Preparing for Measurement Selection: Landscape of Measures

Sarah Hudson ScholleSepheen Byron

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Overview

• Performance Measurement in Medicaid• Quality of Care for Adults in Medicaid• Measures Inventory • Key Challenges

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PERFORMANCE MEASUREMENT IN MEDICAID

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State of Measurement in Medicaid

• There is no national reporting of Medicaid quality data representing all different populations enrolled (that’s why we are here…)

• Two new reports shed light on current efforts• Managed care: NCQA’s Medicaid Benchmarking

Project Report • FFS: CHCS’ Performance Measurement in Fee-for-

Service Medicaid: Emerging Best Practices

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NCQA Medicaid Benchmarking Report

• Purpose: Test the feasibility of collecting comparable performance measure results from state Medicaid agencies and combining these data with existing HEDIS data in NCQA’s database to develop robust benchmarks for Medicaid

• Why Focus on Managed Care and HEDIS? • 71% of the Medicaid population in states that use

managed care arrangements including PCCM and MCOs• 37 states contract with MCOs

• Nearly 90 percent of state Medicaid programs reported using HEDIS measures for evaluate quality of children’s care• No comparable data available for adults

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How Do States Use HEDIS?

• States use HEDIS measures to meet the federal requirements for performance measurement in Medicaid

• States may use the HEDIS data plans have submitted to NCQA, require plans to submit data directly to the state or the EQRO, or calculate performance rates themselves

• Twenty-five Medicaid programs use or require NCQA Accreditation

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Medicaid Programs & HEDIS

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Most Commonly Used Measures

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Most Common Differences Between State Measures and NCQA HEDIS data

• Specification changes– Continuous enrollment– Measurement year– Data source– Numerator changes

• Data collection process• Validation

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CHCS Report: Performance Measurement in FFS Medicaid

• “Just do it”• Key Themes– Leadership – Measures– Resources

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Leadership

• Involve providers and other relevant stakeholders

• Clarify the purpose of measurement –Reporting and comparisons among delivery

systems–Quality improvement

• Set clear goals for public reporting• Value the role of leadership in the

process11

Measures and Data Sources • Consider measures that rely on administrative

data for ease of capture• Consider business case with focus on overuse

measures, such as hospital readmissions• Adapt HEDIS measures to fit the FFS

environment• Look outside HEDIS for special populations like

mental health• Consider other data sources – Patient/family surveys, Registries, Lab test results,

Chronic disease and obstetrics assessment forms, Health information technology

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Resources and Time

• Consider resources needed for development and implementation of the measurement system – Many variations exist depending on structures and

resources available within states• Be patient• Expect it to take a year from the start of

developing a new measure to reporting it, depending on the complexity of the measure and the availability of analytic capacity.

• Devote resources to auditing measures

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PERFORMANCE IN MEDICAID

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Status of Health Care Quality in Medicaid

• 2009 HEDIS provides window on national performance among managed care organizations (MCOs)

• HEDIS performance rates for Medicaid MCOs are often lower than for Commercial and/or Medicare MCOs

• There are a few exceptions…

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2009 HEDIS Performance forMedicaid vs Other MCOs

Medicaid Medicare Commercial

Adult BMI Assessment 34.6 38.8 41.3

Breast Cancer Screening 52.4 69.3 71.3

Cervical Cancer Screening 65.8 NA 77.3

Postpartum Visit 64.1 NA 83.6

Initiation of Alcohol/Drug Treatment 44.3 46.2 42.7

Follow After Mental Health Hosp (30 days) 60.2 54.8 76.8

Persistent Beta Blocker Use After Heart Attack 76.6 82.6 74.4

Diabetes: A1c Screening 80.6 89.6 89.2

Diabetes: Poor A1c Control (>9.0%) (lower=better) 44.9 28.0 28.2

Diabetes: Cholesterol Screening 74.2 87.3 85.0

Diabetes: Cholesterol <100 33.5 50.0 47.0

Hypertension: Blood Pressure <140/90 55.3 59.8 64.1

Asthma: Appropriate Medications 88.6 NA 92.716

Childhood Immunization Retreat in Private Plans, But Not in Medicaid

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Big Gains in Chlamydia Screening – with Medicaid Plans Leading

23.125.4

29.732.2

34.937.3 38.1

41.743.1

40.4 40.9

44.947.2

50.7 52.4 50.754.9

56.7

0

10

20

30

40

50

60

2001 2002 2003 2004 2005 2006 2007 2008 2009

Commercial Medicaid

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USING THE INVENTORY TO IDENTIFY POTENTIAL MEASURES

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Creating Measures Inventory

• Sources of measures• Measures endorsed by National Quality Forum

• Measures nominated by CMS

• Measures submitted by 15 Medicaid medical directors

• Measures suggested by Panel co-chairs and members

• We attempted to “de-duplicate” the list…”

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Contents of Measure Inventory

• Measures• Pivot Table (allows identifying groups of

measures)• Definitions of descriptors• Acronyms• Sources

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Measures List• Measures – Sorted by Measure Steward– All measures have unique “ID number” for searching

(NQF ID provided if relevant)• Contents– Measures characteristics– Information on current use– Category in Revised IOM framework– Population of interest

• Excel makes sorting and filtering of measures possible

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Characteristics of Each Measure• Measure ID• NQF ID• Measure owner/steward• Measure name• Measure description• Specific conditions• Condition type• Measure type• Data sources• Unit of measurement

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From the Legislation….The Secretary shall identify and publish a recommended core set of adult health quality measures for Medicaid eligible adults in the same manner as the Secretary identifies and publishes a core set of child health quality measures under section 1139A, including with respect to identifying and publishing existing adult health quality measures that are in use under public and privately sponsored health care coverage arrangements, or that are part of reporting systems that measure both the presence and duration of health insurance coverage over time, that may be applicable to Medicaid eligible adults.

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Descriptors of Current Use

• Medicaid: in use by Medicaid programs or health plans in the state

• Other: in use by other federal programs (VA, Medicare Advantage, PQRI, etc)

• Any : in use in either Medicaid or other program

• States: list of states in which the measures are used

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Measures Framework

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POPULATIONS DOMAINS

Reproductive Health

Adult < 65 yrs

Complex Health Needs

Mental Health and

Substance Abuse

SafeTimelyEffectiveEfficientAccessPatient & Family CenteredCare CoordinationHealth Systems Infrastructure

Information for Each MeasureIOM Framework• Safe• Timely• Effective• Efficient• Access• Patient & Family centered• Care coordination• Health systems

infrastructure

Population• Condition Type• Female Only• Reproductive Health • Adults <65 • MH & Sub Abuse In Use• Functional status

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Starting Lists for Each Workgroup

• Maternal/reproductive health– Female only and in use at all

• Adult health – Adults <65 and in use in Medicaid

• Mental Health/Substance Use– MH&SA and in use anywhere

• Complex conditions– Cross cutting measures that are in use at all:

functional status, care coordination, health system infrastructure, avoidable hospitalizations

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Key Challenges in Measuring Quality for Adult Medicaid Populations

• Current measures do not address needs of complex populations

• Examples of measure concepts and issues in selecting measures for the core set– Avoidable hospitalizations– Care Coordination– Functional status

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Avoidable Hospitalizations

• Avoidable hospitalization measures, including hospital readmissions and admissions for ambulatory care-sensitive conditions (ACSC), are important markers of waste

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Examples of Avoidable Hospitalization Measures

Steward Measure NameNCQA Plan All-Cause Readmission (new for 2011)

CMS 30-Day All-Cause Risk Standardized Readmission Rate Following Heart Failure Hospitalization (risk adjusted)

State of CO

Number of admissions for Ambulatory Care Sensitive Conditions for waiver and Medicaid clients

AHRQ Diabetes Short-Term Complications Admission Rate/100,000

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Avoidable Hospitalizations• Key issues for Re-admission measures– Population: all age groups, adults only, etc– Hospitalizations: specific-cause discharges versus all-

cause discharges. – Counting of readmissions: all-cause readmissions or

specific-cause readmissions– Readmission timeframe: 30 days versus 3, 7, 14, 90, …– Risk adjustment– Continuous enrollment

• Key issues for ACSC Admissions – Eligible population– Risk adjustment– Continuous enrollment

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Outcomes/Functional Status

• Outcome measures include mortality and functional status

• Patients/families value these measures in particular

• These measures may reflect the net result of care for multiple conditions and care received from multiple providers and settings

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Outcomes/Functional StatusSteward Measure NameCMS Improvement in bathing among home-based care

recipientsFocus on Therapeutic Outcomes, Inc

Functional status change for patients with knee impairments

CREcare Change in Basic Mobility as Measured by the AM-PAC

CMS, NCQA Medicare Health Outcomes Survey (HOS)AHRQ IQI 11: Abdominal Aortic Artery (AAA) Repair

Mortality Rate (risk adjusted)AHRQ IQI 17: Acute Stroke Mortality Rate

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Outcomes/Functional Status

• Key Issues– Population/Site of care/Population size– Cross section versus longitudinal assessment– Risk adjustment – Data source and completeness– Attribution

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Care Coordination• NQF (2006) identified dimensions of care

coordination including – the need for a medical home, – proactive plan of care and follow-up, s– strategy for communication, – availability of information systems to support care, and – process for transitions or “hand-offs” (across providers

and settings)

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Care Coordination Steward Measure NameCMS 30-Day Post-Hospital AMI Discharge Evaluation and

Management Service Measure (In proposed IPPS rule May 2010)

NCQA Care for Older Adults (COA): Functional Status Assessment

NCQA Medication Reconciliation Post-Discharge (MRP)

IPRO Management plan for people with asthma

AMA-PCPI, NCQA

Advance Care Plan

CMS Documentation and Verification of Current Medications in the Medical Record

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Care Coordination

• Key issues:– Availability and use of measures– Data sources/completeness– Feasibility and cost of measurement

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