QUALITY RATING SYSTEM: BACKGROUND
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- Edgar Richardson
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1 QUALITY RATING SYSTEM: BACKGROUND Federally-required quality rating system Originally required for 2017, FFM delayed until 2018 in most states 5 states displaying QRS for FFM pilot states + CA, NY, WA Other state-based Exchanges already show quality data CO, CT, MA, MD QRS includes 46 quality measures; only 31 scored for % clinical, 30% from enrollee survey, 10% resource use measures Current federal QRS methodology gives each category of measures equal weight ⅓ of overall plan score 2
2 FEDERAL QRS Structure Overall Summary Indicators Domains Clinical Effectiveness (13) Composites Asthma Care (1) Behavioral Health (4) Overall Plan Clinical Quality (⅓ of overall rating) Prevention (17) Cardiovascular Care (3) Diabetes Care (5) Checking for Cancer (3) Star System (1-5) Enrollee Experience (⅓ of overall rating) Access (1) Care Coordination (1) Maternal Health (2) Staying Healthy Adult (5) Staying Healthy Child (7) Access to Care (1) Plan Efficiency, Affordability, (⅓ of overall rating) Efficiency and Affordability (4) Care Coordination (1) Efficient Care (4) Plan Service (4) Enrollee Experience with Health Plan (4) 3
3 CONCERNS WITH FEDERAL QRS METHODOLOGY Stakeholder and HBE concerns with federal QRS methodology Weighting Other major quality performance reporting programs place greater weight on clinical measures than the QRS (currently ⅓ of total) Unrepresentative measures Resource use measures focus on pediatrics which makes up a very small fraction of enrollment Not representative of the exchange population; not scored for any QHPs for 2017 HBE hired a consultant to develop revised quality rating scores using CMS quality data 4
4 MODIFIED QRS METHODOLOGY Revised methodology will make two changes: Eliminates the Plan Efficiency, Affordability, and Summary Indicator and uses the Plan Service Domain instead Changes the overall weighting to be as follows: ⅔ of overall rating to Clinical Quality Summary Indicator ⅙ of overall rating to Enrollee Experience Summary Indicator ⅙ of overall rating to Plan Service Domain This modified methodology is also being implemented in CA CMS supports and carriers prefer use of alternate methodology 5
5 WAHBE REVISED QRS Structure for 2017 Overall Summary Indicators Domains Clinical Effectiveness (13) Composites Asthma Care (1) Behavioral Health (4) Overall Plan Clinical Quality (⅔ of overall rating) Prevention (17) Cardiovascular Care (3) Diabetes Care (5) Checking for Cancer (3) Star System (1-5) Enrollee Experience (⅙ of overall rating) Access (1) Care Coordination (1) Maternal Health (2) Staying Healthy Adult (5) Staying Healthy Child (7) Access to Care (1) Care Coordination (1) Plan Efficiency, Affordability, Efficiency and Affordability (4) Efficient Care (4) Plan Service (4) (⅙ of overall rating) Enrollee Experience with Health Plan (4) 6
6 SUMMARY OF 2017 WAHBE QRS Revised QRS is more representative of Exchange population and plan quality Eliminates unscorable pediatric measures Gives more appropriate weight to clinical measures Four carriers will have QRS scores for 2017 Five carriers have plans that are too new to rate or sample size is too small Using revised QRS methodology for 2017 Reevaluate for 2018 based on consumer experience and potential revised federal guidance 7
7 DISPLAY OF QUALITY INFORMATION IN HPF - EYO Data presented is for demonstration purposes only and does not reflect actual information. 8
8 DISPLAY OF QUALITY INFORMATION IN HPF PLAN SUMMARY Data presented is for demonstration purposes only and does not reflect actual information. 9
9 Washington Health Benefit Exchange APPENDIX
10 QUALITY RATING INFORMATION PROPOSED FOR WAHBE CORPORATE SITE Quality System page Central quality rating homepage Includes: General summary of what the Quality System and the two ratings available in HPF are Comparison by carrier of star ratings for the two measures Link to list of 46 measures Link to hierarchy of how measures roll up into the overall plan star rating Language indicating that the WAHBE quality ratings for 2017 are modified from the federal version 11
11 FEDERAL QRS Structure Overall Summary Indicators Domains Clinical Effectiveness (13) Composites Asthma Care (1) Behavioral Health (4) Overall Plan Clinical Quality (⅓ of overall rating) Prevention (17) Cardiovascular Care (3) Diabetes Care (5) Checking for Cancer (3) Star System (1-5) Enrollee Experience (⅓ of overall rating) Access (1) Care Coordination (1) Maternal Health (2) Staying Healthy Adult (5) Staying Healthy Child (7) Access to Care (1) Plan Efficiency, Affordability, (⅓ of overall rating) Efficiency and Affordability (4) Care Coordination (1) Efficient Care (4) Plan Service (4) Enrollee Experience with Health Plan (4) 12
12 PLAN EFFICIENCY, AFFORDABILITY, AND MANAGEMENT SUMMARY INDICATOR Overall Summary Indicators Domains Clinical Effectiveness (13) Composites Asthma Care (1) Behavioral Health (4) Overall Plan Star System (1-5) Clinical Quality (⅓ of overall rating) Enrollee Experience (⅓ of overall rating) Prevention (17) Access (1) Care Coordination (1) Cardiovascular Care (3) Diabetes Care (5) Checking for Cancer (3) Maternal Health (2) Staying Healthy Adult (5) Staying Healthy Child (7) Access to Care (1) Care Coordination (1) Plan Efficiency, Affordability, (⅓ of overall rating) Efficiency and Affordability (4) Plan Service (4) Efficient Care (4) Enrollee Experience with Health Plan (4) 13
13 PLAN EFFICIENCY, AFFORDABILITY, AND MANAGEMENT SUMMARY INDICATOR Summar y Indicator Domains Composites Measures Appropriate testing for children with pharyngitis (sample size too small) Plan, Efficiency, Affordability and (⅓ of overall rating) Efficiency & Affordability (⅙ of overall rating) Efficient Care (⅙ of overall rating) Appropriate Treatment for children with upper respiratory infection (sample size too small) Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (not scored) Use of imaging studies for low back pain (⅙ of overall rating) Plan Service Enrollee Experience with Health Plan Access to Information (CAHPS Plan Information on Costs) Plan Administration (CAHPS Customer Service) of Health Plan Relative Resource Use for People with Diabetes 14
14 WAHBE REVISED QRS Structure for 2017 Overall Summary Indicators Domains Clinical Effectiveness (13) Composites Asthma Care (1) Behavioral Health (4) Overall Plan Clinical Quality (⅔ of overall rating) Prevention (17) Cardiovascular Care (3) Diabetes Care (5) Checking for Cancer (3) Star System (1-5) Enrollee Experience (⅙ of overall rating) Access (1) Care Coordination (1) Maternal Health (2) Staying Healthy Adult (5) Staying Healthy Child (7) Access to Care (1) Care Coordination (1) Plan Efficiency, Affordability, Efficiency and Affordability (4) Efficient Care (4) Plan Service (4) (⅙ of overall rating) Enrollee Experience with Health Plan (4) 15
15 Clinical Quality Measures Adult BMI Assessment Annual Dental Visit Annual Monitoring for Patients on Persistent Medications Antidepression Medication Aspirin Use and Discussion Breast Cancer Screening Cervical Cancer Screening Childhood Immunization Status (Combination 3) Chlamydia Screening in Women Colorectal Cancer Screening Comprehensive Diabetes Care: Eye Exam (Retinal) Performed Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%) Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Testing Comprehensive Diabetes Care: Medical Attention for Nephropathy 16
16 Clinical Quality Measures (continued) Controlling High Blood Pressure Flu Vaccinations for Adults Ages Follow-Up After Hospitalization for Mental Illness (7-Day Follow-Up) Follow-Up Care for Children Prescribed ADHD Medication HPV Vaccination for Female Adolescents Immunizations for Adolescents (Combination 1) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Medical Assistance with Smoking and Tobacco Use Cessation Medication for People with Asthma (75% of Treatment Period) Plan All-Cause Readmissions Prenatal and Postpartum Care: Postpartum Care Prenatal and Postpartum Care: Timeliness of Prenatal Care Proportion of Days Covered (Diabetes All Class) Proportion of Days Covered (RA3 Antagonists) Proportion of Days Covered (Statins) Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Well-Child Visits in the First 15 Months of Life (6+ visits) Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life 17
17 Enrollee Experience Measures Access to Care Care Coordination (CAHPS Coordination of Members Health Care Services) Cultural Competence of All Health Care of Personal Doctor of Specialist (CAHPS of Specialist Seen Most Often) 18
18 Plan Efficiency, Affordability, and Measures Access to Information (CAHPS Plan Information on Costs) Appropriate Testing for Children with Pharyngitis Appropriate Treatment for Children with Upper Respiratory Infection Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Plan Administration of Health Plan Relative Resource Use for People with Diabetes (Inpatient Facility) Use of Imaging Studies for Low Back Pain 19
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