National Advisory Council Subcommittee: Identifying Quality Measures for Medicaid-eligible Adults

Sarah Hudson Scholle and Sepheen Byron made the following slide presentation to the Subcommittee entitled "Preparing for Measurement Selection: Landscape of Measures." Select to access the PowerPoint Version [ - 694 KB]

Slide 1

Preparing for Measurement Selection: Landscape of Measures

Sarah Hudson Scholle
Sepheen Byron

Slide 2

Overview

• Performance Measurement in Medicaid
• Quality of Care for Adults in Medicaid
• Measures Inventory
• Key Challenges

Slide 3

Performance Measurement in Medicaid

Slide 4

State of Measurement in Medicaid

• There is no national reporting of Medicaid quality data representing all different populations enrolled (that's why we are here...)
• Two new reports shed light on current efforts:
  • Managed care: NCQA's Medicaid Benchmarking Project Report
  • FFS: CHCS' Performance Measurement in Fee-for-Service Medicaid: Emerging Best Practices

Slide 5

NCQA Medicaid Benchmarking Rep

• Purpose: Test the feasibility of collecting comparable performance measure results from state Medicaid agencies and combining these data with existing HEDIS data in NCQA's database to develop robust benchmarks for Medicaid.
• Why Focus on Managed Care and HEDIS?
  • 71% of the Medicaid population in states that use managed care arrangements including PCCM and MCOs.
  • 37 states contract with MCOs.
• Nearly 90 percent of state Medicaid programs reported using HEDIS measures for evaluate quality of children's care:
  • No comparable data available for adults.

Slide 6

How Do States Use HEDIS?

• States use HEDIS measures to meet the federal requirements for performance measurement in Medicaid.
• States may use the HEDIS data plans have submitted to NCQA, require plans to submit data directly to the state or the EQRO, or calculate performance rates themselves.
• Twenty-five Medicaid programs use or require NCQA Accreditation.

Slide 7

Medicaid Programs & HEDIS

*Includes the District of Columbia, Puerto Rico, Guam and the Virgin Islands.

Slide 8

Most Commonly Used Measures

Pediatric/Adolescent

• Well-Child Visits in the First 15 Months
• Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
• Adolescent Well-Care Visits
• Childhood Immunization Status

Women

• Cervical Cancer Screening
• Prenatal and Postpartum Care

Chronic Care

• Use of Appropriate Medications for People With Asthma
• Comprehensive Diabetes Care (CDC) - HbA1c Testing
• CDC - Eye Exam (Retinal) Performed
• CDC - LDL - C Screening

Mental Health

• Follow-Up After Hospitalization for Metal Illness

Slide 9

Most Common Differences Between State Measures and NCQA HEDIS data

• Specification changes
  • Continuous enrollment
  • Measurement year
  • Data source
  • Numerator changes
• Data collection process
• Validation

Slide 10

CHCS Report: Performance Measurement in FFS Medicaid

• "Just do it"
• Key Themes:
  • Leadership
  • Measures
  • Resources

Slide 11

Leadership

• Involve providers and other relevant stakeholders
• Clarify the purpose of measurement:
  • Reporting and comparisons among delivery systems
  • Quality improvement
• Set clear goals for public reporting
• Value the role of leadership in the process

Slide 12

Measures and Data Sources

• Consider measures that rely on administrative data for ease of capture.
• Consider business case with focus on overuse measures, such as hospital readmissions.
• Adapt HEDIS measures to fit the FFS environment:
  • Look outside HEDIS for special populations like mental health.
• Consider other data sources:
  • Patient/family surveys, Registries, Lab test results, Chronic disease and obstetrics assessment forms, Health information technology.

Slide 13

Resources and Time

• Consider resources needed for development and implementation of the measurement system:
  • Many variations exist depending on structures and resources available within states:
• Be patient:
  • Expect it to take a year from the start of developing a new measure to reporting it, depending on the complexity of the measure and the availability of analytic capacity.
• Devote resources to auditing measures.

Slide 14

Performance in Medicaid

Slide 15

Status of Health Care Quality in Medicaid

• 2009 HEDIS provides window on national performance among managed care organizations (MCOs).
• HEDIS performance rates for Medicaid MCOs are often lower than for Commercial and/or Medicare MCOs.
• There are a few exceptions...

Slide 16

2009 HEDIS Performance for Medicaid vs Other MCOs

Slide 17

Childhood Immunization Retreat in Private Plans, But Not in Medicaid

Image: A line chart shows the rise in childhood immunizations for both private insurance and Medicaid from 1999-2009, until 2008-2009 when the percentage of immunizations for private insurance drops of by several percentage points.

Notes: The most surprising result was a disturbing 4% drop in childhood immunization rates among private plans that primarily serve kids in middle-class families. This did not happen in Medicaid plans that serve low-income kids, where we saw a 3% rise, continuing the steady improvement they've been making.

Slide 18

Big Gains in Chlamydia Screening—with Medicaid Plans Leading

Image: A line chart shows a large increase in chlamydia screening from the period 2001-2009 for both private insurance and Medicaid plans. Medicaid plans have a consistently higher percentage of screening than private insurance.

Notes: We are also seeing big gains in chlamydia screening, especially in Medicaid plans. This is a common and often silent STD that, left untreated, can cause irreversible damage, including infertility. We're also seeing better scores for diabetic care, prenatal and postpartum care, controlling high blood pressure and other measures.

Slide 19

Using the Inventory to Identify Potential Measures

Slide 20

Creating Measures Inventory

• Sources of measures:
  • Measures endorsed by National Quality Forum
  • Measures nominated by CMS
  • Measures submitted by 15 Medicaid medical directors
  • Measures suggested by Panel co-chairs and members
• We attempted to "de-duplicate" the list..."

Slide 21

Contents of Measure Inventory

• Measures
• Pivot Table (allows identifying groups of measures)
• Definitions of descriptors
• Acronyms
• Sources

Slide 22

Measures List

• Measures:
  • Sorted by Measure Steward
  • All measures have unique "ID number" for searching (NQF ID provided if relevant)
• Contents:
  • Measures characteristics
  • Information on current use
  • Category in Revised IOM framework
  • Population of interest
• Excel makes sorting and filtering of measures possible

Slide 23

Characteristics of Each Measure

• Measure ID
• NQF ID
• Measure owner/steward
• Measure name
• Measure description
• Specific conditions
• Condition type
• Measure type
• Data sources
• Unit of measurement

Slide 24

From the Legislation....

The Secretary shall identify and publish a recommended core set of adult health quality measures for Medicaid eligible adults in the same manner as the Secretary identifies and publishes a core set of child health quality measures under section 1139A, including with respect to identifying and publishing existing adult health quality measures that are in use under public and privately sponsored health care coverage arrangements, or that are part of reporting systems that measure both the presence and duration of health insurance coverage over time, that may be applicable to Medicaid eligible adults.

Slide 25

Descriptors of Current Use

• Medicaid: in use by Medicaid programs or health plans in the state
• Other: in use by other federal programs (VA, Medicare Advantage, PQRI, etc)
• Any: in use in either Medicaid or other program
• States: list of states in which the measures are used

Slide 26

Measures Framework

Slide 27

Information for Each Measure

IOM Framework

• Safe
• Timely
• Effective
• Efficient
• Access
• Patient & Family centered
• Care coordination
• Health systems infrastructure

Population

• Condition Type
• Female Only
• Reproductive Health
• Adults <65
• MH & Sub Abuse In Use
• Functional status

Slide 28

Starting Lists for Each Workgroup

• Maternal/reproductive health:
  • Female only and in use at all
• Adult health:
  • Adults <65 and in use in Medicaid
• Mental Health/Substance Use:
  • MH&SA and in use anywhere
• Complex conditions:
  • Cross cutting measures that are in use at all: functional status, care coordination, health system infrastructure, avoidable hospitalizations

Slide 29

Key Challenges in Measuring Quality for Adult Medicaid Populations

• Current measures do not address needs of complex populations
• Examples of measure concepts and issues in selecting measures for the core set:
  • Avoidable hospitalizations
  • Care Coordination
  • Functional status

Slide 30

Avoidable Hospitalizations

• Avoidable hospitalization measures, including hospital readmissions and admissions for ambulatory care-sensitive conditions (ACSC), are important markers of waste.

Slide 31

Examples of Avoidable Hospitalization Measures

Slide 32

Avoidable Hospitalizations

• Key issues for Re-admission measures:
  • Population: all age groups, adults only, etc
  • Hospitalizations: specific-cause discharges versus all-cause discharges.
  • Counting of readmissions: all-cause readmissions or specific-cause readmissions
  • Readmission timeframe: 30 days versus 3, 7, 14, 90, ...
  • Risk adjustment
  • Continuous enrollment
• Key issues for ACSC Admissions:
  • Eligible population
  • Risk adjustment
  • Continuous enrollment

Slide 33

Outcomes/Functional Status

• Outcome measures include mortality and functional status.
• Patients/families value these measures in particular.
• These measures may reflect the net result of care for multiple conditions and care received from multiple providers and settings.

Slide 34

Outcomes/Functional Status

Slide 35

Outcomes/Functional Status

• Key Issues:
  • Population/Site of care/Population size
  • Cross section versus longitudinal assessment
  • Risk adjustment
  • Data source and completeness
  • Attribution

Slide 36

Care Coordination

• NQF (2006) identified dimensions of care coordination including:
  • The need for a medical home,
  • Proactive plan of care and follow-up
  • Strategy for communication,
  • Availability of information systems to support care
  • Process for transitions or "hand-offs" (across providers and settings)

Slide 37

Care Coordination

Slide 38

Care Coordination

• Key issues:
  • Availability and use of measures
  • Data sources/completeness
  • Feasibility and cost of measurement