Appendix 9: National Committee for Quality Assurance Presentation to the Subcommittee

National Advisory Council Subcommittee: Identifying Quality Measures for Medicaid-eligible adults

Sarah Hudson Scholle and Sepheen Byron made the following slide presentation to the Subcommittee entitled "Preparing for Measurement Selection: Landscape of Measures." Select to access the PowerPoint Version [ Microsoft PowerPoint file - 694 KB]

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Preparing for Measurement Selection: Landscape of Measures

Sarah Hudson Scholle
Sepheen Byron

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Overview

  • Performance Measurement in Medicaid
  • Quality of Care for Adults in Medicaid
  • Measures Inventory
  • Key Challenges

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Performance Measurement in Medicaid

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State of Measurement in Medicaid

  • There is no national reporting of Medicaid quality data representing all different populations enrolled (that's why we are here...)
  • Two new reports shed light on current efforts:
    • Managed care: NCQA's Medicaid Benchmarking Project Report
    • FFS: CHCS' Performance Measurement in Fee-for-Service Medicaid: Emerging Best Practices

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NCQA Medicaid Benchmarking Rep

  • Purpose: Test the feasibility of collecting comparable performance measure results from state Medicaid agencies and combining these data with existing HEDIS data in NCQA's database to develop robust benchmarks for Medicaid.
  • Why Focus on Managed Care and HEDIS?
    • 71% of the Medicaid population in states that use managed care arrangements including PCCM and MCOs.
    • 37 states contract with MCOs.
  • Nearly 90 percent of state Medicaid programs reported using HEDIS measures for evaluate quality of children's care:
    • No comparable data available for adults.

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How Do States Use HEDIS?

  • States use HEDIS measures to meet the federal requirements for performance measurement in Medicaid.
  • States may use the HEDIS data plans have submitted to NCQA, require plans to submit data directly to the state or the EQRO, or calculate performance rates themselves.
  • Twenty-five Medicaid programs use or require NCQA Accreditation.

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Medicaid Programs & HEDIS

Medicaid ProgramCountsStates
States without Medicaid managed care plans (excluded from study)17Alabama, Alaska, Arkansas, Guam, Idaho, Iowa, Louisiana, Maine, Mississippi, Montana, New Hampshire, North Carolina, North Dakota, Oklahoma, South Dakota, Virgin Islands and Wyoming
States where all health plans submitted HEDIS data to NCQA11California, Colorado, District of Columbia, Kentucky, Maryland, Michigan, Nebraska, New Mexico, Tennessee, Virginia and Washington
States where some health plans submitted HEDIS data to NCQA23Indiana, Minnesota, New Jersey, Pennsylvania, Puerto Rico, Rhode Island and West Virginia
States where no health plans submitted HEDIS data to NCQA3Oregon, South Carolina, Vermont
Total Medicaid Programs54* 

*Includes the District of Columbia, Puerto Rico, Guam and the Virgin Islands.

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Most Commonly Used Measures

Pediatric/Adolescent

  • Well-Child Visits in the First 15 Months
  • Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
  • Adolescent Well-Care Visits
  • Childhood Immunization Status

Women

  • Cervical Cancer Screening
  • Prenatal and Postpartum Care

Chronic Care

  • Use of Appropriate Medications for People With Asthma
  • Comprehensive Diabetes Care (CDC) - HbA1c Testing
  • CDC - Eye Exam (Retinal) Performed
  • CDC - LDL - C Screening

Mental Health

  • Follow-Up After Hospitalization for Metal Illness

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Most Common Differences Between State Measures and NCQA HEDIS data

  • Specification changes
    • Continuous enrollment
    • Measurement year
    • Data source
    • Numerator changes
  • Data collection process
  • Validation

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CHCS Report: Performance Measurement in FFS Medicaid

  • "Just do it"
  • Key Themes:
    • Leadership
    • Measures
    • Resources

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Leadership

  • Involve providers and other relevant stakeholders
  • Clarify the purpose of measurement:
    • Reporting and comparisons among delivery systems
    • Quality improvement
  • Set clear goals for public reporting
  • Value the role of leadership in the process

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Measures and Data Sources

  • Consider measures that rely on administrative data for ease of capture.
  • Consider business case with focus on overuse measures, such as hospital readmissions.
  • Adapt HEDIS measures to fit the FFS environment:
    • Look outside HEDIS for special populations like mental health.
  • Consider other data sources:
    • Patient/family surveys, Registries, Lab test results, Chronic disease and obstetrics assessment forms, Health information technology.

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Resources and Time

  • Consider resources needed for development and implementation of the measurement system:
    • Many variations exist depending on structures and resources available within states:
  • Be patient:
    • Expect it to take a year from the start of developing a new measure to reporting it, depending on the complexity of the measure and the availability of analytic capacity.
  • Devote resources to auditing measures.

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Performance in Medicaid

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Status of Health Care Quality in Medicaid

  • 2009 HEDIS provides window on national performance among managed care organizations (MCOs).
  • HEDIS performance rates for Medicaid MCOs are often lower than for Commercial and/or Medicare MCOs.
  • There are a few exceptions...

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2009 HEDIS Performance for Medicaid vs Other MCOs

 MedicaidMedicareCommercial
Adult BMI Assessment34.638.841.3
Breast Cancer Screening52.469.371.3
Cervical Cancer Screening65.8NA77.3
Postpartum Visit64.1NA83.6
Initiation of Alcohol/Drug Treatment44.346.242.7
Follow After Mental Health Hosp (30 days)60.254.876.8
Persistent Beta Blocker Use After Heart Attack76.682.674.4
Diabetes: A1c Screening80.689.689.2
Diabetes: Poor A1c Control (>9.0%) (lower=better)44.928.028.2
Diabetes: Cholesterol Screening74.287.385.0
Diabetes: Cholesterol <10033.550.047.0
Hypertension: Blood Pressure <140/9055.359.864.1
Asthma: Appropriate Medications88.6NA92.7

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Childhood Immunization Retreat in Private Plans, But Not in Medicaid

Image: A line chart shows the rise in childhood immunizations for both private insurance and Medicaid from 1999-2009, until 2008-2009 when the percentage of immunizations for private insurance drops of by several percentage points.

Notes: The most surprising result was a disturbing 4% drop in childhood immunization rates among private plans that primarily serve kids in middle-class families. This did not happen in Medicaid plans that serve low-income kids, where we saw a 3% rise, continuing the steady improvement they've been making.

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Big Gains in Chlamydia Screening—with Medicaid Plans Leading

Image: A line chart shows a large increase in chlamydia screening from the period 2001-2009 for both private insurance and Medicaid plans. Medicaid plans have a consistently higher percentage of screening than private insurance.

Notes: We are also seeing big gains in chlamydia screening, especially in Medicaid plans. This is a common and often silent STD that, left untreated, can cause irreversible damage, including infertility. We're also seeing better scores for diabetic care, prenatal and postpartum care, controlling high blood pressure and other measures.

YearCommercialMedicaid
200123.140.4
200225.440.9
200329.744.9
200432.247.2
200534.950.7
200637.352.4
200738.150.7
200841.754.9
200943.156.7

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Using the Inventory to Identify Potential Measures

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Creating Measures Inventory

  • Sources of measures:
    • Measures endorsed by National Quality Forum
    • Measures nominated by CMS
    • Measures submitted by 15 Medicaid medical directors
    • Measures suggested by Panel co-chairs and members
  • We attempted to "de-duplicate" the list..."

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Contents of Measure Inventory

  • Measures
  • Pivot Table (allows identifying groups of measures)
  • Definitions of descriptors
  • Acronyms
  • Sources

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Measures List

  • Measures:
    • Sorted by Measure Steward
    • All measures have unique "ID number" for searching (NQF ID provided if relevant)
  • Contents:
    • Measures characteristics
    • Information on current use
    • Category in Revised IOM framework
    • Population of interest
  • Excel makes sorting and filtering of measures possible

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Characteristics of Each Measure

  • Measure ID
  • NQF ID
  • Measure owner/steward
  • Measure name
  • Measure description
  • Specific conditions
  • Condition type
  • Measure type
  • Data sources
  • Unit of measurement

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From the Legislation....

The Secretary shall identify and publish a recommended core set of adult health quality measures for Medicaid eligible adults in the same manner as the Secretary identifies and publishes a core set of child health quality measures under section 1139A, including with respect to identifying and publishing existing adult health quality measures that are in use under public and privately sponsored health care coverage arrangements, or that are part of reporting systems that measure both the presence and duration of health insurance coverage over time, that may be applicable to Medicaid eligible adults.

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Descriptors of Current Use

  • Medicaid: in use by Medicaid programs or health plans in the state
  • Other: in use by other federal programs (VA, Medicare Advantage, PQRI, etc)
  • Any: in use in either Medicaid or other program
  • States: list of states in which the measures are used

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Measures Framework

DomainsPopulations
Reproductive HealthAdult <65 yrsComplex Health NeedsMental Health and Substance Abuse
Safe    
Timely    
Effective    
Efficient    
Access    
Patient & Family Centered    
Care Coordination    
Health Systems Infrastructure    

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Information for Each Measure

IOM Framework

  • Safe
  • Timely
  • Effective
  • Efficient
  • Access
  • Patient & Family centered
  • Care coordination
  • Health systems infrastructure

Population

  • Condition Type
  • Female Only
  • Reproductive Health
  • Adults <65
  • MH & Sub Abuse In Use
  • Functional status

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Starting Lists for Each Workgroup

  • Maternal/reproductive health:
    • Female only and in use at all
  • Adult health:
    • Adults <65 and in use in Medicaid
  • Mental Health/Substance Use:
    • MH&SA and in use anywhere
  • Complex conditions:
    • Cross cutting measures that are in use at all: functional status, care coordination, health system infrastructure, avoidable hospitalizations

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Key Challenges in Measuring Quality for Adult Medicaid Populations

  • Current measures do not address needs of complex populations
  • Examples of measure concepts and issues in selecting measures for the core set:
    • Avoidable hospitalizations
    • Care Coordination
    • Functional status

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Avoidable Hospitalizations

  • Avoidable hospitalization measures, including hospital readmissions and admissions for ambulatory care-sensitive conditions (ACSC), are important markers of waste.

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Examples of Avoidable Hospitalization Measures

StewardMeasure Name
NCQAPlan All-Cause Readmission (new for 2011)
CMS30-Day All-Cause Risk Standardized Readmission Rate Following Heart Failure Hospitalization (risk adjusted)
State of CONumber of admissions for Ambulatory Care Sensitive Conditions for waiver and Medicaid clients
AHRQDiabetes Short-Term Complications Admission Rate/100,000

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Avoidable Hospitalizations

  • Key issues for Re-admission measures:
    • Population: all age groups, adults only, etc
    • Hospitalizations: specific-cause discharges versus all-cause discharges.
    • Counting of readmissions: all-cause readmissions or specific-cause readmissions
    • Readmission timeframe: 30 days versus 3, 7, 14, 90, ...
    • Risk adjustment
    • Continuous enrollment
  • Key issues for ACSC Admissions:
    • Eligible population
    • Risk adjustment
    • Continuous enrollment

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Outcomes/Functional Status

  • Outcome measures include mortality and functional status.
  • Patients/families value these measures in particular.
  • These measures may reflect the net result of care for multiple conditions and care received from multiple providers and settings.

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Outcomes/Functional Status

StewardMeasure Name
CMSImprovement in bathing among home-based care recipients
Focus on Therapeutic Outcomes, IncFunctional status change for patients with knee impairments
CREcareChange in Basic Mobility as Measured by the AM-PAC
CMS, NCQAMedicare Health Outcomes Survey (HOS)
AHRQIQI 11: Abdominal Aortic Artery (AAA) Repair Mortality Rate (risk adjusted)
AHRQIQI 17: Acute Stroke Mortality Rate

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Outcomes/Functional Status

  • Key Issues:
    • Population/Site of care/Population size
    • Cross section versus longitudinal assessment
    • Risk adjustment
    • Data source and completeness
    • Attribution

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Care Coordination

  • NQF (2006) identified dimensions of care coordination including:
    • The need for a medical home,
    • Proactive plan of care and follow-up
    • Strategy for communication,
    • Availability of information systems to support care
    • Process for transitions or "hand-offs" (across providers and settings)

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Care Coordination

StewardMeasure Name
CMS30-Day Post-Hospital AMI Discharge Evaluation and Management Service Measure (In proposed IPPS rule May 2010)
NCQACare for Older Adults (COA): Functional Status Assessment
NCQAMedication Reconciliation Post-Discharge (MRP)
IPROManagement plan for people with asthma
AMA-PCPI, NCQAAdvance Care Plan
CMSDocumentation and Verification of Current Medications in the Medical Record

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Care Coordination

  • Key issues:
    • Availability and use of measures
    • Data sources/completeness
    • Feasibility and cost of measurement
Page last reviewed December 2010
Internet Citation: Appendix 9: National Committee for Quality Assurance Presentation to the Subcommittee: National Advisory Council Subcommittee: Identifying Quality Measures for Medicaid-eligible adults. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/nac/reports/nacqm/appendix9.html