January 29, 2018
The Honorable Alexander Azar, MD, Secretary
Department of Health & Human Services
200 Independence Ave. S.W.
Washington, DC 20201
Dear Secretary Azar
Congratulations on your confirmation as Secretary of Health & Human Services (HHS). The National Committee for Quality Assurance (NCQA) is eager to work with you toward our shared goal of high-quality, efficient, affordable health care. I write to highlight priorities where our programs and expertise, developed over 28
Accreditation & Deeming: Using private health plan accreditation to augment government oversight minimizes burden on government, taxpayers and plans alike. NCQA’s Health Plan Accreditation program is the nation’s largest, with nearly 170 million Americans, or 72% of all insured enrolled in NCQA-accredited plans. NCQA does a great deal to support HHS’s oversight of both federal and state managed care plans, and we could do even more. Our rigorous, “performance based” process includes review of actual case files to verify whether plans enforce key consumer protections. We score the quality of clinical care and patients’ experience, and require strict auditing to ensure accuracy. We also publicly report results to hold plans accountable and help employers and consumers make informed choices.
Medicare Advantage Deeming: The bipartisan Balanced Budget Act of 1997 established the policy of “deeming” Medicare Advantage (MA) plans that earn NCQA accreditation as compliant with Center for Medicare & Medicaid Services (CMS) regulations that overlap with our program standards. Deeming streamlines CMS oversight while providing both accountability and regulatory relief for plans. Deeming also promotes accreditation, and NCQA-accredited plans perform better on important quality measures like asthma and diabetes care and nutrition and exercise counseling.
CMS, however, suspended deeming as the Obama Administration focused oversight heavily on coverage and appeals rather than areas previously deemed, leaving little tangible value from deeming for either CMS or plans. We are working with CMS staff and other allies on best ways to restore MA deeming, and look forward working with you on this common-sense way to enhance oversight. Restoring deeming will enhance Medicare’s ability to ensure that enrollees receive the best care and acknowledge accredited plans’ efforts to meet the highest standards for quality and consumer protection.
Medicaid Deeming: Medicaid programs in 25 states require NCQA Accreditation, while another 5 states mandate accreditation and accept NCQA. States rely on NCQA Accreditation for the same reasons the federal government has – it helps them meet quality and cost goals while minimizing direct expenses for the government. We also provide a consistent benchmark for comparisons across states and minimize burden for issuers, particularly those offering Medicaid plans in multiple states.
CMS could expand the value of deeming further, for example by broadening deemable elements of Medicaid managed care oversight to include Network Adequacy. The Medicaid managed care rule issued in 2016 by the previous Administration specifically excluded Network Adequacy, but your Administration’s ongoing reconsideration of the rule provides an opportunity to rectify this problem. NCQA’s standards provide flexibility for plans to tailor networks to meet the health and cultural needs of their members. We review plans’ systems for ongoing monitoring of access and availability, including patient experience and how plans work to addresses any geographic or provider (e.g. high-volume specialist) network gaps. States should have authority to deem NCQA-accredited plans that plans meet these requirements as meeting Medicaid network adequacy standards.
You also could expand deeming’s value and save states money by aligning Medicaid managed care clinical performance audit policy with Medicare Advantage policy. MA plans must report audited HEDIS results and also pay for the audit. Current Medicaid rules, however, require plans that pay for commercial and Medicare audits to also undergo a separate, redundant and costly state audit. A revised Medicaid managed care rule could rectify this as well.
HEDIS Quality Measures & Meaningful Measures Initiative: NCQA stewards HEDIS, the most widely used set of clinical quality measures among public and private payers. HEDIS is integral to nationwide pay-for-performance goals to reward the value instead of the volume of care. There is broad bipartisan and stakeholder consensus on this, as well as HEDIS’s central role in making it work:
- The Medicare Access & CHIP Reauthorization Act (MACRA) passed with overwhelming bipartisan support, and MACRA rules encourage clinicians to report many HEDIS measures.
- The Medicare Advantage Star Ratings pay-for-performance system has tremendously improved quality and cost, and also includes many HEDIS measures.
- Most state Medicaid programs and many private commercial insurers use HEDIS to promote and track quality improvement and as a basis for pay-for-performance.
We would like to explore how to maximize the value of HEDIS to the Department’s efforts to drive higher-quality, lower-cost and better patient outcomes. NCQA believes that the deployment of existing behavioral health and substance use measures, and development of new ones, could be an important part of addressing the opioid epidemic, for example.
Meaningful Measure: NCQA strongly supports and is aggressively working toward CMS’ “Meaningful Measures” initiative goals. We agree on the urgent need to minimize reporting burden, streamline measures and focus on measuring outcomes. Clinicians are now spending far too much time on quality reporting. We want to return time to patient care by deriving measurement data from what clinicians document in routine care delivery without additional input. Data intermediaries (e.g., qualified clinical data registries, health information exchanges, data analytics companies, cloud-based EHRs) should be able to consume data from electronic health records, and then calculate and report measurement data on behalf of their contributors. Health systems managing their own data warehouses would naturally be able do so. However, the ability to accurately calculate and report measure results requires certification by a third-party entity such as through NCQA’s eMeasure Certification program. This pathway would help EHR vendors focus on usability and interoperability rather than updating measure specifications, as data intermediaries would manage measure specifications.
NCQA also is working with Clinical Quality Language (CQL) to update existing measures and develop new measures. NCQA held a Digital Quality Summit last November to address issues and solutions using CQL and Fast Healthcare Interoperability Resources (FHIR) for reporting.
NCQA looks forward to working with CMS to find resources for expediting measure conversion using CQL to create a focused portfolio of meaningful measures that require much less effort to report.
We are systematically reviewing where and how we can retire measures that are duplicative, topped-out or low-value. For example, we are cutting two measures that stakeholders agreed provided little value: Frequency of Ongoing Prenatal Care, and digoxin rates in the Annual Monitoring for Patients on Persistent Medications measure. We also are harmonizing with other measure developers, rather than develop similar measures. For example, we decided to incorporate Minnesota Community Measurement’s PHQ-9 depression screening and follow-up measure into HEDIS rather than develop yet another redundant measure focused on the same priority. We also are beginning to develop outcomes measures, especially patient-reported outcome measures (PROMs), and have two PROMs for depression now included in HEDIS for health plan evaluation. Still in development are several individual goal attainment measures for persons with advanced illness or long-term care needs.
The strong alignment between Meaningful Measures and NCQA’s work is not surprising, as we all understand the urgent need to address today’s situation. We are working with CMS staff in the Center for Clinical Standards & Quality and Medicare Drug & Health Plan Contract Administration Group on best ways to move forward. We look forward to continuing to work with CMS and all stakeholders to achieve Meaningful Measures goals as effectively and expeditiously as possible.
Fair and Accurate Performance Measurement: As we move to more value-based pay, we must ensure that electronic health systems report quality measures accurately and fairly, and that the validity of results are beyond question. The Office of the National Coordinator (ONC)’s current certification program is not providing sufficient rigor for this, and NCQA recently received ONC approval for our eMeasure Certification. Our program significantly reduces high error rates that undervalue the quality clinicians provide. Both the Premier healthcare alliance and MyHealth Access Network in Oklahoma have used and agree that our program produces substantially more valid results.
Patient-Centered Care Programs: Patient-centered care is key to improving quality, costs and patients’ experience of care. President Trump himself has stated that his “Administration’s goal will be to create a patient-centered healthcare system that promotes choice, quality & affordability.” The Medicaid managed care rule highlighted the need for value-based purchasing and the patient-centered medical home model.
NCQA’s Patient-Centered Medical Home (PCMH) program is the nation’s largest, and recognized nearly 1 in five primary care physicians. It gives providers, private payers, Medicare and states a solid foundation for value based purchasing that aligns with existing state and federal initiatives. PCMHs improve quality and costs by preventing avoidable hospitalizations and ED visits, reducing disparities, increasing preventive screenings, and improving adherence to evidenced-based medicine.
This is why more than 124 public and private initiatives across 50 states provide incentives to PCMHs, and why MACRA also provides credit to both NCQA PCMHs and PCSPs. The Center for Medicare & Medicaid Innovation is now urging states to utilize our program rather than invent their own, which helps to reduce burden and promote standardization nationwide. We also are exploring how to give CPC+ practices credit toward our PCMH recognition to further promote a standard approach to patient-centered care. We look forward to continued collaboration toward the goal of standardization and patient-centered care for all Americans.
NCQA, in fact, now has a suite of patient-centered care programs.
- NCQA’s Patient-Centered Specialty Practice (PCSP) program builds on PCMHs to create “medical neighborhoods.” PCSPs feature strong communication with primary care practices on referrals, and enhanced access such as same day appointments for people with urgent needs.
- NCQA’s Oncology Medical Home program builds on PCMHs and PCSPs with extra focus on patient-centered cancer care.
- Our Patient-Centered Connected Care (PCCC) program brings the patient-centered focus to urgent care, retail, physical therapy and similar sites.
Congratulations again on your confirmation. NCQA’s Director of Federal Affairs, Paul Cotton, (202-955-5162, cotton@ncqa.org) will follow up to request a meeting with you to discuss these issues further.
Sincerely,
Margaret O’Kane
President