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FY 16-17: Agency Priority Goal
FEHB Plan Performance
Priority Goal
Goal Overview
To establish a consistent assessment system that includes objective performance standards, OPM has developed the FEHB Plan Performance Assessment. This assessment incorporates a discrete set of quantifiable measures to examine key aspects of health plan performance and a contract oversight evaluation by the contract officer. The FEHB Plan Performance Assessment will be linked to health plan profit. Quantifiable measures are grouped into three performance areas: Clinical Quality, Customer Services, and Resource Use (collectively termed QCR). The QCR measures consist of Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures. The National Committee for Quality Assurance (NCQA) oversees the set of HEDIS and CAHPS measures which is used nationwide to measure performance of health plans in various areas. OPM is using NCQA’s national or regional benchmarks in the FEHB Plan Performance Assessment.
To focus attention on priority issues, OPM has developed a hierarchy for the QCR measures. In assigning priority levels to measures, OPM considered whether the measure assessed health outcomes, supported specific OPM policy priorities, and was relevant to FEHB subpopulations with particular health needs. Improvement on these high priority measures will indicate improved quality and carrier focus on critical healthcare areas for the FEHB Program.
This assessment system directly supports Goal 9 of the 2014-2018 OPM Strategic Plan by requiring that FEHB health plans meet rigorous industry standards and higher levels of health plan accountability. These higher standards and increased accountability lead to higher quality health benefits available to federal employees, federal retirees, their families, and newly eligible populations. This new initiative is also closely aligned with the current Administration’s goal of health care system improvement and parallels other federal agency and private payer processes.
Strategies
For 2016 and 2017, OPM will examine three QCR measures. Each of these measures is scored in comparison to an external benchmark. Measure results are reported annually. OPM will calculate FEHB Program averages to track improvement across the portfolio. OPM will use the information received from the assessment to drive future FEHB policy and procedures.
In addition to annual review of measures and progress across plans, OPM will be engaging in ongoing activities to encourage plan performance. OPM will :
- Execute and operate the Plan Performance Assessment;
- Participate in cross government working groups examining case studies and best practices;
- Research health care performance success in commercial lines of business; and
- Use corrective action plans and provide other targeted assistance for specific plans based on performance in high priority measures
Progress Update
Executed the Plan Performance Assessment.
• Conducted end-to-end testing of implementation of the Plan Performance Assessment using 2015 data.
• Developed methodology for the Plan Performance Assessment Improvement Increment.
• Announced measures for potential future use in the Plan Performance Assessment.
• Prepared processes for receipt, calculation, and reporting of 2016 Plan Performance Assessment scores.
• Provided a QCR preview to carriers for review and comment.
• Participated in working groups examining case studies and best practices
• Held another meeting of the Plan Performance Best Practices workgroup on August 17, 2016 demonstrating root cause analysis techniques.
• Provided FEHB carriers an overview of the Plan Performance Assessment Improvement Increment with a Carrier Letter on August 1, 2016 and a webcast on August 18, 2016.
• Researched health care performance in commercial lines of business.
• Conducted ongoing analysis of the OPM Measure Set alignment with high-priority industry and government measures sets.
• Administered Automated Data Collection to Federal Employees Health Benefits plans to monitor for plan management.
• Used corrective action plans and provide other targeted assistance for specific plans based on performance in high priority measures.
• Identified opportunities for targeted assistance for specific plans based on 2015 data.
Next Steps
Execute the Plan Performance Assessment.
• Generate service charge and performance adjustment based on the 2016 reported data under the Plan Performance Assessment.
• Continue evaluating potential measures for future use in Plan Performance Assessment.
• Create a Carrier Manual for Plan Performance Assessment.
• Continue to conduct working groups examining case studies and best practices
• Hold another meeting of the Plan Performance Best Practices workgroup on the relationship between organizational culture and CAHPS scores
• Research health care performance in commercial lines of business
• Perform research and analysis on performance success in both public and private sector.
• Continue to participate in the Health Care Learning and Action Network.
• Administer the Federal Annuitant Benefits Survey, compile results, and evaluate how retiree feedback could be incorporated into the Plan Performance Assessment process.
• Use corrective action plans and provide other targeted assistance for specific plans based on performance in high priority measures.
• Collaborate with improving carriers to determine successful practices to achieve significant results.
• Continue follow up with carriers requiring additional improvement and corrective action plans to improve quality of care.
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Performance Indicators
Timeliness of Prenatal Care
Plan All-Cause Readmissions
Controlling Blood Pressure
Contributing Programs & Other Factors
The Offices of Planning and Policy Analysis (PPA) and Healthcare and Insurance (HI) collaborate to offer the Federal Employees Health Benefits (FEHB) to ensure Federal employees’ needs are met and available benefits align with best practices. Specifically, PPA provides policy guidance and actuarial support by reviewing the cost of contracts under Federal benefits programs, conducts rate negotiations with carriers, and determines the amount the Government contributes towards employees’ benefits. HI oversees federal benefits programs, which includes contracting with insurance carriers as well as operating an annual open season for federal employees and retirees to review and consider changing their current health choices. HI and PPA also work with the OPM Office of Inspector General (OIG) which conducts audits of FEHB carriers. The OIG conducts onsite and desk audits of carriers, issues preliminary audit findings, draft, and final audit reports.
OPM works with insurance carriers participating in the FEHB Program to negotiate the best rates and value of benefits for federal employees, retirees and their families. OPM also works closely with benefits officers across the Federal Government to provide guidance on the FEHB Program policies and procedures. Benefits officers then communicate this information to employees within their agency to ensure Federal employees are educated on their FEHB benefits.
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Strategic Goals
Strategic Goal:
SG9 Healthier Americans
Statement:
Increase the percentage of states covered by at least one Multi-State insurance carrier and percentage of states covered by two or more Multi-State insurance issuers. Increase the number of carriers receiving OPM “Exemplary” or “Most Improved” distinction for health care quality or customer service.
Improve overall satisfaction with health plan as reported by health plan enrollees in Consumer Assessment of Healthcare Providers and Systems (CAHPS). Decrease the number of ineligible dependents on enrollee’s FEHB coverage.
Strategic Objectives
Statement:
Increase the percentage of states covered by at least one Multi-State insurance issuer and percentage of states covered by two or more Multi-State insurance issuers.
Increase the number of carriers receiving OPM “Exemplary” or “Most Improved” distinction for health care quality or customer service.
Improve overall satisfaction with health plan as reported by health plan enrollees in Consumer Assessment of Healthcare Providers and Systems (CAHPS).
Decrease the number of ineligible dependents on enrollee’s FEHB coverage.
Description:
- Ensuring Multi-State Plans (MSP) and Federal Employees Health Benefits (FEHB) health plans cover the full range of Essential Health Benefits.
- Leveraging our experience in the FEHB and MSP programs to identify and implement best practices across the insurance portfolio.
- Providing responsive customer service to insured populations.
- Analyzing complaints and appeals to elucidate opportunities to better meet the needs of enrollees.
- Updating electronic consumer decision support and health plan selection tools to optimize enrollee choice.
- Developing a comprehensive health plan assessment methodology that evaluates health care quality, customer service, and financial performance.
Statement:
Increase influenza immunization rates, reported as Flu Shots for Adults in CAHPS Effectiveness of Care Measures.
Improve timeliness of prenatal care as reported by health plans in Healthcare Effectiveness Data and Information Set (HEDIS).
Description:
- Increasing influenza immunization rates through optimal use of health insurance benefits, occupational health resources, and employee wellness programs.
- Improving access to and timeliness of prenatal care.
- Increasing awareness and use of health insurance benefits for tobacco cessation.
Statement:
Lower Federal employee tobacco use rates as reported in the Federal Employee Benefits Survey
Description:
- Prioritizing healthy workforce aims in the Chief Human Capital Officers Council, union negotiations, labor-management forums, and interactions with consumer advocates.
- Promoting tobacco free workplaces.
- Collaborating with Substance Abuse and Mental Health Services Administration to promote awareness of mental health and Employee Assistance resources available to Federal Employees.
- Working with the General Services Administration to create a standard contract clause to promote healthy behaviors among embedded contractors.
- Engaging with government agencies and private industry leaders to promote wellness in the work environment through healthy meal and vending choices, safe stairs and walking paths, inclusion of bicycle sharing in transportation subsidies, etc.
Statement:
Description:
- Ensuring Federal agency benefits officers are well informed about insurance programs.
- Targeting use of Direct to Enrollee/Direct to Retiree Emails regarding Open Season and key benefits topics.
- Communication to employees across all OPM platforms, including USAJOBS, USAStaffing®, Retirement ServicesOnline, EmployeeExpress, and OPM.gov.
- Targeting agencies by enrollment to deliver educational seminars on Flexible Spending Accounts and insurance benefits.
- Developing outreach strategy and implementing educational sessions to Indian Tribes on FEHBP.
Agency Priority Goals
Statement:
Improve the efficiency of the Federal Employees Health Benefits Program and affordability of coverage offered to employees. By September 30, 2015, Reduce the rate of growth in per capita spending through a range of activities, including improved data analytics, enhanced accountability measures, and programmatic improvements.
Description:
OPM is continuing to focus on ways to optimize pharmacy practices to ensure the safe and clinically effective use of prescription medications while managing drug costs. We continue to monitor carrier performance in several areas of pharmacy benefits management, including overall pharmacy and specialty drug trends as well as generic dispensing rates. We will collect updated data on these measures of pharmacy performance. Most health plans offer programs such as step therapy, medication therapy management programs, and expanded use of prior authorization for selected drugs. Implementing programs of this type and using tiered drug formularies are positively correlated with better performance on overall and specialty drug trends and generic dispensing rates. We will negotiate with FEHB carriers plan to add and expand on these types of drug management programs that control costs and improve quality and patient outcomes.
OPM is implementing an FEHB Health Plan Performance Assessment project to measure and reward all FEHB plan performance (experience-rated and community-rated) through the use of common, objective, and quantifiable performance measures by the 2016 plan year. This will be a new approach to our assessment of the annual performance of health plans contracted under the program. The performance assessment framework will include a discrete set of qualitative and quantifiable performance measures that will be used to assess key aspects of performance. That overall assessment will then be linked to health plan profit factors. There are four primary categories of health plan performance to be assessed: clinical quality, customer service, resource use, and contract oversight.
Industry standards state that, in private employer plans, as much as 10 percent of health claim benefits paid are incurred by family members who are not eligible for coverage. The FEHB Program provides approximately 23 billion dollars in benefits annually for those covered under Self and Family enrollments. This may translate to approximately 23 million dollars for each percent paid in error. Under current FEHB procedures, agencies and the FEHB carriers both have responsibility for family member eligibility determinations. However, there is no evidence that family member eligibility is systematically verified at the time of the initial enrollment, when enrollment is changed during Open Season or upon experiencing a Qualifying Life Event (QLE) (although some agencies do require documentation for QLE changes) or at any time during the employee’s period of coverage. With the advent of electronic enrollment systems, enrollees can make certain FEHB enrollment changes without submitting any proof to their agency benefit officers.
The extent of ineligible family members covered under FEHB Self and Family enrollments is currently unknown. In addition, presently there is no centralized FEHB enrollment system to maintain a database of eligible enrollees and family members. Enrollment systems that currently exist do not require the input of family member dependent information. Thus, there is no centralized database of the FEHB enrollments and consequently, no mechanism to determine who is receiving benefits under any one Self and Family enrollment.
Strategic Objectives
Strategic Objective:
Statement:
Description:
Agency Priority Goals
Statement: Improve health outcomes for the 8.2 million Federal employees, retirees, and their dependents enrolled in health plans participating in the Federal Employees Health Benefits (FEHB) program. In 2016, FEHB plan performance will be assessed based on a common set of measures of clinical quality, customer service and appropriate resource use; this performance assessment will be used in the determination of plan profit margins. While each plan will be assessed based on its performance, overall progress for the FEHB program will be measured by an increase in the number of FEHB plans at or above the 50th percentile of the relevant national, commercial benchmark year-on-year as measured by FEHB plan scored values on the designated high priority indicators used continuously during the evaluation period. These high priority measures include: risk adjusted all cause readmissions, timeliness of prenatal care and blood pressure control.
Description: To establish a consistent assessment system that includes objective performance standards, OPM has developed the FEHB Plan Performance Assessment. This assessment incorporates a discrete set of quantifiable measures to examine key aspects of health plan performance and a contract oversight evaluation by the contract officer. The FEHB Plan Performance Assessment will be linked to health plan profit. Quantifiable measures are grouped into three performance areas: Clinical Quality, Customer Services, and Resource Use (collectively termed QCR). The QCR measures consist of Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures. The National Committee for Quality Assurance (NCQA) oversees the set of HEDIS and CAHPS measures which is used nationwide to measure performance of health plans in various areas. OPM is using NCQA’s national or regional benchmarks in the FEHB Plan Performance Assessment. To focus attention on priority issues, OPM has developed a hierarchy for the QCR measures. In assigning priority levels to measures, OPM considered whether the measure assessed health outcomes, supported specific OPM policy priorities, and was relevant to FEHB subpopulations with particular health needs. Improvement on these high priority measures will indicate improved quality and carrier focus on critical healthcare areas for the FEHB Program. This assessment system directly supports Goal 9 of the 2014-2018 OPM Strategic Plan by requiring that FEHB health plans meet rigorous industry standards and higher levels of health plan accountability. These higher standards and increased accountability lead to higher quality health benefits available to federal employees, federal retirees, their families, and newly eligible populations. This new initiative is also closely aligned with the current Administration’s goal of health care system improvement and parallels other federal agency and private payer processes.
