Confidential draft / Policy under development / Statements are not binding on MassHealth Primary Care Payment Reform Open Meeting: Quality Metrics Monday, October 22nd, 2012 Confidential draft / Policy under development / Statements are not binding on MassHealth Agenda MassHealth • Recap of program • Selecting metrics • Discussion 2 Confidential draft / Policy under development / Statements are not binding on MassHealth This is the third in our open meeting series Six topic specific open meetings on a weekly basis: • 10/10, 1:30-3pm, Transportation Building, Conference Room 5, Boston: Overview • 10/17, 1-2:30pm, South Street Amphitheatre, Shrewsbury: Clinical Delivery Model • 10/22, 2:30-4pm, Worcester Public Library, Saxe Room, Worcester: Quality metrics • 10/31, 1:30-3pm, Transportation Building, Conference Room 5, Boston: Shared savings • 11/7, 1:30-3pm, Transportation Building, Conference Room 5: Comprehensive Primary Care Payment • 11/15, 1:30-3pm, 1 Ashburton Place, 21st floor, Boston: Provider eligibility and technical assistance 3 Confidential draft / Policy under development / Statements are not binding on MassHealth Overview of Primary Care Payment Reform • The goal of our strategy is improving access, patient experience, quality, and efficiency through care management and coordination and integration of behavioral health • We believe that primary care and behavioral health are important in improving quality and efficiency while preserving access, through the patient-centered medical home capabilities with integrated behavioral health services • The payment mechanism that supports that delivery model is a comprehensive primary care payment (CPCP) combined with shared savings +/- risk arrangement and quality incentives • his program would span MassHealth managed care lives across the PCC Plan and the Managed Care Organizations. We propose to launch a procurement for PCCs to participate in the program and MCOs will participate in a similar payment structure with these organizations • We plan to implement on an aggressive timeframe, with an RFP release planned in January 2013 and with 25% of members participating by July 2013, 50% of members participating by July 2014, and 80% by July 2015 4 Confidential draft / Policy under development / Statements are not binding on MassHealth Proposed payment structure Comprehensive Primary Care Payment (CPCP) • Risk-adjusted capitated payment for primary care services • May include some behavioral health services Quality Incentive Payment • Annual incentive for quality performance, based on primary care performance Shared savings payment • Primary care providers share in savings on non primary care spend, including hospital and specialist services The payment structure will not change billing for non-primary care services (specialists, hospital); PCP’s will not be responsible for paying claims for these services. However, we are evaluating complementary alternative payment methodologies to hospitals and specialists for acute services. 5 Confidential draft / Policy under development / Statements are not binding on MassHealth Role of quality metrics • Financial incentives • Determines amount of quality incentive payment • Determines eligibility for shared savings payment • Determines percentage payout for shared savings payment • Quality improvement • Program monitoring & evaluation 6 Confidential draft / Policy under development / Statements are not binding on MassHealth Agenda • Recap of program • Selecting metrics • Discussion 7 Confidential draft / Policy under development / Statements are not binding on MassHealth What do we mean by high-quality care? • Enhanced access: Improved access to primary care services through extended hours, partnerships with urgent care, or other means • Patient-centeredness: Patient involvement in decision making, increased focus on the patient experience • Behavioral health integration: better management of behavioral health conditions in primary care settings and improved coordination with behavioral health providers • Care coordination: better management of care transitions and better alignment on care plans with other providers • Improved health and wellness: actual improvements in patient health and wellness outcomes; may need to have separate measures geared towards different populations and conditions (e.g., pediatric measures, chronic disease measures) 8 Confidential draft / Policy under development / Statements are not binding on MassHealth How are we prioritizing measures? MassHealth plans to prioritize measures that: • Are broadly accepted and validated (e.g., NQF measures) • Align with MassHealth’s goals and quality domains • Can be influenced by primary care physicians • Have room for improvement • Are feasible to track and report • Align with other EOHHS initiatives and other payors’ programs 9 Confidential draft / Policy under development / Statements are not binding on MassHealth We created an initial list of measures, starting with the CMS ACO measures Italics = not included in CMS ACO measures; ( ) = NQF # Access •CAHPS: Getting Timely Care, Appointments, and Information (#5 & #6) Patient-centeredness •CAHPS: How Well Your Doctors Communicate, Patients’ Rating of Doctor, Access to Specialists, Health Promotion and Education, Shared Decision Making, Health Status / Functional Status (#5 & #6) Behavioral health integration • Depression screening (#418) • Antidepressant medication management (#105) • Initiation and engagement of alcohol / drug dependence treatment (#4) • Follow up after hospitalization for mental illness (includes children and adults) (#576) • ADHD medication management for children (#108) • SBIRT (alcohol abuse) Care coordination • Ambulatory Sensitive Conditions Admissions: CHF (#277) • Medication Reconciliation after discharge from an Inpatient facility • Percent of patients with one primary care visit in the past year • Diabetes hospital admission rates (#638) • Asthma hospital admission rates (#283) Improved health and wellness • Influenza immunization (#41) • Pneumococcal vaccination (#43) • Adult weight screening and follow up (#421) • Tobacco use assessment and tobacco cessation intervention (#28) • Colorectal cancer screening (#34) • Mammography screening (#31) • Screening for high blood pressure • Diabetes Composite (All or Nothing Scoring #729): Hemoglobin A1c Control (<8 percent), LDL (<100), Blood pressure <140/90, Tobacco Non Use, Aspirin Use • Diabetes Mellitus: Hemoglobin A1c Poor Control (>9 percent) (#59) • Hypertension: Controlling high blood pressure (#18) • Ischemic Vascular Disease: Complete Lipid Panel and LDL Control (<100 mg/dL) (#745), Use of Aspirin or other antithrombotic (#68) • Heart Failure: Beta-blocker therapy for LVSD (#83) •Drug therapy for lowering LDL-cholesterol (#74); ACE inhibitor or ARB therapy for patients with CAD and Diabetes and/or LVSD (#66) • Percent of PCP’s who Successfully Qualify for an EHR Program Incentive Payment Women’s Health •Prenatal and postpartum care (includes post partum depression screening) (NQF 1517) •Chlamydia screening (#33) •Cervical cancer screening (#32) Pediatric Health •Asthma medication (#36) BMI assessment and counseling (#24) •Adolescent immunization (#1506) •Developmental screening in first five years (#1448) • Well child visits, <15 months (#1392), 3-6 (#1516), adolescent •Childhood immunizations (#38) •A1c test for children (#60) Confidential draft / Policy under development / Statements are not binding on MassHealth MassHealth We received some important feedback from stakeholders on our selection of measures Domains: Separate health and well-being into chronic disease management, prevention and screening Measures: Include a measure of ambulatory sensitive ED use, remove the hospital ambulatory care sensitive measures due to small sample size Measurement Strategy: Phase in measures with pay for reporting in the first year; consider reporting burden Incentives: Financial incentives should be tied to at least one measure in each domain; include a mix of clinical and patient experience measures Confidential draft / Policy under development / Statements are not binding on MassHealth MassHealth Based on stakeholder feedback, we have narrowed to the following proposed list: Italics = not included in CMS ACO measures; ( ) = NQF # Access – CAHPS: Getting timely care, appointments and information (NQF # 5, 6) Patient Centeredness – CAHPS: Multiple measures Behavioral Health – Depression screening (NQF #418) – Initiation and engagement of alcohol/drug dependence treatment (NQF #4) – Follow-up after hospitalization for mental illness (NQF #576) – ADHD medication management for children (NQF #108) Care Coordination – Asthma hospital admission rates (NQF #283) – Efficient utilization of emergency room services, methodology TBD Prevention and Screening – Adult weight screening and follow-up (NQF #421) – Tobacco use assessment and tobacco cessation intervention (NQF #7) Chronic Disease Management – Diabetes composite (NQF #731) – Controlling high blood pressure (NQF #18) – Asthma medication management (NQF #36) Pediatric Health (BH measures above) – Asthma medication management (NQF #36) – BMI assessment and counseling (NQF #24) – Adolescent immunization (#1506) – Developmental screening in the first five years (NQF #1448) – Well child visits for <15 months, 3-6 and adolescent (NQF #1392 and #1516) – Childhood immunizations (NQF #38) Women’s Health – Prenatal and postpartum care (NQF #1517) – Chlamydia screening (NQF #33) – Cervical cancer screening (NQF #32) – Mammography screening (NQF #31) Confidential draft / Policy under development / Statements are not binding on MassHealth LJ We have developed some preliminary goals around measure collection and reporting - Measures will be reported at a practice level - Measures will be based on three streams of data: - Patient survey (practice-level CAHPS) - Administrative data (claims & encounter data) - Clinical data (EHR-based, record review) - Hybrid (combining administrative & clinical) - We have defined goals for our measure collection process - Ease of collection, accuracy, fairness - Avoid unintended consequences - Build & learn from patient-centered medical home initiative - We plan to calculate quality measures across payers and report them to practices via single portal Confidential draft / Policy under development / Statements are not binding on MassHealth Agenda • Recap of program • Selecting metrics • Discussion 14 Confidential draft / Policy under development / Statements are not binding on MassHealth Questions for discussion • Does this list of measures seem • Aligned to the aims of the program? • Feasible for participants to report on? • Appropriately tailored to the needs of the MassHealth population? • Should we include a measure on ED utilization? If so, which? • We look forward to continuing to receive your feedback. Please visit our website at http://www.mass.gov/eohhs/gov/newsroom/MassHealth/providers/primary- care-payment-reform-initiative.html • Our next open meeting will be10/31, 1:30-3pm, Transportation Building, Conference Room 5, Boston: Shared savings 15