Medi-Cal Performance Measurement: Making the Leap to Value-Based Incentives

Dolores YanagiharaIHA Stakeholders MeetingOctober 3, 2018

© 2018 Integrated Healthcare Association. All rights reserved. 2

Why Standardization?

Based on IHA’s 2014 Inventory, only 1

measure out of 86 distinct measures aligns

across all plan P4P programs: Diabetes

HbA1c Testing

California Health & Wellness Cal

Optima

CenCal

Central California Alliance

Health Net

Health Plan of

San Joaquin

Health Plan of San Mateo

Inland Empire Health

Plan

Kern Health

Systems

LA Care

Partnership

San Francisco

Health Plan

Anthem

Only 2 measures align across all

programs:

1. Controlling Blood Pressure for People with Hypertension

2. Diabetes: Medical Attention for Nephropathy

Federal Quality Rating

System for Covered California

Medicare Advantage

Stars

IHA Value Based P4P

DHCS External

Accountability Set

MEDI-CAL CROSS PRODUCT

© 2018 Integrated Healthcare Association. All rights reserved. 3

Benefits of Measure Alignment

▪ Reduce unnecessary burdens associated with the lack of alignment across incentive programs

▪ Enhance provider effectiveness by “strengthening the signal” – focus improvement efforts and resources

▪ Create opportunities for measure set alignment across markets –including Covered California, Medicare and commercial – as well as across counties

▪ Facilitate the comparability of performance results and benchmarking statewide and by region

© 2018 Integrated Healthcare Association. All rights reserved. 4

IHA’s Medi-Cal P4P Advisory Committee

Health Plans Provider Representatives

Collaborators Associations

© 2018 Integrated Healthcare Association. All rights reserved. 5

Medi-Cal P4P Core Measure Set

Domain Measures NQF #

Cardiovascular

Annual Monitoring for Patients on Persistent

Medications: ACE or ARB indicators0021

Annual Monitoring for Patients on Persistent

Medications: Diuretics indicator0021

Diabetes Care

HbA1c Testing 0057

HbA1c Control 0575

Eye Exam 0055

Maternity Timeliness of Prenatal Care 1517

Prevention

Childhood Immunizations, Combo 3 0038

Well-Child Visits in 3rd, 4th, 5th, and 6th Years

of Life1516

Cervical Cancer Screening 0032

Respiratory Asthma Medication Ratio 1800

© 2018 Integrated Healthcare Association. All rights reserved. 6

Medi-Cal Measure Set Overlap

AMP Medi-Cal Managed Care41 measures

IHA Medi-Cal Core Set

10 measures

DHCS EAS23 measures

Includes additional clinical quality, patient experience, appropriate resource use, and total cost of care measures5 5

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3

10

Includes measures important to Medi-Cal population and measures retired by IHA

© 2018 Integrated Healthcare Association. All rights reserved. 7

Leveraging IHA’s Align. Measure. Perform. (AMP) Programs

Provider Performance Measurement Program

Common Measure Set

Participant Reporting/

Benchmarking

PO Recognition

Public Reporting

Incentives

Commercial HMO

Commercial ACO TBD N/A N/A

Medicare Advantage N/A

Medi-Cal Managed Care TBD TBD TBD

© 2018 Integrated Healthcare Association. All rights reserved. 8

• As Medi-Cal expands, more clinician groups serve both commercial and Medi-Cal enrollees and serve across county lines

• To support any expansion, IHA could leverage existing AMP governance process, data flows, and other program infrastructure

‒ Transparent process and specifications

‒ Reliable and robust measurement

‒ Encompasses clinical quality, hospital utilization, and cost

‒ Comparable and meaningful benchmarks through Cost & Quality Atlas

Benchmarking in Medi-Cal

© 2018 Integrated Healthcare Association. All rights reserved. 9

• Southern CA contains the bulk of enrollment but still achieved lower rates of ED visits than other regions

Atlas: Medi-Cal Utilization Shows Striking Variation; Southern California Has Lowest Utilization

721.1

405.7

350

400

450

500

550

600

650

700

750

ED

Vis

its

Pe

r 1

00

0 M

em

be

r Y

ear

s

Northern Central Southern

© 2018 Integrated Healthcare Association. All rights reserved. 10

Atlas: No Clear Geographic High or Low Performers on Medi-Cal Hospital Utilization

© 2018 Integrated Healthcare Association. All rights reserved. 11

• IHA Issue Brief on Medi-Cal Measure Alignmenthttps://www.iha.org/sites/default/files/resources/issue_brief_medi-cal_p4p_2018.pdf

• USC Annenberg Center for Health Journalism blog: California would benefit from a common yardstick to measure Medicaid performance https://www.centerforhealthjournalism.org/2018/07/16/california-would-benefit-common-yardstick-measure-medicaid-performance

• USC Annenberg Center for Health Journalism blog: State officials show little interest in providing quality of care information for poor https://www.centerforhealthjournalism.org/2018/08/06/state-officials-show-little-interest-providing-quality-care-information-poor

Related Resources

Integrated Healthcare Association

Annual Stakeholders MeetingOctober 3, 2018

Medi-Cal Performance Measurement: Making the Leap to Value-Based Incentives

California Primary Care Association

In 1994, the California Primary Care Association (CPCA) was formed and has become the statewide leader and recognized voice representing the interests of California community health centers and their patients.

CPCA represents more than 1,200 not-for-profit Community Health Centers (CHCs) and Regional Clinic Associations who provide comprehensive, quality health care services, particularly for low-income, uninsured and underserved Californians, who might otherwise not have access to health care.

Need for Alignment to Improve Outcomes

“If you serve too many masters, you'll soon suffer.”

Homer (Odyssey)

Pay for Performance at FQHCs

• FQHCs participate in a wide variety of P4P quality incentive programs with Medi-Cal managed care plans and their subcontracted organizations

• State and federal law clearly allows that FQHCs can participate in these programs and exclude incentive payments from their PPS Managed Care annual reconciliation

Strategies to Improve Outcomes

• Alignment with IHA Measure Set for safety net managed care plans

• Clear rules to live by for P4P programs

• Increased collaboration and sharing of data

Alignment with IHA Measure Set

• CPCA and our members are very interested in working with IHA and Medi-Cal plans to create a standardized measure set for all Medi-Cal P4P programs.

• This effort would “strengthen the signal” from plans to providers regarding high-priority measures, and reduce measurement burden among providers working with multiple plans.

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CPCA’s “Rules to live By” for P4P

1. Plans payments to FQs for primary care must be “no less” than what plans pays other similar primary care providers

2. P4P payments should be completely separate from payments for services (cap or FFS)

3. Clear documentation of P4P programs and payments4. Payments should be "at risk” 5. Incentives should be based on performance measured

against a benchmark 6. P4P payments should be independent of providing any

individual unit of service that generates a PPS payment 7. Rules apply whether P4P payments come directly from

Medi-Cal managed care plan or from the IPA

Collaboration: Key to Success

• To be successful in a value based environment our members need to be able to focus on one set of metrics

• Sites need to be able to partner with plans to be able to share and analyze current, timely data

• We want to capitalize on the lessons learned from IHAs existing work to be successful and not recreate the wheel

CALIFORNIA PRIMARY CARE ASSOCIATION

Questions?

Cynthia Keltner

Deputy Director of Health Center Transformation

916-440-8170

ckeltner@cpca.org

Medi-Cal Performance

Measurement: Making the Leap to

Value-Based Incentives

Integrated Healthcare Association

2018 Stakeholders Meeting

October 3, 2018

Tanya Dansky, MD

VP & Chief Medical Officer

Care1st Health Plan, an affiliate of Blue Shield of California

• Founded in 1994 by a group comprised of providers, organized

medical groups, and hospitals

• In 2015, acquired by Blue Shield of California, a not-for-profit

health plan

• Serves approximately 500,000 members in California

• 400,000 Medi-Cal members in two counties

• 80,000 Medicare members in 12 counties

• 5,000 dual eligible members in the Cal Medi-Connect program

• Opportunity to leverage Blue Shield’s processes, statewide

provider network and decades of service to vulnerable

populations through the Blue Shield Foundation

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About Care1st Health Plan

Our mission

Ensure all Californians have

access to high-quality

health care at an affordable price

• Members more likely to have social, economic,

educational, behavioral, communication and

cultural challenges

• Lower reimbursement compared to commercial and

Medicare

• Provider network includes Federally Qualified Health

Centers (FQHCs)

• Multiple monitoring entities/multiple priorities

• DHCS (EAS, Autoassignment), NCQA, Plan partners

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Pay for Performance (P4P) Challenges in a

Medi-Cal Program

• Value, quality and affordability are universal goals

regardless of the line of business

• We need to bring the highest quality care and

measurement to the most vulnerable Californians

• Safety net providers are committed to the

populations they serve

• IHA experience with commercial HMO quality allows

for leveraging best practices

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Pay for Performance (P4P) Opportunities in a

Medi-Cal Program

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Medi-Cal Provider Incentive Program 2018

© 2018 Integrated Healthcare Association. All rights reserved. 27

Common Measure Set is Key to IHA Measurement

Programs

IHA Performance

Measurement Program by

Product Line

Program Elements

Common Measure

Set

Participant Reporting/

Benchmarking

PO Recognition

Public Reporting

Incentives

Value Based P4P Program

(Commercial HMO)

Medicare Advantage HMO

Program N/A

Managed Medi-Cal Program TBD TBD TBD

Commercial ACO Program TBD N/A N/A

• Multiple monitoring entities/multiple priorities

• DHCS, NCQA, LA Care, Individual plan priorities

• Low Medi-Cal reimbursement compared with

Commercial and Medicare lines of business

• 53 separate reporting Medi-Cal entities in California

• Quality performance impacts default assignments

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P4P Challenges in a Medi-Cal Program

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Measure Set Standardization

Clinical Priority Areas Measure Name DHCS EASIHA Medi-

Cal Core Set

IHA Managed Medi-Cal

Total Number of Measures 23 10 41

Behavioral Health & Substance Abuse

Concurrent Use of Opioids and Benzodiazepines X

Use of Opioids at High Dosage X

Depression Screening and Follow-Up for Adolescents and Adults X

Cardiovascular

Annual Monitoring for Patients on Persistent Medications: ACE or ARB X

X

XAnnual Monitoring for Patients on Persistent Medications: Diuretics

Controlling High Blood Pressure AA X

Controlling Blood Pressure for People with Hypertension XProportion of Days Covered by Medications: Renin Angiotensin System (RAS) Antagonists

X

Proportion of Days Covered by Medications: Statins X

Statin Therapy for Patients With Cardiovascular Disease X

Diabetes

Diabetes Care: Blood Pressure Control <140/90 mm Hg X X

Diabetes Care: Eye Exam X X X

Diabetes Care: HbA1c Control < 8.0% X X X

Diabetes Care: HbA1c Poor Control > 9.0% X X

Diabetes Care: HbA1c Testing AA X

Diabetes Care: Medical Attention for Nephropathy X XDiabetes Care - Combination X XProportion of Days Covered by Medications: Oral Diabetes Medications

X

Statin Therapy for Patients With Diabetes X

Maternity Prenatal and Postpartum Care AA (prenatal) X

Musculoskeletal Use of Imaging Studies for Low Back Pain X X

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Measure Set Standardization

Clinical Priority Areas Measure Name DHCS EASIHA Medi-Cal

Core SetIHA Managed

Medi-Cal

Prevention & Screening

Breast Cancer Screening X X

Cervical Cancer Overscreening X

Cervical Cancer Screening AA X X

Childhood Immunization Status AA (Combo 3) X (Combo 3) X (Combo 10)

Chlamydia Screening in Women X

Colorectal Cancer Screening X

Immunizations for Adolescents: Combination 2 (meningococcal, Tdap, HPV for Adolescents) X X

Screening for Clinical Depression & Follow Up Plan X

Weight Assessment & Counseling for Nutrition and Physical Activity for Children/Adolescents

X

Well-Child Visits in 3rd, 4th, 5th, and 6th Years of Life AA X

Respiratory

Appropriate Testing for Children With Pharyngitis X

Asthma Medication Ratio X X X

Avoidance of Antibiotic Treatment of Adults with Acute Bronchitis X X

Patient Experience

Access Composite X

Care Coordination Composite X

Office Staff Composite X

Overall Ratings of Care Composite (Rating of Doctor & Rating of All Healthcare) X

Provider Communication Composite X

Encounter Data Encounter Rate by Service Type X

Cost Total Cost of Care, incl service categories X

Resource Use

Acute Hospital Utilization (Bed Days, Discharges, ALOS) X

All-Cause Readmissions X X

Ambulatory Care: ED Visits X

Emergency Department Utilization X

Frequency of Selected Procedures X

Generic Prescribing: Overall and Antidepressants, Antimigraine, Anti-Ulcer, Cardiac -Hypertension and Cardiovascular, Nasal Steroids, Statins, Diabetes

X

Inpatient Utilization: General Hospital/Acute Care X

Outpatient Procedures Utilization - Percent Done in Preferred Facility X

AccessChildren & Adolescents’ Access to Primary CarePractitioners (4 indicators)

X

• Care1st program follows

the IHA domains

• Our program includes

not only the clinical

measures but also

appropriate resource

use and total cost of

care

• In year two, Patient

Experience will be

included as well

How does the Medi-Cal Managed Care IHA

program compare?

31

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Our Vision

Create a healthcare

system worthy of our

family and friends and sustainably affordable

Thank youThank youThank you

Blue Shield of California and Care1st are independent licensees of the Blue Shield Association.

• DHCS EAS: MY 2017 / RY 2018

• http://www.dhcs.ca.gov/dataandstats/reports/Documents/MMCD_Q

ual_Rpts/HEDIS_Reports/EAS_Measure_List_RY_2018%20_F1.pdf

• IHA Medi-Cal Core Measure Set MY 2017

• https://www.iha.org/sites/default/files/files/page/medi-cal-p4p-core-

measure-set.pdf

• IHA VBP4P Measure Set MY 2018

• https://www.iha.org/sites/default/files/resources/my_2018_measure_se

t_1.pdf

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Sources for measure set information