Standardizing Medi-Cal P4P -...

Healthy San Diego Meeting

May 12, 2016

Jill Yegian, Ph.D., SVP Programs and Policy

Standardizing Medi-Cal P4P

© 2016 Integrated Healthcare Association. All rights reserved. 2

Today’s Agenda

• Introduction to IHA

• Overview of Medi-Cal P4P Standardization project

• Results to date

• Action plan for Phase 2

• Discussion


Our work creates credible, actionable information that enables sustainable improvement in California health care systems through multi-stakeholder collaboration, and is organized around projects that generate insights, improve accountability, and accelerate solutions.

Our Work

Regional Variation: HEDIS by Geography & Cost & Quality Atlas

Statewide Workgroup on Reducing Overuse

Promoting ABIM Foundation’s Choosing Wisely®

Accountable Care Organizations

Maternity Care

Cancer Care Quality

Bundled Payment

Value Based P4P

Medicare Advantage Stars

Medi-Cal

Encounter Data

Digital Health

Regional Data Collaborative

Transforming Clinical Practices

Insights Accountability Acceleration


Hospitals and Health Systems

Cedars Sinai, Dignity Health, John Muir, MemorialCare, Martin Luther King Jr. Community Hospital, Providence Health & Services, Santa Clara County Hospital and Health System, Stanford Health Care, Sutter Health, U.C. Davis Medical Center

Health Plans

Aetna, Anthem, Blue Shield of California, CalOptima, Cigna, Health Net, Kaiser Foundation, L.A. Care, Partnership Health Plan, UnitedHealthcare

Physician Organizations

Brown & Toland, CEP America, EPIC L.P./Beaver Medical Group, Family Care Specialists Medical Group, HealthCare Partners, HillPhysicians Medical Group, Monarch HealthCare, Palo Alto Medical Foundation, Kaiser Permanente Medical Group, Santé Medical Group, Sharp Rees-Stealy Medical Group

Pharmaceutical, BioTech, IT and Consulting Firms

Cope Health Solutions, Genentech, GlaxoSmithKline, MedeAnalytics, Merck & Company, Novo Nordisk, Pfizer

Purchasers and Consumers

CalPERS, Center for Healthcare Decisions, Covered California, Disney Worldwide, Keenan

Regulators

California Department of Managed Health Care, CMS Region IX

Academic Institutions

Stanford Medical School, Stanford Graduate School of Business, U.C. Berkeley School of Public Health, U.C. Davis Medical Center

Foundations and Research Institutions

California HealthCare Foundation, RAND Corporation

Our Members


Health care measurement important to assess health system performance and improve care delivered

Number and scope of measures providers held accountable for steadily increasing

Lack of alignment across incentive programs creates unnecessary burdens on providers and confusion among consumers

As Medi-Cal enrollment increases and Medi-Cal shifts to managed care, imperative emerging for consistent performance measurement

Performance Measurement Landscape


Medi-Cal P4P Inventory: Program Prevalence

P4P Programs

Of the 20 Medi-Cal managed care plans interviewed, 16 have pay-for-performance programs in place

The P4P programs vary in extent and approach

Overview of Current P4P Activities

Number of Plans

P4P Programs in Place 16

Just Starting 1

Started 2009 - 2013 5

Started 2004 - 2008 3

Started 2003 and before 7

No P4P Program in Place 4

Total 20


Why do we need greater standardization?

Only 1 measure aligns across all programs:

Diabetes HbA1c Testing

California Health & Wellness

Cal Optima

CenCal

Central California Alliance

Health Net

Health Plan of San

JoaquinHealth

Plan of San Mateo

Inland Empire Health

Plan

Kern Health

Systems

LA Care

Partnership

San Francisco

Health Plan

Anthem

Medi-Cal

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

CMS & AHIP Core Quality

Measures Collaborative

Medicare Advantage

Stars

IHA Value Based P4P

DHCS External

Accountability Set

Cross Product

Only one measure out of 86 distinct measures align across all programs

Only two measures align across all measure sets


Convene an Advisory Committee to provide expertise and guidance across project activities

Identify a core measure set that all plans could adopt as a part of their P4P programs

Develop a menu of additional measures that plans can use to supplement the core measure set at the local level as well as a set of incentive design principles and best practices

Funding – Blue Shield of CA Foundation

Timeline: April 2015 – March 2016

Standardizing Medi-Cal P4P


Reduce unnecessary burdens associated with the lack of

alignment across incentive programs

Enhance provider effectiveness by “strengthening the

signal” –focus improvement efforts and resources

Facilitate the comparability of performance results and

benchmarking statewide

Benefits of a Core Measure Set


Health Plans Alameda Alliance for Health Anthem Blue Cross California Health & Wellness CalOptima CenCal Health Central California Alliance for Health Health Net Health Plan of San Joaquin Health Plan of San Mateo Inland Empire Health Plan LA Care Health Plan San Francisco Health Plan Partnership Health Plan

Standardizing Medi-Cal Advisory Committee

Collaborators American Institutes of Research Blue Shield of California Foundation California HealthCare Foundation California Quality Collaborative Center for Care Innovations Center for Health Care Strategies Health Services Advisory Group John Snow, Inc.

Provider Representatives

Alameda Health Consortium AltaMed CHOC Health Alliance Community Clinic Association of Los Angeles County Community Medical Centers County of San Diego Health and Human Services Family Care Specialists Medical Group Hill Physicians Omnicare Medical Group IPA Palo Alto Medical Foundation San Mateo Medical Center Santa Clara Valley Health & Hospital System Santa Rosa Community Health Centers Shasta Community Health Center SynerMed

Associations California Association of Health Plans California Primary Care Association CAPG Local Health Plans of California Safety Net Institute


Medi-Cal P4P Continuum

11

Voluntary Core

Measure Set; shared

specifications and

benchmarks

Voluntary Core & Supplemental

menu of measures;

shared specifications

and benchmarks

Quality based P4P in Medi-Cal; Core and Supplemental measure set

and incentive design

required; payment

amount not required

Quality based P4P in

Medi-Cal; payment amount required

Value based P4P in

Medi-Cal; payment based on

quality and resource use

Voluntary Core and

Supplemental menu of

measures and incentive

design options

IHA’s Standardizing Medi-Cal P4P Project

Current Status Medi-Cal P4P –Uniform/Broad Adoption

COORDINATION / COLLABORATIONLESS MORE

No formal coordination/collaboration;

Variation in performance measurement

& incentive design


Project Scope

WHAT THE PROJECT IS: WHAT THE PROJECT IS NOT:

1 Incorporating a core measure set, developed by

an Advisory Committee, into all Medi-Cal Managed Care P4P programs (voluntary)

Developing a new P4P program, similar to IHA’s commercial program, that all Medi-Cal plans can adopt

2 Focusing provider level measurement on a

subset of measures included in DHCS’s EAS

Focusing plan level measurement on all of the measures included in DHCS’s EAS, or on measures not included in the EAS

3 Varying the unit of measurement by health

plans and their contracted provider entities Standardizing performance measurement at the

physician group level across all Medi-Cal plans

4 Potential for providing comparative data

benchmarked to peers and national metrics, for internal reporting only

Publicly reporting provider performance data

5 Creating a recommended approach to data

collection and reporting for plans to consider Developing a standard data collection method to

be used across all plans

6 Sharing incentive design best practices with

participating health plans to facilitate discussion

Creating greater standardization of incentive design structures or universal adoption of one incentive design structure


IMPORTANCEThe core measure set for Medi-Cal P4P programs will measure areas

that have the greatest impact on Medi-Cal patients.

SCIENTIFIC

ACCEPTABILITY

The core measure set will include measures that are evidence-

based and have been appropriately vetted, endorsed, and

approved.

USEFULNESSThe core measure set will include measures in priority areas where

plans and providers have room for improvement and are able to

demonstrate meaningful changes in performance.

ALIGNMENT

The core measure set will align with other existing performance

measurement requirements for Medi-Cal providers and existing

Medi-Cal P4P programs in order to minimize resource demands and

allow for comparison across managed care plans and populations.

FEASIBILITYThe core measure set will include measures that have clear

specifications and data collection methodologies that do not

impose an undue burden on plans and their contracted providers.

Measure Selection Principles


Key features of the Core Measure Set:• No more than 10 measures

• Included in DHCS’s External Accountability Set

• Feasible for a wide array of providers to report using administrative only data

Core Measure Set Overview

CORE MEASURE SET

Domain Measures Steward NQF #

CardiovascularAnnual Monitoring for Patients on Persistent Medications: ACE or ARB NCQA 0021

Annual Monitoring for Patients on Persistent Medications: Diuretics NCQA 0021

Diabetes Care

HbA1c Testing NCQA 0057

HbA1c Control (<8.0%) NCQA 0575

Eye Exam NCQA 0055

Maternity Timeliness of Prenatal Care NCQA 1517

Prevention

Childhood Immunizations, Combo 3 NCQA 0038

Well-Child Visits in 3rd, 4th, 5th, and 6th Years of Life NCQA 1516

Cervical Cancer Screening NCQA 0032

Respiratory Medication Management for People with Asthma – Medication Compliance 75% NCQA 1799


A menu or library of additional measures that plans can use to supplement the core measure set at the local level

Selection Criteria:

1. EAS measures that were not included in the core measure set

2. Additional measures currently included in Medi-Cal P4P programs

3. Measures included in more than one of the other existing performance measurement requirements for Medi-Cal plans and providers, including:

o DHCS EAS

o Covered California’s Quality Rating System

o NCQA Medicaid Managed Care Health Plan Accreditation Standards

o CMS Medicaid Core Measures for Adults and Children

Supplemental Measure Set Overview


Supplemental Measure SetAccess Children and Adolescents’ Access to PCPs NCQA 1390

Behavioral Health /

Substance Abuse

Antidepressant Medication Management NCQA 0105

Follow-Up for Children Prescribed ADHD Medication NCQA 0108

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment NCQA 0004

Cardiovascular Controlling blood pressure for people with hypertension NCQA 0018

Diabetes Care

Blood Pressure Control <140/90 mm Hg NCQA 0061

HbA1c Poor Control >9% NCQA 0059

Medical Attention for Nephropathy NCQA 0062

Maternity Timeliness of Postpartum Care NCQA 1517

Musculoskeletal Overuse of Imaging Studies for Low Back Pain NQCA 0052

Prevention

Adolescent Well-Care Visits NCQA n/a

Adult BMI Assessment NCQA n/a

Breast Cancer Screening NCQA 2372

Childhood Immunizations, Combo 10 NCQA 0038

Chlamydia Screening NCQA 0033

Colorectal Cancer Screening NCQA 0034

Flu Vaccinations for Adults Ages 18-64 NCQA 0039

Human Papillomavirus Vaccine for Female Adolescents NCQA 1959

Immunizations for Adolescents NCQA 1407

Medical Assistance with Smoking & Tobacco Cessation NCQA 0027

Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents: NCQA 0024

Well-Child Visits in the First 15 Months of Life (6 or more visits) NCQA 1392

Respiratory

Asthma Medication Ratio NCQA 1800

Appropriate Testing for Children with Pharyngitis NCQA 0002

Appropriate Treatment for Children with URI NCQA 0069

Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis NCQA 0058

Resource UseAll-Cause Readmissions NCQA 1768

Emergency Department Visits NCQA n/a


• Smaller subset of more ambitious, outcomes based measures; distinct from core measure set

• Some measures have clear specifications, other do not; additional work needed to determine definitions

• Exploring funding for a new project to create a foundation for ambitious, outcomes based measurement in Medi-Cal

Developmental Measure Set Overview

DEVELOPMENTAL MEASURE SET -- ILLUSTRATIVE

Domain Measures

AccessAlternative Visits (TBD)

Coordination of Care (TBD)

Behavioral HealthScreening for Clinical Depression & Follow-up e-measure (NQF#: 0418; eMeasure Identifier: 2)

Patient Reported Outcome Measure (e.g. Depression Remission)

CardiovascularControlling Blood Pressure for People with Hypertension (NQF#: 0018)

Controlling Blood Pressure e-measure (NQF #0018; eMeasure Identifier: 165)

Patient Experience CG-CAHPS (short form)

Resource Use Avoidable Emergency Department Visits (AHRQ PQI, NYU, DHCS QIP)

Total Cost of Care


• Creation of consensus core, supplemental measure sets

• Active and engaged Advisory Committee, including both plans and providers

• Strong interest from plans not initially involved

• DHCS engagement, including seeking guidance from AC on measure set update

Results to Date


• Core measure set adoption underway – intent to adopt by 7 plans for MY 2017, partial adoption by 6 more

Adoption Efforts to Date

Intent to adopt for MY 2017 Partial adoption for MY 2017

1. Alameda Alliance 1. CalOptima

2. Anthem Blue Cross 2. CalViva

3. California Health & Wellness 3. Health Net

4. CenCal 4. Health Plan of San Joaquin

5. Central California Alliance for Health 5. Health Plan of San Mateo

6. LA Care 6. Partnership Health Plan

7. San Francisco Health Plan


Next Phase of Standardizing Medi-Cal P4P

Create greater measure set alignment across the policy landscape

Support the implementation of the core measure set across all Medi-Cal P4P programs

Spread the adoption of the core measure set to plans not participating on the Advisory Committee

Funding – CMMI (included in Transforming Clinical Practices Initiative grant awarded to PBGH/CQC)

March 2016 – February 2018


Objective:

• Identify opportunities for greater measure set alignment across the policy environment

Planned Activities:

• Identify initiatives underway or planned in Medi-Cal & the safety net

• Develop crosswalk of key initiatives to use as a resource toward creating a shared performance measurement strategy

• Summarize findings in an issue brief

• Support DHCS’ EAS update efforts

Timeline:

• March 2016 – September 2016

Policy Initiatives -- Measure Set Status


Policies/Initiatives

1. Medi-Cal Managed Care -- External Accountability Set (EAS) Update

2. Coordinated Care Initiative (Cal Medi-Connect)

3. Public Hospital Redesign and Incentives in Medi-Cal (PRIME)

4. Whole Person Care Pilots

5. Alternative Payment Methodology (APM) Pilot

6. Health Homes for Patients with Complex Needs (Section 2703)

7. California Children’s Services (CCS) “Whole Child Model” Redesign

Medi-Cal Initiative Landscape


Objective:

• To support implementation efforts and create opportunities for collaboration and learning

Planned Activities:

• Convene quarterly Advisory Committee meetings

• Develop timeline and process for adopting new measures to core measure set and complete one update of core measure set

• Explore feasibility of developing benchmarks at provider level

• Explore providing access to IHA’s web-based portal

• Re-survey plans to identify issues and unintended consequences

Timeline:

• March 2016 – February 2018

Implementation of the Core Measure Set


Spread Core Measure Set

Objective:

• To spread the core measure set to Medi-Cal plans not currently participating on the Advisory Committee

Planned Activities:

• Schedule 1:1 meetings with plan representatives to share information about project and the core measure set

• Develop resources to support plans with adoption

• Provide technical support to plans interested in developing P4P programs

Timeline:

• March 2016 – December 2016


1. What feedback do you have on the idea of a core measure set for Medi-Cal P4P?

2. Are the measures included in the core measure set consistent with your current efforts?

3. What implementation challenges do you anticipate?

4. Are you interested in joining the Advisory Committee?

Discussion Questions

For more information:

Jill Yegian, [email protected]

Sarah Lally, [email protected]

Web: www.iha.org

mailto:[email protected]

mailto:[email protected]

http://www.iha.org/

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