As a part of my professional development, I was certified by the National Committee for Quality Assurance (NCQA) as a Healthcare Effectiveness Data and Information Set (HEDIS) auditor in 2001. I have kept this certification while expanding my skills to include data validation and Pay for Performance Value-Based Program (P4PVBP) certification as I began to recognize the changing environment and the potential shift to VBP.
With today’s uncertainties in health care, the NCQA has joined several health care organizations in a call for a new model of care. In a letter to Congress and the administration, these groups have endorsed a shift from the fee-for-service health care system to value-based care. NCQA and its allies (doctors and specialty societies that represent physicians, health plans and payers) have developed a set of recommendations on how to move our health care system toward innovative, patient-centered care. These recommendations include:
- Empowering and engaging patients so they can make informed health care decisions
- Engaging patients to develop measures of provider performance
- Recognizing that the socioeconomic status of many patients creates challenges to improving care and adjusting payments to providers as appropriate
- Promoting public and private investment in transparency, evidence-based testing and scaling of alternative payment models, as directed by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), so clinicians, providers and payers can learn how payment models work and evolve in the clinical setting
Raising the bar on value-based purchasing will require buy-in across the health care sector. The NCQA and its allies supported further enhancement of HEDIS, one of the most widely used sets of health care performance measures in the country, and the P4PVBP. Health plans and medical groups use the standardized sets of performance measures developed by the NCQA and the Integrated HealthCare Association (IHA) to evaluate quality of care and services provided by their physicians, develop performance improvement initiatives, perform outreach to providers and members, and compare their performance with other health plans and medical groups.
As managed care becomes more a part of post-acute and long-term care and the nation experiences the further narrowing of provider networks, greater emphasis is being placed on quality performance and patient outcomes. Due to these changes, measure sets are focusing more on outcomes and cost effectiveness, rather than process measures, and conscious efforts are being made to align with other health care improvement initiatives.
Such measure sets include the new Quality Payment Program’s (QPP) Advancing Care Information (the ability to report selected eMeasures including appropriate resource use) and the IHA’s Total Cost of Quality (average health plan and member payments associated with care for a member for the year, adjusted for risk and geography). Another example is the newly redesigned P4PVBP (as developed and implemented among California medical groups), which includes a common set of quality and cost measures, a public report, a health plan incentive program, and public recognition programs.
I participated in an NCQA workgroup on eMeasure development and I’m looking forward to seeing the results of implementing a new NCQA/IHA strategy. This strategy strives to align the P4PVBP measure set with other commonly used measure sets (Quality Rating System, NCQA health plan accreditation, QPP), expand the TCOC measurement, evaluate eMeasures, and explore the feasibility of patient-centered measurements.
While performing P4PVBP audits this year in some of the top California medical groups, I was very interested in learning how implementing this program will affect the quality of their reporting and how these changes affect the care they provide their patients. We will begin seeing changes the clinical and cost measures in data from June 2016 and customer satisfaction survey results in the next few months. I appreciate how my unique vantage point as a certified auditor gives me a front row seat to watch the changes play out in our evolving health care system.
About the author
She has expertise is in managing projects involving the design of health care cost and quality reports for employers groups and consumers, national public reporting initiatives for nursing homes and home health agencies, and the development and implementation ambulatory community public reporting. She is widely recognized and trusted throughout the health care system in New Mexico and nationwide, serving on multiple technical expert panels from the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA), often serving on committees at the national level on such topics as contract evaluation and measurement methodologies.
She holds a doctorate in economics and master’s degree in business administration. She is an NCQA certified HEDIS Compliance auditor and a CMS certified data validation auditor. She graduated from the Institute for Healthcare Improvement Breakthrough College covering the use of the Chronic Care Model in Collaborative settings, and was trained as a Quality Improvement Advisor. Galina has published more 70 articles and monographs.
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