then & now: 15 years of performance measurement and ... · capaldi | alwyn cassil | john fisher...

Then & Now: 15 Years of Performance Measurement and Benchmarking

© 2018 Integrated Healthcare Association. All rights reserved. 2© 2018 Integrated Healthcare Association. All rights reserved. 2

Then: 2003


Now: 2018


Foundations of Success

Stakeholder governance

Importance of measure alignment, standardized data collection & reporting

Rewarding performance: attainment and improvement

Responsive forum to address industry challenges!


IHA Performance MeasurementM

EASU

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THEN: 2003 NOW: 2018

215 physician organizations2

Grant funded3

1 6 health plans


Health plan funded3

1 9 health plans

STA

KEH

OLD

ER

GO

VER

NA

NCE


Health Plan Participation

Founding Growing


IHA Performance Measurement

12 measures4

No collective performance data5

43 measures4

15 years of aggregated measurement5

MEA

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ATTA

IN &

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THEN: 2003 NOW: 2018


Grant funded3

1 6 health plans


Health plan funded3

1 9 health plans

STA

KEH

OLD

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GO

VER

NA

NCE


• Clinical Quality1. Childhood Immunizations: Combo 22. Breast Cancer Screening3. Cervical Cancer Screening4. Use of Appropriate Medications for People with Asthma5. Coronary Artery Disease6. Diabetes: HbA1c Screening

• Patient Satisfaction1. Specialty care2. Timely access to care3. Doctor-patient communication4. Overall ratings of care

• IT Investment1. Integrate clinical electronic data sets at group level2. Support clinical decision making at point of care

Original Measure Set


Measure Set Evolution


Quality Measures Improved or Steady

*Statistically significant Measures were excluded due to trending breaks: Immunizations for Adolescents, Breast Cancer Screening, Annual Monitoring for Patients on Persistent Medications, Asthma Medication Ratio.

16 Improved 11 Stable

1 Declined

CLINICAL QUALITY• Immunizations for Adolescents: Combo 2• Childhood Immunization Status: Combo 10• Appropriate Testing for Children With

Pharyngitis• Diabetes Care: HbA1c Control < 8.0%*• Diabetes Care: Combination• Diabetes Care: Two HbA1c Tests*• Avoidance of Antibiotic Treatment for

Adults w/ Acute Bronchitis• Diabetes Care: HbA1c Poor Control > 9.0%• Proportion of Days Covered: Statins• Proportion of Days Covered: Oral Diabetes

Medications*• Proportion of Days Covered: RAS

Antagonists• Use of Imaging Studies for Low Back Pain*• Statin Therapy for Patients with

Cardiovascular Disease• Diabetes Care: Blood Pressure Control • Statin Therapy for Patients with Diabetes

PATIENT EXPERIENCE• Coordination of Care*

CLINICAL QUALITY• Chlamydia Screening• Cervical Cancer Screening• Breast Cancer Screening• Annual Monitoring for Patients on Persistent

Medications: ACEI/ARB and Diuretics

• Diabetes Care: Medical Attention for Nephropathy• Cervical Cancer Overscreening• Colorectal Cancer Screening• Controlling Blood Pressure for Non-Diabetic People

with Hypertension

PATIENT EXPERIENCE• Overall Ratings of Care• Provider Communication• Office Staff

PATIENT EXPERIENCE• Access


0

10

20

30

40

50

60

70

80

90

100

Proportion ofDays Covered:

RAS Antagonists

Proportion ofDays Covered:

Statins

Diabetes Care:Blood Pressure

Control

Diabetes Care:HbA1c Control

Diabetes Care:HbA1c Poor

Control

Diabetes Care:Medical

Attention forNephropathy

Proportion ofDays Covered:Oral DiabetesMedications

ChlamydiaScreening

Avoidance ofAntibiotic

Treatment forAdults with

Acute Bronchitis

AppropriateTesting for

Children withPharyngitis

Ave

rage

Rat

e (%

)

MY 2013 MY 2017

Incremental Gains Add Up…

Cardiovascular Diabetes Prevention Respiratory

+0.8% +2.1%

6.8% +4.8%

+5.1%

+4.7%

+0.2%

+2.8% +3.7%

+9.2%

All measures improved over 5-year trend


0

10

20

30

40

50

60

70

80

90

100

Proportion of Days Covered: RASAntagonists

Diabetes Care: Blood PressureControl

Chlamydia Screening Avoidance of Antibiotic Treatmentfor Adults with Acute Bronchitis

Ave

rage

Rat

e (%

)

MY 2013 MY 2017…And Drive Better Patient Care

Cardiovascular Diabetes Prevention Respiratory

13,203 more patients dispensed

a statin were adherent.

32,377 more diabetic patients with BP under control.

6,879 more sexually active women had

at least one chlamydia test.

2,386 more children who were diagnosed with

pharyngitis and dispensed an antibiotic received a

strep test.


40

45

50

55

60

65

70

75

80

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Ave

rage

Rat

e (%

)

Measurement Year

Breast Cancer Screening: 2003 - 2017

Continued & Sustained Improvement on “Original” Measures


$2,927

$3,246$3,482

$3,633 $3,731 $3,833 $3,794$3,912 $3,944

-2%

0%

2%

4%

6%

8%

10%

12%

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

20084 plans2.7M

20094 plans2.6M

20104 plans2.4M

20114 plans2.3M

20125 plans2.6M

20135 plans2.6M

20148 plans8.4M

20158 plans8.7M

20168 plans8.8M

2017

Tota

l Co

st o

f C

are

Tren

d (

% C

han

ge)

Avg

To

tal C

ost

of

Car

e ($

PM

PY)

Total Cost of Care Trend Over Time

10.9%

7.3%

6.7%

4.9%

2.7%

-1.0%

3.0%

0.8%

-2%

0%

2%

4%

6%

8%

10%

12%

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

20084 plans2.7M

20094 plans2.6M

20104 plans2.4M

20114 plans2.3M

20125 plans2.6M

20135 plans2.6M

20148 plans8.4M

20158 plans8.7M

20168 plans8.8M

2017

Tota

l Co

st o

f C

are

Tren

d (

% C

han

ge)

2017

Coming soon!



12 measures4


43 measures4


MEA

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Proprietary rankings6

Plan-specific quality incentives7

Transparent, value-based reporting6

All health plans have adopted value-based design

7

ATTA

IN &

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PRO

VE

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RES

PON

SIV

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M

THEN: 2003 NOW: 2018


Grant funded3

1 6 health plans


Health plan funded3

1 9 health plans

STA

KEH

OLD

ER

GO

VER

NA

NCE


Good Old Days: Conflicting Plan Report Cards from 1999

Source: California Provider Groups Report Cards: What Do They Tell Us? Simon and Monroe, American Journal of Medical Quality,March/April 2001, p61-70.

Table 4

Results of Spearman Correlation Analysis*

Performance Indicator Plan-to-Plan Comparison

Correlation

Coefficient

Patient satisfaction with medical group Blue Cross of California vs Health Net

Blue Cross of California vs PacifiCare

Blue Cross of California vs PBGH

Health Net vs PacifiCare

Health Net vs PBGH

PacifiCare vs PBGH

0.59

0.48

0.70

0.45

0.58

0.54

Member-requested group transfers Blue Cross of California vs PacifiCare -0.44

Cervical cancer screening Blue Cross of California vs PacifiCare


PacifiCare vs PBGH

0.30

0.27

0.18

Breast cancer screening Blue Cross of California vs PBGH


PacifiCare vs PBGH

0.28

-0.03

0.16

Regional overall performance Blue Cross of California vs Health Net 0.40

California overall performance Blue Cross of California vs PacifiCare 0.37

* PBGH indicates Pacific Business Group on Health


Then: OPA Report Card


Now: OPA Report Card


• Guidance from the Federal Trade Commission

Standard Incentives?


• Beginning in 2019, all participating commercial HMO health plans will have adopted a value-based design

Incentive Adoption – Value Based

MY 2013 MY 2014 MY 2015 MY 2016 MY 2017 MY 2018 MY 2019

Blue Shield

Cigna

United

Aetna

Anthem

Sharp

Western Health

Care1st (Medi-Cal)

Health Net

Kaiser N/A N/A N/A N/A N/A N/A N/A



12 measures4


43 measures4


MEA

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7

ATTA

IN &

IM

PRO

VE

Focused on risk-bearing physician organization performance

8

Commercial HMO measurement only

9

Atlas provides geographic & market context for performance

8

Expanded measurement to Medicare Advantage, Commercial ACO, Managed Medi-Cal

9!

RES

PON

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THEN: 2003 NOW: 2018


Grant funded3

1 6 health plans


Health plan funded3

1 9 health plans

STA

KEH

OLD

ER

GO

VER

NA

NCE


Atlas Provides Market Context


Expanding Provider Organization Measurement Beyond Commercial HMO

ProgramCommon Measure Set

Participant Reporting & Benchmarking

Recognition Awards

Public Reporting

Incentives

Commercial HMO

Medicare Advantage Optional

Managed Medi-Cal TBD TBD Optional

Commercial ACO TBD N/A Optional


Health Plan Participation

Founding Growing Expanding


Broad Stakeholder Endorsement for AMP Commercial ACO Program

HEALTH PLANS

PURCHASERS & ASSOCIATIONS

PHYSICIAN ORGANIZATIONS



12 measures4


43 measures4


MEA

SUR

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NM

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7

ATTA

IN &

IM

PRO

VE


8


9


8


9!

RES

PON

SIV

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THEN: 2003 NOW: 2018


Grant funded3

1 6 health plans


Health plan funded3

1 9 health plans

STA

KEH

OLD

ER

GO

VER

NA

NCE

© 2018 Integrated Healthcare Association. All rights reserved. 33

Evolving Healthcare Landscape

IHA’s commitment to

innovation through

collaboration

New structures and new names

to find new solutions using

the same proven approach

IHA Has Always Taken a Collaborative Approach to Finding Solutions to Challenges Faced by Stakeholders

© 2018 Integrated Healthcare Association. All rights reserved. 34

IHA’s Physician Organization Level Performance Measurement Programs

Value Based Pay for Performance (VBP4P)

IHA-PBGH Commercial ACO Measurement & Benchmarking

Initiative

Medicare Advantage 5 Star Reporting of Physician

Organizations

Performance Measurement & Reporting in Medi-Cal Managed

Care

AMP Commercial HMO

AMP Commercial ACO

AMP Medicare Advantage

AMP Medi-Cal Managed Care

No name change

PERFORMANCE MEASUREMENT COLLABORATIVE



Pay for Performance10 Align. Measure. Perform. (AMP)10

12 measures4


43 measures4


MEA

SUR

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LIG

NM

ENT





7

ATTA

IN &

IM

PRO

VE


8


9


8


9!

RES

PON

SIV

E FO

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M

THEN: 2003 NOW: 2018


Grant funded3

1 6 health plans


Health plan funded3

1 9 health plans

STA

KEH

OLD

ER

GO

VER

NA

NCE


✓ Commitment to electronic data collection

✓ Aggregated data

✓ Physician organization tracking and reporting infrastructures

✓ Pharmacy data and lab results

✓ Standard APCD format

❑ Encounter data – completeness, accuracy, timeliness, and quality

❑ Clinical supplemental data

❑ ACO data completeness

❑ Patient-reported outcomes

Looking Ahead: Data Challenges Evolve & Persist


MeasureCommercial

HMOCommercial

ACOMedicare

AdvantageMedi-Cal

Managed Care

Clinical Quality

Concurrent Use of Opioids & Benzodiazepines Baseline Testing Baseline

Use of Opioids at High Dosage Baseline Testing Baseline

Controlling Blood Pressure for People with Hypertension X X

Controlling High Blood Pressure Baseline Baseline Baseline Baseline

Proportion of Days Covered by Medications: RAS Antagonists X X X

Proportion of Days Covered by Medications: Statins X X X

Statin Therapy for Patients With Cardiovascular Disease X X X X

Diabetes Care: Combo X X

Diabetes Care: Blood Pressure Control X X X

Diabetes Care: Eye Exam Baseline X X Baseline

Diabetes Care: HbA1c Control X X

Diabetes Care: HbA1c Poor Control X X X X

Diabetes Care: Medical Attention for Nephropathy X X X X

Proportion of Days Covered: Oral Diabetes X X X

Statin Therapy for Patients With Diabetes X X X

Use of Imaging Studies for Low Back Pain X X X

Breast Cancer Screening X X X X

Cervical Cancer Overscreening X X X

Cervical Cancer Screening X X X

Childhood Immunization Status: Combo 10 X X X

Chlamydia Screening in Women X X X

Colorectal Cancer Screening X X X X

Immunizations for Adolescents: Combo 2 X X X

Appropriate Testing for Children With Pharyngitis X X X

Asthma Medication Ratio X X X

Avoidance of Antibiotics of Adults with Acute Bronchitis X X X

Encounter Rate by Service Type X Info Only X

Initiation & Engagement of Drug Dependence Treatment Testing

Statin Use in Persons with Diabetes X

Prenatal & Postpartum Care Testing

Disease Modifying Anti-Rheumatic Drug Therapy for RA X

Osteoporosis Management in Women Who Had a Fracture X

Adult BMI Assessment X

Weight Assessment & Counseling for Children/Adolescents Testing

Patient Experience

Access Composite X X

Care Coordination Composite X X

Office Staff Composite X X

Overall Ratings of Care Composite X X

Provider Communication Composite X X

Advancing Care Infoe-Measure: Controlling High Blood Pressure X

e-Measure: Screening for Depression & Follow Up Plan X

ResourceUse

Acute Hospital Utilization X X

All-Cause Readmissions X X Info Only X

Ambulatory Care: ED Visits X X X

Emergency Department Utilization X X X

Frequency of Selected Procedures Info Only Info Only

Generic Prescribing X X

Inpatient Utilization X X

Outpatient Procedures Utilization X X

Cost Total Cost of Care X X X

Looking Ahead: Alignment Across Products Critical


Looking Ahead: Driving Alignment in National Context


• Aligned measurement is a prerequisite—whether the goal is “raising all boats” or “survival of the fittest”

• Collaboration takes time, but ultimately supports sustainable processes

• Transparency and active participation enhances trust in performance results

• Active and engaged leadership is critical

15 Years Older & Wiser?


Questions?

then & now: 15 years of performance measurement and ... · capaldi | alwyn cassil | john fisher...

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