National MACRA/MIPS/APM SummitMini Summit XIV: The Role of Qualified

Entities in Providing Claims Data to Develop Payment Models and Analyze Performance

December 2, 2016

Overview

•Overview of organization •Qualified Entity Program journey •How does this approach support payment reform?

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About us• Independent, nonprofit

organization, neutral, multi-stakeholder collaboration

• Dedicated to improving the quality and affordability of health care in Oregon

• Celebrated our 16th anniversary

Mission• To improve the quality and affordability

of health care in Oregon by leading community collaborations and producing unbiased information.

Oregon Health Care Quality Corporation

Hospitals

Health Plans

Consumers

ProvidersDelivery System

Executives & Managers

Employers

Policymakers

Content Experts & QI

Professionals

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Role of Regional Data Collaboratives

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Regional Collaboratives: The Innovation Infrastructure• Setting a community vision for community benefit• Trusted, neutral conveners• Experts in data use and impact• Knowledge of local challenges and opportunities• Consumer and community engagement• Helping stakeholders improve• Scalable innovations from and for practitioners• Regional partners to implement change

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NRHI Members 11 of 13 Qualified Entities

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2006 situation…. Looking for healthcare data

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Q Corp Voluntary Claims Data Collaborative: 2006-present

• Data Collaborative –major health plans, State of Oregon Medicaid and CMS QE Medicare data

• 3.5 million unique Oregonians captured in claims 600+ million medical and pharmacy claims records

• All providers in the directory are eligible to receive quality reports with patient-level information for follow-up

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Q Corp Claims Data Summary

Fully Insured Commercial population

80% Self Insured Commercial population

35%

Medicaid population

100%Medicare FFS, MA and CMS QE

92%

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Oregon Medicare Advantage Penetration as of 12/31/15

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Increased Number of Providers Receiving Reports

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Measure report period ending 06/30/2015

Medicare Fee for Service members are a distinct demographic

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Measure report period ending 06/30/2015

Q Corp Statewide ReportAnnual Statewide Report• Medical groups• State agencies• Consumer groups• Employer groups• Public policymakers• Participating health plans• Other funders

Available at:www.Q-Corp.org

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Q Corp Statewide Report

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Public Reports: Q Corp Consumer Friendly Website

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Report 1: Group and Clinic Scores

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Background

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What is Total Cost of Care?

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Health Partners Total Cost of Care Overview

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About the Total Cost of Care MeasuresPopulation-based measure of average cost for the health care of an attributed population.• Total per capita costs (or resources used) for a panel of patients attributed to a primary care clinic

– Includes all care delivered to all attributed patients• Professional, Outpatient, Inpatient and Pharmacy

– Includes all allowed amounts

• All payments made by the patient and the insurer• Commercially insured patients only• Clinic-level reporting measured against a benchmark• Based on the patented algorithm of HealthPartners, Inc. • In use for over 10 years and adopted nationally. Over 125 licensees in 35 states

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Risk-Adjusted CostCosts per member per month (PMPM) are adjusted to account for patient characteristics.• Patients are grouped based on diagnoses, age and gender using Johns Hopkins’ Adjusted Clinical

Groups (ACG) risk adjusters

– One ACG per person per time period

– 92 different ACGs active at a given time. Each ACG includes individuals with a similar pattern of morbidity

– Unit of analysis is patient and not visit or service

– Person-focused: captures longitudinal, multi-episode dimension of care• Exclusions:

– Costs over $100k per patient for one year measurement period– Patients under the age of 1 or over the age of 65

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Clinic Comparison Reports

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Clinic Comparison Report Package• Quality, Cost and Utilization at the clinic level• Clinic reports mailed and emailed to 79 medical groups in Oregon. A total of 143 adult

and 44 pediatric clinic-level reports were sent in 2016.• Cover letter• Definitions and Glossary Sheet• Report

– Demographics & Cost Overview– Professional– Outpatient– Imaging and ER– Inpatient– Chronic Conditions– Pharmacy– Year over Year

• Frequently Asked Questions (FAQ)– Includes Section on How to Use These Reports

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Q Corp Clinic Comparison Reports

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Q Corp Clinic Comparison Reports Cost Detail

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Early Findings• Considerable

variation among clinics and between regions across Oregon

• Rural clinics show higher cost and lower quality, on average

• Q Corp is working to better understand cost drivers and what providers can do to influence them

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Expanding to Medicare Population

• Providers eager to see more than Commercial population • Q Corp is able to access data through CMS Qualified Entity program• Key issues:

– Attribution– Dual Eligible – Pharmacy– Compatibility with QRUR reports

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‘Technical Assistance’ Priorities

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Next Steps: Priorities for Total Cost of Care

• With NRHI, exploring reporting for Medicaid and Medicare populations– Q Corp will be one of three regions to pilot TCOC on Medicare FFS

• Review Year over Year trend variations• Phase III grant -Additional reporting through 2017– Further explore potential Medicaid measures–Mentor additional communities

• Explore ways that TCOC work can be expanded beyond grant renewal–Custom services for: IPAs, professional societies, CCOs, etc.

• Technical Assistance planning

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Payment Reform Uses - Evolution

2006-2008 • Early pioneering of quality measures and public reporting

2008-2010 • Education about opportunities for quality improvement

2010-2012• Pay for performance contracting, multi payer

collaborative efforts around primary care• Q Corp data used to evaluate quality and utilization

2012-2014

• Major transformation in State Medicaid programing -PCPCH and use of Q Corp measures

• Oregon Exchange measures • Coordinated Care Measure Validation

2014-2016• Continued use in contracting and P4P, TCOC

introduced, community planning around CPC+ and MACRA, QE data key factor

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Regional Health Improvement Collaboration and QE Data to Support Payment Reform• Neutral convener, facilitation and consensus • Data analytics to test and evaluate APMs • Technical assistance to explore issues and develop improvement plans • Better together – individual plans, payers and health systems can not

capture the data or results alone • Robust, standardized quality, utilization and cost data – don’t compete

for data, compete on the results• It’s better for patients, too!

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Greatest Opportunities for Collaboratives with QE Data to Support APMs• We need public and private data combined to transform healthcare- follow the

people• Providers need the ability to “see” entire population during multiple regional and

national transformation efforts – health plans and providers cannot do this on their own, no matter how large

• Quality improvement activities on the ground at practice level – sense making –all providers and stakeholders need this information together to change care and outcomes

• Standardize methodology and metrics – stop the madness! • RHIC and QE data are QPP enablers!

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Thank youMylia Christensen, Executive Director• Oregon Health Care Quality Corporation• HealthInsight Oregon

Websitewww.Q-Corp.orgwww.healthinsight.org

EmailMylia.Christensen@Q-Corp.orgmchristensen@healthinsight.org

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