achieving breakthrough transformation in us health care · 2013. 9. 10. · our mission. to improve...
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National Quality ColloquiumMargaret E. O’Kane, NCQA President
September 19, 2013
Achieving Breakthrough Transformation in US Health Care
National Quality Colloquium
• The big picture• Health plan and delivery system reform• Payment reform• Cancer demonstration project
Overview
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First, the big picture
National Quality Colloquium
NCQA’s role
Our missionTo improve the quality of health care
Our method Measurement We can’t improve what we don’t measure
Transparency We show how we measure so measurement will be accepted
Accountability Once we measure, we can expect and track progress
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Health care costs are strangling the US
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The Triple Aim is everything
A record 136 million Americans (43%) are in health plans that report HEDIS results
National Quality Colloquium
Game-changers in the Affordable Care Act
• Health plan reform• Exchanges• Delivery system
reform• Payment reform
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Health plan and delivery system reform
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• No rescinding of coverage (2010)• Ban on lifetime and annual limits (2010)• Preventive services without cost sharing (2010)• Pre-existing conditions for children (2010)• Kids under 26 on their parents policy (2010)• Uniform summaries of coverage (2012)• Medical loss ratio (2012)• Plans must cover ‘essential health benefits’ (2014)• Guaranteed issue (2014)
Consumer protections in the Affordable Care Act
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• Need to include health plans, organized delivery systems and medical practices
• Integrate across levels• Payment reform is a must
Controlling costs requires accountability at all levels
The emerging world of narrow networks
• Brings market discipline• Structure is crucial • My prediction:
Narrow networks in exchanges + low premiums = employer interest in narrow networks
NCQA Standards (a.k.a. Four Habits of High-Value Health Care Organizations)
• Specification and Planning Merging operational and clinical decisions with documentation
• Micro-system design Matching subpopulations and pathways, triage algorithms
• Measurement and oversight Targeting internal operational issues
• Commitment to ongoing process improvement Insights for better outcomes fuels modification of Specification and Planning
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“The ability to disseminate and deliver high value clinical innovation is based on similar, portable “habits” of care management … implemented simultaneously” Bohmer, NEJM 12/1/11
PCMH is the fastest-growing delivery system reform
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• Care access and continuity• Identify and manage a population• Treatment planning and care management• Provide self-care support and community
resources• Track and coordinate• Measure to improve performance
What is a medical home? PCMH 2011 standards
National Quality Colloquium
Patient-Centered Specialty Practice (PCSP) Recognition
• Builds on success of PCMH
• Recognizes specialists for exemplary care coordination, communication
• Could be a component of an ACO, network or payment strategy
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Payment reform
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“No satisfaction?”
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Pay for what you want
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• Examine mix of payments to specialists vs. PCPs
• Reward care coordination (PCMH, ACO)
• Reward providers for improving efficiency
• Don’t pay more for care in expensive settings
Pay for what you want
PCMH and high-deductible plans are at cross-purposes
RWJF Clinical Scholars Program
Patient-centered medical homes are the foundation of accountable care
CIGNA
Variation in capabilities and readiness make ACOs risky for payers, patients
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National Quality Colloquium
Why ACO accreditation matters
• Minimize risk of failure• Align purchaser
expectations• Present an attractive
model to the public
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Cancer demonstration project
National Quality Colloquium
Average admissions per chemotherapy patient per year
26Source:
National Quality Colloquium
Average ER evaluations per chemotherapy patient per year
27Source:
USON/Milliman: Approximately 2 emergency room visits per chemotherapy patient per year (n=14 million commercially insured; 104,473 cancer patients)Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009
National Quality Colloquium
Basing oncology patient-centered medical homes on PCMH
NCQA Standards drive Quality, Service & Utilization• Enhanced Access & Continuity• Identify and Manage Populations• Plan and Manage Care• Self-care Support & Community Resources• Track and Coordinate Care• Measure and Improve Performance
28Source:
• 3-year PCORI contract started August 1• Implementing NCQA specialty practice
standards, oncology standards• Includes – Interviews with physicians and staff– Assessment of compliance with standards– Patient experience survey– Follow-up focus groups with patients
Studying patient-centered oncology care
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National Quality Colloquium
Before Q&A, let me invite you…
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What questions do you have?
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