Practical Applications for Benchmarking Commercial ACOs

Lindsay Erickson

IHA Stakeholders Meeting

October 3, 2018, Los Angeles, California

© 2017 Integrated Healthcare Association. All rights reserved. 2Copyright © 2015 Integrated Healthcare Association. All rights reserved. 2

• Marc GottliebPayment Innovation Strategy DirectorAnthem

• Tammie LindquistSenior Director for Strategic Planning for Value Based ContractingAetna

• Nirav Vakharia, MDBoard Certified InternistCleveland Clinic

• Tracy SpinksSenior Director, Quality InnovationNational Quality Forum

Today’s Panel

© 2017 Integrated Healthcare Association. All rights reserved. 3

AMP Commercial ACO Program Objectives

Align Measurement

Broad physician organization participation

Leverage trusted process & reduce burden

Establish meaningful benchmarks

AMP Commercial HMO standard metrics of accountability across participating physician organizations and health plans is actively monitored, developed, and maintained by participant-led committees

Across statewide health plans with an ACO line of business, most physician organizations with ACO contracts—32 of 39, or 82%—are already participating in Value Based P4P

IHA is a neutral party for collecting, aggregating, and reporting clinical quality, utilization, & cost data. VBP4P has a well-established process for collecting and reporting quality and resource use data

Consistent commercial ACO performance & statewide benchmarks for health plans, physician organizations, purchasers, & consumers provides useful context for commercial ACO performance and reduces distractions around performance measurement

© 2017 Integrated Healthcare Association. All rights reserved. 4

1. Necessity of standardized collection and aggregation

2. Attainment and improvement are important for engagement

3. Stable and known benchmarks are critical for effective performance improvement

4. Simplicity and transparency foster trust

5. Striving for consistency is obvious, but achieving it is challenging

6. Value of placing performance in broader context

Lessons Learned from AMP Commercial HMO

© 2017 Integrated Healthcare Association. All rights reserved. 5

AMP Commercial HMO Benchmarks in Practice

MEASUREAttainment

Threshold (MY 2016 75th percentile)

Attainment

Benchmark (MY 2016 95th percentile)

CLINICAL DOMAIN

Cardiovascular:

Annual Monitoring for Patients on Persistent Medications: ACEI/ARB

and Diuretics86.79 90.50

Proportion of Days Covered by Medications: RAS Antagonists 74.56 80.81

Proportion of Days Covered by Medications: Statins 70.03 75.34

Controlling Blood Pressure for Non-Diabetic People with

Hypertension67.87 84.00

Diabetes:

Diabetes Care: Blood Pressure Control <140/90 mm Hg 72.61 84.47

Diabetes Care: HbA1c Control < 8.0% 64.75 70.97

Diabetes Care: Two HbA1c Tests 66.94 76.57

Example 2017 Individual Measure Benchmarks from AMP Commercial HMO Scoring

IHA Stakeholders MeetingOctober, 3, 2018

This Measure Incubator® project is a collaboration between the Integrated Healthcare Association and the National Quality Forum.

Guiding Principles for Developing Performance Measure Benchmarks

in Commercial ACOs

National Quality Forum Measure Incubator®Overview

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▪ National Quality Forum (NQF) is a not-for-profit, nonpartisan,

membership-based organization that works to catalyze

improvements in healthcare

▪ In 2016, NQF founded the Measure Incubator® as an innovative

effort that facilitates efficient measure development and testing

through collaboration

▫ Address important aspects of care for which quality measures are

underdeveloped or nonexistent

▫ NQF facilitates the work of others; NQF itself does not develop measures

Slide courtesy of the NQF Measure Incubator®.

BackgroundProject Goals

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The Integrated Healthcare Association and the NQF Measure

Incubator® convened an Expert Panel to:

▪ Facilitate development of a benchmarking framework for commercial ACOs.

The Expert Panel:

▪ Reviewed an environmental scan of benchmarking methods and factors

associated with variation in commercial ACO performance measure scores.

▪ Identified challenges and potential solutions to benchmarking performance

measures in commercial ACOs.

▪ Identified principles for benchmarking performance measures used within

commercial ACOs.

▪ Lindsey Bourne, BADirector of Education & Patient and Family AdvisorPatient and Family Centered Care Partners

▪ Linda Brady*Health Care Strategy and Policy, ACO Portfolio and Provider Network Strategy Manager, The Boeing Company

▪ Marc Gottlieb, MPA*Payment Innovation Strategy Director Anthem

▪ Cathy Grant*Director, Value-based Contracting Strategy Aetna

▪ Elizabeth HelmsPresident & CEO, Co-FounderCalifornia Chronic Care Coalition

▪ Chip Howard, BBASenior Vice PresidentRemedy Partners

Expert Panel

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▪ Lance Lang, MD, FAAFP*Chief Medical OfficerCovered California

▪ Rachael Matulis, MPHSenior Program OfficerCenter for Health Care Strategies, Inc.

▪ David Muhlestein, PhD, JDChief Research OfficerLeavitt Partners, LLC

▪ Jennifer Perloff, PhDScientist, Deputy DirectorInstitute for Healthcare SystemsThe Heller School, Brandeis University

▪ Adam Solomon, MD, MMM, FACP*Chief Medical OfficerMemorialCare

▪ Nirav Vakharia, MDBoard Certified InternistCleveland Clinic

▪ Wei Ying, MS, MBADirector of Performance Measurement Method and Population HealthBlue Cross Blue Shield of Massachusetts* Participates in IHA AMP Commercial ACO program

Expert Panel Insights Diverse Stakeholder Needs

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Patient

Provider Selection

• Which ACO provides high quality, reasonably priced care to meet my needs?

• How do ACO providers care for “patients like me?”

Purchaser

Plan Design and Provider Network Selection

• Which ACO provides high quality, reasonably priced care that meets my customers' needs?

• Which ACOs are meeting attainment goals?

Plan/Payer

Provider Contracting

• Has a given ACO met its performance target and improvement goals?

• What factors drive performance variations across ACOs under contract?

ACO Provider

Quality Improvement

• How does my ACO compare to similar ACOs?

• How has my ACO’s performance changed over time? What are areas for improvement?

Expert Panel Insights Benchmarking Challenges

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▪ Substantial variation across ACOs impacts performance

▪ Variation influences stakeholder decision-making differently

ACO Size/Composition

Plan DesignProduct Type

(HMO vs. PPO)

AttributionMethod

U.S. RegionBeneficiary

Composition & Attrition

Patient

May be important, if clearly linked to cost and quality

Purchaser

No major influence on decision-making

Plan/Payer

Clarify performance variation, but not used to “adjust” assessments

ACOProvider

Identify comparative peer groups

Expert Panel Insights Benchmarking Challenges

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▪ Limited access to timely, robust performance data

▪ Attribution of services/costs outside the ACO’s control

▪ Measurement/reporting burden and administrative costs

▫ Tradeoff between administrative simplicity and complex analyses

▪ Identifying appropriate comparison group

▫ Factors to Consider: volume, region, attribution method, plan design,

size (e.g., # of contracts and/or beneficiaries)

▪ Instability in performance measures/targets and patient

population

Expert Panel InsightsKey Recommendations

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Contextualize Without Masking Variation

Quality Measures: Risk Stratification

Cost & Utilization Measures:Judicious Risk Adjustment

Adopt a Blended Benchmarking Approach

Target Performance Score + Improvement Goal

Enable “Shift and Shrink”

Incentivize improvement Minimize variationHelp stakeholders understand

variation in performance

Executive SummaryOverview of Proposed Principles*

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Approach should meet the needs of all stakeholders.

Principle 1Meet Multiple

Stakeholder Needs

Approach should support actionable, meaningful, and useful comparisons and be flexibility to accommodate the evolution of ACOs and measure sets.

Principle 2Support Meaningful

Comparisons and Allow for Program Evolution

Approach should present performance data with contextual information, including stratification for ACO characteristics, to support appropriate interpretations and comparisons.

Principle 3Provide Critical Context

for Accurate Interpretation of Results

Approach should be a blend of target scores and improvement goals to support meaningful performance improvement efforts.

Principle 4Incorporate Appropriate

Performance Targets and Improvement Goals

Approach should be simple to implement and remain consistent to facilitate improvement activities and limit administrative costs.

Principle 5Be Simple to Implement

and Stable Over Time

*Note: These principles should be collectively considered when assessing a benchmarking method.