For Public Comment March 5 April 3, 2018 Comments due 5:00 p.m. ET April 3, 2018 Population Health Management Accreditation Public Comment Overview PHM Accreditation 2018 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. 2018 by the National Committee for Quality Assurance 1100 13th Street NW, 3rd Floor Washington, DC 20005 All rights reserved. Printed in U.S.A. NCQA Customer Support: 888-275-7585 w ww.ncqa.org
Table of Contents Table of Contents Population Health Management Accreditation Overview... 3 Our Mission: Improve the Quality of Health Care... 3 The NCQA Advantage... 3 About PHM Accreditation... 3 Why This New Accreditation?... 4 NCQA PHM Advisory Committee... 5 Summary of PHM Accreditation Requirements... 6 PHM Accreditation Draft Standards... 6 Global Questions for Stakeholders Participating in Public Comment... 7 Public Comment Instructions... 8 Public Comment Questions... 8 Documents... 8 Submitting Comments... 8 Next Steps... 8
Introduction to PHM Accreditation 3 Population Health Management Accreditation Overview Our Mission: Improve the Quality of Health Care NCQA is dedicated to improving health care quality. For over 25 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, accountability. This approach works, as evidenced by the dramatic improvements in clinical quality demonstrated by NCQA-Accredited health plans health maintenance organizations (HMO), point-of-service (POS) organizations, preferred provider organizations (PPO) using both standards and performance results. Today, more than 184 million Americans (57%) are enrolled in a plan that collects and/or reports HEDIS data to NCQA. The NCQA Advantage Promoting a proactive, personalized approach to care is at the core of NCQA s mission and programs. NCQA reimagined its approach to population health in Health Plan Accreditation (HPA) 2018 by developing a new category of standards: Population Health Management (PHM) bringing together previously siloed expectations. This category created a need for a standalone accreditation product for organizations that perform PHM activities on behalf of health plans or other clients (e.g., PHM organizations, DM organizations). NCQA PHM Accreditation reduces burden for health plans by letting them receive credit for delegated functions more easily and provides an internal quality check for PHM organizations. Organizations need accreditation solutions that demonstrate value through automatic credit or documentation burden relief and provide flexibility for various organization arrangements. NCQA PHM Accreditation standards closely align with the HPA PHM standards. About PHM Accreditation Population health management is a model of care that strives to address individuals health needs at all points along the continuum of care, including the community setting, by increasing patient participation and engagement and targeting interventions. It entails stratifying a defined population and creating strategies for care based on each group s needs. The goal of PHM is to maintain or improve the physical and psychosocial well-being of individuals and address health disparities through cost-effective and tailored health solutions 1. This new product is for organizations seeking standalone PHM Accreditation. Its requirements draw from NCQA s PHM model (Figure 1), from the PHM category of standards in HPA and from Disease Management Accreditation and Case Management Accreditation. The PHM model guides organizations to consider key functions of PHM, such as data integration and population identification, incorporate community resources and align roles and expectations with those of the delivery system and health plans/payers. 1 PHM definition adapted from Population Health Alliance w ith guidance from PHM Advisory Committee
4 Introduction to PHM Accreditation Eligibility for NCQA PHM Accreditation is flexible. Eligible organizations include, but are not limited to: PHM organizations. Chronic Condition/DM organizations. Organizations may elect to have one or more individual programs reviewed, including: Diabetes management. Asthma management. Chronic kidney disease. Prenatal care. Hospital-based PHM. Other programs that have a whole-person focus. Accreditation is awarded at the organizational level. Figure 1. NCQA PHM Model Why This New Accreditation? NCQA PHM Accreditation is a mutually beneficial solution for health plans and organizations that provide functions to support PHM. There are two accreditation options: 1. Option 1 is for organizations that have attained or plan to seek Wellness and Health Promotion (WHP) and Case Management Accreditation and want to go through additional PHM review to demonstrate their capabilities for population management at all risk levels. 2. Option 2 is for PHM programs offered by organizations that take a whole-person approach to selected subpopulations, such as those with a particular condition. NCQA convened a PHM Advisory Committee to determine how PHM accreditation could meet the needs of plans and PHM organizations. Throughout 2017, PHM experts provided extensive feedback during in-depth discussions with NCQA about the PHM model and suggested relevant functions and requirements of a PHM program. NCQA staff revised the PHM accreditation concepts based on feedback from the Standards Committee, the Clinical Programs Committee, the Employer Advisory Council and the Public Sector Advisory Council. NCQA also received stakeholder input from current and prospective customers, including health plans, PHM organizations, DM organizations and ACOs. Their efforts helped guide development of the PHM accreditation draft standards.
Introduction to PHM Accreditation 5 NQA PHM Advisory Committee Chair: Gordon Norman, MD, MBA Willis Towers Watson Scott Beardsley, PhD Optum Behavioral Health David Burianek, MBA Anthem, Inc. Charles DeShazer, MD Highmark, Inc. Nina Miles Everett, MD Maryland Physicians Care Lynda Flowers, RN, MSN, JD AARP Damon Francis, MD Health Leads Kathleen Fraser, MSN, MHA, RN-BC, CCM, CRRN Case Management Society of America Don Furman, MD Alignment Healthcare Seiji Hayash, MD, MPH, FAAFP Clinical Transformation and Innovation Expert Amy Nguyen Howell, MD, MBA, FAAFP, America s Physician Groups Claire Levitt, MS New York City Mayor s Office of Labor Relations Veronica Mansfield, DNP, APRN, AE-C, CCM Middlesex Hospital David B. Nash MD, MBA Jefferson College of Population Health. Brent Pawlecki, MD The Goodyear Tire & Rubber Company Debbie Welle-Powell, MPA Essentia Health Katherine Schneider, MD Delaware Valley ACO Paul Wallace, MD AcademyHealth Colleen Walsh UPMC Health Plan Bonnie Youngquist, MA StayWell LLC
6 Introduction to PHM Accreditation Summary of PHM Accreditation Requirements Refer to Appendix 1: PHM Accreditation Standards for the full set of proposed standards and explanations for each of the standard areas described below. PHM Accreditation Draft Standards NCQA PHM Accreditation comprises eight standards that address the following areas: PHM 1: Program Description PHM 2: Data Integration PHM 3: Population Assessment PHM 4: Population Segmentation PHM 5: Targeted Interventions PHM 6: Practitioner Support PHM 7: Measurement and Quality Improvement PHM 8: Patients Rights and Responsibilities The organization describes its programs, including its evidence base, and reviews and adopts new findings that are relevant to its programs as they become available. The organization systematically collects, integrates and assesses data to inform its programs. The organization has a process to assess their population s needs and to use the results to update activities and resources. The organization segments or stratifies their population into actionable categories for interventions. The organization provides targeted interventions based on the patient s level of need. The organization communicates important patient information to practitioners. The organization measures patient experience, program effectiveness, and participation rates. The organization communicates its commitment to the rights of patients and its expectations of patients responsibilities.
Introduction to PHM Accreditation 7 Global Questions for Stakeholders Participating in Public Comment NCQA shares draft standards to generate thoughtful commentary and constructive criticism from interested parties. Many comments lead to changes in our standards and policies, and the review process makes our standards stronger for all stakeholders. NCQA asks respondents to consider whether requirements are feasible and clear, and to highlight areas that need clarification. NCQA encourages detailed, specific suggestions to proposed requirements, to facilitate a final set of standards that are valuable to all. NCQA encourages reviewers to keep in mind global questions when reviewing the standards (see Appendix 1): 1. Do the standards clearly state what is being evaluated? 2. Should PHM organizations be evaluated on these functions/actions? 3. Are the requirements comprehensive? If not, what is missing? 4. Do the structure and order of the standards/elements make sense? Reviewers also are encouraged to comment on each element and respond to targeted questions: PHM 3, Element B: Activities and Resources Should PHM organizations be expected to connect individuals to community resources? If so, how might a PHM organization engage with community resources? Give examples. PHM 4, Element A: Segmentation Do you segment/stratify patients for your clients or do your clients perform this function? For populations you segment/stratify, how often and under what circumstances does your organization conduct segmentation or stratification again? PHM 5, Element A: Providing Patient Interventions Do your clients expect you to refer individuals to services that are outside your scope of services (e.g. recommending patients for wellness services that you do not provide)? If so, what are their expectations for how these referrals are managed? PHM 6, Element A: Communicating with Practitioners Does your organization frequently encounter situations that require communication with a patient s doctor a patient s doctor? If so, give examples of situations and when they occur. PHM 7: Measurement and Quality Improvement Should PHM organizations report information about program costs or efficiency to clients? Please give examples of measures or indicators used to report this information.
8 Public Comment Instructions Public Comment Instructions Public Comment Questions Public comment is integral to the development of NCQA standards and measures. NCQA actively seeks thoughtful commentary and constructive criticism from interested parties and 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. Documents Draft standards and explanations for all product updates are contained in the following materials: Appendix 1: Proposed PHM Category of Standards for HPA 2018. Submitting Comments Submit all comments through NCQA s Public Comment website (http://publiccomments.ncqa.org). NCQA does not accept comments via mail, email or fax. All comments are due by 5 p.m. (ET) on April 3. To enter comments: 1. Go to the public comment database. 2. Enter your email address and contact information. 3. Click to select PHM Accreditation. 4. Click the Instructions link to the view public comment materials (including instructions, proposed specifications and measures). 4. Click to select the Topic and Element (question) on which to comment. 5. Click to select the support option (Support, Do not support, Support with modifications). If you choose Do not support, include your rationale in the text box. If you choose Support with modifications, enter the suggested modification in the text box. 6. Enter your comments in the Comments box. Note: There is a 2,500-character limit for each comment. Be concise in your feedback. We suggest you develop your comments in Word, then cut and paste them into the Comments box. 7. Click Submit and Return to enter more than one comment. When you have submitted all comments, click Submit and Logout. You will receive an email notification with your submitted comments. Next Steps The final Standards and Guidelines for PHM Accreditation will be released in November 2018, following approval by the NCQA Standards Committee and the Board of Directors. PHM Accreditation will be launched in November 2018..