Metrics & Scoring Committee 16 June 2017 HEALTH POLICY & - - PowerPoint PPT Presentation

Metrics & Scoring Committee

16 June 2017

HEALTH POLICY & ANALYTICS Office of Health Analytics

Consent Agenda

 Review today’s agenda  Approve May minutes  Written updates (HPQMC on next slide)

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Health Plan Quality Metrics Committee

• Fourth meeting occurred Thursday, June 8
• Agenda included Committee vision; identifying measure

selection criteria and selection decision process; and identifying domains for measure sources.

• Scheduled to meet monthly (second

Thursdays) through 2017 http://www.oregon.gov/oha/analytics/Pages/Qua lity-Metrics-Committee.aspx

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Public testimony

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Childhood Immunization Status

• Several CCOs are requesting that Childhood

Immunization Status be removed from the 2016 incentive measure set. This would impact the June

2017 payments:

• Currently (including Childhood Immunization Status in

the measure set), 7 CCOs are earning 100% of their quality pool.

• If this measure is excluded, 10 CCOs would earn 100%
• f their quality pool.
• Concerns center around revisions to the 2016

rates and improvement targets made as a result

• f the validation process, as well as the individual-

level data shared with CCOs.

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Childhood immunizations timeline

• Released ALERT detail data the first time, with CY2015 period.
• Data only include members turned age 2 or 13 in the year, who are also

enrolled with the CCO in December 2015.

• Preliminary CY2015 CIS & IMA measure results are included in the dashboard.
• Mar. 2016
• Jun. 2016
• Released ALERT detail data
• Included all members age under 18 who are enrolled with the CCO in

December 2015.

• Jun. 2016
• Final CY2015 CIS & IMA results included in the dashboard.

ALERT data Metrics results published 2016 targets

• Midyear-2016 CIS & IMA results are included in the dashboard, including

member-level detail and 2016 targets.

• Oct. 2016
• Published revised CY2015 and mid-year 2016 CIS and IMA results including

member-level numerator/denominator files. There are two changes in this revision: 1. NOT to exclude member who had no records found in ALERT; 2. Corrected the continuous enrollment algorithm to be based on the child’s date of birth (previously anchored to the end of the measurement period).

• Nov. 2016
• Revised CY2015 and midyear-2016 CIS and IMA results incorporated in dashboard;

member-level detail and revised 2016 targets included.

• Dec. 2016
• Sep. 2016
• Released ALERT detail data through June 2016, age under 18 who are enrolled

with the CCO in June 2016.

• CCO noticed missing members who were dis-enrolled before June 2016.

• Preliminary CY 2016 CIS and IMA results are released.
• This also includes a code refinement to incorporate the HEDIS 14-day rule.

CY2015 results are re-calculated and 2016 targets are re-based.

• Also released ALERT detail data through December 2016 (with CCO

calendar year claim submission incorporated).

• A correction was made to include all members age under 18 enrolled with

the CCO anytime throughout 2016; all members qualified for the measure due to continuous enrollment through the birth date are included. May 2017

• Released ALERT detail data through November 2016, for member age under 18

and enrolled with the CCO in November 2016.

• Jan. 2017

June 2017

• Final CY 2016 CIS and IMA results are released.
• This also includes a code refinement to correct for the leap year (yielding

a .4% increase statewide, and moving one CCO beyond its improvement target to qualify for measure).

• No change to improvement targets

Childhood Immunization Status - Decision

• In light of the concerns of some CCOs, does the

Metrics & Scoring Committee want to exclude Childhood Immunization Status from the 2016 incentive measure set?

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2018 TAG and OHA staff recommendations

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Background

• The TAG was consulted regarding feedback

received in the stakeholder survey, as well as current discussions from the Committee (see TAG recommendation document in materials).

• Areas in which the TAG is suggesting

changes for 2018, where there was not consensus, or which relate directly to changes the Committee is considering, are included in the following slides.

• Where appropriate, OHA staff

recommendations are also included in the following slides.

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Dental Sealants

• Include sealants provided in previous years

for children in the denominator

– Some argue that the current specs incentivize reapplying sealants just to get measure credit, even if it’s not clinically necessary. – At TAG request, OHA calculated rates looking back two, rather than one year (see materials)

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Dental Sealants

• Add exclusion for patients who are not clinically

indicated to need sealants (e.g., at low risk)

– There were conflicting opinions from TAG participants about the merits of risk coding. – OHA commissioned an analysis from Q Corp, which showed that, while risk coding is increasing, still only 5% of kids have been coded. – Could be implemented in two ways (see materials):

• Per DQA specifications, only including children coded as elevated risk

in denominator (decreases denominator by 66% or 87k children in CY 2015 and raises performance 11%).

• Only exclude children at low risk, (very few children would be excluded

based on current coding rates). CY 2015 (below) shows drop in rate

Numerator Denominator Rate Total (Current Specifications) 24,371 132,071 18.5% Low risk (D0601) 1,812 4,847 37.4% Rate After Removing Low Risk Patients* 22,559 127,224 17.7%

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Dental Sealants -

• TAG recommendation
• OHA staff recommendation

TAG recommendation Lack of consensus related to both look back period and exclusion for those not clinically indicated to need sealants. OHA staff recommendation 1. Include dental sealants in 2018 incentive measure set, but without changes to specifications. Rationale: Sealants are an effective and evidence-based strategy to prevent caries in children, and CCOs have been showing initial improvements and building infrastructure in this area. 2. Add a preventive dental utilization metric for adults. Rationale: The current oral health metrics (sealants and foster care) are limited to focus on children; adding a metric to focus on the adult population encourages integration and improves access to dental care for adults.

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Developmental Screening

• Modify measure to include “follow-up” component: Referral

to specialist/services

– TAG members expressed concern with availability of timely follow up in some geographies. – Incorporating a “follow-up” component could lead to small denominators. – This information could be difficult to extract from an EHR.

TAG recommendation

No change for 2018, but consider this modification in the future as we move forward with CQM registry.

OHA staff recommendation

Concur with TAG; include in 2018 incentive measure set, but without change to

• specifications. However, create workgroup to explore follow-up component.

Rationale: After consulting with TAG and subject matter experts, change not feasible for 2018; however, work group could craft something for inclusion in future

• years. Subject matter experts also confirmed that shifting the age

range would be infeasible and clinically inappropriate.

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Effective Contraceptive Use

• Modify specifications to include permanent numerator credit for

tubal ligation. TAG recommendation

Modify as above for 2018.

OHA staff recommendation

Concur with TAG; modify to include permanent numerator credit for tubals. Rationale: Conforms with intent of measure and appropriately confers credit for access to effective contraception.

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Follow Up After Hospitalization for Mental Illness

• Modify to accommodate documented patient refusal, particularly as it

relates to small denominators.

– OHA has previously denied this modification for the HTPP program. – TAG expressed concern that there needs to be enough flexibility to accommodate a reasonable rate of refusal. For CCOs with small denominators, if one person refuses it can cause them to miss the measure.

TAG recommendation

Modify measure as above and consider how to address small denominator issue if measure continues in program.

OHA staff recommendation

No modification to measure if Committee chooses to continue it for 2018. Rationale: Consistent with how treated in HTPP program; no such exclusion exists in HEDIS specifications.

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Time for a break.

Equity Measure – ED Use Amongst Those with SPMI

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Adults living with serious mental illness

die 25 years earlier

than other Americans,

largely due to treatable medical conditions

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Aver verage e life fe exp expec ectancy y

Xu, et al, NCHS Data Brief 2016 Colton and Manderscheid, 2006 Preventing Chronic Disease: Public Health Research, Practice and Policy

General population:

78.8 years

People with serious mental illness:

49-60 years

(depending on where they live)

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Caus auses es of

• f deat

eath

Peo eople e wit ith ser erio ious men ental l illn illness (co (compared ed to gen gener eral l popul ulati ation)

• n)

References: Brown, et al, 2000 BJ of Psychiatry Osby et all, 2000 Schizophrenia Research Holt and Peveler, 2005 Diabetic Medicine

Cardiovascular disease

2-3 time higher

Higher rates of

Breast cancer Digestive cancer

Diabetes:

10 percent higher

in people with Schizophrenia (most studied co-morbidity) Looking at 2016 OHP claims data, diabetes is higher among members with SPMI:

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Majo jor in init itiatives

State of Pennsylvania launched key coordination efforts and did an evaluation of ED admissions that showed significant drops after intentional coordination and data sharing between behavioral health and primary care providers—reported out in 2012 In 2016 the Academy of Medical Royal Colleges in UK launched a comprehensive initiative to improve physical health of adults with serious mental illness

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ED visits sits

SPMI members Non-SPMI members

Member Months 1,148,569 3,105,519 ED Visits 14,698 3,636

Per 1,000 member months

12.8 1.2

No MH claims

103 38

WITH MH claims

113 39

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Top

• p 15 Pr

Primar ary Dx for

• r ED

ED visits 2016

Members with SPMI non-SPMI

# Description of Dx # Description of Dx 6,739 Other chest pain 15,294 Acute upper respiratory infection, unspecified 6,252 Chest pain, unspecified 7,116 Fever, unspecified 5,782 Headache 6,417 Unspecified abdominal pain 5,549 Unspecified abdominal pain 6,332 Other chest pain 4,249 Urinary tract infection, site not specified 6,060 Headache 4,232 Low back pain 5,931 Nausea with vomiting, unspecified 3,810 Nausea with vomiting, unspecified 5,903 Urinary tract infection, site not specified 3,099 Migraine, unsp, not intractable 5,889 Chest pain, unspecified 2,888 Epigastric pain 5,726 Viral infection, unspecified 2,642 Acute upper respiratory infection, unspecified 5,429 Acute pharyngitis, unspecified 2,464 Generalized abdominal pain 4,095 Streptococcal pharyngitis 2,395 COPD w (acute) exacerbation 4,038 Low back pain 2,253 Syncope and collapse 3,890 Unspecified injury of head, initial encounter 2,065 Dizziness and giddiness 3,657 Pneumonia, unspecified organism 2,051 Right lower quadrant pain 3,551 Cough

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Obse bservations from da data

• Out of 48 Diagnosis codes for ED Visits of SPMI members

there was only 1 primary diagnosis code related to mental health—Suicidal ideation at 1,646 frequency

• If there were mental health codes they were not the primary

reason for the ED visit as they do not appear in first position

• There were 48 unique diagnosis codes for SPMI primary

reasons for ED visits and 74 unique diagnosis codes for non- SPMI

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In In summar ummary

• Staff recommends keeping the measure as currently

defined.

• There is value in reporting a subset of an existing measure.

As a disparity metric, it’s important to have a standard measure against which to compare.

• Adults with SPMI have higher rates of preventable health
• conditions. Improved coordination between physical and

mental health care is a cornerstone of health system transformation.

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Additional TAG and OHA staff feedback

• The TAG recommendations prior to this slide are from discussions

at the last few TAG meetings.

• The TAG was also consulted on additional changes to the 2018

measure under consideration by the Committee using a survey, the results of which are below.

• Because they could not be discussed with the TAG, only the

aggregate counts from the survey are presented, rather than specific recommendations.

– Note the counts should be treated with caution – one response was requested per CCO, but there was lack of clarity in the initial instructions, so some CCOs may have submitted multiple responses.

• OHA staff recommendations are also presented.

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I am responding to this survey wearing my _________ hat: Please pick one hat.

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CAHPS

• CAHPS measures

– Potentially retire CAHPS satisfaction with care – Split CAHPS access to care into adult and children – TAG thoughts?

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Should the CAHPS satisfaction with care measure be retired in 2018?

74% (20) 26% (7)

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Would you support splitting the CAHPS access to care into separate adult and child metrics?

74% (20) 26% (7) 60% (15) 40% (10)

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If the CAHPS access to care measure is separated into adult and child metrics, how should the separation work in terms

• f achieving the measure?
• A. Distinct measures – two separate measures
• B. Bundled – separate benchmarks, counted as one measure (must hit both)
• C. Other

46% (11) 42% (10) 12% (3)

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OHA Recommendations - CAHPS

• Committee also asked OHA to review health literacy
• measures. After review, OHA confirms there are no

health literacy measures that would be ready for 2018

OHA staff recommendation 1. Retire CAHPS Satisfaction with Care 2. Continue Access, but separate into adult and child, as a bundle (achieve benchmark/improvement target on both to achieve payment). 3. Add prevention or coordination questions (specific recommendation is shared decision making) Rationale:

• Separating into adult and child measures is more actionable and a more

straightforward metric.

• The additional CAHPS metric (rather than just Access) ensure the

measure set as a whole places an emphasis on patient experience.

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Health Aspects of Kindergarten Readiness

• Health aspects of kindergarten readiness measure

– Possibly a bundle of existing measures, with separate

• benchmarks. Under consideration are:
• Developmental screening;
• Immunization status;
• Effective contraceptive use;
• Prenatal care

– To consider:

• Make this challenge pool?
• Make this stand-alone measure (in addition to each

separate measure)?

• Metrics & Scoring Committee consideration: proposal for a

workgroup, supported by the Children’s Institute, to create an overarching measure of kindergarten readiness

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Would you support a 'health aspects of kindergarten readiness' measure which is a bundle of some combination

• f the above four measures?

40% (10) 60% (15)

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Would you support some combination of the above as a health aspects of kindergarten readiness-focused challenge pool for 2018?

70% (16) 30% (7)

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OHA Recommendations – Health Aspects of Kindergarten Readiness

OHA staff recommendation 1. Frame the 2018 challenge pool as focusing on measures that may have an impact on the health aspects of kindergarten readiness (Committee would need to select measures from final 2018 list). 2. Challenge pool payment would be contingent upon meeting all measures in the challenge pool. 3. If no CCO meets all challenge pool measures, we revert to current methodology (payment per measure in challenge pool). Rationale:

• In the absence of a comprehensive measure of kindergarten readiness,

this approach clearly indicates the Committee’s commitment to cross- sector coordination for this often neglected population.

• CCOs could still achieve payment on the individual measures outside

the challenge pool.

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Equity Measure – TAG / staff feedback on how incorporate in measure set

• Retire broader ED utilization measure and replace

with this?

• Have two separate ED utilization measures (entire

population + SPMI population)

• Bundle (separate benchmarks for each – qualify for

payment only if achieve both)

• Challenge pool

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In what way should the Metrics and Scoring Committee include the equity measure (ED utilization among those with SPMI) in the 2018 incentive measure set?

• A. Retire broader ED utilization measure and replace with equity measure
• B. Have two separate ED utilization measures
• C. Bundle (separate benchmarks for each, but must meet both to qualify for

payment)

• D. Only include the SPMI equity measure in the challenge pool

24% (6) 28% (7) 16% (4) 32% (8)

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OHA Recommendations – Equity Measure

OHA staff recommendation 1. Have two separate ED utilization measures. Rationale:

• ED utilization is an important metric, and should be continued across the

entire CCO population.

• Having the equity metric as a metric in its own right ensures the

appropriate weight is given to this metric (bundling might lessen impact).

• OHA’s recommendation regarding the challenge pool is to focus it on

the health aspects of kindergarten readiness

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Obesity

• Committee asked OHA to explore whether there are any

feasible obesity metrics for 2018

• Under consideration are two measures, one focused on

adults, and one on children.

• Adult metric:

– BMI screening and follow-up (adult)

• Percentage of patients aged 18 years and older with a BMI

documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter

• Specifications in packet

https://ecqi.healthit.gov/ep/ecqms-2018-performance-period/preventive- care-and-screening-body-mass-index-bmi-screening-and

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Additional TAG feedback

• Child metric:

– Weight assessment & counseling for nutrition and physical activity (children and adolescents) – Percentage of patients 3-17 years of age who had an

• utpatient visit with a Primary Care Physician (PCP) or

Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.

• Percentage of patients with height, weight, and body mass

index (BMI) percentile documentation

• Percentage of patients with counseling for nutrition
• Percentage of patients with counseling for physical activity

https://ecqi.healthit.gov/ep/ecqms-2018-performance- period/weight-assessment-and-counseling-nutrition-and- physical-activity

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Obesity (survey responses – adult BMI screening)

• Is this measure available from your EHR vendor as a canned report?
• Is this measure built out/enabled as a report you can run now?

Answers # of Respondents Yes 21 No 11 Unsure 4 Other 4 Answers # of Respondents Yes 22 No 10 Unsure 1 Other 5

OHA Recommendations – Obesity

OHA staff recommendation 1. Add child obesity metric (weight assessment & counseling for nutrition and physical activity) to the challenge pool only, as one of the ‘health aspects of kindergarten readiness’ focused challenge pool 2. Add adult obesity measure (BMI screening and follow-up) to on deck list for 2019, and for recommendation to the Health Plan Quality Metrics Committee. Rationale:

• In terms of reporting, these CMS measures would be a (relatively)

lighter lift as they are standard national measures that many EHR vendors make available; however, including in the challenge pool only would incentivize CCOs to focus on obesity while allowing time to get QI processes in place for what would be a new metric.

• In alignment with general goal of health aspects of kindergarten

readiness aim.

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SBIRT

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Revised Staff Recommendations

• At last meeting, the need for additional time to properly pilot the

new SBIRT EHR-based measure was discussed. This means that inclusion in 2018 would require a shortened measurement period for this measure.

• Therefore, staff recommend that the EHR-based SBIRT

measure not be included in the 2018 measure set; instead, adding it to the on deck list for 2019 and proposed to the Health Plan Quality Metrics Committee

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Revised Staff Recommendations

• Rationale:

– Time to pilot test the measure and prepare guidance, without the need to push back the 2018 reporting period – If NCQA goes ahead with the proposed HEDIS measure for unhealthy alcohol screening and follow-up, final measure details should be available in October 2017. Waiting to implement an EHR- based SBIRT means we could align where possible with the HEDIS measure (which could also help inform the benchmark). – If the Committee adopts one of the proposed EHR-based CMS

• besity measure for 2018, the inclusion of an EHR-based SBIRT

measure would be an additional lift (two new EHR-based measures in one year is not insignificant).

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Vote for 2018 Measure Set!

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Next Meeting: July 21, 2017

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