Issue Briefs

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Following are highlights from a recent OPM report on quality measures of Federal Employees Health Benefits program carriers.


OPM has been utilizing the Plan Performance Assessment (PPA) to emphasize the use of common, objective criteria for the evaluation of FEHB Carriers since 2016. The PPA is designed to tie FEHB Carrier performance on a range of performance areas to the profit of the Carriers. Approximately one percent of the overall FEHB premium payable to the Carriers is at-risk based on their respective performance.

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The PPA is comprised of four performance areas:

•Clinical Quality

•Customer Service

•Resource Use

•Contract Oversight

OPM selected measures from the Healthcare Effectiveness Data & Information Set (HEDIS) and the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey to reflect performance within the Clinical Quality, Customer Service and Resource Use (QCR) areas.

In 2019, the average scores earned by FEHB Carriers on the combined set of QCR measures increased. Carriers could earn an Improvement Increment for the third year in a row for demonstrating sufficient improvement over previous years’ scores. We discuss these and other significant findings from the 2019 QCR data below.

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Standardized QCR Score Trends

Standardized QCR Scores continue to reflect a range of performance across all product reporting types. The following trends were observed in the 2018 and 2019 PPA cycle:

•The QCR average increased between 2018 and 2019 for each category of plan type: PPO, HMO, and HMO/POS product reporting types.

•FEHB Carriers’ cumulative performance demonstrated an increase in Standardized QCR Scores for2019 compared to 2018 results. These results build on similar improvements observed in 2017compared to reporting during the inauguration of the PPA in 2016.

High Priority Measures

OPM designates certain HEDIS or CAHPS measures high priority based on their relevance to the needs of the FEHB population. For the past three years, the PPA high priority measures have remained Timeliness of Prenatal Care, Blood Pressure Control, and Plan All-Cause Readmissions. For 2019, the FEHB program-wide average for each of the three high priority measures exceeded the respective commercial median.

Based on data previously reported to OPM through the Automated Data Collection tool, FEHB Carriers reported heart disease and diabetes as their most prevalent and expensive conditions. The prevalence and cost of heart disease affirms OPM’s emphasis on the Controlling High Blood Pressure measure, which focuses on outcomes related to the appropriate treatment of high blood pressure. Controlling high blood pressure alleviates a major risk factor for both heart disease and stroke, both of which are leading causes of death in the U.S. For the third year in a row, the number of FEHB Carriers reporting results below the 25th percentile on this measure fell compared to commercial insurers.

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Improvement Increment

In response to Carrier feedback, OPM introduced the Improvement Increment in 2017, awarding it in 2018 and again in 2019. FEHB Carriers that performed below the 50th percentile on a particular measure during a prior measurement year (2018) and subsequently improved faster than their commercial peers while maintaining the same plan reporting type with NCQA in 2019, were awarded a partial Improvement Increment. The full Improvement Increment is earned by meeting the criteria listed above and demonstrating significant improvement on three or more measures.

Eighty of the 81 FEHB Carrier contracts were eligible for the Improvement Increment in 2019, meaning they had at least one measure below the 50th percentile in 2018. This year, the full Improvement Increment was earned by six Carriers. The pace of improvement in 2019 is noteworthy compared to results for 2018, when none of the eligible FEHB Carriers earned the full Improvement Increment. Three HEDIS measures tied for the highest number of Carriers improving their performance. Those three measures were Cervical Cancer Screening, Controlling High Blood Pressure, and Well Child Visits (15 months – 6 visits). Alternatively, the measure with the highest number of Carriers eligible for an Improvement Increment was Getting Care Quickly. For this measure, 45 Carriers were eligible while two Carriers earned the Improvement Increment.

Measure Specific Highlights

Two HEDIS measures moved into QCR scoring for the first time in 2019:

• Emergency Department Utilization

• Statin Therapy for Patients with Cardiovascular Disease (Adherence).

Emergency Department Utilization is a risk-adjusted ratio of observed-to-expected emergency department visits during the measurement year. In 2019, the combined program-wide average for FEHB Carriers was slightly above the 50th percentile for commercial insurers.

Statin Therapy for Patients with Cardiovascular Disease (Adherence) measures the percentage of males 21–75 years of age and females 40–75 years of age who were identified as having clinical atherosclerotic cardiovascular disease and remained on a high-intensity or moderate-intensity statin medication for at least 80% of the treatment period. FEHB Carriers’ program-wide performance dropped just below the 50th percentile for commercial insurers in 2019, after being slightly above that mark in 2018.

This was also the second year that OPM included Comprehensive Diabetes Care (Control) in QCR scoring. This intermediate outcome measure examines the percentage of an FEHB Carrier’s diabetic patients who had their diabetes under control. Improvement on this measure supports better health outcomes for diabetic enrollees.

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Conclusion

The PPA was implemented incrementally over a three year period ending in 2018. Under the 2019 PPA, calculations based on QCR measurement data represented 65 percent of a FEHB Carriers’ Overall Performance Score. As a group, FEHB Carriers are demonstrating improvement on QCR measures that are highly correlated with better health outcomes for their members.

OPM’s strategic objective remains the improvement of healthcare quality and affordability in the FEHB Program. The PPA will continue to evolve to meet this objective.