measures; identify new SNP-
specific measures, where appropriate
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Objectives of SNP Assessment Program
• Develop a robust and comprehensive
assessment strategy
• 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
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Three-Year Strategy
Phase 1 - FY 2008 Phase 2 - FY 2009 Phase 3 - FY 2010
SNPs Effective as of SNPs Effective as of SNPs Effective as of January
January 2007 January 2008 2008
HEDIS 2009 HEDIS 2010
(15 measures) • Measure development:
•Addition of two 1st year –Potentially Avoidable
HEDIS 2008 Hospitalizations
(13 measures) measures: Care for Older
–Inpatient Readmissions
Adults; Medication
–MDS measures (I-SNPs)
Reconciliation Post- –Disease-specific measures (C-
Discharge SNPs)
Structure & Process Structure & Process Structure & Process
Measures Measures Measures
• SNP 1: Complex Case • SNP1 – 3 •Refinement of existing S&P
Management • SNP 4: Care Transitions measures, includes the
• SNP 2: Improving • SNP 5: Institutional SNP potential development of
Member Satisfaction Relationship with Facility new elements
• SNP 3: Clinical Quality • SNP6:Coordination of •Potential development of new
Improvements Medicare & Medicaid measures
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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 CMS—April 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
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Project Time Line – Phase II
• March - Release final S&P measures
• March 30 - Release ISS Data Collection
Tool
– S & P Measures
• April - Release IDSS Data Collection Tool
– HEDIS Measures
• June 30 - HEDIS submissions and S&P
measures submissions due to NCQA
• October 30 - NCQA delivers SNP
Assessment Report to CMS
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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)
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HEDIS 101
What Is HEDIS?
Healthcare
HEDIS is an evolving
Effectiveness set of standard
Data & specifications for
measuring health
Information plan performance
Set
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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 cost
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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 operations
•Quality Compass, Quality Dividend
Calculator
•US News and World Report - Ranking of
Health Plans
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Data Reporting
• Data are reported to NCQA in
June of the reporting year
• Data reflect events that
occurred during the
measurement year
(calendar year)
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Data Reporting
•Example:
– HEDIS 2009 data are reported in
June 2009
– Data reflects events that occurred
January–December 2008 (per
specs)
– HEDIS 2009 = 2008 data
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Effectiveness of Care Measures
•Clinical quality of care
•Focus
– Preventive care
– Up-to-date treatments for acute
episodes of illness
– Chronic disease care
– Appropriate medication treatment
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Collecting
HEDIS Data
Three HEDIS Data Sources
Claims Encounter Eligibility Provider
Medical
records
Surveys
Administrative
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Data Sources
•Administrative
– Membership data
– Provider data
– Claims/encounter
data
– Hospital discharge
data
– Pharmacy data
– Carve-out data
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Selecting an Eligible Population
• Member ID
• Age (DOB)
• Enrollment date and type
• Dates of service
• Diagnosis and procedure
codes
• Provider specialty
• Pharmacy
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Clinical Measures
Data Collection
• Defining the denominator is critical
• Administrative: Claims and
encounter data
– Denominator: Based on all eligible
members of the population
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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
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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
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Structure & Process Measures
What is a S&P Measure?
• A statement about acceptable
performance or results
• Assesses a plan’s ability to comply with
specific requirements
• Focus on systems necessary for quality
care
– Policies & procedures, reports, materials
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How are S&P 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
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Components of the S&P Measures
• Standard statement: a statement about
acceptable performance or results
• Intent statement: A sentence that describes the
importance of the S&P 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 S&P measure.
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Components of an S&P 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 S&P
assessment:
SNP Training – Intro to NCQA & SNP Assessment Program
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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
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Components of an S&P Measure
• Scope of Review: The extent of the
organization’s services evaluated during an
NCQA survey. Scope of review may vary
• Look-back period: The period of time for which
NCQA evaluates an organization’s
documentation to assess performance against
an element
• Explanation: Guidance for demonstrating
performance against the element
• Example: Descriptive information illustrating
performance against an element’s
requirements. Examples are for guidance and
are not intended to be all-inclusive
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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 submission—March 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.
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2009 SNP Measures Requirements
SNP Assessment Process
• Phased Approach
– Defining and assessing desirable structural
characteristics
– Assessing processes
– Assessing outcomes
• Two main components
– HEDIS Measures-focus on clinical
performance
– Structure & Process measures-focus on
structural characteristics and systems
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SNP Assessment Process
• S&P 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)
SNP Training – Intro to NCQA & SNP Assessment Program
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S&P Assessment: What’s 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.
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S&P measures:
What’s 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
data
• Identifying opportunities for improvement based
on data analysis
– Existing elements: added more examples and
clarified explanations
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S&P measures:
What’s 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 Facility
– (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 I&C SNPs
– Focus on helping members obtain benefits/services
regardless of payer.
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New Phase II HEDIS Measures
• Measures
– Care for Older Adults (COA)
– Medication Reconciliation Post-Discharge
(MRP)
• Hybrid Method Collection
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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
auditor
• S&P measures
– Submission date: June 30, 2009
– ISS data collection tool
• No Fees required to submit
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Who Reports
• HEDIS measures
– All SNP plan benefit packages with 30+
members as of February 2008 Comprehensive
Report (CMS website)
• S&P measures
– All SNP plan benefit packages
– Plans with no enrollment exempt from certain
elements
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What to Report
• S&P measures
• Cohort I—All SNPs operational as of
January 1, 2007 and renewed in 2009.
– S&P measures 4-7 (SNP 2:C & 3:B)
• Cohort II—All SNPs operational as of
January 1, 2008 and renewed in 2009
– All S&P measures (SNP 1-6)
• Do not report SNP 7 (SNP 2:C & 3:B)
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What happens after submission?
• NCQA Analysis of HEDIS and S&P
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 data
– NCQA will not publicly report any of the SNP
data
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And now…
Questions?
SNP Training – Intro to NCQA & SNP Assessment Program
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Contacts
Brett Kay
Director, SNP Assessment
202-955-1722
kay@ncqa.org
Casandra Monroe
Assistant Director, SNP Assessment
202-955-5136
monroe@ncqa.org
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Additional Resources
• NCQA SNP Webpage:
www.ncqa.org/snp.aspx
– FAQs (HEDIS)
– Training descriptions & schedule
– Final HEDIS and S&P measures (March 14)
• NCQA Policy Clarification Support (PCS)
http://app04.ncqa.org/pcs/web/asp/TIL_Client
Login.asp
• HEDIS Audit information
http://www.ncqa.org/tabid/204/Default.aspx
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Additional Information
• HEDIS 2008 Volume 2 Publication
Purchase
http://www.ncqa.org/tabid/78/Default.aspx
• October Specifications Update
http://www.ncqa.org/Portals/0/PolicyUpdat
es/HEDIS%20Technical%20Updates/2008_
Vol2_Technical_Update.pdf
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Additional SNP Trainings
• Introduction to NCQA & SNP Assessment
– March 5th 1:00 – 3:00 pm
– March 10th 1:00 – 300 pm
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Additional SNP Trainings
• SNP Subset of HEDIS Measures
– March 3rd 11:30 – 1:00 pm
– March 11th 11:30 – 1:00 pm
– March 16th 1:00 - 2:30 pm
– March 26th 1:00 - 2:30 pm
– April 1st 12:30 - 2:00 pm
• Structure and Process Measures (S&P 1-3)
– March 12th 1:00 – 2:30 pm
– March 19th 1:00 - 2:30 pm
– March 25th 12:30 - 2:00 pm
– April 23rd 2:00 – 3:30 pm
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Additional SNP Seminars
• Structure and Process Measures (S&P 4-6)
– March 17th 2:00 - 3:30 pm
– March 24th 2:00 - 3:30 pm
– March 31st 2:00 - 3:30 pm
– April 2nd 12:30 – 2:00 pm
– April 7th 2:00 - 3:30 pm
– April 15th 1:00 – 2:30 pm
• Interactive Survey System (ISS)
– April 8th 1:00 – 2:30 pm
– April 14th 1:00 - 2:30 pm
– April 17th 1:00 – 2:30 pm
– April 21st 1:00 - 2:30 pm
– April 28th 1:00 – 2:30 pm
– May 7th 1:00 – 2:30 pm
SNP Training – Intro to NCQA & SNP Assessment Program
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