Metrics & Scoring Committee May 19, 2017 Consent Agenda Review - - PowerPoint PPT Presentation

Metrics & Scoring Committee

May 19, 2017

Consent Agenda

 Review today’s agenda  Approve April minutes  Bylaw amendment (noting that voting by email is not allowed per public meetings law)

2

Health Plan Quality Metrics Committee

• Second meeting occurred Thursday, May 11
• Jon Collins presented on the Metrics & Scoring

Committee and CCO incentive measures

• Scheduled to meet monthly (second

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

3

Innovation Café Debrief

4

Place Your Logo Here - Align Center

Kindergarten Readiness and Early Learning Hub Roles & Indicators

OHA Metrics and Scoring Committee May 19, 2017

Liz Stuart, MPH, OHA Child Systems Collaboration Coordinator Tom George, Early Learning Division Research Analyst Helen Bellanca, MD, Associate Medical Director, Health Share of Oregon

Place Your Logo Here - Align Center

6

Kindergarten Readiness Measurement

• Conversations to date:

– 2015: Child & Family Wellbeing Measures Workgroup discussed a possible KR metric; extensive work is needed to develop such a measure – September 2016: Metrics & Scoring heard from Helen Bellanca and Tim Rusk about KR concepts and measurement implications – October 2016: M&S presentation about measurement in the early learning system – Ongoing conversations in M&S, the TAG, and from the field (both health and early learning) regarding the need for referral and follow-up after developmental screening – Continuing challenges around collecting and sharing data across the health and early learning sectors

Place Your Logo Here - Align Center

7

Early Learning System Goals

• Coordinated and Aligned Systems

(Early learning, K-12, Health, Human services, Business)

• Ready for Kindergarten
• Healthy, Stable, & Attached Families

Place Your Logo Here - Align Center

8

Approaches to Measurement & Outcomes

• 2015 – 17 biennium: “Traditional” (contract/accountability) approach

DATA & Strategies Outcome Measurement & Activities & POLICY

Challenges: -- Measuring coordination & collaboration is challenging

• - Limited data systems, particularly for work that crosses sectors
• - Developmental stages and local contexts vary across Hubs
• - Population-level changes take more time than one contract cycle
• - Moving metrics became focus instead of achieving outcomes

Place Your Logo Here - Align Center

9

Approaches to Measurement & Outcomes

• 2017 – 19 biennium: “Compact” approach

Outcomes Strategies DATA & & POLICY & Activities Measurement

Challenges: -- Allowing for local strategies but having common measures

• - Data and data systems will take considerable time to develop
• - Data not available for strong CQI
• - Compact model not suited for accountability or incentives
• - Convincing stakeholders they’re getting good ROI

Place Your Logo Here - Align Center

10

Framework for ‘17-19 Hub Contract Cycle

READY FOR KINDERGARTEN HUB ROLES STRATEGIES & ACTIVITIES INDICATORS/OUTCOMES 2.1 The role of the hub is to facilitate shared understanding and collaboration between early learning and K-12 partners regarding expectations about the skills and abilities of children entering school. Early learning and K-12 professionals demonstrate increases in shared language, activities, and expectations regarding kindergarten readiness. 2.2 The role of the hub is to work with partners to facilitate family engagement activities across the community that promote seamless transitions into kindergarten and the family’s comfort and engagement at their child’s school. Family reports of comfort, engagement, and adequate preparation; improved early registration; improved kindergarten attendance 2.3 The role of the hub is to work with partners to coordinate identification of children & families from priority and focus populations, to recruit them for early learning activities, enroll them in services, and make timely referrals with smooth transitions. Children furthest from opportunity are part of a timely and effective closed loop system from screening to services. Increase in front line health provider referrals to early learning resources Increased number of providers and SPARK programs. Increased self- reports of reading to children. Books in the home. Improved KA scores; reduced KA disparities. 2.4 The role of the hub is to work with community partners to increase the percentage of children from focus and priority populations who experience early learning activities that prepare them for success in school.

Place Your Logo Here - Align Center

11

Framework for ‘17-19 Hub Contract Cycle

HEALTHY, STABLE, AND ATTACHED FAMILIES HUB ROLES STRATEGIES & ACTIVITIES INDICATORS/OUTCOMES 3.1 The role of the hub is to work with early learning programs and other partners to ensure children and families from focus and priority populations have access to family support services. Reduced food insecurity. Increased stable housing. Reduced poverty/

• joblessness. Increased utilization of

financial supports, such as ERDC, Earned Income Tax Credits, etc. 3.2 The role of hub is to collaborate with the health sector to address the social determinants

• f health that lead to health and well-being for young

children and their families. 3.3 The role of the hub is to work with community partners to increase protective factors and reduce childhood experiences of abuse or neglect. Reduced number of children experiencing abuse and neglect. Reduced time out-of-home. Reduced parental stress and maternal depression 3.4 The role of the hub is to work with community partners to ensure children and families from focus and priority populations have access to medical, dental, mental health and other health care services. Increased well-child visits; dental visits/dental home; immunizations. Partner reports of increased visits for services.

Place Your Logo Here - Align Center

12

Points for Consideration

• Use of Kindergarten Readiness as an overall principle for M&S

to advance

• Lack of agreement on definition of Kindergarten Readiness in

Oregon

• Current potential for alignment with Hub indicator system
• Future potential for shared measurement with early learning

system

• Metrics that drive partnerships with non-health sectors
• Developmental screening continues to be a key driver of cross-

sector partnerships – build on this momentum

Place Your Logo Here - Align Center

13

Points for Consideration

• Kindergarten Readiness metric design:
• Accountability metric: Crosses sectors, compels partnership, drives

data sharing. Transformative, complex, and time-intensive.

• Barriers: Funding not designed to cross sectors; data capacity in the

early learning system

• Measure the health aspects of KR: Feasible in the short term, does

not comprehensively measure KR.

Place Your Logo Here - Align Center

14

Questions/Comments

Liz Stuart, MPH elizabeth.m.stuart@state.or.us (503) 891-9335 Tom George thomas.george@state.or.us (971) 304-4308 Helen Bellanca, MD helen@healthshareoregon.org

Place Your Logo Here - Align Center

DISCUSSION

15

Metrics and Scoring 5/19/17

ECU

H ELEN BELLA NCA , MD, MPH

Effective Contraception Use Metric

Proportion of women at risk for unintended pregnancy who are using an effective method of contraception

Denominator: Women age 15-50 who are physiologically capable of pregnancy Numerator: Women with evidence of Tier 1 or 2 contraception during the measurement period (tubal ligation, IUD, implant, pills, patch, ring, shot, diaphragm)

Questions

What is the intent of this measure? Do the current specifications address the intent? Are we having an impact? Should we consider a pregnancy intention screening metric instead?

The intent of this measure

• 1. Providing high quality primary care for women by improving

contraception access

• Women are fertile for about 40 years, on average they are trying to avoid

pregnancy for 35 of them

• 99% of sexually active women use contraception at some point in their

lives

• Contraception is the most commonly needed primary care service for

women (along with dental care!)

• At least 70% of women age 18-50 need contraception, only 36% of those
• n Medicaid got it in 2015
• 2. Preventing unintended pregnancy
• Having an unintended pregnancy means a woman is three times more

likely to end up below the poverty line 2 years later

• Unintended pregnancies can derail education and job options,

relationships and are associated with worse maternal and infant outcomes

https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states https://www.ansirh.org/research/turnaway-study https://www.nap.edu/catalog/4903/the-best-intentions-unintended-pregnancy-and-the-well-being-of

http://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html

Primary care screenings identified as indicators of high quality care

Cervical cancer screenings (Paps) Alcohol misuse (SBIRT) Breast cancer screenings (exams, mammography) Depression screening (PSQ-2 and 9) Diabetes screening (blood glucose and HgbA1c)

Lifetime risk of those conditions

Percent of women who experience this condition in their lifetime Cervical cancer 0.7% Alcohol misuse 10% Breast cancer 12% Depression 27% Diabetes 35.5% Unintended pregnancy 48%

Is this metric meeting our intent?

Yes, in that it focuses on the measureable outcome of contraception claims.

• Primary outcome for our first intent (more contraception access)
• Intermediary outcome for our second intent (unintended pregnancy)

Shortcomings in the specifications

• We cannot reliably exclude from the denominator women who do not need

contraception (trying to get pregnant, not having sex with men)

• We cannot count vasectomies as they are claims on someone else’s chart
• Lookback for hysterectomy and tubal is 7 years within Medicaid
• Surveillance codes required for multiyear methods

We account for the unfixable shortcomings in specifications by lowering the benchmark

• A “perfect score” is 70%, not 100%

Who is in the denominator?

Women who are abstinent Women who partner with women Women who are trying to conceive (i.e. women who don’t need contraception) Women who are physiologically capable of getting pregnant, are currently sexually active with men and do not want to get pregnant (i.e. women who need contraception) 70% 30%

Benchmark 50%

Excluded Women with a hyst/ooph in past 7 years paid by Medicaid Women who were pregnant in the measurement year who did not also receive contraception Trouble spots Women who had a hysterectomy or tubal more than 7 years ago Women with a hysterectomy or tubal not paid by Medicaid Women with a partner who has a vasectomy

Are we having an impact?

YES (Modest improvement from 2014 to 2015, final 2016 data not available)

Are we having an impact?

We are meeting expectations

• This is a new metric that had no national standard when we adopted it.
• This is a health care service that had never been measured by claims before.
• Minimal improvement action in the first year or two because of systems not

knowing what their performance would be (similar to other metrics)

• We will not see substantive impact on unintended pregnancy for at least 5 years
• 2 year delay from prevention of pregnancy to when data would have been collected on

birth outcomes

• 3% of 20,000 births is 600 – will need several years of clear declines to get to at least a

10% reduction in births.

There is a new NQF-endorsed contraception use metric that is very similar to ours – we are on the right track and setting a national standard!

Should we instead focus on pregnancy intention screening?

No, because you will move farther away from the intent of the metric

• 1. Pregnancy intention screening is a process, not an outcome
• 2. Intention screening would be a metric that would depend entirely on chart review
• There is no procedure code for pregnancy intention screening
• There are no validated tools for pregnancy intention screening
• There is no clear pathway for follow up contraception care or preconception care (Referral?

To whom?)

• 3. There is no standard agreement of what constitutes pregnancy intention screening

(How will you know if it happened? Who decides? Who would be excluded from needing screening?)

• 4. There is no evidence that pregnancy intention screening has any impact on short or

long term outcomes

Questions?

Why is this important?

Goal is to prevent unintended (unwanted) pregnancy A woman with an unintended pregnancy is:

• less likely to seek early prenatal care
• more likely to expose the fetus to harmful substances
• at greater risk of depression
• at greater risk of physical abuse
• at greater risk of having her employment, education and relationship with her

partner derailed

Brown, S. S., & Eisenberg, L. (Eds.). (1995). The best intentions: Unintended pregnancy and the well-being of children and families. Washington, DC: National Academies Press

Why is this important?

Goal is to prevent unintended (unwanted) pregnancy A child of an unintended conception is at greater risk of:

• being born at low birthweight
• dying in his/her first year of life
• being abused or neglected
• not receiving sufficient resources for healthy

development

Brown, S. S., & Eisenberg, L. (Eds.). (1995). The best intentions: Unintended pregnancy and the well-being of children and families. Washington, DC: National Academies Press

Proportion of Births that were Unintended

56.2%51.7% 54.7% 53.2% 55.3% 52.2% 55.7% 53.0% 51.8% 54.2% 55.2% 48.5% 48.2% 32.0% 33.3% 29.8% 28.5% 25.4% 25.5% 23.3% 26.2% 29.2% 28.6% 27.7% 23.5% 22.9% 0% 20% 40% 60% 80% 100% 1998-99* 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Medicaid-paid births

PUBLIC HEALTH DIVISION Reproductive Health Program

Data Source: Oregon PRAMS

Why are women who do not want to be pregnant not using contraception?

I thought I couldn’t get pregnant at that time 31% I thought I was sterile or my partner was sterile 10% My partner did not want to use anything 22% I had side effects from my birth control 11% I had problems getting birth control when I needed it 6% Other 20%

Source: Oregon PRAMS 2011

Don’t women prefer to go to a family planning clinic for contraception?

NOTE: The measure captures claims from ANY site. This is in response to “why does primary care need to do this?”.

Oregon Client Satisfaction Survey 2015, 22 clinics, 1500 completed surveys (70% participation)

prefer all in one place 60% no preference 21% prefer separate locations 18%

• ther

1%

Even among women receiving care at a family planning clinic, 57% prefer to get their care all in one place and 22% had no preference All women 81%

Yes, but what about the perception that we are unfairly or unethically targeting poor women with our contraception efforts?

30 years of data

Lowest income women All women Highest income women

Access to contraception for low- income women

• More than half of women who need contraception need publicly-funded services
• The number of women needing publicly funded contraception services increased

by 17% from 2000 to 2010

• Failing to cover contraception was ruled as a violation of the federal Civil Rights

Act as amended by the 1978 Pregnancy Discrimination Act

• The Federal ACA includes contraception care as a core preventive service that all

women are entitled to without cost sharing or co-pays.

Frost JJ, Zolna MR, Frohwirth L. Contraceptive needs and services, 2010. New York (NY): Guttmacher Institute; 2013. Available at:http://www.guttmacher.org/pubs/win/contraceptive-needs-2010.pdf.

All of these speak to the long history of poor women having less access to contraception than their higher- income peers. Having a quality metric in contraception is a key step in giving low income women equal access to high quality primary care.

NQF measure

Age 15-45 instead of Oregon’s age 15-50 (18-50 for P4P qualifications) Heavy emphasis on LARC utilization, rates called out specifically Includes women with delivery in first two months of year, all other pregnancies excluded Complex algorithm to account for LARC removal and reinsertion https://www.hhs.gov/opa/sites/default/files/MME-and-LARC-2016- Measure-Specifications-for-All-Women.pdf

Discussion

41

42

Time f e for a break. ak.

Public testimony

HEALTH POLICY & ANALYTICS Office of Health Analytics

SBIRT Measure Update

Metrics & Scoring Committee 19 May 2017 Kate Lonborg Clinical Quality Metrics Registry (CQMR) Program Manager Office of Health Analytics

Draft CCO SBIRT Measure

Initial Patient Population (IPP) = All patients aged 12 years and

• lder before the beginning of the measurement period with at least
• ne eligible encounter during the measurement period

Rate 1: Screening D1 = IPP N1 = Patients who received an age-appropriate screening, using an SBIRT screening tool approved by OHA, during the measurement period, and had either a brief screen with a negative result or a full screen Rate 2: Brief intervention and referral D2 = Patients in IPP who had a positive full screen during the measurement period N2 = Patients who received a brief intervention, a referral to treatment, or both within 2 months of a positive full screen

Exclusions and Exceptions

• Numerator exclusion: SBIRT services in ED or hospital setting
• Denominator exceptions*

– Patient refuses – Emergent situation – Patient functional capacity or motivation * These are the same denominator exceptions as depression screening and follow-up measure, but intention is to allow for data capture in a queryable field, not just in SNOMED codes

Denominator Exclusions

• Active diagnosis of alcohol or drug dependency
• Engagement in treatment
• Dementia or mental degeneration
• Limited life expectancy
• Palliative care (includes comfort care and hospice)

Related National Measures – Unhealthy Alcohol Use

• Proposed HEDIS measure: Unhealthy Alcohol Use Screening and

Follow-up

– Specified for electronic data capture – Separate rates for screening and counseling/ follow-up

• NQF 2152: Unhealthy Alcohol Use Screening and Brief Counseling

– Specified as a claims (version used in Merit-based Incentive Payment System (MIPS)) and as an EHR-based measure – Single rate for screening and follow-up

SBIRT WG Feedback on Unhealthy Alcohol Use Measures

The SBIRT workgroup sees a state-specific EHR-based SBIRT measure as a better alternative than the NQF or HEDIS measure

• The NQF and HEDIS measures are limited to adults and do not

capture any information about adolescents

• The NQF and HEDIS measures are limited to alcohol use and do

not capture any information about drug use

• Draft SBIRT measure builds on previous claims-based CCO SBIRT

measure, so workflows could remain consistent

• Draft SBIRT measure is aligned enough with proposed HEDIS

measure to re-use reporting work

Measure Implementation Concerns

• Timing concerns:

– Clinics need lead time to prepare for reporting – Pilots are needed to test out the measure specs – Guidance materials need to be prepared

• Option to shorten reporting period in initial year so reporting doesn’t

begin January 1

DISCUSSION

51

Committee homework summary

(please refer to summary in meeting materials)

52

Next Meeting: June 16, 2017