Lindsay Erickson, Director, Value Based P4P, Integrated Healthcare Association. Measurement Years 2016 & 2017 Proposed Changes to the VBP4P Program

Transcription

1 To: From: Subject: Value Based Pay for Performance (VBP4P) Stakeholders Lindsay Erickson, Director, Value Based P4P, Integrated Healthcare Association Measurement Years 2016 & 2017 Proposed Changes to the VBP4P Program 2016 Value Based P4P Public Comment Period September 1 September 30, 2016 Value Based P4P staff is inviting public comment on the following changes: 1. Measurement Year 2016 (MY 2016) 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 2017 and VBP4P MY 2016 measure the same time period). As a reminder, the MY 2016 Measure Set was finalized in 2015; all changes reflect specification updates, not measure additions or removals. 2. Measurement Year 2017 (MY 2017) The changes outlined reflect the measures that are proposed for payment and public reporting for MY 2017; results will reflect the care provided to members in calendar year 2017 and be collected and reported during calendar year Specifications are provided for any measures that are not already included in the VBP4P manual. 3. Measure Set - General Value Based P4P staff welcome general comments on the VBP4P Measure Set in regards to alignment or other areas of note. Comments are due by 5 p.m. PDT on Friday, September 30, 2016 to the Public Comment website at the following link:

2 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 notification with all submitted comments.

3 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. Measurement Year 2016 (MY 2016) MY 2016 VBP4P Measure Specification Updates As a reminder, the MY 2016 VBP4P Measure Set was finalized in calendar year Changes to the MY 2016 VBP4P Measure Set reflects alignment with HEDIS specification changes made in HEDIS For a list of all specification changes, refer to the draft MY 2016 VBP4P Manual. A summary of measurespecific 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 2016 VBP4P Manual. Major specification changes to note are listed below. The MY 2016 Measure Set can be referenced in full in Appendix A. Immunizations for Adolescents (IMA) VBP4P committees recommend aligning with the HEDIS specification changes. The committees recommend continuing to use the IMA: Tdap rate for payment and public reporting in MY 2016, and moving to the new Combination 2 rate for payment and public reporting beginning in MY During NCQA s reevaluation of the IMA measure, the following changes were approved and included in HEDIS 2017: Add the HPV vaccine for adolescents to the IMA measure. Create Combination 2 (meningococcal, Tdap, HPV). Remove the tetanus, diphtheria toxoids (Td) and meningococcal polysaccharide vaccines. Add CVX codes (vaccine administered codes) to the measure. These changes are intended to reduce measure burden, support normalization of HPV vaccine administration, and align with updated Advisory Committee on Immunization Practices (ACIP) guidelines. The revised IMA measure captures HPV vaccination for both male and females. This aligns with IHA s current measure specification for Human Papillomavirus Vaccine for Female and Male Adolescents see recommendation to retire standalone HPV measure for MY Colorectal Cancer Screening (COL) VBP4P committees recommend aligning with the HEDIS specifications for the COL measure when they are finalized. On June 15, 2016, the U.S. Preventive Services Task Force released an updated recommendation statement on colorectal cancer screening. In response, NCQA initiated a reevaluation of the HEDIS COL measure and has posted proposed changes for a public comment period that was held July 13 August 10, 2016; the changes are being considered for the HEDIS 2017 Technical Specifications

4 update (scheduled for release in October 2016). All approved changes published in the HEDIS 2017 Technical Specifications Update are recommended for inclusion in the final version of the MY 2016 VBP4P Manual (released December 1, 2016). Outpatient Procedures Utilization Percentage Done in Preferred Facility (OSU) The VBP4P committees recommend changing the OSU specifications from relying on plan definitions of preferred to a standard definition. The standard definition of preferred facility is: a contracted freestanding ambulatory surgery facility. Hospital outpatient facilities will be considered nonpreferred. This change is based on a recommendation from a VBP4P Technical Measurement Committee workgroup, which was convened in early 2016 to evaluate opportunities for making the OSU measure more meaningful. Participant feedback indicated the use of plan-specific definitions of preferred facilities resulted in performance distributions that were inconsistent, opaque, and challenging to interpret ultimately limiting physician organization engagement and performance improvement. Comparisons of freestanding ambulatory surgery facilities against plan-specific definitions suggested substantial amounts of overlap. The standard definition was seen as an appropriate and more actionable approximation of preferred for measurement and performance improvement efforts. Total Cost of Care (TCC) In an effort to make the TCC results more informative and actionable, the VBP4P committees recommend expanding the TCC specifications to include service category breakdowns. These breakdowns would reflect the average contribution of the identified services to the average annual per member costs. The categories are intended to be mutually exclusive and, in total, reflective of the total cost of care. The proposed categories are: Inpatient Maternity Inpatient Non-maternity Outpatient Facility Ambulatory Surgery Center Outpatient Facility Hospital Outpatient Facility Emergency Department Professional Pharmacy All Other Pharmacy Specialty/Biologics Capitation Other IHA will be working closely with Truven Health, the VBP4P committees, and health plans to develop the methodology and specifications for calculating these category-specific costs. Testing results will be shared with participants for information purposes and are not intended for public reporting. All other HEDIS measures VBP4P intends to align with all HEDIS measure updates. Please see each measure specification for details; a comprehensive list of all specification changes is available in Appendix 1 of the draft MY 2016 VBP4P Manual. In particular, please note that the Use of Imaging Studies for Low Back Pain received a

5 full reevaluation as part of NCQA s continuous monitoring process and includes more substantive changes. Patient Assessment Survey (PAS) The California Healthcare Performance Information System (CHPI) administers the Patient Assessment Survey (PAS), which is used to measure performance in VBP4P s Patient Experience domain. Based on the decision of the PAS Committee, CHPI is transitioning the PAS instrument from version 2.0 to version 3.0 of the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) beginning in MY As part of the survey transition, supplemental survey items (i.e. supplemental questions included in the PAS survey) are currently under consideration by the PAS Committee. The Health Promotion Composite, unlike the other five patient experience composites used in VBP4P, is not a core, but a supplemental CAHPS item. As such, the MY 2016 VBP4P measure set reflects only the core CAHPS composites currently approved by the PAS Committee; appropriate supplemental items will be reconsidered for inclusion in the measure set once identified. MY 2016 VBP4P Measurement Collection Process and Policy Changes Members in Hospice In alignment with HEDIS, VBP4P adopted a new guideline for Hospice member exclusions (General Guideline 19). A note will be added to all measure specifications as well as the value set. Data Collection & Reporting Timeline There is an updated Data Collection and Reporting Timeline on page 6 of the draft MY 2016 VBP4P Manual. The updated reporting timeline includes additional detail and revised dates. The recommended timeline will allow for a more substantial investigation of participant questions and appeals requests. Measurement Year 2017 (MY 2017) The proposed MY 2017 VBP4P Measure Set can be referenced in full in Appendix B. MY 2017 VBP4P Measure Adoptions Statin Therapy for Patients With Cardiovascular Disease (SPC) Based on MY 2015 testing results, the VBP4P committees recommend the addition of SPC pending comparable HEDIS first year testing results. The committees recommend that the first rate Received Statin Therapy be used for payment and public reporting; the second rate for information only. 1. Received Statin Therapy. Members who were dispensed at least one high or moderate-intensity 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.

6 The SPC measure was included as a testing measure in MY 2015 and was specifically developed to reflect new clinical guidance around cholesterol and replace the retired cholesterol measures. MY 2015 testing measure results can be found in Appendix C. Statin Therapy for Patients With Diabetes (SPD) Based on MY 2015 testing results, the VBP4P committees recommend addition of SPD pending comparable HEDIS first year testing results. The committees recommend that the first rate Received Statin Therapy be used for payment and public reporting; the second rate for information only. 1. Received Statin Therapy. Members who were dispensed at least one statin medication of any intensity during the measurement year. 2. Statin Adherence 80%. Members who remained on a statin medication of any intensity for at least 80% of the treatment period. The SPD measure was tested in MY 2015 and was specifically developed to reflect new clinical guidance around cholesterol and replace the retired cholesterol measures. MY 2015 testing measure results can be found in Appendix C. Antidepressant Medication Management (AMM) The VBP4P Committees recommend that AMM is included in the MY 2017 measure set as an information only measure. The AMM measure was tested in MY This measure targets the current gap in behavioral health measurement, which is a clinical priority despite current contracting arrangements. MY 2015 testing measure results can be found in Appendix C. Depression Utilization of the PHQ-9 Tool e-measure The VBP4P committees recommend adding Depression Utilization of the PHQ-9 Tool to the MUHIT domain as a substitute for the current Screening for Clinical Depression and Follow-up Plan e-measure beginning in MY Depression Utilization of the PHQ-9 Tool measures the number of adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during a 4-month period in which there was a qualifying visit. The recommended substitution is based on the findings from informational interviews conducted with several participating POs regarding the e- measures in Interview participants noted that the Screening for Clinical Depression and Follow-up Plan e-measure was difficult to program in an EHR due to the use of unstructured or non-discrete fields to document a follow-up plan. For reference, the current CMS measure specifications for Depression Utilization of the PHQ-9 Tool can be found at the ecqi Resource Center.

7 MY 2017 VBP4P Measure Removals Appropriate Treatment for Children with Upper Respiratory Infection (URI) The VBP4P committees recommend retirement of URI based on consistently high performance across all POs participating in VBP4P. This measure topped out and was removed from payment beginning in MY Human Papillomavirus Vaccine for Adolescents (HPV) The Human Papillomavirus Vaccine for Adolescents (HPV) measure is being added to the Immunizations for Adolescents (IMA) measure in MY 2016 to align with HEDIS. In conjunction with the change, the standalone HPV measure is recommended for retirement in MY 2017; the antigen will continue to be collected as part of the IMA measure. Screening for Clinical Depression and Follow-up Plan e-measure The VBP4P committees recommend this measure be removed from the MUHIT domain and Depression Utilization of the PHQ-9 Tool e-measure be collected in its place. MY 2017 VBP4P Testing Measures Use of Opioids from Multiple Providers or at High Dosage in Persons Without Cancer The VBP4P committees recommend testing Use of Opioids from Multiple Providers or at High Dosage in Persons Without Cancer in MY This PQA measure examines multi-provider and/or high dosage opioid use among individuals 18 years and older without cancer. Three rates are included the measure: Rate 1 (Opioid High Dosage): The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer. Rate 2 (Multiple Prescribers and Multiple Pharmacies): The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from four (4) or more prescribers AND four (4) or more pharmacies. Rate 3 (Multi-Provider, High Dosage): The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer, AND who received opioid prescriptions from four (4) or more prescribers AND four (4) or more pharmacies. The current PQA measure specification is included in Appendix D.

8 VBP4P Measure Set General Alignment Increasing alignment in the VBP4P measure set was identified as a priority in the Measure Set Strategy. To help inform the committees efforts, VBP4P staff invite stakeholder comments on current measure set alignment opportunities and priorities. 5-Star Reporting for Commercial Physician Organization Level Reporting As federal rating systems increasingly adopt a 5-star rating scale for use in performance reporting, one option that has been raised for consideration is moving the public reporting of VBP4P results (in partnership with the Office of the Patient Advocate) to a 5-star scale instead of the current 4-star scale. IHA seeks stakeholder input and feedback on this alignment opportunity. If this change were adopted, it would likely not be until Other VBP4P staff invite any additional comments and feedback from stakeholders on the program and measure set.

9 APPENDIX A Recommended VBP4P Measure Set for Measurement Year 2016 RED - MY 2016 updates to final MY 2015 measure set Commercial Value Based P4P Clinical Domain Approved Measurement Year 2016/ Reporting Year 2017 Measures NQF# 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 X Proportion of Days Covered by Medications: Statins X N/A 4. Statin Therapy for Patients With Cardiovascular Disease Baseline Baseline Controlling Blood Pressure for People with Hypertension X X¹ Diabetes Diabetes Care: Blood Pressure Control <140/90 mm Hg X X Diabetes Care: HbA1c Control < 7.0% Diabetes Care: HbA1c Control < 8.0% X X N/A 8. Diabetes Care: Two HbA1c Tests X X Diabetes Care: HbA1c Poor Control > 9.0% X Diabetes Care: Medical Attention for Nephropathy X X N/A 11. Optimal Diabetes Care Combination X X¹ 0541 Proportion of Days Covered by Medications: Oral Diabetes 12. Medications X N/A 13. Statin Therapy for Patients With Diabetes Baseline Baseline Musculoskeletal Use of Imaging Studies for Low Back Pain X X¹ Prevention & Screening Breast Cancer Screening X X Chlamydia Screening in Women X X Childhood Immunization Status: Combination Childhood Immunization Status: Combination 10 X X Colorectal Cancer Screening X X Evidence-Based Cervical Cancer Screening: Appropriately Screened Data Source Evidence-Based Cervical Cancer Screening: Underscreened and Screened Too Frequently Cervical Cancer Screening X X N/A 20. Cervical Cancer Overscreening X X Human Papillomavirus Vaccine for Female Adolsecents X X N/A 22. Human Papillomavirus Vaccine for Male Adolescents X X Immunizations for Adolescents: Td/Tdap X X Immunizations for Adolescents: Combination 2 (meningococcal, Tdap, 24. HPV for Adolescents) Baseline Baseline Respiratory Asthma Medication Ratio X X N/A 26. Appropriate Testing for Children With Pharyngitis X X Appropriate Treatment for Children with Upper Respiratory Infection X Avoidance of Antiobiotic Treatment of Adults with Acute Bronchitis X X¹

10 APPENDIX A Clinical Domain (Continued) Value Based P4P Meaningful Use of Health IT Domain Value Based P4P Patient Experience Domain Value Based P4P Resource Use Domain Payment Baseline Testing Recommended VBP4P Measure Set for Measurement Year 2016 RED - MY 2016 updates to final MY 2015 measure set Approved Measurement Year 2016/ Reporting Year 2017 Measures Recommended for Public Payment Reporting* Data Source Behavioral Health Antidepressant Medication Management Info Only Other N/A 31. Encounter Rate by Service Type Info Only HP Clinical Domain Weighting 60% CMS EHR Incentive Program Participation N/A 32. Controlling High Blood Pressure e-measure X PO N/A 33. Screening for Clinical Depression and Follow-up e-measure X PO MUHIT Domain Weighting 10% N/A 34. Doctor-Patient Interaction Composite X N/A PAS N/A 35. Timely Care and Service Composite X N/A PAS N/A 36. Coordination of Care Composite X N/A PAS N/A 37. Office Staff Composite X N/A PAS N/A Health Promotion Composite PAS N/A Overall Ratings of Care Composite (Rating of Doctor & Rating of All 38. Healthcare) X N/A PAS Patient Experience Domain Weighting 30% All-Cause Readmissions X X¹ HP N/A 40. Inpatient Utilization: Acute Care Discharges, Bed Days, Average Length of Stay X HP Submission N/A 43. Maternity Discharges, Average Length of Stay Info Only HP Submission N/A 45. Emergency Department Visits X HP Submission N/A 46. Outpatient Procedures Utilization - Percent Done in Preferred Facility X HP Submission N/A Generic Prescribing: Overall and Antidepressants, Antimigraine, Anti- 47. Ulcer, Cardiac - Hypertension and Cardiovascular, Nasal Steroids, Statins, Diabetes X HP Submission N/A 48. Generic Prescribing: Anxiety/Sedation - Sleep Aids Info Only HP Submission N/A Frequency of Selected Procedures - Angioplasty, Back Surgery, Bariatric Weight Loss Surgery, Cardiac Catheterization, Carotid 49. Endarterectomy, CABG, Total Hip Replacement, Total Knee Replacement, Hysterectomy, Tonsillectomy, Cholecystectomy, Prostatectomy, Mastectomy, Lumpectomy Info Only HP Submission N/A 50. Total Cost of Care X X HP Submission Appropriate 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 PAS HP Submission IHA Vendor = 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. = 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. = An organization partnering with IHA runs these results using the health plan submission to Truven health matched to California birth certificate data.

11 APPENDIX A Medicare Stars Measure Set for Measurement Year 2016 RED - MY 2016 updates to final MY 2015 measure set Medicare Stars Measures Approved Measurement Year 2016/ Reporting Year 2017 Measures Recommended for Public Payment Reporting Data Source Cardiovascular Proportion of Days Covered by Medications: Renin Angiotensin System 1. (RAS) Antagonists X 2. Proportion of Days Covered by Medications: Statins X Diabetes 3. Diabetes Care: HbA1c Poor Control > 9.0% X 4. Diabetes Care: Medical Attention for Nephropathy X 5. Diabetes Care: Eye Exam X 6. Proportion of Days Covered by Medications: Oral Diabetes Medications X Musculoskeletal Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid 7. Arthritis X 8. Osteoporosis Management in Women Who Had a Fracture X Prevention 9. Adult BMI Assessment X 10. Breast Cancer Screening: Ages X 11. Colorectal Cancer Screening: Ages X 12. High Risk Medication X Appropriate Resource Use = 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. Updated December 2, of 3

12 APPENDIX B 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 2016/ Reporting Year 2017 Measures Recommended for Public Payment Reporting* Cardiovascular 2371 Annual Monitoring for Patients on Persistent Medications: ACEI/ARB, 1. Digoxin, and Diuretics X X¹ 0541 Proportion of Days Covered by Medications: Renin Angiotensin 2. System (RAS) Antagonists X Proportion of Days Covered by Medications: Statins X N/A 4. Statin Therapy for Patients With Cardiovascular Disease X X Controlling Blood Pressure for People with Hypertension X X¹ Diabetes Diabetes Care: Blood Pressure Control <140/90 mm Hg X X Diabetes Care: HbA1c Control < 8.0% X X N/A 8. Diabetes Care: Two HbA1c Tests X X Diabetes Care: HbA1c Poor Control > 9.0% X Diabetes Care: Medical Attention for Nephropathy X X N/A 11. Optimal Diabetes Care - Combination X X¹ 0541 Proportion of Days Covered by Medications: Oral Diabetes 12. Medications X N/A 13. Statin Therapy for Patients With Diabetes X X Musculoskeletal Use of Imaging Studies for Low Back Pain X X¹ Prevention & Screening Breast Cancer Screening X X Chlamydia Screening in Women X X Childhood Immunization Status: Combination 10 X X Colorectal Cancer Screening X X Cervical Cancer Screening X X N/A 20. Cervical Cancer Overscreening X X Human Papillomavirus Vaccine for Female Adolescents Human Papillomavirus Vaccine for Male Adolescents Immunizations for Adolescents: Combination 2 (meningococcal, Tdap, 21. HPV for Adolescents) X X Respiratory Asthma Medication Ratio X X N/A 23. Appropriate Testing for Children With Pharyngitis X X Appropriate Treatment for Children with Upper Respiratory Infection Data Source Avoidance of Antiobiotic Treatment of Adults with Acute Bronchitis X X¹

13 APPENDIX B Clinical Domain (Continued) Meangingful Use of Health IT (MUHIT) 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 2016/ Reporting Year 2017 Measures Recommended for Public Payment Reporting* Data Source Behavioral Health & Substance Abuse Antidepressant Medication Management Info Only N/A Use of Opioids from Multiple Providers or at High Dosage in Persons 26. without Cancer Testing Testing Other N/A 27. Encounter Rate by Service Type Info Only HP Clinical Domain Weighting 60% N/A 28. Controlling High Blood Pressure e-measure X PO Screening for Clinical Depression and Follow-up e-measure Depression Utilization of the PHQ-9 Tool e-measure X PO MUHIT Domain Weighting 10% N/A 30. Doctor-Patient Interaction Composite X N/A PAS N/A 31. Timely Care and Service Composite X N/A PAS N/A 32. Coordination of Care Composite X N/A PAS N/A 33. Office Staff Composite X N/A PAS N/A Overall Ratings of Care Composite (Rating of Doctor & Rating of All 34. Healthcare) X N/A PAS Patient Experience Domain Weighting 30% All-Cause Readmissions X X¹ HP N/A Inpatient Utilization: Acute Care Discharges, Bed Days, Average Length 36. of Stay X HP Submission N/A 37. Maternity Discharges, Average Length of Stay Info Only HP Submission N/A 38. Emergency Department Visits X HP Submission N/A 39. Outpatient Procedures Utilization - Percent Done in Preferred Facility X HP Submission N/A Generic Prescribing: Overall and Antidepressants, Antimigraine, Anti- 40. Ulcer, Cardiac - Hypertension and Cardiovascular, Nasal Steroids, Statins, Diabetes X HP Submission N/A 41. Generic Prescribing: Anxiety/Sedation - Sleep Aids Info Only HP Submission N/A Frequency of Selected Procedures - Angioplasty, Back Surgery, Bariatric Weight Loss Surgery, Cardiac Catheterization, Carotid 42. Endarterectomy, CABG, Total Hip Replacement, Total Knee Replacement, Hysterectomy, Tonsillectomy, Cholecystectomy, Prostatectomy, Mastectomy, Lumpectomy Info Only HP Submission N/A 43. Total Cost of Care X X HP Submission Appropriate 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 N/A * 1 = 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 PAS HP Submission IHA Vendor = 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. = 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. = An organization partnering with IHA runs these results using the health plan submission to Truven health matched to California birth certificate data.

14 APPENDIX B 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 Approved Measurement Year 2016/ Reporting Year 2017 Measures Recommended for Public Payment Reporting Data Source Cardiovascular Proportion of Days Covered by Medications: Renin Angiotensin System 1. (RAS) Antagonists X 2. Proportion of Days Covered by Medications: Statins X Diabetes 3. Diabetes Care: HbA1c Poor Control > 9.0% X 4. Diabetes Care: Medical Attention for Nephropathy X 5. Diabetes Care: Eye Exam X 6. Proportion of Days Covered by Medications: Oral Diabetes Medications X Musculoskeletal Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid 7. Arthritis X 8. Osteoporosis Management in Women Who Had a Fracture X Prevention 9. Adult BMI Assessment X 10. Breast Cancer Screening: Ages X 11. Colorectal Cancer Screening: Ages X 12. High Risk Medication Info Only Appropriate Resource Use 13. All-Cause Readmissions X = 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. Updated December 2, of 3

15 APPENDIX C MY 2015 Testing Measure Results Summary This document presents findings from analysis of the Measurement Year (MY) 2015 VBP4P testing measure results. VBP4P tested three new measures, displayed in the table below. VBP4P MY 2015 Testing Measures Measure Title NQF Number Aligns With HEDIS Commercial HMO/POS Medicare Statin Therapy for Patients With Cardiovascular Disease (SPC) None Not tested Statin Therapy for Patients With Diabetes (SPD) None Not tested Antidepressant Medication Management (AMM) 0105 Not tested VBP4P MY 2012 Testing Measures This report presents detailed results for each measure. Measure 1: Statin Therapy for Patients With Cardiovascular Disease (SPC) Description: 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 following criteria: 1. Received Statin Therapy. Members who were dispensed at least one high or moderate-intensity 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. Who Submitted Results: Seven health plans and seven self-reporting POs submitted testing data for the measure. A valid rate means the result met the reporting threshold of a denominator of at least 30 members. Health Plan Data (n=7) PO Data Number of POs Number with valid rate 95 7 Percent with valid rate 55.6% 100% As shown in the table, almost 56% of health plan reported POs and all of the self-reporting POs submitted valid rates.

16 APPENDIX C Testing Results: The tables below show the means, percentiles and interquartile ranges for the health plan reported results and self-reporting POs for both indicators. Percentiles- Received Statin Therapy VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Health Plan Reported Percentiles- Received Statin Therapy VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Self-Reporting POs Percentiles- Statin Adherence 80% VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Health Plan Reported Percentiles- Statin Adherence 80% VBP4P Mean 10th 25th 50th 75th 90th IQR Self-Reporting POs The tables show that the health plan reported results have a higher mean rate of 73.8% for Received Statin Therapy, while the self-reporting POs who participated in testing have a mean rate of almost 60%. For Statin Adherence, self-reporting POs have a higher mean rate of 69.2%, while the health plan reported rates have a mean of 65.9%. Comparative Results: SPC is a first year measure in HEDIS 2016; HEDIS first year results are not yet available for comparison.

17 APPENDIX C Technical Assistance: VBP4P staff noted minimal questions received during data collection and no identified FAQs developed for the measure. Some POs also asked for clarification on how to adjust for prescription overlap, VBP4P staff responded to these questions as they were received. For HEDIS 2016, NCQA released an FAQ to clarify that all members who are numerator compliant for Rate 1 must be used as the eligible population for Rate 2 in both the SPC and SPD measures. Clarifications were also provided regarding the application of optional exclusions to both indicators. Measure 2: Statin Therapy for Patients With Diabetes (SPD) Description: The percentage of members years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria. Two rates are reported: 1. Received Statin Therapy. Members who were dispensed at least one statin medication of any intensity during the measurement year. 2. Statin Adherence 80%. Members who remained on a statin medication of any intensity for at least 80% of the treatment period. Who Submitted Results: Seven health plans and seven self-reporting POs submitted testing data for the measure. A valid rate means the result met the reporting threshold of a denominator of at least 30 members. Health Plan Data (n=7) PO Data Number of POs Number with Valid Rate Percent with Valid Rate 87.36% 100% As shown in the table, most of the POs achieved valid rates regardless of method of data submission. Testing Results: The tables below present the means, percentiles and interquartile ranges for the health plan reported results and the POs that self-reported. Percentiles- Received Statin Therapy VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Health Plan Reported Percentiles-Received Statin Therapy

18 APPENDIX C VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Self-Reporting POs Percentiles- Statin Adherence 80% VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Health Plan Reported Percentiles- Statin Adherence 80% VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Self-Reporting POs The health plan reported mean rate for the percentage receiving statin therapy is higher than the selfreporting PO mean rate by 9 percentage points. For Statin Adherence, the mean rates are very similar. Comparative Results: SPD is a first year measure in HEDIS 2016; HEDIS first year results are not yet available for comparison. Technical Assistance: VBP4P staff noted minimal questions received during data collection and no identified FAQs developed for the measure. Some POs also asked for clarification on how to adjust for prescription overlap, VBP4P staff responded to these questions as they were received. For HEDIS 2016, NCQA released an FAQ to clarify that all members who are numerator compliant for Rate 1 must be used as the eligible population for Rate 2 in both the SPC and SPD measures Clarifications were also provided regarding the application of optional exclusions to both indicators. Measure 3: Antidepressant Medication Management (AMM) Description: The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported. 1. Effective Acute Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks). 2. Effective Continuation Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months). Who Submitted Results: Eight health plans and seven self-reporting POs submitted testing data for the measure. A valid rate means the result met the reporting threshold of a denominator of at least 30

19 APPENDIX C members. One health plan s rates were substantially lower than other health plan rates and the selfreporting PO mean rates. Further investigation showed that this plan s data was likely incorrect, as the testing results are not audited. Omitting results from that plan aligns the health plan reported results with the PO self-reported results; VBP4P staff did so in this analysis. Health Plan Data PO Data (n=7) Number of POs Number with Valid Rate Percent with Valid Rate 58.52% 100% As shown in the table, almost 60% of health plan reported POs achieved valid rates while all seven selfreporting POs achieved valid rates. Testing Results: The table below presents the means, percentiles and interquartile ranges for the health plan reported results and the range of results for the self-reporting POs. Percentiles- Effective Acute Phase Treatment VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Health Plan Reported omitting outlier plan Percentiles- Effective Acute Phase Treatment VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Self-Reporting POs Percentiles- Effective Continuation Phase Treatment VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Health Plan Reported omitting outlier plan

20 APPENDIX C Percentiles - Effective Continuation Phase Treatment VBP4P Mean N 10 th 25 th 50 th 75 th 90 th IQR Self-Reporting POs Comparative Results: For the Effective Acute Phase Treatment indicator, the testing results for both methods are lower than the HEDIS 2015 national mean of 66.2%. For Effective Continuation Phase Treatment, the testing results are also lower than the HEDIS 2015 mean of 49.95%. Technical Assistance: VBP4P staff noted some concerns about the carve out of behavioral health services and accountability. During the public comment period one PO stated that the measure would be difficult to implement for POs that carve out behavioral health benefits, since the PO's primary care physicians are not primarily responsible for managing the eligible patients. NCQA also received a concern from another PO who stated that the PCP may diagnose and prescribe antidepressants, but may refer patients to a mental health provider for continued treatment, thereby losing access to the data for that patient. VBP4P staff also received questions about the calculation of total days supply and responded to these questions as they were received.

21 APPENDIX D Use of Opioids from Multiple Providers or at High Dosage in Persons Without Cancer Description We describe 3 measures that examine multi-provider, high dosage opioid use among individuals 18 years and older without cancer. Patients in hospice also are excluded. The denominator includes individuals with two or more prescription claims for opioids filled on at least two separate days, for which the sum of the days supply is > 15 during the 12-month measurement year. Three measures are described herein that examine the quality of opioid use. Each of the following numerators will be considered: Measure 1 (Opioid High Dosage): The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer. Measure 2 (Multiple Prescribers and Multiple Pharmacies): The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from four (4) or more prescribers AND four (4) or more pharmacies. Measure 3 (Multi-Provider, High Dosage): The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer, AND who received opioid prescriptions from four (4) or more prescribers AND four (4) or more pharmacies. Definitions Measurement Period: Opioid: Morphine Equivalent Dose (MED): Twelve-month measurement year. Also include tramadol and tapentadol (See Table Opioid-A) The dose of oral morphine that is the analgesic equivalent of a given dose of another opioid analgesic (See Appendix A for conversions separate attachment) Rationale The purpose of quality measurement is to improve quality, inform consumers, reduce risk to patients and influence payment. At this time, the goal is to develop measure concepts that are indicative of potential improvements in or to our healthcare system so that evidence-based patient care can be provided and patient outcomes can be achieved, in consideration of costs and, ultimately, value. Towards this end, we propose 3 measures related to opioid use that are indicative of the quality of care for these medications. We propose these measures to examine the quality of use related to the dose of the medications over time, access to the medications and the combination of both of these criteria. Claims data from commercially insured patients indicate that approximately 8% of opioid prescriptions for acute pain and 12% for chronic pain specify a daily dosage of 120 MED or more. 1 The proportion of patients being treated at this dosage for more than 90 days has not been described. However, one study of veterans treated with 180 MED/day or more for 90+ days 2 found that this group was characterized by high rates of psychiatric and substance abuse disorders and frequently did not receive care consistent with clinical guidelines. Other studies

22 APPENDIX D have suggested the people at high opioid dosage are at greater risk of overdoses and fractures. 3,4,5 The Washington State Agency Medical Directors Group has suggested 120 MED as a dosage level that should not be exceeded without special consideration. 6 Prescription drug monitoring programs, which track the use of multiple providers by patients, indicate that such use is typically found among a small proportion of patients, with the proportion declining as the number of providers increases. In Massachusetts in 2006, considering only Schedule II opioids, 0.5% of patients saw 4+ prescribers and 4+ pharmacies. 7 A national study found that 13% of patients had overlapping prescriptions from two or more different prescribers during an 18-month period. Of these, 0.5% used 4+ prescribers and 4+ pharmacies. 8 People who see multiple prescribers or use multiple pharmacies are more likely to die of drug overdoses. 4 Data from the California PDMP indicates that people with higher daily dosages are more likely to see multiple prescribers or go to multiple pharmacies. 9 The data above suggest that prevention of opioid overdose deaths should focus on strategies that target (1) highdose opioid users as well as (2) persons who seek care from multiple doctors and pharmacies. The data suggest that these criteria can be considered separately, as measures related to prescribed opioids for legitimate uses versus diverted uses. Thus, we propose 3 measures: one for each criteria and one that is the intersection of both criteria. This approach will also assist health plans in managing the number of patients who meet the measure criteria and planning their respective interventions, so that a balance of identification and intervention can be determined. Eligible Population Ages: 19 years and older as of the last day of the measurement period. Continuous enrollment using enrollment data Allowable Gap for Medicaid Measurement Period Benefit Stratification Subjects should be continuously enrolled during the measurement period. In cases where Medicaid enrollment is verified monthly, the enrollee is considered continuously enrolled if there is no more than a 1-month gap in coverage (i.e., an enrollee whose coverage lapses for 2 months [60 consecutive days] is not considered continuously enrolled). The patient s measurement period begins on the date of the first fill of the target medication (i.e., index date) and extends through the last day of the measurement year or until death or disenrollment. Pharmacy. Commercial, Medicaid, Medicare (report each product line separately). Low income subsidy (LIS) population (report rates for LIS population and non-lis population separately.) Administrative Specification Intended Use: Health Plans Data Source: Medical claims, Pharmacy claims, Prescription Drug Hierarchical Condition Categories (RxHCCs) Measure 1 Denominator: Any member with two or more prescription claims for opioids filled on at least two separate days, for which the sum of the days supply is > 15. Numerator: Any member in the denominator with greater than 120mg MED for > 90 consecutive days * Rate: The rate is to be reported as a proportion: XX out of 1,000 enrollees.

23 APPENDIX D Measure 2 Denominator: Any member with two or more prescription claims for opioids filled on at least two separate days, for which the sum of the days supply is > 15. Numerator: Any member in the denominator who received opioids from 4 or more prescribers AND 4 or more pharmacies. Rate: The rate is to be reported as a proportion: XX out of 1,000 enrollees. Measure 3 (intersection of 1 & 2) Denominator: Any member with two or more prescription claims for opioids filled on at least two separate days, for which the sum of the days supply is > 15. Numerator: Any member in the denominator with greater than 120mg MED for > 90 consecutive days * AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies. Rate: The rate is to be reported as a proportion: XX out of 1,000 enrollees. *Identifying members with prescription opioids that exceeded the MED threshold: To identify members with prescription opioids that exceeded the MED threshold, each claim is to be converted into the MED using the appropriate conversion factor associated with the opioid product of that prescription claim (see Appendix A). The MED for each day s claims then are summed to determine the total MED for that day. For each member in the denominator: 1. Calculate the MED for each opioid prescription claim during the measurement period, using the following equations: # of Opioid Dosage Units per day = (Opioid claim quantity) / (Opioid claim days supply) MED Daily Dose per claim = (# of opioid dosage units per day) X (# mg opioid per dosage unit) X (MED conversion factor) 2. Sum the daily MEDs of all opioid claims for each day to arrive at a total daily MED for each member. 3. Identify the days where the MED threshold is exceeded. 4. Any member, for whom the MED threshold is exceeded for 90 consecutive days or longer, meets the criteria for the MED component of the numerator. Exclusions: Denominator exclusion: Any member with Prescription Drug Hierarchical Condition Categories (RxHCCs) 8, 9, 10, 11 for Payment Year 2015; or RxHCCs 15, 16, 17, 18, 19 for Payment Year 2016; or a hospice indicator from the enrollment database. (See Appendix B for RxHCC lists and associated diagnoses.) Payment Year 2015 RxHCC 8 Chronic Myeloid Leukemia RxHCC 9 Multiple Myeloma and Other Neoplastic Disorders RxHCC 10 Breast, Lung, and Other Cancers and Tumors RxHCC 11 Prostate and Other Cancers and Tumors Payment Year 2016 RxHCC 15 Chronic Myeloid Leukemia RxHCC 16 Multiple Myeloma and Other Neoplastic Disorders RxHCC 17 Secondary Cancers of Bone, Lung, Brain and Other Specified Sites; Liver Cancer RxHCC 18 Lung, Kidney, and Other Cancers RxHCC 19 Breast and Other Cancers and Tumors

24 APPENDIX D Table Opioid-A: Opioid Medications ** Opioid Medications buprenorphine hydrocodone morphine oxymorphone butorphanol hydromorphone opium pentazocine codeine levorphanol oxycodone tapentadol dihydrocodeine meperidine tramadol fentanyl methadone ** Note: Injectables and Opioid cough and cold products and combination products containing buprenorphine and naloxone (e.g., BunavailTM, Suboxone, Zubsolv ) are excluded from the MED calculations. Ionsys (fentanyl transdermal patch) is also excluded as it is only for inpatient use; It is also only available through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS)