safety net apm workgroup for advancing delivery & payment ... · 12/12/2018 · vision for...
TRANSCRIPT
Safety Net APM Workgroup forAdvancing Delivery & Payment Reform
December 12, 2018 Webcast
Agenda
• AACHC, CVN, & SNAC Overview
• Presentation- Measurement for Alternative Payment Methodologies
• Tony Rogers– Health System Leader and APM Extraordinaire
• Next steps- APM Readiness Assessment; survey(s) sent out
• Next educational event, please mark your calendar:• AACHC and CVN annual conference February 11-13, 2019
Arizona Community Health Centers
Arizona
• Population of 7+ million
• Nearly 114,000 square miles
Arizona Community Health Centers:
• 230+ individual sites
• Located in 14 of the 15 counties
• Served over 680,000 patients in 2017
• Provide over 2.3 million annual visits
Mission
Strategic Goals
25 Full Members
9 Associate Members
• 21 FQHCs
• 2 FQHC-LAs
• 1 RHC
• 1 Urban Indian Program
11 Active Peer Networking Committees
• Value Based Reimbursement
• Position Health Centers as
Primary Care Providers of Choice
• Innovative Practice Models
• Health Informatics
• Position Health Centers as
Employers of Choice
To promote and facilitate the development and delivery of affordable and accessible community oriented, high-quality, culturally effective primary
healthcare for everyone in the state of Arizona. This will be accomplished through advocacy, education and technical assistance.
Mission
Business Objectives
• Collaboration across communities for affordable quality health care
• Statewide community-based patient-centered primary care network
• Data-based benchmarking and decision making
• Demonstrable value-based care through QI, health outcomes, and lower costs
• Fiscally sustainable operations to meet continued growth in populations served
Business Model
To foster collaborative business activities which enhance Community Health Centers’ individual abilities to serve their communities to meet the
needs of Arizona’s uninsured, underinsured and underserved.
• 18 CVN Corporate Members
• 19 HCCN Participating Health Centers
• 17 HAN Participating Provider Entities
AACHC
Associate Members
FQHC-LAs
FQHCs
RHCs
Sponsors
Primary Care Association
Advocacy for BPHC Grantees
Support CHC Services throughout AZ
11 Peer Networking (QI, CFO, etc.)
Technical Assistance, Education & Training
CVN
FQHC-LAs
FQHCs
RHCs
Implementation of “Best Practices”
Integrated Data Management
Integrated Services Network
Clinical Integration (IPA)
Other Collaborative Business Services
Clarifying AACHC and CVN Roles
Advancing Delivery & Payment Reform
National Safety Net Advancement Center
The National Safety Net Advancement Center (SNAC) aims to transform the ability of U.S. safety net organizations to respond to payment and care delivery reform efforts in health
care’s fast evolving financial and delivery environment. This will be accomplished by leveraging new and existing knowledge into actionable tools for safety net organizations.
SNAC is supported by the Robert Wood Johnson Foundation.
Safety Net Advancement CenterSafety Net APM Workgroup
SNAC is providing CVN funding to facilitate a collaborative effort to advance a Payment Reform Strategy for Safety Net providers in Arizona that supports
• Achievement of the Quadruple Aim in health care transformation
• Future operational/financial sustainability of patient-centered value-based primary care through these organizations
The Safety Net APM Workgroup’s approach to advancing Delivery and Payment Reform will be to identify APMs that support a Value-based Transformation Framework which interlinks value-based “Quadruple Aim” goals with four domains of primary care clinical operations: care delivery, operating infrastructure, people and funding. These APMs should support and promote patient-centered value-based primary care
Safety Net APM WorkgroupOrganizational Participants and Stakeholders
Participants: Arizona Safety Net provider organizations able to participate in APM
FQHCs and FQHC-LAs; Behavioral Health Organizations; and Arizona
Tribal Health Organizations
Stakeholders: Other provider and non-provider organizations enabling successful Delivery & Payment Reform
• Acute Care Providers (CIPNs, Hospitals, Specialists, etc.)
• Community-based Agencies and Organizations
• Health Plans (multiple product lines), ACOs, AHCCCS and CMS
• Health Care Associations (e.g., AACHC, AZ Council for Behavioral
Health, Arizona Tribal Health Council, AzDA, etc.)
Safety Net APM WorkgroupCycle One Project Goals
• Identify the driving forces of Delivery and Payment Reform
• Define current APMs in use and available to Safety Net providers
• Discuss the challenges and barriers to Safety Net providers’ participation in Delivery and Payment Reform and strategies that may address them
• Provide tools for a self-assessment of the Safety Net organization’s readiness and adaptability to Delivery and Payment reform
• Recommend a Value-based Transformation Framework for identifying and prioritizing “next steps” toward Delivery and Payment Reform
Vision for Safety Net APMsValue-Based Transformation Framework
Safety Net APM Workgroup
Identify and prioritize opportunities to advance integrated patient-centered
value-based care through the efficient and effective application of resources across all domains of primary care operations and improve financial sustainability through alternative payment methodologies that give recognition to achievement of the
Quadruple Aim.
Safety Net APM Workgroup
Webinar Series
Date Time Topic
September 26th 12:30-1:30 Kick-off Meeting: APM Methodology for Value Based Care
October 24th 12:30-1:30 How Do You Assess Your Organization’s Readiness
November 14th 12:30-1:30 Strategies and Activities to Achieve Readiness
December 12th 12:30-1:30 Measurement for Alternative Payment Methodologies
Measurement for Alternative Payment Methodologies
Tony Rodgers
CVN Chief Strategy Officer
Topics To Be Covered
I. Background: Alternative Payment Models
II. Payer and Provider Alignment Around Common Performance Measures
III. Performance Measure Development and Use
IV. Performance Measure Benchmarking and Results Reporting
V. Cost and Service Utilization Benchmarking
VI. Summary
14
Background: Alternative
Payment Models
15
Alternative Payment Models Alternative Payment Models requires “two to tango”:
1. The Payer’s role:
Establishes an alternative payment method
Establishes an agreement or contract with willing providers
Determines the quality/outcome and financial performance requirements to earn alternative payment
Determines which patients are eligible
Performs the patient attribution or assignment to the participating network providers or healthcare organization
Collect data and evaluate performance against benchmarks
Establish a process to accurately pay the alternative payment
2. The Participating Provider (Network or Healthcare Organization):
Meet the contract performance requirements (i.e. quality/outcome and cost performance benchmarks).
Cost effectively manage the care of assigned/attributed patients.
Provide the required data and performance information to the payer.
Alternative Payment Models (APM) refers to a provider payment
arrangement that is used as an alternative to a straight Fee for
Service payment method. Alternative payment is a term coined by
Medicare and is CMS’s version of value-based payment.
APM payment arrangements require agreement between a payer
and a either a participating provider, provider network, and/or
healthcare organization.
Alternative payment arrangements have two key elements:
1. A set of quality or outcome measures and benchmarks.
2. Embedded financial risks and rewards that are based
on the total cost of care performance.
16
Economic Principles Underlying Alternative Payment Methods
Alternative Payment Methodologies are demand side healthcare management and cost containment strategies, designed to financially incentivize providers to be accountable for the efficient used of resources and for the management patient’s total cost of care.
Alternative payment places healthcare providers at shared financial risk for both cost (resource utilization) and as well as achievement of desired healthcare outcomes (quality performance).
The behavioral economic principles behind alternative payment methods:
1. Shared Financial Risk- will encourages healthcare providers to manage cost, improve quality, and use healthcare resources more efficiently.
2. Clinician Accountability- Healthcare provider become the de facto point for controlling unnecessary service utilization and cost, which means providers should benefit from savings earned by their efficient use resources and management of cost.
3. Aligned Performance Priorities and Goals- Payers and healthcare providers have aligned financial incentives around common performance goals and priorities.
4. Continuous Performance Improvement- Healthcare providers have an embedded economic incentive in alternative payment to continually improve performance in both cost and quality.
17
The Specific Purpose of Alternative Payment
Arrangements
Alternative payment methods are designed to enable healthcare providers or healthcare organizations to:
Improve care for patients who are receiving a specific treatment or medical procedures.
Improve care during a specific time periods or cycle of care for patients who have a specific health condition or combination of conditions.
Deliver more coordinated, efficient care for patients who have a specific condition or are receiving a specific treatment or medical procedure.
Improve the efficiency of care and/or outcomes for patients receiving care for multiple chronic conditions or at multiple provider sites in the healthcare delivery system.
Improve care for patients with specific conditions or who are in early stages of a condition to prevent the conditions progression to a more acute stage.
Improve care for the health conditions of a population of patients, or to prevent the development of health problems in a population of patients with particular risk factors.
Support delivery of innovative model of care or a different mix of services that reduce acute care utilization and cost for a population or group of patients.
Better align healthcare provider payment with patient health outcomes.
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Types of Alternative Payment Models
Common alternative payment arrangements:
Shared Savings without Downside Risk: Pays providers a share of the savings generated by achieving quality and reducing total the cost of care for an assigned/attribute population of patients.
Shared Saving with Downside Risk: Pays net savings or recoups net losses earn by the participating providers for assigned or attributed patients.
Bundle Payment: Pays the provider one all-inclusive rate for a bundle of services provided for a specific patient’s medical condition or for a specific medical or surgical procedure. This type of payment may include a withhold or bonus by the payer to assure that quality measures are met by provider.
Episode of Care: An episode of care payment pays the provider a set all-inclusive payment for a scope of services for a specific medical condition over a specific time period (e.g. an episode of care payment for prenatal, delivery, and post partum care).
Global Payment: A global payment is usually a pre-paid capitated payment provided for the provision of a scope of services provided to a defined population (e.g. patients with HIV/AIDS). The provider organization have financial risk for the provision of a define scope of services to a specific population of assigned patients. This type of payment is usually considered for a high-risk chronically ill patients, who can benefit from effective care management and care coordination.
Alternative payment methods may continue to
use Fee for Service in the construction of the
provider payment arrangement For example:
1. Financial incentives and penalties may be
applied to the Fee for Service payment.
2. Fee for Service rates may be used to
establish financial benchmarks for shared
savings.
3. Fee for Service schedule may be used as
the basis for a bundled, episode of care
payment, or to determine a global all-
inclusive payment.
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Key Factors in Designing Alternative Payment Methods
Key Components of Alternative Payment Arrangements
Payer Attribution
Assignment
Methodologies
The process used by the payer to attribute or assigned a patient to an accountable provider.
The attribute/assignment can impact the healthcare provider’s ability to meet the quality
measure benchmark. Attribution parameters can include:
The criteria used to determine which providers are eligible for patient assignment
The minimum and maximum length of time (in months) that the patient is
attributed/assigned to the provider for the purpose of performance reporting and
alternative payment.
Patient opt-in opt-out criteria
Patient’s knowledge and compliance with attribution or assignment to the provider
Quality Measures
and Benchmarks
The population appropriate measures and benchmarks used to compare and evaluate quality
performance.
Total Cost of Care
Benchmark
The average per beneficiary per year total cost of care baseline or target as determined from
previous years claims data.
Risk Adjustment
Factors
The formula and factors used to stratify patient by risk categories or logical risk groupings and
application of these factors to make risk adjustments equitable to providers as it relates to
total cost of care performance.
Scope of ServicesThe scope of services that are included in the alternative payment arrangement on which the
total cost of care benchmark analysis is based.
Provider
Accountability
The method used to determine the specific providers financial and quality performance
accountability.
Data Collection
Reporting
Requirements
The specific data sources, data types and data sets must be collected and analyze to validate
provider quality and cost of care performance results.
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Payers and Providers Alignment Around Common
Performance Measures
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Alignment Around
Healthcare Value
22
Value-based care requires the alignment of payers/health plans, and providers around common sets of performance measures that in aggregate represent “value”.
Healthcare Value is measured by cost, quality/outcome, and patient experience.
To evaluate the healthcare value provided to patients, payers and health plans establish performance measures and benchmarks.
Performance measures represent a proxy for healthcare value.
Value may be segmented into performance ranges that differentiate levels of value (e.g. poor, acceptable, better, and best).
In addition, payers must be mindful of creating significant additional administrative burden and operational costs for themselves and healthcare providers.
Alternative payment methods (aka value-based payment) have embedded financial incentives to align providers to payer performance improvement priorities.
Outcomes from the
Care Process
Efficient Resource Used Containment of
Service Cost Reduction of
Unnecessary or Preventable Service Utilization Reduction in
Administrative Burden and Cost
Evidence-based Management of Illness and Disease Better Health
OutcomesPopulation Health Improve Patient
Functional StatusImprove Wellness and
Quality of Life
Payers, Health Plans, and Providers Seek Alignment
Around the Domains of Healthcare Value
Domains of Healthcare Value
Cost of Care
Improve Patient Experience with CarePatient SafetyCompliance with Care
& TreatmentPatient and Caregiver
Engagement in Care Reduction of Patient
Risk Factors
Patient and
Caregiver Experience
23
Payers establish performance
measures as a “proxy” for
value.
Alternative payment methods
are used to align providers to
the performance improvement
priorities of payers.
Performance Measures
Performance measurement is a process that uses claims, clinical, or self-reported data to calculate standardized measurements of performance.
Standardizing performance measurements make it possible to compare performance improvement year to year, or between providers or health systems.
The level of quality performance is determined using standardized measures of one or more aspects of care that are believed to be important in achieving specific patient outcomes.
Cost performance is measure of the change in the total cost of care from one performance period to the next, starting with a baseline total cost of care that is calculated from previous period aggregate cost and utilization for a similar population.
Patient experience with care is usually calculated from patient responses to standardized patient experience surveys.
In addition to CMS and other federal healthcare agencies, there are several national healthcare organizations and professional societies that are involved in developing quality and outcome measures that can be used by payers for care of specific medical conditions and populations of patients.
Individual quality/outcome measures are typically calculated using standardized formulas with a numerator (individuals receiving specific care/treatment), denominator (number of individual eligible for the specific care/treatment), from which a performance value is calculated.
Measure results are usually shown as a ratio, a percentage, or numeric score (as in the case of a composite score).
Payers have some discretion on determining the performance benchmark or target for each required performance measure.
24
Types of Quality Measures
Types of Quality Measures Used with Alternative Payment Models
Measure Type Description
Appropriate UseThis is a measure of the use of a medical equipment, medical procedure, medication, treatment or process based on
the patient condition or medical need. For example, appropriate use antibiotics for Otitis Media if a previous chest x-
ray was performed.
Composite
Combination of two of more individual measures into a single measure with a single score. The information can be
greater than the sum of its parts because it paints a more complete picture. This measure type is typically used to
evaluate a “cycle of care” for a patient with a specific chronic or medical condition.
Cost/Resource Use A measure of the amount, usually specified in dollars, related to receiving, providing, or paying for medical care.
Resources use measure focus on the effective use of goods or services that are combined to produce medical care.
They are inputs that have a price assigned to them.
Efficiency Measures that combine factors of cost and quality. At a given level of quality, services can be highly efficient or
inefficient. Improved efficiency comes from providing high-quality healthcare at lower cost.
OutcomeOutcome measures assess the results of healthcare that are experienced by patients. They include endpoints like
well-being, ability to perform daily activities, or even death. An intermediate outcome measure assesses a factor or
short-term result that contributes to an ultimate outcome, such as having an appropriate cholesterol level.
PRO-PM OutcomePRO-BASED PERFORMANCE MEASURE (PRO-PM): a way to aggregate the information that has been shared by
the patient and collected into a reliable, valid measure of health system performance. Patient reported outcomes can
include patient self-report experience with care, patient self-assessment, etc.
ProcessProcess measures are indications of what a provider does to maintain or improve health, either for healthy people or
for those diagnosed with a health care condition
Structural Structural measures are measures of infrastructure in the care setting such as: physical elements, EHR and
information systems, procedural and workflow capability and capacity to provide high-quality care.
Intermediate Clinical
Outcome
Measure of a preliminary or initial stage patient outcome.
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The Role of Alternative Payment in Aligning Payer’s and Provider’s Quality Priorities
Alternative payment methods is a financial mechanism for aligning payer and providers to common quality performance priorities.
Organizational Entity Role
HHS and other Federal
Healthcare Agencies
Establish national strategy, priorities, and goals
National Quality Organizations
and Profession Societies
Develop, maintain, propagate, and evaluate quality
measures
Payers (Including Employers) Set specific quality performance priorities and
targets and use alternative payment to incentivize
improved quality and outcome performance.
Health Plans Apply payer quality priorities, assesses the services
provided by the health plan and the overall
performance of providers in the plan’s network.
Report overall quality results and use alternative
payment arrangement to incentivize improvement in
quality performance and outcomes.
Healthcare Provider Networks
and Organizations
Assesses the overall quality performance of
providers in their networks and healthcare
organization, report quality performance, and
support continuous quality improvement efforts.
Individual Providers Provide data for quality reporting, participate in
quality improvement efforts, align healthcare
practices with to achieve quality benchmarks.
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AHCCCS Goal for Alternative (Value-Based) Payment
AHCCCS requires its Medicaid managed care health plans to phase-in alternative value-based payment methods for their contracted provider networks over the next four years.
AHCCCS’s goal is that eventually 80% of AHCCCS healthcare providers will be paid using some form of alternative payment.
AHCCCS believes that alternative value-based payment should:
1. Incentivize and reward healthcare providers for performance improvement and cost containment
2. Align healthcare providers to AHCCCS performance improvement priorities.
27
Performance Measure Development and Use
28
What Goes into Designing Quality Performance Measures?
Measure Description: A short description of the measure and measure parameters
Numerator Statement: An explanation of which patient types or clinical events are included in the measure numerator. e.g. patients readmitted with 30 days of hospital discharge
Denominator Statement: An explanation of patient types or clinical events that are included in the measure denominator e.g. all patient admitted to hospital during the performance period
Exclusions: A explanation of what specific condition related to patient types, clinical events, or measure parameter that would exclude the data from being included in the numerator or denominator for measure calculation. e.g. patients that are readmitted under a second diagnosis
Risk Adjustment: Determination of whether the measure is to be risk adjusted
Classification: How is the measure classified
Measure Type: Define the measure type: e.g. Process, Measure, Composite, Outcome Measure etc.
Measure Format: Description of the format of the measure e.g. percentage, average, number, ratio, aggregate score etc.
Use in Federal/State Program: Is the measure used by a federal program e.g. Medicare, Medicaid, HRSA, or other
Condition: Description of the relevant medical condition the measure is targeting
Non-Condition Specific: Description on non-condition specific events or activities the measure is targeting e.g. Care Coordination of high-risk patients, Readmissions, Care Planning Transitions of Care, Safety, Overuse
Care Setting: Description of the care setting the measure is relevant for e.g. hospital, primary care site, skill nursing facility etc.
National Quality Strategy Priorities: Describe which National Quality Strategy Priorities the measure is addressing
Actual/Planned Use: Describe how the measure is or will be used e.g. Quality Improvement (external benchmarking to organizations), Quality Improvement (Internal to the specific organization), value-based payment arrangement quality measure, etc.
Data Source: Description of the source of data that will be used in the measure calculation e.g. Claims, EHR clinical data, Other
Level of Analysis: A description of the level that the analysis for the measure will be applied e.g. clinic/provider level, provider network level, population specific level, service area, statewide, national
Target Population: Description of the relevant target population the measure is focused on e.g. Children, Elderly, Patient with person with specific chronic illness, dual eligible beneficiaries
Measure Steward and Contact Information: Who is the measure sponsor e.g. CMS, State Medicaid, Health Plan, NCQA, HRSA etc. 29
National Quality Forum (NQF)Measurement Development Process
The Department of Health and Human Services establish broad strategies and priorities for quality performance and population health outcomes.
Medicare and Medicaid contract with organizations like the National Quality Forum to help design and promulgate common quality measures in both the private and public healthcare sectors.
Professional groups and foundations also contribute to the quality measurement portfolio of NQF.
NQF provides excellent documentation and training materials on their quality measures.
30
CMS Vision for Measure Development
31
CMS supports measure alignment across federal, state, and private programs.
CMS is interested in promoting efficient data collection of measure-related data and in improving population health.
CMS will continue to work towards balancing individual and shared provider accountability.
Measures should address critical clinical gaps in care, support evidence-based medicine, and should engage patients as well as clinicians in care delivery.
Measures should promote healthy living, assist in a better understanding of a patient’s overall health, promote coordinated care, and help in reducing disparities in healthcare.
Publicly reported measures should help consumers make informed decisions regarding their healthcare and choice of clinician, facility, and services.
CMS Measure Development Process
Determine
Basis for
Measures
Develop a
work planDefine Measure
Topics
Technical
Advisory
Panel (TEP)
Develop a
Framework for
Measure
Construction
Search for
Existing
Measures
TEP Confirms Measure
Appropriateness &
Framework
Public Comment
if deemed
necessary
Public Comment
on Test
Measures
Conduct
Measure
Testing
TEP evaluates
list of measures
Develop list of
candidate
measures
CMS Approves
recommended
measures
Develop
measure detail
specifications
CMS Approves
Final Measures
Consensus
Endorsement, if
deemed necessary
Consider Sending
for Consensus
Endorsement
Measure Ready For
Use
21
63 4 5
10
987
11 12 1314
18171615
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CMS Measure Development Priorities
Person and caregiver-centered experience and outcomes: Measures that address the experience of each person and their family; and the extent to which they are engaged as partners in their care.
Patient Reported Outcome Measures (PROMs). Measures of person or family-reported experiences about their involvement and active engagement with the health care team as a collaborative partnerships with providers and provider organizations.
Communication and care coordination: Measures of the promotion of effective communication and coordination of care; and coordination of care and treatment with other providers.
Efficiency/cost reduction: Measures that address the affordability of health care, including unnecessary health services, inefficiencies in health care delivery, high prices, fraud, and measure value over volume.
Patient Safety: Measures that address an explicit structural element, process, outcome intended to make care safer. Measure should be based on evidence that the presence or absence of such structural element or process has been shown to cause harm in the delivery of care.
Appropriate use: Measures that address appropriate use of services and resources, including measures of over use.
33
Example of Medicaid Core Measure Set for Children
Primary Care Access and Prevention Measures
NQF # Measure
Steward
Measure Name
0024 NCQA Weight Assessment and Counseling for Nutrition and Physical
Activity for Children/Adolescents – Body Mass Index Assessment for
Children/Adolescents (WCC-CH)
0033 NCQA Chlamydia Screening in Women Ages 16–20 (CHL-CH
0038 NCQA Childhood Immunization Status (CIS-CH
0418/
0418e
CMS CMS Screening for Depression and Follow-Up Plan: Ages 12–17
(CDF-CH)
1392 NCQA Well-Child Visits in the First 15 Months of Life (W15-CH)
1407 NCQA Immunizations for Adolescents (IMA-CH)
1448 OHSU Developmental Screening in the First Three Years of Life (DEV-CH)
1516 NCQA Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
(W34-CH)
NA NCQA Adolescent Well-Care Visits (AWC-CH)
NA NCQA Children and Adolescents’ Access to Primary Care Practitioners
(CAP-CH)
Quality measure in Medicaid are:
1. Core measures are developed
and approved by CMS.
2. State Medicaid agencies have
discretion on which measures
they include in the State Medicaid
Quality Strategy.
3. Medicaid agencies can also
develop their own state specific
quality measures.
4. The state Medicaid agency may
use the quality measure as part of
a provider incentive payments
program.
5. State Medicaid agency may
delegate the monitoring and
alignment of provider quality
performance to Medicaid manage
care plans.
34
Performance Measure Benchmarking and Results Reporting
35
Establishing Quality Benchmarks for Alternative Payment Arrangements
A Quality Measure Benchmark represents a specific level or range of quality performance.
Payers establish quality benchmarks to differentiate acceptable from non-acceptable provider quality performance.
Payers should be transparent about the construction and design of their quality measures and any performance grouping approach they will use to evaluate and compare provider performance.
A quality benchmark can be a single value, such as a minimum performance target, a range of values, or grouped by quartile, decile etc.
Benchmarking is typically used as part of alternative payment to establish performance targets that demarcate where a financial bonus or penalties will be applied, or the required performance for a provider to become eligible for shared savings.
Multiple quality benchmarks can be used as part of a composite scoring approach.
36
Calculating Quality Measures Results
Name of Measure Data Elements Description of Elements in Measure Calculation
Measure Name:Name or Title of the Measure
Measure ID:An alpha and/or numeric provided to create a Measure ID
Submission Method: The method used to submit measure data or information (e.g.
electronic EHR file, claims data file, attestation etc.)
Measure Type:Alpha or numeric code given that identifies the type of measure e.g.
(process, appropriate use, outcome, etc. )
Benchmark:
An indicator for whether a measure is to be compared to benchmark
or is part of an initial benchmark analysis.
Y = Yes, the measure is included in benchmark analysis
N = No, the measure is not included in benchmark analysis
Standard Deviation:Calculate a standard deviation of performance rate(s)
AverageCalculate average performance rate(s)
Decile data ranges and ending range
Ten equal groups into which a quality results can be divided
according to the equal distribution of values The lower and upper
bound of decile data range(s) to be used and end data range
Topped Out
Measure that have reach the top of their possible performance level
are indicated as “Topped Out”.
Indicate whether or not a measure is topped out.
Y = Yes, the measure is topped out
N = No, the measure is not topped out
Special Scoring
Indicate whether or not a Topped-Out Measure will receive special
scoring.
Y=Yes, the measure is capped.
N=No, the measure is not capped.
Other Scoring Adjustment or Criteria
Indicates additional measure results screening criteria or numeric
adjustments that are applied the final quality score or to the
performance results. 37
Example of Decile Performance Grouping
Diabetes Foot Exam Measure (EHR Submission Method)
Decile Quality Measure
Benchmarks
(In Percent)
Possible Points
Added to
Composite
Score
Below Decile 3 <5.31 3
Decile 3 5.31-10.90 3-3.9
Decile 4 10.99-19.99 4-4.9
Decile 5 20.00-29.26 5-5.9
Decile 6 29.27-38.77 6-6.9
Decile 7 38.78-50.09 7-7.9
Decile 8 50.10-62.60 8-8.9
Decile 9 62.61-76.16 9-9.9
Decile 10 >=76.17 1038
Example of Quality Performance Results
Measure Title Measure
ID
Submission
Method
Measure
Type
Benchmark Standard
Deviation
Average Decile
Range
3
Decile
Range
4
Decile
Range
5
Decile
Range
10
Topped
Out
Diabetes:
Hemoglobin A1c
(HbA1c) Poor
Control (>9%)
1 Claims Outcome Yes 21.7 2233.33-
23.54
23.54-
18.25
18.24-
14.30<=3.3 No
Controlling High Blood
Pressure236 Claims Process Yes 18.1 71.4
58.02 -
63.90
63.91 -
68.36
68.37 -
72.91
>= 94.07No
Weight Assessment
and Counseling for
Nutrition and Physical
Activity for Children
and Adolescents
239 EHR Process Yes 13.9 30.321.69 -
26.09
26.10 -
28.86
28.87 -
30.47>= 40.78 No
Colorectal Cancer
screeningPPRNET18* Registry/QCDR Process Yes 17.4 60.9
46.82 -
51.65
51.66 -
56.97
56.98 -
62.00>= 80.95 No
* NOTE: Measure ID PPRNET18 is a measure sponsored (Measure Steward) by the PPRNet Foundation, which is a member-based
organization whose purpose is to improve the health of the American people by helping primary care clinicians provide evidence-based high-
value quality care.
39
Example of AHCCCS MCO
Quality Measures Benchmarks
MCO Adult Measures
Measure Description Minimum Performance
Standard
Inpatient Utilization Inpatient Days/1000 (IPU) - All Ages 33/1000 Member Months
Ambulatory Care - ED Utilization (AMB) - All Ages 55/1000 Member Months
Plan All-Cause Readmissions (PCR) 11%
Breast Cancer Screening (BCS) 50%
Cervical Cancer Screening (CCS) 64%
Chlamydia Screening in Women (CHL) 63%
Colorectal Screening (COL) 65%
CDC - HbA1c Testing 77%
CDC - HbA1c Poor Control (>9.0%) 41%
CDC - Eye Exam 80%
Timeliness of Prenatal Care: Prenatal Care Visit in the First Trimester or Within 42 Days
of Enrollment (PPC)
64%
Timeliness of Prenatal Care: Postpartum Care Rate (PPC) Baseline Year
Mental Health Utilization (MPT) - All Ages Baseline Year
Use of Opioids From Multiple Providers (UOP) Baseline Year
Use of Opioids at High Dosage in Persons Without Cancer (OHD) Baseline Year
AHCCCS establishes quality measures for
its Medicaid managed care organization.
This includes:
1. National and state specific quality
measures.
2. It establish state specific performance
benchmarks (minimum performance
standards) for its MCOs.
3. AHCCCS expects MCOs to use the
AHCCCS quality measures in value-
based alternative payment
arrangements.
4. MCOs have the discretion to also add
their own quality measures and
benchmarks to alternative payment
arrangements.
40
Quality Measure Transparency
At a minimum payers/health plans should provide the following information to participating providers on each of the quality measures used in alternative payment arrangements:
Description of each quality measure: A statement describing the measure.
Type of measure: Process, composite, structural, outcome, etc.
Data Source(s): The data source (s) that will be used to compile the health care providers performance results.
Target Population: A description of the population that measure is a targeted at.
Denominator: A description of the subset of patients or health plan members for whom a measure is relevant (measure denominator).
Numerator: A description of the healthcare provider’s eligible patients or health plan members for whom the quality measure will be applied.
Exclusions: A description of health plan eligible members that are excluded from the denominator or the numerator.
Frequency: The number of times or frequency the patient is eligible to receive the service during the performance period (once a month, at each visit etc.)
Performance Period: The time frames associated with those achieving the performance target for the patients to be included in the numerator.
Weighting: Any weight given to a quality measures (a percent between 1% and 100%) as a measure of priority that health plan applies to the specific quality measure. The higher the weight the more important the measure.
Scoring Method: The description of the timeframe and score method that the health plan will used to determined the healthcare provider raw performance score for each measure. .
Benchmark: The specific performance target percentage, ration, range, or numeric score that has been set by the health plan as the benchmark for quality performance.
Minimum Level of Participation: The minimum number of patients that must be included in the denominator to have a statistically valid performance score.
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Healthcare Cost and Utilization Benchmarking
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Benchmarking Cost and Utilization for Target Patient Population
Category of Services
Service Utilization and Cost for Target Group of Patients
Average Units of Services Per Patient
Per Year Cost Per Unit
of ServicePer Patient
Cost Per Year
Inpatient Service 3.6 days $1,250 $4,500.00
Outpatient Hospital 4.5 visits $165.00 $742.50
Emergency Room Visits 1.2 visits $445.00 $534.00
Primary Care 3.2 visits $85.00 $272.00
Specialty Care 2.4 visits $135.00 $324.00
Prescription Drugs 56 scripts $45.00 $2,520.00
Laboratory Services 25 tests $38.00 $950.00
Imaging and Radiology 3.2 procedures $205.00 $656.00
Other Institutional 0.8 days $185.00 $148.00
Case Management 3.5 units $45.00 $157.50
Other Medical Services 4.5 services $55.00 $247.50
Average Annual Per Beneficiary Total Cost of Care Benchmark
$10,694.50
An Example of Cost and Utilization Benchmarking
Cost and Service Utilization The payer determines the target cost and
utilization benchmark based on the estimated average
per beneficiary expenditures of the target population of
patients using previous period claims data.
The benchmark should also be adjusted for:
Service and cost trend factors
Service carve out
Benefit or healthcare policy changes
Risk factors
Efficiency discounts or other contingencies (e.g.
reinsurance)
The cost of care benchmark is used as the target to
compare the actual cost performance of the participating
providers and determine the level of cost savings
necessary for the payer share a portion of the net
savings with providers. The cost benchmark is also used
to determine the amount the payer is willing to pay in a
bundle, episode, or global payment arrangement. 43
Modeling Cost and Utilization for a Target Population of Patients
Financial model assumptions include:
The alternative model of care will reduce unnecessary acute care and other service utilization and costs.
The model of care intervention is applied to the entire target population in the “service area”.
Some categories of service utilization and cost will go up while others will go down.
The results of the model intervention will be sustainable.
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Target Change in
Patient Population Cost and Utilization
Current Total Cost Baseline :
$3,968 PMPY
New Total Cost Level
$3,838 PMPY3.3% SAVINGS
Additional Cost of the
Alternative Model of
Care Intervention
$90 PMPY
PLUS
Net cost and utilization reduction from new model: $220 PMPY
MINUS
EQUALS
TOTAL UNITS UNIT COST TOTAL COST OF CARE
Services Per 1000 Beneficiaries Expen Per Baseline Pro Forma
SERVICE BASKET Baseline % Change Pro Forma Service PBPM PBPM
Inpatient hospital
Acute inpatient 2,200 admits -10.0% 1,980 admits $9,100 $1,668 $1,502
Post-acute care
Skilled nursing 400 admits -7.0% 372 admits $13,000 $433 $403
Inpatient rehab 95 admits 95 admits $15,000 $119 $119
Inpatient LTCH 20 admits 20 admits $32,700 $55 $55
Home Health 550 episodes 10.0% 605 episodes $5,500 $252 $277
Total PAC $859 $854
Other benefits/services
OP services 6,200 events -7.0% 5,766 events $630 $326 $303
Emergency room 1,100 visits 1,100 visits
Evaluation & Mgmt 30,000 visits 15.0% 34,500 events $90 $225 $259
Procedures 6,500 events 6,500 events $325 $176 $176
Imaging 7,500 events 7,500 events $85 $53 $53
Lab tests 15,000 events 15,000 events $25 $31 $31
Other tests 4,000 events 4,000 events $35 $12 $12
Prescription Drugs/vac. $360 $360
DME 2,000 events 2,000 events $150 $25 $25
ASC proced. 700 events 700 events $415 $24 $24
Hospice 200 admits 200 admits $9,200 $153 $153
Other 55.0% $56 $87
Total Medicare Cost of Care $3,968 $3,838
Financial Modeling of Cost and Utilization
for Alternative Payment
Cost Benchmarking Medicaid/CHIP Performance
Health Care
Expenditures by
Categories of
Services
Medicaid/CHIP Total Cost of Care
Adult Child Dual Eligible (Only) Disabled/Elderly
PMPM Cost
Benchmark
Estimated
Actual PMPM
Cost for
Performance
Year
PMPM Cost
Benchmark
Estimated
Actual PMPM
Cost for
Performance
Year
PMPM Cost
Benchmark
Estimated
Actual PMPM
Cost for
Performance
Year
PMPM Cost
Benchmark
Estimated
Actual PMPM
Cost for
Performance
Year
Inpatient Hospital $ 300.00 $ 220.00 $ 250.00 $ 170.00 $ 4,000.00 $ 4,500.00 $ 4,000.00 $ 2,500.00
Outpatient Hospital $ 150.00 $ 110.00 $ 130.00 $ 55.00 $ 100.00 $ 130.00 $ 100.00 $ 130.00
Emergency Dept $ 60.00 $ 45.00 $ 70.00 $ 30.00 $ 50.00 $ 50.00 $ 50.00 $ 50.00
Prescription Drugs
(Outpatient)$ 100.00 $ 110.00 $ 20.00 $ 30.00 $ 100.00 $ 120.00 $ 100.00 $ 120.00
Professional Primary
Care $ 400.00 $ 460.00 $ 240.00 $ 275.00 $ 400.00 $ 500.00 $ 400.00 $ 500.00
Professional
Specialty Care $ 150.00 $ 130.00 $ 50.00 $ 75.00 $ 1,500.00 $ 1,500.00 $ 1,500.00 $ 1,500.00
Diagnostic
Imaging/X-Ray$ 20.00 $ 10.00 $ 10.00 $ 20.00 $ 250.00 $ 250.00 $ 250.00 $ 250.00
Laboratory Services $ 7.00 $ 10.00 $ 2.00 $ 7.00 $ 200.00 $ 200.00 $ 200.00 $ 200.00
Dialysis Procedures $ 50.00 $ 50.00 $ 10.00 $ 10.00 $ 200.00 $ 220.00 $ 200.00 $ 220.00
Professional Other $ 50.00 $ 40.00 $ 10.00 $ 20.00 $ 200.00 $ 220.00 $ 200.00 $ 220.00
Skilled Nursing
Facility$ 100.00 $ 60.00 $ 10.00 $ 10.00 $ 500.00 $ 500.00 $ 500.00 $ 500.00
Home Health $ 20.00 $ 30.00 $ 20.00 $ 30.00 $ 300.00 $ 300.00 $ 300.00 $ 300.00
ICF/MR $ 20.00 $ 15.00 $ 30.00 $ 25.00 $ 200.00 $ 200.00 $ 200.00 $ 200.00
Home and
Community-Based
Services
$ 50.00 $ 75.00 $ 20.00 $ 25.00 $ 300.00 $ 500.00 $ 300.00 $ 500.00
Other $ 20.00 $ 30.00 $ 20.00 $ 30.00 $ 150.00 $ 170.00 $ 150.00 $ 170.00
Total $ 1,497.00 $ 1,395.00 $ 892.00 $ 812.00 $ 8,450.00 $ 9,360.00 $ 8,450.00 $ 7,360.00
Net Savings $ 102.00 $ 80.00 $ (910.00) $ 1,090.00
Medicaid Cost Benchmarking is used in
conjunction with alternative payment
arrangements:
1. Medicaid managed care plan determine
the per member per month or per year
benchmark based on previous year
experience.
2. At a minimum is important to separate
benchmarks for each major population
group.
3. The cost benchmark should have any
adjustments, trend factors or withholds
already applied to the benchmark.
4. The healthcare providers participating in
the alternative payment need to
managed cost below the benchmark in
order to receive a share of the net
savings.
5. There must be a minimum of 5,000
patients assigned/attributed from each
Medicaid group (adult, children, Dual
etc.) for the share savings to be
actuarially sound.
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Provider Accountability for Cost and Utilization Performance in Alternative Payment Arrangements
Inherent in an alternative payment arrangement is the healthcare provider’s accountability for one or more of the following aspects of cost and utilization management:
1. Controlling total healthcare cost from the provision of all services that individual patients receive that are related to their condition, risk factor(s), or medically necessary treatment.
2. Controlling the aggregate total medical expenditures from the provision of services to population of patients receive.
3. Improving long-term performance on measures of healthcare cost and utilization, that are primary drivers of total healthcare expenditures in the population that are related to prevention of a condition, risk factor, or future acute care service or high cost treatment.
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Summary
47
Uses of Quality and Performance Measures
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Evaluate Best
Practices
Evaluate Cost and
Service Utilization
against Benchmark
Distribution of Financial
Incentives or Penalties
Among Providers
Negotiation with
Payers Related to
Value-Based
Arrangements
Provider Network
Performance
Profiling
To Establish
Performance
Improvement Priorities
Regulatory
Reporting
Public Reporting of
Performance
Consumer and
Marketing Information
Payer Quality
Improvement
Initiatives
Distribute Financial
Incentive or
Penalties
Provider Network
Scorecards
Create Quality &
Cost Performance
Dashboard
Internal Organizational Use of Performance Measures
Payer and External Use of Performance Measures
Consumer
Information to
Facilitate Choice
Alternative Payment
Shared Savings
Distribution
Provider
Recognition
Summary Take Aways
Although there are various alternative payment arrangements, they all attempt to drive quality performance and healthcare cost reduction by financially incentivizing healthcare provider performance improvement.
CMS is using alternative payment models in Medicare and Medicaid to align health plans and healthcare providers to national quality priorities.
Broad adoption of alternative payment methods is believed to be the best way to hold health plans and providers accountable for improving quality performance, containing costs, and reducing unnecessary service utilization in Medicare and Medicaid.
There needs to be greater transparency by payers regarding on how performance measures and benchmarks are developed and evaluated.
Managing quality performance and healthcare cost will require effective use of analytical tools and performance data by healthcare providers to be able to focus their performance improvement efforts.
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