The Significant Lack of Alignment Across State and Regional Health Measure Sets:An Analysis of 48 State and Regional Measure Sets, Resource Document
Kate Reinhalter BazinskyMichael BailitSeptember 10, 2013
2
Executive summary
The are many state/regional performance measures for providers in use today. – 1367 measures identified across 48 measure sets.
Unfortunately, current state and regional measure sets are not aligned. – Only 20% of all measures were used by more than one program.
Non-alignment persists despite the tendency to use standard, NQF-endorsed and/or HEDIS measures.– Although 59% of the measures come from standard sources, they
are selecting different subsets of these standard measures for use.– The most frequently used measure was only used by 63% of the
programs.
3
Executive summary (cont’d)
With few exceptions, regardless of how we analyzed the data, the programs’ measures were not aligned. – This lack of alignment persists across programs of the same type
and for the same purpose.– Medicaid MCOs are the exception and use far more of the same
measures than any other type of program. This is partially because they rely almost exclusively on HEDIS measures.
– We also found that California has more alignment. This may be due to our sample or the work the state has done to align measures.
While many programs use measures from the same domains, they are not selecting the same measures within these domains.– This suggests that simply specifying the domains from which
programs should select measures will not facilitate measure set alignment.
4
Executive summary (cont’d)
Even when the measures are “the same,” the programs often modify the traditional specifications for the standard measures.– 83% of the measure sets contained at least one modified measure. – Two of the programs modified every single measure and six of the
programs modified at least 50% of their measures. Many programs create their own “homegrown” measures.
– 40% of the programs created their own homegrown measures. – Some of these may be measure concepts, rather than measures
that are ready to be implemented Unfortunately most of these homegrown measures do not
represent true innovation in the measures space.– There appears to be a need for new standardized measures in the
areas of self-management, cost, and care management and coordination.
5
Conclusions Bottom line: Measures sets appear to be developed
independently without an eye towards alignment with other sets.
The diversity in measures allows states and regions interested in creating measure sets to select measures that they believe best meet their local needs. Even the few who seek to create alignment struggle due to a paucity of tools to facilitate such alignment.
The result is “measure chaos” for providers subject to multiple measure sets and related accountability expectations and performance incentives. Mixed signals make it difficult for providers to focus their quality improvement efforts.
6
Purpose
Goal: Paint a picture of the measures landscape across states and regions to inform development of the emerging Buying Value measure set.
Process: Identify and collect 48 measure sets used by 25 states for a range of purposes and conduct a multi-pronged analysis:– Provide basic summary information to describe the 48 measure
sets– Provide an overview of the measures included in the 48
measure sets– Analyze the non-NQF endorsed measures– Analyze the measures by measure set type– Analyze the measures by measure set purpose– Analyze the measures by domain/ clinical areas– Assess the extent of alignment within the states of CA and MA
7
Methodology We used a convenience sample of measure sets from
states, by requesting assistance from our contacts in states and by:– Obtaining sets through state websites:
• Patient-Centered Medical Home (PCMH) projects • Accountable Care Organization (ACO) projects• CMS’ Comprehensive Primary Care Initiative (CPCI)
– Soliciting sets from the Buying Value measures work group We also included measure sets from specific regional
collaboratives. We have not surveyed every state, nor have we
captured all of the sets used by the studied states. We did not include any hospital measures sets in our
analysis.– Excluded 53 hospital measures from the analysis
8
Methodology (cont’d) Organized the measures by:
– Measure steward– NQF status/ number– Age of the population of interest– Program type (e.g., ACO, PCMH, health home)– Program purpose (e.g., payment or reporting)– Domain (used the NQS tagging taxonomy)– Clinical areas of interest (used NQF taxonomy detail)
Unduplicated the total measures list to identify the “distinct” measures–If a measure showed up in multiple measure sets, we only counted it once.– If a program used a measure multiple times (variations on a theme) we also only counted it once.
9
Methodology (cont’d)
Assessed whether the measure is standard, modified, homegrown or undetermined.
• If we did not have access to the specifications, but the measure appeared to be standard through combination of steward and title or NQF#, we considered it to be a “standard” measure. This approach is likely to underestimate the number of modified measures.
• We labeled measures “modified” if they were standard measures with a change to the traditional specifications.
• We labeled measures “homegrown” if they were were indicated on the source document as having been created by the developer of the measure set.
• We labeled measures “undetermined” if the source of the measure was unclear. Some of these measures may be “homegrown” while others may be drawn from niche sources.
Table of contents
10
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
11
1. Overview of measure sets
Goal: provide some basic summary information to describe the group of measures sets and answer the following questions:1. How many measures are included across the measure
sets?2. How many measures are included in the average measure
set?
12
Measure sets by state
Reviewed 48 measure sets used by 25 states.
Intentionally gave a closer look at two states: CA and MA.
1. AR2. CA (7)3. CO4. FL5. IA (2)6. ID7. IL8. LA9. MA (8)10.MD
11.ME (2)12.MI13.MN (2)14.MO (3)15.MT16.NY17.OH18.OK19.OR20.PA (4)
21.RI22.TX23.UT (2)24.WA25.WI
Note: If we reviewed more than one measure set from a state, the number of sets included in the analysis is noted above.
13
Program types
ACO: Measure sets used by states to evaluate Accountable Care Organizations. Organizations of providers that agree to be accountable for the clinical care and cost of a specific attributed population
Alignment Initiative: Measure sets created by statewide initiatives in an attempt to align the various measures being used throughout the state by various payers or entities
Commercial Plans: Measure sets used by states to evaluate insurers serving commercial members
Duals: Measure sets used by state Medicaid agencies in programs serving beneficiaries who are dually eligible for Medicare and Medicaid
Exchange: Measure sets used to assess plan performance in a state-operated marketplace for individuals buying health insurance coverage
Note: these categories are meant to be mutually exclusive. Each measure set was only included in one category.
14
Program types (cont’d)
Medicaid: Measure sets used by states to evaluate the Medicaid agency performance
Medicaid MCO: Measure sets used by state Medicaid agencies to assess performance of their contracted managed care organizations
Medicaid BH MCO: Measure sets used by state Medicaid agencies to assess performance of their contracted behavioral health managed care organizations
PCMH: Measure sets used by patient-centered medical home initiatives
Other Provider: Measure sets used by states to assess performance at the provider level, but are not for assessing ACO, PCMH or Health Home initiatives
Regional Collaboratives: A coalition of organizations coordinating measurement efforts at a regional level, often with the purpose of supporting health and health care improvement in the geographic area
15
Measure sets by program type
PCMH
Other p
rovide
r
Medica
id MCO
Medica
id ACO
Commerc
ial P
lans
Health
Hom
e
Region
al Coll
abora
tive
Alignm
ent In
itiativ
eDua
ls
Excha
nge
Medica
id BH M
COMCO
0
2
4
6
8
10
12
14 13
65
3 3 3 3 32 2 2 2
1
16
Measure sets by purpose
Report
ing
Paymen
t
Report
ing an
d othe
r purp
ose
Alignm
ent
0
5
10
15
20
25 2219
52
16
Reporting: measure sets used for performance reporting, this reporting may be public or may be for internal use only
Payment: measure sets used for payment distribution to providers (e.g., pay for performance, shared savings, etc.)
Reporting and Other: measure sets used for reporting and an additional non-payment purpose, such as tiering providers or contract management
Alignment: measure sets resulting from state initiatives to establish a core measure set for the state
Defining Terms
17
Measure sets ranged significantly in size
Note: This is counting the measures as NQF counts them (or if the measure was not NQF-endorsed, as the program counted them).
108 measures
29 measures
3 measures
[max]
[min]
[avg]
Table of contents
18
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
19
2. Overview of measures
Goals: To describe the measures used across the sets and
answer the following questions:1. Are the measures used primarily standard measures?2. To what extent are measures NQF-endorsed? 3. What are the primary sources of the measures? 4. Into which domains do most of the measures fall?5. To what extent do the measures cover all age ranges?
To assess the extent of alignment across the measure sets1. To what extent are measures shared? 2. What are the most frequently shared measures?
20
Finding: Many state/regional performance measures for providers in use todayIn total, we identified 1367 measures across the 48 measure sets
– This is counting the measures as NQF counts them or if the measure was not NQF-endorsed, as the program counted them
We identified 509 distinct measures–If a measure showed up in multiple measure sets, we only counted it once –If a program used a measure multiple times (variations on a theme) we also only counted it once
We excluded 53 additional hospital measures from the analysis.
21
Programs use measures across all of the domains
Access, affordability & inapprop care
9%Comm & care coordination
2%
Health and well-be-ing
27%
Infrastructure2%Person- centered
9%
Safety13%
Treatment and Secondary Preven-
tion33%
Utilization5%
Total measures by domainn = 1367
22
Access, affordability & in-approp care
11%Comm & care co-
ordination5%
Health and well-be-ing
14%
Infrastructure4%
Person- centered11%
Safety19%
Treatment and secondary preven-
tion 28%
Utilization8%
Distinct measures by domainn = 509
The distinct measures actually are more evenly distributed across the domains
23
Most implemented measures are for adults
Adult (18-64)4%
Adult (65+)3%
All Adults (18+)58%
Pediatric (0-17)16%
Pediatric and Adult (0-64)
20%
Measures by age groupn = 1367
But there does not appear to be a deficiency in the number of measures that could be used in the pediatric or the 65+ population.
24
Finding: Little alignment exists across the measure sets
Not shared80%
Shared*20%
Number of distinct measures shared by multiple measure sets
n = 509
Programs have very few measures in common or “sharing” across the measure sets
Of the 1367 measures, 509 were “distinct” measures
Only 20% of these distinct measures were used by more than one program
* By “shared,” we mean that the programs have measures in common with one another, not that they are working together.
How often are the “shared measures” shared?
Measures not shared 80%
2 sets, 5% (28 measures)
3-5 sets, 4% (20 measures)
6-10 sets, 4% (21 measures)
11-15 sets, 3% (14 measures)
16-30 sets, 4% (19 measures)
25
Only 19 measures were shared by at least 1/3 (16+) of the measure sets
Most measures are not shared
Not that often…
6 Preventative Care
Categories of 19 most frequently used measures
26
•Breast Cancer Screening
•Cervical Cancer Screening
•Childhood Immunization Status
•Colorectal Cancer Screening
•Weight Assessment and Counseling for Children and Adolescents
•Tobacco Use: Screening & Cessation Intervention
7 Diabetes Care
•Comprehensive Diabetes Care (CDC): LDL-C Control <100 mg/dL
•CDC: Hemoglobin A1c (HbA1c) Control (<8.0%)
•CDC: Medical Attention for Nephropathy
•CDC: HbA1c Testing
•CDC: HbA1c Poor Control (>9.0%)
•CDC: LDL-C Screening
•CDC: Eye Exam
1 Mental Health/Sub-
stance Abuse•Follow-up after Hospitalization for Mental Illness
1 Patient Experience
•CAHPS Surveys(various versions)
4 Other Chronic
Conditions•Controlling High Blood Pressure
•Use of Appropriate Medications for People with Asthma
•Cardiovascular Disease: Blood Pressure Management <140/90 mmHg
•Cholesterol Management for Patients with Cardiovascular Conditions
27
Finding: Non-alignment persists despite preference for standard measures
Standard59%
Modi-fied17%
Home- grown15%
Undeter-mined6%
Other3%
Measures by measure typen = 1367
Standard: measures from a known source (e.g., NCQA, AHRQ)
Modified: standard measures with a change to the traditional specifications
Homegrown: measures that were indicated on the source document as having been created by the developer of the measure set
Undetermined: measures that were not indicated as “homegrown”, but for which the source could not be identified
Other: a measure bundle or composite
Defining Terms
28
In particular, states show a preference for NQF- endorsed measures
NQF- endorsed
63%No longer
NQF- endorsed
5%
Never NQF- endorsed
32%
Percentage of total measures that are NQF- endorsedn = 1367
29
But looking at the distinct measures, they are clearly willing to use non-NQF measures
NQF- en-
dorsed32%
No longer NQF- en-
dorsed4%
Never NQF- en-
dorsed64%
Percentage of distinct measures that are NQF-endorsed
n = 509 29
• If a measure showed up in multiple measure sets, we only counted it once (e.g., breast cancer screening was counted 30 times in the total measures chart since it appeared in 30 different measure sets; here it is counted once)
• If a program used a measure multiple times (variations on a theme) we also only counted it once (e.g., MA PCMH used 3 different versions of the tobacco screening measure; here it is counted once)
What are “distinct” measures?
30
HEDIS52%
AHRQ5%
AMA-PCPI4%
CAHPS4%
CMS4%
Resolution Health2%
Source with fewer than 20 measures
8%
Homegrown14%
Undetermined6%
Other3%
NCQA (HEDIS) is clearly the most common source of measures
Total measures by sourcen = 1367
31
But only 16% of the distinct measures come from HEDIS
HEDIS16%
Resolution Health
5%AHRQ
4%
CMS4%
AMA- PCPRI3%
Standard source with less than 10 measures
13%
Homegrown39%
Undetermined15%
Distinct measures by sourcen = 509
In other words, the 81 HEDIS
measures are used by multiple programs.
32
There is a lot of overlap between NQF and HEDIS but it is not 100%
NQF HEDIS
33
Why HEDIS measures are often the first choice for programs
HEDIS measures are known and trusted– They have been available and in use for a long time– The specifications are widely available and clearly defined
NCQA offers national and regional benchmark information – Although information is at the health plan level, programs can get a
sense of how to define “good performance”– They are already used by most health plans, thus providing some
information about baseline performance relative to the benchmark It’s good for the health plans if other programs use HEDIS
– If health plan success is being measured on the basis of the HEDIS set, the health plans have an interest in getting other parties to engage in improving scores of those measures
NCQA regularly updates the specifications in response to use, feedback and changes in guidelines– Since another organization is doing this work, it takes the burden
off of the program managers
Programs are selecting different subsets of standard measures
34
ProgramA
ProgramB
ProgramC
ProgramD
ProgramE
While the programs may be primarily using standard, NQF-endorsed measures, they are not selecting the same standard measures Not one measure was used by every program
– Breast Cancer Screening is the most frequently used measure and it is used by only 30 of the programs (63%)
35
Finding: Even shared measures aren’t always the same - the problem of modification!
Most state programs modify measures 23% of the identifiable standardized measures were
modified (237/1051) 40 of the 48 measure sets modified at least one measure Two programs modified every single measure
1. RI PCMH2. UT Department of Health
Six programs modified at least 50% of their measures1. CA Medi-Cal Managed Care Specialty Plans (67%) 2. WA PCMH (67%)3. MA PCMH (56%)4. PA Chronic Care Initiative (56%)5. OR Coordinated Care Organizations (53%)6. WI Regional Collaborative (51%)
36
Do modifications indicate a problem with the measure specifications?
Perhaps… some types of modifications suggest that the measure deserves a closer look:– Adding additional detail to or changing details in the specifications– Eliminating detail from the specifications– Changes in the CPT codes used in the measure specifications– Changes in the source of the data (i.e., from hybrid/clinical records to
claims) However, we found that there are many modifications that
programs make that don’t necessarily indicate a fundamental problem with the measure. For example, frequent modifications include:– Reporting only some of the rates/components of the measure (e.g., if the
measure has two components: screening and follow-up, they may only do the screening component of the measure)
– Narrowing or expanding the age of the population measured– Applying the measure to a new or sub-population– Applying the measure to an alternative setting
37
Frequency of modification type
Report
s only
some r
ates
Adds d
etail
Measu
remen
t peri
od Age
Notes a
chan
ge
Targete
d pop
ulatio
n
Alterna
tive s
etting
Report
s diffe
rent r
ates
Remov
es de
tail
CPT code
chan
ges
Chang
es de
tail
Data so
urce
010203040506070
59
3931 28 23
17 12 12 8 6 4 4
Note: some of the measures were modified in more than one way and each modification is represented on this chart
38
Why do organizations modify measures? To tailor the measure to a specific program
– If the program is specific to a subpopulation, then the organization may alter the measure to apply it to the population of interest
To make implementation easier– The systems that the organizations have in place may make an
alternative approach to implementing the measure easier To obtain buy-in and consensus on a measure
– Sometimes providers have strong opinions about the particular CPT codes that should be included in a measure in order to make it more consistent with their experiences. In order to get consensus on the measure, the organization may agree to modify the specifications.
– Sometimes providers are anxious about being evaluated on particular measure and request changes that they believe reflect best practice
39
Most frequently modified measures# programs modifying the measure
Measure Name Steward NQF #
12 Childhood Immunization Status NCQA (HEDIS) 3810 Use of Appropriate Medications for Asthma NCQA (HEDIS) 368 Tobacco Use: Screening & Cessation Intervention AMA-PCPI 28
7 CDC: Blood Pressure Control (<140/90 mm Hg) NCQA (HEDIS) 61
7 CDC: Hemoglobin A1c (HbA1c) Control (<8.0%) NCQA (HEDIS) 575
7 Breast Cancer Screening NCQA (HEDIS)31 (no longer
endorsed)
7 Cholesterol Management for Patients with Cardiovascular Conditions NCQA (HEDIS) NA
6 Controlling High Blood Pressure NCQA (HEDIS) 18
6 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents NCQA (HEDIS) 24
6 CDC: Hemoglobin-A1c Testing NCQA (HEDIS 57
40
Most frequently modified measures (cont’d)# programs modifying the measure
Measure Name Steward NQF #
5 Colorectal Cancer Screening NCQA (HEDIS) 34
5 CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS) 59
5 CDC: LDL-C Screening NCQA (HEDIS) 63
5 CDC: LDL-C Control <100 mg/dL NCQA (HEDIS) 64
4 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: Engagement Only NCQA (HEDIS) 4
4 CDC: Medical Attention for Nephropathy NCQA (HEDIS) 62
4 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up CMS 421
4 Frequency of Ongoing Prenatal Care NCQA (HEDIS) 1391
Table of contents
41
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
42
Finding: Many programs use non-standard measures
Homegrown36%
Other4%
Standard46%
Undetermined14%
Distinct measures by typen =509
43
Some measures were from “undetermined” sources
78 of the measures were from “undetermined” sources across 12 measure sets
These measures are in this category due to difficulty interpreting the source documents. – Source was not indicated in the source document– The measure did not include an NQF# – The measure did not use a recognizable measure name
11 VT ACO utilization measures are considered “undetermined” because the specifications for these measures have not been finalized. They are undetermined from the program’s perspective.
44
There were 78 undetermined measures across 12 measure sets
MA GIC
TX DSRIP
VT ACO
NY Med
icaid
IA D
uals
CO ACO
OH PCMH
MA Dua
ls
MI PCMH
PA HH
PA PCMH
WA P
CMH0
5
10
15
20
25
3026 26
11
42 2 2 1 1 1 1 1
69% percent of the undetermined measures come from two sources.
45
Finding : Many programs create homegrown measures
Homegrown36%
Other4%
Standard46%
Undetermined14%
Distinct measures by typen =509
Homegrown measures are measures that were indicated on the source document as having been created by the developer of the measure set.
If a measure was not clearly attributed to the developer, the source was considered to be “undetermined” rather than “homegrown.”
What are “homegrown”
measures?
46
40% of the programs created at least one homegrown measure
MO BHMCO
TX DSRIP
MO HH
MA PCMH
WCHQ
NY Med
MiPCT
PA CCI
OR CCO
IA D
uals
LA M
ed
MA MBHP
CA Med
i-Cal
Specia
lty
MA Dua
ls
ME PCMH
CA Med
i-Cal
MA SQAC
MN SQRMS
MO PCMH
010203040506070 65
3221 21 16
9 6 5 4 3 3 3 2 2 2 1 1 1 1
There were 198 homegrown measures across 19 measure sets
47
Programs create homegrown measures across all domains
Access, affordabil-ity, and inappro-
priate care17%
Communica-tion and care coordina-
tion7%
Health and well-be-ing8%
Infrastructure10%
Person and family-cen-tered care
20%
Safety12%
Secondary preven-tion and treatment
9%
Utilization17%
Homegrown measures by domainn =198
48
Four basic types of homegrown measures
Measures that are specific to one
program41%
Measures that at-tempt to fill a
measurement gap35%
Unclear as to why the program used a
homegrown measure 14%
Provider choice measures10%
Homegrown measures by typen =198
49
Some homegrown measures that are specific to one program 81 programmatic measures: measures related to
infrastructure, utilization, geographic access, and program oversight– Percent Eligibility Determination Done at State Level– Child Psychiatrist Count– Provider Satisfaction
These measures are unlikely to become standardized because they are specific to the management or structure of a particular program.
50
Other homegrown measures may be “reinventing the wheel” Of these 198 measures, there were 28 measures (14%) for
which it was not readily apparent as to why the program created the measures, as these measures appeared to replicate standard measures.
Perhaps the programs were unaware of the availability of the standard measures– Adherence to prescription medications for asthma and/or COPD
(could have used NQF #1799: Medication management for people with asthma)
– ED appropriate utilization: reduce all ED visits (could have used the ED rates from the HEDIS Ambulatory Care measure)
– Emergency Department Visits: Previously Diagnosed Asthma (ages 2 - 17) (could have used NQF# 1381 Asthma Emergency Department Visits)
– Fall Prevention (could have used NQF #35 Fall Risk Management)
51
A few homegrown measures are designed to give providers flexibility and options
20 “provider choice” measures: measures that give the provider an option with regard to the measurement tool or outcome– Quality of Life: provider selects a validated tool– Percentage of patients 18 years of age and older receiving
depression screening through the use of PHQ-2 or other approved screening instruments
– Activities of Daily Living: Provider selects a validated assessment tool
18 of these measures came from Texas and 2 came from MA PCMH
These types of measures could become standardized but are not traditional measures at this point
52
Some homegrown measures attempt to fill a measurement gap 22 care management measures: measures related to care
transitions, care management or patient self-management– Percent of patients in the highest risk registry who have a
documented self-management goal– Post-discharge follow-up
11 cost measures:– Cost of care: PMPM rolling annual cost total and by service
category– Cost savings from improved chronic care coordination and
management 14 unique measures:
– Advance directives determination (Do Not Resuscitate)– Functional status assessment for knee replacement– Mental health admissions and readmissions to criminal justice
settings such as jails or prisons
53
Do homegrown measures represent innovation? “Innovative” measures are measures that are not NQF
endorsed and:a. address an important health care concern that is not
addressed in most state measure sets, e.g., • Care coordination• Care management/ transitions• Cost• End-of-life care/ hospice/ palliative care
b. address an issue/condition for which few measures are commonly employed, e.g., • Dementia• Dental care• Depression• Maternal health
• Patient self-management• Procedure-specific quality
concerns• Social determinants of health
• Mental health• Pain• Quality of life• Substance abuse
54
Finding #7: Most homegrown measures are not innovative
Non-innovative homegrown measures
149
Innovative measures that are
not homegrown
23
Innovative homegrown measures
53
But most innovative measures are homegrown
Note: The numbers on this slide vary slightly from the others since we have added the four additional homegrown innovative measures from MN AF4Q.
55
Innovative measures We identified 76 innovative measures across 50 measure
sets – 48 measures sets from the state measure set analysis– 2 additional regional collaborative measure sets
• Minnesota AF4Q• Oregon AF4Q
20 of the measure sets included at least one innovative measure– 35% of MA PCMH measures were innovative (17)– 31% of MN SQRMS measures were innovative (4)– 25% of MA MBHP measures were innovative (2)– 16% of TX Delivery System Reform Incentive Program measures
were innovative (17) Some of the innovative measures may simply be
“measure concepts” that are not ready for implementation.
56
Examples of innovative measures
% of hospitalized patients who have clinical, telephonic or face-to-face follow-up interaction with the care team within 2 days of discharge during the measurement month (MA PCMH)
Patient visits that occur with the selected provider/care team (ID PCMH)
Cost savings from improved chronic care coordination and management (IA dually eligible program)
Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons (TX DSRIP)
Mental and physical health assessment within 60 days for children in DHS custody (OR CCO)
57
Innovation across the measure sets
0
4
8
12
1617 17
6 5 4 4 3 3 3 2 2 2 2 1 1 1 1 1 1
58
There appears to be a need for new measures in certain areas
self-m
anag
emen
tco
st
care
coord
inatio
nde
ntal
proce
dure-
spec
ific
quali
ty of
life
subs
tance
abus
e
depre
ssion
materna
l hea
lth
cons
isten
t care
prov
ider
mental
healt
h
socia
l dete
rmina
nts other
02468
10121416 15
1110
76
4 43 3
2 2 2
8
59
Other measures: Bundles and composites
Bundles are combinations of measures that use an “all-or-nothing” approach. In order to achieve success on the bundle, the entity must successfully meet the target on each of the component pieces of the measure.
Composites are combinations of measures in which the various components are averaged in some fashion to yield an overall view of performance on the group of measures.
These are considered separate from the modified measures
60
Other: Some organizations create their own bundles and composites
There are two standard bundles that were used by some programs:– Optimal Diabetes Care bundle (NQF #729)– Optimal Vascular Care bundle (NQF #76)
There were 39 non-standard bundles and composites used across 6 programs – 15 CA Office of the Patient Advocate (HMO)– 14 CA Office of the Patient Advocate (PPO)– 6 CA Office of the Patient Advocate (medical group)– 2 WI Regional Collaborative – 1 MA MBHP– 1 MN SQRMS
Table of contents
61
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
62
Finding: Regardless of how we analyzed the data, the programs were not aligned We conducted multiple analyses and found non-alignment
persisted across:– Program types– Program purposes– Domains, and– A review of sets within CA and MA
The only program type that showed alignment was the Medicaid MCOs – 62% of their measures were shared – Only 3 measures out of 42 measures were not HEDIS measures
California also showed more alignment than usual – This may be due to state efforts or to the fact that three of the
seven CA measure sets were created by the same entity.
63
4. Analyzing the measures by program type
Goals: To analyze the measures by provider type and answer
the following questions:1. What is the average size of the measure sets by program type?2. To what extent do programs of the same type use the same
measures?3. To what extent are the measures NQF-endorsed?4. What are the most frequently used measures within each
program type?
64
Selected four measure set types for analysis
PCMH
Other p
rovide
r
Medica
id MCO
Medica
id ACO
Commerc
ial P
lans
Health
Hom
e
Region
al Coll
abora
tive
Alignm
ent In
itiativ
eDua
ls
Excha
nge
Medica
id BH M
COMCO
0
2
4
6
8
10
12
14 13
65
3 3 3 3 32 2 2 2
1
65
Finding: Not as much sharing within program type as expected
Medica
id MCO
PCMH
All mea
sures
Region
al Coll
abora
tive
Other p
rovide
r0%
10%20%30%40%50%60%70% 62%
34%
20%13% 12%
We had anticipated that programs of the same type would use the same measures
We found that except for Medicaid MCOs which share more than other types, this was generally not the case
66
Summary of program type analysis
Program Type Average number of measures in the set
Number of distinct measures
Percent of distinct measures NQF- endorsed
All measures 29 509 32%
PCMH 20 116 41%
Medicaid MCO 19 42 55%
Other provider 46 222 49%Regional collaborative 25 56 64%
67
PCMH measures
267 measures across 13 measure sets– Average of 20 measures per set (range: 6-48)– All of the PCMH programs except for one modified at least
one of its measures
116 distinct measures
13 programs located in the following states:– Idaho, Massachusetts, Maryland, Maine, Michigan,
Minnesota, Missouri, Pennsylvania, Rhode Island, Washington
68
PCMH: Greater percentage shared but still many used in only one set
Not shared66%
Shared34%
Number of distinct PCMH measures shared by multiple measure sets
n = 116
69
PCMH: Majority of measures implemented are NQF-endorsed
NQF- endorsed
68%-No longer NQF en-dorsed
5%
Never NQF-
endorsed27%
Percentage of total measures that are NQF- endorsedn = 267
70
PCMH: But less than half of the distinct measures are NQF-endorsed
NQF- endorsed
41%
No longer NQF-
endorsed4%
Never NQF-
endorsed55%
Percentage of distinct PCMH measures that are NQF-endorsed
n = 116
71
Most frequently used PCMH measures# programs modifying the measure
Measure Name Steward NQF #
9 CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS) 599 Controlling High Blood Pressure NCQA (HEDIS) 189 Tobacco Use: Screening & Cessation Intervention AMA 28
8 Body Mass Index (BMI) Screening and Follow-Up CMS 421
8 Cardiovascular Disease: Blood Pressure Management <140/90 mmHg NCQA (HEDIS) 61
8 CDC: HbA1c Control (<8.0%) NCQA (HEDIS) 575
8 Colorectal Cancer Screening NCQA (HEDIS) 34
8 Use of Appropriate Medications for Asthma NCQA (HEDIS) 36
7 Breast Cancer Screening NCQA (HEDIS)31 (no longer
endorsed)
7 Cardiovascular Disease: LDL Cholesterol Management <100 mg/dl (CMC) NCQA (HEDIS) 64
72
Medicaid Managed Care Organization (MCO) measures
111 measures across 6 measure sets– Average of 19 measures per set (range: 6-42)
42 distinct measures– All except for 3 homegrown measures come from HEDIS
All except one program modified measures
6 Medicaid MCO programs included in analysis:– California, California (specialty plans), Florida, Illinois,
Massachusetts, Pennsylvania
73
Medicaid MCO: Share more measures than they don’t share
Not shared38%
Shared62%
Number of distinct Medicaid MCO measures shared by multiple measure sets
n = 42
74
Medicaid MCO: Most of the measures implemented are NQF-endorsed
NQF- endorsed
69%
No longer NQF-
endorsed4%
Never NQF- endorsed
27%
Percentage of Medicaid MCO measures that are NQF-endorsed
n = 111
75
Medicaid MCO: Majority of distinct measures are also NQF-endorsed
NQF- endorsed
55%No longer NQF-
endorsed5%
Never NQF-
endorsed40%
Percentage of distinct Medicaid measures that are NQF-endorsed
n = 42
76
Most frequently used Medicaid MCO measures
# programs modifying the measure
Measure Name Steward NQF #
5 Controlling High Blood Pressure NCQA (HEDIS) 18
4 Adolescent Well-Care Visits NCQA (HEDIS) NA
4 Breast Cancer Screening NCQA (HEDIS)31 (no longer
endorsed)4 CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS) 59
4 CDC: LDL-C Control <100 mg/dL NCQA (HEDIS) 64
4 Childhood Immunization Status NCQA (HEDIS) 38
4 Prenatal and Postpartum Care NCQA (HEDIS) 1517
4 Well-Child Visits in the 3rd, 4th, 5th, & 6th Years of Life NCQA (HEDIS) 1516
77
Other provider measures
276 measures across 6 measure sets– Average of 46 measures per set (range: 5-108)
222 distinct measures
All of the provider programs modified at least one of its measures
6 Other provider programs included in analysis:– California, Massachusetts GIC, Massachusetts PCPRI, PA
provider P4P program, TX Delivery System Reform Incentive Program, and Utah’s Department of Health reporting system
78
Other provider: Very small percentage shared
Not shared88%
Shared12%
Number of distinct provider measures shared by multiple measure sets
n = 222
79
Other provider: Most of the measures implemented are NQF-endorsed
NQF- endorsed
54%
-No longer NQF endorsed
7%
Never NQF- endorsed
39%
Percentage of Medicaid measures that are NQF-endorsed
n = 276
80
Other provider: Just under half of the distinct measures are NQF-endorsed
NQF- endorsed
49%
-No longer NQF endorsed
5%
Never NQF-
endorsed46%
Percentage of distinct provider measures that are NQF-endorsed
n = 222
81
Other provider: Most frequently used measures# programs modifying the measure
Measure Name Steward NQF #
6 Breast Cancer Screening NCQA (HEDIS)31 (no longer
endorsed)5 Cervical Cancer Screening NCQA (HEDIS) 32
4 CDC: HbA1c Testing NCQA (HEDIS) 57
4 CDC: Medical Attention for Nephropathy NCQA (HEDIS) 62
3 Controlling High Blood Pressure NCQA (HEDIS) 18
3 Chlamydia Screening in Women NCQA (HEDIS) 33
3 CDC: LDL-C Screening NCQA (HEDIS) 63
3 Annual Monitoring for Patients on Persistent Medications NCQA (HEDIS)
21 (no longer
endorsed)
3Cholesterol Management for Patients with Cardiovascular Conditions (LDL-C Screening & LDL-C Control (< 100 mg/dL))
NCQA (HEDIS) NA
82
Regional collaborative measures
75 measures across only 3 studied measure sets– Average of 25 measures per set (range: 10-37)
56 distinct measures
Two out of the three collaboratives modified at least one of its measures
3 Regional collaboratives included in the analysis:– Maine Health Management Coalition, HealthInsight Utah,
Wisconsin Collaborative for Healthcare Quality
83
Regional collaborative: Very small percentage shared
Not shared88%
Shared13%
Number of distinct regional collaborative measures shared by multiple measure sets
n = 56
84
Regional collaborative: Most of the measures implemented are NQF-endorsed
NQF- endorsed
73%
No longer NQF-
endorsed2%
Never NQF-
endorsed25%
Percentage of regional collaborative measures that are NQF-endorsed
n = 75
85
Regional collaborative: Most distinct measures are NQF-endorsed
NQF- endorsed
64%
No longer NQF-
endorsed2%
Never NQF- endorsed
34%
Percentage of distinct regional collaborative measures that are NQF-endorsed
n = 56
86
7 shared regional collaborative measures# programs modifying the measure
Measure Name Steward NQF #
2 CDC: Blood Pressure Control (<140/90 mm Hg) NCQA (HEDIS) 61
2 CDC: HbA1c Control (<8.0%) NCQA (HEDIS) 575
2 CDC: Hemoglobin-A1c Testing NCQA (HEDIS) 57
2 CDC: LDL-C Control <100 mg/dL NCQA (HEDIS) 64
2 CDC: LDL-C Screening NCQA (HEDIS) 63
2 CDC: Medical Attention for Nephropathy NCQA (HEDIS) 62
2 Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention AMA-PCPI 28
87
Conclusions from measure-type analysis
Surprised that there is not more overlap of measures within measure set type
Medicaid MCOs are the exception and share far more measures than any other type of program. – This is partially because they rely almost exclusively on the
HEDIS measures. The “other provider” focused measures sets tend to
be larger on average and there is less sharing across the provider measure sets
The interest in modifying was not limited to one type While most of the implemented measures are NQF-
endorsed, many of the distinct measures used are not endorsed
Table of contents
88
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
89
5. Analyzing the measures by program purpose
Goals: To analyze the measures by provider purpose and
answer the following questions:1. What is the average size of the measure sets by program
purpose?2. To what extent do programs designed for the same purpose use
the same measures?3. To what extent are the measures NQF endorsed?4. What are the most frequently used measures within each
program purpose?
90
Selected two measure set purposes for analysis
Reporting Payment (and reporting)
Reporting and other purpose
Other0
5
10
15
20
2522
19
5
2
91
Finding: More sharing within reporting programs than in payment
Reporting Payment All measures0%
5%
10%
15%
20%
25%
30%
35%
40%
45%39%
26%
20%
We had anticipated that the payment programs would use more similar measures, but we found that was not the case.
92
Finding: Not as much use of NQF measures for payment as expected
Reporting Payment All measures0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
37% 36%32%
We had anticipated that the payment programs would use mostly NQF endorsed measures, but we found that was not the case.
93
Summary of program purpose analysis
Program Type
Number of programs included in category
Average number of measures in the set
Number of distinct measures
Percent of distinct measures NQF endorsed
All measures 48 29 509 32%Reporting measures 22 22 157 37%
Payment measures 19 30 250 36%
94
Measures for reporting
490 measures across 22 measure sets– Average of 22 measures per set (range: 5-50)
157 distinct measures
82% of the programs modified at least one of their measures
95
Reporting: More sharing than the general analysis
Not shared61%
Shared39%
Number of distinct reporting measures shared by multiple measure sets
n = 157
96
Reporting: The majority of implemented reporting measures are NQF-endorsed
NQF- endorsed
70%
-No longer NQF en-dorsed
7%
Never NQF- endorsed
23%
Percentage of reporting measures that are NQF-endorsed
n = 490
97
Reporting: Most of the distinct measures are not endorsed
NQF- endorsed
37%
-No longer NQF en-dorsed
6%
Never NQF-
endorsed57%
Percentage of distinct reporting measures that are NQF-endorsed
n = 157
98
Most frequently used reporting measures# programs modifying the measure
Measure Name Steward NQF #
16 CDC: Hemoglobin A1c (HbA1c) Control (<8.0%) NCQA HEDIS 575
15 CDC: LDL-C Control <100 mg/dL NCQA HEDIS 64
14 Controlling High Blood Pressure NCQA HEDIS 18
14 CDC: Blood Pressure Control (<140/90 mm Hg) NCQA HEDIS 61
14 CDC: Medical Attention for Nephropathy NCQA HEDIS 62
13 CDC: Hemoglobin-A1c Testing NCQA HEDIS 57
13 Breast Cancer Screening NCQA HEDIS31 (no longer
endorsed)12 CDC: LDL-C Screening NCQA HEDIS 63
11 Cervical Cancer Screening NCQA HEDIS 32
11 CDC: Eye Exam NCQA HEDIS 55
99
Measures for payment
563 measures across 19 measure sets– Average of 30 measures per set (range: 3-108)
250 distinct measures
All except two of the measure sets used for payment modified at least one of their measures
100
Payment: Shares slightly more than the general, but less than the reporting
Not shared74%
Shared26%
Number of distinct payment measures shared by multiple measure sets
n = 250
101
Payment: Most implemented measures are NQF-endorsed
NQF- endorsed
64%No longer
NQF- endorsed
4%
Never NQF- endorsed
32%
Percentage of payment measures that are NQF-endorsed
n = 563
102
Payment: …but most distinct measures are not NQF-endorsed
NQF- endorsed
36%
No longer NQF-
endorsed3%
Never NQF- endorsed
61%
Percentage of distinct payment measures that are NQ- endorsed
n = 250
103
Most frequently used payment measures# programs modifying the measure
Measure Name Steward NQF #
13 Breast Cancer Screening NCQA (HEDIS)31 (no longer
endorsed)12 Controlling High Blood Pressure NCQA (HEDIS) 18
10 Cervical Cancer Screening NCQA (HEDIS) 32
10 Follow-Up After Hospitalization for Mental Illness (7 day rate only) NCQA (HEDIS) 576
9 Use of Appropriate Medications for Asthma NCQA (HEDIS) 36
9 Childhood Immunization Status NCQA (HEDIS) 38
9 CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS) 59
9 Screening for Clinical Depression and Follow-up Plan CMS (PQRI 134) 418
Table of contents
104
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
105
Summary of domain analysis
Domain Total # of measures
#of distinct
measures
% of measures
shared
% of distinct measures
NQF- endorsed
# of programs that share the
most frequently
used measureAccess, affordability, and inappropriate care 120 55 21% 24% 12
Communication and care coordination 32 26 12% 25% 4
Health and well-being 371 70 40% 44% 30Infrastructure 23 20 0 0 0Person and family-centered care 127 58 5% 12% 16
Safety 181 95 16% 34% 19Treatment and secondary prevention 448 143 25% 49% 29
Utilization 65 38 8% 3% 9
106
6. Access, affordability, and inappropriate care
120 access, affordability, and inappropriate care (AAIC) measures– Only 4% were modified
55 distinct measures
107
AAIC: Many measures used by only one program
Not shared79%
Shared21%
Number of distinct AAIC measures shared by multiple measure sets
n = 55
108
AAIC: Exactly half of the measures are NQF endorsed
NQF- endorsed
50%
Never NQF-
endorsed50%
Percentage of total AAIC measures that are NQF-endorsed
n = 120
109
AAIC: …but most of the distinct measures are not endorsed
NQF- endorsed
24%
Never NQF- endorsed
76%Percentage of distinct AAIC measures that
are NQF-endorsedn =55
110
Most frequently used AAIC measures# programs modifying the measure
Measure Name Steward NQF #
12 Appropriate Testing for Children With Pharyngitis NCQA (HEDIS) 2
11 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis NCQA (HEDIS) 58
10 Appropriate Treatment for Children with Upper Respiratory Infections NCQA (HEDIS) 69
7 Child and Adolescent Access to Primary Care Practitioners (12-14, 25mo-6yr, 7-11, 12-19) HEDIS NCQA (HEDIS) NA
7 Use of Imaging Studies for Low Back Pain NCQA (HEDIS) 52
6 Adult Access to Preventive/Ambulatory Health Services NCQA (HEDIS) NA
6 Use of Spirometry Testing in the Assessment and Diagnosis of COPD NCQA (HEDIS) 577
4 PC-01 Elective Delivery The Joint Commission 469
3 Cesarean Rate for Low-Risk First Birth Women AHRQ/CHIRPA NA
3 Third Next Available Appointment NCQA Standard NA
111
Communication and care coordination
32 communication and care coordination measures– None of the measures were modified
26 distinct measures
112
Communication: Most distinct measures used by only one program
Not shared88%
Shared12%
Number of distinct communication measures shared by multiple measure sets
n = 26
113
Communication: Most measures used are not NQF-endorsed
NQF- en-
dorsed36%
No longer NQF endorsed
9%
Never NQF- endorsed
55%
Percentage of total communication measures that are NQF-endorsed
n = 33
114
Communication: Most of the distinct measures are not NQF-endorsed
NQF- endorsed
25%
No longer NQF-
endorsed11%
Never NQF- endorsed
64%
Percentage of distinct communication measures that are NQF-endorsed
n = 26
115
Communication measures shared across programs# programs modifying the measure
Measure Name Steward NQF #
4 Care Transition — Transition Record Transmitted to Health Care Professional AMA-PCPI 648
2 3-Item Care Transition Measure (CTM-3)University of Colorado Health Sciences Center
228
2Medication reconciliation after discharge from an inpatient facility NCQA (HEDIS) 97
116
Health and well-being measures
371 health and well-being measures– None of the measures were modified
70 distinct measures
117
Health and well-being: Greater number of measures shared
Not shared60%
Shared40%
Number of distinct health and well-being measures shared by multiple measure sets
n = 70
118
Health and well-being: Most measures used are NQF-endorsed
NQF- endorsed
73%
No longer NQF-
endorsed9%
Never NQF- endorsed
18%
Percentage of total health and well-being measures that are NQF-endorsed
n = 371
119
Health and well-being: Most of the distinct measures are not endorsed
NQF- endorsed
44%
No longer NQF- endorsed
6%
Never NQF-
endorsed50%
Percentage of distinct health and well-being measures that are NQF-endorsed
n = 70
120
Most frequently used health and well-being measures# programs modifying the measure
Measure Name Steward NQF #
30 Breast Cancer Screening NCQA (HEDIS)31 (no longer
endorsed)24 Cervical Cancer Screening NCQA (HEDIS) 32
21 Childhood Immunization Status NCQA (HEDIS) 3819 Colorectal Cancer Screening NCQA (HEDIS) 34
17 Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention AMA-PCPI 28
17 Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents NCQA (HEDIS) 24
15 Chlamydia Screening NCQA (HEDIS) 33
15 Maternity Care: Postpartum Care (PPC), Prenatal Visit During 1st Trimester (PPC) NCQA (HEDIS) 1517
14 Adolescent Well-Care Visits NCQA (HEDIS) NA
14 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: Composite NCQA (HEDIS) 4
14 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up CMS 421
121
Infrastructure measures
23 Infrastructure measures– None of the measures were modified – 87% of the measures were homegrown
20 distinct measures
122
Examples of infrastructure measures
MO Medicaid managed care - BH measures– Adult psychiatrist count– Psychiatric practices contacted to complete survey
regarding patient services, services provided, service availability
Oregon CCO Incentive Measures Set– Electronic health record adoption
NY Medicaid Redesign Initiative– Percent eligibility determination done at state level
MiPCT Clinical Metrics– PCMH registry with decision support & performance reports
123
Infrastructure: No measures shared
Not shared100%
Number of distinct Infrastructure measures shared by multiple measure sets
n = 20
124
Infrastructure: None of the measures are NQF-endorsed
Never NQF-
endorsed100%
Percentage of infrastructure measures that are NQF-endorsed
n = 23
125
Person and family-centered care measures
127 person and family-centered care measures– Only 4% of the measures were modified
58 distinct measures
126
Person and family-centered care: Very small number of measures shared
Not shared95%
Shared5%
Number of distinct person and family-centered care measures shared by multiple measure sets
n = 58
127
Person and family-centered care: Most measures are NQF-endorsed
NQF- endorsed
59%
No longer NQF-
endorsed1%
Never NQF-
endorsed40%
Percentage of total person and family-centered care measures that are NQF-endorsed
n = 127
128
Person and family-centered care: Most of the distinct measures are not NQF-endorsed
NQF- endorsed12% No longer NQF-
endorsed2%
Never NQF- endorsed
86%Percentage of distinct person and family-
centered care measures that are NQF-endorsedn = 58
129
Shared person and family-centered care measures# programs using the measure
Measure Name Steward NQF #
16 CAHPS Survey1 AHRQ YES
2 Hospice and Palliative Care – Treatment Preferences
University of North Carolina-Chapel Hill
1641
2 Quality of Life survey: choice of tool NA NA
1: If a program used one question from a CAHPS survey, we counted it as using CAHPS. We did not look at the specific surveys or which questions/composites from the surveys they used.
130
Safety measures
181 safety measures– 17% of the measures were modified
95 distinct measures
131
Safety: Most measure used by only one program
Not shared84%
Shared16%
Number of distinct safety measures shared by multiple measure sets
n = 95
132
Safety: Most measures used are NQF-endorsed
NQF- endorsed
55%
No longer NQF-
endorsed12%
Never NQF- endorsed
33%
Percentage of total safety measures that are NQF-endorsed
n = 181
133
Safety: Most of the distinct measures are not NQF-endorsed
NQF- endorsed
34%
-No longer NQF en-dorsed
4%
Never NQF-
endorsed62%
Percentage of distinct safety measures that are NQF-endorsed
n = 95
134
Most frequently used safety measures# programs using the measure
Measure Name Steward NQF #
19 Follow-Up After Hospitalization for Mental Illness (30 day only) NCQA (HEDIS) 576
11 Annual Monitoring for Patients on Persistent Medications NCQA (HEDIS) 21 (no longer
endorsed)
9 Plan All-Cause Readmission NCQA (HEDIS) 1768
6 Chronic Obstructive Pulmonary Disease - Admission Rate AHRQ (PQI) 275
6 Heart Failure Admission Rate (PQI 8) AHRQ (PQI) 277
6 Pharmacotherapy Management of COPD Exacerbation (bronchodilator only) NCQA (HEDIS)
549 (no longer
endorsed)5 Medication Management for People With Asthma NCQA (HEDIS) 1799
4 Asthma in Younger Adults Admission Rate (PQI 15) AHRQ (PQI) 283
4 Hospital-Wide All-Cause Unplanned Readmission Measure (HWR) Yale/CMS 1789
3 Diabetes Short-Term Complications Admission Rate AHRQ (PQI) 272
135
Treatment measures, including treatment and secondary prevention measures
448 treatment and secondary prevention measures– 23% of the measures were modified
143 distinct measures
136
Treatment and secondary prevention: Larger percentage shared than in other domains
Not shared75%
Shared25%
Number of distinct treatment and secondary prevention measures shared by multiple measure sets
n = 143
137
Treatment and secondary prevention: Very high percentage of measures are NQF-endorsed
NQF- endorsed
77%
No longer NQF-
endorsed3%
Never NQF- endorsed
20%
Percentage of total treatment and secondary prevention measures that are NQF-endorsed
n = 448
138
Treatment and secondary prevention: Only half of distinct measures are NQF-endorsed
NQF- endorsed
49%
-No longer NQF endorsed
6%
Never NQF-
endorsed45%
Percentage of distinct treatment and secondary prevention measures that are NQF endorsed
n = 143
139
Most frequently used treatment and secondary prevention measures# programs using the measure
Measure Name Steward NQF #
29 Controlling High Blood Pressure NCQA (HEDIS) 18
23 CDC: Hemoglobin A1c (HbA1c) Control (<8.0%) NCQA (HEDIS) 575
23 CDC: LDL-C Control <100 mg/dL NCQA (HEDIS) 64
21 Use of Appropriate Medications for Asthma NCQA (HEDIS) 36
20 CDC: Medical Attention for Nephropathy NCQA (HEDIS) 62
20 CDC: Blood Pressure Control (<140/90 mm Hg) NCQA (HEDIS) 61
19 CDC: Hemoglobin-A1c Testing NCQA (HEDIS) 57
18 CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS) 59
17 CDC: LDL-C Screening NCQA (HEDIS) 63
17Cholesterol Management for Patients with Cardiovascular Conditions (LDL-C Screening & LDL-C Control (< 100 mg/dL))
NCQA (HEDIS) NA
140
Most frequently used treatment and secondary prevention measures# programs using the measure
Measure Name Steward NQF #
16 CDC: Eye Exam NCQA (HEDIS) 55
13 Follow-Up Care for Children Prescribed ADHD Medication NCQA (HEDIS) 108
13 Antidepressant Medication Management NCQA (HEDIS) 105
8 Comprehensive Diabetes Care (Composite Measure)NCQA (HEDIS) 731
6 Persistence of Beta-Blocker Treatment After a Heart Attack NCQA (HEDIS) 71
6 Disease Modifying Anti-rheumatic Drug (DMARD) Therapy in Rheumatoid Arthritis NCQA (HEDIS) 54
6 Diabetes Care Foot Exam NCQA (HEDIS) 56
6 Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100 mg/dL NCQA (HEDIS) 75
5Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction
AMA-PCPI 81
141
Utilization measures
65 utilization measures– 17% of the measures were modified
38 distinct measures
142
Utilization: Larger percentage not shared than in other domains
Not shared92%
Shared8%
Number of distinct utilization measures shared by multiple measure sets
n = 38
143
Utilization: Very high percent of measures are NQF-endorsed
NQF- endorsed
77%
No longer NQF-
endorsed3%
Never NQF- endorsed
20%
Percentage of total utilization measures that are NQF-endorsed
n = 65
144
Utilization: Only one distinct measure is NQF-endorsed
NQF endorsed3%
Never NQF endorsed
97%Percentage of distinct utilization measures that are
NQF endorsedn = 38
145
Shared utilization measures# programs using the measure
Measure Name Steward NQF #
9 Ambulatory Care NCQA (HEDIS) NA
6 Asthma Emergency Department VisitsAlabama Medicaid Agency
1381
2 Mental Health Utilization NCQA (HEDIS) NA
146
Conclusions from domain analysis
Programs select measures from the same domains, with an emphasis on the Treatment and Secondary Prevention and the Health and Well-being domains
However, programs are not picking the same measures within those domains
Simply specifying the domains from which programs should select measures will not facilitate measure set alignment
147
Measures by clinical areas of interest
01020304050 44 42 41 40
21 18 17 16 14 12
Distinct measures
148
Summary of clinical areas of interest analysis
Clinical area of interest # of distinct measures# of programs that share the most frequently used
measureBehavioral health 44 19
Diabetes measures 42 23Cardiovascular measures 41 29
Pulmonary/critical care 40 21
Cancer-related 12 30
149
44 behavioral health measures by category
0
4
8
1213
97 7
53
Distinct measures
150
Shared behavioral health measures# programs using the measure
Measure Name Steward NQF #
19 Follow-Up After Hospitalization for Mental Illness NCQA (HEDIS) 576
17 Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention AMA-PCPI 28
14 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment NCQA (HEDIS) 4
13 Antidepressant Medication Management NCQA (HEDIS) 105
13 Follow-Up Care for Children Prescribed ADHD Medication NCQA (HEDIS) 108
12 Screening for Clinical Depression CMS 418
2 Depression Remission at Six Months MN Community Measurement 711
2 Medical Assistance With Smoking and Tobacco Use Cessation
NCQA (CAHPS) 27
151
Most frequently used diabetes measures# programs using the measure
Measure Name Steward NQF #
23 CDC: LDL-C Control <100 mg/dL NCQA (HEDIS) 64
23 CDC: Hemoglobin A1c (HbA1c) Control (<8.0%) NCQA (HEDIS) 575
20 CDC: Blood Pressure Control (<140/90 mm Hg) NCQA (HEDIS) 61
20 CDC: Medical Attention for Nephropathy NCQA (HEDIS) 62
19 CDC: Hemoglobin-A1c Testing NCQA (HEDIS) 57
18 CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS) 59
17 CDC: LDL-C Screening NCQA (HEDIS) 63
16 CDC: Eye Exam NCQA (HEDIS) 55
8 Comprehensive Diabetes Care (Composite Measure) NCQA (HEDIS) 731
6 Diabetes Care Foot Exam NCQA (HEDIS) 56
152
Most frequently used diabetes measures (cont’d)# programs using the measure
Measure Name Steward NQF #
3 Diabetes Short-Term Complications Admission Rate (PQI 1) AHRQ (PQI) 272
3 Uncontrolled Diabetes Admission Rate (PQI 14) AHRQ (PQI) 638
3 Optimal diabetes care (ODC) (bundle) MN Community Measurement 729
2 Diabetes Long Term Complications Admission Rate- (PQI 3) AHRQ (PQI) 274
2 Comprehensive Diabetes Care: Blood Pressure Control (<140/80 mm Hg) NCQA (HEDIS) NA
2 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<7.0%) NCQA (HEDIS) NA
153
41 cardiovascular disease measures by category
0
4
8
1213
9 8
4 4 3
Distinct measures
154
Shared cardiovascular disease measures# programs using the measure
Measure Name Steward NQF #
29 Controlling High Blood Pressure NCQA (HEDIS) 18
17 Cholesterol Management for Patients with Cardiovascular Conditions NCQA (HEDIS) NA
6 Persistence of Beta-Blocker Treatment After a Heart Attack NCQA (HEDIS) 71
6 Heart Failure Admission Rate (PQI 8) AHRQ (PQI) 277
6 Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100 mg/dL NCQA (HEDIS) 75
5 Heart Failure: ACE Inhibitor or ARB Therapy for LVSD AMA-PCPI 81
4 Hypertension: Blood Pressure Measurement NCQA (HEDIS) 13 (no longer endorsed)
3 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic NCQA (HEDIS) 68
3 Ischemic Vascular Disease (IVD): Blood Pressure Control NCQA (HEDIS) 73
2 Heart Failure : Beta-blocker therapy for LVSD AMA-PCPI 83
2 Optimal Vascular Care (OVC) (bundle) MN Community Measurement
76
155
40 pulmonary/critical care measures by category
Asthma COPD Pneumonia0
5
10
15
20
25
30 28
9
3
Distinct measures
156
Shared pulmonary/critical care measures# programs using the measure
Measure Name Steward NQF #
21 Use of Appropriate Medications for Asthma NCQA (HEDIS) 36
6 Asthma Emergency Department VisitsAlabama Medicaid Agency
1381
6 Use of Spirometry Testing in the Assessment and Diagnosis of COPD
NCQA (HEDIS) 577
6 Chronic Obstructive Pulmonary Disease - Admission Rate (PQI 5) AHRQ (PQI) 275
6 Pharmacotherapy Management of COPD Exacerbation NCQA (HEDIS)
549 (no longer
endorsed)5 Medication Management for People With Asthma NCQA (HEDIS) 1799
4 Asthma in Younger Adults Admission Rate (PQI 15) AHRQ (PQI) 283
3 Optimal Asthma Care MN Community Measurement NA
157
12 cancer-related measures
Most measures related to cancer screening Four shared measures
# programs using the measure
Measure Name Steward NQF #
30 Breast Cancer Screening NCQA (HEDIS) 31 (no longer endorsed)
24 Cervical Cancer Screening NCQA (HEDIS) 32
19 Colorectal Cancer Screening NCQA (HEDIS) 34
2“Checking for Cancer” Composite: Breast Cancer Screening, Cervical Cancer Screening, Colorectal Cancer Screening
NCQA (HEDIS) NA
Table of contents
158
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
159
7. Summary of intrastate analysis
State # of programs
Total # of measures
# of distinct
measures
% of measures
shared
% of distinct measures
NQF- endorsed
% of programs that share the most
frequently used
measure
California 7 231 64 69% 59% 86%Massachusetts 8 334 214 24% 59% 75%All measures 48 1367 509 20% 32% 63%
160
California measures
231 measures across 7 measure sets– Average of 33 measures per set (range: 6-51)
64 distinct measures
All of the CA programs modified at least one of their measures
Three of the 7 sets were created by the Office of the Patient Advocate
161
California: Significantly more alignment than typical
Not shared31%
Shared69%
Number of distinct CA measures shared by multiple measure sets
n = 64
162
California: Uses mostly NQF measures
NQF- endorsed
77%
-No longer NQF endorsed
8%
Never NQF- endorsed
15%
Percentage of CA measures that are NQF- endorsedn = 276
163
California: Most of the distinct measures are NQF-endorsed too
NQF- endorsed
59%
No longer NQF-
endorsed5%
Never NQF- endorsed
36%
Percentage of distinct CA measures that are NQF-endorsed
n = 64
164
Most frequently used CA measures# programs modifying the measure
Measure Name Steward NQF #
6 Annual Monitoring for Patients on Persistent Medications
NCQA (HEDIS)
21 (no longer
endorsed)6 Avoidance of Antibiotic Treatment in Adults with Acute
BronchitisNCQA (HEDIS) 58
6 Breast Cancer Screening NCQA (HEDIS)
31 (no longer
endorsed)6 CDC: Blood Pressure Control (<140/90 mm Hg) NCQA
(HEDIS) 61
6 CDC: Hemoglobin A1c (HbA1c) Control (<8.0%) NCQA (HEDIS) 575
6 CDC: Hemoglobin-A1c Testing NCQA (HEDIS) 57
6 CDC: LDL-C Control <100 mg/dL NCQA (HEDIS) 64
165
Most frequently used CA measures (cont’d)# programs modifying the measure
Measure Name Steward NQF #
6 CDC: LDL-C Screening NCQA (HEDIS) 63
6 CDC: Medical Attention for Nephropathy NCQA (HEDIS) 62
6 Cervical Cancer Screening NCQA (HEDIS) 32
6 Cholesterol Management for Patients with Cardiovascular Conditions
NCQA (HEDIS) NA
6 Controlling High Blood Pressure NCQA (HEDIS) 18
6 Use of Imaging Studies for Low Back Pain NCQA (HEDIS) 52
166
Massachusetts measures
334 measures across 8 measure sets– Average of 42 measures per set (range: 8-99)
214 distinct measures
6 of the 8 MA sets modified at least one of their measures
167
Massachusetts: Less alignment than CA
Not shared76%
Shared24%
Number of distinct MA measures shared by multiple measure sets
n = 214
168
Massachusetts: Most measures are NQF-endorsed
NQF- endorsed
70%
-No longer NQF en-dorsed
7%
Never NQF- endorsed
23%
Percentage of MA measures that are NQF- endorsedn = 334
169
Massachusetts: Most of the distinct measures are NQF-endorsed too
NQF- endorsed
59%
-No longer NQF en-dorsed
7%
Never NQF- endorsed
34%
Percentage of distinct provider measures that are NQF-endorsed
n = 214
170
Most frequently used MA measures# programs modifying the measure
Measure Name Steward NQF #
6 Breast Cancer Screening NCQA (HEDIS)
31 (no longer
endorsed)
6 Follow-Up After Hospitalization for Mental Illness NCQA (HEDIS) 576
6 Use of Appropriate Medications for Asthma NCQA (HEDIS) 36
5 Cervical Cancer Screening NCQA (HEDIS) 32
5 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
NCQA (HEDIS) 4
4 Annual Monitoring for Patients on Persistent Medications
NCQA (HEDIS)
21 (no longer
endorsed)
4 Screening for Clinical Depression CMS 418
171
Intrastate analysis summary
California has significantly more alignment across its measure sets when compared to Massachusetts and the total measures set.
Part of the reason for the alignment within CA is that three of the seven measure sets were developed by the same organization (Office of the Patient Advocate).
Anecdotally, we have been told that CA has worked to align its measure sets.
While MA has work underway to align its measure sets across the state though the Statewide Quality Committee, currently there is little alignment within the state.
Table of Contents
172
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
173
Summary of findings There are many, many measures in use today.
Current state and regional measure sets are not aligned.
Non-alignment persists despite the tendency to use standard, NQF-endorsed and/or HEDIS measures.
With few exceptions, regardless of how we analyzed the data, the programs’ measures were not aligned. – With the exception of the Medicaid MCO programs, we found
this lack of alignment existed across domains, and programs of the same type or for the same purpose.
– We also found that California has more alignment. This may be due to our sample or the work the state has done to align measures.
174
Summary of findings (cont’d)
While many programs use measures from the same domains, they are not selecting the same measures within these domains.– This suggests that simply specifying the domains from which
programs should select measures will not facilitate measure set alignment.
Even when the measures are “the same,” the programs often modify the traditional specifications for the standard measures.
175
Summary of findings (cont’d)
Many programs create their own “homegrown” measures.– Some of these may be measure concepts, rather than
measures that are ready to be implemented
Unfortunately most of these homegrown measures do not represent true innovation in the measures space.
There appears to be a need for new standardized measures in the areas of self-management, cost, and care management and coordination.
176
Conclusions Bottom line: Measures sets appear to be developed
independently without an eye towards alignment with other sets.
The diversity in measures allows states and regions interested in creating measure sets to select measures that they believe best meet their local needs. Even the few who seek to create alignment struggle due to a paucity of tools to facilitate such alignment.
The result is “measure chaos” for providers subject to multiple measure sets and related accountability expectations and performance incentives. Mixed signals make it difficult for providers to focus their quality improvement efforts.
177
This is only the beginning…
We anticipate that as states and health systems become more sophisticated in their use of electronic health records and health information exchanges, there will be more opportunities to easily collect clinical data-based measures and thus increase selection of those types of measures over the traditional claims-based measures.
Combining this shifting landscape with the national movement to increase the number of providers that are paid for value rather than volume suggests that the proliferation of new measures and new measure sets is only in its infancy.
178
A call to action
In the absence of a fundamental shift in the way in which new measure sets are created, we should prepare to see the problem of unaligned measure sets grow significantly.
179
Recommendations1. Launch a campaign to raise awareness about the current
lack of alignment across measure sets and the need for a national measures framework.– help states and regions interested in creating measure sets
understand why lack of alignment is problematic
2. Communicate with measure stewards to indicate to them when their measures have been frequently modified and why this is problematic.– in particular in the cases in which additional detail has been added,
removed or changed
3. Develop an interactive database of recommended measures to establish a national measures framework.– consisting primarily of the standardized measures that are used
most frequently for each population and domain– selecting and/or defining measures for the areas in which there is
currently a paucity of standardized measures
180
Recommendations (cont’d)
4. Provide technical assistance to states to help them select high-quality measures that both meet their needs and encourage alignment across programs in their region and market. This assistance could include:– a measures hotline– learning collaboratives and online question boards, blogs and/or
listservs – benchmarking resources for the recommended measures
selected for inclusion in the interactive measures tool.
5. Acknowledge the areas where measure alignment is potentially not feasible or desirable. – different populations of focus– program-specific measures
Contact information
Michael Bailit, MBA
• President• mbailit@bailit-heal
th.com• 781-599-4700
Kate Bazinsky, MPH
• Senior Consultant• kbazinsky@bailit-
health.com• 781-599-4704
182
Appendix
Overview of measure sets included in analysis
State Name Type # of measures
NQF-endorsed
Modified Homegrown
AR Arkansas Medicaid Medicaid 14 79% None None
CA CA Medi-Cal Managed Care Division
Medicaid 22 82% 45% 5%
CA CA Medi-Cal Managed Care Division: Specialty Plans
Medicaid 6 50% 67% 33%
CA Office of the Patient Advocate (HMO)
Commercial Plans
50 74% 18% None
CA Office of the Patient Advocate (Medical Group)
Commercial Plans
25 68% 4% None
CA Office of the Patient Advocate (PPO)
Other Provider 44 73% 14% None
183
Overview of measure sets included in analysis (cont’d)
State Name Type # of measures
NQF-endorsed
Modified Homegrown
CA CALPERSCommercial Plans for Public Employees
33 85% 6% None
CA
Quality and Network Management – Quality Reporting System (QRS)
Exchange 51 84% 6% None
COMedicaid's Accountable Care Collaborative
ACO with Primary Care Medical Provider
3 None 33% None
FLMedicaid MCO Procurement Measures
Medicaid MCO 8 75% None None
IA IA Duals Duals 31 65% 10% 10%
IA IA Health Homes Health Home 12 92% None None
184
Overview of measure sets included in analysis (cont’d)
State Name Type # of measures
NQF-endorsed
Modified Homegrown
ID Idaho Medical Home Collaborative PCMH 17 59% 12% None
IL IL Medicaid MCO Medicaid MCO 42 88% 12% None
LA Coordinated Care Networks Medicaid 35 71% 6% 9%
MA MA Connector Exchange 9 67% None None
MA MA Duals Project Duals 42 86% None 5%
MA MA GIC Other Provider 99 60% 16% None
185
Overview of measure sets included in analysis (cont’d)
State Name Type # of measures
NQF-endorsed
Modified Homegrown
MA MA MBHP Behavioral Health MCO P4P 8 38% 13% 38%
MA MA MMCO Medicaid 19 79% 11% None
MA MA PCPRI Other Provider 26 96% 4% None
MA PCMH PCMH 48 52% 56% 44%
MAStatewide Quality Advisory Committee (SQAC)
Alignment Initiative 83 78% 7% 1%
MDMaryland Multi-Payer Pilot Program (MMPP)
PCMH 20 90% 5% None
186
Overview of measure sets included in analysis (cont’d)
State Name Type # of measures
NQF-endorsed
Modified Homegrown
MEMaine Health Management Coalition
Regional Collaborative 28 100% 43% None
ME Maine's PCMH Project PCMH 29 79% 24% 7%
MI
The Michigan Primary Care Transformation Project (MiPCT)
PCMH 36 61% 19% 17%
MN MN AF4Q Innovative measures only NA NA NA NA
MNMN Dept Health (Medicaid) Health Care Home
PCMH 7 86% None None
MN
MN SQRMS: MN Statewide Quality Reporting and Measurement System (SQRMS)
Alignment Initiative 13 46% 15% 8%
187
Overview of measure sets included in analysis (cont’d)
State Name Type # of measures
NQF-endorsed
Modified Homegrown
MO MO BHMCO measures
Medicaid BH MCO 69 3% 4% 94%
MO MO Medicaid Health Home Health Home 41 41% 17% 51%
MOMissouri Medical Home Collaborative (MMHC)
PCMH 9 89% 33% 11%
MTMontana Medical Home Advisory Council
PCMH 13 92% 8% None
NY Medicaid Redesign Initiative Medicaid 38 55% 24% 24%
OH SW OH CPCI PCMH 21 86% 5% None
Overview of measure sets included in analysis (cont’d)
State
Name Type # of measures
NQF-endorsed
Modified Homegrown
OK OK Medicaid Soonercare PCMH 17 65% 18% None
OR CCO's Incentive Measures Set ACO 17 65% 53% 24%
PA Chronic Care Initiative PCMH 34 47% 56% 15%
PA Health Home Care set
Health Home 8 75% None None
PA MCO/Vendor P4P MCO P4P 14 64% 29% None
PA Provider P4P Other Provider 13 62% 31% None
Overview of measure sets included in analysis (cont’d)
State Name Type # of measures
NQF-endorsed
Modified Homegrown
RI RI PCMH (CSI) PCMH 10 80% 100% None
TXTX Delivery System Reform Incentive Program
Other Provider 108 35% 2% 30%
UT UT Dept. of Health Other Provider 5 60% 100% None
UT Health Insight Utah Regional Collaborative 10 100% None None
VT VT ACO Measures Work Group ACO 37 54% 11% None
WA Multi-payer PCMH PCMH 6 67% 67% None
WI WI Regional Collaborative
Regional Collaborative 10 80% 100% None