In keeping with the national focus and ongoing evolution of the healthcare environment, NCQA has been soliciting feedback and suggestions on some significant changes to existing Health Plan Accreditation (HPA) standards and HEDIS measures. NCQA is also exploring the possible need for updates to the CAHPS® 5.0H Survey.
SPH Analytics (SPH) has been monitoring NCQA communications and updates surrounding this initiative and has compiled the following overview to summarize these proposed changes.
NCQA’s goal in proposing these changes is to ensure the focus and reporting requirements of Health Plan Accreditation standards:
In March 2018, NCQA released an overview of the proposed 2019 Health Plan Accreditation Updates for public comment and feedback. These updates included multiple changes to existing requirements and the deletion of one or more elements in the existing standards.
NCQA is proposing updates to elements of the following standards:
UM 5, Elements A–D, H: Timeliness of UM Decisions
UM 5, Element H: Timeliness of UM Decisions
MEM 3, Element B: Personalized Information on Health Plan Services
Delegation Standards, Element B: Provision of Member Data to the Delegate
NCQA is proposing deletion of requirements in the following standards:
QI 1, Element A (Factor 3 and 9): Program Structure
QI 3, Elements A, C (Factor 2): Health Services Contracting
UM 12, Element A: Triage and Referral for Behavioral Healthcare
UM Standards: Must-Pass Elements Scoring (Increase threshold on must pass elements from 50% to 80%)
CR 1, Element A (Factor 6): Credentialing Policies
CR 6, Element A (Factor 2 and 3): Notification to Authorities and Practitioner Appeal Rights
Delegation, Element C: Provisions for PHI
NCQA also shared a redacted draft of the existing standards outlining proposed changes and/or deletions. These changes were said to be based on comments and feedback from health plans, NCQA surveyors, and other stakeholders (including healthcare consumers, states, and CMS).
NCQA plans to release the final Standards and Guidelines for HPA 2019 in July 2018, following approval by the NCQA Standards Committee and the Board of Directors.
Of equal interest to health plans and SPH Analytics, are the anticipated changes to the CAHPS 5.0H Survey. NCQA, working in conjunction with the AHRQ CAHPS Consortium, is considering the need for updates to the CAHPS 5.0H Survey. NCQA had requested feedback and suggestions from market stakeholders during the HEDIS public comment period from February 13 through March 13, 2018.
While NCQA is open to all feedback and suggestions, some of the topics or issues identified for consideration include:
SPH applauds NCQA’s continuing efforts to evaluate and improve the CAHPS 5.0H Survey. As an NCQA-certified survey vendor for the CAHPS 5.0H Survey since the program’s inception, SPH welcomed the opportunity to respond to the proposed changes based on our extensive experience administering CAHPS Surveys and understanding of our clients’ challenges and objectives.
Health plans are faced with multiple CAHPS Survey reporting and data submission requirements for NCQA and for state and federal reporting programs. SPH endorsed the suggestions to align the list of CAHPS measures (i.e., Coordination of Care, Shared Decision Making, Claims) required of regulatory quality programs (NCQA Accreditation, QHP QRS, CMS Star Ratings) for different lines of business (Commercial, Medicaid, Medicare).
The current CAHPS Survey methodology is based on a random sample of health plan members. SPH has advocated for a sampling alternative to allow plans to target high volume utilizers of care or services to satisfy minimum valid n requirement on gated questions for select CAHPS measures (i.e., Customer Service, Claims, Getting Care Quickly).
SPH also emphasized the potential benefits of more frequent data collection to assist health plans in monitoring change and developing targeted quality improvement initiatives with higher confidence.
Consistent with healthcare issues of national concern, NCQA has expanded their focus on behavioral health quality measures, opioid abuse, and the care needs of high-risk patients with multiple chronic conditions.
Following is a list of proposed new measure and those with proposed changes:
NCQA proposes to exclude members with advanced illness from 11 HEDIS measures that address prevention, screening, and disease management. NCQA explains that these measures are “designed and intended for the general adult population and may not be clinically appropriate, relevant or in line with goals of care for patients with advanced illness and frailty.”
Telehealth is predicted to change the way healthcare is provided from the point of emergency care needed, monitoring patients with chronic conditions, and overall expanding patients’ access to care. Though the in-person interaction is often preferred in providing clinical care or services, research has shown telehealth services may be equally appropriate and effective.
NCQA introduced telehealth in seven behavioral health measures for HEDIS 2018. NCQA is, therefore, looking closely at select “HEDIS physical health measures” and the option to include telehealth services.
Prior to determining final updates to 2019 HEDIS/CAHPS measures, NCQA will review and discuss public comments with industry stakeholder groups, advisory committees, and user groups, including the CAHPS Consortium.
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