D I S C E R N Q u a l i t y M e a s u r e G a p s i n To d a y ’ s A c c o u n t a b l e C a r e P r o g r a m s Tom Valuck, MD, JD Dis Discern Hea Health th October 30, 2014 1120 11 20 North orth Char Charles Str Street Suit Suite 20 200 Balti Baltimore, , MD MD 21 21201 201 (41 (410) 54 542-4470 www.d .dis iscernhealth th.c .com
D I S C E R N Accountable Care Measures for High-Cost Specialty Care and Innovative Treatment You Get What You Pay For: Improving Measures for Accountable Care 2
D I S C E R N Highlights Gaps in accountable care measure sets cannot be completely addressed with more of the same measure types and measurement strategies currently in use We recommend enhancements that include increased use of outcome, cross-cutting, and patient-reported measures, and new measurement approaches including layered and modular models 3
D I S C E R N Background Quality measurement, tied to financial incentives, is one of many approaches accountable care programs are using to promote system-wide improvement Accountable care incentives are geared toward controlling cost Focus of measure sets is typically limited to the clinical conditions of a few at-risk populations Measurement influences priorities and care delivery to the potential detriment of patients with conditions outside the scope of measure sets Measure sets need breadth, depth, and new approaches to promote appropriate care across the relevant population 4
D I S C E R N 5
D I S C E R N Optimal Diabetes Care Saves 417 Hearts, 72 Legs & 745 Pairs of Eyes Each Year 80.0 45.0% 41.9% 41.8% 39.0% 40.0% 70.0 68.0 35.0% 60.0 AMI/1000 30.5% 59.8 57.4 30.0% 56.4 56.1 54.5 Optimal Diabetes % 50.0 Events/1000 53.1 25.0% 48.2 47.9 AMPUTATIONS/ 46.9 1000 40.0 43.3 41.8 41.0 18.4% 20.0% 17.5% 16.9% 30.0 NEW 15.0% 13.1% 12.8% 12.7% RETINOPATHY 12.5% 10.8% CASES/1000 17.8 20.0 17.5 10.0% 7.8% OPTIMAL 10.1 10.1 10.0 8.8 7.6 DIABETES RATE 7.4 10.0 6.5 6.3 5.9 5.0% 5.8 5.1 4.8 4.9 4.6 4.3 0.0 4.0 3.9 0.0% 3.6 3.3 3.3 2.6 2.6 2.6 2.6 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 HealthPartners’ 32,747 members with diabetes in 2012 suffered 417 fewer heart attacks, 72 fewer leg amputations and 745 peopl e did not experience eye complications compared to what would have happened to the same 32,747 plus members in 2000. 6
D I S C E R N Project Purpose Examine gaps in accountable care measure sets and available measures for certain conditions Priority focus was gaps for high-priority conditions; that is, conditions that are prevalent and costly Understand the implications of the measure gaps to inform recommendations for improving accountable care measurement 7
D I S C E R N Project Limitations and Clarifications Quality measurement is one of many tools to promote improvement Lack of measurement does not imply providers will not deliver high quality care Focus is accountable care generally, not only ACOs “Inappropriate care” includes both overuse and underuse of services Project scope includes policy-level solutions and recommendations, but not specific measures for specific conditions or topics Project solutions and recommendations are not meant to suggest that all processes of care for every condition should be measured 8
D I S C E R N Condition Selection Primary criteria Prevalence Cost Overall Specialty pharmaceutical Imaging Surgical procedures Hospitalization Secondary criteria Mix of acute and chronic Applicability to all populations No duplication 9
D I S C E R N Selected Conditions Asthma Hypertension ADHD Influenza Breast Cancer Ischemic Heart Disease Chronic Back Pain Major Depression Chronic Kidney Disease Multiple Sclerosis COPD Osteoarthritis Diabetes Osteoporosis Glaucoma Prostate Cancer Hepatitis C Rheumatoid Arthritis HIV Stroke 10 10
D I S C E R N Logic Model 11
D I S C E R N MSSP Direct and Indirect Measures for Selected Conditions 20 18 16 14 12 10 8 Indirect Direct 6 4 2 0 12
D I S C E R N NCQA Direct and Indirect Measures for Selected Conditions 20 18 16 14 12 10 8 Indirect Direct 6 4 2 0 13
D I S C E R N Direct Available Measures to Fill Gaps, Including Outcome Measures 35 30 25 20 15 Process Outcome 10 5 0 14
D I S C E R N Measure Gaps Ranked by Cost Tier 1 (Low Cost) Cost Categories Patient education Screening/immunizations Simple labwork Appt scheduling/follow-up OTC medications Simple imaging Tier 2 (Medium Cost) n = 55 Tier 1 Traditional medications n = 116 Tier 2 Complex imaging Advanced lab testing Tier 3 Invasive diagnostics n = 93 Specialist/other referrals Tier 3 (High Cost) Surgical procedures Specialty medications Long-term chronic medications Hospitalization 15
D I S C E R N Cross-Cutting Measures and Gaps Use of Available Measures Measure Gaps Shared decision making Patient CAHPS measure set Patient activation Experience Patient-reported outcomes Prevention / BMI assessment Nutrition / exercise Healthy Tobacco cessation Genetic testing Flu and Pneumovax Environmental risk assessment Behaviors Specialist referral rates Care Inpatient admission rates Non-physician referral rates Coordination Hospital readmissions (behavioral and PT/OT therapy) Medication reconciliation High-risk behavior education Patient Safety Hospital readmissions Disease transmission education Confirmatory diagnoses Clinical Medication reconciliation Medication adherence Effectiveness Treatment escalation 16
D I S C E R N Roundtable-Identified Priority Measure Gaps Outcome Measures • Mortality, complications, functional status, readmissions Cross-Cutting Measures • Medication adherence, avoidance of polypharmacy, patient safety, care coordination Measures of Patient Centeredness • Shared decision making, shared care plan documentation/adherence, experience of care, patient-reported outcomes Appropriateness Measures • Overuse measures (low back pain, antibiotic use) Cost of Care Measures • Total cost of care, episode of care, out-of-pocket costs Composite Measures • e.g., Optimal Diabetes Care 17
D I S C E R N Recommendations Most prevalent and costly conditions, 1. Identify and Prioritize Measure Gaps unmeasured aspects of care, use of early indicators. 2. Use Alternative Measurement Use of alternative models: layering and modular approaches Approaches 3. Use the Most Meaningful Measure Maximization of preferred measure types: outcomes, cross-cutting, patient-reported Types New or optimized data sources, logistical, 4. Address Barriers to Measurement analytical, systemic challenges 5. Assess Opportunities to Continuously Feedback, input from patients, measure set review process Improve 18
D I S C E R N Select Available Measures to Fill Gaps Accountable Care Measure Set Types 1 and 2 Multiple Rheumatoid Diabetes Arthritis Sclerosis Cross Cutting Measures Existing Quality HbA1c DMARD Gap Measures Control Use Hypo- glycemic Gap Gap Gap Events Measure Gap 19
D I S C E R N Develop Measures to Fill Gaps Accountable Care Measure Set Types 1 and 2 Multiple Rheumatoid Diabetes Sclerosis Arthritis Cross Cutting Measures Existing Quality HbA1c DMARD Developed Quality Gap Measures Control Use Measures Hypo- Functional glycemic Gap Gap Gap Status Events Change Measure Gap 20
D I S C E R N Use Cross-Cutting Measures Accountable Care Measure Set Types 1 and 2 Multiple Rheumatoid Diabetes Arthritis Sclerosis Condition- HbA1c DMARD Specific Gap Control Use Measures Cross Cutting Cross-Cutting Measure Gap Gap Timely Care Access to Specialists 21
D I S C E R N Existing or Developed Cross-Cutting Accountable Care Measure Set Measure Types 1 and 2 Multiple Rheumatoid Diabetes Arthritis Sclerosis Medication Adherence Condition- HbA1c DMARD Specific Gap Control Use Measures Cross Cutting Cross-Cutting Measure Gap Gap Timely Care Access to Specialists 22
D I S C E R N Alternative Measurement Models: Layered Approach 23
D I S C E R N Diabetes Care Population Level External Hypo- Depression Accountability Glycemic Remission Events Measure Set Composite System Level Measure Internal Management Comp- Appropriate rehensive Use of Anti- Measures Diabetes Depressants Care Provider Level HbA1c Lipid Panel Test Internal Depression Improvement Screening Measures Tobacco Blood Assess- Pressure ment Test 24
D I S C E R N Rheumatoid Arthritis Care Population Level External Functional Accountability Status Pain Control Change Measure Set System Level Internal Appropriate Pain Management DMARD Assessment Use Measures Sed Rate & Provider Level Serum C-Reactive Creatinine Protein Internal Test Tests Pain Improvement Screening Measures Liver Function Test 25
D I S C E R N Alternative Measurement Models: Modular Approach 26
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