State Perspectives on Quality Performance Measures and

State Perspectives on Quality Performance Measures and Payment Innovation

November 16, 2016

Patrick J. RoohanDirector, Office of Quality and Patient Safety

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New York State Department of Health

• Core mission is consistent with the triple aim:– Improve quality of care– Improve population health– Reduce costs

• Office of Quality and Patient Safety is the focal point of quality/safety initiatives for the DOH and beyond

• Lead in quality, data, HIT, evaluation and Healthcare innovation

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Why Healthcare Reform, Why Now?

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$19,630

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$19,630• $19,630 is the cost of family health insurance coverage in NY

• Up from $12,075 in 2006, 60% increase over 9 years

• Cost sharing is going up – premium and deductibles are 10% of median income

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Quality Results are Mixed

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Quality Results are MixedGood News:• NY Ranks 14th in access to care: low % uninsured, high % accessing MDs• NY Ranks 13th in healthy living: low % smokers, low obesity rate,

low in many mortality measuresBad News:• NY Ranks 26th in avoidable hospital use and costs: high rate of avoidable hospitalizations

and ER visits• NY Ranks 28th in prevention and treatment: low rate of vaccinations,

poor hospital discharge planning, high rate of pressure sores

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Healthcare Reform• PCMH• SHIP• SIM• APC• MACRA• MIPS• APMs• CPC+• DSRIP• VBP

How can we keep up with the “Alphabet Soup?”

All programs are well-intended – improve quality, reward quality, and control costs

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Definitions• PCMH (Patient Centered Medical Home)

– A certification process developed by NCQA that can lead to lower costs, improved patient experience and better health outcomes.

• SHIP (State Health Improvement Plan)– A five year comprehensive plan to move NY’s health care system towards triple

aim goals: improved health, better health care, affordability

• SIM (State Innovation Model) Grant– $100 million dollar grant from CMMI towards implementing parts of the SHIP

• Specific ‘deliverables’ including a substantial movement from FFS payment to ‘value based’ payments over 5 years

• APC (Advanced Primary Care Model)– A primary care model for multi-payer engagement as part of the SIM grant.

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Definitions

• MACRA (Medicare Access and CHIP Reauthorization Act)– Medicare’s new model that rewards value over volume, moving away from Fee-

for-service. Two tracks: MIPS and APMs

• MIPS (Merit-based Incentive Payment System)– Medicare’s new incentive program that combines quality, resource use, clinical

improvement and meaningful use of HIT

• APMs (Alternative Payment Models)– APMs are new approaches to paying for medical care through Medicare that

incentivize quality and value.

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Definitions

• CPC+ (Comprehensive Primary Care Plus)– A national advanced primary care medical home model that aims to strengthen

primary care through a regionally-based multi-payer payment reform and care delivery transformation. Improved from the CPC program.

• DSRIP (Delivery System Redesign Investment Payment Program)– $6.4 billion dollar investment from CMS in NY Medicaid to provide more

integrated care focused on improving quality, reducing avoidable costs• Specific deliverables on quality improvement, avoidable admission reductions

• VBP (Value-Base Purchasing)– Is a strategy for linking payment to quality, not payment for volume. VBP is the

cornerstone of SIM, MACRA and DSRIP

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What is Value Based Payment?• Pay for Performance (may be transitional)

• Care Coordination and Care Management Payments

• Episode of Care Payments

• Shared Savings

• Shared Risk

• Global Payments

FFS P4P Care Coordination

Episodes of Care

Shared Savings

Shared Risk

Global Payments

No Quality Measurement

No Financial Risk

More Quality Measurement

More Financial Risk

Source: DFS Report (http://www.dfs.ny.gov/reportpub/payment-reform-report.pdf)

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Health Plans and Providers are Already Engaged in Payment ReformDFS Survey (published July 2014) found:

• Variability. All major insurers had value-based payment (VBP) programs. But they are independent with inconsistent progress.

• Few Providers Impacted. Just 15% of participating providers were in VBP.• Few Consumers Impacted. Just 12% of insurers’ members were in VBP.• Most VBP Programs Still Pay on FFS Basis. Most insurers’ VBP (80%) make value-based or care

coordination payments in addition to FFS payments.• Pay-for-Performance (P4P) Predominates. Almost half of VBP are “Pay-for-Performance” models.• Some Evidence of Savings, But Most Yet to Be Measured. • Primary Care Focused. Most of VBP models involve primary care. Specialists, hospitals, non-physician

services and emergency room (ER) to a lesser degree. Lab and radiology services the least.

Source: DFS Report (http://www.dfs.ny.gov/reportpub/payment-reform-report.pdf)

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Health Plans and Providers are Already Engaged in Payment ReformCatalyst for Payment Reform (2015)

• NY continues to pay FFS in both commercial (94%) and Medicaid sectors (72%)

• 34% of commercial health care payments are considered value-oriented

• 33% of Medicaid health care payments are considered value-oriented

Source: CPM: http://www.catalyzepaymentreform.org/

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Value Based PaymentIncreases the Importance of and

Need forQuality Measurement

RAINA JOSBERGEROFFICE OF QUALITY AND PATIENT SAFETYNEW YORK STAT DEPARTMENT OF HEALTHNOVEMBER 19, 2014

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Health Care Reform and Value Base Payment:Need for Quality Measurement and HIT to Succeed

Health Care Reform

‐ Quality Measurement‐ Use of HIT

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New York State Initiatives in Quality

RAINA JOSBERGEROFFICE OF QUALITY AND PATIENT SAFETYNEW YORK STATE DEPARTMENT OF HEALTHNOVEMBER 19, 2014

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Quality Measurement

• Quality measurement of health plans (QARR)– Current: Medicaid, CHPlus, special needs plans, commercial

managed care, MLTC, qualified health plans, the Essential Plan

– Proposed: FIDA, behavioral health, HARP• DSRIP

– Significant measurement component across PPS projects

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Quality Measurement (continued)

• Quality measurement of hospitals – Cardiac– Stroke care– HAI– Potentially Preventable Readmissions– Potentially Preventable Complications

• Long term care quality– Nursing home quality measures– Nursing home quality initiative– Home care quality measures

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Financial Incentives for Higher Quality:

Current Medicaid Quality Incentive Programs

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Medicaid Managed Care Quality Incentive

• Uses the QARR measurement set for the health care delivery system:

– Healthcare Effectiveness Data & Information Set (HEDIS®) measures which are developed by the National Committee for Quality Assurance (NCQA) AND

– New York State-Specific Measures

– CAHPS® – Consumer Assessment of Healthcare Providers and Systems- Satisfaction

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Overview of the Medicaid Managed Care Quality Incentive

– Calculated since 2001– Based on aggregated score from plan performance for selected measures– Funded through additional monies– Data reported in June, quality payment awarded the following April for the State

fiscal year– Points earned based on 50th, 75th and 90th percentiles – Plans earn points in the areas of:

Awards include financial and auto-assignment preference

Component Measures Points

Quality ‐ QARR 27 measures 100 points

Satisfaction ‐ Survey 3 measures 30 points

Preventive Quality Indicators 4 measures 20 points

Total points 150 points

Compliance (Subtracted from Total) 6 measures Up to 20 points

Final Score Final points/150

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MMC Quality Incentive Measures

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Quality measure examples• Avoidance of Antibiotics for Adults with Acute Bronchitis• Breast Cancer Screening• Cervical Cancer Screening

Satisfaction measure examples• Rating of Health Plan• Getting Care Needed

Preventive Quality Indicators • Two composites of select adult and pediatric PQIs/PDIs and a respiratory composite measure for adults and an asthma measure for children

Compliance• Any statement of deficiency for Plan Network, Encounter data submission,

Quality Reporting, etc.

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Overview of the Nursing Home Quality Initiative (NHQI)

• First year, 2012, Pay for Reporting year• In 2013, $50 million, self-funded pool. October 2014, we received CMS State Plan Amendment (SPA)

approval.• Currently analyzing 2013 MDS 3.0, cost report information received in September, ranking of facilities

completed by November/December for 2014 NH QI • Points earned based on performance to peers, ranking of performance into quintiles (approx. 600

Nursing Homes)

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Component Measures Points

Quality – MDS 3.0 14 measures 70 points

Satisfaction ‐ ‐

Compliance – cost reports and employee flu vaccination data

3 measures (employee flu vaccination data has two deadlines)

20 points

Efficiency – SPARCS 1 measure 10 points

Total points 100 points

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NHQI Measures

Quality examples Percent of Long Stay Residents Who Self‐Report Moderate to Severe Pain Percent of Long Stay High Risk Residents With Pressure Ulcers Percent of Long Stay Residents Whose Need for Help with Daily Activities Has Increased

Percent of Long Stay Residents with a Urinary Tract InfectionCompliance CMS’ Five‐Star Quality Rating for Health Inspections Timely submission of Nursing Home Certified Cost Reports (due 8/15/14 for non‐fiscal filers and 9/30/14 for fiscal filers)

Timely submission of Employee Flu data (due 11/15/13 and 5/1/14)Efficiency – Potentially Avoidable Hospitalizations The number of potentially avoidable hospitalizations per 10,000 long stay episode days

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Overview of the Managed Long‐Term Care Quality Incentive

• First year, 2013, Pay for Reporting year• Second year, 2014, Pay for Performance• Funded through reduction in admin cap and surplus reduction, $65 million • Using Jan-June ’14 data, ran in October/November, award by year end• Workgroup formed in early 2014 to advise the Department on all measures, • Quality points earned based on 50th, 75th and 90th percentiles, Satisfaction and

Efficiency points earned by statistical significance

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Component Measure Points

Quality – UAS‐NY 5 40

Satisfaction ‐ Survey 6 40

Compliance – MEDS, etc. 3 10

Efficiency – SPARCS 1 10

Total 100

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MLTC QI MeasuresQuality examples Percentage of members who received an influenza vaccination in the last year Percentage of members who did not have falls resulting in medical intervention in the last 90 days Percentage of members who did not have an emergency room visit in the last 90 days

Satisfaction examples Percentage of members who rated their managed long‐term care plan as good or excellent Percentage of members who rated the quality of home health aide or personal care aide services within the last six months as good or excellent

Compliance examples No statement of deficiency for timeliness or completeness of Medicaid Encounter Data III submission for the measurement year

Efficiency – Potentially Avoidable Hospitalizations The number of potentially avoidable hospitalizations

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FIDA Quality• January 1, 2015 start date• FIDA plans will be reporting

– Medicare Healthcare Effectiveness Data and Information Set (HEDIS)• Annual data collection by the health plans

– Health Outcome Survey (HOS)• Annual survey sponsored by the health plans

– Consumer Assessment of Healthcare Providers and Systems (CAHPS) satisfaction data• Annual survey sponsored by the health plans

– They will also be using the UAS‐NY to assess their members every six months• 1% Quality Withhold on the Medicaid/Medicare components of the capitation rate. These

withheld amounts will be repaid subject to FIDA plans’ performance.

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FIDA Quality Withhold Measures

• Year 1 measure examples– Encounter data submitted accurately and completely in compliance with

contractual requirements– Customer Service – CAHPS measure– Getting appointments and care quickly – CAHPS measure

• Year 2 and 3 measure examples– Plan all‐cause readmissions – NCQA/HEDIS measure– Annual Flu vaccine – CAHPS measure– Controlling High Blood pressure – NCQA/HEDIS measure

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Delivery Service Reform Incentive Payment (DSRIP)

• $6.2B from CMS to reform healthcare in NYS• Awarded in 2014• First year will be 2015, incentives to Performing Provider Systems (PPS) will be based on

milestones reached each year• Money is not guaranteed • PPS’s must choose projects from a list and must show improvement for the associated

measures to obtain the full incentive

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Issues being AddressedIssues being Addressed

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Managed Care Publications • Medicaid managed care quality reports:

http://www.health.ny.gov/health_care/managed_care/reports/index.htm

– Regional Consumer Guides: http://www.health.ny.gov/health_care/managed_care/reports/quality_performance_improvement.htm#link4

• Nursing home quality Initiative:http://www.health.ny.gov/health_care/medicaid/redesign/nursing_home_quality_initiative.htm

• Managed Long Term Care quality reports: http://www.health.ny.gov/health_care/managed_care/mltc/reports.htm– Regional Consumer Guides:

http://www.health.ny.gov/health_care/managed_care/mltc/consumer_guides/

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Data Transparency

Open Data NY:https://health.data.ny.gov/

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Current Mechanisms to Monitor Quality are not sufficient

• Current measurement activities rely on:– Claims– Chart reviews– Disease or content-based data collection

• Not timely

• Costly

• Significant provider burden 33

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(EHR + Registry + Claims + Other)

Health IT‐enabled Quality Measurement

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Initiatives that collect or intend to collect EHR data for use in quality measurement

To name a few of the current ones… Adirondack multi‐payer initiative

Value Based Payment initiatives APC Scorecard as part of SIM DSRIP PPS CMS MACRA with MIPS/APM

MEIPASS(Medicaid Meaningful Use) Providers must report eCQMs generated EHRs

KEY REQUIREMENT – Alignment of capability to integrate data for calculation of quality measures for various uses

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Principles and Assumptions for Data Collection

Connect once, use multiple times Should align with, and invoke, federal standards for certified technology Ensure data can be used to calculate measures at multiple population

health levels Data collected from EHRs should be used to support multiple measures EHR derived data will provide some, but not all, data necessary to calculate

quality measures Would be used in combination with claims, registry and other data

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Claims‐based Quality

Measurement

and use data

Advanced quality

improvement ecosystem to collect, share, and use data

Provider/Practice/Encounter Level Data

Claims data quality measurement and/or HEDIS data collected from surveys, chart reviews, and claims data

Live automated data

Automated data acquisition from EHRs to central aggregator tool for calculation, comparison, reporting, and population level measures

Self‐reported

Data captured, eCQMcalculated in EHR and only numerator/ denominator reported

Integrated data

Claims and clinical data integrated to analyze quality and address population health needs

Patient‐Centric ReportingProvider‐Centric ReportingPractice‐Centric ReportingSystem‐centric ReportingPopulation‐level Reporting

Quality Measurement Continuum

From ONC Conference:IT‐enabled Quality Measurement (Aug 31 –Sep 1, 2016)

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Quality Measurement

Quality Improvement

Care Delivery

Risk Adjustment for Quality

Measurement

Cohort Identification & Management

Reimbursement

Reimbursement for Improved Quality of Care

Administrative Efficiencies

Central QM Calculation and

Reporting

Reuse of Quality

Measure data

ResearchPopulation Health

measurement

Disease‐specific measurement

Cost and Quality Transparency

Priority Use Cases for Clinical Quality Measure Information

Program Evaluation/ Reporting


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Infrastructure Needed for Quality Measurement

Provider Directory- provider/practice based calculation Data source- provider network data system

Data quality Data completeness and consistency – address data gaps and

missing data elements Providers as partners in increasing data quality

Provider portal- need to know how they are performing

Governance-HIT Transparency and Evaluation workgroup Patient/provider attribution decisions

Data Intermediary/Extraction Qualifications Data Use policies

Data Aggregation

Reporting Services

Notification Services

Consumer Tools

Analytic Services

Provider Portal

Data QualityPt. /Prov. Attribution

Data Transport and Load (Warehouse/Repository)

Data Extraction

Identity Management Provider Directory/Registry

Security Mechanisms Consent Management

Governance

Financing

Policy/LegalBusiness

Operations

Major Dependencies Reporting Services

Notification Services

Consumer Tools

Analytic Services

Provider Portal

Data Quality

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CQM Data Sources & Intermediaries

Payers/APD

Registries

Patie

nt data

Data Sources

Data Intermediary(possibly state, payer, third party)

EHRs

Data SourcingData Sourcing

PriorityUses

Clinical Quality Measurement

DSR

Pay for Value

Clinical action and population

health measurement

Pt Cohort Decision support &

management

Program requirementsand evaluation

Cost and quality

transparency public

reporting

ReportingFormats

EHRs

EHRs

CalculationCalculation

CleansingCleansing

Consistent formatting Consistent formatting

Data SourcingData Sourcing

QE

CleansingCleansing

QRDA11

CCDA22

ADT33

*Custom queries

QRDA III/I

ReportingReporting

Functio

nsFunctio

ns

Immunizations HL7

Num Denom

ClaimsX12

44 Care plan


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Investments in HIT:The SHIN‐NY

All Payer Database (APD)RAINA JOSBERGEROFFICE OF QUALITY AND PATIENT SAFETYNEW YORK STATE DEPARTMENT OF HEALTHNOVEMBER 19, 2014

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SHIN‐NY

• Statewide Health Information Network for New York (SHIN‐NY) is a network that connects electronic medical records across New York State. – Within Regions through RHIOs (Regional Health Information Organizations)

– Across Regions through Statewide Patient Record Lookup

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SHIN-NY Technical Structure

Healthix

STHL &

THINC

Interboro eHNL

I

Bronx

HIXNY

Rochester

HeCon

HeLink Statewide

Services(NYeC)

Statewide MPI

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SHIN‐NY Core Services

• Allows a provider to see all of your medical records in his/her electronic medical record, including information from other providers and other health systems

• If your physician doesn’t have an electronic system, your records can still be accessed by him or her through an application that will include information from other doctors, hospitals and clinics

• Provides alerts (immediate notifications) if you are in the ED, you are admitted to the hospital, or you are discharged from the hospital

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SHIN‐NY Core Services

• Consent management – approval by the patient for clinicians to view their data

• Identity management and security – system to assure access to the correct records, with proper security protocols

• Connections to public health systems

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SHIN‐NY Stakeholder Adoption

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Issues being Addressed• Consent. The SHIN‐NY Policy Committee is reviewing the current

consent model, with a report due in December• In the process of implementing cross‐QE alerts with 3 QEs, with

more to follow• Adoption• Complete data• Improving quality of the data• Using the data for quality measurement across providers, plans,

health systems

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Expanding Long Term Care Providers’ Connections to the SHIN‐NY

• New York eHealth Collaborative administers an incentive program for Medicaid Meaningful Use Incentive program Eligible Providers to connect to the SHIN-NY

• Would expand the Data Exchange Incentive Program beyond Meaningful Use Incentive eligible providers, including long-term care, mental health, home care and others

– Allowed by CMS Medicaid Director Letter 16-003• Allow for $10,000 for those providers who connect and make data available to the SHIN-

NY• Awaiting approval from CMS

Challenges:• Dealing with non-certified systems

– Amount of data that can be made available– Security of non-certified systems- program will likely need to invoke federal HIT certification

standards related to security

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All Payer Database (APD): What is it?The APD will be a large repository of consolidated information that will integrate health care data across all payers and all sites of care.

The APD will:• Support health care finance policy, population health and health care

system comparisons and improvements.• Serve as a key resource for consumers, providers and payers.

• The APD will begin with claims and encounter data from insurance companies.

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APD Background

• New York State legislation enacted in the spring of 2011 (same statutory authority as SPARCS).

• Funded through Health Insurance Exchange Establishment Grants, SFY 2014‐2015 budget (HCRA funds), State Medicaid, and Federal Medicaid matching funds.

• https://www.health.ny.gov/technology/all_payer_database/

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What is the Value of the All Payer Database

Utilization of Services Quality of Care

Cost of Care Population Health

APD

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Who Benefits from the APD?

• State policy makers / public health• Consumers• Health insurance plans• Health care providers• Employers• Researchers

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Progress

• APD proposed regulations out for comment– Received comments in October and in the process of reviewing

• APD Guidance Document– Under review. Policies, data reporting formats, operational

requirements

• Contract with Optum Government Solutions for data warehousing and analytic tools

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Challenges• APD data intake solution has been delayed

– Commercial data to start in 2017

• Authority to collect self‐insured data is in question. March Supreme Court Decision, Gobeille vs. Liberty Mutual – disallowed APD reporting mandate on Self‐Insured Plans (ERISA pre‐emption ruling)

– Approximately 50% of commercially insured New Yorkers are in self‐insured products– The New York State Health Insurance Plan (NYSHIP) is self‐insured, and we are working with

the Department of Civial Service to get their participants to submit data to the APD– The court suggests that states’ APD interests might be served pursuing newly created reporting rules from

the US Depts. of Labor or Health and Human Services; the APCD National Council is coordinating a unified states’ dialogue with USDoL

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The New York State Health Insurance Program (NYSHIP) includes both state and local government enrollees with coverage for 1.2 million

APD discussions are ongoing with Civil Service as voluntary reporting by this payer would instantly pull in a third of NY’s currently self‐insured pool (though continued growth in the self‐insured segment is expected to erode NYSHIP’s portion of the pie)

More limited dialogue on voluntary reporting has also taken place with smaller self‐insured plans in western and northern NY

Lastly, the Court suggests that states’ APD interests might be served pursuing newly created reporting rules from the US Depts. of Labor or Health and Human Services (removing federal statute pre‐emption from the equation); the APCD National Council is coordinating a unified states’ dialogue with USDoL

March Supreme Court Decision (cont.)

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Questions?

Documents

State Perspectives on Quality Performance Measures and