Medi-Cal Performance Measurement: Making the Leap to Value-Based Incentives. Dolores Yanagihara IHA Stakeholders Meeting October 3, 2018

Transcription

1 Medi-Cal Performance Measurement: Making the Leap to Value-Based Incentives Dolores Yanagihara IHA Stakeholders Meeting October 3, 2018

2 Why Standardization? MEDI-CAL CROSS PRODUCT San Francisco Health Plan Partnership LA Care Anthem California Health & Wellness Cal Optima Based on IHA s 2014 Inventory, only 1 measure out of 86 distinct measures aligns across all plan P4P programs: Diabetes HbA1c Testing CenCal Central California Alliance Health Net DHCS External Accountability Set Federal Quality Rating System for Covered California Only 2 measures align across all programs: 1. Controlling Blood Pressure for People with Hypertension 2. Diabetes: Medical Attention for Nephropathy Medicare Advantage Stars Kern Health Systems Inland Empire Health Plan Health Plan of San Mateo Health Plan of San Joaquin IHA Value Based P4P 2018 Integrated Healthcare Association. All rights reserved. 2

3 Benefits of Measure Alignment Reduce unnecessary burdens associated with the lack of alignment across incentive programs Enhance provider effectiveness by strengthening the signal focus improvement efforts and resources Create opportunities for measure set alignment across markets including Covered California, Medicare and commercial as well as across counties Facilitate the comparability of performance results and benchmarking statewide and by region 2018 Integrated Healthcare Association. All rights reserved. 3

4 IHA s Medi-Cal P4P Advisory Committee Health Plans Provider Representatives Collaborators Associations 2018 Integrated Healthcare Association. All rights reserved. 4

5 Medi-Cal P4P Core Measure Set Domain Measures NQF # Cardiovascular Diabetes Care Annual Monitoring for Patients on Persistent Medications: ACE or ARB indicators Annual Monitoring for Patients on Persistent Medications: Diuretics indicator HbA1c Testing 0057 HbA1c Control 0575 Eye Exam 0055 Maternity Timeliness of Prenatal Care 1517 Prevention Childhood Immunizations, Combo Well-Child Visits in 3 rd, 4 th, 5 th, and 6 th Years of Life 1516 Cervical Cancer Screening 0032 Respiratory Asthma Medication Ratio Integrated Healthcare Association. All rights reserved. 5

6 Medi-Cal Measure Set Overlap Includes measures important to Medi-Cal population and measures retired by IHA DHCS EAS 23 measures 3 AMP Medi-Cal Managed Care 41 measures IHA Medi-Cal Core Set 10 measures Includes additional clinical quality, patient experience, appropriate resource use, and total cost of care measures 2018 Integrated Healthcare Association. All rights reserved. 6

7 Leveraging IHA s Align. Measure. Perform. (AMP) Programs Provider Performance Measurement Program Common Measure Set Participant Reporting/ Benchmarking PO Recognition Public Reporting Incentives Commercial HMO Commercial ACO TBD N/A N/A Medicare Advantage N/A Medi-Cal Managed Care TBD TBD TBD 2018 Integrated Healthcare Association. All rights reserved. 7

8 Benchmarking in Medi-Cal As Medi-Cal expands, more clinician groups serve both commercial and Medi-Cal enrollees and serve across county lines To support any expansion, IHA could leverage existing AMP governance process, data flows, and other program infrastructure Transparent process and specifications Reliable and robust measurement Encompasses clinical quality, hospital utilization, and cost Comparable and meaningful benchmarks through Cost & Quality Atlas 2018 Integrated Healthcare Association. All rights reserved. 8

9 ED Visits Per 1000 Member Years Atlas: Medi-Cal Utilization Shows Striking Variation; Southern California Has Lowest Utilization Southern CA contains the bulk of enrollment but still achieved lower rates of ED visits than other regions Northern Central Southern Integrated Healthcare Association. All rights reserved. 9

10 Atlas: No Clear Geographic High or Low Performers on Medi-Cal Hospital Utilization 2018 Integrated Healthcare Association. All rights reserved. 10

11 Related Resources IHA Issue Brief on Medi-Cal Measure Alignment USC Annenberg Center for Health Journalism blog: California would benefit from a common yardstick to measure Medicaid performance USC Annenberg Center for Health Journalism blog: State officials show little interest in providing quality of care information for poor Integrated Healthcare Association. All rights reserved. 11

12 Integrated Healthcare Association Annual Stakeholders Meeting October 3, 2018 Medi-Cal Performance Measurement: Making the Leap to Value-Based Incentives

13 California Primary Care Association In 1994, the California Primary Care Association (CPCA) was formed and has become the statewide leader and recognized voice representing the interests of California community health centers and their patients. CPCA represents more than 1,200 not-for-profit Community Health Centers (CHCs) and Regional Clinic Associations who provide comprehensive, quality health care services, particularly for low-income, uninsured and underserved Californians, who might otherwise not have access to health care.

14 Need for Alignment to Improve Outcomes If you serve too many masters, you'll soon suffer. Homer (Odyssey)

15 Pay for Performance at FQHCs FQHCs participate in a wide variety of P4P quality incentive programs with Medi-Cal managed care plans and their subcontracted organizations State and federal law clearly allows that FQHCs can participate in these programs and exclude incentive payments from their PPS Managed Care annual reconciliation

16 Strategies to Improve Outcomes Alignment with IHA Measure Set for safety net managed care plans Clear rules to live by for P4P programs Increased collaboration and sharing of data

17 Alignment with IHA Measure Set CPCA and our members are very interested in working with IHA and Medi-Cal plans to create a standardized measure set for all Medi-Cal P4P programs. This effort would strengthen the signal from plans to providers regarding high-priority measures, and reduce measurement burden among providers working with multiple plans. 1 7

18 CPCA s Rules to live By for P4P 1. Plans payments to FQs for primary care must be no less than what plans pays other similar primary care providers 2. P4P payments should be completely separate from payments for services (cap or FFS) 3. Clear documentation of P4P programs and payments 4. Payments should be "at risk 5. Incentives should be based on performance measured against a benchmark 6. P4P payments should be independent of providing any individual unit of service that generates a PPS payment 7. Rules apply whether P4P payments come directly from Medi-Cal managed care plan or from the IPA

19 Collaboration: Key to Success To be successful in a value based environment our members need to be able to focus on one set of metrics Sites need to be able to partner with plans to be able to share and analyze current, timely data We want to capitalize on the lessons learned from IHAs existing work to be successful and not recreate the wheel CALIFORNIA PRIMARY CARE ASSOCIATION

20 Questions? Cynthia Keltner Deputy Director of Health Center Transformation

21 Medi-Cal Performance Measurement: Making the Leap to Value-Based Incentives Integrated Healthcare Association 2018 Stakeholders Meeting October 3, 2018 Tanya Dansky, MD VP & Chief Medical Officer Care1st Health Plan, an affiliate of Blue Shield of California

22 About Care1st Health Plan Founded in 1994 by a group comprised of providers, organized medical groups, and hospitals In 2015, acquired by Blue Shield of California, a not-for-profit health plan Serves approximately 500,000 members in California 400,000 Medi-Cal members in two counties 80,000 Medicare members in 12 counties 5,000 dual eligible members in the Cal Medi-Connect program Opportunity to leverage Blue Shield s processes, statewide provider network and decades of service to vulnerable populations through the Blue Shield Foundation 22

23 Our mission Ensure all Californians have access to high-quality health care at an affordable price

24 Pay for Performance (P4P) Challenges in a Medi-Cal Program Members more likely to have social, economic, educational, behavioral, communication and cultural challenges Lower reimbursement compared to commercial and Medicare Provider network includes Federally Qualified Health Centers (FQHCs) Multiple monitoring entities/multiple priorities DHCS (EAS, Autoassignment), NCQA, Plan partners 24

25 Pay for Performance (P4P) Opportunities in a Medi-Cal Program Value, quality and affordability are universal goals regardless of the line of business We need to bring the highest quality care and measurement to the most vulnerable Californians Safety net providers are committed to the populations they serve IHA experience with commercial HMO quality allows for leveraging best practices 25

26 Medi-Cal Provider Incentive Program

27 Common Measure Set is Key to IHA Measurement Programs IHA Performance Measurement Program by Product Line Common Measure Set Participant Reporting/ Benchmarking Program Elements PO Recognition Public Reporting Incentives Value Based P4P Program (Commercial HMO) Medicare Advantage HMO Program N/A Managed Medi-Cal Program TBD TBD TBD Commercial ACO Program TBD N/A N/A 2018 Integrated Healthcare Association. All rights reserved. 27

28 P4P Challenges in a Medi-Cal Program Multiple monitoring entities/multiple priorities DHCS, NCQA, LA Care, Individual plan priorities Low Medi-Cal reimbursement compared with Commercial and Medicare lines of business 53 separate reporting Medi-Cal entities in California Quality performance impacts default assignments 28

29 Measure Set Standardization Clinical Priority Areas Measure Name DHCS EAS Behavioral Health & Substance Abuse Cardiovascular Diabetes IHA Medi- Cal Core Set IHA Managed Medi-Cal Total Number of Measures Concurrent Use of Opioids and Benzodiazepines Use of Opioids at High Dosage Depression Screening and Follow-Up for Adolescents and Adults Annual Monitoring for Patients on Persistent Medications: ACE or ARB Annual Monitoring for Patients on Persistent Medications: Diuretics Controlling High Blood Pressure AA Controlling Blood Pressure for People with Hypertension Proportion of Days Covered by Medications: Renin Angiotensin System (RAS) Antagonists Proportion of Days Covered by Medications: Statins Statin Therapy for Patients With Cardiovascular Disease Diabetes Care: Blood Pressure Control <140/90 mm Hg Diabetes Care: Eye Exam Diabetes Care: HbA1c Control < 8.0% Diabetes Care: HbA1c Poor Control > 9.0% Diabetes Care: HbA1c Testing AA Diabetes Care: Medical Attention for Nephropathy Diabetes Care - Combination Proportion of Days Covered by Medications: Oral Diabetes Medications Statin Therapy for Patients With Diabetes Maternity Prenatal and Postpartum Care AA (prenatal) Musculoskeletal Use of Imaging Studies for Low Back Pain 29

30 Measure Set Standardization Clinical Priority Areas Measure Name DHCS EAS Prevention & Screening Respiratory Patient Experience IHA Medi-Cal Core Set IHA Managed Medi-Cal Breast Cancer Screening Cervical Cancer Overscreening Cervical Cancer Screening AA Childhood Immunization Status AA (Combo 3) (Combo 3) (Combo 10) Chlamydia Screening in Women Colorectal Cancer Screening Immunizations for Adolescents: Combination 2 (meningococcal, Tdap, HPV for Adolescents) Screening for Clinical Depression & Follow Up Plan Weight Assessment & Counseling for Nutrition and Physical Activity for Children/Adolescents Well-Child Visits in 3rd, 4th, 5th, and 6th Years of Life AA Appropriate Testing for Children With Pharyngitis Asthma Medication Ratio Avoidance of Antibiotic Treatment of Adults with Acute Bronchitis Access Composite Care Coordination Composite Office Staff Composite Overall Ratings of Care Composite (Rating of Doctor & Rating of All Healthcare) Provider Communication Composite Encounter Data Encounter Rate by Service Type Cost Total Cost of Care, incl service categories Acute Hospital Utilization (Bed Days, Discharges, ALOS) All-Cause Readmissions Ambulatory Care: ED Visits Emergency Department Utilization Resource Use Frequency of Selected Procedures Generic Prescribing: Overall and Antidepressants, Antimigraine, Anti-Ulcer, Cardiac - Hypertension and Cardiovascular, Nasal Steroids, Statins, Diabetes Access Inpatient Utilization: General Hospital/Acute Care Outpatient Procedures Utilization - Percent Done in Preferred Facility Children & Adolescents Access to Primary Care Practitioners (4 indicators) 30

31 How does the Medi-Cal Managed Care IHA program compare? Care1st program follows the IHA domains Our program includes not only the clinical measures but also appropriate resource use and total cost of care In year two, Patient Experience will be included as well 31

32 Our Vision Create a healthcare system worthy of our family and friends and sustainably affordable 32

33 Thank you

34 Blue Shield of California and Care1st are independent licensees of the Blue Shield Association.

35 Sources for measure set information DHCS EAS: MY 2017 / RY ual_rpts/hedis_reports/eas_measure_list_ry_2018%20_f1.pdf IHA Medi-Cal Core Measure Set MY IHA VBP4P Measure Set MY t_1.pdf 35