ENGAGING SAFETY NET PROVIDERS TO DESIGN A STATEWIDE QUALITY MEASUREMENT STRATEGY AcademyHealth Annual Research Meeting June 25, 2017 1
Medicaid and the District • Medicaid • Health in the District – 1 in 3 District residents – 96.2% of residents with health insurance (2015) – 7 in 10 District children – 12.9% of District adults are covered by Medicaid reported their health was – FY18 Budget Request: fair or poor (2014 DC BRFSS) $3.2 billion (96% spent – High ED utilization, almost on provider payments) twice the national rate (746:1,000 v. 423:1000) – High readmission rate: (65:1,000 v. 45: 1,000) 2
Guiding Principles to Increase the Value of Health Care in the District Expand Access Ensure appropriate and adequate access to services across all eight (8) wards. Improve patient-centered care coordination for all Medicaid beneficiaries. This includes efforts to coordinate physical, behavioral, and long-term health care, and support preventive health. Improve Quality Enhance hospital quality and outcomes. Promote partnerships between DC hospitals and primary care providers to improve care delivery and outcomes. Promote Health Equity Develop programs and services for the District’s high -need populations, particularly those with a high-burden of chronic illness, and homeless. Need to understand life circumstances better to improve health in the District. Enhance Value and Efficiency Pay for value, not for volume of health care services. Promote efficiency, transparency, and flexibility of DHCF’s programs 3
Steps Towards Managing Population Health and Risk Global Payments Shared Savings Financial Reserves Bundled Payment: Risk Adjusted Total Cost of Care Payments Care Coordination : Fully Integrated Care Coordination : Integrated Across Care Continuum Pay-for- Performance FQHC HIE : Real-Time Clinical Data Quality Measurement : Payment Tied to Performance Care Coordination : More Integrated Care Supplemental Payments HIE : Population Health Management Quality Measurement : Reporting Required Care Coordination : Basic Fee-for- Service HIE : Use of Certified EHRs and Basic Exchange Payment : FFS Architecture No Risk Full Risk 4
STEPS TO MEASURE SET DEVELOPMENT 5
Measure Set Development Is An Evolving Process Should the group include those just party to the contract(s)? How large should the group be? Is there a mix of clinical, measurement and financial expertise? Step 1: Determine who should participate in the process 6
Measure Set Development Is An Evolving Process Federal agencies HRSA Payers Medicaid Medicare Commercial Foundations Step 2: State and Local Agencies Identify current activities/initiatives 7
Measure Set Development Is An Evolving Process Measures Currently in use by contracted providers/payers. Found in national/regional measure sets. Address a priority opportunity for performance improvement. Specific populations Performance domains Step 3: Number of measures Align priorities, Data sources Clinical goals, and Claims outcomes Survey 8
Measure Set Development Is An Evolving Process At the individual measure level Has a relevant benchmark Validated Aligned with other measure sets Step 4: Sufficient denominator size Identify selection criteria Actionable Transformative potential At the measure set level Representative of the diversity of patients served Parsimonious 9
Measure Set Development Is An Evolving Process Step 5: To monitor performance with or without financial Develop policy & consequence? To inform consumers as part of a transparency incentive structure strategy? To test new measures for potential future use? 10
Measure Set Development Is An Evolving Process Step 6: Implement Step 5: program Develop Step 4: policy & Identify Step 3: incentive selection Align priorities, structure Step 2: criteria goals, and Identify current outcomes Step 1: activities/ Determine who initiatives should participate in the process 11
THE DISTRICT’S JOURNEY TO A MEASUREMENT STRATEGY 12
DC Journey for Safety-Net Providers 13
Accountability Period • February 2015 to January 2016 • Monthly and Ad hoc meetings Stakeholders • DHCF, DC Primary Care Association, FQHC Quality Improvement • No External Parties Policy • Monitor FQHC performance in DHCF priority areas Alignment • HRSA Uniform Data System (UDS), Medicaid Core Set, Health Home, Medicare PQRS Measure Domains • Asthma, Behavioral Health, Child Health, Cardiovascular, Diabetes, HIV/AIDS, Prevention, Perinatal/Prenatal 14
Accountability Proposed Core Measure Set Asthma Child Health Prevention • Medication Management for People with Appropriate Testing for Children with • Weight Assessment and Asthma Pharyngitis Counseling for Nutrition and • Well-Child Visits Physical Activity for Children/ Behavioral Health Adolescents • • Initiation and Engagement of Alcohol and Tobacco Use: Screening and Diabetes Other Drug Dependence Treatment Cessation Intervention • • Comprehensive Diabetes Care: Eye Exam • Anti-depressant Medication Management Childhood Immunization Status • • • Diabetes: Foot Exam* Screening for Clinical Depression and Adult Body Mass Index (BMI) • Comprehensive Diabetes Care: Hemoglobin Follow-Up Plan Assessment • A1c testing • Follow-Up After Hospitalization for Mental Prevention Quality Indicators • Comprehensive Diabetes Care: Hemoglobin Illness #92: Chronic Composite A1c (HbA1c) Poor Control (>9.0%) • Comprehensive Diabetes Care: Medical Cancer Sexual Health Attention for Nephropathy • • Cervical Cancer Screening Chlamydia Screening • • Colorectal Cancer Screening HIV Viral Load Suppression Maternal and Infant Health • • Breast Cancer Screening HIV Medical Visit Frequency • Elective Delivery Prior to 39 Completed Weeks Gestation (PC-01) Cardiovascular Future Consideration • Live Births Weighing Less Than 2,500 Grams • • Substance Use Ischemic Vascular Disease (IVD): Use of • Frequency of Ongoing Prenatal Care • Depression Remission at Twelve Aspirin or Another Antithrombotic • Timeliness of Prenatal Care • Controlling High Blood Pressure Months • Postpartum Care • • Child and Adolescent Major Persistence of Beta-Blocker Treatment After a Heart Attack Depressive Disorder: Suicide Risk Oral Health Assessment • Annual Dental Visits • Cesarean Rate for Nulliparous Care Coordination • Primary Caries Prevention Intervention as • Singleton Vertex (PC-02) Plan All-Cause Readmission Part of Well/Ill Child Care • Flu Vaccinations for Adults Ages • Low-Acuity Non-Emergent Emergency Visits • 18 – 64 Care Transition Record Transmitted to Health • Patient Satisfaction Care Professional • Prevention Quality Indicators #92: Chronic 15 Composite
Pay-for-Performance: Care Coordination Period • January 2016 to July 2016 • Monthly and Ad hoc meetings Stakeholders • DHCF, DC Primary Care Association, FQHC Quality Improvement, Technical Assistance Partners • Public Comment Period Policy • Monitor FQHC performance in DHCF priority areas + emphasize care coordination Alignment HRSA Uniform Data System (UDS), Medicaid Core Set, Health Home, Medicare PQRS Measure Domains • Asthma, Behavioral Health, Child Health, Cardiovascular, Diabetes, HIV/AIDS, Prevention, Perinatal/Prenatal, Care Coordination 16
Pay-for-Performance: Care Coordination Added Barriers Report UDS measures quarterly Meet 3% on at least one of the following: Low Acuity Non-Emergent Emergency Department, 30-day All-Cause Readmissions, Potentially Preventable Hospitalizations Had to meet the following requirements: APM selection, HRSA Quality Improvement Plan, NCQA PCMH Level 2, 24/7 Access Policy, Agree to report UDS measures quarterly 17
Pay-for-Performance: Care Coordination + Access Period • July 2016 to December 2016 • Monthly and Ad hoc meetings Stakeholders • DHCF, DC Primary Care Association, FQHC Quality Improvement, FQHC Finance, Medicaid Managed Care Organizations • Public Comment Period Policy • Incentivize care coordination activities while facilitating linkages between providers Alignment • HRSA Uniform Data System (UDS) + Health Home Measure Domains • Access, Transitions of Care, Clinical Outcomes 18
Pay-for-Performance: Care Coordination + Access Rationale Domain Measures Patient- Allow DHCF to set expectations that 24/7 Access Policy, answering service, being open 30- Extended Hours, Access to Centered minutes later than normal hours is not Preventive/Ambulatory sufficient. An opportunity to tie into Services Access Access Monitoring Review Plan. Follow-Up after Hospital Model should not solely rely on events Discharge, Follow-Up Transitions of outside the control of the FQHC but on after Hospital Discharge types of care and interventions directly Care for Mental Illness, Timely furnished by the FQHC Transmission of Records LANE, All-Cause 30-day Improve care coordination and ensure Clinical beneficiaries are receiving care in the Readmissions, appropriate setting, DHCF plans to hold Preventable Outcomes providers and MCOs to work towards a Hospitalizations common goal. 19
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