2013 Performance Incentive Metrics

Transcription

1 Performance Incentive Metrics The Performance Incentive Subcommittee presents the following set of proposed 2013 MiPCT Performance Incentive Metrics for consideration and recommends they be approved for use in These metrics will be used for both the 18 month mid-year and 24 month end-of-year performance incentive assessments. The focus of the Performance Incentive Program is designed to transition during the MiPCT project from primarily rewarding infrastructure and process development in 2012 to rewarding desired outcomes in The 2013 Performance Incentive Metrics set is a combination of metrics that demonstrate improvement and those that demonstrate important capabilities are in place. Outcome/Improvement Measures (70%) 1. Emergency department and hospital utilization: Reduced utilization is an expected outcome of the improved care processes that characterize patient- centered medical homes. Decreased/stable utilization compared to baseline will be rewarded. 2. Claims Based Clinical Quality Metrics: These measures indicate that evidence - based screening, testing and preventive care were provided and rewards improvement/stability in comparison to baseline measurements. Process Measures (30%) 3. EHR/Registry Based Clinical Quality Metrics: MDC will begin collecting clinical data for performance reporting in These measures reward practices/pos that regularly submit the requested data during 2013 to establish a baseline. 4. Process measures: These self-reported capabilities support moderate and complex care management in the areas of notification of hospital admissions/discharges, development of team capacity to provide self-management support and linkages with community based programs and services. The metrics reward attainment of the capability. The following table identifies the metrics and point weights for each category. The clinical quality metrics in sections II and III have specific age ranges. Practices will be assessed for the metrics applicable to the population they serve - adults, children, or both. The point value for individual metrics will be calculated by MDC and will vary in accordance with the number of measures in the category that are applicable to each practice. The table is followed by a description of each metric. Respectfully, David Livingston, co-chair Performance Incentive Subcommittee MiPCT Performance Incentive Subcommittee Members Members: Carol Callaghan, Charlie Carpenter, Ruth Clark, Jim Forshee, Margaret Mason, Ewa Matuszewski, Devorah Rich, Alicia Simmer (alternate) and Betsy Wasilevich (alternate). MiPCT Staff: Dana Watt, Diane Bechel Marriott, Amanda First Committee Consultants: Myron Hepner, Mallory Lawrenchuk and Clare Tanner

2 Performance Incentive Metrics Outcome/ Improvement Measures Points I. Utilization (Improvement over baseline) Primary care sensitive ED visits (NYU algorithm) Ambulatory Care Sensitive Hospitalizations Readmissions 10 II. Clinical Quality Metrics - Claims Based ( Improvement over baseline) 15* 1. Diabetes: AIC tests completed 2. Diabetes: Annual retinal eye exams 3. Breast Cancer Screening 4. Cervical Cancer Screening 5. Well Child Visits - 15 months 6. Well Child Visits years 7. Adolescent immunizations Outcome Subtotal 70 Process Measures Points III. Clinical Quality Metrics EHR or registry (Pay for Reporting) 15* 1. Diabetes Control (adults): a. AIC < 8 2. Diabetes Poor Control (adults): AIC > 9 3. Diabetes (adults): Blood Pressure < 140/90 4. Cardiovascular Disease (adults): Blood Pressure < 140/90 5. Hypertension (adults): Blood Pressure < 140/90 6. Asthma (ages 5-64): Asthma Action Plan or self-management plan for a. all asthma and b. persistent asthma 7. Tobacco Use ( 13 years and older): Percent smokers 8. Obesity - children: BMI Percentile IV. Process Measures (Numbers 2-6: Capability is in Place per PGIP SRD Report) Notification of hospital admissions & discharges 3 2. Tracking referrals of high-risk patients to community resources. (10.7) Follow-up of high-risk with community referrals for next steps. (10.8) 4. At least one member of PO or practice unit has completed formal training in a 3 nationally or internationally-accredited self-management support program and works with/educates practice unit staff members to actively use selfmanagement support concepts and techniques. (11.8) 5. Self-management support is offered to all patients with the chronic condition 3 selected for initial focus (based on need, suitability, and patient interest. (11.2) Process Subtotal Measures Total 100 *The number of points assigned to individual measures for internal medicine, family practice and pediatric practices will vary depending on the number of applicable measures for the patient population.

3 3 I. Utilization Metrics 2013 Performance Metric Descriptions 1. Primary Care Sensitive ED Visits Primary Care Sensitive ED Visits/1000 patients during measurement year compared to PO s rate for prior year(s). The NYU Algorithm for ED Visit classification will be used. ED visits will be sorted into four categories. The first three categories are collectively referred to as preventable/avoidable or primary care sensitive (PCS) conditions/visits. Non-emergent. Cases where immediate (within 12 hours) care is not required (e.g., sore throat, back pain, ingrown toenail, eczema, and attention to dressings). Emergent, but primary care treatable. Care is needed within 12 hours, but care could be provided in a typical primary care setting (e.g., infant with a 102 fever, nosebleed, abdominal pain, acute bronchitis, painful breathing). Emergent, ED care needed but preventable/avoidable. Immediate care in an ED setting is needed, but the condition potentially could have been prevented or avoided with timely and effective ambulatory care (e.g., asthma, cellulitis, emphysema, pelvic inflammatory disease, diabetic ketoacidosis, etc.). Emergent, ED care needed, not preventable/avoidable. Immediate care in an ED setting is needed and the condition could not have been prevented/avoided even with effective ambulatory care (e.g., heart attack, appendicitis, kidney stone, multiple trauma, and chest pain). This category includes visits with a principle diagnosis relating to injury, mental health, alcohol and drug related, and visits with an unclassified diagnosis that does not fall into one of the other categories. This classification is then used to calculate rates of preventable/avoidable/pcs conditions per 1000 patients. Rates are known to vary by patient demographics, health plan source, and geography. Points will be allocated to POs whose rates have decreased during the measurement year. NYU Wagner

4 4 2. ACSC Hospitalization Rate. The Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQI) together with the Pediatric Quality Indicators (PDI) is commonly referred to as ACSCs, Ambulatory Care Sensitive Conditions. ACSCs are a subset of inpatient discharges that are classified by the AHRQ algorithm and thought to be potentially avoidable through early intervention and appropriate outpatient care. The PQI are Adults age 18 or older at admission and not in MDC 14 (Pregnancy, Childbirth and the Puerperium). Definitions for ACSCs are based on ICD-9-CM diagnosis and procedure codes (often along with diagnosis related group (DRG), major diagnostic category (MDC), sex, age, procedure dates, admission type, admission source, discharge disposition). Numerator is the number of cases flagged with the outcome of interest and the Denominator is the inpatient discharges for the population at risk. The observed rate is numerator / denominator. Adult ACSCs include Acute and Chronic conditions. There are 9 chronic conditions and 4 Acute Conditions. The Chronic conditions are : Chronic Diabetes Short Term Complications; Chronic Diabetes Long Term Complications; Chronic Diabetes Amputation; Chronic Diabetes Uncontrolled; Chronic Hypertension; Chronic Angina no procedure; Chronic Congestive Heart Failure; Chronic COPD and Chronic Asthma in Young Adults (the only PQI with an upper limit Age at admission > 18 AND < 40.) The Acute Conditions are: Acute Bacterial Pneumonia; Acute Dehydration; Acute UTI (urinary tract infection) and Acute Perforated Appendix. Source: AHRQ Quality Indicators, Prevention Quality Indicators: Technical Specifications, Department of Health and Human Services, Agency for Healthcare Research and Quality. Updated March ( Pediatric Quality Indicators (PDI). Identifies potentially preventable inpatient admissions in the pediatric population (Age under 18 years) and not in MDC 14 (Pregnancy, Childbirth and the Puerperium) or in Adult Diagnostic Related Groups. PDIs included in the ACSC measure: Asthma Admission Rate (Pediatric Members 2 to 17 years), Diabetes Shortterm Complications (Pediatric Members 6 to 17 years), Gastroenteritis Admission (Pediatric Members 3 months to 17 years) Perforated Appendix Admission (Pediatric Members 1 to 17 years) and Urinary Tract Infection (Pediatric Members 3 months to 17 years). Source: AHRQ Pediatric Quality Indicators 3. All-Cause Readmissions (HEDIS): The number of acute inpatient stays during the measurement year that was followed by an acute readmission for any diagnosis within 30 days for adults 18 years of age and older. II. Clinical Quality - Claims Based Points will be allotted for each measure for which the value for the measure period is unchanged or improved compared to the value for the baseline period. 1. Diabetes: HbA1c Management-Testing Percentage of patients years of age with diabetes who had one or more HbA1c test(s) during the measurement year.

5 5 2. Diabetes: Eye Examination Percentage of patients years of age with diabetes who had a dilated or retinal eye exam during the measurement year or a negative retinal eye exam during the prior year. 3. Breast Cancer Screening Percentage of women years of age who had a mammogram to screen for breast cancer within the measurement year or one year prior. 4. Cervical Cancer Screening Percentage of women years of age who received one or more Pap tests to screen for cervical cancer within the measurement year or prior 2 years. 5. Well-Child Visits in the First 15 Months of Life (HEDIS): Percent of children who turned 15 months old during the measurement year and who had six or more well-child visits with a PCP during their first 15 months of life. 6. Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life(HEDIS): Percent of children 3-6 years of age who had one or more well-child visits with a PCP during the measurement year. 7. Adolescent Immunizations (HEDIS): Percent of youth who have received the following a. Meningococcal vaccine on or between the members 11th to 13th birthdays. b. 1 Tdap or 1 Td on or between the members 10th to 13th birthdays. III. Clinical Quality EHR/Registry Based Points will be allotted for the regular submission of data to MDC using an approved format during the measurement period to enable MDC to calculate the following measures. 1. Diabetes AIC<8 (HEDIS) Ages 18-75: Percent of adults with a diagnosis of diabetes who had a screening AIC test in the measurement year with result of AIC<8 2. Diabetes Poor Control AIC >9 (HEDIS) Ages 18-75: Percent of adults with a diagnosis of diabetes who had a screening AIC test in the measurement year with result of AIC>9 3. Diabetes BP<140/90 (HEDIS) Ages 18-75: Percent of adults with a diagnosis of diabetes with the most recent blood pressure during the measurement year recorded as <140/90 4. Cardiovascular Disease BP<140/90 (HEDIS): Percent of adults years of age who were discharged alive for AMI, CABG or PCI from January 1 to November 1 of the year prior to the measurement year, or who had a diagnosis of IVD during the measurement year and the year prior to the measurement year, with blood pressure control (<140/90) in the most recent blood pressure reading in medical chart in the measurement year: The lowest systolic and lowest diastolic reading will be used if there are several BP recorded on the same date. 5. Hypertension Controlling High Blood Pressure (HEDIS) (ages 18-85): Percent of adults who had a diagnosis of hypertension with blood pressure control (<140/90) in the most recent blood pressure reading in medical chart in the measurement year: The lowest systolic and lowest diastolic reading will be used if there are several blood pressures recorded on the same date. 6. Asthma Self- Management Plan or Action Plan (non-hedis) Ages 5-64: Percent of children and adults with a diagnosis of asthma for whom an asthma self-management plan or action plan was created or reviewed/updated during the measurement year. Clinicians should provide all patients with a written asthma action plan that includes instructions for: a. Daily management

6 6 b. Recognizing and handling worsening asthma, including self-adjustment of medications in response to acute symptoms or changes in PEF measures. Written asthma action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B). MiPCT will calculate rates for all asthma and persistent asthma. Source: National Heart, Lung, and Blood Institute National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma The CDC provides several examples of asthma action plans Tobacco Use (13 years and older): Percent of individuals 13 years of age and older with an office visit during the measurement period who reported they currently smoke tobacco. 8. Obesity (children): Percentage of patients 2-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or OB/GYN and who had evidence of BMI percentile documentation IV. Process Measures Measures 2-6 are PGIP capabilities that will be assessed through the BCBSM self-report process. 1. Notification of Hospital Admissions and/or Discharges A process is in place for the MiPCT practice to obtain daily notification of more than 50% of the hospital admissions and/or discharges and transfers for their patients. POs will indicate in MiPCT Quarterly Report the hospitals for each practice where a notification process is in place. Credit will be awarded if the sum of the admissions to the identified hospitals represents >50% of the total admissions for that practice. 2. A systematic approach is in place for tracking referrals of high-risk patients to community resources made by the care team, and making every effort to ensure that patients complete the referral activity. (10.7) 3. A systematic approach is in place for conducting follow-up with high-risk patients regarding any indicated next steps as an outcome of their referral to a community-based program or agency. (10.8) 4. At least one member of PO or practice unit is formally trained through completion of a nationally or internationally-accredited program in self-management support concepts and techniques, and regularly works with appropriate staff members at the practice unit to educate them so they are able to actively use self-management support concepts and techniques. (11.8) 5. Self-management support is offered to all patients with the chronic condition selected for initial focus (based on need, suitability, and patient interest. (11.2)