Performance Measurement - amga.org Patel.pdf · Pathway for Quality and Cost Measurement Core Core...

The Engelberg Center for Health Care Reform at Brookings | The Dartmouth Institute

April 8, 2013

Kavita Patel MD, MS

Fellow and Managing Director, The Brookings Institution

[email protected]

Performance Measurement


ACO Implementation Across the Country

{Not exhaustive}

ACO implementation is now accelerating

across the country

*Upwards of 390

ACOs*

Private Sector

= Beacon Communities

= PGP Demonstration, MHCQ

Public Sector

= Pioneer

= MSSP

= Private Sector ACO’s


Accountable-care payment reforms

Medical Homes for

Primary Care • Supports care coord,

prevention, chronic disease

mgmt, and other key

primary-care activities

• Rewards reductions in

primary care-related cost

trends

Bundled Payments for

Specialty/Intensive Care

and Post-Acute Care • Combine payments across

providers/ settings for specific

episodes for better coord

• Linked to quality measures and

resource use measures

Accountable Care Organizations • Reimburses population-level improvements in quality and overall

per-capita costs

• Encourages coordination across care continuum

• Can reinforce/ support “piecewise” accountable-care reforms

• Performance measures

for quality and cost

(outcome-oriented)

• Timely and consistent

methods for sharing

underlying data with

providers, suppliers to

improve performance

• Rapid evaluation

methods based on

common measures

Performance-Based Payments for Drugs, Devices • Supports targeting treatments to patients likely to benefit, not

necessarily greater volume

• Likely to succeed with timely performance measures and

differences across patients


Updates from Public Initiatives: Medicare

Medicare ACO Programs (Most Recent Statistics):

– Medicare Shared Savings Program (221), Pioneer Program (32), Physician Group Practice Transition Program (6)

• More than 4 million beneficiaries currently served by Medicare ACOs • Diverse participants in MSSP

– January 2013, CMS announced 106 new participants in the MSSP Program • 48 States, DC, and Puerto Rico now included in MSSP • Over 1.5 million beneficiaries newly covered, total of 4 million beneficiaries • About 50% of ACOs are physician-led • 15 new organizations are Advanced Payment Model ACOs

– Applications for fourth round of MSSP participants will be due this summer and will join program in January 2014

ACO Pioneers Express Concerns About 33 Quality Metrics:

– Requested revising metrics and delaying until next year any penalties or bonuses – CMS is in negotiations with Pioneer leaders and will give them an extra month (May 31st) to decide whether to continuing participation in the program


Updates from Public Initiatives: Medicaid

6

• At least 14 states undertaking ACO initiatives in Medicaid and SCHIP

– Example: Oregon Community Care Organizations

• Large-scale demonstration programs for Medicare-Medicaid Financial Alignment

– 3 states likely starting in 2013, and many more in 2014

– Example: Massachusetts

Our quality improvement strategy is to concurrently pursue three aims

7

Better Care Improve overall quality by making health

care more patient-centered, reliable,

accessible and safe.

Healthy People /

Healthy Communities

Improve population health by supporting

proven interventions to address

behavioral, social and environmental

determinants of health, in addition to

delivering higher-quality care.

Affordable Care Reduce the cost of quality health care for

individuals, families, employers and

government.

CMS Vision for Quality Measurement

• Align measures with the National Quality Strategy and Six Measure Domains

• Implement measures that fill critical gaps within the 6 domains

• Align measures across CMS programs whenever possible

• Parsimonious sets of measures; core sets of measures

• Removal of measures that are no longer appropriate (e.g., topped out)

• Align measures with external stakeholders, including private payers and boards and specialty societies

• Major aim of measurement is improvement over time

8

Quality Measurement & Performance for ACOs

Quality measures are separated into the

following four key domains that will serve

as the basis for assessing, benchmarking,

rewarding and improving ACO quality

performance:

– Better Care

1. Patient/Caregiver Experience

2. Care Coordination/Patient Safety

– Better Health

3. Preventative Health

4. At-Risk Population

Quality Measurement & Performance for ACOs Continued

ACO Quality Performance Standard made up of 33 measures

intended to do the following:

• Improve individual health and the health of populations

• Address quality aims such as prevention, care of chronic

illness, high prevalence conditions, patient safety, patient

and caregiver engagement and care coordination

• Support the Shared Savings Program goals of better care,

better health and lower growth in expenditures

• Align with other incentive programs like PQRS and EHR

• Exhibit sensitivity to administrative burden

Quality Data Reporting

• Quality data collected three ways:

– Claims and other internal data

– ACO-GPRO tool

– CG-CAHPS (Survey)

• Complete and accurate reporting in the first year qualifies the

ACO to share in the maximum available quality sharing rate

• Pay for reporting is phased in for the remaining performance

years

• Shared savings payments are linked to quality performance

based on a sliding scale that rewards attainment

– High performing ACOs receive a higher sharing rate

• ACO quality measures are monitored to determine if

ACOs are avoiding at risk beneficiaries

• ACOs must meet minimum attainment level on 70

percent of the measures in a given domain in order to

avoid poor performance sanctions

• An ACO determined to be avoiding at risk

beneficiaries could receive sanctions or be

terminated

Quality Measurement and ACO Monitoring

Next Steps for Performance Measurement for ACOs

• Development of Outcome measures, specified at the

ACO level

– Complications of outpatient procedures/surgeries

(colonoscopy, cataract) within 7 days

– All-cause unplanned admissions for individual chronic

diseases and patients with MCCs

– PROs (function, symptom resolution, etc.)

• Expand reporting options

– Clinical Data Registry

– EHRs

• starting 2014, groups can report CQMs as a group for stage 2 of

MU

13

Ongoing Work Related to Aligning CMS Programs with other Measure Reporting Efforts

• Registries (many led by physician specialty societies) are the

fastest growing portion of PQRS

– all payer data

– robust set of measures

– success rates via registries are very high

• PQRS incentive related to MOC

• ATRA requirement to allow measures reported to registries

count for PQRS

• Increased bidirectional communication and engagement

between CMS and Boards and Specialty Societies

• Significant work to align measures across public and private

payers

14

© 2011 Advocate Physician Partners

Value a la Porter

Advocate Porter

• Inpatient Mortality • Survival

• Inpatient Complications and Intermediate Measures to Reduce Complications

• Degree of Recovery

• Amb. Sensitive ER Visits/1000

• Disutility of Care

• Functional Status in MSSP • Functional Status

• Access • Time to Recovery

© 2011 Advocate Physician Partners

Exhibit 2. Pathway for Quality and

Cost Measurement

Core

Core Plus

Advanced

Interim Process

Diabetes: HbA1c Testing CAD: ACE Inhibitor or ARB Therapy

Diabetes: HbA1c Control (<8%) CAD: LDL-C Level <100 mg/dl

Diabetes: Cost of Care Over 1-Year Period CAD: Drug Therapy for Lowering LDL Cholesterol

Diabetes: Physical Functioning CAD: 10-Year Risk of Developing Hard CHD

17

Domain Measure Title

Quality and Cost Measures: Ramp-Up Strategy

B-D Pilot Initial Contracts CMS Proposal for MSSP Final MSSP Core Core Plus Interim Process Advanced

Patient / Care Giver Experience CAHPS: Getting Timely Care, Appointments, and Information X X X X

CAHPS: How Well Your Doctors Communicate X X X X

CAHPS: Patients' Rating of Doctor X X X X

CAHPS: Health Promotion and Education X X X

CAHPS: Shared Decision Making X X X

CAHPS: Access to Specialists X X

CAHPS: Health Status/Functional Status X X X

Family Evaluation of Hospice Care (NHPCO) X

Care Coordination / Patient Safety Risk-Standardized, All Condition Readmission X X X

Care Transition Measure X X

Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease X X X

Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure X X X

Annual Monitoring for Patients on Persistent Medications X X

Percent of PCPs who Successfully Qualify for an EHR Incentive Program Payment X X

Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility X X X

Falls: Screening for Fall Risk X X X

Preventive Health Breast Cancer Screening X X X X

Cervical Cancer Screening X X

Proportion of Adults 18+ who had their Blood Pressure Measured within the preceding 2 years X X

Cholesterol Management for Patients with Cardiovascular Conditions X X X

Influenza Immunization X X X

Pneumococcal Vaccination X X X

Colorectal Cancer Screening X X X X

Adult Weight Screening and Follow-up X X X

Tobacco Use Assessment and Tobacco Cessation Intervention X X X

Depression Screening X X X

Health Risk Assessment X

4/11/2013 18




At-Risk Population

Diabetes Hemoglobin A1c Management (testing) X X

LDL-C Screening X X

Hemoglobin A1c Control (<8%) X X X X

Low Density Lipoprotein (LDL-C) Control X X X X

Hemoglobin A1c Poor Control (>9%) X X X X

High Blood Pressure Control X X X X

Urine Screening for Microalbumin or Medical Attention for Nephropathy X X X

Dilated Eye Exam X X

Total Cost of Care: Diabetes over a 1-Year Period X

Tobacco Non-Use X X X

Aspirin Use X X X

Foot Exam X X

Quality of Life in Patients with Diabetes (DQOL, ADDQoL) X

Psychological Functioning in Patients with Diabetes (DHP) X

Heart Failure Left Ventricular Function (LVF) Assessment X X

Left Ventricular Function (LVF) Testing X X

Total Cost of Care: CHF Over 1-Year Period X

Weight Measurement X X

Patient Education X X

Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) X X X

Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) X X

Warfarin Therapy for Patients with Atrial Fibrillation X X

Physical Function in Patients with Heart Failure (KCCQ) X

Quality of Life in Patients with Heart Failure (KCCQ) X

Cardiac and Vascular Conditions

Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) X X X X

LDL-C level <100 mg/dl X X

IVD: Complete Lipid Panel and LDL Control X X

Total Cost of Care: CAD Over 1-Year Period X

Composite: All or Nothing Scoring X X

Oral Antiplatelet Therapy Prescribed for Patients with CAD X X

Drug Therapy for Lowering LDL Cholesterol X X X

Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) X X

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic X X

6-Month Mortality Following CABG Surgery X

10-Year Risk of Developing Hard CHD (Framingham Risk Score) X

Physical Limitation from Angina (SAQ) X

Quality of Life in Patients with CAD (KCCQ) X

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Hypertension Blood Pressure Control X X X X

Plan of Care X

Quality of Life in Patients with Hypertension (CAMPHOR) X

COPD

Total Cost of Care: Patients with Stable COPD Over a 1-Year Period X

Total Cost of Care: Patients with Unstable COPD Over a 1-Year Period X

Spirometry Evaluation X X

Smoking Cessation Counseling Received X X

Bronchodilator Therapy based on FEV1 X X

Respiratory Function in Patients with COPD (SGRQ) X

Emotional Functioning in Patients with COPD (CRQ) X

Frail /Elderly Osteoporosis Management in Women Who had a Fracture X X

Monthly INR for Beneficiaries on Warfarin X X

Total Cost of Care: Management of Frail Elderly X

Physical Functioning (IADL) X

Depression in Older Adults (GDS) X

Pediatrics Appropriate Testing for Children with Pharyngitis X X

Treatment for Children with Upper Respiratory Infection X X

Childhood Immunization Status X X

Immunization for Adolescents X X

Physical Functioning in Children (CHQ) X

Asthma Use of Appropriate Medications for People with Asthma X X

Functional Status: Asthma Impact (PROMIS) X

Palliative Care and End-of-life Care*

Patients with Advanced Cancer Assessed for Pain at an Outpatient Visit (RAND) X

Patients Admitted to ICU Who Have Care Preferences Documented (RAND) X

Pain Management: Pain Brought to a Comfortable Level with 48 Hours of Initial Assessment (NHPCO) X

Percentage of Hospice or Palliative Care Patients Who Were Screened for Dyspnea during the Hospice Admission Evaluation/Palliative Care Initial Encounter (UNC/PEACE) X

Overuse Low Back Pain: Use of Imaging Studies X X

Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use X X

Other Conditions ESRD: Plan of Care for Inadequate Peritoneal Dialysis, Adult X

Ambulatory Status at 6 Months Following Knee Replacement Surgery X

Cost of Care

Per Capita Resource Utilization for All Patients over a 1-Year Period (risk adjusted) X

All Populations Functional Status: Physical Functioning (PROMIS, SF-36) X

Functional Status: Physical Activity (UCLA Activity Scale) X

Functional Status: Emotional Distress (Anxiety/Depression) (PROMIS) X

Functional Status: Depression Severity (PHQ-9) X

Functional Status: Social Functioning (SF-36) X


• In year 1, scoring is based on complete and accurate reporting

• Benchmarks are calculated based on FFS/MA or ACO performance

• Beginning in year 2, CMS will set a performance benchmark and a minimum attainment level. For each measure: 1) performance below minimum attainment level = 0 quality points; 2) between minimum attainment level and benchmark, quality points are awarded on a sliding scale; 3) above benchmark = 2 quality points

0% 100%

Quality

Points

Minimum

Attainment Level

Performance

Benchmark

2

1

0 Points

Maximum quality

score: 2 Points

Quality measure scoring


• Individual measure scores are accumulated within each domain.

• The total number of points are then divided by the total available points to obtain the domain-level score. A Preventive Health domain example:

Measure Quality Points

Influenza Immunization 1.7

Pneumococcal Vaccination 1.55

Mammography Screening 1.7

Colorectal Cancer Screening 1.55

Cholesterol Management for Patients with Cardiovascular Conditions 1.25

Adult Weight Screening and Follow-up 1.1

Blood Pressure Measurement 2

Tobacco Use Assessment and Tobacco Cessation Intervention 1.4

Depression Screening 1.7

Total points: 13.95

Total available points (2 per measure): 18

Domain score: 78%

Domain-level scoring


• Each of the five domains is weighted equally to determine the quality performance sharing rate.

• For example:

Domain Year 1 Year 2 Year 3

Patient/Caregiver Experience 57% 71%

Care Coordination 75% 78%

Patient Safety 50% 50%

Preventive Health 78% 78%

At-Risk Population/Frail Elderly Health 80% 75%

Quality performance sharing rate: 100% 68% 70%

Must report all

measures for

payment

Note: CMS is reserving the right to audit submitted performance data; proposed is

audit mechanism as in PGP demo.

Calculating the Quality Performance Sharing

rate

The Engelberg Center for Health Care Reform at Brookings | The Dartmouth Institute Courtesy of HealthReformWatch

4/11/2013 25


Thank You [email protected]

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