kate reinhalter bazinsky michael bailit september 10, 2013

The Significant Lack of Alignment Across State and Regional Health Measure Sets:An Analysis of 48 State and Regional Measure Sets, Resource Document

Kate Reinhalter BazinskyMichael BailitSeptember 10, 2013

2

Executive summary

The are many state/regional performance measures for providers in use today. – 1367 measures identified across 48 measure sets.

Unfortunately, current state and regional measure sets are not aligned. – Only 20% of all measures were used by more than one program.

Non-alignment persists despite the tendency to use standard, NQF-endorsed and/or HEDIS measures.– Although 59% of the measures come from standard sources, they

are selecting different subsets of these standard measures for use.– The most frequently used measure was only used by 63% of the

programs.

3

Executive summary (cont’d)

With few exceptions, regardless of how we analyzed the data, the programs’ measures were not aligned. – This lack of alignment persists across programs of the same type

and for the same purpose.– Medicaid MCOs are the exception and use far more of the same

measures than any other type of program. This is partially because they rely almost exclusively on HEDIS measures.

– We also found that California has more alignment. This may be due to our sample or the work the state has done to align measures.

While many programs use measures from the same domains, they are not selecting the same measures within these domains.– This suggests that simply specifying the domains from which

programs should select measures will not facilitate measure set alignment.

4

Executive summary (cont’d)

Even when the measures are “the same,” the programs often modify the traditional specifications for the standard measures.– 83% of the measure sets contained at least one modified measure. – Two of the programs modified every single measure and six of the

programs modified at least 50% of their measures. Many programs create their own “homegrown” measures.

– 40% of the programs created their own homegrown measures. – Some of these may be measure concepts, rather than measures

that are ready to be implemented Unfortunately most of these homegrown measures do not

represent true innovation in the measures space.– There appears to be a need for new standardized measures in the

areas of self-management, cost, and care management and coordination.

5

Conclusions Bottom line: Measures sets appear to be developed

independently without an eye towards alignment with other sets.

The diversity in measures allows states and regions interested in creating measure sets to select measures that they believe best meet their local needs. Even the few who seek to create alignment struggle due to a paucity of tools to facilitate such alignment.

The result is “measure chaos” for providers subject to multiple measure sets and related accountability expectations and performance incentives. Mixed signals make it difficult for providers to focus their quality improvement efforts.

6

Purpose

Goal: Paint a picture of the measures landscape across states and regions to inform development of the emerging Buying Value measure set.

Process: Identify and collect 48 measure sets used by 25 states for a range of purposes and conduct a multi-pronged analysis:– Provide basic summary information to describe the 48 measure

sets– Provide an overview of the measures included in the 48

measure sets– Analyze the non-NQF endorsed measures– Analyze the measures by measure set type– Analyze the measures by measure set purpose– Analyze the measures by domain/ clinical areas– Assess the extent of alignment within the states of CA and MA

7

Methodology We used a convenience sample of measure sets from

states, by requesting assistance from our contacts in states and by:– Obtaining sets through state websites:

• Patient-Centered Medical Home (PCMH) projects • Accountable Care Organization (ACO) projects• CMS’ Comprehensive Primary Care Initiative (CPCI)

– Soliciting sets from the Buying Value measures work group We also included measure sets from specific regional

collaboratives. We have not surveyed every state, nor have we

captured all of the sets used by the studied states. We did not include any hospital measures sets in our

analysis.– Excluded 53 hospital measures from the analysis

8

Methodology (cont’d) Organized the measures by:

– Measure steward– NQF status/ number– Age of the population of interest– Program type (e.g., ACO, PCMH, health home)– Program purpose (e.g., payment or reporting)– Domain (used the NQS tagging taxonomy)– Clinical areas of interest (used NQF taxonomy detail)

Unduplicated the total measures list to identify the “distinct” measures–If a measure showed up in multiple measure sets, we only counted it once.– If a program used a measure multiple times (variations on a theme) we also only counted it once.

9

Methodology (cont’d)

Assessed whether the measure is standard, modified, homegrown or undetermined.

• If we did not have access to the specifications, but the measure appeared to be standard through combination of steward and title or NQF#, we considered it to be a “standard” measure. This approach is likely to underestimate the number of modified measures.

• We labeled measures “modified” if they were standard measures with a change to the traditional specifications.

• We labeled measures “homegrown” if they were were indicated on the source document as having been created by the developer of the measure set.

• We labeled measures “undetermined” if the source of the measure was unclear. Some of these measures may be “homegrown” while others may be drawn from niche sources.

Table of contents

10

1. Overview of measure sets

2. Overview of measures

3. Non-standard measures

4. Analysis by measure set type

5. Analysis by measure set purpose

6. Analysis by measure domain/clinical area

7. Intrastate analysis of CA and MA

8. Conclusions / recommendations

11


Goal: provide some basic summary information to describe the group of measures sets and answer the following questions:1. How many measures are included across the measure

sets?2. How many measures are included in the average measure

set?

12

Measure sets by state

Reviewed 48 measure sets used by 25 states.

Intentionally gave a closer look at two states: CA and MA.

1. AR2. CA (7)3. CO4. FL5. IA (2)6. ID7. IL8. LA9. MA (8)10.MD

11.ME (2)12.MI13.MN (2)14.MO (3)15.MT16.NY17.OH18.OK19.OR20.PA (4)

21.RI22.TX23.UT (2)24.WA25.WI

Note: If we reviewed more than one measure set from a state, the number of sets included in the analysis is noted above.

13

Program types

ACO: Measure sets used by states to evaluate Accountable Care Organizations. Organizations of providers that agree to be accountable for the clinical care and cost of a specific attributed population

Alignment Initiative: Measure sets created by statewide initiatives in an attempt to align the various measures being used throughout the state by various payers or entities

Commercial Plans: Measure sets used by states to evaluate insurers serving commercial members

Duals: Measure sets used by state Medicaid agencies in programs serving beneficiaries who are dually eligible for Medicare and Medicaid

Exchange: Measure sets used to assess plan performance in a state-operated marketplace for individuals buying health insurance coverage

Note: these categories are meant to be mutually exclusive. Each measure set was only included in one category.

14

Program types (cont’d)

Medicaid: Measure sets used by states to evaluate the Medicaid agency performance

Medicaid MCO: Measure sets used by state Medicaid agencies to assess performance of their contracted managed care organizations

Medicaid BH MCO: Measure sets used by state Medicaid agencies to assess performance of their contracted behavioral health managed care organizations

PCMH: Measure sets used by patient-centered medical home initiatives

Other Provider: Measure sets used by states to assess performance at the provider level, but are not for assessing ACO, PCMH or Health Home initiatives

Regional Collaboratives: A coalition of organizations coordinating measurement efforts at a regional level, often with the purpose of supporting health and health care improvement in the geographic area

15

Measure sets by program type

PCMH

Other p

rovide

r

Medica

id MCO

Medica

id ACO

Commerc

ial P

lans

Health

Hom

e

Region

al Coll

abora

tive

Alignm

ent In

itiativ

eDua

ls

Excha

nge

Medica

id BH M

COMCO

0

2

4

6

8

10

12

14 13

65

3 3 3 3 32 2 2 2

1

16

Measure sets by purpose

Report

ing

Paymen

t

Report

ing an

d othe

r purp

ose

Alignm

ent

0

5

10

15

20

25 2219

52

16

Reporting: measure sets used for performance reporting, this reporting may be public or may be for internal use only

Payment: measure sets used for payment distribution to providers (e.g., pay for performance, shared savings, etc.)

Reporting and Other: measure sets used for reporting and an additional non-payment purpose, such as tiering providers or contract management

Alignment: measure sets resulting from state initiatives to establish a core measure set for the state

Defining Terms

17

Measure sets ranged significantly in size

Note: This is counting the measures as NQF counts them (or if the measure was not NQF-endorsed, as the program counted them).

108 measures

29 measures

3 measures

[max]

[min]

[avg]

Table of contents

18









19


Goals: To describe the measures used across the sets and

answer the following questions:1. Are the measures used primarily standard measures?2. To what extent are measures NQF-endorsed? 3. What are the primary sources of the measures? 4. Into which domains do most of the measures fall?5. To what extent do the measures cover all age ranges?

To assess the extent of alignment across the measure sets1. To what extent are measures shared? 2. What are the most frequently shared measures?

20

Finding: Many state/regional performance measures for providers in use todayIn total, we identified 1367 measures across the 48 measure sets

– This is counting the measures as NQF counts them or if the measure was not NQF-endorsed, as the program counted them

We identified 509 distinct measures–If a measure showed up in multiple measure sets, we only counted it once –If a program used a measure multiple times (variations on a theme) we also only counted it once

We excluded 53 additional hospital measures from the analysis.

21

Programs use measures across all of the domains

Access, affordability & inapprop care

9%Comm & care coordination

2%

Health and well-be-ing

27%

Infrastructure2%Person- centered

9%

Safety13%

Treatment and Secondary Preven-

tion33%

Utilization5%

Total measures by domainn = 1367

22

Access, affordability & in-approp care

11%Comm & care co-

ordination5%

Health and well-be-ing

14%

Infrastructure4%

Person- centered11%

Safety19%

Treatment and secondary preven-

tion 28%

Utilization8%

Distinct measures by domainn = 509

The distinct measures actually are more evenly distributed across the domains

23

Most implemented measures are for adults

Adult (18-64)4%

Adult (65+)3%

All Adults (18+)58%

Pediatric (0-17)16%

Pediatric and Adult (0-64)

20%

Measures by age groupn = 1367

But there does not appear to be a deficiency in the number of measures that could be used in the pediatric or the 65+ population.

24

Finding: Little alignment exists across the measure sets

Not shared80%

Shared*20%

Number of distinct measures shared by multiple measure sets

n = 509

Programs have very few measures in common or “sharing” across the measure sets

Of the 1367 measures, 509 were “distinct” measures

Only 20% of these distinct measures were used by more than one program

* By “shared,” we mean that the programs have measures in common with one another, not that they are working together.

How often are the “shared measures” shared?

Measures not shared 80%

2 sets, 5% (28 measures)

3-5 sets, 4% (20 measures)




25

Only 19 measures were shared by at least 1/3 (16+) of the measure sets

Most measures are not shared

Not that often…

6 Preventative Care

Categories of 19 most frequently used measures

26

•Breast Cancer Screening

•Cervical Cancer Screening

•Childhood Immunization Status

•Colorectal Cancer Screening

•Weight Assessment and Counseling for Children and Adolescents

•Tobacco Use: Screening & Cessation Intervention

7 Diabetes Care

•Comprehensive Diabetes Care (CDC): LDL-C Control <100 mg/dL

•CDC: Hemoglobin A1c (HbA1c) Control (<8.0%)

•CDC: Medical Attention for Nephropathy

•CDC: HbA1c Testing

•CDC: HbA1c Poor Control (>9.0%)

•CDC: LDL-C Screening

•CDC: Eye Exam

1 Mental Health/Sub-

stance Abuse•Follow-up after Hospitalization for Mental Illness

1 Patient Experience

•CAHPS Surveys(various versions)

4 Other Chronic

Conditions•Controlling High Blood Pressure

•Use of Appropriate Medications for People with Asthma

•Cardiovascular Disease: Blood Pressure Management <140/90 mmHg

•Cholesterol Management for Patients with Cardiovascular Conditions

27

Finding: Non-alignment persists despite preference for standard measures

Standard59%

Modi-fied17%

Home- grown15%

Undeter-mined6%

Other3%

Measures by measure typen = 1367

Standard: measures from a known source (e.g., NCQA, AHRQ)

Modified: standard measures with a change to the traditional specifications

Homegrown: measures that were indicated on the source document as having been created by the developer of the measure set

Undetermined: measures that were not indicated as “homegrown”, but for which the source could not be identified

Other: a measure bundle or composite

Defining Terms

28

In particular, states show a preference for NQF- endorsed measures

NQF- endorsed

63%No longer

NQF- endorsed

5%

Never NQF- endorsed

32%

Percentage of total measures that are NQF- endorsedn = 1367

29

But looking at the distinct measures, they are clearly willing to use non-NQF measures

NQF- en-

dorsed32%

No longer NQF- en-

dorsed4%

Never NQF- en-

dorsed64%

Percentage of distinct measures that are NQF-endorsed

n = 509 29

• If a measure showed up in multiple measure sets, we only counted it once (e.g., breast cancer screening was counted 30 times in the total measures chart since it appeared in 30 different measure sets; here it is counted once)

• If a program used a measure multiple times (variations on a theme) we also only counted it once (e.g., MA PCMH used 3 different versions of the tobacco screening measure; here it is counted once)

What are “distinct” measures?

30

HEDIS52%

AHRQ5%

AMA-PCPI4%

CAHPS4%

CMS4%

Resolution Health2%

Source with fewer than 20 measures

8%

Homegrown14%

Undetermined6%

Other3%

NCQA (HEDIS) is clearly the most common source of measures

Total measures by sourcen = 1367

31

But only 16% of the distinct measures come from HEDIS

HEDIS16%

Resolution Health

5%AHRQ

4%

CMS4%

AMA- PCPRI3%

Standard source with less than 10 measures

13%

Homegrown39%

Undetermined15%

Distinct measures by sourcen = 509

In other words, the 81 HEDIS

measures are used by multiple programs.

32

There is a lot of overlap between NQF and HEDIS but it is not 100%

NQF HEDIS

33

Why HEDIS measures are often the first choice for programs

HEDIS measures are known and trusted– They have been available and in use for a long time– The specifications are widely available and clearly defined

NCQA offers national and regional benchmark information – Although information is at the health plan level, programs can get a

sense of how to define “good performance”– They are already used by most health plans, thus providing some

information about baseline performance relative to the benchmark It’s good for the health plans if other programs use HEDIS

– If health plan success is being measured on the basis of the HEDIS set, the health plans have an interest in getting other parties to engage in improving scores of those measures

NCQA regularly updates the specifications in response to use, feedback and changes in guidelines– Since another organization is doing this work, it takes the burden

off of the program managers

Programs are selecting different subsets of standard measures

34

ProgramA

ProgramB

ProgramC

ProgramD

ProgramE

While the programs may be primarily using standard, NQF-endorsed measures, they are not selecting the same standard measures Not one measure was used by every program

– Breast Cancer Screening is the most frequently used measure and it is used by only 30 of the programs (63%)

35

Finding: Even shared measures aren’t always the same - the problem of modification!

Most state programs modify measures 23% of the identifiable standardized measures were

modified (237/1051) 40 of the 48 measure sets modified at least one measure Two programs modified every single measure

1. RI PCMH2. UT Department of Health

Six programs modified at least 50% of their measures1. CA Medi-Cal Managed Care Specialty Plans (67%) 2. WA PCMH (67%)3. MA PCMH (56%)4. PA Chronic Care Initiative (56%)5. OR Coordinated Care Organizations (53%)6. WI Regional Collaborative (51%)

36

Do modifications indicate a problem with the measure specifications?

Perhaps… some types of modifications suggest that the measure deserves a closer look:– Adding additional detail to or changing details in the specifications– Eliminating detail from the specifications– Changes in the CPT codes used in the measure specifications– Changes in the source of the data (i.e., from hybrid/clinical records to

claims) However, we found that there are many modifications that

programs make that don’t necessarily indicate a fundamental problem with the measure. For example, frequent modifications include:– Reporting only some of the rates/components of the measure (e.g., if the

measure has two components: screening and follow-up, they may only do the screening component of the measure)

– Narrowing or expanding the age of the population measured– Applying the measure to a new or sub-population– Applying the measure to an alternative setting

37

Frequency of modification type

Report

s only

some r

ates

Adds d

etail

Measu

remen

t peri

od Age

Notes a

chan

ge

Targete

d pop

ulatio

n

Alterna

tive s

etting

Report

s diffe

rent r

ates

Remov

es de

tail

CPT code

chan

ges

Chang

es de

tail

Data so

urce

010203040506070

59

3931 28 23

17 12 12 8 6 4 4

Note: some of the measures were modified in more than one way and each modification is represented on this chart

38

Why do organizations modify measures? To tailor the measure to a specific program

– If the program is specific to a subpopulation, then the organization may alter the measure to apply it to the population of interest

To make implementation easier– The systems that the organizations have in place may make an

alternative approach to implementing the measure easier To obtain buy-in and consensus on a measure

– Sometimes providers have strong opinions about the particular CPT codes that should be included in a measure in order to make it more consistent with their experiences. In order to get consensus on the measure, the organization may agree to modify the specifications.

– Sometimes providers are anxious about being evaluated on particular measure and request changes that they believe reflect best practice

39

Most frequently modified measures# programs modifying the measure

Measure Name Steward NQF #

12 Childhood Immunization Status NCQA (HEDIS) 3810 Use of Appropriate Medications for Asthma NCQA (HEDIS) 368 Tobacco Use: Screening & Cessation Intervention AMA-PCPI 28

7 CDC: Blood Pressure Control (<140/90 mm Hg) NCQA (HEDIS) 61

7 CDC: Hemoglobin A1c (HbA1c) Control (<8.0%) NCQA (HEDIS) 575

7 Breast Cancer Screening NCQA (HEDIS)31 (no longer

endorsed)

7 Cholesterol Management for Patients with Cardiovascular Conditions NCQA (HEDIS) NA

6 Controlling High Blood Pressure NCQA (HEDIS) 18

6 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents NCQA (HEDIS) 24

6 CDC: Hemoglobin-A1c Testing NCQA (HEDIS 57

40

Most frequently modified measures (cont’d)# programs modifying the measure


5 Colorectal Cancer Screening NCQA (HEDIS) 34

5 CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS) 59

5 CDC: LDL-C Screening NCQA (HEDIS) 63

5 CDC: LDL-C Control <100 mg/dL NCQA (HEDIS) 64

4 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: Engagement Only NCQA (HEDIS) 4

4 CDC: Medical Attention for Nephropathy NCQA (HEDIS) 62

4 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up CMS 421

4 Frequency of Ongoing Prenatal Care NCQA (HEDIS) 1391

Table of contents

41









42

Finding: Many programs use non-standard measures

Homegrown36%

Other4%

Standard46%

Undetermined14%

Distinct measures by typen =509

43

Some measures were from “undetermined” sources

78 of the measures were from “undetermined” sources across 12 measure sets

These measures are in this category due to difficulty interpreting the source documents. – Source was not indicated in the source document– The measure did not include an NQF# – The measure did not use a recognizable measure name

11 VT ACO utilization measures are considered “undetermined” because the specifications for these measures have not been finalized. They are undetermined from the program’s perspective.

44

There were 78 undetermined measures across 12 measure sets

MA GIC

TX DSRIP

VT ACO

NY Med

icaid

IA D

uals

CO ACO

OH PCMH

MA Dua

ls

MI PCMH

PA HH

PA PCMH

WA P

CMH0

5

10

15

20

25

3026 26

11

42 2 2 1 1 1 1 1

69% percent of the undetermined measures come from two sources.

45

Finding : Many programs create homegrown measures

Homegrown36%

Other4%

Standard46%

Undetermined14%

Distinct measures by typen =509

Homegrown measures are measures that were indicated on the source document as having been created by the developer of the measure set.

If a measure was not clearly attributed to the developer, the source was considered to be “undetermined” rather than “homegrown.”

What are “homegrown”

measures?

46

40% of the programs created at least one homegrown measure

MO BHMCO

TX DSRIP

MO HH

MA PCMH

WCHQ

NY Med

MiPCT

PA CCI

OR CCO

IA D

uals

LA M

ed

MA MBHP

CA Med

i-Cal

Specia

lty

MA Dua

ls

ME PCMH

CA Med

i-Cal

MA SQAC

MN SQRMS

MO PCMH

010203040506070 65

3221 21 16

9 6 5 4 3 3 3 2 2 2 1 1 1 1

There were 198 homegrown measures across 19 measure sets

47

Programs create homegrown measures across all domains

Access, affordabil-ity, and inappro-

priate care17%

Communica-tion and care coordina-

tion7%

Health and well-be-ing8%

Infrastructure10%

Person and family-cen-tered care

20%

Safety12%

Secondary preven-tion and treatment

9%

Utilization17%

Homegrown measures by domainn =198

48

Four basic types of homegrown measures

Measures that are specific to one

program41%

Measures that at-tempt to fill a

measurement gap35%

Unclear as to why the program used a

homegrown measure 14%

Provider choice measures10%

Homegrown measures by typen =198

49

Some homegrown measures that are specific to one program 81 programmatic measures: measures related to

infrastructure, utilization, geographic access, and program oversight– Percent Eligibility Determination Done at State Level– Child Psychiatrist Count– Provider Satisfaction

These measures are unlikely to become standardized because they are specific to the management or structure of a particular program.

50

Other homegrown measures may be “reinventing the wheel” Of these 198 measures, there were 28 measures (14%) for

which it was not readily apparent as to why the program created the measures, as these measures appeared to replicate standard measures.

Perhaps the programs were unaware of the availability of the standard measures– Adherence to prescription medications for asthma and/or COPD

(could have used NQF #1799: Medication management for people with asthma)

– ED appropriate utilization: reduce all ED visits (could have used the ED rates from the HEDIS Ambulatory Care measure)

– Emergency Department Visits: Previously Diagnosed Asthma (ages 2 - 17) (could have used NQF# 1381 Asthma Emergency Department Visits)

– Fall Prevention (could have used NQF #35 Fall Risk Management)

51

A few homegrown measures are designed to give providers flexibility and options

20 “provider choice” measures: measures that give the provider an option with regard to the measurement tool or outcome– Quality of Life: provider selects a validated tool– Percentage of patients 18 years of age and older receiving

depression screening through the use of PHQ-2 or other approved screening instruments

– Activities of Daily Living: Provider selects a validated assessment tool

18 of these measures came from Texas and 2 came from MA PCMH

These types of measures could become standardized but are not traditional measures at this point

52

Some homegrown measures attempt to fill a measurement gap 22 care management measures: measures related to care

transitions, care management or patient self-management– Percent of patients in the highest risk registry who have a

documented self-management goal– Post-discharge follow-up

11 cost measures:– Cost of care: PMPM rolling annual cost total and by service

category– Cost savings from improved chronic care coordination and

management 14 unique measures:

– Advance directives determination (Do Not Resuscitate)– Functional status assessment for knee replacement– Mental health admissions and readmissions to criminal justice

settings such as jails or prisons

53

Do homegrown measures represent innovation? “Innovative” measures are measures that are not NQF

endorsed and:a. address an important health care concern that is not

addressed in most state measure sets, e.g., • Care coordination• Care management/ transitions• Cost• End-of-life care/ hospice/ palliative care

b. address an issue/condition for which few measures are commonly employed, e.g., • Dementia• Dental care• Depression• Maternal health

• Patient self-management• Procedure-specific quality

concerns• Social determinants of health

• Mental health• Pain• Quality of life• Substance abuse

54

Finding #7: Most homegrown measures are not innovative

Non-innovative homegrown measures

149

Innovative measures that are

not homegrown

23

Innovative homegrown measures

53

But most innovative measures are homegrown

Note: The numbers on this slide vary slightly from the others since we have added the four additional homegrown innovative measures from MN AF4Q.

55

Innovative measures We identified 76 innovative measures across 50 measure

sets – 48 measures sets from the state measure set analysis– 2 additional regional collaborative measure sets

• Minnesota AF4Q• Oregon AF4Q

20 of the measure sets included at least one innovative measure– 35% of MA PCMH measures were innovative (17)– 31% of MN SQRMS measures were innovative (4)– 25% of MA MBHP measures were innovative (2)– 16% of TX Delivery System Reform Incentive Program measures

were innovative (17) Some of the innovative measures may simply be

“measure concepts” that are not ready for implementation.

56

Examples of innovative measures

% of hospitalized patients who have clinical, telephonic or face-to-face follow-up interaction with the care team within 2 days of discharge during the measurement month (MA PCMH)

Patient visits that occur with the selected provider/care team (ID PCMH)

Cost savings from improved chronic care coordination and management (IA dually eligible program)

Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons (TX DSRIP)

Mental and physical health assessment within 60 days for children in DHS custody (OR CCO)

57

Innovation across the measure sets

0

4

8

12

1617 17

6 5 4 4 3 3 3 2 2 2 2 1 1 1 1 1 1

58

There appears to be a need for new measures in certain areas

self-m

anag

emen

tco

st

care

coord

inatio

nde

ntal

proce

dure-

spec

ific

quali

ty of

life

subs

tance

abus

e

depre

ssion

materna

l hea

lth

cons

isten

t care

prov

ider

mental

healt

h

socia

l dete

rmina

nts other

02468

10121416 15

1110

76

4 43 3

2 2 2

8

59

Other measures: Bundles and composites

Bundles are combinations of measures that use an “all-or-nothing” approach. In order to achieve success on the bundle, the entity must successfully meet the target on each of the component pieces of the measure.

Composites are combinations of measures in which the various components are averaged in some fashion to yield an overall view of performance on the group of measures.

These are considered separate from the modified measures

60

Other: Some organizations create their own bundles and composites

There are two standard bundles that were used by some programs:– Optimal Diabetes Care bundle (NQF #729)– Optimal Vascular Care bundle (NQF #76)

There were 39 non-standard bundles and composites used across 6 programs – 15 CA Office of the Patient Advocate (HMO)– 14 CA Office of the Patient Advocate (PPO)– 6 CA Office of the Patient Advocate (medical group)– 2 WI Regional Collaborative – 1 MA MBHP– 1 MN SQRMS

Table of contents

61









62

Finding: Regardless of how we analyzed the data, the programs were not aligned We conducted multiple analyses and found non-alignment

persisted across:– Program types– Program purposes– Domains, and– A review of sets within CA and MA

The only program type that showed alignment was the Medicaid MCOs – 62% of their measures were shared – Only 3 measures out of 42 measures were not HEDIS measures

California also showed more alignment than usual – This may be due to state efforts or to the fact that three of the

seven CA measure sets were created by the same entity.

63

4. Analyzing the measures by program type

Goals: To analyze the measures by provider type and answer

the following questions:1. What is the average size of the measure sets by program type?2. To what extent do programs of the same type use the same

measures?3. To what extent are the measures NQF-endorsed?4. What are the most frequently used measures within each

program type?

64

Selected four measure set types for analysis

PCMH

Other p

rovide

r

Medica

id MCO

Medica

id ACO

Commerc

ial P

lans

Health

Hom

e

Region

al Coll

abora

tive

Alignm

ent In

itiativ

eDua

ls

Excha

nge

Medica

id BH M

COMCO

0

2

4

6

8

10

12

14 13

65

3 3 3 3 32 2 2 2

1

65

Finding: Not as much sharing within program type as expected

Medica

id MCO

PCMH

All mea

sures

Region

al Coll

abora

tive

Other p

rovide

r0%

10%20%30%40%50%60%70% 62%

34%

20%13% 12%

We had anticipated that programs of the same type would use the same measures

We found that except for Medicaid MCOs which share more than other types, this was generally not the case

66

Summary of program type analysis

Program Type Average number of measures in the set

Number of distinct measures

Percent of distinct measures NQF- endorsed

All measures 29 509 32%

PCMH 20 116 41%

Medicaid MCO 19 42 55%

Other provider 46 222 49%Regional collaborative 25 56 64%

67

PCMH measures

267 measures across 13 measure sets– Average of 20 measures per set (range: 6-48)– All of the PCMH programs except for one modified at least

one of its measures

116 distinct measures

13 programs located in the following states:– Idaho, Massachusetts, Maryland, Maine, Michigan,

Minnesota, Missouri, Pennsylvania, Rhode Island, Washington

68

PCMH: Greater percentage shared but still many used in only one set

Not shared66%

Shared34%

Number of distinct PCMH measures shared by multiple measure sets

n = 116

69

PCMH: Majority of measures implemented are NQF-endorsed

NQF- endorsed

68%-No longer NQF en-dorsed

5%

Never NQF-

endorsed27%

Percentage of total measures that are NQF- endorsedn = 267

70

PCMH: But less than half of the distinct measures are NQF-endorsed

NQF- endorsed

41%

No longer NQF-

endorsed4%

Never NQF-

endorsed55%

Percentage of distinct PCMH measures that are NQF-endorsed

n = 116

71

Most frequently used PCMH measures# programs modifying the measure


9 CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS) 599 Controlling High Blood Pressure NCQA (HEDIS) 189 Tobacco Use: Screening & Cessation Intervention AMA 28

8 Body Mass Index (BMI) Screening and Follow-Up CMS 421

8 Cardiovascular Disease: Blood Pressure Management <140/90 mmHg NCQA (HEDIS) 61

8 CDC: HbA1c Control (<8.0%) NCQA (HEDIS) 575


8 Use of Appropriate Medications for Asthma NCQA (HEDIS) 36


endorsed)

7 Cardiovascular Disease: LDL Cholesterol Management <100 mg/dl (CMC) NCQA (HEDIS) 64

72

Medicaid Managed Care Organization (MCO) measures

111 measures across 6 measure sets– Average of 19 measures per set (range: 6-42)

42 distinct measures– All except for 3 homegrown measures come from HEDIS

All except one program modified measures

6 Medicaid MCO programs included in analysis:– California, California (specialty plans), Florida, Illinois,

Massachusetts, Pennsylvania

73

Medicaid MCO: Share more measures than they don’t share

Not shared38%

Shared62%

Number of distinct Medicaid MCO measures shared by multiple measure sets

n = 42

74

Medicaid MCO: Most of the measures implemented are NQF-endorsed

NQF- endorsed

69%

No longer NQF-

endorsed4%

Never NQF- endorsed

27%

Percentage of Medicaid MCO measures that are NQF-endorsed

n = 111

75

Medicaid MCO: Majority of distinct measures are also NQF-endorsed

NQF- endorsed

55%No longer NQF-

endorsed5%

Never NQF-

endorsed40%

Percentage of distinct Medicaid measures that are NQF-endorsed

n = 42

76

Most frequently used Medicaid MCO measures

# programs modifying the measure



4 Adolescent Well-Care Visits NCQA (HEDIS) NA


endorsed)4 CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS) 59


4 Childhood Immunization Status NCQA (HEDIS) 38

4 Prenatal and Postpartum Care NCQA (HEDIS) 1517

4 Well-Child Visits in the 3rd, 4th, 5th, & 6th Years of Life NCQA (HEDIS) 1516

77

Other provider measures



All of the provider programs modified at least one of its measures

6 Other provider programs included in analysis:– California, Massachusetts GIC, Massachusetts PCPRI, PA

provider P4P program, TX Delivery System Reform Incentive Program, and Utah’s Department of Health reporting system

78

Other provider: Very small percentage shared

Not shared88%

Shared12%

Number of distinct provider measures shared by multiple measure sets

n = 222

79

Other provider: Most of the measures implemented are NQF-endorsed

NQF- endorsed

54%

-No longer NQF endorsed

7%

Never NQF- endorsed

39%

Percentage of Medicaid measures that are NQF-endorsed

n = 276

80

Other provider: Just under half of the distinct measures are NQF-endorsed

NQF- endorsed

49%


5%

Never NQF-

endorsed46%

Percentage of distinct provider measures that are NQF-endorsed

n = 222

81

Other provider: Most frequently used measures# programs modifying the measure



endorsed)5 Cervical Cancer Screening NCQA (HEDIS) 32

4 CDC: HbA1c Testing NCQA (HEDIS) 57



3 Chlamydia Screening in Women NCQA (HEDIS) 33


3 Annual Monitoring for Patients on Persistent Medications NCQA (HEDIS)

21 (no longer

endorsed)

3Cholesterol Management for Patients with Cardiovascular Conditions (LDL-C Screening & LDL-C Control (< 100 mg/dL))

NCQA (HEDIS) NA

82

Regional collaborative measures

75 measures across only 3 studied measure sets– Average of 25 measures per set (range: 10-37)


Two out of the three collaboratives modified at least one of its measures

3 Regional collaboratives included in the analysis:– Maine Health Management Coalition, HealthInsight Utah,

Wisconsin Collaborative for Healthcare Quality

83

Regional collaborative: Very small percentage shared

Not shared88%

Shared13%

Number of distinct regional collaborative measures shared by multiple measure sets

n = 56

84

Regional collaborative: Most of the measures implemented are NQF-endorsed

NQF- endorsed

73%

No longer NQF-

endorsed2%

Never NQF-

endorsed25%

Percentage of regional collaborative measures that are NQF-endorsed

n = 75

85

Regional collaborative: Most distinct measures are NQF-endorsed

NQF- endorsed

64%

No longer NQF-

endorsed2%

Never NQF- endorsed

34%

Percentage of distinct regional collaborative measures that are NQF-endorsed

n = 56

86

7 shared regional collaborative measures# programs modifying the measure



2 CDC: HbA1c Control (<8.0%) NCQA (HEDIS) 575

2 CDC: Hemoglobin-A1c Testing NCQA (HEDIS) 57




2 Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention AMA-PCPI 28

87

Conclusions from measure-type analysis

Surprised that there is not more overlap of measures within measure set type

Medicaid MCOs are the exception and share far more measures than any other type of program. – This is partially because they rely almost exclusively on the

HEDIS measures. The “other provider” focused measures sets tend to

be larger on average and there is less sharing across the provider measure sets

The interest in modifying was not limited to one type While most of the implemented measures are NQF-

endorsed, many of the distinct measures used are not endorsed

Table of contents

88









89

5. Analyzing the measures by program purpose

Goals: To analyze the measures by provider purpose and

answer the following questions:1. What is the average size of the measure sets by program

purpose?2. To what extent do programs designed for the same purpose use

the same measures?3. To what extent are the measures NQF endorsed?4. What are the most frequently used measures within each

program purpose?

90

Selected two measure set purposes for analysis

Reporting Payment (and reporting)

Reporting and other purpose

Other0

5

10

15

20

2522

19

5

2

91

Finding: More sharing within reporting programs than in payment

Reporting Payment All measures0%

5%

10%

15%

20%

25%

30%

35%

40%

45%39%

26%

20%

We had anticipated that the payment programs would use more similar measures, but we found that was not the case.

92

Finding: Not as much use of NQF measures for payment as expected

Reporting Payment All measures0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

37% 36%32%

We had anticipated that the payment programs would use mostly NQF endorsed measures, but we found that was not the case.

93

Summary of program purpose analysis

Program Type

Number of programs included in category

Average number of measures in the set

Number of distinct measures

Percent of distinct measures NQF endorsed

All measures 48 29 509 32%Reporting measures 22 22 157 37%

Payment measures 19 30 250 36%

94

Measures for reporting



82% of the programs modified at least one of their measures

95

Reporting: More sharing than the general analysis

Not shared61%

Shared39%

Number of distinct reporting measures shared by multiple measure sets

n = 157

96

Reporting: The majority of implemented reporting measures are NQF-endorsed

NQF- endorsed

70%

-No longer NQF en-dorsed

7%

Never NQF- endorsed

23%

Percentage of reporting measures that are NQF-endorsed

n = 490

97

Reporting: Most of the distinct measures are not endorsed

NQF- endorsed

37%


6%

Never NQF-

endorsed57%

Percentage of distinct reporting measures that are NQF-endorsed

n = 157

98

Most frequently used reporting measures# programs modifying the measure


16 CDC: Hemoglobin A1c (HbA1c) Control (<8.0%) NCQA HEDIS 575

15 CDC: LDL-C Control <100 mg/dL NCQA HEDIS 64

14 Controlling High Blood Pressure NCQA HEDIS 18

14 CDC: Blood Pressure Control (<140/90 mm Hg) NCQA HEDIS 61

14 CDC: Medical Attention for Nephropathy NCQA HEDIS 62

13 CDC: Hemoglobin-A1c Testing NCQA HEDIS 57

13 Breast Cancer Screening NCQA HEDIS31 (no longer

endorsed)12 CDC: LDL-C Screening NCQA HEDIS 63

11 Cervical Cancer Screening NCQA HEDIS 32

11 CDC: Eye Exam NCQA HEDIS 55

99

Measures for payment



All except two of the measure sets used for payment modified at least one of their measures

100

Payment: Shares slightly more than the general, but less than the reporting

Not shared74%

Shared26%

Number of distinct payment measures shared by multiple measure sets

n = 250

101

Payment: Most implemented measures are NQF-endorsed

NQF- endorsed

64%No longer

NQF- endorsed

4%

Never NQF- endorsed

32%

Percentage of payment measures that are NQF-endorsed

n = 563

102

Payment: …but most distinct measures are not NQF-endorsed

NQF- endorsed

36%

No longer NQF-

endorsed3%

Never NQF- endorsed

61%

Percentage of distinct payment measures that are NQ- endorsed

n = 250

103

Most frequently used payment measures# programs modifying the measure



endorsed)12 Controlling High Blood Pressure NCQA (HEDIS) 18

10 Cervical Cancer Screening NCQA (HEDIS) 32

10 Follow-Up After Hospitalization for Mental Illness (7 day rate only) NCQA (HEDIS) 576


9 Childhood Immunization Status NCQA (HEDIS) 38


9 Screening for Clinical Depression and Follow-up Plan CMS (PQRI 134) 418

Table of contents

104









105

Summary of domain analysis

Domain Total # of measures

#of distinct

measures

% of measures

shared

% of distinct measures

NQF- endorsed

# of programs that share the

most frequently

used measureAccess, affordability, and inappropriate care 120 55 21% 24% 12

Communication and care coordination 32 26 12% 25% 4

Health and well-being 371 70 40% 44% 30Infrastructure 23 20 0 0 0Person and family-centered care 127 58 5% 12% 16

Safety 181 95 16% 34% 19Treatment and secondary prevention 448 143 25% 49% 29

Utilization 65 38 8% 3% 9

106

6. Access, affordability, and inappropriate care

120 access, affordability, and inappropriate care (AAIC) measures– Only 4% were modified


107

AAIC: Many measures used by only one program

Not shared79%

Shared21%

Number of distinct AAIC measures shared by multiple measure sets

n = 55

108

AAIC: Exactly half of the measures are NQF endorsed

NQF- endorsed

50%

Never NQF-

endorsed50%

Percentage of total AAIC measures that are NQF-endorsed

n = 120

109

AAIC: …but most of the distinct measures are not endorsed

NQF- endorsed

24%

Never NQF- endorsed

76%Percentage of distinct AAIC measures that

are NQF-endorsedn =55

110

Most frequently used AAIC measures# programs modifying the measure


12 Appropriate Testing for Children With Pharyngitis NCQA (HEDIS) 2

11 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis NCQA (HEDIS) 58

10 Appropriate Treatment for Children with Upper Respiratory Infections NCQA (HEDIS) 69

7 Child and Adolescent Access to Primary Care Practitioners (12-14, 25mo-6yr, 7-11, 12-19) HEDIS NCQA (HEDIS) NA

7 Use of Imaging Studies for Low Back Pain NCQA (HEDIS) 52

6 Adult Access to Preventive/Ambulatory Health Services NCQA (HEDIS) NA

6 Use of Spirometry Testing in the Assessment and Diagnosis of COPD NCQA (HEDIS) 577

4 PC-01 Elective Delivery The Joint Commission 469

3 Cesarean Rate for Low-Risk First Birth Women AHRQ/CHIRPA NA

3 Third Next Available Appointment NCQA Standard NA

111

Communication and care coordination

32 communication and care coordination measures– None of the measures were modified


112

Communication: Most distinct measures used by only one program

Not shared88%

Shared12%

Number of distinct communication measures shared by multiple measure sets

n = 26

113

Communication: Most measures used are not NQF-endorsed

NQF- en-

dorsed36%

No longer NQF endorsed

9%

Never NQF- endorsed

55%

Percentage of total communication measures that are NQF-endorsed

n = 33

114

Communication: Most of the distinct measures are not NQF-endorsed

NQF- endorsed

25%

No longer NQF-

endorsed11%

Never NQF- endorsed

64%

Percentage of distinct communication measures that are NQF-endorsed

n = 26

115

Communication measures shared across programs# programs modifying the measure


4 Care Transition — Transition Record Transmitted to Health Care Professional AMA-PCPI 648

2 3-Item Care Transition Measure (CTM-3)University of Colorado Health Sciences Center

228

2Medication reconciliation after discharge from an inpatient facility NCQA (HEDIS) 97

116

Health and well-being measures

371 health and well-being measures– None of the measures were modified


117

Health and well-being: Greater number of measures shared

Not shared60%

Shared40%

Number of distinct health and well-being measures shared by multiple measure sets

n = 70

118

Health and well-being: Most measures used are NQF-endorsed

NQF- endorsed

73%

No longer NQF-

endorsed9%

Never NQF- endorsed

18%

Percentage of total health and well-being measures that are NQF-endorsed

n = 371

119

Health and well-being: Most of the distinct measures are not endorsed

NQF- endorsed

44%

No longer NQF- endorsed

6%

Never NQF-

endorsed50%

Percentage of distinct health and well-being measures that are NQF-endorsed

n = 70

120

Most frequently used health and well-being measures# programs modifying the measure



endorsed)24 Cervical Cancer Screening NCQA (HEDIS) 32

21 Childhood Immunization Status NCQA (HEDIS) 3819 Colorectal Cancer Screening NCQA (HEDIS) 34


17 Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents NCQA (HEDIS) 24

15 Chlamydia Screening NCQA (HEDIS) 33

15 Maternity Care: Postpartum Care (PPC), Prenatal Visit During 1st Trimester (PPC) NCQA (HEDIS) 1517

14 Adolescent Well-Care Visits NCQA (HEDIS) NA

14 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: Composite NCQA (HEDIS) 4

14 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up CMS 421

121

Infrastructure measures

23 Infrastructure measures– None of the measures were modified – 87% of the measures were homegrown


122

Examples of infrastructure measures

MO Medicaid managed care - BH measures– Adult psychiatrist count– Psychiatric practices contacted to complete survey

regarding patient services, services provided, service availability

Oregon CCO Incentive Measures Set– Electronic health record adoption

NY Medicaid Redesign Initiative– Percent eligibility determination done at state level

MiPCT Clinical Metrics– PCMH registry with decision support & performance reports

123

Infrastructure: No measures shared

Not shared100%

Number of distinct Infrastructure measures shared by multiple measure sets

n = 20

124

Infrastructure: None of the measures are NQF-endorsed

Never NQF-

endorsed100%

Percentage of infrastructure measures that are NQF-endorsed

n = 23

125

Person and family-centered care measures

127 person and family-centered care measures– Only 4% of the measures were modified


126

Person and family-centered care: Very small number of measures shared

Not shared95%

Shared5%

Number of distinct person and family-centered care measures shared by multiple measure sets

n = 58

127

Person and family-centered care: Most measures are NQF-endorsed

NQF- endorsed

59%

No longer NQF-

endorsed1%

Never NQF-

endorsed40%

Percentage of total person and family-centered care measures that are NQF-endorsed

n = 127

128

Person and family-centered care: Most of the distinct measures are not NQF-endorsed

NQF- endorsed12% No longer NQF-

endorsed2%

Never NQF- endorsed

86%Percentage of distinct person and family-

centered care measures that are NQF-endorsedn = 58

129

Shared person and family-centered care measures# programs using the measure


16 CAHPS Survey1 AHRQ YES

2 Hospice and Palliative Care – Treatment Preferences

University of North Carolina-Chapel Hill

1641

2 Quality of Life survey: choice of tool NA NA

1: If a program used one question from a CAHPS survey, we counted it as using CAHPS. We did not look at the specific surveys or which questions/composites from the surveys they used.

130

Safety measures

181 safety measures– 17% of the measures were modified


131

Safety: Most measure used by only one program

Not shared84%

Shared16%

Number of distinct safety measures shared by multiple measure sets

n = 95

132

Safety: Most measures used are NQF-endorsed

NQF- endorsed

55%

No longer NQF-

endorsed12%

Never NQF- endorsed

33%

Percentage of total safety measures that are NQF-endorsed

n = 181

133

Safety: Most of the distinct measures are not NQF-endorsed

NQF- endorsed

34%


4%

Never NQF-

endorsed62%

Percentage of distinct safety measures that are NQF-endorsed

n = 95

134

Most frequently used safety measures# programs using the measure


19 Follow-Up After Hospitalization for Mental Illness (30 day only) NCQA (HEDIS) 576

11 Annual Monitoring for Patients on Persistent Medications NCQA (HEDIS) 21 (no longer

endorsed)

9 Plan All-Cause Readmission NCQA (HEDIS) 1768

6 Chronic Obstructive Pulmonary Disease - Admission Rate AHRQ (PQI) 275

6 Heart Failure Admission Rate (PQI 8) AHRQ (PQI) 277

6 Pharmacotherapy Management of COPD Exacerbation (bronchodilator only) NCQA (HEDIS)

549 (no longer

endorsed)5 Medication Management for People With Asthma NCQA (HEDIS) 1799

4 Asthma in Younger Adults Admission Rate (PQI 15) AHRQ (PQI) 283

4 Hospital-Wide All-Cause Unplanned Readmission Measure (HWR) Yale/CMS 1789

3 Diabetes Short-Term Complications Admission Rate AHRQ (PQI) 272

135

Treatment measures, including treatment and secondary prevention measures

448 treatment and secondary prevention measures– 23% of the measures were modified


136

Treatment and secondary prevention: Larger percentage shared than in other domains

Not shared75%

Shared25%

Number of distinct treatment and secondary prevention measures shared by multiple measure sets

n = 143

137

Treatment and secondary prevention: Very high percentage of measures are NQF-endorsed

NQF- endorsed

77%

No longer NQF-

endorsed3%

Never NQF- endorsed

20%

Percentage of total treatment and secondary prevention measures that are NQF-endorsed

n = 448

138

Treatment and secondary prevention: Only half of distinct measures are NQF-endorsed

NQF- endorsed

49%


6%

Never NQF-

endorsed45%

Percentage of distinct treatment and secondary prevention measures that are NQF endorsed

n = 143

139

Most frequently used treatment and secondary prevention measures# programs using the measure











17Cholesterol Management for Patients with Cardiovascular Conditions (LDL-C Screening & LDL-C Control (< 100 mg/dL))

NCQA (HEDIS) NA

140

Most frequently used treatment and secondary prevention measures# programs using the measure


16 CDC: Eye Exam NCQA (HEDIS) 55

13 Follow-Up Care for Children Prescribed ADHD Medication NCQA (HEDIS) 108

13 Antidepressant Medication Management NCQA (HEDIS) 105

8 Comprehensive Diabetes Care (Composite Measure)NCQA (HEDIS) 731

6 Persistence of Beta-Blocker Treatment After a Heart Attack NCQA (HEDIS) 71

6 Disease Modifying Anti-rheumatic Drug (DMARD) Therapy in Rheumatoid Arthritis NCQA (HEDIS) 54

6 Diabetes Care Foot Exam NCQA (HEDIS) 56

6 Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100 mg/dL NCQA (HEDIS) 75

5Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction

AMA-PCPI 81

141

Utilization measures

65 utilization measures– 17% of the measures were modified


142

Utilization: Larger percentage not shared than in other domains

Not shared92%

Shared8%

Number of distinct utilization measures shared by multiple measure sets

n = 38

143

Utilization: Very high percent of measures are NQF-endorsed

NQF- endorsed

77%

No longer NQF-

endorsed3%

Never NQF- endorsed

20%

Percentage of total utilization measures that are NQF-endorsed

n = 65

144

Utilization: Only one distinct measure is NQF-endorsed

NQF endorsed3%

Never NQF endorsed

97%Percentage of distinct utilization measures that are

NQF endorsedn = 38

145

Shared utilization measures# programs using the measure


9 Ambulatory Care NCQA (HEDIS) NA

6 Asthma Emergency Department VisitsAlabama Medicaid Agency

1381

2 Mental Health Utilization NCQA (HEDIS) NA

146

Conclusions from domain analysis

Programs select measures from the same domains, with an emphasis on the Treatment and Secondary Prevention and the Health and Well-being domains

However, programs are not picking the same measures within those domains

Simply specifying the domains from which programs should select measures will not facilitate measure set alignment

147

Measures by clinical areas of interest

01020304050 44 42 41 40

21 18 17 16 14 12

Distinct measures

148

Summary of clinical areas of interest analysis

Clinical area of interest # of distinct measures# of programs that share the most frequently used

measureBehavioral health 44 19

Diabetes measures 42 23Cardiovascular measures 41 29

Pulmonary/critical care 40 21

Cancer-related 12 30

149

44 behavioral health measures by category

0

4

8

1213

97 7

53

Distinct measures

150

Shared behavioral health measures# programs using the measure


19 Follow-Up After Hospitalization for Mental Illness NCQA (HEDIS) 576


14 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment NCQA (HEDIS) 4

13 Antidepressant Medication Management NCQA (HEDIS) 105

13 Follow-Up Care for Children Prescribed ADHD Medication NCQA (HEDIS) 108

12 Screening for Clinical Depression CMS 418

2 Depression Remission at Six Months MN Community Measurement 711

2 Medical Assistance With Smoking and Tobacco Use Cessation

NCQA (CAHPS) 27

151

Most frequently used diabetes measures# programs using the measure









16 CDC: Eye Exam NCQA (HEDIS) 55

8 Comprehensive Diabetes Care (Composite Measure) NCQA (HEDIS) 731

6 Diabetes Care Foot Exam NCQA (HEDIS) 56

152

Most frequently used diabetes measures (cont’d)# programs using the measure


3 Diabetes Short-Term Complications Admission Rate (PQI 1) AHRQ (PQI) 272

3 Uncontrolled Diabetes Admission Rate (PQI 14) AHRQ (PQI) 638

3 Optimal diabetes care (ODC) (bundle) MN Community Measurement 729

2 Diabetes Long Term Complications Admission Rate- (PQI 3) AHRQ (PQI) 274

2 Comprehensive Diabetes Care: Blood Pressure Control (<140/80 mm Hg) NCQA (HEDIS) NA

2 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<7.0%) NCQA (HEDIS) NA

153

41 cardiovascular disease measures by category

0

4

8

1213

9 8

4 4 3

Distinct measures

154

Shared cardiovascular disease measures# programs using the measure



17 Cholesterol Management for Patients with Cardiovascular Conditions NCQA (HEDIS) NA

6 Persistence of Beta-Blocker Treatment After a Heart Attack NCQA (HEDIS) 71

6 Heart Failure Admission Rate (PQI 8) AHRQ (PQI) 277

6 Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100 mg/dL NCQA (HEDIS) 75

5 Heart Failure: ACE Inhibitor or ARB Therapy for LVSD AMA-PCPI 81

4 Hypertension: Blood Pressure Measurement NCQA (HEDIS) 13 (no longer endorsed)

3 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic NCQA (HEDIS) 68

3 Ischemic Vascular Disease (IVD): Blood Pressure Control NCQA (HEDIS) 73

2 Heart Failure : Beta-blocker therapy for LVSD AMA-PCPI 83

2 Optimal Vascular Care (OVC) (bundle) MN Community Measurement

76

155

40 pulmonary/critical care measures by category

Asthma COPD Pneumonia0

5

10

15

20

25

30 28

9

3

Distinct measures

156

Shared pulmonary/critical care measures# programs using the measure



6 Asthma Emergency Department VisitsAlabama Medicaid Agency

1381

6 Use of Spirometry Testing in the Assessment and Diagnosis of COPD

NCQA (HEDIS) 577

6 Chronic Obstructive Pulmonary Disease - Admission Rate (PQI 5) AHRQ (PQI) 275

6 Pharmacotherapy Management of COPD Exacerbation NCQA (HEDIS)

549 (no longer

endorsed)5 Medication Management for People With Asthma NCQA (HEDIS) 1799

4 Asthma in Younger Adults Admission Rate (PQI 15) AHRQ (PQI) 283

3 Optimal Asthma Care MN Community Measurement NA

157

12 cancer-related measures

Most measures related to cancer screening Four shared measures

# programs using the measure


30 Breast Cancer Screening NCQA (HEDIS) 31 (no longer endorsed)



2“Checking for Cancer” Composite: Breast Cancer Screening, Cervical Cancer Screening, Colorectal Cancer Screening

NCQA (HEDIS) NA

Table of contents

158









159

7. Summary of intrastate analysis

State # of programs

Total # of measures

# of distinct

measures

% of measures

shared

% of distinct measures

NQF- endorsed

% of programs that share the most

frequently used

measure

California 7 231 64 69% 59% 86%Massachusetts 8 334 214 24% 59% 75%All measures 48 1367 509 20% 32% 63%

160

California measures



All of the CA programs modified at least one of their measures

Three of the 7 sets were created by the Office of the Patient Advocate

161

California: Significantly more alignment than typical

Not shared31%

Shared69%

Number of distinct CA measures shared by multiple measure sets

n = 64

162

California: Uses mostly NQF measures

NQF- endorsed

77%


8%

Never NQF- endorsed

15%

Percentage of CA measures that are NQF- endorsedn = 276

163

California: Most of the distinct measures are NQF-endorsed too

NQF- endorsed

59%

No longer NQF-

endorsed5%

Never NQF- endorsed

36%

Percentage of distinct CA measures that are NQF-endorsed

n = 64

164

Most frequently used CA measures# programs modifying the measure


6 Annual Monitoring for Patients on Persistent Medications

NCQA (HEDIS)

21 (no longer

endorsed)6 Avoidance of Antibiotic Treatment in Adults with Acute

BronchitisNCQA (HEDIS) 58

6 Breast Cancer Screening NCQA (HEDIS)

31 (no longer

endorsed)6 CDC: Blood Pressure Control (<140/90 mm Hg) NCQA

(HEDIS) 61




165

Most frequently used CA measures (cont’d)# programs modifying the measure





6 Cholesterol Management for Patients with Cardiovascular Conditions

NCQA (HEDIS) NA


6 Use of Imaging Studies for Low Back Pain NCQA (HEDIS) 52

166

Massachusetts measures



6 of the 8 MA sets modified at least one of their measures

167

Massachusetts: Less alignment than CA

Not shared76%

Shared24%

Number of distinct MA measures shared by multiple measure sets

n = 214

168

Massachusetts: Most measures are NQF-endorsed

NQF- endorsed

70%


7%

Never NQF- endorsed

23%

Percentage of MA measures that are NQF- endorsedn = 334

169

Massachusetts: Most of the distinct measures are NQF-endorsed too

NQF- endorsed

59%


7%

Never NQF- endorsed

34%

Percentage of distinct provider measures that are NQF-endorsed

n = 214

170

Most frequently used MA measures# programs modifying the measure


6 Breast Cancer Screening NCQA (HEDIS)

31 (no longer

endorsed)

6 Follow-Up After Hospitalization for Mental Illness NCQA (HEDIS) 576



5 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

NCQA (HEDIS) 4

4 Annual Monitoring for Patients on Persistent Medications

NCQA (HEDIS)

21 (no longer

endorsed)

4 Screening for Clinical Depression CMS 418

171

Intrastate analysis summary

California has significantly more alignment across its measure sets when compared to Massachusetts and the total measures set.

Part of the reason for the alignment within CA is that three of the seven measure sets were developed by the same organization (Office of the Patient Advocate).

Anecdotally, we have been told that CA has worked to align its measure sets.

While MA has work underway to align its measure sets across the state though the Statewide Quality Committee, currently there is little alignment within the state.

Table of Contents

172









173

Summary of findings There are many, many measures in use today.

Current state and regional measure sets are not aligned.

Non-alignment persists despite the tendency to use standard, NQF-endorsed and/or HEDIS measures.

With few exceptions, regardless of how we analyzed the data, the programs’ measures were not aligned. – With the exception of the Medicaid MCO programs, we found

this lack of alignment existed across domains, and programs of the same type or for the same purpose.

– We also found that California has more alignment. This may be due to our sample or the work the state has done to align measures.

174

Summary of findings (cont’d)

While many programs use measures from the same domains, they are not selecting the same measures within these domains.– This suggests that simply specifying the domains from which

programs should select measures will not facilitate measure set alignment.

Even when the measures are “the same,” the programs often modify the traditional specifications for the standard measures.

175

Summary of findings (cont’d)

Many programs create their own “homegrown” measures.– Some of these may be measure concepts, rather than

measures that are ready to be implemented

Unfortunately most of these homegrown measures do not represent true innovation in the measures space.

There appears to be a need for new standardized measures in the areas of self-management, cost, and care management and coordination.

176

Conclusions Bottom line: Measures sets appear to be developed

independently without an eye towards alignment with other sets.

The diversity in measures allows states and regions interested in creating measure sets to select measures that they believe best meet their local needs. Even the few who seek to create alignment struggle due to a paucity of tools to facilitate such alignment.

The result is “measure chaos” for providers subject to multiple measure sets and related accountability expectations and performance incentives. Mixed signals make it difficult for providers to focus their quality improvement efforts.

177

This is only the beginning…

We anticipate that as states and health systems become more sophisticated in their use of electronic health records and health information exchanges, there will be more opportunities to easily collect clinical data-based measures and thus increase selection of those types of measures over the traditional claims-based measures.

Combining this shifting landscape with the national movement to increase the number of providers that are paid for value rather than volume suggests that the proliferation of new measures and new measure sets is only in its infancy.

178

A call to action

In the absence of a fundamental shift in the way in which new measure sets are created, we should prepare to see the problem of unaligned measure sets grow significantly.

179

Recommendations1. Launch a campaign to raise awareness about the current

lack of alignment across measure sets and the need for a national measures framework.– help states and regions interested in creating measure sets

understand why lack of alignment is problematic

2. Communicate with measure stewards to indicate to them when their measures have been frequently modified and why this is problematic.– in particular in the cases in which additional detail has been added,

removed or changed

3. Develop an interactive database of recommended measures to establish a national measures framework.– consisting primarily of the standardized measures that are used

most frequently for each population and domain– selecting and/or defining measures for the areas in which there is

currently a paucity of standardized measures

180

Recommendations (cont’d)

4. Provide technical assistance to states to help them select high-quality measures that both meet their needs and encourage alignment across programs in their region and market. This assistance could include:– a measures hotline– learning collaboratives and online question boards, blogs and/or

listservs – benchmarking resources for the recommended measures

selected for inclusion in the interactive measures tool.

5. Acknowledge the areas where measure alignment is potentially not feasible or desirable. – different populations of focus– program-specific measures

Contact information

Michael Bailit, MBA

• President• mbailit@bailit-heal

th.com• 781-599-4700

Kate Bazinsky, MPH

• Senior Consultant• kbazinsky@bailit-

health.com• 781-599-4704

mailto:[email protected]




182

Appendix

Overview of measure sets included in analysis

State Name Type # of measures

NQF-endorsed

Modified Homegrown

AR Arkansas Medicaid Medicaid 14 79% None None

CA CA Medi-Cal Managed Care Division

Medicaid 22 82% 45% 5%

CA CA Medi-Cal Managed Care Division: Specialty Plans

Medicaid 6 50% 67% 33%

CA Office of the Patient Advocate (HMO)

Commercial Plans

50 74% 18% None

CA Office of the Patient Advocate (Medical Group)

Commercial Plans

25 68% 4% None

CA Office of the Patient Advocate (PPO)

Other Provider 44 73% 14% None

183

Overview of measure sets included in analysis (cont’d)


NQF-endorsed

Modified Homegrown

CA CALPERSCommercial Plans for Public Employees

33 85% 6% None

CA

Quality and Network Management – Quality Reporting System (QRS)

Exchange 51 84% 6% None

COMedicaid's Accountable Care Collaborative

ACO with Primary Care Medical Provider

3 None 33% None

FLMedicaid MCO Procurement Measures

Medicaid MCO 8 75% None None

IA IA Duals Duals 31 65% 10% 10%

IA IA Health Homes Health Home 12 92% None None

184



NQF-endorsed

Modified Homegrown

ID Idaho Medical Home Collaborative PCMH 17 59% 12% None

IL IL Medicaid MCO Medicaid MCO 42 88% 12% None

LA Coordinated Care Networks Medicaid 35 71% 6% 9%

MA MA Connector Exchange 9 67% None None

MA MA Duals Project Duals 42 86% None 5%

MA MA GIC Other Provider 99 60% 16% None

185



NQF-endorsed

Modified Homegrown

MA MA MBHP Behavioral Health MCO P4P 8 38% 13% 38%

MA MA MMCO Medicaid 19 79% 11% None

MA MA PCPRI Other Provider 26 96% 4% None

MA PCMH PCMH 48 52% 56% 44%

MAStatewide Quality Advisory Committee (SQAC)

Alignment Initiative 83 78% 7% 1%

MDMaryland Multi-Payer Pilot Program (MMPP)

PCMH 20 90% 5% None

186



NQF-endorsed

Modified Homegrown

MEMaine Health Management Coalition

Regional Collaborative 28 100% 43% None

ME Maine's PCMH Project PCMH 29 79% 24% 7%

MI

The Michigan Primary Care Transformation Project (MiPCT)

PCMH 36 61% 19% 17%

MN MN AF4Q Innovative measures only NA NA NA NA

MNMN Dept Health (Medicaid) Health Care Home

PCMH 7 86% None None

MN

MN SQRMS: MN Statewide Quality Reporting and Measurement System (SQRMS)

Alignment Initiative 13 46% 15% 8%

187



NQF-endorsed

Modified Homegrown

MO MO BHMCO measures

Medicaid BH MCO 69 3% 4% 94%

MO MO Medicaid Health Home Health Home 41 41% 17% 51%

MOMissouri Medical Home Collaborative (MMHC)

PCMH 9 89% 33% 11%

MTMontana Medical Home Advisory Council

PCMH 13 92% 8% None

NY Medicaid Redesign Initiative Medicaid 38 55% 24% 24%

OH SW OH CPCI PCMH 21 86% 5% None


State

Name Type # of measures

NQF-endorsed

Modified Homegrown

OK OK Medicaid Soonercare PCMH 17 65% 18% None

OR CCO's Incentive Measures Set ACO 17 65% 53% 24%

PA Chronic Care Initiative PCMH 34 47% 56% 15%

PA Health Home Care set

Health Home 8 75% None None

PA MCO/Vendor P4P MCO P4P 14 64% 29% None

PA Provider P4P Other Provider 13 62% 31% None



NQF-endorsed

Modified Homegrown

RI RI PCMH (CSI) PCMH 10 80% 100% None

TXTX Delivery System Reform Incentive Program

Other Provider 108 35% 2% 30%

UT UT Dept. of Health Other Provider 5 60% 100% None

UT Health Insight Utah Regional Collaborative 10 100% None None

VT VT ACO Measures Work Group ACO 37 54% 11% None

WA Multi-payer PCMH PCMH 6 67% 67% None

WI WI Regional Collaborative

Regional Collaborative 10 80% 100% None

kate reinhalter bazinsky michael bailit september 10, 2013

Documents

programs measures

standard measures

homegrown measures

measures landscape

measures space

andor hedis measures

used measure

regional measure sets