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Purpose. Describe the current Quality Improvement (QI) program for the Medicare Advantage (MA) plansProvide an update on future directions for the QI program. Presentation Overview. Background on the Development of the QI StrategyDefining QualityMA QI ProgramComponents of the QI StrategyResources and Program Enhancements.
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1. Overview of the Medicare Advantage Quality Strategy Vanessa DuranDirector, Division of Policy, Analysis and PlanningMedicare Drug & Health Plan Administration GroupSeptember 20, 2011
2. Purpose Describe the current Quality Improvement (QI) program for the Medicare Advantage (MA) plans
Provide an update on future directions for the QI program
3. Presentation Overview Background on the Development of the QI Strategy
Defining Quality
MA QI Program
Components of the QI Strategy
Resources and Program Enhancements
5. Foundations of the QI Strategy 42 Code of Federal Regulations (CFR)
§ 422.152
2001 Institute of Medicine Report
Triple AIM
Health and Human Services (HHS) National Quality Strategy 2011
HHS National Prevention Strategy 2011
6. 42 CFR §422.152 Contains description of the requirements for the QI program for MA Organizations (MAOs)
Separate section for Special Needs Plans (SNPs)
7. Triple AIM Improve the individual experience of care
Improve the health of populations
Reduce the per capita costs of care for populations
Source: Berwick, D., Nolan,T.W., and Whittington, J. The Triple Aim: Care, Health, and Cost. Health Affairs, 27, no 8 (2008): 759-769.
8. HHS National Quality Strategy (NQS) Mandated under the Affordable Care Act
Released in March 2011
Will require all agencies within HHS to develop their strategy
9. HHS National Quality Strategy: National Aims and Priorities Three National Aims
Better care
Healthy people/healthy communities
Affordable care
10. HHS National Quality Strategy: Priorities Six Priorities
Make care safer by reducing harm caused in the delivery of care
Ensure that each person and family are engaged as partners in their care
Promote effective communication and coordination of care
Promote the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular diseases
Work with communities to promote wide use of best practices to enable healthy living
Make quality care more affordable by developing new health care delivery models
11. HHS National Prevention Strategy (NPS): Strategic Directions Also mandated under the Affordable Care Act
Builds on the principles of the HHS NQS
Focus is to improve health care quality and quality of life through increased access to preventive services
12. HHS National Prevention Strategy (NPS): Strategic Directions Four strategic directions
Healthy and safe community environments
Clinical and community prevention services
Empowered people
Elimination of health disparities
13. HHS NPS Priorities Seven Priorities
Tobacco free living
Preventing drug abuse and excessive alcohol use
Healthy eating
Active living
Injury and violence free living
Reproductive and sexual health
Mental and emotional well-being
15. Defining Quality Complex
Contains multiple dimensions
May have different meanings depending on the context
Dr. Berwick has defined quality during his trainings as:
“ Meeting and exceeding the needs and expectations of our customers”
16. Defining Quality: Our Goals for MA We want the industry to compete on quality
We want MAOs to provide leadership and innovation in delivering quality health care
Our MA QI Strategy is the framework to guide the MA program
17. Defining Quality
18. Quality is Multidimensional
19. Quality for MA System
Benefits
Access
Provider Network
Well-trained
Coordinated care
Patient
Health status and health outcomes
Satisfaction
20. Quality for SNPs System
C-SNP
D-SNP
I-SNP
Provider
Model of Care: Interdisciplinary Care Team
Patient
Model of Care: Health Risk Assessment
22. Quality Improvement (QI) Program Applies to all MAOs, including SNPs
Seven components of the QI program
Chronic care improvement program (CCIP)
Meets the requirements of 42 CFR §422.152(c)
Addresses populations identified by CMS based on a review of current quality performance
Quality improvement projects (QIP)
Meet the requirements of 42 CFR §422.152(d)
Expected to have a favorable effect on health outcomes and enrollee satisfaction
Address areas identified by CMS
Develop and maintain a health information system
23. QI Program (continued) Encourage providers to participate in CMS and HHS QI initiatives
Contract with an approved Medicare CAHPS® vendor to conduct the Medicare CAHPS® satisfaction survey of Medicare enrollees
Include a program review process for formal evaluation of the QI program that addresses at least the following areas on an annual basis:
Impact
Effectiveness
Correct problems for the plan
24. SNP QI Program Model of care (MOC)
Eleven elements:
Description of the SNP-specific target population
Measurable goals
Staff structure and care management goals
Interdisciplinary care team (ICT)
Provider network having specialized expertise and use of clinical practice guidelines and protocols
MOC training for personnel and provider network
Health risk assessment (HRA)
Individualized care plan
Communication network
Care management for the most vulnerable subpopulations
Performance and health outcome measurement
26. QI Strategy Components Vision
Mission
Core Values
Goals
Objectives
Define specific objectives for our goals
Develop metrics to monitor objectives and measure progress
Implementation or Action Plan
Comprehensive
Designed to assess, develop, and implement the best possible standards of care to assure that the health care systems deliver the highest quality of care across all plan types
28. QI Program Resources Code of Federal Regulations (CFR)
Central Office and Regional Office Staff
CMS website
Medicare Managed Care Manual Chapter 5
Refer plans with specific or technical plan rating questions to:
PartCRatings@cms.hhs.gov or PartDMetrics@cms.hhs.gov
29. Resources by Topics General MA and SNP QI program, Medicare Managed Care Manual Chapter 5, QIPs/CCIPs, SNP performance measures
Margot Blige Holloway
Jaya Ghildiyal
Vanessa Sammy
Dr. Marsha Davenport
Plan Ratings; HEDIS®; CAHPS®
Dr. Elizabeth Goldstein
Health Outcome Survey (HOS)
Jason Petrowski
Sonya Bowen
30. QI Program Enhancements Improve methods for reporting the CCIPs and QIPs
Provide technical assistance early in the process
Provide ongoing technical assistance
31. Expand QI Program Resources CMS website pages
Will be developed and updated regularly
Other areas being developed to support the QI program:
Guidance
Training
Outreach materials for plans
32. Summary Quality is a focus for the MA program
Achieve quality health care through a strong QI strategy and program
Continue to develop better clinical outcomes measures to demonstrate the impact the MA program has on improving health and health outcomes for our beneficiaries
33. Contact Marsha Davenport, MD, MPH
CAPT, USPHS
Chief Medical Officer
Medicare Drug and Health Plan Contract Administration Group (MCAG)
Division of Policy, Analysis and Planning (DPAP)
Marsha.davenport@cms.hhs.gov
410-786-0230