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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), ...
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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 advanceof health care quality to the top of the national agenda. NCQA’s programs and serthe issue vices 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 thindustry’s changing capabilities and priorities, NCQA regularly updatese health care 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.
Overview of Draft Changes to 2012 Products 2012 Product Update—Draft Changes for Public Comment
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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 o r 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, of Healthcare Providers andpatient experience ratings on a standardized Consumer Assessm ent 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 2012 Product Update—Draft Changes for Public Comment
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Overview of Draft Changes to 2012 Products 3
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…
Standards
HEDIS and CAHPS
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) Incorporate updates from PPACA to HP accreditation.NCQA proposes updating the Utilization Management (UM) standards to align with the federal requirements in the ACA. changes specific to MBHOs, NHPs, HPs.Incorporate Changes will align products and simplify scoring. Add a HEDIS measure required for accreditation.AddPharmacotherapy Management of COPD Exacerbation (PCE)to accreditation scoring.
Overview of Draft Changes to 2012 Products 2012 Product Update—Draft Changes for Public Comment
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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 make s our standards stronger and more worthwhile for all stakeholders. NCQA encourages readers to provide thoughts and insight s 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.
Overview of Draft Changes to 2012 Products 2012 Product Update—Draft Changes for Public Comment
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Standard/ Measure Policies and Procedures/ HEDIS Clinical Measures
QI 4, Element B
STANDARDS & GUIDELINES CHANGES Action Type Product Current Requirement Addition HP Measures not included
2012 Policy Accreditation Recommendations
Recommendation Add new HEDIS measures required for accreditation Add Pharmacotherapy Management of COPD Exacerbation (PCE) to accreditation scoring. Rationale:PCE applies to all three product lines. Both rates in this measure have been publicly reported since 2009. The rates were stable from 2009–2010 for both the commercial and Medicaid populations. Minor clarifications have been made to the specification from 2009–2011, but there are no major spec changes. Modifications MBHOElement B: Ensuring Availability of BHPsClarify the factor text to include types of practitioners. pTroa cetintisounree rtsh ew iathviani liatsb ilditeyl ivofe rbye shyasvtieorma,l thheea lotrhgcaanriez ation: Explanation: Types of practitioners and providers The organization must define all types of behavioral healthcare 1. Defines the types of behavioral healthcare practitioners practitioners and providers within its delivery system, not just high -volume practitioners. At a minimum, it must include MD, doctoral Explanation: Types of practitioners and providerslevel non-MD and non-doctoral level non-MD practitioners and The organization must define all types of behavioral inpatient, residential and ambulatory provider organizations. The healthcare practitioners and providers within its delivery organization's performance score will be lower if it does not system, not just high-volume practitioners. The evaluate a nd organization's performance score will be lower if it does not ll factors for these practitioners a providers. evaluate all factors for both practitioners and providers. Rationale:It is not clear to MBHOs what types of practitioners need to be included. In addition, according to BH practitioners, there is no significant difference in the services the different types of non-MD, non-doctoral level BH practitioners provide.
Appendix 1: 2012 Accreditation Products Update 2012 Product Update–Draft Changes for Public Comment
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2012 Policy Accreditation Recommendations
STANDARDS & GUIDELINES CHANGES Standard/ Measure Action Type Product Current Requirement Recommendation QI 7,Modification HPElement I: Measuring EffectivenessRevise the stem to require annual measurement. Element IThe organization measures the effectiveness of its The organization annually measures the effectiveness of its case case management program using three measures. management program using three measures. For each measure, the For each measure, the organization: organization: 1. Identifies a relevant process or outcome 1. Identifies a relevant process or outcome 2. Uses valid methods that provide quantitative 2. Uses valid methods that provide quantitative results results 3. Sets a performance goal 3. 4.Sets a performance goal Clearly identifies measure specifications 4. 5.Clearly identifies measure specifications Analyzes results 5. Analyzes results 6. Identifies opportunities for improvement, if applicable 6. 7.Identifies opportunities for improvement, if Develops a plan for intervention and remeasurement. applicable 7. Develops a plan for intervention andRatio remeasurement measunrael ep:wit sthilim arzation se organiemtn ,hti pmorevua qtylieno resudro t renI emene els thligntna eremaeuslam nuAn. lyalicodrie dluoh requirements. Element J: Annual AssessmentRevise requirement to implement an opportunity and measure that Based on the results of its measurement and analysisaction. of case management effectiveness, the organization: 1. Implements at least one intervention to improve Revise ISS to score each measure separately. performance 2. Remeasures to determine performance.Rationale:The element requires review of 3 measures, but the current ISS Select the choice that most closely reflects the set-up does not allow scoring of each measure. organization's performance. 100%: The organization implements an intervention and remeasures 80%: The organization implements an intervention but does not remeasure 50%: No scoring option 20%: No scoring option 0%: The organization does not implement an intervention or remeasure
QI 7,Modification HP Element J
Appendix 1: 2012 Accreditation Products Update 2012 Product Update–Draft Changes for Public Comment
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2012 Policy Accreditation Recommendations
STANDARDS & GUIDELINES CHANGES Standard/ Measure Action Type Product Current Requirement Recommendation QI 12 are no current NCQA requirements. There NHP,Addition HP,for organizations to audit Complex CaseAdd requirement MBHOManagement delegate files. New element: File Audit For delegation arrangements in effect for 12 months or longer, the organization audits complex case management files against NCQA standards for each year that delegation has been in effect. Scoring 100% The organization annually audits the appropriate number of files 80% The organization audits the appropriate number of files less than annually 50% The organization audits fewer than the appropriate number of files 20% The organization performs a general evaluation without an adequate audit 0% The organization does not perform an evaluation or audit Explanation The organization receives a 100% score for this element if all delegates are NCQA accredited health plans. If a delegate is not NCQA accredited, the annual evaluation must be based on the responsibilities stated in the mutually agreed-upon delegation document and the appropriate NCQA standards. The or anization must use one of the following two auditing methods. The organization may audit either 5 percent or 50 of its files, whichever is less, to ensure that QI 7 file review requirements are met. At a minimum, the sample must include at least 10 files. or The organization may use the NCQA “8/30 methodology” available athttp://www.ncqa.org/updatesto review delegate files. For Initial Surveys, the organization must provide at least one annual audit. For Renewal Surveys, the organization must provide the last two annual audits. There must be yearly documentation of substantive evaluation and action plans, if needed. Exceptions The element is NA in the following circumstances. Page 3 of 15 Obsolete After 4/1/11
Appendix 1: 2012 Accreditation Products Update 2012 Product Update–Draft Changes for Public Comment
Standard/ Measure Action Type Product
2012 Policy Accreditation Recommendations
STANDARDS & GUIDELINES CHANGES Current Requirement Recommendation The organization does not delegate complex case management activities Delegation arrangements with non-NCQA Accredited delegates have been in effect for less than 12 months Rationale:There are delegation file audits for CR but not for CCM. The organization should be conducting similar oversight to CR, including oversight of how the delegate is performing on actual cases conducted by non-NCQA Accredited organizations. UM 9, MBHO,Modification HP,UM 9, Element A: Preservice and PostserviceRemove duplicate requirements from Element E and move one Element ENHP, UM-Appealsrequirement in Element A. CRAn NCQA review of the organization’s appeal filesEliminate Element E. indicates that they contain the following information. AddDocumentation of the substance of appeals response to the appeal to Element A. Investigation of appealsUM 9, Element A: Preservice and Postservice Appeals ScoringAntNCinQtAh er efovilleoww ionfgt hinef oorrgmaantiization’s appeal files indicates that they 100% High (90-100%) on file review con a on. 80% No scoring option 1. Documentation of the substance of appeals 50% Medium (60-89%) on file review 2. Investigation of appeals 20% No scoring option 3. Appropriate response to the substance of appeals 0% Low (0-59%) on file review
Appendix 1: 2012 Accreditation Products Update 2012 Product Update–Draft Changes for Public Comment
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2012 Policy Accreditation Recommendations
STANDARDS & GUIDELINES CHANGES Standard/ Measure Action Type Product Current Requirement Recommendation UM 9, UM 9, Element E: Appropriate Handling of Appeals Scoring Element EAn NCQA review of the organization’s internal appeal files100% High (90-100%) on file review continued scoring option No 80%indicates appropriate handling of appeals. Scoring (60-89%) on file review50% Medium 100% High (90-100%) on file review 20% No scoring option 80% No scoring option 0% Low (0-59%) on file review 50% Medium (60-89%) on file review 20% No scoring optionthe fourth paragraph in the explanation:Add as 0% Low (0-59%) on file review For factor 3, NCQA reviews whether the extent and timing of the organization’s response was commensurate with the Explanationseriousness and urgency of the appeal. NCQA conducts onsite file review in the presence of the organization’s staff and works with the organization to resolve any disputes during the onsite survey. An organization that isRationale:contains factors that are reviewed in otherElement E unable to resolve a dispute with the survey team should contact reelespmoennstes itno tUhMe a9.p pEelealm aenndt tBh ee veaxltueantte sa nthd et itimminegli nofe sths eo fa tphpee al. NCQA before the onsite survey is complete. File review results may not be disputed, and may not be appealed once the onsite survey is complete. NCQA uses three questions to determine whether internal appeals from members and members’ authorized representatives were handled appropriately. 1. Did the organization overturn the appeal within the specified time frame? 2. Did the organization respond to the substance of the appeal? 3. Was the extentand timing of the organization’s response commensurate with the seriousness and urgency of the appeal?
Appendix 1: 2012 Accreditation Products Update 2012 Product Update–Draft Changes for Public Comment
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