2012 Public Comment Overview

Cleveland Moffett

Description

For Public Comment March 4–April 1, 2011 Comments due 5:00 pm ET Friday, April 1, 2011 2012 Accreditation and Certification Products Update Overview ®HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). ®CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Note: This publication is protected by U.S. and international copyright laws. You may reproduce this document for the sole purpose of facilitating public comment. 2011 by the National Committee for Quality Assurance 1100 13th Street NW Suite 1000 Washington, DC 20005 All rights reserved. Printed in U.S.A. NCQA Customer Support: 888-275-7585 www.ncqa.org Overview of Draft Changes to 2012 Products 1 Overview Our Mission: Improve the Quality of Health Care NCQA is dedicated to improving health care quality. For more than 20 years, NCQA has been driving improvement throughout the health care system, helping to advance the issue of health care quality to the top of the national agenda. NCQA’s programs and services reflect a straightforward formula for improvement: measurement, transparency and accountability. This approach works, as evidenced by dramatic improvements in clinical quality demonstrated by health plans that NCQA accredits—health maintenance organizations (HMO), ...

Informations

• Publié par: Ifta
• Nombre de lectures: 8
• Langue: English

Extrait

2012 Accreditation and

Certification Products

Update

Overview

For Public Comment

March 4–April 1, 2011

Comments due 5:00 pm ET

Friday, April 1, 2011

HEDIS

®

is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS

®

is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Note:

This publication is protected by U.S. and international copyright laws. You may reproduce this document for the

sole purpose of facilitating public comment.

2011 by the National Committee for Quality Assurance

1100 13th Street NW Suite 1000

Washington, DC 20005

All rights reserved. Printed in U.S.A.

NCQA Customer Support: 888-275-7585

www.ncqa.org

Overview of Draft Changes to 2012 Products

1

Overview of Draft Changes to 2012 Products

2012 Product Update—Draft Changes for Public Comment

Obsolete after 4/1/11

Overview

Our Mission: Improve the Quality of Health Care

NCQA is dedicated to improving health care quality.

For more than 20 years, NCQA has been driving improvement throughout the health care system, helping to

advance the issue of health care quality to the top of the national agenda. NCQA’s programs and services

reflect a straightforward formula for improvement: measurement, transparency and accountability.

This approach works, as evidenced by dramatic improvements in clinical quality demonstrated by health plans

that NCQA accredits—health maintenance organizations (HMO), point-of-service (POS) and preferred

provider organizations (PPO)—using both standards and performance results. Today, two in five Americans

are enrolled in a plan that collects and reports HEDIS data to NCQA.

Health Plan Accreditation

NCQA Health Plan Accreditation is designed to help employers, public purchasers and consumers

understand and distinguish among health plans based on quality, while helping health plans identify

opportunities for quality improvement.

To remain current with the health care industry’s changing capabilities and priorities, NCQA regularly updates

its accreditation and certification requirements. Proposed updates for 2012 highlight opportunities to

incorporate industry changes, such as the new Patient Protection and Affordable Care Act (PPACA)

requirements for all health plans.

In addition to annual updates and PPACA requirements, NCQA is interested in receiving comments about:

Delivery system reform

Health insurance Exchanges.

Patient Protection and Affordable Care Act Requirements

NCQA reviewed all Affordable Care Act requirements that became effective in 2010, which are applicable for

all health plans. When assessing requirements to include in the standards, NCQA considered whether an

addition would enhance the quality and strength of the standards and the evaluation process. NCQA

determined that many requirements are already addressed in the current accreditation standards and some

are more appropriate for federal review than for an accreditation-based review. NCQA’s Standards

Committee recommended including provisions related to the appeals process (29 CFR Part 2590; Section

54.9815—2719T), which incorporate the following requirements:

Clarify the definition of ―adverse benefit determination‖ to include rescissions of coverage

Expedite notification of benefit determinations involving urgent care

Include full and fair review of evidence used to determine a denial

Avoid conflict of interest by not influencing decisions through hiring, compensation, termination,

promotion or other practices

Provide notice to claimants with sufficient information about an adverse benefit determination or a final

internal adverse benefit determination.

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Overview of Draft Changes to 2012 Products

Overview of Draft Changes to 2012 Products

2012 Product Update—Draft Changes for Public Comment

Obsolete after 4/1/11

NCQA proposes aligning with federal requirements by adding rules related to the appeals process. We

welcome feedback on our general approach for incorporating these requirements, as well as

recommendations for additional components our stakeholders believe should be included.

Delivery System and Payment Reform

Delivery system and payment reform initiatives such as patient-centered medical homes (PCMH) and

accountable care organizations (ACO) are receiving significant attention as methods of simultaneously

reducing cost and improving quality. NCQA is considering opportunities to encourage health plan investment

in these types of system redesign initiatives through health plan accreditation. We want your input on

strategies to reward health plans for supporting initiatives such as PCMH, for use in the NCQA Accreditation

standards.

We are considering offering delegation oversight relief when delegating certain case management or disease

management activities to NCQA Recognized PCMH practices.

Questions for consideration:

Should NCQA allow plans to delegate to practices for case management or disease management? If

so, which activities?

How else could NCQA reward health plans for investing in delivery system and payment reform

initiatives?

How do health plans currently support delivery system and payment reform?

Health Insurance Exchanges

The Patient Protection and Affordable Care Act (PPACA) creates health insurance Exchanges, a new avenue

for the currently uninsured to purchase health insurance coverage in an organized and competitive market.

Exchanges will be created and operated in each state and will offer a choice of health plans, with common

rules about offering and pricing insurance. Exchanges will also provide information on health plans and

benefit plans, to help consumers understand their options. Operation of Exchanges will be directed by federal

government requirements and by requirements established by the state Exchange governance.

State Exchanges will be responsible for certifying health plans that are qualified to provide products in the

Exchange market. A PPACA requirement for qualified health plan is that at a minimum, a plan

“must be

accredited with respect to

local performance on clinical quality measures such as the Health Effectiveness Data and Information

Set,

patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and

Systems survey, as well as

–

consumer access,

–

utilization management,

–

quality assurance,

–

provider credentialing,

–

complaints and appeals,

–

network adequacy and access, and

–

patient information program” (Section 1311).”

Overview of Draft Changes to 2012 Products

3

Overview of Draft Changes to 2012 Products

2012 Product Update—Draft Changes for Public Comment

Obsolete after 4/1/11

Broad federal accreditation requirements align closely with the current NCQA Health Plan Accreditation

program. Plan-level HEDIS and CAHPS measure results reported to NCQA for accreditation can also be used

to aid additional qualified health plan certification requirements, Exchange oversight and consumer

information reporting.

NCQA is interested in receiving feedback about issues we should consider to align accreditation and HEDIS

and CAHPS reporting with federal and developing state Exchange requirements. NCQA will use Public

Comment feedback and will continue to work with health plans and federal and state governments to help

these parties meet and oversee Exchange requirements. NCQA will release additional information and

questions in the near future.

Public Comment

Public Comment is integral to the development of all NCQA standards and measures. NCQA actively seeks

input from all interested parties during the development cycle of programs and routinely integrates input into

the final versions of its programs.

Comments on the proposed changes to NCQA Accreditation and Certification requirements will be considered

as NCQA finalizes the products for release in July 2011. Surveys incorporating these product changes will

begin on July 1, 2012.

Draft Changes

Changes

proposed

for…

Health Plan Accreditation (HP)

New Health Plan Accreditation (NHP)

Managed Behavioral Health Organization Accreditation (MBHO)

Disease Management Accreditation and Certification (DM)

Wellness & Health Promotion Accreditation (WHP)

Health Information Products Certification (HIP)

Standards

Incorporate updates from PPACA to HP accreditation.

NCQA proposes updating

the Utilization Management (UM) standards to align with the federal requirements in

the ACA.

Incorporate changes specific to MBHOs, NHPs, HPs.

Changes will align products

and simplify scoring.

HEDIS and

CAHPS

Add a HEDIS measure required for accreditation.

Add

Pharmacotherapy

Management of COPD Exacerbation (PCE)

to accreditation scoring.

4

Overview of Draft Changes to 2012 Products

Overview of Draft Changes to 2012 Products

2012 Product Update—Draft Changes for Public Comment

Obsolete after 4/1/11

Documents

Draft changes to 2012 Accreditation and Certification products are explained in detail in the following

documents.

Appendix 1: Updates to HP, NHP, MBHO, DM and WHP standards

Appendix 2: Affordable Care Act Updates to Health Plan Accreditation

Proposed changes to standards and to HEDIS/CAHPS scoring policies are shared to generate thoughtful

commentary and constructive criticism from interested parties. NCQA seriously considers all suggestions.

Many comments lead to changes in our standards and policies, and the review process makes our standards

stronger and more worthwhile for all stakeholders.

NCQA encourages readers to provide thoughts and insights on certain global issues related to the 2012

products update.

Are standards, intent statements and explanations clearly articulated? If not, which areas should be

more clear or need more explanation/examples?

Do standards align with organization services and stakeholder expectations? Are there gaps? Are there

areas that should be addressed but are not?

Generally, does your organization have the necessary materials (e.g., documents) to demonstrate

compliance with standards? If not, which areas are challenging?

Next Steps

Final 2012 NCQA Accreditation and Certification products will be released in July 2011, following approval by

the NCQA Standards Committee and the Board of Directors. Requirements will take effect July 1, 2012.

Plans coming forward for accreditation on or after that date must meet the new requirements.