In mid-September, KPMAS was recognized by the National Committee for Quality Assurance as the only health plan in the nation to receive the highest ratings for its Private, Medicare and Medicaid insurance plans. In the October 1, 2018 edition of Health Plan Weekly, this stunning accomplishment by KPMAS is highlighted and Kim Horn, President of KPMAS, and Dr. Joe Territo, Associate Medical Director for Quality MAPMG, are quoted discussing the 2018 ratings. Read the full article below:
NCQA Plan Ratings Highlight Two ‘Perfect’ Commercial Plans
By Judy Packer-Tursman
Numerous press releases are flooding into public view now that the National Committee for Quality Assurance (NCQA) has unveiled its latest annual iteration of health plan ratings based on consumer satisfaction, prevention and treatment.
Many press release headlines are state-specific: “Anthem Blue Cross Blue Shield Rated Among Top Health Plans in Maine by NCQA.” Some focus on one of three business lines — private commercial, Medicare and Medicaid — covered by the ratings: “Amerigroup Ranked Top Medicaid Plan in Georgia by NCQA.” Others are national in scope: “Blue Cross Blue Shield of Massachusetts Among Nation’s Highest-Rated Health Plans for Quality.”
Even FirstCare in Texas, which earned mostly 3s on NCQA’s five-point performance scale for its commercial and Medicaid plans, along with a 2.5 for its commercial plan in Waco, headlined the news: “FirstCare Health Plans Awarded NCQA Commendable Status.”
However, this year only two of 445 health plans earned a top 5 out of 5 for their commercial business in NCQA’s ratings. Both insurers tell AIS Health they credit their strong performance to integrated delivery models and continuous efforts to improve quality of care — and they see value in such ratings well beyond plan marketing and bragging rights.
On the surface, the duo — Group Health Cooperative of South Central Wisconsin and Kaiser Permanente of the Mid-Atlantic Region — “seem as if they couldn’t be more different,” especially in terms of size and service area, says Ceci Connolly, president and CEO of the Alliance of Community Health Plans (ACHP) in which both plans are members.
Group Health is a staff model HMO with 80,000-plus members, primarily in Dane County and its dozens of towns, villages and unincorporated communities in addition to Madison, the state capital. The Kaiser plan is one of eight regions of California-based Kaiser Permanente, whose health plans combined serve more than 12 million members. Its enrollment is closer to 800,000 in the densely populated Washington, D.C., region, including parts of Maryland and Virginia.
Yet Connolly sees both nonprofit plans’ integrated delivery systems as a unifying point. “Any time the model brings the health plan and providers closer together, we believe that’s better… for the health of the community,” she says, “and we see it over and over again in NCQA, CAPHS [Consumer Assessment of Healthcare Providers and Systems] and CMS ratings.”
As for the two plans’ considerable size difference, she says: “That’s good news for consumers. You know it’s not the size of the company that matters. It’s the care delivery model…and both of these companies take [financial]risks [in terms of capitated agreements and value-based arrangements with providers], and that’s beginning to make a difference as well.”
Not all employers purchasing commercial coverage for their workers are necessarily invested in plan ratings, Connolly notes. “I’d say some employers hear about it and say, ‘That’s good news.’ Others say, ‘What’s NCQA?’” But Medicare plans’ NCQA ratings are considered predictive of CMS’s Medicare Advantage (MA) Star Ratings, which are tied to bonus payments and due out soon. “At least now with Stars, the average purchaser can understand ‘4’ vs. ‘5,’” she says.
Consistent Performance Is Key
The bottom line is that ACHP considers transparency and quality ratings in general to be “important and valuable,” Connolly says. “I think that we have hit an important juncture where we really do need to push away from process measures to outcomes measures…and become more sophisticated [about how]we identify true quality in health care.”
She asserts that steady performance is key. A plan “can get lucky any quarter, any year,” and perhaps end up atop the ratings one year and well down in the pack the next, she says. But “when you start consistently hitting a 4, 4.5 year after year, that’s worth taking notice…because it’s built into everything they do. It’s not accidental.”
From a plan perspective, it’s worth noting the difference in markets across the U.S. in terms of higher or lower quality and cost, Connolly says. “We often work with our members to see how they’re doing in their [respective]market,” she says. “AultCare [based in Canton, Ohio]said it was pleased being in the top tier in Ohio. For them, that’s more important than how they compare to plans in Dallas or Boston.”
Kaiser Aims for ‘Reliably Excellent Care’
Kim Horn, president of Kaiser Permanente of the Mid-Atlantic States, points out that the plan scored 5 out of 5 on NCQA’s rankings for Medicare and Medicaid as well as commercial, thus scoring “perfect” in every business line and service area.
“It’s just really a testament of our commitment to quality,” she says.“ First of all, it does start with the model. We’re an integrated model — in most cases in one building, under one roof…but we also partner with our [affiliated]hospitals. It allows us to collaborate and coordinate care across every specialty.”
Horn says the Kaiser plan has maintained its quality amid rapid growth over the past several years. She also notes that “this region, for Kaiser Permanente, is one of the most diverse populations in terms of ethnicity, age” — and, beyond Medicare and Medicaid, the insurer also “heavily participates on the exchanges, which is typically lower income populations.”
The Kaiser plan values that diversity and is NCQA-certified for multicultural care, says Joe Territo, M.D., associate medical director of quality for the Mid-Atlantic Permanente Medical Group.
“At every level of the organization, quality is prioritized,” says Territo, a pediatric ophthalmologist. He adds that the organization defines quality as “reliably excellent care.”
In the typical sense of quality, people think of whole population screening programs, which are important, he says. But NCQA’s ratings incorporate more than 34 measures, “and to get to 5 you need to be perfect in all of those,” he says. “And that means every day attention to all of those measures and how we’re performing on them and what opportunities we have to improve our performance.”
The Kaiser plan uses electronic health records (EHRs) with decision support tools to track performance and look for opportunities to improve it, Territo says. In addition, the patient- centered medical home model is used to help members navigate services. “It is the system being aligned around the patient,” he says. “There are no gaps in care and they don’t have to find linkages.”
Kaiser Invests in New Facilities
Horn also cites the Kaiser Mid-Atlantic Region’s significant investment in facilities, including three additional multispecialty hubs (medical centers with pharmacies, radiology and physician offices) set to open in northern Virginia next year, and a new facility in Prince George’s County, Md., in 2020. “So, we have this very purposeful planning around the delivery of care as our membership grows,” she says.
According to Horn, NCQA’s plan ratings are useful, providing guideposts that indicate the plan is on track in serving a diverse membership. “We focus on every single element internally,” she says. “It’s very motivating.”
“The great thing about…NCQA is it is an apples-to-apples comparison across plans,” adds Territo. “It doesn’t let [health plans]define where they’re successful.”
In Wisconsin, Group Health has a long history, becoming the area’s first HMO more than 40 years ago. It is member owned, its physicians, physician assistants, nurse practitioners and support staff are salaried employees, and its primary care providers and clinics operate under a single organization: a model that it sees as key to its success.
“Our organizational vision drives the effort. We have a very strong mission here that we’re in business specifically to serve our membership,” says Mark Huth, M.D., Group Health’s president and CEO. “Every member is also an owner…I think that’s a pretty dramatic difference that keeps the patient voice first and foremost.”
Group Health Looks for Ways to Improve
Group Health’s ratings performance is partly driven by how it looks at the measures, Huth says. “We’re proud of places where it’s going really well, but behind our success is our procedure that has us constantly looking at places where we’re middle of the pack,” he says. “We’re always looking for ways to improve outcomes and patient experience.” As an example, he says the plan began a program a few weeks ago offering a money-back guarantee — up to a 100% refund of a patient’s out-of-pocket costs at its clinics — “as a way for people to tell us when things aren’t as good.”
In Dane County, Group Health’s HMO network includes six of its own clinics; the UW Health, the academic medical center and health system for the University of Wisconsin, is used for much of its hospital and higher-level specialty care. Its PPO, geared toward large employers with workers living outside the county, serves a much smaller percentage of its membership.
“In our organization, we have delivery system discussions about keeping costs down so members can pay premiums…and our [health plan]people talk about insurance benefits and the quality of our medical care,” Huth says. “We have top-rated doctors, good clinics with same-day access. All the leadership works in one building and we see the integration between delivery system and plan as a vital piece of who we are.”
Plan Aims for Accessibility
Several years ago, the plan began a Coordinated Access program offering routine primary care appointments the same day or next day, and physicals or longer primary care visits within a week. “It’s helped us keep our people healthier and out of the hospital,” he says. “If we can get that person into primary care, we can tune them up…. So we have to be more accessible to drive quality and patient experience.”
Group Health also integrated behavioral health into its primary care teams. A patient with a sore elbow may also be depressed or anxious, “and the old model was, ‘Let me refer you to behavioral health,’ but it took three to six weeks to get in,” says Huth, who is a family physician. “Now behavioral health is in the same location so patients can see them on the same visit.”
Group Health also found 30% to 40% of members’ urgent visits were for musculoskeletal issues, such as back pain, so physical therapists were brought in to its urgent care clinics.
View NCQA’s 2018-2019 plan ratings at https://tinyurl.com/ybr8tjuf. Contact Huth at mhuth@ghcscw.com, Horn and Territo via Shana Selender at shana.selender@kp.org, and Connolly via Alaina Monismith at amonismith@achp.org.
Article originally published in the October 1, 2018 issue, Volume 28, Number 39, of Health Plan Weekly. Republished courtesy of AIS Health.
