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IOM Calls for National System to Measure and
Report on Health Care Performance; AHQA Proposes QIO Program as a Framework
Study: GAP-Employer-QIO Collaboration Yields
Lower Mortality
AHQA Disputes CMS Report on Claims Payment
Errors
CMS: P4P Demo Leads to Improved Quality of
Care
House Subcommittee: McClellan, Hackbarth Testify
on P4P
HHS Awards Contracts to Develop National Health
Information Network
HHS Takes Step to Facilitate EHRs in Gulf Coast
Region
AHRQ Launches Audio Newscast
AHRQ Transitions to Electronic Grants Process
Revised Diabetes Services Order Form Includes
DSMT/MNT Referral
Surgeon General Releases Online Version of
Family Health Tool
ISMP Campaign to Target Dangerous Medical Abbreviations
NCQA Releases
Draft Quality Standards for Comment
IOM
Calls for National System to Measure and Report on Health Care Performance;
AHQA Proposes QIO Program as a Framework
The Institute of Medicine (IOM) recently called for the creation of
a comprehensive system to measure and report on the performance of health
care organizations and practitioners. This is the first of three IOM
reports mandated by Congress in the Medicare Modernization Act. The next,
addressing the value of the QIO program, is expected in late February
2006.
In this report, the IOM proposed establishing a national system to create
measures that will be universally accepted as a basis for informing the
public about the performance of providers, and for initiatives that reward
high quality care.
The IOM said Congress should create a new board within the U.S. Department
of Health and Human Services to coordinate the development of standardized
performance measures and monitor the nation's progress toward improving
the health care system. The National Quality Coordination Board would
be located outside of all existing agencies of HHS. For an executive
summary of the report: www.nap.edu/execsumm_pdf/11517.pdf.
As the
report was released, AHQA proposed that current QIO program measurement
and reporting initiatives should serve as a framework for building
the new system. AHQA’s written recommendations were distributed
to all members of the IOM Committee present at the briefing, comprising
about two-thirds of the total members.
“The new system should take advantage of the existing QIO national
measurement and improvement infrastructure, which has been developed
by Medicare and QIO experts in the field with significant federal investment
over more than a decade,” said AHQA Executive Vice President David
Schulke.
“QIOs have led the effort to help providers collect and report
data since the beginning of federal public reporting initiatives and
they have spearheaded state-wide efforts all over the country to educate
consumers about quality reporting. In the process, QIOs have built a
national infrastructure of expertise which can ensure the success of
the IOM’s proposed system,” Schulke said in a news release
distributed to media, the IOM Committee, and Capitol Hill policymakers
with background on QIO promotion of a wide array of quality measures.
“The public briefing stressed, much more than the written report,
the notion that CMS must lead adoption and reporting of the standard
measures, which bodes well for a continuing significant QIO role,” Schulke
noted, adding, “This first report is really about measures, rather
than the way they are used, and scarcely referred to QIOs. But this is
the system we can expect the IOM to be thinking of when they recommend
the future role of QIOs, so we tied them closely together in our comments.”
AHQA recommended the QIO measurement and improvement infrastructure
should be scaled up to create the system proposed by the IOM, calling
on Congress to take the following steps:
- Use QIOs to continuously promote public awareness of reported data.
- Direct QIOs to offer technical assistance and feedback to providers
of all types, under all payers, using measures promulgated by the new
system, and direct QIOs to research innovative interventions that improve
provider performance.
- Establish concurrent QIO auditing of quality data to ensure that
reported information is timely and accurate.
- Scale
up current QIO work in support of Medicare health plan “pay-for-performance” initiatives
into support for all value-based purchasing programs that rely on the
standardized measures promulgated by the new system.
- Recruit
all payers to join in Medicare’s investment in funding
QIO support of HIT adoption.
- Use extensive
local QIO relationships to regularly convene stakeholders to identify
each state’s priorities for allocating a portion
of Medicare QIO program resources.
- Instruct QIOs to report regularly on the practicality and acceptance
of existing quality measures and recommend changes to keep measures
up-to-date.
- Use QIOs to test new performance measures for validity and reliability.
- Direct all QIOs to enhance continuity of care through patient-centered
(rather than setting-centered) use of existing measures, and to recommend
and field-test new measures reflecting the quality of care coordination
between settings.
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Study:
GAP-Employer-QIO Collaboration Yields Lower Mortality
In a study presented at a national meeting of the American Heart Association
in Dallas, researchers found that heart failure patients are less likely
to die after they go home from the hospital if the hospital has participated
in an organized quality improvement program to streamline care. The study
also indicates that heart failure patients are less likely to need another
hospital stay when quality improvement programs are implemented.
The two-year
study involved more than 2,500 heart failure patients treated at 14
community hospitals in and around Flint, Michigan. MPRO, Michigan’s
QIO, collaborated on this project with University of Michigan physicians,
the Michigan Chapter of the ACC, Greater Detroit Area Health Council,
and Greater Flint Health Coalition.
The study, “Guideline-Based Standardized Care Is Associated With
Substantially Lower Mortality in Medicare Patients with Acute Myocardial
Infarction,” was published in the October 4 issue of the Journal
of the AmericanCollege of Cardiology. It
involves research conducted as part of the Guidelines Applied in Practice
or GAP project sponsored by the American College of Cardiology (ACC).
The GAP project aims to ensure that all hospitalized heart patients receive
proven treatments, counseling for lifestyle changes, and education that
can help them care for themselves after they go home.
Findings of the study, which employed a non-randomly selected comparison
group of hospitals, include:
- Significantly
lower death rates in the month after hospitalization among patients
treated at eight hospitals cooperating in the project compared with
six hospitals that didn’t take part. The 30-day
mortality rates fell from 9.4 percent to 7 percent at participating
hospitals, compared with a jump from 8.5 percent to 10.7 percent in
non-participating hospitals.
- Re-hospitalization
rates dropped, by 22 percent, when doctors and nurses used a “toolkit” of heart failure specific standard
admission orders, in-patient clinical pathways, and discharge checklists
to make sure that patients didn’t miss out on treatments or counseling.
- 30-day re-hospitalization rates for patients treated at the participating
hospitals fell from 26.1 percent to 21.7 percent, compared with a slight
increase among patients treated at the non-participating hospitals.
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The project began in 2003 when lead physicians and nurses from each
of the eight hospitals came together in a series of learning sessions
to develop evidence-based tools that could be used in each hospital to
ensure that heart failure patients received optimal care.
The Tool Kit they developed includes standard orders for drugs called
beta blockers, diuretics, ACE inhibitors, and aldosterone antagonists.
Other interventions include in-hospital counseling of heart failure patients
on stopping smoking, exercising, limiting salt intake, and more lifestyle
steps that have been shown to slow the progression of heart failure.
In addition,
the group created a discharge contract, which patients, doctors, and
nurses all must read, understand, and sign before the patient leaves
the hospital. The discharge contract also explains the individual’s
at-home plan and prompts doctors and nurses to make sure that all prescriptions
have been written and educational sessions conducted before the patient
goes home.
After developing
the Tool Kit cooperatively, the lead physicians and nurse liaisons
from each hospital met several more times to share successes and problems
and refine their process. The Tool Kit is available from the ACC at: http://www.acc.org/gap/mi/ami_downloadA.htm.
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The MPRO Role
As a partner in the GAP project, MPRO provided quality improvement
expertise, an established network of quality improvement contacts and
projects, high quality data collection analysis, and feedback to health
care providers. The QIO also created continuing education materials to
assist providers in reducing the gaps in care.
“This is a great opportunity for other QIOs to benefit from the
combined efforts of the American College of Cardiology and QIO partnerships,” said
Debra L. Moss, MD, MBA, President and CEO, MPRO. Dr. Moss added, “The
projects offer a template for success in improving cardiovascular care
and meeting the goals of the Centers for Medicare & Medicaid Services
for the 8 th Scope of Work.”
In response
to a congratulatory email from AHQA EVP David Schulke, study author
and University of Michigan cardiologist Kim Eagle, MD said, “If
we partner between the ACC and its local leaders and chapters, and organizations
like yours, this can be replicated across the nation.” Dr. Eagle
has worked with MPRO as a champion of the GAP project in Michigan since
its inception.
MPRO’s
education materials can be accessed by contacting Pat Baker, RN, MS,
CPHQ, MPRO Project Manager at pbaker@mpro.org or
248-465-7324.
Information
on the GAP project is available at: http://www.acc.org/gap/mi/ami%5Fgap.htm.
Read the article at: http://www.acc.org/media/releases/highlights/2005/oct05/guidelines.pdf
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AHQA
Disputes CMS Report on Claims Payment Errors
The Centers
for Medicare & Medicaid Services (CMS) recently reported
a reduction in the number of improper fee-for-service (FFS) Medicare
claims payments, from 10.1% in 2004 to 5.2% in 2005 – at a savings
of $9.5 billion. The November 2005 “Improper Medicare Fee-for-Service
Payments Report” breaks down error rates by type of contractor
and notes reductions in improper claims by all contractors except one – Quality
Improvement Organizations (QIOs).
Carriers reduced improper payments from 11.4% in 2004 to 6.4% in 2005;
durable medical equipment regional carriers (DMERC) reduced their paid
claim error rate from 11.1% to 8.6%; and fiscal intermediary (FI) claims
payment errors dropped from 16.4% to 3.4%.
The report
states—incorrectly—that
the paid claim error rate for QIOs increased from 4.8% in 2004 to 5.2%
in 2005.
“The ‘QIO error rate’ reported for 2005 includes
new categories of payment in its calculations that were not included
in 2004,” said Lisa Croce, AHQA Director of Government Affairs. “The
CMS 2005 report does not adequately explain these changes. It does not
provide a way to adjust for changes in the calculation formula, so it
is not possible to accurately compare this year’s results with
previous QIO efforts to reduce payment errors.”
“The bottom line is that the CMS report is wrong about QIO performance
over the past year,” said Croce. AHQA is working with members of
the HPMP/Case Review Network to develop talking points and to answer
questions from policy makers and stakeholders concerning the CMS report.
In an effort to further reduce the claims payment error rate, CMS is
requiring all of its FFS contractors to:
- Develop corrective action plans that include efforts to educate providers
about the importance of submitting thorough and complete medical records;
- Identify which providers or contractors need to review their submission
of claims and improve their educational efforts, based on information
that shows where the highest percentage of errors on overused billing
codes are occurring; and
- Use the
performance results to develop local efforts to lower their error
rates by addressing the cause of the errors and outlining corrective
steps.
CMS is developing a comprehensive plan for a similar oversight program
for payments to Medicare health and prescription drug plans and Medicaid.
The November
2005 report is at: https://www.cms.hhs.gov/apps/er_report/edit_report_1.asp?from=public&reportID=3).
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CMS: P4P Demo Leads to Improved Quality of
Care
The Centers
for Medicare & Medicaid
Services (CMS) has reported that quality of care improved significantly
in hospitals participating in the Premier Hospital Quality Incentive
demonstration, a Medicare pay-for-performance project. Quality of care
improved in all of the five clinical areas measured.
Five composite quality scores, comprising a distillation of 35 quality
measures, improved between the first and last quarters of the first year
of the demonstration:
- From 87 percent to 91 percent for patients with acute myocardial
infarction.
- From 65 to 74 percent for patients with heart failure.
- From 69 percent to 79 percent for patients with pneumonia.
- From 85 percent to 90 percent for patients with coronary artery bypass
graft.
- From 85 percent to 90 percent for patients with hip and knee replacement.
For the first time, Medicare will award $8.85 million to top performing
hospitals that showed improvements for inpatients with the five conditions
measured. Improvement in these evidence-based quality measures is expected
to provide long term savings because of their demonstrated relationship
to improved patient health, fewer complications, and fewer hospital readmissions.
Hospitals
in the top 10 percent for a given condition received a two percent
bonus on their Medicare payments for that condition. Hospitals
in the second 10 percent were given a one percent bonus. The remaining
high performing hospitals received recognition but no bonus.
Baselines
were set for the bottom 20 and bottom 10 percent of participating hospitals.
If any hospitals are below the 10 percent baseline in the third year
of the demonstration, they will get a two percent reduction in Medicare
payments for the clinical area involved. Those between 20 and 10 percent
will get a one percent reduction.
“We are examining the first year data and working with our partners
in the quality improvement community to share and apply the lessons learned,” said
CMS Administrator Mark McClellan, MD, PhD. “But the major
early finding is that the project did substantially improve important
areas of health care quality at the participating hospitals.”
The Premier
demonstration began in October 2003, with more than 260 hospitals voluntarily
participating. It
is scheduled to end in September 2006.
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House Subcommittee: McClellan, Hackbarth Testify
on P4P
Centers
for Medicare & Medicaid Services Administrator Mark McClellan,
MD, PhD, and MedPAC Chairman Glenn Hackbarth testified at a House Energy
and Commerce Subcommittee on Health hearing, “Medicare Physician
Payment: How to Build a More Efficient Payment System.”
In January 2006, Medicare payments to physicians, currently based on
the sustainable growth rate (SGR) formula, will be cut 4.4% unless Congress
intervenes. The hearing focused on current problems with the SGR methodology,
the impending payment reductions faced by physicians, and testimony from
witnesses on options for repairing the current system.
In his
opening remarks, Energy and Commerce Committee Chairman Joe Barton
(R-TX) commended McClellan for the agency’s recent hospital
quality initiatives and asked how they might be leveraged to transform
the physician payment system.
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P4P Concerns
Subcommittee members expressed varying views on the potential of a
pay-for-performance (P4P) based reimbursement system. Charlie Norwood,
DDS, (R-GA) said he is uncertain that a P4P system would actually improve
quality or save money and questioned the ultimate cost of such a program.
Other members wondered who would decide the levels of performance merit
rewards and whether P4P might discourage new physicians from participating
in the Medicare program.
McClellan/Hackbarth Testimony
McClellan told the Subcommittee that the current system does not adequately
support improving quality or reducing costs. He stated that CMS plans
to work with Congress to fix physician payments for 2006 and 2007 as
part of budget reconciliation legislation this year, including linking
payment to quality measures for physicians. McClellan mentioned a number
of steps the Agency is already taking to create incentives for quality,
including the hospital quality reporting initiative, the Premier hospital
demonstration, and the recently announced physician voluntary reporting
project (PVRP).
MedPAC Chairman Glenn Hackbarth testified that the Commission has recommended
a series of steps to resolve the physician payment issue, including eliminating
the SGR, implementing a year-to-year evaluation of payment adequacy,
linking payments to quality, providing comparative resource use data
to physicians, focusing on rapidly growing areas in the health system,
and finally evaluating and refining the fee schedule to ensure that services
are paid accurately.
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Q&A
When questioned
about P4P, McClellan noted that such a system should be implemented
in steps, starting with better information on quality. Hackbarth clarified
that quality should be determined by evidence-based standards of care,
and that it is important to engage professional societies in this process.
When asked if he thought Congress should appropriate additional funding
for P4P, or instead redistribute the money within the current system
to reward high performing providers, McClellan stated that right now
steps need to be taken to stabilize the payment system. Similarly,
Dr. Norwood suggested that the Subcommittee’s first
priority should be figuring out how to fairly reimburse physicians so
they can continue to treat patients, then experiment with P4P.
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HHS Awards Contracts to Develop National Health
Information Network
Department of Health and Human Services (HHS) Secretary Mike Leavitt
has announced the award of $18.6 million to four consortia led by Accenture,
Computer Science Corporation, IBM, and Northrop Grumman to develop prototypes
for a Nationwide Health Information Network (NHIN) architecture.
Each consortium represents a partnership of technology developers and
health care providers that will collaborate in three local health care
markets. During the coming year, each group will develop an architecture
and a prototype network for secure information sharing among hospitals,
laboratories, pharmacies, and physicians in its three participating markets.
They will also work together to ensure that information can move seamlessly
between each market network and share ideas and information about the
architecture and prototypes with each other and with the public.
The prototypes will test patient identification and information locator
services; user authentication, access control and other security protections
and specialized network functions, as well as test the feasibility of
large-scale deployment. Once created, the architecture design for each
of the networks will be placed in the public domain to stimulate others
to develop innovative approaches to implementing health information technology.
The consortia
will work closely with other HHS partners, including the Health Information
Technology Standards Panel established by the American National Standards
Institute, the Certification Commission for Health Information Technology,
and the Health Information Security and Privacy Collaboration established
by RTI and the National Governor’s Association.
The four contracts result from an HHS Request for Proposals (RFP) that
was announced on June 6, 2005. These contracts complete the foundation
for an interoperable, standards-based network for the secure exchange
of health care information. HHS previously has awarded contracts to create
processes to harmonize health information standards, develop criteria
to certify and evaluate health IT products, and develop solutions to
address variations in business policies and state laws that affect privacy
and security practices that may pose challenges to the secure communication
of health information.
For more information, http://www.hhs.gov/news/press/2005pres/20051110.html
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HHS Takes Step to Facilitate EHRs in Gulf
Coast Region
Department
of Health and Human Services (HHS) Secretary Mike Leavitt announced
agreements with the Southern Governors’ Association and
the State of Louisiana Department of Health and Hospitals to plan and
promote the widespread use of electronic health records in the Gulf Coast
regions affected by recent hurricanes.
The Southern
Governors’ Association
is expected to host the Gulf Coast Health Information Task Force, which
will bring together local and national resources and coordinate the
planning for a digital health information recovery. The State of Louisiana
Department of Health and Hospitals will develop a prototype of health
information sharing and electronic health record (EHR) support that
can be replicated throughout the region.
HHS is undertaking these efforts to establish a task force of local
and national experts to help area providers turn to electronic medical
records as they rebuild. When Hurricane Katrina hit, those physicians,
hospitals, nursing homes, and other health care providers relying on
paper records were devastated while those using electronic medical records
were largely able to preserve their systems and patient information.
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AHRQ Launches Audio Newscast
The Agency
for Healthcare Research and Quality (AHRQ) recently launched a new,
innovative resource that will provide the public with easy access to
research-based health information. “Healthcare 411” is
an on-demand weekly audio series that consumers can listen to on a computer
or portable media player such as an iPod.
The weekly
newscasts cover timely health issues in addition to special reports.
The 10 to 20 minute newscasts feature a range of topics including:
nurse fatigue, over-prescribing of antibiotics for childhood sore throat,
and smoking cessation. Special reports are also available on such topics
as “Personal Health and Electronic Health Records” and “Understanding
Health Care Quality.”
For more information or to download audio newscasts, visit: http://www.healthcare411.org/
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AHRQ Transitions to Electronic Grants Process
The Agency for Healthcare Research and Quality is transitioning to
electronic submission of grant
applications and use of a new research grant application form. Grants.gov
( http://www.grants.gov/) is now
the main access point for all grant programs offered by 26 Federal grant-making
agencies. It will provide a platform for all agencies to announce grant
opportunities and for grant applicants to find and apply for those funding
opportunities.
First time users must register with grants.gov; data submitted with
registration will enable electronic submission of grant materials. Applicants
must also register with the National Institutes of Health Electronic
Research Administration System (also known as the eRA Commons): http://era.nih.gov/commons/index.cfm.
AHRQ will be phasing in the changes by type of grant mechanism as follows:
- December
20, 2005 -- Small Conference Grant Program
(R13) http://grants.nih.gov/grants/guide/notice-files/NOT-HS-06-010.html
- February
1, 2006 - Large Conference Grant Program (R13)
- February
17, 2006 -- Research Dissertation Grant Program (R36)
- July
24, 2006 -Small Research Grant Programs (R03)
- October
1, 2006 -Research Project Grant Program (R01)
The transition
for career development grant mechanisms and fellowship mechanisms will
occur later in 2006. All grant applications will be submitted electronically
by the end of 2007. For more
information, http://ahrq.gov/fund/grantix.htm
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Revised Diabetes Services Order Form Includes
DSMT/MNT Referral
The American Dietetic Association and American Association of Diabetes
Educators have revised the Diabetes Services Order Form released
in May. At the request of the Centers for Medicare & Medicaid Services,
the groups added check-off boxes pertaining to diabetes self-management
training (DSMT). CMS had previously commented on the document but this
change was not among those requested at that time.
Another
new feature of the form includes designation of the sections that must
be completed for compliance with the Medicare referral for DSMT or
MNT. Other
sections of the form are not changed from the earlier document.
Many experts believe that Medicare patients who see Medicare-certified
DSMT and Medicare-certified medical nutrition therapy (MNT) providers
are more likely to get timely tests and preventive benefits. Using the
revised Diabetes Services Order Form will prompt physicians and other
health care providers to refer patients for appropriate DSMT and/or MNT
services and potentially increase the likelihood of improvement on quality
measures in SOW8.
QIOs are
encouraged to share the updated form and the background handout that
describes the CMS regulations for both Medicare MNT services and DSMT
services with physicians and their office staff. Both documents are
accessible from either ADA’s Web page: www.eatright.org (search
for Diabetes Services Order Form) or AADE’s Web page: www.diabeteseducator.org/Publications/dsof.shtml
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Surgeon General Releases Online Version of
Family Health Tool
U.S. Surgeon
General Richard H. Carmona, MD, MPH, unveiled an updated, Web-based
version of a free, computerized tool that organizes family health information
to assist health care professionals in determining whether families
are at higher risk for disease. The tool, called “My
Family Health Portrait,” is available at www.hhs.gov/familyhistory.
Carmona
explained that a detailed family history can predict the disorders
for which a person may be at increased risk, and thereby help to develop
more personalized action plans – in short “knowing your
family history can save your life.”
The new
online version guides users through a series of screens that helps
them compile information about six common diseases for each of their
family members, as well as enter information about any other conditions
not on the list. A graphic printout can be generated for each family
member to take to health care professionals who can use the information
to better individualize diagnosis, treatment, and prevention plans.
All personal information entered into the program resides on the user’s
computer only -- no information is available to the federal government
or any other agency.
Packets
of family history resource materials have recently been distributed
to chronic disease and genetic experts in the state health departments
across the country. Free, print versions of the tool are also available
in English and Spanish at the Health Resources and Services Administration’s
(HRSA) Information Center at 1-888-275-4772.
Department of Health and Human Service agencies that are partnering
with the U.S. Surgeon General in the family history public health campaign
are the National Institutes of Health, Centers for Disease Control, HRSA
and the Agency for Healthcare Research and Quality (AHRQ).
For additional information, visit: www.hhs.gov/familyhistory.
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ISMP Campaign to Target Dangerous Medical Abbreviations
The Institute for Safe Medical Practices (ISMP) and the U.S. Food and
Drug Administration (FDA) announced an educational campaign to eliminate
potentially harmful medical abbreviations. The campaign is slated to
begin in early 2006.
The campaign
will promote the use of ISMP’s list of abbreviations,
symbols, and dose designations (http://www.ismp.org/PDF/ErrorProne.pdf)
most often associated with medication errors. The ISMP’s list builds
on the current Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) “do not use” list of error-prone abbreviations and
dose designations.
Target audiences will include: healthcare professionals (physicians,
pharmacists, nurses, other healthcare providers, and medical students);
medical writers; the pharmaceutical industry; and FDA staff. The campaign
plans to reach those audiences through development of targeted educational
materials, articles in professional journals, and presentations at key
conferences and meetings. Educational materials will be available in
print and online.
For more information, visit: www.ismp.org
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NCQA Releases Draft Quality Standards for Comment
The National Committee for Quality Assurance (NCQA) issued a draft
version of Physician and Hospital Quality standards, the third
content area of its voluntary Quality Plus program. Comments are due
by December 19.
The draft standards focus on how health plans measure the quality and
efficiency of care provided by network physicians and hospitals and recognize
plans for using such data in pay-for-performance efforts or to help inform
consumer choice. The standards also assess how plans communicate about
their measurement efforts to providers, and promote collaboration between
plans in order to create a robust set of data for customers and to streamline
reporting for doctors and hospitals.
The performance measures used in Physician and Hospital Quality have
received broad support from physician groups, consumer organizations,
purchasers, and health plans including the National Quality Forum (NQF),
the Ambulatory Care Quality Alliance, and the Hospital Quality Alliance.
Comments
on the draft Physician and Hospital Quality standards are due by December
19. To download the draft standards, or to submit a comment, visit
NCQA’s Web site at www.ncqa.org.
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