benchmarking quality

Quality in Healthcare Update

Rubén J. Nazario, M.D.Medical Director

October 2016

Agenda• Industry Background and Overview

• Accrediting Entities

• Quality Program Overview

− Federal Programs− Local Programs

• Risk Adjustment Overview

• Quality Documentation

Background

Paradigm Shift

Volume & Consumption

Value & Quality

Quality-focused care

Care coordination and transparency

Patient-centric

Cost containment

The US healthcare system is in the midst of a sea change transformation.

Fee for service

Uncoordinated care

Unnecessary utilizationand cost

Siloed work

Expansion of Data-Driven Patient Populations

Oregon Health Plan Receives Waiver to Reimburse Based on Patient-Level Data

ACG Risk Adjustment Model Released

NCQA Releases HEDIS 2.0

NY Launches QARR

HIPAA

CDPSCreated

Balanced Budget Act

Medicare Modernization Act

Medicare Part D

CMS Star Ratings Launch

160

140

120

110

80

60

40

20

01994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

ACA Passed

Managed Medicaid Medicare Advantage MSSP/Pioneer Accountable Care Organization Commercial ACA

Patie

nt C

ount

(mill

ions

)

Aon Hewitt Launches Private Exchange

Blue KC Exchange Launches

Bridges to Excellence Founded

PQRI Launched

Premier Hospital Quality

Incentive Launched

National Committee

on Evidence-Based Benefit

Design Established

California P4P

Program Launched

ACO Launch

Commercial HIX Marketplace Launch

Sears, IBM & Walgreens Move to Exchanges

Medicare + Choice Launch

E E E E E E

Estimates based upon internal Inovalon analyses and industry sources. Please see the Company’s prospectus filed pursuant to Rule 424 on February 12, 2015.

Overview The Centers for Medicare & Medicaid Services’ (CMS) Center for Clinical Standards & Quality supported by state health agencies, and numerous oversight and accrediting bodies such as the NCQA, URAC, American Medical Association (AMA), the American Heart Association (AHA), the Agency for Healthcare Research and Quality (AHRQ), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have developed initiatives to assure quality healthcare for Medicare beneficiaries, Medicaid, and people participating in the Exchange marketplace through accountability and public disclosure with the end goal of:

1) Preventing the overuse, underuse, and misuse of healthcare services and ensuring patient safety;

2) Identifying what works in healthcare—and what doesn’t—to drive improvement;

3) Holding health insurance plans and healthcare providers accountable for providing high-quality care;

4) Measuring and addressing disparities in how care is delivered and in health outcomes; and

5) Helping consumers make informed choices about their care.

BenefitsPatients benefit from:

• Improved quality of care• Reduced healthcare costs• Transparent rating system on health

plan performance• Improved patient/physician engagement

Physicians benefit from:• Accurate patient profiles leveraging

technology• Greater access to patient data that may

be outside of the network • Improved quality initiatives• Streamlined cost in the delivery of care• Improved communication between the

physician and patient• Better care coordination

Health plans benefit from:

• Improved operational and financial performance

• Improved communication between the health plan, physician, and patient

• Improved competitive stance

Accrediting Entities

An independent non-profit organization that works to improve healthcare quality through the administration of evidence-based standards, measures, programs, and accreditation. NCQA administers the Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

An independent, non-profit organization that promotes continuous improvement in the quality and efficiency of healthcare management through processes of accreditation, education, and measurement.

The purpose of clinical and quality outcomes accrediting organization is to standardize how quality of care is measured while driving improvements, and bettering the care and services being dispensed to the patient population.

Health organizations that acquire and maintain accreditation benefit through:• Increased enrollment• Improved quality of care for their members• Better financial performance

Two key accrediting organizations are:

8

Key Federal Quality Improvement Models: Medicare and Commercial

Program LOB

CMS Five-Star Quality Rating Medicare Advantage

Quality Rating System (QRS) Commercial ACA

Medicare Shared Savings Program Medicare FFS

In addition to regulatory requirements and standards developed by oversight and accrediting bodies, there are federal and state-specific programs that incentivize improvements in clinical and quality outcomes.

ASES Quality Retention Fund • Performance measures to monitor and assure quality of care to all Plan de Salud del

Gobierno de Puerto Rico members across multiple preventive services and chronic conditions management domains:

• Breast Cancer Screening

• Cervical Cancer Screening

• Cholesterol Management for High Risk Population

• Diabetes Care Management

• Access to Preventive Visits

• Annual Dentist Visit

• Timeliness in Prenatal Care

• Asthma Management

• Disease Management and Emergency Room Utilization metrics

9INOV PPT Template (1.1.16) v1.0.0

Breast Cancer Screening

10

• The number of women 42-69 years of age who had a mammogram to screen breast cancer

• One or more mammograms any time on or between October 1st two years prior to the measurement year and December 31st of the measurement year

• Excludes patients with documented:– Bilateral mastectomy any time during the patient’s history

• Including two unilateral mastectomies at least 2 weeks apart

INOV PPT Template (1.1.16) v1.0.0

Cervical Cancer Screening

11

• The number of women 24-64 years of age who receive one or more Pap Tests to screen for cervical cancer using either:

• Cervical cytology during the measurement year, or the two years prior

• Cervical cytology/HPV co-testing during the measurement year or four years prior– Document when the cervical pathology and/or the HPV test was performed, and

the results or findings

• Exclusion:– Hysterectomy with no residual cervix , cervical agenesis, or acquired absence of

the cervix


Cholesterol Management for High Risk Population

12

• Patients 18-75 years with a high risk diagnoses (Acute MI, CABG, PCI) who have had a LDL-C screening

• Document when the LDL-C test was performed and the results or finding


Diabetes Care Management

13

Members 18-75 years of age with Diabetes (Type 1 or 2) who had each of the following screening tests:

• Hemoglobin A1c

• Eye exam– Retinal or dilated eye exam by optometrist or ophthalmologist in the measurement year– A negative retinal or dilated eye exam in the year prior to the measurement year

• LDL-C

• Nephropathy screening:– Microalbumin (24 hour urine, timed urine, spot urine, microalbumin/creatinine ratio, 24 hour

protein, random protein/creatinine ratio)– Diagnosis of nephropathy by nephrologist– Renal transplant– Documentation of chronic kidney disease, including acute renal failure, ESRD, and diabetic

nephropathy– Positive urine macroalbumin test


Early and Periodic Screening Diagnosis and Treatment (EPSDT)

14

Members under 21 years old , based on age stages:

• Preventive visit (well child)

• Inmunizations

• Developmental screening

• Counseling for nutrition and physical activity, BMI percentile

• Dental care

• Hearing and vision screening


Medicare Advantage Commercial ACA Managed Medicaid

Payment Model CMS-HCC model HHS-HCC model State-specific model (CDPS,

CRG, ACG, Medicaid Rx, etc.)

PaymentTimeline

Prospective (future payments adjusted twice per year, plus one lump-sum reconciliation payment)

Concurrent (one lump-sum transfer payment determined by June 30 each year)

Prospective (future payments adjusted quarterly)

Risk Score CalculationRisk score based on age, gender, diagnosis and geography

Risk score based on age, gender, diagnosis and geography

Varies by state (diagnostic or demographic-only) and population (TANF, SSI)

Member or Population Risk Score

Individual member-level risk scores

Group, plan-level risk scores(Average of member-level scores)

Generally group, plan-level risk scores by population (TANF, SSI, etc.)

Submission ScheduleThree annual data submission deadlines (March, September and January)

One annual submission deadline (April 30) Varies by State

Comparing Risk Adjustment Programs

Medicare Advantage Commercial ACA Managed Medicaid

Diagnosis Grouping ICD-10 codes grouped into 79 HCCs*

ICD-10 codes grouped into 127 HCCs, separate risk pools for age (Infant, Child, Adult) and metal level (Bronze, Silver, Gold, Platinum, Catastrophic)

ICD-10 codes grouped into condition categories specific to risk adjustment model (CDPS groups, CRGs, ACGs) and relevant populations (TANF, SSI, etc.)

Budget NeutralityNot budget-neutral, but risk factors are adjusted annually based on Medicare budget

Zero-sum settlement (budget neutral)• If one plan’s risk score

changes, all plans’ scores change

Generally zero-sum settlement (budget neutral)• If one plan’s risk score

changes, all plans’ scores change

Data Submission Format RAPS and EDS (837/5010) data format EDGE Server (XML format) Generally 837/5010 format

Supplemental DataSupplemental data permitted (allows for medical record review)

Supplemental data permitted (allows for medical record review)

Supplemental data generally not accepted

Comparing Risk Adjustment Programs (cont.)

*Note: 87 HCCs in ESRD model

Managed Medicaid Risk Adjustment Overview

• 37 States have Managed Care programs with a capitated payment model

• Many states expanded Medicaid eligibility under the Affordable Care Act (ACA)

• About half of states use a diagnostic-based risk adjustment model for their managed care populations

• Most Medicaid risk adjustment programs are budget neutral

• States May Choose from Multiple Risk Adjustment Models− CDPS – Chronic Disability Payment System− CDPS + Rx− CRG – Clinical Risk Groups− ACG – Adjusted Clinical Groups− DCG – Diagnostic Cost Groups− ERG – Episodic Risk Groups− Medicaid Rx− Demographic-only Risk Adjustment

Monitoring, Evaluation, Assessment or Treatment (MEAT):

• Only diagnoses documented in the patient’s medical record are considered when calculating a member’s compliance.

• Clinical validation rules require documentation of physical exam findings or evaluation of symptoms for conditions such as depression, COPD, PVD, heart failure, rheumatoid arthritis or diabetes.

• Assessment/Plan section requires documentation of evaluation if conditions are assessed to be stable and specification of recommended treatment plan.

Documentation Support for Compliance

Challenges with Diagnostic Coding

Doctors have a lack of or limited

knowledge of risk adjustment

methods

ICD codes must be documented every year in a patient-

provider visit

Physicians are often not incentivized to

improve patient risk score accuracy

Systems, processes, and/or training

programs do not stress the importance of risk

adjustment

Continued use of CPT codes for

reimbursement

Incomplete and erroneous coding is common and can affect the accuracy of a managed-care plan’s risk score

and resulting reimbursement.

Factors contributing to inaccurate diagnostic coding by providers:

Initial Priorities for Measure Development by Quality Domain

Clinical Care

• Measures incorporating patient preferences and shared decision-making

• Cross-cutting measures that may apply to more than one specialty

• Focused measures for specialties that have clear gaps

• Outcome measures

Safety

• Measures of diagnostic accuracy

• Medication safety related to important drug classes

Care Coordination

• Assessing team-based care (e.g., timely exchange of clinical information)

• Effective use of new technologies, such as telehealth


Initial Priorities for Measure Development by Quality Domain

Patient and Caregiver Experience

• Patient-reported outcome measures (PROMs)

• Additional topics that are important to patients and families/caregivers (e.g., knowledge, skill, and confidence for self-management)

Population Health and Prevention

• Developing or adapting outcome measures at a population level, such as a community or other identified population, to assess the effectiveness of the health promotion and preventive services delivered by professionals

• IOM Vital Signs topics (e.g., life expectancy, well-being, addictive behavior)

• Detection or prevention of chronic disease (e.g., chronic kidney disease)

Affordable Care

• Overuse measures (e.g., overuse of clinical tests/procedures)


Quality Documentation

Important aspects of documentation:• Utilization of proper codes in claims and encounters

• Submit all related codes accurately

• Submit all service encounters timely

• Progress notes in record that evidence the submitted codes

• Use of technology, specially electronic health records

• It reflects your work, compliance and quality of care offered

• Supports contracted requirements of quality activities

• HEDIS

• EPSDT

• Performance Measures

• Disease Management

• Wellness Program


Questions
