2017 Public Comment Overview & Summary

Transcription

1 2017 Public Comment Overview & Summary Background The VBP4P public comment period gives stakeholders the opportunity to comment on any updates to the Value Based P4P Program. The public comment period begins when the draft version of the Value Based P4P Manual is released on September 1, and continues throughout the month of September. VBP4P staff release a Call for Public Comment document and invite stakeholders to comment on any program policy updates, changes to the measure set, or changes to measure specifications. During this time, VBP4P staff review comments and draft responses. These responses are reviewed with the VBP4P committees in the and posted on the IHA website in early December in conjunction with the final program manual and measure sets to inform VBP4P data collection and reporting for Measurement Year The 2017 VBP4P Public Comment period highlighted changes to the following areas: Measurement Year 2017 (MY 2017) The changes outlined reflect the proposed process and guidelines for collecting the results, measures identified for testing, and the incorporation of updates to the specifications of existing VBP4P measures to align with measure steward s specifications for the same period (e.g., HEDIS 2018 and VBP4P MY 2017 measure the same time period). As a reminder, the MY 2017 Measure Set was finalized in 2016; all changes reflect specification updates, not measure additions or removals. Measurement Year 2018 (MY 2018) The changes outlined reflect the measures that are proposed for payment and public reporting for MY 2018; results will reflect the care provided to members in calendar year 2018 and be collected and reported during calendar year Specifications are provided for any measures that are not already included in the VBP4P manual. The report containing all comments received, as well as IHA s response, are below. Additionally, the 2017 Call for Public Comment document is included for further detail and reference. December 2017 Page 1 of 45

2 # Org Measure/Topic Support Comment IHA Response IHA Performance Measurement Changes (General) 1 Health Plan Support with mods Specialty Pharmacy Measure Development MY 2017 Commercial VBP4P Measure Specification Updates & Testing Measures 2 PO Align with Steward Measure Specifications Do not support Our health plan previously provided feedback through the technical payment committee that we would like to include a Medical Director, Pharmacist, and Business Representative to come up with the framework for this measure. For the 2017 measurement year IHA technical specifications associated with the Low Back Pain (LBP) measure, we recommend the following value set changes: #1: We recommend adding the following to the "trauma value set" - S20.219A is contusion of the front wall of the thorax - S20.229S is a contusion of the back wall of the thorax - T14.8, unspecified body region injury - S20.90 series is for superficial injuries to the trunk #2: We recommend adding the following codes under the "neurologic impairment" category to allow patients to get imaging without failing the measure - lumbar radiculopathy (M54.16), radiculopathy - lumbosacral radiculopathy (M54.17) - sacral or sacro coccygeal radiculopathy (M54.18). - Stenosis codes: M99.23, M993.3, M99.43, M99.53, M99.63, and M Thank you for your input. IHA is working with members of the VBP4P committees to identify appropriate participants for the pharmacy workgroup that will tackle this issue. IHA staff look forward to your input shaping the new pharmacy measure(s) for the VBP4P program. It is a VBP4P program policy to align with measure steward's specifications whenever possible in order to maintain alignment with regional and national performance measurement and benchmarking efforts. VBP4P staff have forwarded your comments to NCQA, where your input and suggested codes were reviewed by the appropriate staff and panels and received the following response: "LBP underwent measure reevaluation for HEDIS 2017 and trauma codes were not included as HEDIS does not include codes where the trauma could have been minor (bruises, paper cuts). Based on feedback from the HEDIS panels and committees, NCQA thinks that it is not appropriate to exclude all patients with radiculopathy, as the severity of radiculopathy varies (but cannot be identified by claims data) and the guidelines suggest that imaging should not be done in the first 4-6 weeks after onset of pain for radiculopathy unless red flags are present. Exclusions for spinal stenosis are not included because that condition is not common in people under the age of 50." IHA will collect LBP in alignment with NCQA's measure specifications for Measurement Year Health Plan 4 Health Plan 5 Health Plan Align with Steward Measure Specifications Align with Steward Measure Specifications Align to Standard Specifications for Total Cost of Care Support We support aligning with all HEDIS 2018 measure specification updates. Thank you for your support. IHA will align with HEDIS 2018 measure specification updates as appropriate in Measurement Year Support Support w/ mods We support the alignment to NCQA HEDIS specifications. Our global preference is that NCQA HEDIS specifications be used, rather than other PQA, CMS, or NQF measures. We need clarification as to the implementation date for the proposed methodology change. 1) Is it to apply for MY2017 or is MY2017 the "baseline" year so that it can be implemented in 2018? We need to know a bit more about the methodology to ultimately understand the impact of that recalibration. I think the question our CA groups would ask is how does the CA experience compares to that of Health Partners' to feel that it is credible and applicable. 2) Will IHA be purchasing a license from Health Partners to administer the methodology? If so, is there an anticipated cost to the IHA stakeholders? Will there be any vendor changes as a result of this implementation (data aggregator, risk scores, etc.) 3) Will there be any changes to the data collection processes such as the pending consolidation of Atlas and VBP4P processes? Any expected changes to file layout to support it? 4) It says that to support consistency and trending IHA will work to provide updated MY2016 and MY2017 to participants in MY2018. Does that mean that prior year periods will be restated (apple-to-apple comparison)? 5) What is the impact of excluding PO's self-reporting data from the resource use measures? Thank you for your support. As a strategic priority of VBP4P's Measure Set Strategy, the VBP4P Committees work diligently to ensure that the VBP4P Common Measure Set is highly aligned with other priority measure sets. While NCQA HEDIS measures are one priority set for health plan accountability, MIPS and Medicare Advantage have also been identified as priorities by the VBP4P Committees and include measures stewarded by PQA and CMS. 1) IHA's intention is to transition to standard TCC measure specification in MY 2017 in order to minimize disruption to participants as IHA onboards a new data vendor. IHA will be working closely with the VBP4P Committees to review, analyze, and guide the implementation of the specifications in a manner that is appropriate for participating health plans and physician organizations. 2) Health Partners makes a no-cost license available for the TCC measure. No additional costs are anticipated for health plans already submitting data for IHA appropriate resource use and cost measures. 3) Changes to the data collection process are anticipated as part of IHA's transition to a new vendor (Onpoint Health Data) and consolidating the VBP4P and Atlas data submissions. IHA does not anticipate any new data elements as a result of the use of standard specifications. IHA and Onpoint will provide resources for health plan reporting in MY ) Yes -- IHA's data partner will be providing updated MY 2016 results that use the same specifications as MY 2017 results, so that organizations can track their performance over time. 5) There should be no impact. Since resource use measures were added to the program in 2006 they have been run entirely from health plan claims, encounter, and eligiblity data, no PO-self-reported data. IHA will move towards standard measure specifications for Total Cost of Care in Measurement Year Health Plan Comprehensive Diabetes Care: Eye Exam (CDC: Eye Exam) Support We support the addition of the CDC Eye Exam measure as an important quality indicator for care for members with diabetes. Thank you for your support. IHA will test CDC: Eye Exam in Measurement Year December 2017 Page 2 of 45

3 # Org Measure/Topic Support Comment IHA Response 7 Health Plan Use of Opioids at High Dosage (UOD) Support We support the addition of the NCQA HEDIS UOD measure as an important quality indicator. Thank you for your support. IHA will test UOD in Measurement Year Health Plan Concurrent Use of Opioids and Benzodiazepines (COB) Do not support We support IHA's efforts at aligning with NCQA HEDIS specifications, and we oppose adding the COB measure to the VBP4P measure set as a testing measure. We suggest that IHA instead consider the HEDIS measure for studying the Use of Opioids from Multiple Providers, as this could be highly informative to Provider Organizations about both their providers and their members access to multiple pharmacies. Further, additional resources are required to produce non-hedis measures, and there are two new HEDIS measures for Opioid medications. The VBP4P Committees considered all available opioid measures from NCQA, including Use of Opioids from Multiple Providers, and recommended prioritizing NCQA's Use of Opioids at High Dosage and PQA's Concurrent Use of Opioids and Benzodiazepines. The Technical Measurement Committee (TMC) considered the Multiple Providers measures, but ultimately recommended against testing because internal testing results for the Multiple Providers measure showed less performance variation across POs and TMC discussion raised concerns about the actionability of the measure due to limitations of current state registries (e.g., CURES). Due to these concerns, the VBP4P Committees recommend testing opioid measures that allow physician organization and health plan focus on both high dosage and concurrent use. These efforts are in alignment with Smart Care California's (a partnership of Covered California, DHCS, and CalPERS convened by IHA) comprehensive strategies for reducing overuse in California. IHA will test COB in Measurement Year IHA recognizes that the measure may be challenging for physician organizations and health plans to report and have therefore recommended that the results be collected as part of the health plan claims submission to Onpoint only. Self-reporting physician organizations will not have the option to self-report this measure, and health plans will not have to program or include it in the submission of clinical data to TransUnion. The VBP4P Committes will review testing results in MY 2017 and make a recommendation for how this measure is incorporated into the VBP4P measure set in future years. 9 Health Plan Concurrent Use of Opioids and Benzodiazepines (COB) Support w/ mods Concurrent Use of Opioids and Benzodiazepines is a non-hedis measure. However, we are committed to reduction in the use of Opioids and would be happy to discuss further. Currently, NCQA does not have an available measure of concurrent opioid and benzodiazepine use available. As such, the VBP4P Committees recommend testing the PQA measure Concurrent Use of Opioids and Benzodiazepines in order to incorporate measures focused on opioid use, including high dose usage and risky combination opioid use, which address a timely and relevant public health issue. The VBP4P Committees recommend advancing measurement in this area to inform physician organizations and health plans of the prevalence of high dose or risky use of opioids in the commercial population. These efforts are in alignment with Smart Care California's (a partnership of Covered California, DHCS, and CalPERS convened by IHA) comprehensive strategies for reducing overuse in California. IHA will test COB in Measurement Year IHA recognizes that the measure may be challenging for physician organizations and health plans to report and have therefore recommended that the results be collected as part of the health plan claims submission to Onpoint Health data only. Self-reporting physician organizations will not have the option to self-report this measure, and health plans will not have to program or include it in the submission of clinical data to TransUnion. The VBP4P Committes will review testing results in MY 2017 and make a recommendation for how this measure is incorporated into the VBP4P measure set in future years. December 2017 Page 3 of 45

4 # Org Measure/Topic Support Comment IHA Response 10 PO Concurrent Use of Do not Opioids and support Benzodiazepines (COB) IHA proposes to add the Concurrent Use of Opioids and Benzodiazepines (COB) Pharmacy Quality Alliance (PQA) measure. We work diligently with our patients to manage chronic pain safely and responsibly, and we have put in place safety measures to avoid and protect patients against unsafe prescribing practices. We currently does not report PQA measures because we are a medical group, not a drug plan. Were IHA to add COB to its measure set, we would have to create a new data reporting stream to produce, report, and audit the data. This would necessitate significant time and resources, and has no additional performance improvement or public reporting benefit. That is why we strongly oppose adding the COB measure to the IHA VBP4P program, even for testing purposes. Conversely, we urge IHA to consider aligning with HEDIS measures instead. It is a VBP4P program priority to align to high-priority measures such as HEDIS measures whenever possible. At this time there is not a HEDIS measure for Concurrent Use of Opioids. The VBP4P Committees recommend advancing measurement in this area to inform physician organizations and health plans of the prevalence of high dose or risky use of opioids in the commercial population. In addition, Smart Care California (a partnership of Covered California, DHCS, and CalPERS convened by IHA) has included opioids as one of three focus areas for reducing overuse in California. IHA will test COB in Measurement Year IHA recognizes that the measure may be challenging for physician organizations and health plans to report and have therefore recommended that the results be collected as part of the health plan claims submission to Onpoint only. Self-reporting physician organizations will not have the option to self-report this measure, and health plans will not have to program or include it in the submission of clinical data to TransUnion. The VBP4P Committes will review testing results in MY 2017 and make a recommendation for how this measure is incorporated into the VBP4P measure set in future years. MY Commercial VBP4P Other Measure Feedback 11 Health Plan Annual Monitoring of Persistent Medications (MPM) Support If NCQA retires the measure this year we strongly encourage IHA to retire this measure for P4P MY Maintaining the measure one extra year if NCQA retires it is burdensome for plans and POs. Thank you for your support. In response to the HEDIS 2018 Technical Update released in Oct. 2017, the VBP4P Committees recommend aligning Annual Monitoring for Patients on Persistent Medications (MPM) with HEDIS 2018 measure specifications. 12 PO Diabetes Care: Eye Exam (CDC: Eye Exam) Support w/ mods The current IHA specifications indicate that eye screening for diabetic retinal disease must be performed by an eye care professional. However, there are currently vendors available that allow primary care providers to initiate and bill for eye exams (e.g., Retinavue Network). Such vendors allow the PCP to purchase a camera that captures retinal images; the images are securely sent to an ophthalmologist for review and assessment; a diagnostic report is then returned to the PCP. In such a scenario, the billing of the service comes directly from the PCP. Can IHA/NCQA please clarify the measure description to allow such services as a valid form of eye exam for numerator compliance? IHA will retire the MPM - digoxin indicator in alignment with HEDIS in Measurement Year MPM - ACEI/ARB and MPM - Diuretics will continue to be collected and recommended for payment and public reporting in MY IHA will retire MPM in full in Measurement Year 2018, givenhigh measure performance and low variation amongst POs. VBP4P staff forwarded this question to NCQA, who indicated that their understanding is that the scenario described is permitted as a valid form of eye exam for numerator compliance. However, because the measure requires that an eye care professional reviewed the results, there must be documentation that this was done, which will not be present if only the PCP billing of the service is included. See additional detail below that outlines the acceptable documentation for counting this service as numerator compliant. Because the situation described is numerator compliant, IHA will continue testing of CDC: Eye Exam in Measurement Year 2017 and will not update the measure description. Additional information: The CDC measure does permit the use of retinal imaging provided it includes the date when the fundus photography was performed and evidence that an eye care professional (optometrist or ophthalmologist) reviewed the results. Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist. In order to use this when reporting the eye exam indicator, the required documentation (e.g., date when the fundus photography was performed and evidence that an eye care professional or reading center reviewed the results) must be added to the member's medical record. Please keep in mind that it is not acceptable for a PCP to interpret/review the image. CPT Cat II codes are intended to be billed by primary care providers. The 'Diabetic Retinal Screening With Eye Care Professional Value Set' contains only CPT Category II codes which are used for performance reporting and are not used for billing purposes (even though they are coded on billing claim forms. The intent is to use the claim form and the CPT Cat II codes as a means to relay performance reporting information between the provider and the payer). The intent is that the PCP receives documentation prepared by the optometrist or ophthalmologist and then uses a CPT Cat II code to document the services. For example, a PCP can use 2026F (Eye imaging validated to match diagnosis from 7 standard field stereoscopic photos results documented and reviewed) to document that the patient had retinal imaging (using a technology equivalent to 7 standard field stereoscopic photos) and the results were read by an optometrist or ophthalmologist. The PCP should use the date of the retinal imaging as the date of service when billing this code. Keep in mind that NCQA is not a coding authority and cannot provide information on what codes to use for specific tests. The American Medical Association (AMA) maintains the CPT codes and provides support on CPT coding questions ( Typically when a company develops technology it contacts the AMA to determine the appropriate billing code (so the RetinaVue company may be able to answer this question as well). December 2017 Page 4 of 45

5 # Org Measure/Topic Support Comment IHA Response 13 PO Breast Cancer Support Greetings, I truly believe in rewarding those who practice preventive medicine and high quality. I am not Screening w/ mods convinced, though, that this system is helping, and has brought me a great deal of frustration. (BCS) 1) The deadlines are too stringent. If a pt is due for a measure in November, then in order to get the credit, we almost need to have them get the testing done at the month mark instead of the 12 month mark. THERE Colorectal Cancer SHOULD BE A REASONABLE TIME FRAME TO DO CERTAIN MEASURES, SUCH AS MAMMO AND COLONOSCOPY Screening 2) BP- Many have documented good readings at home with the machine calibrated in the office, but still white (CCS) coat HTN. WE SHOULD HONOR BP HOME READINGS 3) I am VERY diligent about thorough discussion and advocacy for colonoscopies. Even so, some pts still decline. WE NEED TO ACKNOWLEDGE AT LEAST A CONVERSATION OR REFERRAL FOR COLONOSCOPY. We should not be penalized for difficult pts. Thanks for considering the feedback. Controlling High Pressure for People with Hypertension (CBPH) As a reminder, it is a Value Based P4P principle to align measure specifications with national standards like HEDIS whenever possible. BCS and CCS are are HEDIS measures, so VBP4P staff forwarded your question to NCQA for their consideration. NCQA provided the following information in response to your feedback: " 1. Timing: Measurement timeframes for measures often include grace periods. For example, The Breast Cancer Screening measure assesses whether a mammogram was performed on or between October 1 two years prior to the measurement year and December 31 of the measurement year. The measure look-back period includes an additional 3 months (October-December two years prior to the measurement year) which allows flexibility to account for possible wait times women experience when scheduling a mammogram. 2. Home BP readings: Per General Guideline 36 of the draft MY 2017 VBP4P Manual, member-collected blood pressure readings are not eligible for use in VBP4P. BP home readings are only eligible for use if taken by a qualified provider during a home visit and documented in the appropriate medical record of the practitioner or provider team managing the member's hypertension, by the deadline established for the measure are eligible for use. BPs obtained by automated machine are considered self-administered, even if the results are transmitted electronically to the clinic office, since the member has to set themselves up in the machine, press the button, etc. and no provider is there to monitor and make sure that the member did everything correctly. 3. Decline of Services : VBP4P does not allow patient decline of services as a valid reason for exclusion. The VBP4P Committees agree that measures are developed based on clinical guidelines which are intended to apply for the majority of patients, but are not intended to replace clinical judgment or patient choice. No guideline is expected to be followed 100 percent of the time, and the impact of patient refusal of services is expected to impact all physician organizations equally." IHA will continute to collect BCS, CCS, and CBPH in alignment with the measure steward's specifications in Measurement Year PO e-measures Controlling High Blood Pressure Screening for Clinical Depression and Follow-Up Plan Support w/ mods Data collection for these e-measures is extremely difficult for IPA's that do not have integrated EHR systems. For The VBP4P Committees acknowledge the challenges posed by e-measurement, particularly for IPAs. Although one, it is difficult to promote the use of the e-modules across multiple different practices and EHR systems. Also, challenging, the Technical Measurement Committee (TMC) has recommended keeping e-measures in the ACI if a module is already in use, it is difficult to determine the usage and reporting capabilities of the various domain as a key priority within the VBP4P Measure Set Strategy to support increasing alignment with physician offices and associated EHR systems. Thus far, our solution has been to manually survey our physicians other electronic reporting requirements, as well as gaining increased understanding and movement towards EHR on the e-module usage, but the survey response rate has been historically low and the data has been difficult to reporting. The VBP4P Committees monitor available e-measures for inclusion in the VBP4P measure set, and to date analyze. Given that the measure is especially burdensome for IPA's, we would like to suggest that the e-measures have not found other metrics that avoid the challenges associated with e-measures. In addition, the TMC felt it was be revisited for an alternative metric, so that IPAs are not penalized when compared to PO's with more important to keep the blood pressure and depression screening e-measures in the Advancing Care Information (ACI) integrated care models. domain as these address gaps in current VBP4P measurement and are traditionally difficult to assess through claims data. IHA will continute collecting the CBPH and Depression Screening e-measures in Measurement Year PO Immunizations for Adolescents (IMA) Support w/ mods Per the CDC and AAP recommendations, if a child did not receive the appropriate number of DTaP vaccines as an infant and received a Tdap vaccine between the ages of 7-9 years per the catch-up schedule they do not need to receive another Tdap vaccine between the ages of years. The P4P specifications do not take this into account. IHA only considers children who received the vaccine after their 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. It is a VBP4P program policy to align with measure steward's specifications whenever possible in order to maintain alignment with regional and national performance measurement and benchmarking efforts. VBP4P staff forwarded this comment to the measure steward, NCQA, and received the following response: "The IMA measure is intended to assess whether adolescents are immunized as recommended by the 'standard' CDC and ACIP guidelines for immunizations. The measure does not give credit for adolescents who are immunized on the 'catch-up' schedule." IHA will continute to collect IMA in alignment with the measure steward's specifications in Measurement Year December 2017 Page 5 of 45

6 # Org Measure/Topic Support Comment IHA Response 16 PO Measures that Support Currently many of the P4P quality measures require the use of pharmacy files for dispensing information rather require the use of w/ mods pharmacy data than relying on prescribing and medication documentation in the certified EHR. Given that CMS quality measures accept prescribing information and medication documentation as sufficient for calculation of analogous quality measures, it would greatly relieve the reporting burden (expense and time) to provider organization if P4P would conform to CMS regarding medication data. Thank you. It is a VBP4P program principles to use measures that are broadly applicable for health plan and physician organization accountability. Since CMS ecqms are run from the EHR, they do not align with existing measures that support health plan accountability. To this end, the VBP4P Committees recommend phamarcy based HEDIS and PQA measures, although potentially challenging, because they are accessible to all VBP4P participants and allow measurement in clinically important areas. As a reminder, if a PO feels a measure is too burdensome to self-report, POs have the option to rely only on the health plan aggregated rate in lieu of PO self-reporting. IHA will continue to align with measure stewards on measures that require pharmacy data in Measurement Year PO Childhood Immunization Status (CIS) Support w/ mods 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. As you note, recent implementation of SB 277 is expected to reduce the impact of PBE on vaccination rates in California as no new PBE will be honored for children entering CA public school's after Jan. 1, Indeed, the rate of PBE fell from 2.37% to 0.56% from 2015 to ( 18 PO Controlling Blood Pressure for People with Hypertension (CBPH) Support w/ mods The measure specification requires that numerator compliance be determined by using automated data to identify the most recent BP reading taken during an outpatient visit (Outpatient Value Set). The requirement that each BP be associated with an outpatient visit code becomes prohibitive in situations where a provider's office offers free blood pressure checks to patients in order to remove cost barriers. In this situation, the BP is taken by a qualified health professional (associated with the provider's office) in an outpatient office visit setting, but an outpatient office visit may not be billed. Is it possible to remove the requirement that each BP be associated with an outpatient visit code in order to determine measure compliance? For example, allowing POs to rule-out BP data associated with invalid visit types (e.g., an inpatient visit)? It is a VBP4P program policy that patient refusal of services is not a sufficient reason for exclusion from the denominator of any VBP4P measure. The VBP4P Committees have reemphasized this policy, and agree that measures are developed based on clinical guidelines which are intended to apply for the majority of patients, but are not intended to replace clinical judgment or patient choice. No guideline is expected to be followed 100 percent of the time, and the impact of patient refusal of services is expected to be minimal and impact all physician organizations equally. Recent changes to the measure specifications for CBPH have expanded the way to identify appropriate blood pressure readings. In MY 2016, the VBP4P Committees recommended revisions of the CBPH blood pressure measure to include the nonacute inpatient visit as an appropriate way to identify blood pressue readings in an effort to align as closely as possible with HEDIS specifications for blood pressure measurement. For both CBPH and CDC blood pressure measures, as of MY 2016 the BP reading criteria is: Use automated data to identify the most recent BP reading taken during an outpatient visit (Outpatient Value Set) or a nonacute inpatient encounter (Nonacute Inpatient Value Set) during the measurement year. Please note that mapping is allowed under the VBP4P supplemental data guidelines, so the scenario you described would be numerator compliant if the visits are mapped to the outpatient visit value set. Mapping is subject to auditor approval to confirm that the mapping is appropriate. Please see Value Based P4P General Guidelines 29 "Supplemental Data" and 44 "Mapping Proprietary or Other Codes" for more information on using supplemental and mapping codes. December 2017 Page 6 of 45

7 # Org Measure/Topic Support Comment IHA Response 19 PO Controlling Blood Pressure for People with Hypertension (CBPH) Support w/ mods The measure specifications and eligibility requirements (e.g., number and timing of hypertension diagnoses, patient age ranges, diabetic status) for this measure differ from the other BP control measures that are tracked across the various line of business (e.g., P4P Diabetes BP Control and the HEDIS/Medicare "Controlling Blood Pressure" measure). These differences often cause confusion for the end-user (e.g., physicians and office staff), resulting in time wasted on data collection and submission. We would recommend a more consistent approach to the BP control measures so that POs and provider offices can focus their efforts on providing care for the eligible patients, rather than data management activities. Would it be possible to align the P4P BP measures with the HEDIS Controlling Blood Pressure (CBP) measure? Unfortunately, because the NCQA CBP measure requires application of a hybrid methodology that requires chart review, it is not possible to fully align with CBP in VBP4P. As a reminder, VBP4P clinical quality measures must be reported using an administrative (i.e., claims based) approach. IHA will continue collecting CBPH in Measurement Year In order to measure this important clinical area, the VBP4P Committees adapted the Comprehensive Diabetes Care: Blood Pressure Control measure in alignment with current clinical guidelines for BP control to get to the current Controlling Blood Pressure for People with Hypertension measure. CBPH is as closely aligned to the NCQA HEDIS measure as possible, and the VBP4P Committees will continue to align measure specifications whenever possible. IHA recognizes that non-alignment increases reporting burden for POs; as a reminder, if a PO feels a measure is too burdensome to self-report, POs have the option to rely only on the health plan aggregated rate in lieu of PO self-reporting. 20 PO Statin Therapy for Patients with Diabetes (SPD) Support w/ mods The ACC/AHA currently recommends use of a statin in patients with diabetes age years old with LDL between mg/dl; clinician discretion can be used to determine if a statin is appropriate for patients with LDL < 70 mg/dl. Many providers will not prescribe a statin if a patient's LDL is <70. However, the SPD measure does not allow exclusions for patients that fall into this category. We recommend allowing exclusions for diabetic patients whose LDL is <70 mg/dl. As a reminder, it is a VBP4P program policy to align with measure steward's specifications whenever possible in order to maintain alignment with regional and national performance measurement and benchmarking efforts. VBP4P staff forwarded this comment to the measure steward, NCQA, and received the following response: "The SPD measure is based on ACC/AHA guideline recommendations that state patients with diabetes, age should be treated with statins. The measure is based on the cardiovascular risk that having diabetes poses; not necessarily the LDL levels. Furthermore, the SPD measure allows for any intensity of statin to enable more individualized care and shared decision-making between the provider and patient." IHA will continute to collect SPD in alignment with the measure steward's specifications in Measurement Year PO Breast Cancer Screening (BCS) Support w/ mods The Breast Cancer Screening measure still needs to have an exclusion of presence of breast cancer. It does not make clinical sense to screen for breast cancer when a patient is being treated for breast cancer currently. This would align with the logic used for colorectal and cervical cancer screenings. As a reminder, it is a VBP4P program policy to align with measure steward's specifications whenever possible in order to maintain alignment with regional and national performance measurement and benchmarking efforts. VBP4P staff forwarded this comment to the measure steward, NCQA and received the following response: "NCQA s advisory panels noted that although women with metastatic breast cancer may halt screening, an exclusion is unnecessary, as it is a small proportion of women. The advisory panel advised not removing women with a history of breast cancer because many guidelines recommend continuing to screen women who have had breast cancer and have a life expectancy of 10 or more years. Additionally, the current measure includes an exclusion for women who have had a bilateral or two unilateral mastectomies." IHA will continute to collect BCS in alignment with the measure steward's specifications in Measurement Year December 2017 Page 7 of 45

8 # Org Measure/Topic Support Comment IHA Response MY 2017 Medicare Advantage Measures 22 Health Plan Statin Therapy for Patients with Cardiovascular Disease (SPC) Support We support the addition of the NCQA HEDIS SPC measure as an important quality indicator. Thank you for your support. IHA will add SPC to the Medicare Advantage measure set as a baseline measure in Measurement Year PO Statin Use in Persons Do not with Diabetes (SUPD) support We work diligently with our patients at increased risk of major atherosclerotic events to use statin therapy, as clinically appropriate. As part of that, we publicly report two statin therapy HEDIS measures: SPC and Statin Therapy for Patients with Diabetes (SPD). Our reporting department and analysts put significant time and resources into monitoring and measuring these two HEDIS statin therapy rates for purposes of promoting evidence-based care for these two high risk populations. We participate in the Medicare Stars program, which assesses performance on statin therapy for patients with diabetes based on the SUPD PQA measure. CMS directly pulls this rate from Medicare pharmacy claims, the data for this measure comes from pharmacy drug event data files submitted by the drug plans to Medicare. As such, we do not report or have access to this data in order to be able to report it to IHA. Furthermore, the IHA VBP4P reporting timeline by early May occurs before the Medicare Stars submission, which means two separate timelines for producing, reporting and auditing the data would be needed if IHA were to add SUPD to its measure set. The disparity in timelines would further require two separate data reporting streams for the same SUPD PQA measure. We currently do not have infrastructure to report an additional and separate SUPD rate for IHA's VBP4P program. Were IHA to add SUPD to its measure set, we would have to create a new data reporting stream to produce, report, and audit the data. This would consume significant time and resources, and has no additional performance improvement or public reporting benefit. It would be a duplicative use of unnecessary, inefficient, and wasteful health care resources. That is why we strongly oppose adding the SUPD measure to the IHA VBP4P program. Conversely, we urge IHA to consider whether instead it can use the HEDIS SPD measure, in the same manner IHA is proposing to add the SPC HEDIS measure. We already produce this measure for NCQA, and NCQA has benchmarks that can be used for the VBP4P program. Creating a second reporting stream for the SUPD measure for the sake of including it in the IHA VBP4P program, unfortunately, would challenge performance improvement efforts for statin therapy use rather than fuel it. For that reason, we strongly oppose the SUPD PQA measure and urge IHA to consider HEDIS SPD instead. At this time, it is not feasible for IHA to align Statin Therapy for Patients with Diabetes for Medicare Advantage Stars measurement because IHA's Medicare Advantage Stars measurement must align with the CMS Medicare Advantage Stars measures to support consistent star ratings and cutpoints. Building on CMS MA star rating system for health plans, IHA uses a subset of clinical quality measures identified by CMS to measure performance and publicly report star ratings at the physician organization (PO) level in California. To do this, IHA leverages CMS measures that are feasible for administrative data collection and reporting in the PO population and applies CMS methodology (i.e. measure cut points) to determine PO level Star Ratings. The IHA Medicare Advantage measure set is therefore dependent on the ongoing evolution of the CMS measure set; IHA monitors what CMS is measuring to ensure that the IHA measure set is as up to date and broadly applicable as possible. CMS plans to add the SUPD measure to the RY 2019 Star Ratings. In alignment with CMS, IHA will add SUPD as a baseline measure for MY IHA's Technical Measurement Committee reviewed the MY 2017 Medicare Advantage Stars measure set and recommended including SUPD despite mis-alignment with commercial VBP4P reporting. IHA recognizes that this is not aligned with the commercial Value Based P4P reporting, and will continue to influence CMS through use of Medicare Advantage Stars public comment periods to encourage ongoing measure alignment between performance measurement programs. It is a principle of IHA's Medicare Advantage Stars Reporting for physician organizations program to align with the CMS Medicare Star Ratings whenever possible. 24 Health Plan Statin Use in Persons Do not with Diabetes (SUPD) support We support IHA's efforts at aligning with other publicly recognized ratings, but we disagree in this instance that it would be better to use the SUPD measure that is calculated by CMS from prescription data. The NCQA HEDIS measure for Statin Therapy in members with Diabetes (SPD) is simply a better measure of clinically appropriate care than the SUPD measure, given the additional clinical information brought in by diagnosis data. Specifically, the NCQA HEDIS measure is designed to run in parallel to the Statin Therapy for Cardiovascular Conditions, and the SPD measure then highlights statin therapy in members with diabetes who do not have comorbidity with other cardiovascular disease. Further, the NCQA HEDIS measure addresses statin therapy in members with diabetes who are not currently on diabetes medications but who would benefit from statin therapy, nonetheless. There is also the concern that the attempt to calculate the SUPD measure themselves could produce conflicting results with the ones from CMS. Finally, if IHA adopts the SUPD measure, additional analytical resources would have to be marshaled to calculate the measure, since it is otherwise not a measure reported by Health Plans. For this reason, and the reasons stated above, we strongly urge IHA to reconsider using the HEDIS SPD measure, which is also publicly reported instead of the SUPD measure. NCQA may add the SPD measure to their Medicare Rating system, so there would be alignment in that matter. IHA recognizes that the measure may be challenging for physician organizations and health plans to report and have recommended that the results be collected as part of the health plan claims submission to Onpoint. Self-reporting physician organizations will still have the option to self-report this measure, but health plans will not have to program or include it in the submission of clinical data to TransUnion. IHA will add SUPD to the Medicare Advantage measure set as a baseline measure in Measurement Year December 2017 Page 8 of 45

9 # Org Measure/Topic Support Comment IHA Response MY Medicare Advantage Other Measure Feedback 25 PO Adult BMI Assessment (ABA) Do not support We recommend dropping the BMI measure from the IHA Medicare Stars measure set as this measure has basically topped-out, as the P90 value is 99.04%. Other measures (like URI) have been dropped as they top out at nearly 100%. BMI should be considered as a measure to be dropped for the 2017 MY. Per the agreed upon VBP4P Committee definition of a topped out measure (P25 > 90%), ABA has not yet topped out. IHA's Technical Measurement Committee considered the MY 2017 Medicare Advantage Stars measure set and recommended including the ABA measure in the MA measure set for MY 2017, as it is still included in the CMS Medicare Star Ratings program. IHA will continue collecting ABA in Measurement Year As a reminder, it is a principle of IHA's Medicare Advantage Stars Reporting for physician organizations program to align with the CMS Medicare Star Ratings whenever possible. Building on CMS MA star rating system for health plans, IHA uses a subset of clinical quality measures identified by CMS to measure performance and publicly report star ratings at the physician organization level in California. The IHA Medicare Advantage measure set is therefore dependent on the ongoing evolution of the CMS measure set; IHA monitors what CMS is measuring to ensure that the IHA measure set is as up to date and broadly applicable as possible. MY 2018 Commercial VBP4P Measure Removals 26 Health Plan Two HbA1c Tests Support Thank you for your support. IHA will retire Two HbA1C Tests in Measurement Year December 2017 Page 9 of 45

10 To: Value Based Pay for Performance (VBP4P) Stakeholders From: Lindsay Erickson, Director, Value Based P4P, Integrated Healthcare Association Subject: Measurement Years 2017 & 2018 Proposed Changes to the VBP4P Program 2017 Value Based P4P Public Comment Period September 1 September 29, 2017 Value Based P4P staff is inviting public comment on the following: 1. IHA Performance Measurement Changes IHA seeks comment on proposed timeline, process, and measurement changes. 2. Measurement Year 2017 (MY 2017) The changes outlined reflect the proposed process and guidelines for collecting the results, measures identified for testing, and the incorporation of updates to the specifications of existing VBP4P measures to align with measure steward s specifications for the same period (e.g., HEDIS 2018 and VBP4P MY 2017 measure the same time period). As a reminder, the MY 2017 Measure Set was finalized in 2016; all changes reflect specification updates, not measure additions or removals. 3. Measurement Year 2018 (MY 2018) The changes outlined reflect the measures that are proposed for payment and public reporting for MY 2018; results will reflect the care provided to members in calendar year 2018 and be collected and reported during calendar year Specifications are provided for any measures that are not already included in the VBP4P manual. 4. General Feedback on VBP4P Program and Measure Sets Value Based P4P staff welcome general comments on the VBP4P program and measure sets. Comments are due by 5 p.m. PDT on Friday, September 29, 2017 to the Public Comment website at the following link: December 2017 Page 10 of 45

11 Public Comment Login Instructions: Access the Public Comment System Step 1: The public comment system is integrated with NCQA s single sign-on platform. If you have access to any of the systems below you can use the same credentials to login and submit your comments: Interactive Data Submission System (IDSS) Health Organization Questionnaire (HOQ) Download Center Recognition Program Online Application Quality Compass (QC) Policy/Program Clarification Support (PCS) Note: Use the Forgot Password button if you are unsure of your password. By using this feature you are changing your password for any NCQA system to which you have access. Step 2: If you do not have access to any of the systems from step 1, click the Create an Account button and complete the entire form. Please retain the password for your records. Submit a Comment NCQA and IHA will not accept comments submitted outside of the system. Step 1: Begin by selecting a Product. Step 2: Click on the Instructions link to view public comment materials including instructions, proposed specifications and measures. Step 3: Select a Topic and Element (if applicable) Step 4: Select a Support Type Step 5: Complete the Comments box. Note: the character limit for all comments is 2500 characters. Step 6: If you are submitting more than one comment, use the Submit and Return button. When finished submitting all comments, use the Submit and Logout button to receive an e- mail notification with all submitted comments. December 2017 Page 11 of 45

12 Introduction All comments received during the Public Comment period will be reviewed by the VBP4P Technical Measurement or Technical Payment Committee, and responses, including applicable changes, will be approved by the VBP4P Governance Committee before being incorporated where appropriate. IHA Performance Measurement Changes New Timeline to Support Consolidation of VBP4P & Atlas Health Plan Data Submission One of the takeaways from VBP4P participant feedback, bolstered by market research IHA conducted in 2017, is that IHA should take steps to increase operational efficiencies and strengthen data capabilities to reduce reporting burden on stakeholders and increase the meaningfulness of the information and reports we produce. There was support to enhance the services and products we already provide, rather than expanding information and reports produced. As one step toward this end, and in concert with recent data vendor re-procurement efforts, IHA plans to consolidate the VBP4P and Atlas data submissions from health plans in To support a successful transition to a consolidated process, the proposed MY 2017 reporting timeline has been pushed out. The current VBP4P reporting timelines for resource use and cost are not realistic, as evidenced by the frequent delays due to health plan data issues each year. As such, the reporting timeline for 2018 has been adjusted to allow more time to get clean, useable data. See pages 6-7 of the draft MY 2017 VBP4P Manual for the updated timeline. Specialty Pharmacy Measure Development Generic Prescribing has been a VBP4P resource use measure since Over time, participating physician organizations have driven substantial gains in the generic prescribing rates statewide. Over the same period, the drug pipeline has shifted and new cost drivers beyond branded drugs, including specialty and biologic drugs, have emerged. Together these changes translate to less opportunity for physician organization improvement and less impact on overall pharmacy spend. The VBP4P committees have identified the desire to establish a replacement measure or measures that targets the current opportunities to impact pharmacy spend. Doing so will help support more meaningful incentives across all VBP4P participating POs. There is not an obvious candidate measure to replace generic prescribing, so a workgroup of health plan and physician organization pharmacy management staff will be convened later this Fall to take up the issue. In preparation, IHA is seeking stakeholder input that may contribute to this effort. Measurement Year 2017 (MY 2017) MY 2017 VBP4P Measure Specification Updates Align to Measure Steward Specifications As a reminder, the MY 2017 VBP4P Measure Set was finalized in calendar year VBP4P intends to align with all HEDIS 2018 measure specification updates to ensure measure alignment and reduce reporting burden for participating physician organizations and health plans. Changes to the MY 2017 VBP4P Measure Set reflect alignment with HEDIS specification changes made in HEDIS A December 2017 Page 12 of 45

13 summary of measure specification changes is listed at the beginning of each measure specification, and a complete Summary of Changes can be found in Appendix 1 of the draft MY 2017 VBP4P Manual. The MY 2017 Measure Set can be referenced online in full in Appendix B. Please note that the Breast Cancer Screening and Immunizations for Adolescents: HPV Vaccine for Adolescents include notable updates as part of NCQA s continuous monitoring process for HEDIS, and that an update has been made to the non-hedis Controlling Blood Pressure for People with Hypertension measure to better align with the intent of the HEDIS Controlling Blood Pressure measure. Align to Standard Specifications for Inpatient & Emergency Department Resource Use In addition to increasing data collection efficiency and alignment, efforts underway to consolidate health plan data submissions and update our vendor contracts afford the opportunity to increase measurement efficiency and alignment. Optimally, any changes would be implemented in measurement year 2017, as IHA executes a new contract with a data aggregation vendor. Towards this end, IHA is considering replacing the specifications for current Inpatient Utilization, Inpatient Bed Days, and Emergency Department Visits and aligning with the current HEDIS utilization (Inpatient Utilization General Hospital/Acute Care and Ambulatory Care) and risk-adjusted utilization measures (Inpatient Hospital Utilization and Emergency Department Utilization). One of the guiding principles of the VBP4P program has been to align with standard specifications. When VBP4P first tested the risk-adjusted resource use measures, there were not standardized, riskadjusted measures available. Within the last year, HEDIS has added standard specifications for riskadjusted inpatient discharge and ED utilization. These new HEDIS measures incorporate a transparent, public domain HCC-based risk adjustment methodology, which is similar to the approach used for All-Cause Readmissions. Complete HEDIS specifications for these measures are available in Appendix A. Please note that this measure will only be generated by the IHA data aggregation vendor from claims data submitted by health plans. Like other appropriate resource use measures, these measures will not be self-reported by physician organizations. Aligning to standard specifications will affect the trending of these measures. To support consistency and trending, IHA will work with its data aggregation vendor to provide updated MY 2016 and MY 2017 results to participants in reporting year Align to Standard Specifications for Total Cost of Care In addition to increasing data collection efficiency and alignment, efforts underway to consolidate health plan data submissions and update our vendor contracts afford the opportunity to increase measurement efficiency and alignment. Optimally, any changes would be implemented in measurement year 2017, as IHA executes a new contract with a data aggregation vendor. Towards this end, there is now an NQF endorsed national standard total cost of care measure (and companion total resource use measure) that was not available when IHA started developing and measuring total cost of care. The NQF measure has had significant uptake, and is currently in use in 37 states and the District of Columbia. It is very similar to IHA s total cost of care measure. In addition to aligning to a national standard, the use of the NQF measure would also address a December 2017 Page 13 of 45

14 methodological challenge that has continued to affect the timeliness of producing IHA s total cost of care results. The endorsed specifications are available here. This measure will only be generated by the IHA data aggregation vendor from data submitted by health plans and will not be self-reported by physician organizations. Please note that changing the total cost of care specifications will affect the trending of results between years. To support consistency and trending, IHA will work with its vendor to provide updated MY 2016 and MY 2017 results to participants in MY 2017 Commercial VBP4P - Testing Measures The VBP4P committees continuously evaluate approaches for measuring the commercial HMO/POS population to ensure a targeted, highly aligned measure set that meets the needs of VBP4P participating physician organizations and health plans. To this end, the Committees have recommended testing three new measures in MY 2017: Comprehensive Diabetes Care - Eye Exam, Use of Opioids at High Dosage, and Concurrent Use of Opioids and Benzodiazepines. Measures tested in MY 2017 will be reviewed in reporting year 2018 and considered for addition to the IHA measure set for future years (e.g., baseline in MY 2018 and recommended for payment/public reporting as early as MY 2019). All participating health plans and self-reporting physician organizations are encouraged to submit data for these testing measure in MY Comprehensive Diabetes Care: Eye Exam (CDC) The Committees reevaluated the Comprehensive Diabetes Care (CDC) measures to review opportunities to increase alignment. Toward greater consistency with NCQA s health plan accreditation standards as well as Medicare Advantage Stars measurement, they have recommended testing this measure in the VBP4P commercial HMO/POS product line for MY Please refer to the draft MY 2017 VBP4P Manual for full measure specifications. CDC: Eye Exam measures the percentage of members years of age with diabetes (type 1 and type 2) who had an eye exam. Use of Opioids at High Dosage (UOD) Lowering opioid-related morbidity and mortality has emerged as a focus area for many providers, health plans, purchasers, and policymakers in California and is now a national priority. Reducing the overuse of opioids is also one of three focus areas for Smart Care California, a multi-stakeholder effort to promote safe, affordable care led by California s three largest state purchasers. An important aspect of reducing opioid overuse is identifying patients who are at highest risk of opioid overdose, such as patients on high doses of opioids, and working with patients to taper them to safer doses. Measuring high dose opioid use will support understanding of the scope of high dose opioid use in the Commercial population and provide valuable information to health plans and physician organizations. Use of Opioids at High Dosage measures the rate per 1,000 members 18 years and older, receiving prescription opioids for 15 days during the measurement year who are prescribed opioids at high dosage MED >120 mg. Please refer to the draft MY 2017 VBP4P December 2017 Page 14 of 45

15 Manual for full measure specifications. The VBP4P Committees recognize that high dose opioid use is a focus area for providers, health plans, purchasers, and policymakers. Please note that due to anticipated programming complexity of the measure specifications, this measure will only be submitted by participating health plans. Concurrent Use of Opioids and Benzodiazepines (COB) Smart Care California has identified opioid overuse as a focus area, with monitoring of high-risk regimens (such as opioids and benzodiazepines) of particular importance. Studies of fatal opioid overdose deaths found evidence of concurrent benzodiazepine use in 31% 61% of decedents 1, and CDC guidelines for prescribing opioids for chronic pain recommend avoiding concurrent opioid and benzodiazepine prescribing 2. Concurrent Use of Opioids and Benzodiazepines measures the percentage of individuals 18 years and older with concurrent use of prescription opioids and benzodiazepines. Please refer to the draft MY 2017 VBP4P Manual for full measure specifications. Please note that due to anticipated programming complexity of the measure specifications, this measure will only be submitted by participating health plans. MY 2017 Medicare Advantage - Baseline Measure Additions These measures will be added as baseline measures (reported by participating health plans and selfreporting physician organizations) in an effort to align with CMS Medicare Advantage Star measurement. Please refer to the draft MY 2017 VBP4P Manual for full measure specifications. Statin Therapy for Patients with Cardiovascular Disease (SPC) Statin Therapy for Patients with Cardiovascular Disease assesses the percentage of males years of age and females years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the required criteria. Two rates are reported: 1. Received Statin Therapy - Members who were dispensed at least one high or moderateintensity statin medication during the measurement year 2. Statin Adherence 80%. Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period. Statin Use in Persons with Diabetes (SUPD) Statin Use in Persons with Diabetes measures the percentage of patients ages years who were dispensed a medication for diabetes that receive a statin medication. 1 Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain United States, MMWR Recomm Rep 2016;65(No. RR-1):1 49. DOI: December 2017 Page 15 of 45

16 Measurement Year 2018 (MY 2018) MY 2018 Commercial VBP4P - Measure Removals The MY 2018 Measure Set is available in full online and in Appendix C. Annual Monitoring of Patients on Persistent Medications (MPM) Due to high performance as well as low variation amongst the VBP4P commercial HMO/POS population, the VBP4P Committees have recommended retirement of Annual Monitoring of Patients on Persistent Medications beginning in MY Diabetes Care: Two HbA1c Tests (CDC) The VBP4P Committees have recommended retirement of Diabetes Care: Two HbA1c Tests in Measurement Year 2018 to increase focus on a more meaningful outcomes measure (CDC: HbA1c Control <8%). Additionally, the HbA1c screening is no longer part of NCQA health plan accreditation and the two test version of the screening measure is not broadly used. Please note that due to the retirement of this measure, the Optimal Diabetes Care Combination Rate (an all-or-none rate which includes: HbA1c Control <8%, Two HbA1c Tests, Blood Pressure Control, and Medical Attention for Nephropathy) will become a baseline measure in MY 2018 to ensure trending in future years. December 2017 Page 16 of 45

17 Inpatient Utilization General Hospital/Acute Care (IPU) SUMMARY OF CHANGES TO HEDIS 2018 Revised the data elements tables to indicate that rates are calculated for the Discharges/1,000 Member Months/Years in the unknown category. Description This measure summarizes utilization of acute inpatient care and services in the following categories: Total inpatient. Maternity. Surgery. Medicine. Calculations Note: Members in hospice are excluded from this measure. Refer to General Guideline 20: Members in Hospice. Product lines Member months Report the following tables for each applicable product line: Table IPU-1a Total Medicaid. Table IPU-1b Medicaid/Medicare Dual-Eligibles. Table IPU-1c Medicaid Disabled. Table IPU-1d Medicaid Other Low Income. Table IPU-2 Commercial by Product or Combined HMO/POS. Table IPU-3 Medicare. For each product line and table, report all member months for the measurement year. IDSS automatically produces member years data for the commercial and Medicare product lines. Refer to Specific Instructions for Utilization Tables for more information. Maternity rates are reported per 1,000 male and per 1,000 female total member months in order to capture deliveries as a percentage of the total inpatient discharges. Days ALOS Count all days associated with the identified discharges. Report days for total inpatient, maternity, surgery and medicine. Refer to Specific Instructions for Utilization Tables for the formula. Calculate average length of stay for total inpatient, maternity, surgery and medicine. December 2017 Page 17 of 45

18 Use the following steps to identify and categorize inpatient discharges. Step 1 Identify all acute inpatient discharges on or between January 1 and December 31 of the measurement year. To identify acute inpatient discharges: 1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set). 3. Identify the discharge date for the stay. Step 2 Exclude discharges with a principal diagnosis of mental health or chemical dependency (Mental and Behavioral Disorders Value Set), or an MS-DRG for mental health, chemical dependency or rehabilitation (IPU Exclusions MS-DRG Value Set). Exclude newborn care rendered from birth to discharge home from delivery (only include care rendered during subsequent rehospitalizations after the delivery discharge). Identify newborn care by a principal diagnosis of live-born infant (Deliveries Infant Record Value Set) or the presence of a code from the Newborn/Neonates MS-DRG Value Set. Organizations must develop methods to differentiate between the mother s claim and the newborn s claim, if needed. Step 3 Report total inpatient, using all discharges identified after completing steps 1 and 2. Step 4 Report maternity, surgery and medicine using MS-DRGs. For organizations that use DRGs, categorize each discharge as maternity, surgery or medicine. Maternity (Maternity MS-DRG Value Set). A delivery is not required for inclusion in the Maternity category; any maternity-related stay is included. Include birthing center deliveries and count them as one day of stay. Surgery (Surgery MS-DRG Value Set). Medicine: Medicine MS-DRG Value Set. Newborns/Neonates MS-DRG Value Set. Do not include newborn care rendered from birth to discharge home from delivery; only report newborn care rendered if the baby is discharged home from delivery and is subsequently rehospitalized. Note: If reporting using MS-DRGs, Total Inpatient will not equal the sum of Maternity, Surgery and Medicine because DRGs for Principal Diagnosis Invalid as Discharge Diagnosis and Ungroupable are included in Total Inpatient, but are not included in maternity, surgery or medicine. If the organization does not use MS-DRGs, follow steps 5 7 to categorize discharges. Step 5 Report maternity. A delivery is not required for inclusion in the Maternity category; any maternity-related stay is included. Include birthing center deliveries and count them as one day of stay. Starting with all discharges identified in step 3, identify maternity using either of the following: A maternity-related principal diagnosis (Maternity Diagnosis Value Set). A maternity-related stay (Maternity Value Set). Step 6 Step 7 Report surgery. From discharges remaining after removing maternity (identified in step 5) from total inpatient (identified in step 3), identify surgery (Surgery Value Set). Report medicine. Categorize as medicine the discharges remaining after removing maternity (identified in step 5) and surgery (identified in step 6) from total inpatient (identified in step 3). December 2017 Page 18 of 45

19 Table IPU-1: Inpatient Utilization General Hospital/Acute Care Age Member Months < Unknown Total Discharges/1,000 Member Months Days/1,000 Member Months Average Length of Stay Age Discharges Days Total Inpatient < Unknown Total Maternity* Unknown Total Surgery < Unknown Total *The Maternity category is calculated using member months for members years. December 2017 Page 19 of 45

20 Age Medicine Discharges Discharges/1,000 Member Months Days Days/1,000 Member Months Average Length of Stay < Unknown Total Table IPU-2/3: Inpatient Utilization General Hospital/Acute Care Age Member Months < Unknown Total Age Total Inpatient Discharges Discharges/ 1,000 Member Years Days Days/ 1,000 Member Years Average Length of Stay < Unknown Total December 2017 Page 20 of 45

21 Age Maternity* Discharges Discharges/ 1,000 Member Years Days Days/ 1,000 Member Years Average Length of Stay Unknown Surgery Total < Unknown Medicine Total < Unknown Total *The Maternity category is calculated using member months for members years. December 2017 Page 21 of 45

22 Ambulatory Care (AMB) SUMMARY OF CHANGES TO HEDIS 2018 Clarified how to identify an ED visit that resulted in an inpatient stay. Removed the AOD Rehab and Detox Value Set from the required exclusions (exclusions will be identified based on a principal diagnosis of chemical dependency). Revised the data elements tables to indicate that rates are calculated for the Visits/1,000 Member Months/ Years in the unknown category. Description This measure summarizes utilization of ambulatory care in the following categories: Outpatient Visits. ED Visits. Calculations Note: Members in hospice are excluded from this measure. Refer to General Guideline 20: Members in Hospice. Product lines Member months Counting multiple services Outpatient visits Report the following tables for each applicable product line: Table AMB-1a Total Medicaid. Table AMB-1b Medicaid/Medicare Dual-Eligibles. Table AMB-1c Medicaid Disabled. Table AMB-1d Medicaid Other Low Income. Table AMB-2 Table AMB-3 Commercial by Product or Combined HMO/POS. Medicare. For each product line and table, report all member months for the measurement year. IDSS automatically produces member years data for the commercial and Medicare product lines. Refer to Specific Instructions for Utilization Tables for more information. For combinations of multiple ambulatory services falling in different categories on the same day, report each service that meets the criteria in the appropriate category. Outpatient visits (Ambulatory Outpatient Visits Value Set). Count multiple codes with the same practitioner on the same date of service as a single visit. Count visits with different practitioners separately (count visits with different providers on the same date of service as different visits). Report services without regard to practitioner type, training or licensing. December 2017 Page 22 of 45

23 ED visits Count each visit to an ED once, regardless of the intensity or duration of the visit. Count multiple ED visits on the same date of service as one visit. Identify ED visits using either of the following: An ED visit (ED Value Set). A procedure code (ED Procedure Code Value Set) with an ED place of service code (ED POS Value Set). Exclusions (required) Do not include ED visits that result in an inpatient stay (Inpatient Stay Value Set). When an ED visit and an inpatient stay are billed on separate claims, the visit results in an inpatient stay when the admission date for the inpatient stay occurs on the ED date of service or one calendar day after. An ED visit billed on the same claim as an inpatient stay is considered a visit that resulted in an inpatient stay. The measure does not include mental health or chemical dependency services. Exclude claims and encounters that indicate the encounter was for mental health or chemical dependency. Any of the following meet criteria: A principal diagnosis of mental health or chemical dependency (Mental and Behavioral Disorders Value Set). Psychiatry (Psychiatry Value Set). Electroconvulsive therapy (Electroconvulsive Therapy Value Set). Note This measure provides a reasonable proxy for professional ambulatory encounters. It is neither a strict accounting of all ambulatory resources nor an effort to be all-inclusive. December 2017 Page 23 of 45

24 Table AMB-1: Ambulatory Care Age Member Months < Unknown Total OUTPATIENT VISITS ED VISITS Visits/1,000 Visits/1,000 Member Age Visits Months Visits Member Months < Unknown Total December 2017 Page 24 of 45

25 Table AMB-2/3: Ambulatory Care Age Member Months < Unknown Total OUTPATIENT VISITS ED VISITS Visits/1,000 Visits/1,000 Age Visits Member Years Visits Member Years < Unknown Total December 2017 Page 25 of 45

26 Inpatient Hospital Utilization (IHU) SUMMARY OF CHANGES TO HEDIS 2018 Added a note to clarify that Total Inpatient will not equal Surgery and Medicine sum if reporting using MS-DRGs. Clarified to round to ten decimal places using the.5 rule during the intermediate calculations of Expected events. Added steps 5 and 6 to the calculation of the PUCD risk weights to calculate covariance and total variance for each category. Removed the Risk Adjustment Weighting Process diagram. Added Total Variance as a data elements to Table IHU-B-2/3, Table IHU-C-2/3 and Table IHU-D-2/3. Description For members 18 years of age and older, the risk-adjusted ratio of observed to expected acute inpatient discharges during the measurement year reported by Surgery, Medicine and Total. Definitions Classification period PPD PUCD The year prior to the measurement year. Predicted probability of discharge. The predicted probability of a member having any discharge in the measurement year. Predicted unconditional count of discharge. The predicted unconditional count of discharges for members during the measurement year. Eligible Population Note: Members in hospice are excluded from the eligible population. Refer to General Guideline 20: Members in Hospice. Product lines Ages Continuous enrollment Allowable gap Anchor date Benefit Event/diagnosis Commercial, Medicare (report each product line separately). 18 and older as of December 31 of the measurement year. The measurement year and the year prior to the measurement year. No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. December 31 of the measurement year. Medical. None. December 2017 Page 26 of 45

27 Calculation of Observed Events Use the following steps to identify and categorize inpatient discharges. Step 1 Step 2 Identify all acute inpatient discharges during the measurement year. To identify acute inpatient discharges: 1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set). 3. Identify the discharge date for the stay. Exclude discharges with: A principal diagnosis of mental health or chemical dependency (Mental and Behavioral Disorders Value Set). A principal diagnosis of live-born infant (Deliveries Infant Record Value Set). A maternity-related principal diagnosis (Maternity Diagnosis Value Set). A maternity-related stay (Maternity Value Set; Maternity MS-DRG Value Set). A mental health, chemical dependency or rehabilitation related stay (IPU Exclusions MS- DRG Value Set). Newborn care (Newborns/Neonates MS-DRG Value Set). Inpatient stays with a discharge for death. Step 3 Calculate total inpatient using all discharges identified after completing steps 1 and 2. Step 4 Identify surgery and medicine using MS-DRGs. For organizations that use DRGs, categorize each discharge as surgery or medicine. Surgery (Surgery MS-DRG Value Set). Medicine (Medicine MS-DRG Value Set). Note: If reporting using MS-DRGs, Total Inpatient will not equal the sum of Surgery and Medicine because DRGs for Principal Diagnosis Invalid as Discharge Diagnosis and Ungroupable are included in Total Inpatient, but are not included in surgery or medicine. If the organization does not use MS-DRGs, follow steps 5 6 to categorize discharges. Step 5 Step 6 Calculate surgery. Identify the surgery discharges (Surgery Value Set) from the total inpatient discharges (step 3). Calculate medicine. Categorize as medicine the discharges remaining after removing surgery (step 5) from total inpatient (step 3). Risk Adjustment Determination For each member in the eligible population, use the steps in the Utilization Risk Adjustment Determination section in the Guidelines for Risk Adjusted Utilization Measures to identify risk adjustment categories based on presence of comorbidities. December 2017 Page 27 of 45

28 Risk Adjustment Weighting and Calculation of Expected Events Calculation of risk-adjusted outcomes (counts of discharges) uses predetermined risk weights generated by two separate regression models. Weights from each model are combined to predict how many discharges each member may have during the measurement year, given age, gender and presence or absence of a comorbid condition. Refer to the Risk Adjustment Weight Process diagram for an overview of the process. For each member in the eligible population, assign Predicted Probability of Discharge (PPD) risk weights. Calculate the PPD for each service utilization category: Surgery, Medicine, Total. Step 1 For each member with a comorbidity HCC category, link the PPD weights. For the Medicare product line, use the following tables: For Surgery: Use Table IHUS-MA-PPD-ComorbidHCC. For Medicine: Use Table IHUM-MA-PPD-ComorbidHCC. For Total: Use Table IHUT-MA-PPD-ComorbidHCC. For the commercial product line, use the following tables: For Surgery: Use Table IHUS-Comm-PPD-ComorbidHCC. For Medicine: Use Table IHUM-Comm-PPD-ComorbidHCC. For Total: Use Table IHUT-Comm-PPD-ComorbidHCC. Step 2 Link the age-gender PPD weights for each member. For the Medicare product line, use the following tables: For Surgery: Use Table IHUS-MA-PPD. For Medicine: Use Table IHUM-MA-PPD. For Total: Use Table IHUT-MA-PPD. For the commercial product line, use the following tables: For Surgery: Use Table IHUS-Comm-PPD. For Medicine: Use Table IHUM-Comm-PPD. For Total: Use Table IHUT-Comm-PPD. Step 3 Identify the base PPD risk weight for each member. For the Medicare product line, use the following tables: For Surgery: Use Table IHUS-MA-PPD. For Medicine: Use Table IHUM-MA-PPD. For Total: Use Table IHUT-MA-PPD. For the commercial product line, use the following tables: For Surgery: Use Table IHUS-Comm-PPD. For Medicine: Use Table IHUM-Comm-PPD. For Total: Use Table IHUT-Comm-PPD. Step 4 Step 5 Sum all PPD weights (HCC, age, gender, base weight) associated with the member for each category (Medicine, Surgery, Total). Calculate the predicted probability of having at least one discharge in the measurement year based on the sum of the weights for each member, for each category (Surgery, Medicine, Total), using the formula below. PPD = e ( PPD WeightsForEachMember) 1+e ( PPD WeightsForEachMember) Note: The risk adjustment tables will be released on November 1, 2017, and posted to December 2017 Page 28 of 45

29 For each member in the eligible population, assign Predicted Unconditional Count of Discharge (PUCD) risk weights. Step 1 For each member with a comorbidity HCC Category, link the PUCD weights. If a member does not have any comorbidities to which a weight could be linked, assign a weight of 1. For Medicare product line, use the following tables: For Surgery: Use Table IHUS-MA-PUCD-ComorbidHCC. For Medicine: Use Table IHUM-MA-PUCD-ComorbidHCC. For Total: Use Table IHUT-MA-PUCD-ComorbidHCC. For the commercial product line, use the following tables: For Surgery: Use Table IHUS-Comm-PUCD-ComorbidHCC. For Medicine: Use Table IHUM-Comm-PUCD-ComorbidHCC. For Total: Use Table IHUT-Comm-PUCD-ComorbidHCC. Step 2 Link the PUCD age-gender weights for each member. For Medicare product line, use the following tables: For Surgery: Use Table IHUS-MA-PUCD. For Medicine: Use Table IHUM-MA-PUCD. For Total: Use Table IHUT-MA-PUCD. For the commercial product line, use the following tables: For Surgery: Use Table IHUS-Comm-PUCD. For Medicine: Use Table IHUM-Comm-PUCD. For Total: Use Table IHUT-Comm-PUCD. Step 3 Identify the base PUCD risk weight. For Medicare product line use the following tables: For Surgery: Use Table IHUS-MA-PUCD. For Medicine: Use Table IHUM-MA-PUCD. For Total: Use Table IHUT-MA-PUCD. For the commercial product line, use the following tables: For Surgery: Use Table IHUS-Comm-PUCD. For Medicine: Use Table IHUM-Comm-PUCD. For Total: Use Table IHUT-Comm-PUCD. Step 4 Calculate the predicted unconditional count of discharges in the measurement year, by multiplying all PUCD weights (HCC, age, gender and base weight) associated with the member for each category (Surgery, Medicine, Total). Use the following formula: PUCD = Base Weight * Age/gender Weight * HCC Weight Note: Multiply by each HCC associated with the member. For example, assume a member with HCC-2, HCC-10, HCC-47. The formula would be: PUCD = Base Weight * Age/gender Weight * HCC-2 * HCC-10 * HCC-47 Round intermediate calculations to 10 decimal places using the.5 rule. December 2017 Page 29 of 45

30 Expected count of hospitalization Step 5 Step 6 Report the final member-level expected count of discharges for each category using the formula below. Round to four decimal places using the.5 rule and enter these values into the reporting table. Expected Count of Discharges = PPD x PUCD Use the formula below to calculate the covariance of the predicted outcomes for each category (i.e., gender, age group and type of hospital stay). CCCCCC = nn ii=1(pppppp mmmmmmmm(pppppp)) (PPPPPPPP mmmmmmmm(pppppppp)) nn 1 Use the formula below to calculate the variance for each category. nn TTTTTTTTTT VVVVVVVVVVVVVVVV = (PPPPPP PPPPPPPP) (1 PPPPPP) 2 2 CCCCCC + PPPPPP PPPPPPPP ii=1 Reporting: Number of Members in the Eligible Population The number of members in the eligible population for each age and gender group and the overall total. Enter these values into the reporting table (Table IHU-A-2/3). Reporting: Number of Observed Events The number of observed discharges within each age and gender group and the overall total for each category (Surgery, Medicine, Total). Reporting: Observed Discharges per 1,000 Members The number of observed discharges divided by the number of members in the eligible population, multiplied by 1,000 within each age and gender group and the overall total for each category (Surgery, Medicine, Total). Reporting: Number of Expected Events The number of expected inpatient discharges within each age and gender group and the overall total for each category (Surgery, Medicine, Total). Reporting: Expected Discharges per 1,000 Members The number of expected inpatient discharges divided by the number of members in the eligible population, multiplied by 1,000 within each age and gender group and the overall total for each category (Surgery, Medicine, Total). Reporting: Total Variance The variance (from Risk Adjustment Weighting and Calculation of Expected Events, PUCD, step 6) within each age and gender group and the overall total for each category (i.e., Surgery, Medicine and Total Inpatient). December 2017 Page 30 of 45

31 Table IHU-A-2/3: Number of Members in the Eligible Population Age Sex Members Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male 85+ Female Total Male Total Female Total December 2017 Page 31 of 45

32 Table IHU-B-2/3: Inpatient Discharges by Age and Risk Adjustment: Surgery Age Total Sex Observed Inpatient Discharges Observed Inpatient Discharges/ 1,000 Members Expected Inpatient Discharges Expected Inpatient Discharges/ 1,000 Members Total Variance (O/E) O/E Ratio (Observed Discharges/ Expected Discharges) Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total December 2017 Page 32 of 45

33 Table IHU-C-2/3: Inpatient Discharges by Age and Risk Adjustment: Medicine Age Total Sex Observed Inpatient Discharges Observed Inpatient Discharges/ 1,000 Members Expected Inpatient Discharges Expected Inpatient Discharges/ 1,000 Members Total Variance (O/E) O/E Ratio (Observed Discharges/ Expected Discharges) Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total December 2017 Page 33 of 45

34 Table IHU-D-2/3: Inpatient Discharges by Age and Risk Adjustment: Total Inpatient Age Total Sex Observed Inpatient Discharges Observed Inpatient Discharges/ 1,000 Members Expected Inpatient Discharges Expected Inpatient Discharges/ 1,000 Members Total Variance (O/E) O/E Ratio (Observed Discharges/ Expected Discharges) Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total December 2017 Page 34 of 45

35 Emergency Department Utilization (EDU) SUMMARY OF CHANGES TO HEDIS 2018 Clarified how to identify an ED visit that resulted in an inpatient stay. Removed the AOD Rehab and Detox Value Set from the required exclusions (claims and encounters with a principal diagnosis of chemical dependency are excluded from the measure). Clarified to round to 10 decimal places using the.5 rule during the intermediate calculations of Expected events. Added steps 5 and 6 to the calculation of the PUCV risk weights to calculate covariance and total variance for each category. Removed the Risk Adjustment Weighting Process diagram. Added Total Variance as a data element to Table EDU-B-2/3. Description For members 18 years of age and older, the risk-adjusted ratio of observed to expected emergency department (ED) visits during the measurement year. Definitions Classification period PPV PUCV The year prior to the measurement year. Predicted probability of a visit. The predicted probability of a member having an emergency department visit in the measurement year. Predicted unconditional count of visits. The unconditional count of emergency department visits for members during the measurement year. Eligible Population Note: Members in hospice are excluded from the eligible population. Refer to General Guideline 20: Members in Hospice. Product lines Ages Continuous enrollment Allowable gap Anchor date Benefit Event/diagnosis Commercial, Medicare (report each product line separately). 18 and older as of December 31 of the measurement year. The measurement year and the year prior to the measurement year. No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. December 31 of the measurement year. Medical. None. December 2017 Page 35 of 45

36 Calculation of Observed Events Step 1 Count each visit to an ED once, regardless of the intensity or duration of the visit. Count multiple ED visits on the same date of service as one visit. Identify all ED visits during the measurement year using either of the following: An ED Visit (ED Value Set). A procedure code (ED Procedure Code Value Set) with an ED place of service code (ED POS Value Set). Do not include ED visits that result in an inpatient stay (Inpatient Stay Value Set). When an ED visit and an inpatient stay are billed on separate claims, the visit results in an inpatient stay when the admission date for the inpatient stay occurs on the ED date of service or one calendar day after. An ED visit billed on the same claim as an inpatient stay is considered a visit that resulted in an inpatient stay. Step 2 Exclude encounters with any of the following: A principal diagnosis of mental health or chemical dependency (Mental and Behavioral Disorders Value Set). Psychiatry (Psychiatry Value Set). Electroconvulsive therapy (Electroconvulsive Therapy Value Set). Risk Adjustment Determination For each member in the eligible population, use the steps in the Utilization Risk Adjustment Determination section in the Guidelines for Risk Adjusted Utilization Measures to identify risk adjustment categories based on presence of comorbidities. Risk Adjustment Weighting and Calculation of Expected Events Calculation of risk-adjusted outcomes (counts of ED visits) uses predetermined risk weights generated by two separate regression models. Weights from each model are combined to predict how many visits each member may have during the measurement year. Refer to the Risk Adjustment Weight Process diagram for an overview of the process. For each member in the eligible population, assign Predicted Probability of a Visit (PPV) risk weights. Step 1 Step 2 Step 3 Step 4 For each member with a comorbidity HCC Category, link the PPV weights. For the Medicare product line: Use Table EDU-MA-PPV-ComorbidHCC. For the commercial product line: Use Table EDU-Comm-PPV-ComorbidHCC. Link the age-gender PPV weights for each member using the following tables. For the Medicare product line: Use Table EDU-MA-PPV. For the commercial product line: Use Table EDU-Comm-PPV. Identify the base PPV risk weight for each member using the following tables. For the Medicare product line: Use Table EDU-MA-PPV. For the commercial product line: Use Table EDU-Comm-PPV. Sum all PPV weights associated with the member (HCC, age, gender, base weight). December 2017 Page 36 of 45

37 Step 5 Calculate the predicted probability of each member having at least one visit based on the sum of the weights for each member using the formula below. PPV = ee ( PPV WeightsForEachMember) 1+ee ( PPV WeightsForEachMember) Note: The risk adjustment tables will be released on November 1, 2017, and posted to For each member in the eligible population, assign Predicted Unconditional Count of Visits (PUCV) risk weights. Step 1 Step 2 Step 3 Step 4 For each member with a comorbidity HCC Category, link the PUCV weights. If a member does not have any comorbidities to which weights can be linked, assign a weight of 1. For the Medicare product line: Use Table EDU-MA-PUCV-ComorbidHCC. For the commercial product line: Use Table EDU-Comm-PUCV- ComorbidHCC. Link the PUCV age-gender weights for each member using the following tables. For the Medicare product line: Use Table EDU-MA-PUCV. For the commercial product line: Use Table EDU-Comm-PUCV. Identify the base PUCV risk weight for each member using the following tables. For the Medicare product line: Use Table EDU-MA-PUCV. For the commercial product line: Use Table EDU-Comm-PUCV. Calculate the predicted unconditional count of visits in the measurement year, by multiplying all PUCV weights (HCC, age, gender and base weight). Use the following formula: PUCV = Base Weight * Age/gender Weight * HCC Weight Note: Multiply by each HCC associated with the member. For example, assume a member with HCC-2, HCC-10, HCC-47. The formula would be: PUCV = Base Weight * Age/gender Weight * HCC-2 * HCC-10 * HCC-47 Note: Round intermediate calculations to 10 decimal places using the.5 rule. Expected count of hospitalization Step 5 Step 6 Report the final member-level expected count of ED visits for each category using the formula below. Round to four decimal places using the.5 rule and enter these values into the reporting table. Expected Count of ED Visits = PPV x PUCV Use the formula below to calculate to calculate the covariance of the predicted outcomes for each category (i.e., gender and age group). CCCCCC = nn ii=1(pppppp mmmmmmmm(pppppp)) (PPPPPPPP mmmmmmmm(pppppppp)) nn 1 Use the formula below to calculate the variance for each category. nn TTTTTTTTTT VVVVVVVVVVVVVVVV = (PPPPPP PPPPPPPP) (1 PPPPPP) CCCCCC PPPPPP PPPPPPPP ii=1 December 2017 Page 37 of 45

38 Reporting: Number of Members in the Eligible Population The number of members in the eligible population for each age and gender combination and enter these values into the reporting table (Table EDU-A-2/3). Reporting: Number of Observed Events The number of observed ED visits within each age and gender group and the overall total. Reporting: Observed Visits per 1,000 Members The number of observed ED visits divided by the number of members in the eligible population, multiplied by 1,000 within each age and gender group and the overall total. Reporting: Number of Expected Events The number of expected ED visits within each age and gender group and the overall total. Reporting: Expected Visits per 1,000 Members The number of expected ED visits divided by the number of members in the eligible population, multiplied by 1,000 within each age and gender group and the overall total. Reporting: Total Variance The variance (from Risk Adjustment Weighting and Calculation of Expected Events, PUCD, step 6) within each age and gender group and the overall total. Table EDU-A-2/3: Number of Members in the Eligible Population Age Sex Members Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male 85+ Female Total Male Total Female Total December 2017 Page 38 of 45

39 Table EDU-B-2/3: Number of ED visits by Age and Risk Adjustment Age Total Sex Observed ED Visits Observed ED Visits/ 1,000 Members Expected ED Visits Expected ED Visits/ 1,000 Members Total Variance (O/E) O/E Ratio (Observed ED Visits/Expected ED Visits) Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total December 2017 Page 39 of 45

40 Recommended VBP4P Measure Set for Measurement Year 2017 RED - Proposed MY 2017 changes compared to final MY 2016 measure set Commercial Value Based P4P Clinical Domain NQF# Approved Measurement Year 2017/ Reporting Year 2018 Measures Cardiovascular 2371 Annual Monitoring for Patients on Persistent Medications: ACEI/ARB, 1. Digoxin, and Diuretics 0541 Proportion of Days Covered by Medications: Renin Angiotensin 2. System (RAS) Antagonists Recommended for Public Payment Reporting* X X¹ Clinical Submission X Clinical Submission Proportion of Days Covered by Medications: Statins X Clinical Submission N/A 4. Statin Therapy for Patients With Cardiovascular Disease X X Clinical Submission Controlling Blood Pressure for People with Hypertension X X¹ Clinical Submission Diabetes Diabetes Care: Blood Pressure Control <140/90 mm Hg X X Clinical Submission Diabetes Care: HbA1c Control < 8.0% X X Clinical Submission N/A 8. Diabetes Care: Two HbA1c Tests X X Clinical Submission Diabetes Care: HbA1c Poor Control > 9.0% X X Clinical Submission Diabetes Care: Medical Attention for Nephropathy X X Clinical Submission N/A 11. Optimal Diabetes Care - Combination X X¹ Clinical Submission 0541 Proportion of Days Covered by Medications: Oral Diabetes 12. Medications X Clinical Submission N/A 13. Statin Therapy for Patients With Diabetes X X Clinical Submission Diabetes Care: Eye Exam Testing Testing Clinical Submission Musculoskeletal Use of Imaging Studies for Low Back Pain X X¹ Clinical Submission Prevention & Screening Breast Cancer Screening X X Clinical Submission Chlamydia Screening in Women X X Clinical Submission Childhood Immunization Status: Combination 10 X X Clinical Submission Colorectal Cancer Screening X X Clinical Submission Cervical Cancer Screening X X Clinical Submission N/A 21. Cervical Cancer Overscreening X X Clinical Submission Human Papillomavirus Vaccine for Female Adolescents Human Papillomavirus Vaccine for Male Adolescents Immunizations for Adolescents: Combination 2 (meningococcal, Tdap, 22. HPV for Adolescents) X X Clinical Submission Respiratory Asthma Medication Ratio X X Clinical Submission Appropriate Testing for Children With Pharyngitis X X Clinical Submission Appropriate Treatment for Children with Upper Respiratory Infection Data Source Avoidance of Antibiotic Treatment of Adults with Acute Bronchitis X X¹ Clinical Submission December 2017 Page 40 of 45

41 Clinical Domain (Continued) Advancing Care Information Domain Value Based P4P Patient Experience Domain Value Based P4P Resource Use Domain Payment Baseline Testing Recommended VBP4P Measure Set for Measurement Year 2017 NQF# RED - Proposed MY 2017 changes compared to final MY 2016 measure set Approved Measurement Year 2017/ Reporting Year 2018 Measures Recommended for Public Payment Reporting* Data Source Behavioral Health & Substance Use N/A 26. Use of Opioids at High Dosage Testing Testing HP Clinical Submission N/A 27. Concurrent Use of Opioids and Benzodiazepines Testing Testing HP Clinical Submission Other N/A 28. Encounter Rate by Service Type Info Only HP Clinical Submission Clinical Domain Weighting 60% N/A 29. Controlling High Blood Pressure e-measure X PO Clinical Submission 30. Screening for Clinical Depression and Follow-up e-measure X PO Clinical Submission Advancing Care Information Domain Weighting 10% N/A 31. Provider Communication Composite X N/A PAS N/A 32. Access Composite X N/A PAS N/A 33. Care Coordination Composite X N/A PAS N/A 34. Office Staff Composite X N/A PAS N/A Overall Ratings of Care Composite (Rating of Doctor & Rating of All 35. Healthcare) X N/A PAS Patient Experience Domain Weighting 30% All-Cause Readmissions X X¹ HP Clinical Submission N/A Inpatient Utilization: Acute Care Discharges, Bed Days, Average Length 37. of Stay X HP Submission N/A 38. Maternity Discharges, Average Length of Stay Info Only HP Submission N/A 39. Emergency Department Visits X HP Submission N/A 40. Outpatient Procedures Utilization - Percent Done in Preferred Facility X HP Submission Generic Prescribing: Overall and Antidepressants, Antimigraine, Anti- Ulcer, Cardiac - Hypertension and Cardiovascular, Nasal Steroids, N/A 41. Statins, Diabetes, Anxiety/Sedation - Sleep Aids N/A 42. Frequency of Selected Procedures - Angioplasty, Back Surgery, Bariatric Weight Loss Surgery, Cardiac Catheterization, Carotid Endarterectomy, CABG, Total Hip Replacement, Total Knee Replacement, Hysterectomy, Tonsillectomy, Cholecystectomy, Prostatectomy, Mastectomy, Lumpectomy X HP Submission HP Submission N/A 43. Total Cost of Care X X HP Submission Resource Use Domain Weighting Info Only Value Based P4P / Shared Savings = Indicates that the measure is in its first year of reporting and will not be used for payment this year (because it is not possible to assess relative improvement). It is intended for payment next year. = Indicates that the measure is being tested with the intent of adding it to the measure set next year, but will not be used for payment or public reporting this year. Public Reporting * 1 N/A = In general, The Office of the Patient Advocate (OPA) reports all measures that are available for public reporting; final decisions are made when baseline data becomes available for analysis. For measures in baseline year, OPA will not publicly report the measure but will consider whether the measure will be included in the following year's public reporting and whether it will be included in the star ratings or as a stand-alone measure. = Indicates the measure is reported on the OPA Report Card but not included in a topic star rating or the Medical Group Provides Recommended Care star rating. = The Patient Experience questions are collected and administered by California Healthcare Performance Information System (CHPI), including decisions about public reporting. Data Source Clinical Submission PAS HP Submission = Self-reporting POs and health plans submit audited files of numerator, denominator, and rate for these measures unless otherwise specified. = The Patient Assessment Survey is a CG-CAHPs survey administered by CHPI. = Health plans submit eligibility, claims/encounter, and cost data to Truven Health Analytics to run these measures. December 2017 Page 41 of 45

42 Medicare Stars Measure Set for Measurement Year 2017 RED - Proposed MY 2017 changes compared to final MY 2016 measure set Medicare Stars Measures Data Source Clinical Submission Info Only NQF # Recommended for Public Payment Reporting Cardiovascular 0541 Proportion of Days Covered by Medications: Renin Angiotensin 1. System (RAS) Antagonists X Clinical Submission Proportion of Days Covered by Medications: Statins X Clinical Submission N/A 3. Statin Therapy for Patients with Cardiovascular Disease Baseline Clinical Submission Diabetes Diabetes Care: HbA1c Poor Control > 9.0% X Clinical Submission Diabetes Care: Medical Attention for Nephropathy X Clinical Submission Diabetes Care: Eye Exam X Clinical Submission 0541 Proportion of Days Covered by Medications: Oral Diabetes 7. Medications X Clinical Submission Statin Use in Persons with Diabetes Baseline Clinical Submission Musculoskeletal 0054 Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid 9. Arthritis X Clinical Submission Osteoporosis Management in Women Who Had a Fracture X Clinical Submission Prevention N/A 11. Adult BMI Assessment X Clinical Submission Breast Cancer Screening: Ages X Clinical Submission Colorectal Cancer Screening: Ages X Clinical Submission N/A 14. High Risk Medication Info Only Clinical Submission Appropriate Resource Use All-Cause Readmissions X HP Clinical Submission Other Approved Measurement Year 2017/ Reporting Year 2018 Measures Data Source N/A 16. Encounter Rate by Service Type Info Only Clinical Submission = Self-reporting POs and health plans submit audited files of numerator, denominator, and rate for these measures. The All-Cause Readmission measure is only submitted by health plans. = CMS cut points required for calculating star ratings not available December 2017 Page 42 of 45

43 Recommended VBP4P Measure Set for Measurement Year 2018 RED - Proposed MY 2018 changes compared to final MY 2017 measure set Commercial Value Based P4P Clinical Domain NQF# Approved Measurement Year 2018/ Reporting Year 2019 Measures Cardiovascular Annual Monitoring of Persistent Medications Proportion of Days Covered by Medications: Renin Angiotensin System (RAS) Antagonists Recommended for Public Payment Reporting* Data Source X X Clinical Submission Proportion of Days Covered by Medications: Statins X X Clinical Submission N/A 3. Statin Therapy for Patients With Cardiovascular Disease X X Clinical Submission Controlling Blood Pressure for People with Hypertension X X¹ Clinical Submission Diabetes Diabetes Care: Blood Pressure Control <140/90 mm Hg X X Clinical Submission Diabetes Care: HbA1c Control < 8.0% X Clinical Submission Diabetes Care: Two HbA1c Tests Diabetes Care: HbA1c Poor Control > 9.0% X X Clinical Submission Diabetes Care: Medical Attention for Nephropathy X X Clinical Submission Diabetes Care: Eye Exam Baseline Baseline Clinical Submission Optimal Diabetes Care: Combination (Hba1c Control, 2 HbA1c tests, BP Control, Med Attn. Nephropathy) Baseline Baseline 0541 Proportion of Days Covered by Medications: Oral Diabetes 10. Medications X X Clinical Submission N/A 11. Statin Therapy for Patients With Diabetes X X Clinical Submission Musculoskeletal Use of Imaging Studies for Low Back Pain X X¹ Clinical Submission Prevention & Screening Breast Cancer Screening X X Clinical Submission Chlamydia Screening in Women X X Clinical Submission Childhood Immunization Status: Combination 10 X X Clinical Submission Colorectal Cancer Screening X X Clinical Submission Cervical Cancer Screening X X Clinical Submission N/A 18. Cervical Cancer Overscreening X X Clinical Submission 1407 Immunizations for Adolescents: Combination 2 (meningococcal, Tdap, 19. HPV for Adolescents) X X Clinical Submission Respiratory Asthma Medication Ratio X X Clinical Submission Appropriate Testing for Children With Pharyngitis X X Clinical Submission Avoidance of Antibiotic Treatment of Adults with Acute Bronchitis X X¹ Clinical Submission December 2017 Page 43 of 45

44 Clinical Domain (Continued) Advancing Care Information Domain Value Based P4P Patient Experience Domain Value Based P4P Resource Use Domain Payment Baseline Testing Recommended VBP4P Measure Set for Measurement Year 2018 NQF# RED - Proposed MY 2018 changes compared to final MY 2017 measure set Approved Measurement Year 2018/ Reporting Year 2019 Measures Recommended for Public Payment Reporting* Data Source Behavioral Health & Substance Use N/A 23. Use of Opioids at High Dosage Baseline Baseline HP Clinical Submission N/A 24. Concurrent Use of Opioids and Benzodiazepines Baseline Baseline HP Clinical Submission Other N/A 25. Encounter Rate by Service Type Info Only HP Clinical Submission Clinical Domain Weighting 60% N/A 26. Controlling High Blood Pressure e-measure X PO Clinical Submission Screening for Clinical Depression and Follow-up e-measure X PO Clinical Submission Advancing Care Information Domain Weighting 10% N/A 28. Provider Communication Composite X N/A PAS N/A 29. Access Composite X N/A PAS N/A 30. Care Coordination Composite X N/A PAS N/A 31. Office Staff Composite X N/A PAS N/A Overall Ratings of Care Composite 32. (Rating of Doctor & Rating of All Healthcare) X N/A PAS Patient Experience Domain Weighting 30% All-Cause Readmissions X X¹ HP Clinical Submission N/A Inpatient Utilization: Acute Care Discharges, Bed Days, Average Length 34. of Stay X HP Submission N/A 35. Maternity Discharges, Average Length of Stay Info Only HP Submission N/A 36. Emergency Department Visits X HP Submission N/A 37. Outpatient Procedures Utilization - Percent Done in Preferred Facility X HP Submission N/A 38. Specialty Pharmacy TBD Under consideration HP Submission Generic Prescribing: Overall and Antidepressants, Antimigraine, Anti- 39. Ulcer, Cardiac - Hypertension and Cardiovascular, Nasal Steroids, X HP Submission Statins, Diabetes N/A Frequency of Selected Procedures - Angioplasty, Back Surgery, Bariatric Weight Loss Surgery, Cardiac Catheterization, Carotid 40. Endarterectomy, CABG, Total Hip Replacement, Total Knee Replacement, Hysterectomy, Tonsillectomy, Cholecystectomy, Prostatectomy, Mastectomy, Lumpectomy Info Only HP Submission N/A 41. Total Cost of Care (incl. service categories) X X (overall TCC only) HP Submission Resource Use Domain Weighting Value Based P4P / Shared Savings = Indicates that the measure is in its first year of reporting and will not be used for payment this year (because it is not possible to assess relative improvement). It is intended for payment next year. = Indicates that the measure is being tested with the intent of adding it to the measure set next year, but will not be used for payment or public reporting this year. Public Reporting * 1 N/A = In general, The Office of the Patient Advocate (OPA) reports all measures that are available for public reporting; final decisions are made when baseline data becomes available for analysis. For measures in baseline year, OPA will not publicly report the measure but will consider whether the measure will be included in the following year's public reporting and whether it will be included in the star ratings or as a stand-alone measure. = Indicates the measure is reported on the OPA Report Card but not included in a topic star rating or the Medical Group Provides Recommended Care star rating. = The Patient Experience questions are collected and administered by California Healthcare Performance Information System (CHPI), including decisions about public reporting. Data Source Clinical Submission PAS HP Submission = Self-reporting POs and health plans submit audited files of numerator, denominator, and rate for these measures unless otherwise specified. = The Patient Assessment Survey is a CG-CAHPs survey administered by CHPI. = Health plans submit eligibility, claims/encounter, and cost data to Truven Health Analytics to run these measures. December 2017 Page 44 of 45