Standardizing Medi-Cal Pay for Performance Advisory Committee Meeting. November 3, 2016

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1 Standardizing Medi-Cal Pay for Performance Advisory Committee Meeting November 3, 2016

2 Agenda Welcome & Introductions Core Measure Set MY 2017 EAS Measure Set Update Benchmarks Core Measure Set Adoption Update Spread Plan Update Core Measure Set MY 2018 Medi-Cal Initiative Landscape Issue Brief Related IHA Projects Next Steps Behavioral Health Performance Measurement Smart Care California California Regional Quality and Cost Atlas 2016 Integrated Healthcare Association. All rights reserved. 2

4 Core Measure Set Overview Key features of the Core Measure Set: No more than 10 measures Included in DHCS s External Accountability Set Feasible for a wide array of providers to report using administrative only data Domain Measures DHCS Acronym Annual Monitoring for Patients on Persistent Medications: ACE or ARB MPM-ACE Cardiovascular Annual Monitoring for Patients on Persistent Medications: Diuretics MPM-DIU Auto- Assignment HbA1c Testing CDC-HT X Diabetes Care HbA1c Control (<8.0%) CDC-H8 Eye Exam CDC-E Maternity Timeliness of Prenatal Care PPC-Pre X Childhood Immunizations, Combo 3 CIS-3 X Prevention Respiratory Well-Child Visits in 3 rd, 4 th, 5 th, and 6 th Years of Life W-34 X Cervical Cancer Screening CCS X Medication Management for People with Asthma Medication Compliance 75% MMA Integrated Healthcare Association. All rights reserved. 4

5 External Accountability Set Update EAS Change Elimination of Annual Monitoring for Patients on Persistent Medications Digoxin (MPM-DIG). Elimination of Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents BMI (WCC-BMI). Replacement of Medication Management for Asthma (MMA) with the Asthma Medication Ration (AMR). Adoption of the new NCQA combination measure: Immunizations for Adolescents this new measure will combine two existing measures (Immunizations for Adolescents (IMA) and Human Papillomavirus Vaccine for Female Adolescents (HPV)) and apply for both boys and girls at 13 years of age. Impact on Medi-Cal P4P Core Measure Set No impact; the core measure set currently includes the MPM-ACE and MPM-DIU indicators, not the MPM-DIG indicator No impact; the core measure set does not include the WCC-BMI indicator The current measure set includes the MMA measure; the Advisory Committee should replace the MMA measure with the AMR measure to align with the EAS No impact; the core measure set does not include either the IMA or HPV measures. The Advisory Committee might consider adding this measure to the core measure set in the future. 5 Addition of Screening for Clinical Depression and Follow Up Plan measure 6 Adoption of the Breast Cancer Screening measure No impact since this is a new EAS measure. The Advisory Committee might consider adding this measure to the core measure set in the future. No impact since this is a new EAS measure. The Advisory Committee might consider adding this measure to the core measure set in the future. Final Update to Core Set for MY 2017: Replace the Medication Management for People with Asthma (AMR) with the Medication Management for Asthma (MMA) to retain alignment of core measure set with DHCS EAS 2016 Integrated Healthcare Association. All rights reserved. 5

6 Core Measure Set Benchmarks Measure Name Annual Monitoring for Patients on Persistent Medications: ACE or ARB Annual Monitoring for Patients on Persistent Medications: Diuretics 2016 MMC Range* (Low to High) Medicaid 2015 Medicaid 2016 California HMO Average California HMO Average National HMO Average Commercial 2016 California HMO Average ( ) ( ) HbA1c Testing ( ) HbA1c Control (<8%) ( ) Eye Exam ( ) Timeliness of Prenatal Care ( ) Childhood Immunizations, Combo ( ) Cervical Cancer Screening ( ) Well-Child Visits in 3 rd, 4 th, 5 th, and 6 th Years of Life Medication Management for Asthma: Medication Compliance 75% (Total) Asthma Medication Ratio (Replacement Measure) ( ) ( ) ( ) / : Change relative to prior year (CA Medi-Cal HMO 2016 vs Colors: CA Medi-Cal HMO average compared to National HMO average Worse (dark pink) vs. Better (dark green) Commercial HMO average compared to CA Medi-Cal HMO Worse (light pink) vs. Better (light green) 2016 Integrated Healthcare Association. All rights reserved. 6

7 Core Measure Set Adoption Health Plan Adoption Progress Adoption Goals Alameda Alliance for Health Currently their program includes the core measures but a few have different specifications. For 2017 planning on including all the core measures for full adoption. Full Adoption Anthem Blue Cross Most measures already included, except cardiovascular; on track for 2017 adoption. Full Adoption California Health & Wellness Currently reporting all 10 core measures and planning to continue. Full Adoption CalOptima Holding current measures steady for 2017; 5 out of 10 core measures included in P4P measure set. Partial Adoption Care1st Re-establishing P4P program in 2017; pay for reporting on all EAS measures Full Adoption CenCal Central California Alliance Health Net Health Plan of San Joaquin Team is currently working to incorporate the core measure set into the 2017 PCP Incentive Program; desire to adopt all measures but working on feasibility now. Recommendation to board in April to adopt all measures for 2017, along with a few others; no major issues. Some concern with HbA1c control (lab data issue) but hopefully will have a plan to collect those values in place by Only including two measures; this year added incentive dollars for maternity, prenatal and postpartum. Setting up energy around collective action plan with the state. Current program includes 6 of 10 core measures; measures not included are cardiovascular measures, HbA1C control and childhood immunizations. Will make decision about 2017 measures later in 2016 based on current year s performance. Full Adoption Full Adoption Partial Adoption Undetermined Health Plan of San Mateo Inland Empire Health Plan Kern Family Health Care Continuing with measures we have, tweaking to align with HEDIS specifications; don t have cardiovascular or respiratory measure. Looking at revising program and adding access measures for adult and pediatric; not quite at commitment stage. Program currently includes 7 out of 10 core measures (cardiovascular measures and Diabetes eye exam not included); for MY 2017, planning on including all core measures for full adoption Currently includes 7 of 10 core measures in P4P program (cardiovascular measures and HbA1c control not included); no update about adding additional measures. Undetermined Full Adoption Undetermined LA Care Currently reporting all 10 core measures Full Adoption Partnership Health Plan Removed HbA1c Testing, use the HbA1c threshold of >9%=poor control, adopted Asthma Medication Management (but 50% compliance), and don t have prenatal care. Measuring only DTaP for Combo 3, which is a big data entry burden. Overall, metrics almost finalized, no major changes planned in these categories. Will look at changes in late 2016 (October-November) and will certainly take the core measure set into account in this process. Partial Adoption San Francisco Health Plan Have 8 of the 10 measures in our P4P program; planning on full adoption for MY Biggest hurdle is getting measures to work with current infrastructure, most of our folks are small primary care clinics with small denominators. For prenatal Full Adoption care, providers are already at 2016 the 90th Integrated percentile Healthcare so not much Association. incentive All to rights add reserved. at this point. 7

8 Core Measure Set Adoption Health Plan Alameda Alliance for Health Anthem Blue Cross California Health & Wellness CalOptima Care1st CenCal Central California Alliance Health Net Health Plan of San Joaquin Health Plan of San Mateo Inland Empire Health Plan Kern Family Health Care LA Care Partnership Health Plan San Francisco Health Plan Adoption Goals Full Adoption Full Adoption Full Adoption Partial Adoption Full Adoption Full Adoption Full Adoption Partial Adoption Undetermined Undetermined Full Adoption Undetermined Full Adoption Partial Adoption Full Adoption Discussion Questions: Are the adoption goals included in the table above accurate? Are there any updates about implementation efforts since our last meeting in June? 2016 Integrated Healthcare Association. All rights reserved. 8

9 Spread Plan Overview Approach: With input from the Advisory Committee, IHA s spread plan has included: 1:1 meetings with the remaining Medi-Cal plans not participating on the Advisory Committee Presentations at existing plan meetings to socialize the project and the core measure set to a broader audience The first priority has been to begin outreach to the Medi-Cal plans with P4P programs followed by the plans that do not currently have a P4P program Update since June Meeting: In August: IHA presented information about the Standardizing Medi-Cal P4P project at a meeting of health plan executives with Santa Clara Family Health Plan and Valley Health Plan IHA presented information about the Standardizing Medi-Cal P4P project on CPCA s Quarterly Payment Reform webinar In October: IHA presented information about the Standardizing Medi-Cal P4P project at the CAHP s Annual Conference IHA held a call with Care 1 st and Blue Shield quality experts to discuss the Standardizing Medi-Cal P4P project 2016 Integrated Healthcare Association. All rights reserved. 9

10 Spread Plan: Final Results Health Plan Outreach Approach Status 1 Aetna Outreach through existing plan meeting in San Diego No change 2 Alameda Alliance for Health 1:1 Discussion Joined Advisory Committee 3 CalViva Health Communication Joined Advisory Committee via Health Net 4 Care 1st / Blue Shield Outreach through existing plan meeting in San Diego followed by 1:1 discussion Joined Advisory Committee 5 Community Health Group Outreach through existing plan meeting in San Diego Phasing out P4P program 6 Contra Costa Health Plan Communication Supportive of project but currently no P4P Program; no plan to develop one in the near future 7 Gold Coast Health Plan 1:1 Discussion Joined Advisory Committee 8 Health Plan of San Mateo 1:1 Discussion Joined Advisory Committee 9 Kaiser Foundation Outreach through existing plan meeting in San Diego No P4P program for providers 10 Kern Family Health Care 1:1 Discussion Joined Advisory Committee 11 Molina Healthcare Outreach through existing plan meeting in San Diego Pending 12 Santa Clara Family Health Plan 1:1 Discussion Declined invitation to join 13 UnitedHealthCare Outreach through existing plan meeting in San Diego followed by 1:1 discussion 14 Valley Health Plan 1:1 Discussion Joined Advisory Committee Expressed interest in joining Advisory Committee 2016 Integrated Healthcare Association. All rights reserved. 10

12 Measure Set Strategy Today s Objective: To share a draft timeline and process for incorporating new measures into the core set and obtain feedback from Advisory Committee Timeline: Development of the Core Measure Set: The Advisory Committee met several times and reached consensus on a core set that all Medi-Cal managed care plans could incorporate into their existing P4P programs. Determine Core Measure Set Adoption Plan: The Medi-Cal plans on the Advisory Committee worked with their plan leadership to determine their level of adoption for MY Develop plan to adopt new measures into the Core Set: The Advisory Committee will work together to develop a measure set strategy and timeline for incorporating new measures into the Medi-Cal P4P core measure set 2017 Implementation of Core Measure Set: The Medi-Cal plans on the Advisory Committee implement the core measure set into their P4P programs Integrated Healthcare Association. All rights reserved. 12

13 Core Measure Set Overview Key features of the Core Measure Set: No more than 10 measures Included in DHCS s External Accountability Set Feasible for a wide array of providers to report using administrative only data Domain Measures DHCS Acronym Annual Monitoring for Patients on Persistent Medications: ACE or ARB MPM-ACE Cardiovascular Annual Monitoring for Patients on Persistent Medications: Diuretics MPM-DIU Auto- Assignment HbA1c Testing CDC-HT X Diabetes Care HbA1c Control (<8.0%) CDC-H8 Eye Exam CDC-E Maternity Timeliness of Prenatal Care PPC-Pre X Childhood Immunizations, Combo 3 CIS-3 X Prevention Well-Child Visits in 3 rd, 4 th, 5 th, and 6 th Years of Life W-34 X Cervical Cancer Screening CCS X Respiratory Asthma Medication Ratio TBD 2016 Integrated Healthcare Association. All rights reserved. 13

14 Measure Set Strategy Pathways OPTION #1: Adopt new measures for MY 2018 #1A: Swap out existing core measures with new EAS measures (no more than 2 measures) New EAS measures: Prevention Measures: 1. Immunizations for Adolescents (combines two existing measures - Immunizations for Adolescents (IMA) and Human Papillomavirus Vaccine for Female Adolescents (HPV)) 2. Breast Cancer Screening Behavioral Health Measure: 1. Screening for Clinical Depression and Follow Up Plan measure #1B: Swap out existing core measures with Controlling High Blood Pressure measure (added to Auto-Assignment in 2016) OPTION #2: No change for MY 2018 Create Stability for another year by not updating measure set for the first two years of implementation 2016 Integrated Healthcare Association. All rights reserved. 14

15 Measure Set Strategy Discussion Questions: What approach resonates more? Is there another approach that we have not considered? If the Advisory Committee agrees on Option #1, which of the new EAS measures should be added? Which of the existing measures should be removed? 2016 Integrated Healthcare Association. All rights reserved. 15

17 Medi-Cal Initiatives Landscape Objective: Identify opportunities for greater measure set alignment across the Medi-Cal initiative landscape Planned Activities: Identify initiatives impacting Medi-Cal & the safety net Develop crosswalk of performance measures included in key initiatives Summarize findings in an issue brief Timeline: March 2016 December Integrated Healthcare Association. All rights reserved. 17

18 Multiple Related Initiatives Underway Policies/Initiatives Coordinated Care Initiative Public Hospital Redesign and Incentives in Medi-Cal (PRIME) Whole Person Care Pilots (WPC) Alternative Payment Methodology (APM) Pilot Health Homes for Patients with Complex Needs (Section 2703) California Children s Services (CCS) Whole Child Model Redesign Global Payment Program (GPP) Drug Medi-Cal Organized Delivery System (Drug Medi-Cal Waiver) 2016 Integrated Healthcare Association. All rights reserved. 18

19 Initiative Landscape Outline Introduction/Background Significant changes have impacted Medi-Cal program Need for greater performance measurement alignment Medi-Cal Initiative Landscape Overview IHA (with AC input) identified 8 Medi-Cal initiatives Crosswalk of initiatives Performance Measurement Overview IHA s Medi-Cal Core Measure Set derived from collaborative process Great starting place for primary care Additional measures required for complex beneficiaries 2016 Integrated Healthcare Association. All rights reserved. 19

20 Initiative Landscape Outline Deeper Dive on Two Related Initiatives Health Homes & Whole Person Care Similarities across initiatives Target population: focused on SMI and high utilizers Improved coordination and integration of delivery systems Physical and behavioral health integration Financial flexibility for non-clinical services Drill down on measure sets lack of alignment Looking Ahead Don t reinvent the wheel; build on existing alignment efforts Several related opportunities exist, including: 1. Adopting a Core Measure Set for emerging initiatives 2. Forming a measure set clearing house 3. Creating opportunities for measure set collaboration 2016 Integrated Healthcare Association. All rights reserved. 20

21 Initiative Landscape Outline Bright Spot Candidates 1. Health Homes: IEHP & Behavioral Health Focus IEHP s Behavioral Health Integration and Complex Care Initiative footprint for Health Homes Target Population: Complex patients with chronic physical health condition as well as one mental health condition and/or SUD Multidisciplinary teams in 13 safety net health care organizations; 29 sites in Riverside and San Bernardino Counties 2. Whole Person Care: Alameda County & Improved coordination of delivery systems Target Medi-Cal population consists 20,000 people, 30% are high-utilizers and 50% homeless WPC supported by local governance, implementation of a data sharing infrastructure, supported by connecting navigators with community resources, and establish care coordination linkages across agencies 3. Innovative Practices: San Mateo county Integrated Medication Assisted Therapy 2016 Integrated Healthcare Association. All rights reserved. 21

23 Behavioral Health Performance Measurement Small-scale assessment of performance measurement for ambulatory services in behavioral health Approach: Development of a measurement framework to identify a standard set of measures Mini review of the literature Key informant interviews with 10 experts and leaders in the field Assessment of IHA s current projects, including the testing of two behavioral health measures included in Value Based P4P Timeline: May October 2016 Funding: California HealthCare Foundation 2016 Integrated Healthcare Association. All rights reserved. 23

24 Key Findings Growing attention to performance measurement in behavioral health Treatment to Target gaining acceptance in behavioral health -- requires active patient engagement to monitor outcomes Patient engagement is a key component of treatment to target Development of registries could support treatment to target approach Data challenges remain Growing convergence around the PHQ-9 as standard instrument for assessing depression NCQA exploring the development of new HEDIS measures that utilize the PHQ-9 Table: Comparative Assessment of Emerging Measures of Depression Significant need for screening and intervention in substance abuse and childhood trauma especially in Medi-Cal 2016 Integrated Healthcare Association. All rights reserved. 24

25 Growing Adoption of Depression Measures NCQA Measures Program Measure Adoption Status Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults Value Based P4P Technical Advisory Committee is considering testing this measure in MY 2017 Depression Remission or Response for Adolescents and Adults Pioneer ACO, MSSP Implemented 2015; reporting only (not for payment) Depression Screening and Follow-up for Adolescents and Adults Medi-Cal External Accountability Set Value Based P4P Implementation 2017 Technical Advisory Committee is considering testing this measure in MY Integrated Healthcare Association. All rights reserved. 25

26 Considerations & Recommendations 1. Explore support for implementation of the patient-reported outcome measure for depression screening that is required for Medi-Cal managed care plans for MY Promote data sharing and access to data to strengthen measurement and care improvement 3. Expand the information and knowledge base regarding the current state of behavioral health measurement in California particularly what s working and disseminate it broadly 4. Advance behavioral health performance measurement that is patientcentered Integrated Healthcare Association. All rights reserved. 26

Smart Care California Public-private partnership working to promote safe, affordable health care in California Co-chaired by Covered California CalPERS, and DHCS IHA convenes and coordinates the

27 Smart Care California Public-private partnership working to promote safe, affordable health care in California Co-chaired by Covered California CalPERS, and DHCS IHA convenes and coordinates the partnership with funding from CHCF Targeting overuse in three focus areas: Cesarean section for low-risk, first-time birth Low back pain without red flags Opioid dependence 2016 Integrated Healthcare Association. All rights reserved. 27

28 Smart Care California Participants Co-Chairs Covered California CA Dept. of Health Care Services CalPERS Consumer Representatives Center for Healthcare Decisions Consumers Union Western Center on Law & Poverty Plan/Purchasers Anthem Blue Cross Blue Shield of California Inland Empire Health Plan Pacific Business Group on Health Partnership Health Plan San Francisco Health Service System Providers American College of Physicians, CA Chapter CAPG CAPH/Safety Net Institute California Hospital Association California Primary Care Association Cedars-Sinai Health System Hospital Association of Southern California Hospital Quality Institute Los Angeles County Dept. of Health Services MemorialCare Health System San Mateo Medical Center Sharp Rees-Stealy Medical Group Southern CA Permanente Medical Group Sutter Health UCLA Department of Medicine Collaborators California Health and Human Services Agency California Health Care Foundation Integrated Healthcare Association 2016 Integrated Healthcare Association. All rights reserved. 28

29 Multiple Levers for Change Purchaser Requirements Data/ Transparency Payment Reduce Overuse Quality Improvement Public Policy Patient Engagement 2016 Integrated Healthcare Association. All rights reserved. 29

Atlas: Variation Data, by Geography & Product 2016

31 Clinical Quality Hospital Utilization Total Cost of Care Atlas Measures 1. Breast Cancer Screening 2. Colorectal Cancer Screening 3. Blood Sugar Screening for People with Diabetes 4. Poorly Controlled Blood Sugar for People with Diabetes 5. Kidney Disease Monitoring for People with Diabetes 1. Emergency Department Visits per thousand member years (PTMY) 2. All-Cause Readmissions 3. Inpatient Bed Days PTMY 4. Hospital Utilization Composite 1. Risk-Adjusted Cost (average per enrollee per year) 2. Observed (unadjusted) Cost 3. Total Cost Index 6. Medication Management for People with Asthma 7. Clinical Quality Composite 2016 Integrated Healthcare Association. All rights reserved. 31

32 Atlas Coverage Two-thirds of 2013 California population is included in the Atlas. California Total Population: 37.2 million Atlas Total Population: 24.4 million Payer Product Enrollment by Product Enrollment by Payer Total CA Enrollment Commercial HMO PPO 10.1 M 4.3 M 14.5 M Medicare Advantage FFS 1.6 M No memberlevel data 1.6 M 24.4 million Californians Medi-Cal Managed Care FFS 5.7 M 2.6 M 8.3 M Source: California Regional Health Care Cost & Quality Atlas Integrated Healthcare Association. All rights reserved. 32

33 Upcoming Webinar Event: Medi-Cal Findings from IHA s Cost & Quality Atlas Date/Time: Tuesday, December 13, 2016, 10:30-11:30am Overview: IHA will demonstrate the interactive Web Atlas and present key findings before opening discussion up for feedback, questions, and suggestions for further analysis To register: ge/g.php?mtid=e004902fbbe6e165f5000c3f1d665934d 2016 Integrated Healthcare Association. All rights reserved. 33

35 Next Steps Next Advisory Committee meeting to be scheduled for late April / early May Topics for discussion may include: Core Measure Set Implementation Core Measure Set Update Strategy 2016 Integrated Healthcare Association. All rights reserved. 35

FQHC Incentive Payments: A Critical Practice for Quality and Patient Satisfaction

FQHC Incentive Payments: A Critical Practice for Quality and Patient Satisfaction Meaghan McCamman Assistant Director of Policy California Primary Care Association 1 Agenda Incentives in PPS: what does