October 15, 2018
Director, Office of Regulation Policy and Management
Department of Veterans Affairs
810 Vermont Avenue NW, Room 1063B
Washington, DC 20420
Docket ID: VA-2018-VACO-0001-2183
Thank you for the opportunity to participate in the September 24th VA MISSION Act Public Meeting Regarding Health Care Standards for Quality. The National Committee for Quality Assurance (NCQA) is a non-profit organization established in 1990 to improve health care quality through measurement, transparency and accountability. We work to build consensus among stakeholders from government, private industry, consumers and academia on ways to improve quality. As a result, our programs are nationwide market leaders that enjoy broad public and private sector support and closely align with Mission Act requirements.
We believe we can add real value based on our extensive experience, consensus-building approach and market leading products that track MISSION Act requirements. We stand ready and eager to help in any way we can and hope the Department of Veterans’ Administration will consider NCQA a valued partner to support its quality improvement efforts.
Accreditation: NCQA has the nation’s largest health plan accreditation program, with over 181 million Americans in NCQA-accredited plans. We accredit plans by rating their actual performance and make the results publicly available to help the VA and many others set benchmarks. The federal government requires such performance-based accreditation for all plans participating in the Affordable Care Act Marketplaces. As a result, more than 85 percent of Marketplace plans are NCQA Accredited. In addition, 26 state Medicaid programs specifically require NCQA Accreditation for managed care plans and another 4 accept NCQA Accreditation. In addition, NCQA has the only long-term services and supports (LTSS) accreditation program, which four states require for managed care plans providing LTSS.
We also have accreditation programs for managed behavioral health care, case management, disease management, utilization management, credentialing, provider networks, wellness and health promotion, and a multicultural health care distinction program to help address culturally and linguistically appropriate services and reduce disparities. We are happy to share the Standards and Guidelines materials for any of these programs and explore how they, or parts of them, might help meet MISSION Act requirements.
Quality Measures: NCQA stewards the Healthcare Effectiveness Data and Information Set, or HEDIS® quality measures. HEDIS is the most widely used clinical quality performance measures and includes more than 90 measures that track prevention, management of chronic conditions, misuse and patients’ experience of care. Medicare, most states and many private purchasers require HEDIS, and insurers covering 57% of all Americans now report HEDIS.
We continuously update HEDIS for new scientific evidence, to remove “topped out” measures with little further opportunity for improvement, and to raise the bar in areas that need improvement. We are fortunate to have a liaison from the VA, along with other private and public entities, on our HEDIS Committee for Performance Measurement (CPM) Committee, which guides this work.
We have specific HEDIS sets tailored to the populations of different product lines, such as Medicare, Medicaid and CHIP, Marketplace and Commercial plans. We would be happy to work with the VA to similarly tailor a set of HEDIS and other measures that meet the specific needs of the veterans you serve.
Comparable Results for Public Reporting: It is critical to have all clinicians within each specialty report the same measures to ensure comparable information for MISSION Act public reporting. Programs that let clinicians choose measures from a menu get the false impression that quality is higher than it actually is because people will report measures that make them look best.
It also is important to ensure that clinicians have sufficient numbers of patients to obtain statistically valid measurement results. Results for clinicians with small numbers of specific types of patients are unreliable and will not provide useful comparative information to VA stakeholders. Medicare’s “virtual group” option addresses this small numbers problem by letting clinicians voluntarily join together for measurement as a group to achieve numbers large enough for valid measurement results. The VA therefore may also want to explore virtual groups as a way to obtain more valid comparable information for the MISSION Act.
Reporting Burden & Meaningful Measures: We are well aware of the amount of time clinicians now spend to report on quality, which takes time away from patient care. We are diligently working to reduce reporting burden by moving to a system in which we automatically derive measurement data from electronic health systems, registries and other electronic sources. This will allow us to access more robust clinical data that are in these systems compared to health care claims that are primary sources for most measures today. It also will let clinicians report measures by merely entering data electronically as they do in the normal course of patient care without additional data entry as required today.
Additionally, we are working toward the same goals as the Centers for Medicare & Medicaid (CMS) Meaningful Measures Initiative that seeks to minimize reporting burden, streamline measures and focus on outcomes. This includes automated reporting, systematic review of measures to retire and developing outcome measures, especially patient-reported outcome measures (PROMs).
Patient-Centered Medical Homes & Neighborhoods: NCQA has the nation’s largest Patient-Centered Medical Home (PCMH) program which includes nearly 20 percent of all primary care physicians, plus additional primary care clinicians, at over 14,000 sites.
PCMHs transform primary care into what patients want by building better relationships between patients and the teams who care for them and directly addressing fragmentation1 that plagues health care. PCMHs do this by:
- Helping patients get care when they need it, including electronically and after hours.
- Coordinating personalized, comprehensive, integrated care.
- Preventing costly, avoidable hospitalizations and emergency department visits – particularly for complex chronic conditions.
- Improving staff satisfaction by ensuring practices have systems and structures to work efficiently.
- Leveraging health information technology (HIT) to enhance access and coordinate care.
- Reducing health care disparities and clinician burnout
A growing body of evidence documents that PCMHs improve cost, quality and patients’ experience of care while reducing both disparities and clinician burn-out.2 In Medicare, for example, PCMHs reduce per capita spending by 4.9%.3
We also have related “medical neighborhood” programs for specialists, retail and other clinics. Over 100 public and private payers support our patient-centered care programs. Congress recognized the value of PCMHs and Patient-Centered Specialty Practices (PCSP) by legislating automatic credit for them under Medicare’s Merit-Based Incentive Payment System.
Patient-Centered Specialty Practices: Our PCSP program, in particular, aligns with MISSION Act provisions for ensuring quality and access for non-Department clinicians. The PCSP program builds off of a PCMH foundation to establish “medical neighborhoods.4,5 The program requires agreements for two-way exchange of critical data between specialty practices and the primary care clinicians who refer patients to them.
These agreements are essential for preventing quality problems with patient referrals. Primary care clinicians report sending referral information 69.3% of the time to specialists, but specialists report receiving it just 34.8% of the time. Specialists say they send reports back 80.6% of the time, but primary care clinicians say they receive them just 62.2% of the time.6 In fact, up to half of referring physicians do not know if their patient sees the specialist.7
| NCQA Patient-Centered Specialty Practice Standards | |
|---|---|
| 1. Track & Coordinate Referrals A. *Referral Process & Agreements B. Referral Content C. *Referral Response | 4. Plan & Manage Care A. Care Planning & Support Self-Care B. *Medication Management C. Use Electronic Prescribing |
| 2. Provide Access & Communication A. Access B. Electronic Access C. Specialty Practice Responsibilities D. Culturally & Linguistically Appropriate Services E. *The Practice Team | 5. Track & Coordinate Care A. Test Tracking & Follow-Up B. Referral Tracking & Follow-Up C. Coordinate Care Transitions |
| 3. Identify & Coordinate Patient Populations A. Patient Information B. Clinical Data C. Coordinate Patient Populations | 6. Measure & Improve Performance A. Measure Performance B. Measure Patient/Family Experience C. *Implement & Demonstrate Continuous Quality Improvement D. Report Performance E. Use Certified EHR Technology |
| *Must Pass Elements |
Additional “must-pass” standards required for practices to achieve recognition include team-based care, medication management, tracking and coordinating referrals and continuous quality improvement.
The program also includes optional criteria practices can meet to earn additional points needed for recognition, such as electronic and same-day access, patient experience surveys, and measuring and reporting their performance. PCSP Recognition there could be a basis for certification of eligible providers, as required by the statue.
The chart below shows how our PCSP standards align with key VA MISSION Act provisions for access – including same-day appointments, measuring and reporting on quality, coordination and patient surveys.
| VA MISSION Act & NCQA PCSP Alignment | |
|---|---|
| VA MISSION ACT | NCQA PCSPs |
| Measure Quality | 6 A: Measure Performance |
| Continuity & Coordination | 1 A-C: Track & Coordinate Referrals |
| Standards & Systems for Monitoring Quality | 6 A-E: Measure & Improve Performance |
| Standards for Access | 2 A-E: Access & Communication |
| Offer Comparative Information | 6 D: Report Performance |
| Survey veteran satisfaction | 6 B: Measure Patient/Family Experience |
| Access To & Continuity for Walk-In Care | 2 A – Access: Reserves time for same-day appts |
| Inclusion of Medical History & Current Medications | 4 B: Medication Management |
| Potential for Tiered Network & Certifying Eligible Providers |
We would be happy to work with the VA and its stakeholders to tailor the PCSP program to meet specific MISSION Act provisions. For example, we have a PCMH standard on query of prescription drug monitoring program we could add to PCSP to align with the MISSION Act provision on monitoring opioids.
We also could make optional criteria like same-day access and measuring patient experience must-pass to fully align PCSP with other MISSION Act provisions.
Conclusion: NCQA for nearly three decades has worked toward our mission to improve quality, access and patients’ experience of care in ways that closely align with the VA MISSION Act. We believe our extensive experience, consensus-building approach and market leading products that track MISSION Act requirements can add real value to your efforts. We stand ready and eager to help any way we can, including tailoring our work to best meet the VA’s unique needs and challenges in implementing the MISSION Act.
Thank you again for the opportunity to participate in the Public Meeting and submit this written statement. We welcome the opportunity to discuss these ideas in greater depth. To coordinate, please contact Paul Cotton, Director of Federal Affairs, at 202-955-5162 or cotton@ncqa.org.
Sincerely,
Michael S. Barr, MD, MBA, MACP, FRCP
Executive Vice President
Quality Measurement & Research Group
- Frandsen et al, Care Fragmentation, Quality, and Costs Among Chronically Ill Patients, 2015.
- NCQA, Benefits of NCQA Patient-Centered Medical Home Recognition, 2017.
- Health Services Research, Total Cost of Care Lower among Medicare Fee-for-Service Beneficiaries Receiving Care from Patient-Centered Medical Homes, 2015.
- American College of Physicians, The Patient-Centered Medical Home Neighbor, 2010.
- Agency for Healthcare Research & Quality, Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanism, 2011.
- O’Malley, Referral & Consultation Communication between Primary Care & Specialist Physicians: Finding Common Ground, 2011.
- Mehrotra, Dropping the Baton: Specialty Referrals in the United States, 2011.