Enabling Performance Improvement Through Aligned Measurement · October 12, 2016 Jill M. Yegian,...

October 12, 2016

Jill M. Yegian, Ph.D., SVP Programs and Policy

Enabling Performance Improvement Through Aligned Measurement

© 2016 Integrated Healthcare Association. All rights reserved.

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Our work creates credible, actionable information that enables sustainable improvement in California health care systems through multi-stakeholder collaboration, and is organized around projects that generate insights, improve accountability, and accelerate solutions.

Our Work

Regional Variation: HEDIS by Geography & Cost & Quality Atlas

Statewide Workgroup on Reducing Overuse

Promoting ABIM Foundation’s Choosing Wisely®

Accountable Care Organizations

Maternity Care

Cancer Care Quality

Bundled Payment

Value Based P4P

Medicare Advantage Stars

Medi-Cal

Encounter Data

Digital Health

Regional Data Collaborative

Transforming Clinical Practices

Insights Accountability Acceleration


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Hospitals and Health Systems

Cedars Sinai, Dignity Health, John Muir, MemorialCare, Martin Luther King Jr. Community Hospital, Providence Health & Services,

Santa Clara County Hospital and Health System, Stanford Health Care, Sutter Health, U.C. Davis Medical Center

Health Plans

Aetna, Anthem, Blue Shield of California, CalOptima, Cigna, Health Net, Kaiser Foundation, L.A. Care, Partnership Health Plan,

UnitedHealthcare

Physician Organizations

Brown & Toland, CEP America, EPIC L.P./Beaver Medical Group, Family Care Specialists Medical Group, HealthCare Partners, Hill

Physicians Medical Group, Monarch HealthCare, Palo Alto Medical Foundation, Kaiser Permanente Medical Group, Santé Medical

Group, Sharp Rees-Stealy Medical Group

Pharmaceutical, BioTech, IT and Consulting Firms

Cope Health Solutions, Genentech, GlaxoSmithKline, MedeAnalytics, Merck & Company, Novo Nordisk, Pfizer

Purchasers and Consumers

CalPERS, Center for Healthcare Decisions, Covered California, Disney Worldwide, Keenan

Regulators

California Department of Managed Health Care, CMS Region IX

Academic Institutions

Stanford Medical School, Stanford Graduate School of Business, U.C. Berkeley School of Public Health, U.C. Davis Medical Center

Foundations and Research Institutions

California HealthCare Foundation, RAND Corporation

Our Members


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Today’s Agenda

• How does IHA approach measure alignment?

• Brief tour of measurement strategy for:

• Value Based P4P

• Medicare Advantage

• Medi-Cal P4P

• CA Regional Health Care Cost & Quality Atlas

• Opportunities

• Discussion


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Common Elements, Goal

Enable performance

improvement, reduce

measurement burden

Standard measure set

Stakeholder Advisory

Committee Voluntary

Participation


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Value Based P4P (Commercial HMO)


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Value Based P4P At A Glance

Copyright © 2015 Integrated Healthcare Association. All rights reserved. 7

10 Plans

200+ Medical Groups

and IPAs

Approx. $550m paid out

9 Million Californians


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IHA Staff

Stakeholder Governance

Partners

Committee Structure for Health Plan & Physician Organization Involvement

Governance Committee

Technical Measurement Committee Clinical and Data Reporting Experts

Technical Payment Committee Contracting, Actuarial, and Medical Economics Experts


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MY 2017 Value Based P4P Clinical Quality Measures

NCQA Accreditation

(2016)

CMS Quality Rating System

(2016)

MIPS ! – high priority

* – Core Measure Collaborative (w/AHIP)

All Cause Readmissions X X Hospital All-cause Readmissions

Antidepressant Medication Management X X X Annual Monitoring Persistent Medications: ACEI/ARB, Digoxin, Diuretics X Appropriate Testing for Children with Pharyngitis X X X! Asthma Medication Ratio X Avoidance of Antibiotic Treatment of Adults with Acute Bronchitis X X X!* Breast Cancer Screening X X X* Cervical Cancer Overscreening Cervical Cancer Screening X X X * Childhood Immunization Status Combination 10 X Combo 3 X Chlamydia Screening in Women X X X* Colorectal Cancer Screening X X X Controlling High Blood Pressure X X X!* Diabetes Care: Blood Pressure Control X Diabetes Care: HbA1c Control <8% X X Diabetes Care: HbA1c Poor Control >9% X X!* Diabetes Care: Nephropathy X X Diabetes Care: Two HbA1c Tests 1 Test Proportion of Days Covered – Oral Diabetes Medications X

Optimal Diabetes Care Combination Immunizations for Adolescents X X X Proportion of Days Covered – RAS Antagonists X Proportion of Days Covered – Statins X Statin Therapy for Patients with Cardiovascular Disease

Statin Therapy for Patients with Diabetes

Use of Imaging Studies for Low Back Pain X X X!*

Aligned Measurement Sets Us Up for Success


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PO Reporting Improves Plan Scores for HEDIS

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10

20

30

40

50

60

70

80

90

ControllingHigh Blood

Pressure

DiabetesCare: Blood

PressureControl

<140/90 mmHg

ChildhoodImmunization

Status

OptimalDiabetes Care

DiabetesCare: HbA1c

Control <8.0%

DiabetesCare: HbA1cPoor Control

> 9.0%

DiabetesCare: HbA1c

Control <7.0%

Proportion ofDays Covered

byMedications:

Statins


byMedications:Oral DiabetesMedications


byMedications:

RASAntagonists

Ave

rage

Mea

sure

Rat

e (%

)

Paid Clinical Measures

Self-Reported Physician Organizations vs. Health Plan Aggregate Data

SRPO Rate HP for SRPO Rate

Pharmacy Based Measures Lab & Registry Based Measures


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1. Increase alignment in the VBP4P measure set • Work to align with other commonly used measure sets

• Document and communicate where measure set diverges

• Decrease unwarranted variation in measure specs

2. Targeted development of the VBP4P measure set • Expand and emphasize TCC measurement

• Evaluate potential of e-Measures

• Explore feasibility of patient centered measurement

3. Support less burdensome data collection, more timely reporting • Understand and identify improvements to data sharing processes

• Support standard mid-year reporting

Measurement Priorities – 5 Year Strategy


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Medicare Advantage Stars at PO Level


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IHA MA PO Star Rating Measurement

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37

33

37

27

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0 10 20 30 40

1

2

3

4

5

Number of Physician Organizations

Number of Health Plan Contracts

POs by Number of Health Plan Contracts

Kaiser non Kaiser

• 6 health plans with over 80% of 2.1M Medicare Advantage enrollees in CA participate in IHA PO star rating program:

• Anthem Blue Cross • Blue Shield of California • Health Net • Kaiser Permanente • SCAN Health Plan • UnitedHealthcare

• 179 participating physician

organizations


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Aggregated and Plan-Specific Rates for Colorectal Cancer Screening, IHA Medicare Stars PO Ratings, MY 2014

Aggregated Data Enables Improvement

0

10

20

30

40

50

60

70

80

90

100

Co

lore

ctal

Can

cer

Scre

enin

g R

ate

(%)

Physician organizations contracting with more than one health plan

Aggregated Rate Min Plan-Specific Rate Max Plan-Specific Rate

For example, the identified PO has aggregated performance across contracted plans of 70.4. On a plan-specific basis the PO’s performance ranges from 52.7 to 81.4 – the plan-specific results are more sensitive to variation in small numbers and reflect uncertainty about the PO’s actual performance.


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IHA Medicare Advantage Stars Measure Set Aligns with CMS

Overlap with VBP4P set shown in orange

1. Adult BMI assessment

2. All-cause readmissions

3. Breast cancer screening

4. Colorectal cancer screening

5-7. Diabetes care: Blood Sugar Controlled

Kidney Disease Monitoring

Eye exam

8. Rheumatoid arthritis management

9. High risk medication

10. Osteoporosis management in women who had a fracture

11-13. Medication Adherence for: Hypertension (RAS Antagonists)

Cholesterol (Statins)

Diabetes medications

Criteria: • Included in CMS MA Stars Measure Set • Relevant to PO performance in delivering care • Administrative-only data (no chart review or patient survey)


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Standardizing Medi-Cal P4P


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Why do we need greater standardization?

Only 1 measure aligns across all programs:

Diabetes HbA1c Testing

California Health & Wellness

Cal Optima

CenCal

Central California Alliance

Health Net

Health Plan of San

Joaquin Health

Plan of San Mateo

Inland Empire Health

Plan

Kern Health

Systems

LA Care

Partnership

San Francisco

Health Plan

Anthem

Medi-Cal

Only 2 measures align across all programs:

1. Controlling Blood Pressure for People with Hypertension

2. Diabetes: Medical Attention for Nephropathy

Federal Quality Rating

System for Covered

California

CMS & AHIP Core Quality

Measures Collaborative

Medicare Advantage

Stars

IHA Value Based P4P

DHCS External Accountability

Set

Cross Product

Only one measure out of 86 distinct measures align across all programs

Only two measures align across all measure sets


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Medi-Cal P4P Continuum

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Voluntary Core

Measure Set; shared

specifications and

benchmarks

Voluntary Core & Supplemental

menu of measures;

shared specifications

and benchmarks

Quality based P4P in Medi-Cal; Core and Supplemental measure set

and incentive design

required; payment

amount not required

Quality based P4P in

Medi-Cal; payment amount required

Value based P4P in

Medi-Cal; payment based on

quality and resource use

Voluntary Core and

Supplemental menu of

measures and incentive

design options

IHA’s Standardizing Medi-Cal P4P Project

Current Status Medi-Cal P4P – Uniform/Broad Adoption

COORDINATION / COLLABORATION LESS MORE

No formal coordination/collaboration;

Variation in performance measurement

& incentive design


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Health Plans Alameda Alliance for Health Anthem Blue Cross California Health & Wellness CalOptima CenCal Health Central California Alliance for Health Health Net Health Plan of San Joaquin Health Plan of San Mateo Inland Empire Health Plan Kern Health Systems LA Care Health Plan Partnership Health Plan San Francisco Health Plan UnitedHealthcare

Standardizing Medi-Cal Advisory Committee

Collaborators American Institutes of Research

Blue Shield of California Foundation

California HealthCare Foundation

California Quality Collaborative

Center for Care Innovations

Center for Health Care Strategies

Health Services Advisory Group

John Snow, Inc.

Provider Representatives

Alameda Health Consortium

AltaMed

CHOC Health Alliance

Community Clinic Association of Los Angeles County

Community Medical Centers

County of San Mateo

Family Care Specialists Medical Group

Hill Physicians

Integrated Health Partners

Omnicare Medical Group IPA

Palo Alto Medical Foundation

San Mateo Medical Center

Santa Clara Valley Health & Hospital System

Santa Rosa Community Health Centers

Shasta Community Health Center

SynerMed

West County Health Center

Associations California Association of Health Plans

California Primary Care Association

CAPG

Local Health Plans of California

Safety Net Institute


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Key features of the Core Measure Set:

• No more than 10 measures

• Included in DHCS’s External Accountability Set

• Feasible for a wide array of providers to report using administrative only data

Core Measure Set Overview

CORE MEASURE SET

Domain Measures Auto Assign VBP4P

Cardiovascular Annual Monitoring for Patients on Persistent Medications: ACE or ARB

X Annual Monitoring for Patients on Persistent Medications: Diuretics

Diabetes Care

HbA1c Testing X Two Tests

HbA1c Control (<8.0%) X

Eye Exam

Maternity Timeliness of Prenatal Care X

Prevention

Childhood Immunizations, Combo 3 X Combo 10

Well-Child Visits in 3rd, 4th, 5th, and 6th Years of Life X

Cervical Cancer Screening X X

Respiratory Medication Management for People with Asthma – Medication Compliance 75%


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• Core measure set adoption underway – intent to adopt by 6 plans for MY 2017, partial adoption by 7 more

Adoption Efforts to Date

Intent to adopt for MY 2017 Partial adoption for MY 2017

1. Alameda Alliance 1. CalOptima

2. Anthem Blue Cross 2. CalViva

3. California Health & Wellness 3. Health Net

4. CenCal 4. Health Plan of San Joaquin

5. Central California Alliance for Health 5. Health Plan of San Mateo

6. LA Care 6. Partnership Health Plan

7. San Francisco Health Plan


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California Regional Health Care Cost & Quality Atlas


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Atlas: Variation Data, by Geography & Product


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Anthem Blue Cross

Leticia Schumann

Program Director, Network

Management & HMO Strategy

Blue Shield of California

Bill Panek, MD

Core Account Medical Director

Health Net

Rob Kuecks

Vice President, Actuarial Services

SCAN Health Plan

Moon Leung, PhD

Senior Vice President, Healthcare Informatics

United Healthcare

Ranyan Lu, PhD

Vice President, Clinical Performance Measurement

Western Health Advantage

Don Hufford, MD

Chief Medical Officer

Atlas Technical Advisory Group


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Atlas Measures Align with VBP4P C

linic

al Q

ual

ity

Tota

l Co

st o

f C

are

1. Risk-Adjusted Cost (average per enrollee per year)

2. Observed (unadjusted) Cost

3. Total Cost Index

Ho

spit

al U

tiliz

atio

n

1. Emergency Department Visits per thousand member years (PTMY)

2. All-Cause Readmissions

3. Inpatient Bed Days PTMY

4. Hospital Utilization Composite

1. Breast Cancer Screening

2. Colorectal Cancer Screening

3. Blood Sugar Screening for People with Diabetes

4. Poorly Controlled Blood Sugar for People with Diabetes

5. Kidney Disease Monitoring for People with Diabetes

6. Medication Management for People with Asthma

7. Clinical Quality Composite


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Expansion of Atlas

Atlas Edition 1

(available online)

Atlas Edition 2

(coming in 2017) 2013 data 2015 data

6 clinical measures + composite 10-15 clinical measures + composite

3 hospital utilization measures +

composite

10-15+ hospital utilization measures +

composite

2 cost measures + index 9 cost measures + index

24 million Californians 30 million Californians • More PPO, including more self-insured

• Medicare FFS

• Medi-Cal expansion


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Opportunities


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1. Standardize Measurement for Commercial ACOs • ACOs heading down path reminiscent of HMOs 15 years ago –proliferating,

uncoordinated measurement requirements cause duplication, burden

• VBP4P set provides solid starting place, vetted by plans and POs

2. Resource Use and Total Cost of Care Measurement • Growing focus and attention in a value world, but little coordination

• Challenging to identify relevant, publicly reported benchmarks

• Risk adjustment varies, and is often proprietary

3. Behavioral Health Measurement • Growing momentum for integration of behavioral and physical health

• Increasing attention to measurement but little agreement on priority indicators

• Convergence on PHQ-9, but specifications vary and data sources challenging

4. Patient-Centered Measurement • Widespread agreement that measures that matter to patients are essential

• Need to incorporate patients into PCM design and implementation

Opportunities for Collaboration, Alignment


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Why does aligned measurement matter?


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Excellence in Healthcare Winners Are Top Performers in Quality and Cost

50

55

60

65

70

75

80

35 40 45 50 55 60 65 70 75 80

Pati

ent

Exp

erie

nce

Ach

ieve

men

t Sc

ore

Clinical Achievement Score

Below TCC Median Above TCC Median Excellence in Healthcare Winner

Patient Experience Median: 67.27

Clin

ica

l M

ed

ian

: 5

8.0

2


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If all POs performed like “Excellence” Winners…

0

10

20

30

40

50

60

70

80

90

100

Dia

bet

es C

are:

Hb

A1

c C

on

tro

l Rat

e (%

)

41,496 More Diabetic Patients with Blood Sugar Controlled

VBP4P PO Average 55.65%

Excellence in Healthcare Award PO Average

65.17%

9.5% difference


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0

10

20

30

40

50

60

70

80

90

100

Ove

rall

Rat

ing

of

Car

e (%

)

291,121 More Patients Rate Overall Care a “9” or “10”

VBP4P PO Average 69.21%


72.29%

3.08% difference


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$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

Tota

l Co

st o

f C

are,

Geo

grap

hy

Ris

k-A

djs

ute

d (

$P

MP

Y)

$3.9 Billion Saved

$441 difference


$3,719

VBP4P PO Average $4,160


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Contact information: Jill Yegian, SVP Programs and Policy, [email protected]

For information on specific projects: • Value Based P4P and Medicare Stars at the PO Level: Lindsay Erickson, Director, Value

Based P4P, [email protected]

• Medi-Cal Standardization: Sarah Lally, Project Manager, [email protected]

• California Regional Health Care Cost & Quality Atlas: Dolores Yanagihara, VP Performance Measurement, [email protected]

Questions?

mailto:[email protected]




Enabling Performance Improvement Through Aligned Measurement · October 12, 2016 Jill M. Yegian,...

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