Metrics & Scoring Committee April 22, 2016
Consent agenda *Approve February minutes
Agenda overview • Updates • Public testimony • Measures by race, ethnicity, etc • Health Equity Index development • Health Share Presentation • Committee discussion
• Committee applications open through May 13 th • CY 2015 data in – CCOs will start final validation May 1 st • Stakeholder survey in the field through May 13 th
Public testimony
MEASURES BY RACE / ETHNICITY / GENDER / AGE / GEOGRAPHY Milena Malone
Health Equity Index Sarah Bartelmann Kristen Rohde
History May 2015: Committee received public testimony from Dr. Dannenhoffer suggesting a novel “meta-measure” that would: – Measure the reduction of health disparities – Use already collected data and existing measures with large denominators – Incentivize CCOs to attain the same performance for the historically disadvantaged populations as they do for the overall CCO population June 2015: Committee expressed interest in using this type of measure as a challenge pool measure in the future, requested additional information and measurement development from staff. 8
Today’s goal • Share Health Equity Index development to date. • Request Committee input on 3 high-level questions to guide additional development. • Avoid getting too far in the weeds! 9
Step 1: convened workgroup Health Analytics Office of Equity & Inclusion Program Design & Evaluation Services Transformation Center OHSU Center for Health Systems Effectiveness Oregon Health Care Quality Corp. FamilyCare | Health Share | PacificSource CareOregon 10
Step 2: reviewed what is known Initial concept for the health equity index was based on key documents: • National Quality Forum’s National Voluntary Consensus Standards for Ambulatory Care – Measuring Healthcare Disparities (2008). • Institute of Medicine. Access to Health Care in America: A Model for Monitoring Access (1993). • Institute of Medicine. Unequal Treatment: What Healthcare Providers Need to Know about Racial and Ethnic Disparities in Health Care (2002). • Health Affairs. Analysis Raises Questions on Whether Pay-For- Performance In Medicaid Can Efficiently Reduce Racial And Ethnic Disparities (2011). 11
Step 3: developed a framework Variable 1 Variable 2 Variable 3 Variable 4 Variable 5 Facets Measures Seeking Care Measure 1 Each measure in the composite could be stratified in a Measure 2 Access to Provider variety of ways, including, but not limited to: Measure 3 • Race / ethnicity Measure 4 • Language Measure 5 • Gender Quality of Care • SPMI Measure 6 • Disability Measure 7 Differential • Geography Treatment based on • Etc… Needs Measure 8 Composite will likely start with race/ethnicity at minimum, then expand to include other variables. Self ‐ Reported Measure 9 Health Status 12
Step 4: identified parameters MUST • address the Medicaid population • use available data • be statistically sound • be applicable to other populations (gender, disability, etc) • have some way to tie performance to quality pool $ IDEALLY • based on current CCO incentive / state performance metrics • generate meaningful and actionable results • be understandable • allow for tracking over time 13
Many options with different implications 14
Question #1 Is the intent of the Index to: • Reduce variation in performance across groups within a CCO… • Improve performance of all groups towards the benchmark or target? 15
SBIRT: “variation” 16
SBIRT: “benchmark” 17
Considerations VARIATION BENCHMARK/TARGET • Measuring variation between • May be easier to interpret / groups may not be the best understand than variation. measure of equity. All groups could do equally well / poorly. • Does not measure variation between groups. • CCOs could improve their “variation” score if performance • CCOs are already incentivized worsens for some populations. for meeting the benchmark or improvement target through • May be hard to measure individual measures (but may trends over time. leave some groups behind). 18
Question #2 Is the intent of the Index to: • Reduce measurement burden by using existing CCO incentive measures, regardless of their appropriateness for measuring disparities… • Use measures that are more sensitive to identifying disparities, even if they are not currently in use? 19
Question #2 (cont) Report identified set of 76 measures that are “disparities- sensitive,” based on • Prevalence of conditions • Gaps in quality of care • Community impact • Communication challenges • Clinical discretion • Social determinants of health http://www.qualityforum.org/Publications/2012/11/Healthcare_Disparities_and_Cultural _Competency_Consensus_Standards__Disparities ‐ Sensitive_Measure_Assessment.aspx 20
Question #3 Just because we can make an Index methodology work, should we? Consider: what will motivate CCOs to engage in disparities reduction work? Incentives may motivate CCOs but measure needs to be “moveable” to see progress. Will a composite measure motivate behavior change? 21
Other considerations for Index • Can we expect CCOs to move an aggregate score within 12 months? • Does single aggregate score have meaning? • More statistical analysis may hinder understanding. • May not be meaningful to communities being measured. • May not reflect real clinical implications / known risk factors. 22
Alternate suggestion #1 Instead of the Index, select specific measure(s) of disparities (using list of known disparities-sensitive measures, or other method) and adopt into measure set (or challenge pool). 23
Alternate suggestion #2 Instead of the Index, utilize the new core / menu measure set concept to require one (or more?) of the CCO menu measures be related to disparities. Allow CCOs flexibility to identify disparities within their own population and prioritize the measures that make the most sense for them (based on local community need, data, etc). 24
Next steps Depending on Committee discussion today – workgroup can finalize recommendation (either Index methodology, or develop one of the alternate suggestions) and bring back to future meeting. Variation across v. improvement toward benchmark? Use existing metrics or use disparities-sensitive metrics? Just because we can build an Index, should we? 25
Health Share of Oregon Metrics and Equity Work
Quick Caveats: All CCOs lack complete data about Race, Ethnicity and Language Our data and numbers may look slightly different from that reported by OHA (different sources) Timeframes of these data may be inconsistent
Health Share’s metrics and equity work Metrics are increasingly familiar and well ‐ understood gauges of system health Use as a critical framework for identifying potential areas of inequity Develop a framework for assessing and making meaning from these performance differences (Disparities Data Analysis and Reporting Team)
Equity can be assessed in a number of ways As it relates to • Race & Ethnicity • Language • Gender • Age • Eligibility Category • Geography • Special Populations (foster kids, SPMI, refugees) • Others…
Developmental Screening – CCO Level Performance by CCO 70% 65% 60% 55.2% 55% 50% 45% 40% 35% 30% Oct'14 Dec'14 Feb'15 Apr'15 Jun'15 Aug'15
Developmental Screening—by Race Performance by Race 70% 60% 50% 40% 30% 20% African American American Indian or Alaska Native Asian Caucasian 10% Unknown 2014 Benchmark Target 0% Oct'14 Dec'14 Feb'15 Apr'15 Jun'15 Aug'15
Developmental Screening—By Language Performance by Language Sorted by Current Rolling Performance % Descending 70% Spanish 60% Undetermined English 50% Other 40% Vietnamese Chinese 30% Russian Arabic 20% Somali 10% Burmese 2014 Benchmark 0% Oct'14 Nov'14 Dec'14 Jan'15 Feb'15 Mar'15 Apr'15 May'15 Jun'15 Jul'15 Aug'15 Sep'15 Target
Developmental Screening—Making Meaning Metric improvement approach Gap reports, incentives to providers or families, tests of change Meaning ‐ making approach Deeper dive on population: • Of those not screened, many were engaged in primary care Is the screening tool translated into other languages? What is the perception of refugees of screening tools? How to best engage these populations? Would improvement in Dev Screening address the root of the disparity? Or the system intended to help?
Developmental Screening—System Mapping
Foster Care Assessment Metric Metric improvement approach get lists for assessments physical, mental and dental health care (we do that) Meaning making approach how well does the system respond to the actual health needs of the foster care population? How can we use the measures to monitor system performance? Interview providers, analyze the system, reveal the chronic health conditions of the population
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