President's Perspective: You Get What You Pay For

 

Of the many issues that were debated at our recent Policy Conference that examined the patient-centered medical home, one was implicitly agreed upon by all participants: our health care system is in dire need of reform. But any successful effort to effect change has to start with the way we pay for health care.

 

Right now, the overwhelming majority of health care is paid for on a piecework basis. We pay for encounters, procedures and devices- and that's exactly what we get out of our system. What we don't pay for is what we all want: better health. So it should surprise none of us that our system is a crazy quilt of competing interests with no overarching strategy.

 

Our current payment system is a $2 trillion gravitational field that anchors all of us to the status quo. It's why we don't have widespread implementation of electronic health records. It's why aggressive infection control programs in hospitals are the exception rather than the rule. It's why telemedicine is more science fiction than accepted practice.

 

And since all payment reforms inevitably result in winners and losers, the sheer size of our system is a powerful obstacle to change. An awful lot of "winners" stand in the way of bringing rationality to our system. Of course, they have good reason: every inefficiency in the system is somebody's jobs program.

 

How, then, can we move towards reforming how we pay for health care so that it aligns with the interests of the patients that the system serves?

 

The first step is implementing broader accountability at the provider level. While it's still going through some growing pains, the demand for granular, actionable information about plan and provider performance is here to stay. As we progress, models of plan and provider measurement and pay for performance will become more and more sophisticated. The medical home model we discussed at our recent Policy Conference can serve as a cornerstone of this effort. Patients with complex conditions may require more sophisticated models of accountability, but these can borrow heavily from many of the medical home's overarching principles - care coordination and shared decision-making.

 

Another piece of the puzzle is a concerted effort to developing information about the comparative risks, benefits and costs of different treatments and technologies. The absence of such information undermines our ability to make rational choices. Better data on comparative effectiveness would support national and regional decisions about Medicare coverage, development of practice guidelines and performance measures, and inform patient and clinician decision-making about treatment alternatives.

 

Interest in comparative effectiveness is very high - think back to a study released this past summer that compared the effectiveness of stents to medical intervention. It shows the degree to which we're thirsting for this kind of information, and the powerful role that comparative effectiveness can play in influencing clinical decision-making.

 

Ideally, a physician who is operating in a patient-centered medical home could tap into this kind of information to serve as a trusted guide through the increasingly complex web of treatment options and tradeoffs that mark health care today. The medical home can help patients safely navigate the system, help inform the decision-making of patients and specialists alike, and above all provide continuous healing relationships that help keep us healthy in the first place - and help patients with illness restore their health rationally and humanely.

 

Health, not health care, is what we want out of our system. It's time that we started paying for health care that way.

 

Congressional Roundup: 2007 Ends With a Whimper Amid Signs of Bipartisan Support for Quality Improvement

 

In the end, the first session of the 110th Congress was more talk than action but much of the talk represented strong progress on advancing a health care value agenda.  Strong partisan divisions prevented Congress from acting on such key issues as a long-term extension and expansion of the State Children's Health Insurance Program (SCHIP), legislation to encourage greater use of health information technology (HIT), and changes to Medicare to require greater public reporting and accountability for plans, physicians, and others.

 

Instead lawmakers agreed to a series of short-term extensions of current law and to come back in 2008 to wrangle over many of these issues once again.  Given that 2008 is a Congressional and Presidential election year the prospect for significant compromise and agreement is not likely but incremental change may be possible

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It would be easy, then, to chalk 2007 up as a year of disappointments. But there were some welcome signs of positive movement.  Among them:

• Medicare Physician Payments. Congress approved and President Bush signed legislation delaying for six months a looming 10 percent cut in Medicare physician fees. By delaying the cuts until only the mid-year, lawmakers made a tacit commitment to coming back to returning to the issue in 2008. The legislation also provided new flexibility for the administration of Medicare's Physician Quality Reporting Initiative (PQRI), which creates incentives for doctors to report quality measures and receive additional payments.
• Medicare Advantage Plan Reporting.  Congress could not agree on changes to the Medicare Advantage program due to strong differences over payment rates for plans. But there were signs of agreement in both parties and both houses of Congress to expand HEDIS® reporting by MA plans.  The House passed legislation that would have required reporting by Private Fee for Service (PFFS) plans, which currently cover more than 1 million Medicare beneficiaries, as well as Special Needs Plans (SNPs), serving another million members. These proposals are likely to rise again in 2008.
• SCHIP and Medicaid.  Congress and the President could not agree on an SCHIP bill to expand funding and eligibility for children in families with incomes too high to qualify for Medicaid but too low to afford private coverage. In the end lawmakers extended the current SCHIP program through March 2009. But again there were very positive signs on the quality front.  Both houses agreed on a series of policy changes to expand HEDIS reporting by health plans participating in SCHIP and Medicaid.  These included provisions to develop new measures and to persuade states to require reporting of a core set of measures to allow regional and national benchmarking. These provisions, too, are expected to return in 2008 and 2009.

NCQA Policy Conference Examines Patient-Centered Medical Home

 

NCQA convened its second annual Policy Conference, Building the Patient-Centered Medical Home, on December 6 in Washington. This one-day conference brought together health care experts, health plans, employers, consumer advocates, providers and government officials to discuss and debate current and proposed medical home projects and define how this concept can address disparities in access and quality of care in the current American system.

Although several variations of the patient-centered medical home have been proposed, they share common elements. Proponents of the model seek to restructure traditional reimbursement practices, which currently encourage physician specialization, to support personalized primary care with primary care physicians serving as coordinators of the health needs of their patients. Proponents believe the medical home concept will provide a more efficient and cost-effective care delivery model. 

Expert panelists discussed why we need the medical home concept, how can it improve the quality of care and who will pay for this new approach. The event ended with a roundtable with leaders from Capitol Hill discussing the political feasibility of implementing the medical home in the United States.

For more information on the Policy Conference, click here. Next year's NCQA Policy Conference is scheduled for December 5, 2008 in Washington, D.C. Watch our Web site for more information.

   

NCQA to Launch Medical Home Recognition Program

 

The medical home concept has received considerable attention of late, including a recent article (sub. req.) in the New York Times and this cover article in Modern Healthcare magazine.

 

In an effort to clearly define and recognize medical homes across the country, on January 2 NCQA launched a new recognition program, Physician Practice Connections - Patient-Centered Medical Home (PPC-PCMH).

 

PPC-PCMH assesses physician practices functioning as medical homes and emphasizes the use of systematic, patient-centered and coordinated care management. Supported by the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA), the program is a modification of the current NCQA Physician Practice Connections (PPC) program.

 

PPC-PCMH includes nine standards, including 10 must-pass elements. The program stresses advanced electronic communication, patient-centeredness and care coordination. Practices seeking PPC-PCMH will document their responses through a Web-based data collection tool.

 

The Standards and Guidelines are available now for preorder at www.ncqa.org/publications. For more information on this program, or the other four NCQA Recognition programs, visit http://www.ncqa.org/.

 

Health Care Disparities Focus of Conference, Awards Event

 

Did you know that by 2020, more than 35 percent of the American population will consist of ethnic minorities? Today, 1 in 6 Americans speak a language other than English at home. As our population becomes increasingly diverse, health plans and physicians must adjust their systems of delivery to accommodate different cultural attitudes.

 

On November 12 and 13, NCQA convened a group of experts and thought leaders in the field of multicultural health care in Washington to discuss the latest efforts to reduce disparities and address language and cultural needs, among health plans and physician practices. Key policy makers, health plan representatives and practicing physicians discussed topics ranging from pay for performance, data collection and cultural competency.

 

The conference culminated with an awards luncheon sponsored by Eli Lilly and Company, Verizon, Abbott Laboratories and Healthways that honored the nine recipients of the 2007 Recognizing Innovation in Multicultural Health Care Awards. The winners are:

• Aetna Life Insurance Company and its HMO Affiliates
• Chinese Community Health Plan (San Francisco)
• CIGNA
• Excellus Health Plan (New York)
• Harvard Pilgrim Health Care (Massachusetts, Maine, New Hampshire)
• Health Alliance Plan (Michigan)
  
• Kaiser Foundation Health Plan, Inc.
• UnitedHealthcare
  
• UPMC Health Plan (Pennsylvania)
  

More information on the winners and their programs, including an online poster session and the 2007 Innovative Practices Report, are available by clicking here.

 

Public Comment Now Open for Special Needs Plan Standards

 

NCQA and the Centers for Medicare & Medicaid Services (CMS) recently released for public comment a proposed set of structure and process measures for Medicare Special Needs Plans (SNPs). SNPs serve certain vulnerable groups of Medicare beneficiaries and provide special clinical programs to help people with distinct health care needs. The proposed set of measures is the first step of a multi-year strategy to evaluate the structure, processes and performance of SNPs.

 

The public comment will be open until January 18, 2008. Interested parties are invited to comment on the proposed measures by visiting http://www.ncqa.org/.

 

NCQA's 2008 Health Quality Awards to Honor Health Care Leaders

 

On Tuesday, April 1, 2008, NCQA will host the 2008 Health Quality Awards Dinner in Washington, D.C. At the event, NCQA will recognize the achievements of individuals and organizations whose efforts have been instrumental in highlighting the need for and driving health care quality improvement. The Awards Dinner will bring together a diverse group of health care stakeholders, including health plans, employers, consumers, caregivers and others.

 

Confirmed honorees include Joe Thompson, M.D., M.P.H., Director of Arkansas Center for Health Improvement and Arkansas Surgeon General, and Ron Sims, County Executive of King County, Washington. In addition Senator Edward Kennedy, Democrat of Massachusetts, has been invited to the event. The event will be emceed by Mara Liasson, National Political Correspondent for National Public Radio.

 

The NCQA Health Quality Awards has annually highlighted some of the best and brightest health care minds and innovations. Last year, recipients included Senator Chuck Grassley (R-Iowa) and The Let's Just Play Go Healthy Challenge, a collective effort from the Alliance for a Healthier Generation (American Heart Association, the William J. Clinton Foundation) and Nickelodeon to combat the epidemic of obesity in America's children. Previous award winners include Senator Hillary Clinton (D-New York) and former House Speaker Newt Gingrich (R-Georgia).

 

The 2008 Health Quality Awards Dinner will be held at Andrew W. Mellon Auditorium in Washington, D.C. For more information on attending or sponsoring the event, please contact Brett Gerson, Manager, Corporate & Foundation Relations, at 202-955-3577.

2008 Education Calendar Now Available Online

 

NCQA's Spring 2008 Education Planner is now available online at www.ncqa.org/education. The final offering of the popular "Accreditation 2008" seminar, which details changes for the standards that go into effect July 1, will be held January 17 at NCQA's Washington offices. NCQA Education can bring both existing seminars and customized training to organizations.  For details, contact Victoria Street, Director of Education, at (202) 955-1708 or street@ncqa.org.

 

Your Feedback Wanted on NCQA.org

 

In March, NCQA launched a newly redesigned Web site. This site reflected the feedback of our internal and external customers to create a more user-friendly, functional and informative site. Since the launch, we have continued to make changes to the site reflecting your valued feedback. Recent enhancements aimed at improving user experience include a more readable font size and print option. You can also sign up for email alerts directly on the site by clicking on "Email Alerts", located on the top of every page. At the site's nine-month anniversary, we ask for your feedback once again. Please take a short survey by clicking here. Your ideas and opinions are extremely valuable to us as we continue to build a Web site that best serves your needs. Thank you!