CCO 2.0 Final Report Framework & Reflections Final report draft outline: – Vision of CCO 2.0 – Goals of the coordinated care model – Prioritized policy recommendations, including: • Any sequencing needed • Contract changes needed in year 1 • Legislation or support needed from Legislature and Governor • Operational changes for OHA – Appendices: • Additional goals and opportunities that have surfaced through this process (not necessarily CCO 2.0) • Promising policies that need additional development work • Housekeeping changes to contracts 27
For more information on CCO 2.0 visit: www.health.oregon.gov Questions, comments, or recommendations? Email CCO2.0@state.or.us Thank you! 28
2018 Incentive Measure Program Changes 29
2018 Incentive Measure Program Changes • Given changes to CCO composition in 2018, OHA would like to identify a set of modifications to be implemented for any CCO experiencing extraordinary capacity changes now, or in the future. • The intent and design of the incentive dollar pool is based on the idea of a bonus that would be paid for transformations through quality improvement in care. • Where rule changes are made to the incentive payment program rules, it should only be due to large, unplanned, and sudden events that impact CCO capacity. 30
2018 Incentive Measure Program Changes • The options under consideration on the next slide would be implemented based on significant policy or business changes that occur in a single calendar year. As background: – During Medicaid expansion in 2014, for example, CCOs expanded between 45% to over 100% during a planned addition of many new members. – In any single 12 month year, under normal fluctuation conditions , CCO membership goes up and down between 1 and 3% from month to month. – In 2018, Health Share had its membership increase by ~54%, WVCH by ~6%, and Yamhill by about 100 members. • Given this, the Metrics & Scoring Committee could consider a threshold of a 45% single year increase in order to make any of the program change options on the next slide. 31
2018 Incentive Measure Program Changes – Options • In all options below, Minnesota method and improvement target floors are not applicable Population Used to Description Rebase Targets Hold previous performance steady, rebase. Final CCO population from performance from year BEFORE increase becomes target previous year, augmented to for year in which increase occurs. include new members (i.e., • New target = performance in previous year, but recalculate previous Option 1 recalculated ("rebased") to give proxy of what performance to estimate previous performance may have been with inclusion performance with new of new members members) Hold previous performance steady, NO rebase. Final n/a performance from year BEFORE increase becomes target for year in which increase occurs. Option 2 • New target = performance in previous year, with no recalculation Hold previous targets steady, no rebase. Final targets n/a from year BEFORE increase carried forward as target for Option 3 year in which increase occurs. New target = same target as in previous year • 32
2019 measure set: Information for consideration (June follow-up) 33
Smoking Prevalence Measure Kate Lonborg Clinical Quality Metrics Registry (CQMR) Program Manager Office of Health IT and Office of Health Analytics Health Policy and Analytics Division Kirsten Aird Cross Agency Systems Manager Health Promotion and Chronic Disease Prevention Section Public Health Division
Follow-up from earlier discussion • Can we use NQF0028 (tobacco use screening and cessation intervention) and add adolescents? – Larger change to metric than changing age range (e.g., different visit types coded for adolescents v. adults) – Difficulty in feasibility of reporting and consistency with HPQMC menu • Other measures of adolescent tobacco use? – Staff researched existing measures; did not find adolescent- specific measures that are viable for 2019 • Neither our current smoking prevalence measure nor the measure captures e-cigarette use 35
Current Adolescent Tobacco Use In 2017, 8.4% of Oregon 8 th graders and 18.9% of 11 th graders • used any type of tobacco product (Oregon Tobacco Facts: https://apps.state.or.us/Forms/Served/le9139.pdf) • Patient-level data (2016) from some clinics for CCO smoking prevalence measure reporting showed the smoking rate in adolescents to be 2.8% Public Health Division Health Promotion and Chronic Disease Prevention Section
Unique characteristics of adolescent smokers Nearly all smokers (9 of 10) start before the age of 18 What makes this population different from adults? – While cigarette smoking is decreasing, e-cigarette use in increasing – Tobacco industry markets appealing flavors to kids – New product use (juul) – Many youth see themselves as non-addicted (low reporting) – Effective cessation treatments are limited • No medication approved by FDA • Studies are of established smokers only • Behavioral interventions only slightly effective Public Health Division Health Promotion and Chronic Disease Prevention Section
What works for prevention and treatment in adolescents? Evidence-based practices can prevent kids from starting to smoke (from CDC Community Guide): • Higher cost (i.e. tobacco taxes) • Smoke-free laws • Raising the minimum age to 21 • TV, radio and other media to counter tobacco industry ads • Community and school policies to encourage tobacco-free lifestyles • Reducing advertising and availability • Behavioral counseling in school and communities (USPSTF) Public Health Division Health Promotion and Chronic Disease Prevention Section
MULTISECTOR INTERVENTION NOTES MULTISECTOR INTERVENTION 1: COVERAGE GUIDANCE To reduce the use of tobacco during pregnancy and improve associated outcomes, the evidence supports the following interventions: • Financial incentives (incentives contingent upon laboratory tests confirming tobacco abstinence are the most effective) • Smoke-free legislation • Tobacco excise taxes Public Health Division Health Promotion and Chronic Disease Prevention Section
Staff Recommendation Recommendation Rationale Use NQF-endorsed tobacco • Improve data validity and use screening and cessation consistency in reporting intervention measure to • Separate data on adult population calculate tobacco prevalence • Align with commonly used standard measure (MU, MIPS, CPC+, UDS) “Restart” minimum population • Allows time to build reporting threshold at 25% capacity Require reporting only for • Allows time to build reporting 2019 capacity before benchmarking • Collects baseline data for 2020 improvement targets 40
Tobacco Use: Screening and Cessation Intervention (2018)
Substance Use Disorder Measure Options 42
SUD Measure Options • At its last meeting the Committee heard about public health interest in incentive measures on substance use disorder. • Previously, the Committee tentatively voted to include the EHR-sourced SBIRT measure in the 2019 incentive measure set, but wanted to hear more before making a final decision. • The Committee also briefly discussed the Initiation of alcohol or other drug treatment measure (IET) as a possible SBIRT alternative. • The IET measure is the percentage of adolescent and adult patients with a new episode of alcohol or other drug dependence (AOD) who: – initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis and – initiated treatment and who had two or more additional services with a diagnosis of AOD within 34 days of the initiation visit 43
SUD Measure Options - Considerations • IET – Which component is benchmarked (or both)? • SBIRT – The U.S. Preventive Services Taskforce (USPSTF) recently released the following draft recommendation regarding SBIRT: • General – Does the Committee want to focus on prevention/early detection (SBIRT), or access to care for those with a disorder (engagement and treatment)? – Both measures relate to general substance use disorder, not opioid use disorder (though beginning in 2018 IET specs break out performance by opioid, alcohol, or other drugs). 44
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Report Back EHR-based SBIRT Measure Metrics and Scoring Committee July 20, 2018 Kristin Tehrani Katherine Castro Kate Lonborg 49
Objectives 1. Provide more detail on measure specifications 2. Providing more information on capturing a brief intervention 50
SBIRT Pilot Test Project Purpose Test the measure specifications proposed by the SBIRT work group Test the capability of producing SBIRT reports using different EHRs and clinics without making system or workflow changes Key Findings • SBIRT as an EHR-based measure is feasible. • Report production varies by EHR system. • For OCHIN Epic users, Rate 1 can use existing Depression Screening reports. • Rate 2 is more difficult than Rate 1 to produce. • Most clinics will need to develop custom query reports, especially for Rate 2. • The 2-month period for follow-up (brief intervention or referral to treatment made) proposed in draft specifications is inconsistent with most clinic work flows and seemed unnecessary. 51
Implementation of the measure specifications A Clinical Perspective Katherine Castro Consulting Analyst, PRM Analytics to Advanced Health 52
All patients aged 12 years and older before the beginning of the measurement period with at least SBIRT 1 eligible encounter during the measurement period Denominator 1 (D1) Flowchart Rate 1 SBIRT BRIEF screen COMPLETED Rate 2 SBIRT FULL screen Negative Result Positive COMPLETED COUNTS as COUNTS as Result Numerator 1 (N1) Numerator 1 (N1) Full Screen Negative Result COMPLETED DONE Positive Result Denominator (D2) DOCUMENTED Within 48 hours Brief Intervention, Referral to Treatment, or Both Numerator 2 (N2) 53
2019 SBIRT EHR-based Measure Specifications What constitutes a positive result on screening? Clinician judgment on scoring What is required for documentation of Brief Intervention? Some kind of checkbox, flowsheet or other structured data in the EHR Not looking for particular billing codes to meet the metric 54
Questions ? 55
Time for a break. 56
Select 2019 Measure Set (including challenge pool)! 57
Consensus Consensus Notes Measure Include? Exclude? 1. Adolescent well-care visits 2. Emergency department utilization 3. Assessments for children in DHS custody 4. Access to care (CAHPS) 5. Childhood immunization status 6. Cigarette smoking prevalence 7. Colorectal cancer screening 8. Controlling hypertension (EHR) 9. Dental sealants 10. Depression screening and follow-up (EHR) 11. Developmental screenings 12. Diabetes: Hba1c poor control 13. Disparity measure: ED utilization for members w MI 14. Effective contraceptive use 15. PCPCH enrollment 16. Prenatal care 17. Weight assessment and counseling for kids and adol. New? 18. Postpartum care 19. Adults with diabetes – oral evaluation 20. Drug and alcohol screening (SBIRT) 21. Initiation and engagement of alcohol or drug abuse or dependence treatment
Wrap-Up Next Meeting: August 17, 2018 • Welcome new members • Begin selecting 2019 benchmarks and improvement target floors (to finalize in September) 59
THE FOLLOWING SLIDES ARE INCLUDED AS BACKGROUND, AND WILL ONLY BE REFERENCED IN THE MEETING IF NEEDED 60
2018 Incentive Measures 1. Access to care (CAHPS survey) 10. Dental sealants for kids 2.Adolescent well-care visits 11. Depression screening and f/u plan 3. Emergency department utilization 12. Developmental screenings**** 4. Assessments for kids in DHS 13. Diabetes HbA1c poor control custody**** 14. Disparity measure: ED utilization for 5. Childhood immunization status**** members with mental illness 6. Cigarette smoking prevalence 15. Effective contraceptive use 7. Colorectal cancer screening 16. PCPCH enrollment 17. Weight assessment and counseling 8. Controlling high blood pressure for kids and adolescents 9. Timely prenatal care**** ****=challenge pool, (challenge pool focuses on early childhood health; Committee ultimately wants a measure of kindergarten readiness) 61
CCO Incentive Measures since 2013 CCO Incentive Measures 2013 2014 2015 2016 2017 2018 Adolescent well-care visits x x x x x x Alcohol or other substance misuse screening (SBIRT) x x x x Ambulatory care: Emergency department (ED) visits x x x x x x CAHPS composite: Access to care x x x x x x CAHPS composite: Satisfaction with care x x x x x Childhood immunization status x x x Cigarette smoking prevalence x x x Colorectal cancer screening x x x x x x Controlling high blood pressure x x x x x x Dental sealants x x x x Depression screening and follow-up plan x x x x x x Developmental screening (0-36 months) x x x x x x Disparity measure: ED visits among members with mental illness x Early elective delivery x x Diabetes: HbA1c poor control x x x x x x Effective contraceptive use x x x x Electronic health record adoption x x x Follow-up after hospitalization for mental illness x x x x x Follow-up for children prescribed ADHD medication x x Health assessments within 60 days for children in DHS custody x x x x x x Patient centered primary care home enrollment x x x x x x x Timeliness of prenatal care x x x x x Weight assessment and counseling for children and adolescents x 62
Waiver Goals Governor’s Direction for CCO 2.0 Waiver - Four Key Goals (p. 10) Increasing value-based payment Commit to ongoing sustainable rate of growth and adopt a payment methodology and contracting protocol for CCOs that promotes increased investments in health-related services, advances the use of value-based payments; Focus on social determinants of health Increase the state’s focus on encouraging CCOs to address the and equity social determinants of health and improve health equity across all low-income, vulnerable Oregonians to improve population health outcomes; Maintaining a sustainable rate of Commit to ongoing sustainable rate of growth and adopt a growth payment methodology and contracting protocol for CCOs that promotes increased investments in health-related services, advances the use of value-based payments; Improving the behavioral health Enhance Oregon’s Medicaid delivery system transformation with a system stronger focus on integration of physical, behavioral, and oral health care through a performance- driven system aimed at improving health outcomes and continuing to bend the cost curve; Expand the coordinated care model by implementing innovative strategies for providing high-quality, cost-effective, person-centered health care for Medicaid and Medicare dual- eligible members. 63
Measure Selection Criteria (1/2) Technical Measure Criterion 1. Evidence-based and scientifically acceptable 2. Has relevant benchmark 3. Not greatly influenced by patient case mix Program-Specific Measure Criterion 4. Consistent with goals of program 5. Useable and relevant 6. Feasible to collect 7. Aligned with other measure sets 8. Promotes increased value 9. Present opportunity for QI 10. Transformative potential 11. Sufficient denominator size 64
Measure Selection Criteria (2/2) Measure Set Criteria 12. Representative of the array of services provided by the program 13. Representative of the diversity of patients served by the program 14. Not unreasonably burdensome to payers or providers 65
Metrics & Scoring Measure Set Health Measures Other Measures 8 – 12 from the following: 3-6 from the following: Prevention Satisfaction/Patient Exp. Childhood Social Determinants of Adulthood Health Chronic Disease Health Equity/Race Oral Health Cost/Efficiency Behavioral Health/A&D Link to Public Health Acute/Inpatient Care Access Maternity Care Glide Path Process Outcome
Oral Health Measures 67
Comparison of Oregon specifications versus DQA specifications (sealants) Current CCO specifications DQA specifications Which teeth Count all permanent Sealant must be on first molar (6- counted in molars 9); second molar (10-14) numerator? Only children at elevated caries risk are included, as identified by: Visit D0602 (moderate caries • risk) or D0603 (high caries risk) All children on Medicaid during measurement year Who is included in ages 6-14 meeting Service code from a list of CDT • denominator? continuous enrollment codes indicating restorative criteria service in either the measurement year or in the 3 years prior to the measurement year 68
Comparison of Current OHA vs DQA Specs, 2017 (preliminary, unvalidated data) Current OHA CCO specs DQA specs (elevated Den. - Rate - % (no risk algorithm) risk criteria) % Pt. CCO Den. Num. Rate Den. Num. Rate change Change ADVANCED HEALTH 2,327 644 27.7% 1,281 445 34.7% -45% 7.1% ALLCARE 6,635 1,582 23.8% 3,722 1,073 28.8% -44% 5.0% CASCADE HEALTH ALLIANCE- 2,244 492 21.9% 1,311 336 25.6% -42% 3.7% COLUMBIA PACIFIC CCO 3,225 759 23.5% 1,586 447 28.2% -51% 4.6% EASTERN OREGON CCO 7,866 1,930 24.5% 5,203 1,590 30.6% -34% 6.0% FAMILYCARE 15,509 3,591 23.2% 8,688 2,433 28.0% -44% 4.8% HEALTH SHARE OF OREGON 31,094 7,942 25.5% 18,718 5,607 30.0% -40% 4.4% INTERCOMMUNITY HEALTH NETWORK 7,513 1,782 23.7% 4,039 1,223 30.3% -46% 6.6% JACKSON CARE CONNECT 4,550 1,183 26.0% 2,790 824 29.5% -39% 3.5% PACIFICSOURCE GORGE 2,112 565 26.8% 1,156 376 32.5% -45% 5.8% PACIFICSOURCE CENTRAL 7,238 1,708 23.6% 3,972 1,265 31.8% -45% 8.3% PRIMARYHEALTH JOSEPHINE CO 1,051 235 22.4% 574 152 26.5% -45% 4.1% TRILLIUM COMMUNITY HEALTH PLAN 11,698 2,701 23.1% 6,164 1,811 29.4% -47% 6.3% UMPQUA HEALTH ALLIANCE 3,486 781 22.4% 2,016 558 27.7% -42% 5.3% WILLAMETTE VALLEY COMM. HEALTH 17,874 3,941 22.0% 9,982 2,702 27.1% -44% 5.0% YAMHILL COMMUNITY CARE 3,820 879 23.0% 2,259 656 29.0% -41% 6.0% STATEWIDE RATE 128,242 30,715 24.0% 73,461 21,498 29.3% -43% 5.3% 70
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