HBCH Purchaser Meeting

eValue8 CORE 2018 Overview

May 30, 2019

Chris SkisakHouston Business Coalition on Health

Foong-Khwan Siew, PhD, MBADirector, National Alliance of Healthcare Purchaser Coalitions

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What is eValue8TM?

A national, standardized health plan evaluation created by

business coalitions and employers like Marriott and General Motors

to measure and evaluate health plan performance

The eValue8 process is used to:

– Articulate purchaser expectations

– Facilitate purchasers’ value-based selection of health plans by

supplying the “Quality Factor” in the value equation

– Provide benchmarks for local and national comparisons - between

plans, and over time

– Identify and promote opportunities for quality improvement

– Drive collaboration between health plans and purchasers

– Educate employees on health plan quality

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Other Assessments based on eValue8

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Other Assessments based on eValue8

WA Coalition’s Objectives in Sponsoring eValue8

1. Generate consistency in health plan assessment

that enables transparency of performance and

permits comparison within and across markets

2. Stimulate improved performance from health plans

3. Enable purchasers and plans to work collaboratively

to organize strategies and structure programs to

improve value in our market

4. Inform purchasers’ procurement decisions about

health insurance for their employees and

dependents

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What are HEDIS and CAHPS?The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used

by more than 90% of America's health plans to measure performance on

important dimensions of care and service. Because so many plans collect

HEDIS data, and because the measures are so specifically defined,

HEDIS makes it possible to compare the performance of health plans on an

"apples-to-apples" basis. Health plans also use HEDIS results themselves to

see where they need to focus their improvement efforts.

To ensure the validity of HEDIS results, all data are rigorously audited by

certified auditors using a process designed by NCQA (National Committee

for Quality Assurance)

Consumer Assessment of Healthcare Providers and Systems (CAHPS)

surveys ask consumers/patients to report on and evaluate their

experiences with a range of health care services at multiple levels of the

delivery system. There is a Health Plan CAHPS survey.

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Overview of eValue8 CORE 2018

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Total Points = 484.5

Member Support (“Helping Members”) Total = 56%

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Summary of Accreditation Status

Plan NCQA URAC

Plan 1Accredited (Dec 2019)

Physician QualityMBHO

Pharmacy Benefit MgmtSpecialty Pharmacy

Plan 2Accredited (Sept 2020)

Physician & Hospital QualityMBHO

Pharmacy Benefit MgmtSpecialty PharmacyCase Management

Plan 3

Commendable (Nov 2021)Physician Quality

MBHOCase Management

Pharmacy Benefit MgmtSpecialty Pharmacy

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MBHO = Managed Behavioral Health Organization

Summary of Participation in Select Initiatives

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Plan Multi-Payer PCMH

Prometheus/BTE

CMS HCPLAN

CDC Nat’l Diabetes Prevention

Core Qual.MeasuresCollab (CQMC)

TX Common Measure Set

Plan 1 ✓ ✓ ✓ ✓ ?

Plan 2 ✓ ✓ ✓ ✓ ?

Plan 3 ✓ ✓ ✓ ✓ ?

High Level Summary: Focus Areas in eValue8• Provider (Physician and Hospital) Management, Support and Measurement

– Support for engaging members

– Support for care management, identification of gaps in care

– Scope of measurement for transparency, feedback and rewards

– Effective use of contracting to drive innovation and improved performance among providers

• Member Support and Engagement -- “Helping Members . . .”

– Member screening, identification of gaps in care

– Price and quality transparency

– Robustness of tools: shared decision-making and physician choice and telehealth

– Health literacy, technology/mobile apps

– Maternity (including C-section, VBAC and elective delivery rates)

– Alignment of plan design with desired outcome (value-based benefit design)

• Pharmaceutical Management

– Quality and Safety

– Specialty Pharmaceuticals

– Generic & Appropriate Drug Use

• Performance Results

– CAHPS and HEDIS (Diabetes, Heart, Behavioral Health, Cancer screening, Women’s health, Immunizations, Tobacco Use, Obesity, Overuse/appropriate utilization)

– Accreditation

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Module #2:

Physician and Hospital (Provider)

Management and Measurement

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Overview of Module #2 ContentPhysician & Hospital Management & Measurement (28.6% of total points) (in order of weighting within the module)

• Physician and Hospital Measurement

– Key areas measured and used in provider performance feedback and transparency for members

– HEDIS ED and All-cause hospital readmissions

– Leapfrog survey response and admission rates to top and lower quartile hospitals

– Use of common measure set(s) to standardize measurement

• Physician/Hospital – Network management and contracting

– Impact on members when no negotiated contracts in place (surpsrse billing)

– Use of tiered or high-value networks and spend

– Spend on legacy FFS versus payment innovation

• Physician Management/Support to Help Members Manage Chronic Conditions

– Education and support related to high-risk, medically complex patients, diabetes and depression

– Monitoring appropriate prescribing of antidepressants and pain medications

• Physician Management/Support to Help Members Get/Stay Healthy

– Education and support related to tobacco cessation, obesity

– Monitor providers’ use of screening (e.g., depression, diabetes, alcohol)

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Physician & Hosp. Mgt. & Measurement (29% of RFI points)

Highlights of Top Performance

Physician & Hospital Measurement (54% of Module)

• Broad use of evidence-based measures in monitoring & reporting on performance and payment

• Adoption of common measure set

• HEDIS performance - all cause readmissions and ED utilization

• High rate for LF survey response and admission to LF top quartile hospitals and low admission rates to LF lowest quartile hospitals

Management & Contracting including payment innovation(21% of Module)

• Presence of ACO/PCMH and/or high-value networks and allocation of payment – market level information

•Greater % in VB payments, breadth and depth of non-FFS payment models

•Members held harmless when no negotiated contracts are in place

Support to Physicians to help id and manage patients with Chronic Conditions(16% of Module)

• Robust support (educations/information, incentives and practice support) to help physicians identify and manage high-risk medically complex patients, patients with diabetes and depression.

• Monitoring of appropriate prescribing for antidepressants and pain medications among PCPs

Support to Physicians to help patients Stay/Get Healthy(10% of Module)

• Robust monitoring of physicians re: USPSTF recommended screenings

• Robust support to help physicians identify and manage patients who use tobacco and those who are overweight/obese

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Summary Level Results – Module 2

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Common Strengths

▪ All have payment innovation programs (no TX specific information)▪ All have strong non-payment policies for addressing healthcare acquired conditions (HACs) and serious reportable events (SREs) that are not HACs▪ All use a broad set of measures for monitoring, feedback & transparent reporting and payment to physicians/PCMH/ACOs▪ All hospital-based specialists have discounted contracts/claims considered in-network▪ All promote and reimburse for use of obesity and smoking-related coding

Common Opportunities

▪ All have 50% or more of $ in legacy FFS ▪ All are using bundled/episode based payment, $ paid <3 % of all dollars (One plan is ~6%)▪ 2 of 3 are below 50th percentile for hospital readmissions and ED Utilization▪ All need to shift % admissions from LF lowest quartile hospitals to highest quartile▪ All need to provide stronger support to physicians to help them manage patients with

depression▪ Stronger support to physicians to help manage members who are obese (except for 1 plan)

and/or who use tobacco

Where Plans are Differentiated

▪ 1 of 3 has > 50% $ in HPN and/or ACOs▪ 1 of 3 is > 50th percentile for HEDIS all cause readmission▪ 1 of3 is > 50th percentile for ED utilization▪ 1 of 3 has over one-third of hospitals reporting to LF survey nationally▪ 1 of 3: Comprehensive support to help physicians help manage patients with diabetes, and

those who are high-risk/medically complex▪ 1 of 3: No monitoring that physicians are screening for: depression among adolescents and for

obesity in children (USPSTF A/B recommendation)▪ 2 of 3 have robust monitoring of PCPs’ appropriateness of prescribing for pain medications and

antidepressants

Module #2 (Provider Management/Measurement)

Potential Key Questions for Health Plan to Respond to:

1. What is the status of your plan’s implementation of value-based provider contracting in Houston?

• Please describe and include how you identify and reward value and the current # of covered lives in each type of arrangement to give a sense of scale/scope.

• Why is the uptake of bundled payment so low and what are you doing to position your plan to successfully implement bundles in the future?

2. What performance metrics are you emphasizing – what is most important in the areas of quality, access, patient experience and cost?

3. What tools and information do you give to providers, if any, to help them steer patients to higher quality health care in the Houston market?

4. What are you doing to support physicians in identification and management of patients with depression

5. What is your approach to balance billing, particularly for out-of-network surprise bills, and what specific things do you have in place to protect our members?

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Module #4:

Helping Members Become Good

Consumers

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Overview of Module #4 ContentModule 4: Helping Members Become Good Consumers (16.2% of total points) (in order of weighting within the module)

• HEDIS and CAHPS Performance

– HEDIS results for overused procedures

– CAHPS results (getting needed care, getting care quickly, customer service, shared decision-making)

• Shared Decision-Making and Treatment Option Support

– Use of social media, digital tools and/or telephonic support to engage consumers in decision-making

– Scope of treatment option support and evaluation

• Help Finding the Right Care

– Activities to address health literacy

– Online physician selection tool(s)

– Telehealth opportunities

• Price Transparency

– Accessible and easy to use cost calculator to compare costs of alternative treatments, physicians hospitals, ASCs, drugs, bundles, etc., and CAHPS result

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Helping Members Become Good Consumers(16% of RFI points)

Highlights of Top Performance

HEDIS & CAHPS(38% of Module)

• Above 75th percentile performance on HEDIS overused procedures

• Above 75th percentile on CAHPS composite measures (getting needed care, getting care quickly, customer service, shared decision-making)

Shared Decision Making (SDM) and treatment Option Support (TOS) (36% of Module)

• Use of personal health technology (Mobile apps, devices, social media, etc.)

• Scope of treatment option support (online, telephonic) and evaluation

• Activities to id of members that would benefit from SDM

Help Finding the Right Care(15% of Module)

• Activities to address health literacy

• Online physician selection tool(s)

• Scope of Telehealth and utilization

Price Transparency(11% of Module)

• Accessible and easy to use cost calculator to compare costs of alternative treatments, physicians, hospitals, facilities, drugs, bundles, etc.

• CAHPS result on cost tool

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Summary Level Results – Module 4

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Common Strengths

▪ All have robust shared decision making (SDM) tool and offer telephonic support for treatment decisions

▪ All have comprehensive activities to identify members who need treatment option support

▪ All 3 carriers have comprehensive activities to address health literacy

Common Opportunities

▪All need to improve certain features within their physician selection tool (functionality and content such as physician performance information)▪ Improve usage rates for tools and telehealth (less than 1%)▪CAHPS rating on Plan Information on Cost: below 50th percentile (1 plan) or insufficient

sample size▪ All need to reduce overused procedures (e.g., back surgery)▪ All need to improve on some/all 4 CAHPS ratings (getting needed care, care quickly,

Shared Decision Making (SDM) and customer service) and satisfaction with cost information

Where Plans are Differentiated

▪ 2 of 3: Robust evaluation of SDM/Treatment Option Support (TOS) tool including measuring change in utilization patterns for preference-sensitive services (e.g., back surgery)

▪ 2 of 3 have a comprehensive cost calculator▪ 1 of 3: HEDIS >50th percentile for 2 of the overused procedures (angioplasty (F) and

prostatectomy)▪ 1 of 3: CAHPS > 50th percentile “Getting Needed Care” composite▪ 2 of 3: SDM/TOS tool has cost calculator integrated

Module #4 (Helping Members be Good Consumers)

Potential Key Questions for Health Plan to Respond to:

1. Are you promoting and paying for telehealth to improve access and

convenience for members? Describe (most do not have this information in

directory)

2. What is the status of your plan’s implementation of user friendly, web-based tools

to help consumers and purchasers assess value and find a hospital or physician?

• Does your cost calculator combine cost and quality information in one

place? How robust is the tool and what is included? Is it REALLY easy to find

on your website?

• Do your tools combine a cost calculator with treatment decision support

(education/info about choices) in a single, user-friendly tool?

3. What are your specific strategies to improve member experience (CAHPS

scores)? (e.g., getting needed care, getting timely care, customer service, etc.)

4. How can you inform your efforts to improve patient experience when you have

an insufficient sample size for so many CAHPS measures?

5. How can we collectively increase use of tools and telehealth?

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Module #6:

Helping Members Manage

Chronic Conditions

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Overview of Module #6 ContentHelping Members Manage Chronic Conditions (21.1% of total points)(in order of weighting within the module)

• HEDIS Performance: Heart Disease, Diabetes

– 12 measures

• HEDIS Performance: Behavioral Health

– 12 measures

• Member Engagement: Heart Disease and Diabetes

– Identification and engagement of members to address specific needs

– Medication compliance (3 measures)

• Member Engagement: Behavioral Health

– Identification and engagement of members to address specific needs

– Access to substance use (SU) medications with limited obstacles for those diagnosed with SU disorder

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HEDIS – % Members with diabetes (type 1 and type 2) who

had HbA1c control of less than 8%.

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