VBP4P Response to Public Comment 2015

Transcription

1 Organization Element Name Type Comment Response Value Based P4P Program and Policy Updates 1 Cigna Corporation Attainment Pathway 2 Blue Shield of California Attainment Pathway Do not support Blue Shield of California does not support the proposed attainment solution. Critical elements of this proposal must be solved before we can offer support: 1. How the attainment pathway will be funded 2. Determination of the Total Cost of Care gate The attainment pathway was developed by the P4P committees and received majority support as part of the recommended design. All aspects of the VBP4P incentive design are voluntary and health plans may choose to adopt the proposed elements as recommended, adapt them to meet their business needs, or not adopt them. Below is a summary of the committee's input on the identified elements. Element #1 - Funding VBP4P incentives have largely been left to the purview of the health plans. During the P4P committee discussions of the pathway, the following funding sources were identified as appropriate and feasible options: 1. Use portions of a health plan s share of savings not paid out (e.g., differential between PO s initial base incentive of 50% share and adjusted share of savings; or the estimated savings from POs that didn t pass trend gates; or offset from optional ARU attainment adjustment) 2. Redirect and repurpose the budget previously used for quality incentive Element #2 - Element #2 - The P4P committees supported using the recommendation for the high cost PO outlier criteria as a definition for the TCC Amount Gate utilized in the design. High cost PO outlier criteria is defined by the P4P committees as POs above the 90th percentile statewide, for both the measurement year and preceding year, using geographyand risk-adjusted Total Cost of Care. 3 Cigna Corporation Quality Domain Weighting 4 Kaiser Permanente Quality Domain Weighting with Given that the Meaningful Use of Health IT component is more directly related to Clinical Quality measures, it would make sense to shift more of the MU weighting to Clinical Quality, while still also increasing the weight of Patient Experience. We would suggest: Clinical Quality 65%; Patient Experience 25%, and MU 10%. Thank you for your feedback. 5 Blue Shield of California Quality Domain Weighting Blue Shield of California supports the proposed change in quality domain weighting. MY 2016 P4P Changes to Measure for Payment and Public Reporting 6 Cigna Corporation Asthma Medication Ratio 7 Cigna Corporation Asthma Medication Ratio Consistent with HEDIS Updated 12/22/15 1 of 10

2 8 Kaiser Permanente Asthma Medication Ratio Do not support VBP4P Response to Public Comment Asthma commonly begins before age 40 and the obstruction it causes is generally described as being fully reversible, while COPD is generally diagnosed later in life and - by definition - has a significant irreversible (chronic) component. With aging, environmental exposures (including cigarette smoke) and long term airway inflammation, obstruction in Asthma can often develop a significant fixed obstruction that mimics COPD. Accurately identifying those members over 65 with 'pure' asthma and little to no chronic obstruction will likely be difficult and problematic to execute. Therefore, we feel that using this measure in the Medicare population may lead to inappropriate care for many older members with an unclear or mixed diagnosis. It is a P4P principle to align with national standards like HEDIS whenever possible. For this particular measure the intention is to align with HEDIS by adding the 5-85 years total age band. P4P will continue to report this measure for Commercial only. The 5-64 years total age band will continue to be collected in MY, to maintain trendability from MY 2014 to MY. The 5-85 age band will be used to establish a baseline for measuring performance and change for payment and public reporting in MY 2016 and beyond. P4P staff forwarded this comment to NCQA and received the following response regarding the HEDIS AMR measure: Literature indicates there is a significant number of older adults with uncontrolled asthma. The measures include an exclusion for COPD; therefore, the target is only those who are clearly identified with persistent asthma and no other respiratory comorbidities. We acknowledge that although some older patients that have asthma might be misdiagnosed as having COPD, we have the opportunity to measure the quality of care being provided to those older adults that we know have persistent asthma using our robust denominator and exclusion criteria. 9 Kaiser Permanente Asthma Medication Ratio We support alignment with NCQA HEDIS measure changes, though we do not support NCQA in their change with the age range. 10 MemorialCare Childhood with Immunization 10 The providers of MCMG and GNP would like to continue to receive data on Combo 7 so we can track improvements in this measure. Combo 7 is also part of our physician quality incentive, and childhood immunizations (Combo 7) is a MemorialCare Medical Foundation Bold Goal for, our goal to reach the IHA 90th percentile in this measure representing over 200 primary care providers. It is a P4P principle to align with the national standards like HEDIS whenever possible, and the P4P Governance Committee has reemphasized the importance of this principle and the need for a targeted measure set. Combination 10 is included in the HEDIS Health Plan Accreditation measure set. We understand that this is a priority area for your organization and encourage self-reporting POs to continue collecting and reporting CIS combination 7 for internal use if desired. Additionally, the rates for each of underlying antigens of combination 10 will be collected for P4P with generated benchmarks. These individual antigen rates may be helpful in tracking PO performance against California HMO/POS performance trends. 11 Cigna Corporation Childhood Immunization Hill Physicians Childhood Immunization 10 with Regarding Childhood Immunization Status 12 month Continuous Enrollment: Since the State of California will grandfather in the rule that allows parents to lawfully exempt their children from receiving immunizations through the "Personal Belief Exemption" exception, providers will still be penalized as a result. If the state of California allows for vaccine exemptions, this exemption should also apply to this particular measure as a measure exclusion. Providers and medical groups should not be penalized for the PBE. P4P does not allow client decline of services as a valid reason for exclusion. Please refer to the PDF document on the IHA website that outline the reasons for this decision. s.pdf 13 Kaiser Permanente Childhood Immunization Cigna Corporation Cervical Cancer Screening 15 Kaiser Permanente Cervical Cancer Screening We support addition of Combo 10. We support alignment with HEDIS measures. Updated 12/22/15 2 of 10

3 16 Cigna Corporation Cervical Cancer Overscreening Use of CCO in conjunction with CCS to replace ECS will reduce the burden on plans to report this measure and will help to clearly separate the measure categories. 17 Kaiser Permanente 18 Kaiser Permanente Cervical Cancer Overscreening Cervical Cancer Overscreening Do not support We strongly support alignment with HEDIS, which decreases the burden associated with multiple reporting programs. We support use of measures to avoid unnecessary screening which can lead to harm to members. While it is a P4P principle to align with a national standard like HEDIS whenever possible, if the P4P committees determine that there is a compelling clinical reason not to, then we will not align. Currently, there is not a cervical cancer screening measure that includes both an overscreening and underscreening measure for women. This measure, in combination with the HEDIS CCS measure, addresses both of these areas of concern. The P4P Committees believe that this is an important clinical area and wanted to try and capture this data and replace the difficult to implement ECS measure, which is also a non-hedis measure. MY 2016 P4P Measure Removed from Measure Set 19 Cigna Corporation Evidence-Based Cervical Cancer Screening: Appropriately Screened 20 Kaiser Permanente Evidence-Based Cervical Cancer Screening: Appropriately Screened 21 Cigna Corporation Childhood Immunization 3 22 Kaiser Permanente Childhood Immunization 3 23 Cigna Corporation Diabetes HbA1c Control (<7%) for a Selected Population Use of CCO in conjunction with CCS to replace ECS will reduce the burden on plans to report this measure and will help to clearly separate the measure categories. It was a confusing measure to explain, and the HEDIS measure is more recognized. Aligns with NCQA accreditation. If there are organizations which argue that tracking flu shots for Combo 10 is too difficult, then adding Combo 7 would make more sense than just keeping Combo 3. We will still report for HEDIS but this decision makes sense for other program alignment and payment. 24 Kaiser Permanente Diabetes HbA1c Control (<7%) for a Selected Population We agree with the removal of the A1c <7% from this measure set. While an A1c target of <7% may be very appropriate for some patients, clinical studies published in the last 5 years (VADT, ACCORD, ADVANCE) have questioned the safety of applying a target A1c of 7% to a population of diabetic patients with different risks. The American Diabetes Association currently advises an A1c target of 7%, but further adds that the target should be individualized based on age/life expectancy, comorbid conditions, diabetes duration, hypoglycemia status, known CVD/advanced microvascular complications, and individual patient considerations. Thus, for a measure of "good control", it is more appropriate to use a measure that takes into account the need for individualization required to achieve good outcomes without increasing risks. 25 Kaiser Permanente Diabetes HbA1c Control (<7%) for a Selected Population the removal. Setting a goal of HbA1c < 7% should be an individualized target and an administrative measure is not good for capturing that. Updated 12/22/15 3 of 10

4 26 Kaiser Permanente Percent of Providers Receiving Payment in CMS or Medi-Cal EHR Incentive Programs VBP4P Response to Public Comment removal. MY P4P Testing measures 27 MemorialCare Testing Measures with There are 4 proposed measures for that rely on pharmacy data (antidepressant medication, statin therapy for hypertension, statin therapy for diabetes, and medication management for asthma). Pharmacy data from health plans are not formatted to be clinically useful. Health plan data is also incomplete in that it does not capture those patients paying cash for generics, filling prescriptions at pharmacies such as Target or Costco, or by certain mail order pharmacies. If additional pharmacy measures are adopted, there should be an easier mechanism to send supplemental data, health plans should provider more detailed, user friendly reports, and more complete pharmacy data needs to be captured. The medication adherence measures are tools to look at overall patient adherence for use to improve quality. The P4P committees are aware of the concern that some of the prescription claims for low-cost generics are not captured by claims data. Some health plans are lowering co-payments as an incentive to capture more dispensed generic medications. We also expect that the use of alternative prescription sources such as Target or Costco would affect most POs equally. While we are aware of the issues around the usability of pharmacy data from health plans, the P4P committees feel that these measures are clinically important and reliable enough to continue collecting as testing measures for MY. Health plans should be making the pharmacy data available to POs in the industry standard CALINX industry format. IHA continues to encourage and support greater standardization in data exchange. Starting with MY 2014, POs are permitted to consider pharmacy data shared by health plans as encounter data (instead of supplemental data) if they can obtain and provide the appropriate Roadmap documentation and attachments to support this. 28 Cigna Corporation Antidepressant Medication Management 29 Hill Physicians Antidepressant Medication Management Consistent with HEDIS with This measure will be difficult to implement for POs that carve out behavioral health AMM was added as a testing measure for MY as an initial attempt at incorporating benefits, since the PO's primary care physicians are not primarily responsible for managing behavioral health into the P4P measure set. The P4P Committees believe that this is an the eligible patients. In these situations, will IHA work with the health plans to hold the important clinical area, as well as being important to health plans, who are responsible for behavioral health partners accountable for the management of the eligible patients? this measure in national data sets. As a result, they wanted to try and capture this data. P4P staff have also heard from committees in the past that a majority of the initial prescriptions are prescribed by PCPs, so it is believed that they should be managing those patients. Recognizing the concerns posed by behavioral health carve-outs, IHA will ensure that testing results are closely reviewed with the Technical Measurement Committee and during 2016 public comment before the measure would be considered and adopted for incentive payments, public reporting, and awards. IHA always encourages data sharing between plans and POs and will continue to do so. However, we are not currently positioned to work directly with the behavioral health partners. In our experience, however, measuring performance is a necessary first step in facilitating the broader and transparent discussion around performance and accountability. 30 Kaiser Permanente Antidepressant Medication Management We agree that there should be adequate attention to behavioral health care, and this measure is one way to look at whether members are getting appropriate care. Updated 12/22/15 4 of 10

5 31 Cigna Corporation Medication Consistent with HEDIS Management for People With Asthma 32 Kaiser Permanente Medication Do not support Management for People With Asthma Based on KP's experience in the under 65 population, we do not support this measure. The current NCQA measure does not support the NIH-recommended step-down of asthma controller therapy or appropriate seasonal asthma management (the NIH supports discontinuing controllers for patients with seasonal asthma). In addition, KP has found that MMA compliance does not lead to improved clinical outcomes in the under 65 population. An analysis conducted by shows MMA compliance greater than 20% has no impact on the ED/Hospitalization rates for that population. Furthermore, an analysis conducted by * reinforces the limited value of MMA compliance by showing there is no significant clinical difference in ED/Hospitalization, Oral Steroid usage, or SABA usage in those >75% MMA compliant vs. those <50% MMA compliant. We believe that these limitations in the under-65 population would also be present in the over-65 population. Additional considerations for MMA include calculation of days supply around end of year and for medications with an overlap: - With MMA truncating the days supply at the end of a calendar year, 90 day dispensing after October 1st is not appropriately accounted for, undervaluing the true controller compliance. - For many patients with seasonally exacerbated asthma, it may be appropriate to prescribe multiple different medications on one day with the intention of using the stronger controller during the pollen and stepping down to a lesser potency controller for the remainder of the year. This strategy, based on NIH guidelines, is not considered in the current MMA measure, which gives credit for only one medication. *Reference: Yoon, A. C., Crawford, W., Sheikh, J. () The HEDIS Medication Management for People with Asthma Measure is Not Related to Improved Asthma Outcomes. The Journal of Allergy and Clinical Immunology: In Practice, 3(4) This measure was added to the testing measure set in an effort to reach more alignment with other measure sets; MMA is included both in the federal Quality Rating System measure set and the HEDIS Health Plan Accreditation measure set. Regarding the denominator for this measure, P4P staff forwarded this comment to NCQA and received the following response regarding the HEDIS MMA measure: The measure denominator has been validated to include people with persistent moderate to severe asthma and does not include those with seasonal asthma or allergies. NCQA hopes to continue working with KP and learning about the results. Based on this feedback from Kaiser and support from the P4P committees, we will be removing the MMA measure from the MY testing measures. Asthma Medication Ratio (AMR) will continue to be reported and paid on for MY. 33 Kaiser Permanente Medication Do not support Management for People With Asthma We do not support inclusion of this measure. A simple measure of adherence to medication does not apply to good asthma care. An analysis conducted by our Asthma Care Regional Physician leader (cf. article citation below*) reinforces the limited value of MMA compliance by showing there is no significant clinical difference in ED/Hospitalization, Oral Steroid usage, or SABA usage in those >75% MMA compliant vs. those <50% MMA compliant. We believe that these limitations in the under-65 population would also be present in the over-65 population. - For many patients with seasonally exacerbated asthma, it may be appropriate to prescribe multiple different medications on one day with the intention of using the stronger controller during the pollen and stepping down to a lesser potency controller for the remainder of the year. This strategy, based on NIH guidelines, is not considered in the current MMA measure, which gives credit for only one medication. *Reference: Yoon, A. C., Crawford, W., Sheikh, J. () The HEDIS Medication Management for People with Asthma Measure is Not Related to Improved Asthma Outcomes. The Journal of Allergy and Clinical Immunology: In Practice, 3(4) This measure was added to the testing measure set in an effort to reach more alignment with other measure sets; MMA is included both in the federal Quality Rating System measure set and the HEDIS Health Plan Accreditation measure set. Regarding the concern about medication dispensing, P4P staff forwarded this comment to NCQA and received the following response regarding the HEDIS MMA measure: None of the asthma medications in the specifications are indicated as high risk for older adults. We have not found any literature linking poor asthma medication adherence in older adults to the risk of adverse effects from medications. Based on feedback from Kaiser and the P4P committees, we will be removing the MMA measure from the MY testing measures. Asthma Medication Ratio continues to be supported as a clinically relevant measure and will be reported and paid on for MY. 34 Cigna Corporation Statin Therapy for Cardiovascular Disease Consistent with HEDIS Updated 12/22/15 5 of 10

6 35 Kaiser Permanente Statin Therapy for Cardiovascular Disease with VBP4P Response to Public Comment We support adoption of NCQA's new Statin Therapy measures, however we feel strongly that certain diagnosis codes should be removed, specifically those for Aortic Atherosclerosis and Embolic Diseases and Vasospasm. Aortic atherosclerosis identified on imaging is very common, but does not necessarily indicate high cardiovascular risk.* Furthermore, the 2013 AHA/ACC Cholesterol Treatment guidelines do not include Aortic Atherosclerosis in their definition of clinical ASCVD.** We also feel that the measure includes several Embolic Disease and Vasospasm codes that are not consistent with the ACC/AHA definition of clinical ASCVD, as neither Embolic Diseases nor Vasospasm are included in the?clinical ASCVD? definition. These include , , , , , , 444.1, , , , , (diagnoses where embolism is present without atherosclerosis), and (which is the result of vasospasm, but can occur without atherosclerosis). References: *Van der Meer IM, Bots MI, Hofman A, Del Sol, AI, Van der Kuip, DAM, Witteman, JCM et al. Predictive Value of Noninvasive Measures of Atherosclerosis for Incident Myocardial Infarction: The Rotterdam Study. Circulation 2004; 109: **Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero ST, Smith SC Jr, Watson K, Wilson PWF ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63(25, Part B): 2889?2934. It is a P4P principle to align with national standards like HEDIS whenever possible. P4P staff forwarded this comment to NCQA and received the following response: NCQA will review your other recommendations with our clinical expert panels and potentially incorporate any changes during our next update for HEDIS SPC is a first year measure for HEDIS 2016 and a testing measure for P4P MY, which means that SPC won t be considered for P4P payment and public reporting until MY 2017 (HEDIS 2018). It is IHA s intention to align with the HEDIS specifications each measure year, so if the HEDIS specifications are updated in future years, the P4P specifications will be updated as well. 36 Kaiser Permanente Statin Therapy for Cardiovascular Disease 37 Cigna Corporation Statin Therapy for Diabetes 38 Kaiser Permanente 39 Kaiser Permanente Statin Therapy for Diabetes Statin Therapy for Diabetes MY Measure Set Corrections 40 Cigna Corporation Diabetes Care: Two HbA1c Tests- added for public reporting 41 Kaiser Permanente Diabetes Care: Two HbA1c Tests- added for public reporting We agree that this measure is valuable for measuring quality of care for members with cardiovascular conditions. We are reaching out to NCQA to suggest refinement of the denominator criteria and would hope that IHA would continue to align with HEDIS if changes in the NCQA specifications go through. Consistent with HEDIS We agree that this measure is valuable for measuring quality of care for members with diabetes. We are reaching out to NCQA to suggest refinement of the denominator criteria and would hope that IHA would continue to align with HEDIS if changes in the NCQA specifications go through. We are prepared to report this measure if it is considered to be more meaningful.. MY P4P Measurement Collection Process and Policy Changes 42 Cigna Corporation Continuous enrollment change Consistent with HEDIS 43 Kaiser Permanente Continuous enrollment change. Updated 12/22/15 6 of 10

7 44 Cigna Corporation Inclusion of Marketplace members in P4P reporting Do not support Reporting for the marketplace population should be done separately to allow for comparisons between products. In order to achieve the most inclusive reporting possible, for the purposes of P4P reporting, Marketplace (i.e., Covered California) HMO/POS members are reported with the commercial HMO/POS population. Please note: the members were included in MY 2014 results, based on feedback from the P4P Governance Committee. While there wasn't a targeted evaluation of the effect, there were not any noted issues. P4P committees discussed the possibility of reporting the "Marketplace" population separately from the commercial population and decided to include "Marketplace" members in commercial reports for MY. P4P staff and committees do not think the size of the "Marketplace" HMO/POS population is large enough to have a significant impact on P4P rates, but will continue to monitor this issue as the "Marketplace" evolves. 45 Kaiser Permanente Inclusion of Marketplace members in P4P reporting. Otherwise, the Exchange members would not be accounted for in the P4P domain, and it makes sense to view them in the same light as Commercial members. 46 Cigna Corporation Supplemental Data This will help with data flow tracking. Hopefully this will allow for inclusion and not another set of NCQA audits of the NCQA auditor's work at another entity. 47 Hill Physicians Supplemental Data with Can you please clarify the new supplemental data collection and health plan submission requirement for MY? What is meant by having the health plans "parse" the data prior to sending to the health plans for use in P4P/HEDIS measurements? Please also clarify the timing of the approval and submission process. According to the data submission deadlines timeline in the draft MY manual, the last day for health plans to collect/enter nonstandard supplemental data is March 2. Therefore, according to the new rule, it appears that the PO must submit the auditor approved/locked supplemental data to the health plans by this date. However, the supplemental data validation deadline occurs after this time, on March 15. A breakdown of the proposed steps and timing would help clarify the issue, including auditor-involved steps. 1)There is no change to the supplemental data collection and submission process other than the new requirement for an auditor locked file. Physician organizations that work with data aggregators to collect and maintain their supplemental data need to ensure that memberlevel data are only being shared with the health plan that member belongs to. For example, if a vendor is collecting supplemental data for a PO, the PO cannot send their entire vendor data file to every health plan they contract with. They should only be sending the data to each health plan the members belong to. 2)The date in the last sentence under Supplemental Data Validation Deadline should state: "Auditor finalizes approval of all supplemental data. Primary source verification (PSV) for member-reported and nonstandard supplemental data must not occur prior to February 15 unless the organization finished all supplemental data processes, collection and entry." We will an release an FAQ and correct this date for the final version of the MY Value Based P4P Manual release on December 1,. 48 Kaiser Permanente Supplemental Data. MY P4P Measure Specification Changes 49 Cigna Corporation Annual Monitoring for Patients on Persistent Medications Consistent with HEDIS 50 Cigna Corporation Diabetes Care Consistent with HEDIS 51 Cigna Corporation Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis Consistent with HEDIS Updated 12/22/15 7 of 10

8 52 Cigna Corporation Disease-Modifying Consistent with HEDIS Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis 53 Cigna Corporation Osteoporosis Consistent with HEDIS Management in Women Who Had a Fracture 54 Cigna Corporation All-Cause Consistent with HEDIS Readmissions 55 Cigna Corporation Frequency of Selected Procedures Consistent with HEDIS Other comments- Clinical Domain 56 Kaiser Permanente Other We support all changes that align with HEDIS changes. 57 Hill Physicians Immunizations for Adolescents with Regarding Immunizations for Adolescents: Per the CDC and AAP recommendations, if a P4P staff forwarded this comment to NCQA and received the following response regarding child did not receive the appropriate number of DTaP vaccines as an infant and received a the HEDIS IMA measure: The IMA measure is intended to assess whether adolescents are Tdap vaccine between the ages of 7-9 years per the catch-up schedule they do not need to immunized as recommended by the "standard CDC and ACIP guidelines for immunizations. receive another Tdap vaccine between the ages of years. The P4P specifications do Our measure does not give credit for adolescents who are immunized on the "catch-up" not take this into account. IHA only considers children who received the vaccine after their schedule. 10th birthday and before their 13th as compliant to this measure. There are no exclusion for children who received the vaccine earlier as part of the catch-up schedule. 58 Hill Physicians Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women: with Regarding the Evidence-Based Cervical Cancer Screening of Average-Risk, Asymptomatic Women: Our providers with significant LGBT patient populations are concerned that they are unfairly penalized as their transgender patients should be removed from measure as eligible patients. Recommend adding measure exclusion for transgender patients. In order to be counted in the denominator for the ECS measure, the member must meet the eligible population criteria; thus, the member must be a biological female. If it is documented in the medical record that the member was born biologically male (e.g., transgender male to female), then this is evidence that the member does not meet that criterion and should not be counted in the denominator or numerator for this measure, but a biological female would meet the criterion and should be counted in the denominator and assessed for the numerator. P4P staff understand the concerns about this patient population and believe the number of transgender members is expected to be small and will likely affect all POs equally. Additionally, POs should remember that performance measures are based on guidelines, and that no guideline is ever expected to be followed 100% of the time. Guidelines are intended to apply for the majority of patients and are intended to address the routine, but are not intended to replace clinical judgment. Updated 12/22/15 8 of 10

9 59 Hill Physicians Breast Cancer Screening with Regarding Breast Cancer Screening: Our providers with significant LGBT patient populations are concerned that they are unfairly penalized as their transgender patients should be removed from measure as eligible patients. Recommend adding measure exclusion for transgender patients. P4P staff have forwarded this question to HEDIS and received the following response: For the BCS measure, transgender members should remain in the measure. It is our understanding that transgender members can and do have mammograms. This may be due to the fact that they could be taking hormones that can increase the risk of breast cancer. However, NCQA has not formally pursued the clinical appropriateness because the number of members in this situation is likely to be too small to result in bias of the HEDIS rate. P4P staff understand the concerns about this patient population and believe the number of transgender members is expected to be small and will likely affect all POs equally. Additionally, POs should remember that performance measures are based on guidelines, and that no guideline is ever expected to be followed 100% of the time. Guidelines are intended to apply for the majority of patients and are intended to address the routine, but are not intended to replace clinical judgment. Other comments- Resource Use Domain 60 MemorialCare Outpatient Procedures Utilization- Percentage Done in a Preferred Facility Do not support Regarding ARU measure percent of procedures in a preferred facility. It is very difficult to find each plans preferred facility and as PO's organize into large integrated delivery systems with multiple product lines, it becomes a huge administrative burden to focus on this measure. IHA has requested that health plans make this information available to POs, and will continue to reinforce this message. Given the importance of the measure, both as a health plan priority and as a shared savings opportunity in Value Based P4P, the P4P committees want to ensure that it is actionable for POs. The P4P committees have requested that IHA convene a work group to revisit this measure and consider approaches to better tailor the procedures/services, create a standard definition of preferred facilities, and/or consider alternate measure concepts that target outpatient utilization. 61 Sutter Health Main Clinic Generic Prescribing Do not support Please review the current Nasal Steroid generic prescribing measure for discontinuation or modification. It appears that the availability of two over-the-counter (OTC) nasal steroids (Flonase and Nasacort) is negatively affecting Generic Prescribing rates. Most health plans are no longer covering prescriptions for generic fluticasone (Flonase). This has led to patients buying the product OTC or the prescriber switching the patient to a brand nasal steroid (i.e. Nasonex) that is still being covered by the health plan. Either way, shifting volume to OTC has resulted in a decrease generic prescriptions while brand prescriptions remain the same, or slightly increased. In our organization, the Nasal Steroid generic prescribing rate has dropped 17% over the past two quarters. P4P committees feel that the Nasal Steroid measure continues to be clinically relevant and will continue to be collected. The Technical Measurement Committee has discussed concerns around missing scripts that are filled outside of the pharmacy benefit. While the committee acknowledged the concern, the sense was that the impact was not likely to be biased across physician organizations. A similar situation occurred with the release of the OTC PPIs. Despite the release of several OTC versions, results for recent years continue to show across-the-board upticks in generic prescribing. The Generic Prescribing measure is only used for internal participant reporting and health plan shared savings. The VBP4P shared savings methodology includes a recommended adjustment to the target for GRX measures in instances where there is a release of a new brand or expiration of a major patent expiration. The P4P Technical Payment Committee felt this adjustment would be an appropriate accommodation for the nasal steroid measure in MY to ensure POs aren't unduly penalized. 62 Hill Physicians Total Cost of Care with Regarding the Total Cost of Care results: Moving forward into MY, it would be helpful if the health plans could provide interim total cost of care results and drilldowns to POs throughout the year (e.g., quarterly). This will allow sufficient time for POs to analyze and implement program changes with enough time to change patterns and improve scores prior to the interim/final results are released in September. P4P staff would also like to provide additional detail for Total Cost of Care reports. IHA is actively working with health plans to support interim ARU reporting. Currently, the data IHA receives only has costs as a lump-sum at the member-level. We will be exploring what additional information we are able to provide that would support greater understanding and insight into the results. 63 MemorialCare Total Cost of Care Other comments- MUHIT Domain with Total Cost of Care should be more transparent so PO's can drill down to identify areas of improvement and resource allocation Please see response #62. Updated 12/22/15 9 of 10

10 64 Sutter Health Main Clinic MUHIT: e-measures with Please provide additional details and examples of how to calculate the four e-metrics, as there is very little guidance on how to calculate performance. For MY, P4P staff added an example and additional information for submitting results to the Clinical Quality Measures section of the MUHIT domain. P4P staff also plan to hold training webinars early next year to provide examples and further explanation on how to calculate and report the e-measures. While the POs are expected to aggregate both rates for each measure, P4P staff are not prescriptive about how this is done. Other comments P4P General 65 EPIC Management, LP Other I wonder if there would be any way you could share the info at least quarterly instead of yearly. Something to consider. Thank you for all your work. P4P staff understand the need for more frequent reporting and are actively working with P4P committees to determine the feasibility of providing interim resource use reports. Updated 12/22/15 10 of 10