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Healthy San Diego Meeting
May 12, 2016
Jill Yegian, Ph.D., SVP Programs and Policy
Standardizing Medi-Cal P4P
© 2016 Integrated Healthcare Association. All rights reserved. 2
Today’s Agenda
• Introduction to IHA
• Overview of Medi-Cal P4P Standardization project
• Results to date
• Action plan for Phase 2
• Discussion
© 2016 Integrated Healthcare Association. All rights reserved. 3
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
© 2016 Integrated Healthcare Association. All rights reserved. 4
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, HillPhysicians 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
© 2016 Integrated Healthcare Association. All rights reserved. 5
Health care measurement important to assess health system performance and improve care delivered
Number and scope of measures providers held accountable for steadily increasing
Lack of alignment across incentive programs creates unnecessary burdens on providers and confusion among consumers
As Medi-Cal enrollment increases and Medi-Cal shifts to managed care, imperative emerging for consistent performance measurement
Performance Measurement Landscape
© 2016 Integrated Healthcare Association. All rights reserved. 6
Medi-Cal P4P Inventory: Program Prevalence
P4P Programs
Of the 20 Medi-Cal managed care plans interviewed, 16 have pay-for-performance programs in place
The P4P programs vary in extent and approach
Overview of Current P4P Activities
Number of Plans
P4P Programs in Place 16
Just Starting 1
Started 2009 - 2013 5
Started 2004 - 2008 3
Started 2003 and before 7
No P4P Program in Place 4
Total 20
© 2016 Integrated Healthcare Association. All rights reserved. 7
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
JoaquinHealth
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
© 2016 Integrated Healthcare Association. All rights reserved. 8
Convene an Advisory Committee to provide expertise and guidance across project activities
Identify a core measure set that all plans could adopt as a part of their P4P programs
Develop a menu of additional measures that plans can use to supplement the core measure set at the local level as well as a set of incentive design principles and best practices
Funding – Blue Shield of CA Foundation
Timeline: April 2015 – March 2016
Standardizing Medi-Cal P4P
© 2016 Integrated Healthcare Association. All rights reserved. 9
Reduce unnecessary burdens associated with the lack of
alignment across incentive programs
Enhance provider effectiveness by “strengthening the
signal” –focus improvement efforts and resources
Facilitate the comparability of performance results and
benchmarking statewide
Benefits of a Core Measure Set
© 2016 Integrated Healthcare Association. All rights reserved. 10
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 LA Care Health Plan San Francisco Health Plan Partnership Health Plan
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 Diego Health and Human Services Family Care Specialists Medical Group Hill Physicians 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
Associations California Association of Health Plans California Primary Care Association CAPG Local Health Plans of California Safety Net Institute
© 2016 Integrated Healthcare Association. All rights reserved. 11
Medi-Cal P4P Continuum
11
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 / COLLABORATIONLESS MORE
No formal coordination/collaboration;
Variation in performance measurement
& incentive design
© 2016 Integrated Healthcare Association. All rights reserved. 12
Project Scope
WHAT THE PROJECT IS: WHAT THE PROJECT IS NOT:
1 Incorporating a core measure set, developed by
an Advisory Committee, into all Medi-Cal Managed Care P4P programs (voluntary)
Developing a new P4P program, similar to IHA’s commercial program, that all Medi-Cal plans can adopt
2 Focusing provider level measurement on a
subset of measures included in DHCS’s EAS
Focusing plan level measurement on all of the measures included in DHCS’s EAS, or on measures not included in the EAS
3 Varying the unit of measurement by health
plans and their contracted provider entities Standardizing performance measurement at the
physician group level across all Medi-Cal plans
4 Potential for providing comparative data
benchmarked to peers and national metrics, for internal reporting only
Publicly reporting provider performance data
5 Creating a recommended approach to data
collection and reporting for plans to consider Developing a standard data collection method to
be used across all plans
6 Sharing incentive design best practices with
participating health plans to facilitate discussion
Creating greater standardization of incentive design structures or universal adoption of one incentive design structure
© 2016 Integrated Healthcare Association. All rights reserved. 13
IMPORTANCEThe core measure set for Medi-Cal P4P programs will measure areas
that have the greatest impact on Medi-Cal patients.
SCIENTIFIC
ACCEPTABILITY
The core measure set will include measures that are evidence-
based and have been appropriately vetted, endorsed, and
approved.
USEFULNESSThe core measure set will include measures in priority areas where
plans and providers have room for improvement and are able to
demonstrate meaningful changes in performance.
ALIGNMENT
The core measure set will align with other existing performance
measurement requirements for Medi-Cal providers and existing
Medi-Cal P4P programs in order to minimize resource demands and
allow for comparison across managed care plans and populations.
FEASIBILITYThe core measure set will include measures that have clear
specifications and data collection methodologies that do not
impose an undue burden on plans and their contracted providers.
Measure Selection Principles
© 2016 Integrated Healthcare Association. All rights reserved. 14
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 Steward NQF #
CardiovascularAnnual Monitoring for Patients on Persistent Medications: ACE or ARB NCQA 0021
Annual Monitoring for Patients on Persistent Medications: Diuretics NCQA 0021
Diabetes Care
HbA1c Testing NCQA 0057
HbA1c Control (<8.0%) NCQA 0575
Eye Exam NCQA 0055
Maternity Timeliness of Prenatal Care NCQA 1517
Prevention
Childhood Immunizations, Combo 3 NCQA 0038
Well-Child Visits in 3rd, 4th, 5th, and 6th Years of Life NCQA 1516
Cervical Cancer Screening NCQA 0032
Respiratory Medication Management for People with Asthma – Medication Compliance 75% NCQA 1799
© 2016 Integrated Healthcare Association. All rights reserved. 15
A menu or library of additional measures that plans can use to supplement the core measure set at the local level
Selection Criteria:
1. EAS measures that were not included in the core measure set
2. Additional measures currently included in Medi-Cal P4P programs
3. Measures included in more than one of the other existing performance measurement requirements for Medi-Cal plans and providers, including:
o DHCS EAS
o Covered California’s Quality Rating System
o NCQA Medicaid Managed Care Health Plan Accreditation Standards
o CMS Medicaid Core Measures for Adults and Children
Supplemental Measure Set Overview
© 2016 Integrated Healthcare Association. All rights reserved. 16
Supplemental Measure SetAccess Children and Adolescents’ Access to PCPs NCQA 1390
Behavioral Health /
Substance Abuse
Antidepressant Medication Management NCQA 0105
Follow-Up for Children Prescribed ADHD Medication NCQA 0108
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment NCQA 0004
Cardiovascular Controlling blood pressure for people with hypertension NCQA 0018
Diabetes Care
Blood Pressure Control <140/90 mm Hg NCQA 0061
HbA1c Poor Control >9% NCQA 0059
Medical Attention for Nephropathy NCQA 0062
Maternity Timeliness of Postpartum Care NCQA 1517
Musculoskeletal Overuse of Imaging Studies for Low Back Pain NQCA 0052
Prevention
Adolescent Well-Care Visits NCQA n/a
Adult BMI Assessment NCQA n/a
Breast Cancer Screening NCQA 2372
Childhood Immunizations, Combo 10 NCQA 0038
Chlamydia Screening NCQA 0033
Colorectal Cancer Screening NCQA 0034
Flu Vaccinations for Adults Ages 18-64 NCQA 0039
Human Papillomavirus Vaccine for Female Adolescents NCQA 1959
Immunizations for Adolescents NCQA 1407
Medical Assistance with Smoking & Tobacco Cessation NCQA 0027
Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents: NCQA 0024
Well-Child Visits in the First 15 Months of Life (6 or more visits) NCQA 1392
Respiratory
Asthma Medication Ratio NCQA 1800
Appropriate Testing for Children with Pharyngitis NCQA 0002
Appropriate Treatment for Children with URI NCQA 0069
Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis NCQA 0058
Resource UseAll-Cause Readmissions NCQA 1768
Emergency Department Visits NCQA n/a
© 2016 Integrated Healthcare Association. All rights reserved. 17
• Smaller subset of more ambitious, outcomes based measures; distinct from core measure set
• Some measures have clear specifications, other do not; additional work needed to determine definitions
• Exploring funding for a new project to create a foundation for ambitious, outcomes based measurement in Medi-Cal
Developmental Measure Set Overview
DEVELOPMENTAL MEASURE SET -- ILLUSTRATIVE
Domain Measures
AccessAlternative Visits (TBD)
Coordination of Care (TBD)
Behavioral HealthScreening for Clinical Depression & Follow-up e-measure (NQF#: 0418; eMeasure Identifier: 2)
Patient Reported Outcome Measure (e.g. Depression Remission)
CardiovascularControlling Blood Pressure for People with Hypertension (NQF#: 0018)
Controlling Blood Pressure e-measure (NQF #0018; eMeasure Identifier: 165)
Patient Experience CG-CAHPS (short form)
Resource Use Avoidable Emergency Department Visits (AHRQ PQI, NYU, DHCS QIP)
Total Cost of Care
© 2016 Integrated Healthcare Association. All rights reserved. 18
• Creation of consensus core, supplemental measure sets
• Active and engaged Advisory Committee, including both plans and providers
• Strong interest from plans not initially involved
• DHCS engagement, including seeking guidance from AC on measure set update
Results to Date
© 2016 Integrated Healthcare Association. All rights reserved. 19
• Core measure set adoption underway – intent to adopt by 7 plans for MY 2017, partial adoption by 6 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
© 2016 Integrated Healthcare Association. All rights reserved. 20
Next Phase of Standardizing Medi-Cal P4P
Create greater measure set alignment across the policy landscape
Support the implementation of the core measure set across all Medi-Cal P4P programs
Spread the adoption of the core measure set to plans not participating on the Advisory Committee
Funding – CMMI (included in Transforming Clinical Practices Initiative grant awarded to PBGH/CQC)
March 2016 – February 2018
© 2016 Integrated Healthcare Association. All rights reserved. 21
Objective:
• Identify opportunities for greater measure set alignment across the policy environment
Planned Activities:
• Identify initiatives underway or planned in Medi-Cal & the safety net
• Develop crosswalk of key initiatives to use as a resource toward creating a shared performance measurement strategy
• Summarize findings in an issue brief
• Support DHCS’ EAS update efforts
Timeline:
• March 2016 – September 2016
Policy Initiatives -- Measure Set Status
© 2016 Integrated Healthcare Association. All rights reserved. 22
Policies/Initiatives
1. Medi-Cal Managed Care -- External Accountability Set (EAS) Update
2. Coordinated Care Initiative (Cal Medi-Connect)
3. Public Hospital Redesign and Incentives in Medi-Cal (PRIME)
4. Whole Person Care Pilots
5. Alternative Payment Methodology (APM) Pilot
6. Health Homes for Patients with Complex Needs (Section 2703)
7. California Children’s Services (CCS) “Whole Child Model” Redesign
Medi-Cal Initiative Landscape
© 2016 Integrated Healthcare Association. All rights reserved. 23
Objective:
• To support implementation efforts and create opportunities for collaboration and learning
Planned Activities:
• Convene quarterly Advisory Committee meetings
• Develop timeline and process for adopting new measures to core measure set and complete one update of core measure set
• Explore feasibility of developing benchmarks at provider level
• Explore providing access to IHA’s web-based portal
• Re-survey plans to identify issues and unintended consequences
Timeline:
• March 2016 – February 2018
Implementation of the Core Measure Set
© 2016 Integrated Healthcare Association. All rights reserved. 24
Spread Core Measure Set
Objective:
• To spread the core measure set to Medi-Cal plans not currently participating on the Advisory Committee
Planned Activities:
• Schedule 1:1 meetings with plan representatives to share information about project and the core measure set
• Develop resources to support plans with adoption
• Provide technical support to plans interested in developing P4P programs
Timeline:
• March 2016 – December 2016
© 2016 Integrated Healthcare Association. All rights reserved. 25
1. What feedback do you have on the idea of a core measure set for Medi-Cal P4P?
2. Are the measures included in the core measure set consistent with your current efforts?
3. What implementation challenges do you anticipate?
4. Are you interested in joining the Advisory Committee?
Discussion Questions
For more information:
Jill Yegian, jyegian@iha.org
Sarah Lally, slally@iha.org
Web: www.iha.org
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