AMCP Webinar Series Exchanges and Qualified Health Plans: How your voice can shape the future of quality reporting 14 January 2014 Speaker Mitzi Wasik, Pharm.D., BCPS Director, Pharmacy Medicare Programs (Corp), Coventry Health Care 1
How to Ask A Question Raise your hand to ask verbally Or, type your question in the Questions area Webinar Agenda Background National Quality Strategy, Triple Aim Opportunity to Provide Comment to CMS Solicit Your Overall Comments on Measure Selection Proposed measures: Are these priority measures for Managed Care Technical guidance on specific measures Priority areas for additional measures Measures to retire We will review each measure in detail Solicit your comments on Organization And Hierarchical Structure of Measures Solicit your comments on Data Structure Solicit your comments on Rating Methodology (note CMS will not provide technical guidance until a later date) Time Permitting, solicit comments on individual measures Separate webinar to comment on Measure Applications Partnership (MAP) Pre- Rulemaking Report? 2
Background Affordable Care and Patient Protection Act (ACA) seeks to increase access to high-quality, affordable health care ACA tasked the Secretary of the Department of Health and Human Services (HHS) to establish a National Strategy for Quality Improvement in Health Care known as the National Quality Strategy (NQS). NQS sets priorities to help guide the effort for quality improvement, which also has a strategic plan on how to achieve this improvement Background Through a collaborative process, the Secretary of HHS developed an initial NQS strategy that involved what is commonly known as the Triple Aim which help guide efforts to improve the quality of health care. Better Care Healthy People/Healthy Communities Affordable Costs NQS also adopted a set of 10 priorities along with the Triple Aim to help further improve quality 3
Opportunity to Provide Information November 2013 (CMS-3288-NC) CMS announced a request for comments on: List of proposed QRS quality measures that QHP issuers would be required to collect and report Hierarchical structure of the measure sets Elements of the QRS rating methodology How to ensure the integrity of QRS ratings Priority areas for future QRS measure enhancement and development Measures Selection Overall Measure Selection Process for selecting and evaluating the measure sets of the QRS included a review of existing health plan measures to ensure consistency across State, Federal, and private-sector entities Measure selection and measure set evaluation criteria were developed using the National Quality Forum (NQF) Measure Evaluation Criteria and the Measures Application Partnership (MAP) Measure-Selection Criteria Solicit Comments proposed measures in the QRS and Child-only QRS measures sets 42 total measures (29 clinical / 13 CAHPS) for family/adult-only coverage 76% of measures are presently NQF-endorsed 83% of measures are included in at least one of the reviewed Federally-established measure sets (e.g. OPM FEHB) 25 total measures (15 clinical / 10 CAHPS) for child-only coverage 84% NQF endorsed 4
QRS Proposed Measure Sets Do these represent managed care pharmacy Are there enough or are there too many? Pharmacy Related QRS Measure Sets Measure Title Annual monitoring for patients on persistent medications NQF ID Antidepressant Medication Management 0105 Appropriate treatment for children with upper respiratory infection (Child-only QRS) Not endorsed 0069 Avoidance of antibiotic treatment in adults with acute bronchitis 0058 CAHPS Aspirin use and discussion CAHPS Flu Shots for Adults 0039 Childhood Immunization Status 0038 Cholesterol management for patients with cardiovascular conditions: LDL-C Control (<100mg/dL) Controlling high blood pressure 0018 Diabetes Care: HbA1c control <8.0% 0575 Not endorsed Not endorsed 5
Pharmacy Related QRS Measure Sets Cont d Measure Title NQF ID Follow-Up care for children prescribed ADHD Medication: Initiation Phase Follow-Up care for children prescribed ADHD Medication: Continuation and Maintenance Phase (Child-only QRS) 0108 0108 HPV Vaccination for Female Adolescents (Child-only QRS) 1959 Immunizations for adolescents 1407 Medication Management for people with asthma 1799 Medication Management for people with asthma (Ages 5-18) (Childonly QRS) 1799 Plan All-Cause Readmissions 1768 Relative resource use for people with cardiovascular conditions inpatient facility index 1558 Relative resource use for people with Diabetes inpatient facility index 1557 Comments on Organization And Hierarchical Structure of Measures For consumer usefulness trying to organize rating systems to present a large collection of measures Want to organize measures to ensure QRS information is approachable and understandable to easily compare and select a QHP in the Exchange See graphic example next slide Baseline Structure: Individual measure Composite Domain Summary Indicator Summary Indicators will then be grouped into a single Global Rating a score that will summarize all measures, composites and domains Thoughts on organization and hierarchical structure? 6
Organization and Hierarchical Structure of Measures Global Rating Overall Score Summary Indicators (3) Clinical Quality Management Member Experience Domains (8) Plan efficiency, affordability and management Clinical Effectiveness Patient Safety Care Coordination Prevention Access Doctor and Care Efficiency and Affordability Plan Services Composites (12) not all measures have a composite Measures (42 Adult/family; 25 Child-only) Comments on QRS Data Strategy QRS Data Strategy how data are collected, calculated, and submitted which will help inform how data is displayed CMS plans to use a full-scale rule at the Global Rating and Summary Indicator levels to ensure accurate representations CMS intends to display Global Ratings using a five-star scale Acknowledge some QHPs in Exchanges may have missing data due to data quality issues or low enrollment in initial years Specifically, If QHP is missing any of the domain ratings used for creating the Summary Indicators, that Summary Indicator would not be displayed The Clinical Quality Management Summary Indicator must have the Care Coordination, Clinical Effectiveness, and Prevention domains to have the Summary Indicator rating displayed Only display a Global Rating when all three Summary Indicator ratings are available For lower levels of the hierarchy, half of the components of the domain or composite must be present for the rating to be displayed (half-scale rule). Solicit Comments Potential ways to enhance the QRS data strategy for QHP issuers Comment on the full-scale and half-scale rules described as well as any additional ways to address data quality issues or potential low enrollment in QHPs in the initial years 7
Comments on Rating Methodology Rating methodology combines health plan scores into performance ratings via rules and formulas CMS will provide at a later date technical guidance that identifies further details regarding this Rating Methodology component, elements, and measures specifications. 6 elements are grouped within three broad categories 1. Measure Scoring Rules. Standardize individual measure scores to be on the same scale Sampling and Attribution Scoring 2. Aggregation Rules. Combine measures quality constructs e.g. diabetes care or preventative health Aggregation Rules 3. Reference Standards. Will determine how scores are converted to categorical ratings (e.g. star groups on a scale of one to five) that can be easily understood Performance Classification Values Population and other adjustments Peer Groups Comments on Individual Proposed Measures Solicit Comments For each proposed measure Proposed measures: Are these priority measures for Managed Care Is this high or low on your pharmacy measure priority list Technical guidance on specific measures Should measure be retired 8
Annual monitoring for patients on persistent medications Not currently endorsed However, AHRQ does have documentation for this quality measure that states: Percentage of members 18 years of age and older who received at least 180 treatment days of anticonvulsants during the measurement year and had at least one drug serum concentration level monitoring test for the prescribed drug in the measurement year http://www.qualitymeasures.ahrq.gov/summary_redirect.aspx?type=r eplaced&objectid=34680 Antidepressant Medication Management NQF ID 0105 The percentage of patients 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant http://www.qualityforum.org/qps/measuredetails.aspx?standardid=8 55&print=1&entityTypeID=1 9
Appropriate treatment for children with upper respiratory infection NQF ID 0069 Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode http://www.qualityforum.org/qps/measuredetails.aspx?standardid=3 69&print=1&entityTypeID=1 Avoidance of antibiotic treatment in adults with acute bronchitis NQF ID 0058 percentage of adults 18 to 64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription assesses whether antibiotics were inappropriately prescribed for healthy adults 18 to 64 years of age with bronchitis - builds on an existing HEDIS measure http://www.qualityforum.org/qps/measuredetails.aspx?standardid=1 216&print=1&entityTypeID=1 10
CAHPS Aspirin use and discussion Not currently endorsed However, AHRQ does have documentation for this quality measure that states: Percentage of women 56 through 79 years of age and men 46 through 79 years of age who discussed the risks and benefits of using aspirin with a doctor or other health provider http://www.qualitymeasures.ahrq.gov/content.aspx?id=39370 Specifically add or pharmacist? CAHPS Flu Shots for Adults NQF ID 0039 Percentage of adults aged 50 and over who received an influenza vaccine within the measurement period within the respective agestratified CAHPS surveys. http://www.qualityforum.org/qps/measuredetails.aspx?standardid=3 96&print=1&entityTypeID=1 11
Childhood immunization status NQF ID 0038 Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP); three polio (IPV); one measles, mumps and rubella (MMR); three H influenza type B(HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates. http://www.qualityforum.org/qps/measuredetails.aspx?standardid=3 95&print=1&entityTypeID=1 Cholesterol management for patients with cardiovascular conditions: LDL-C Control (<100mg/dL) Not currently endorsed However, AHRQ does have documentation for this quality measure that states: Cholesterol management for patients with cardiovascular conditions: percentage of members 18 to 75 years of age who were discharged alive for AMI, coronary artery bypass graft (CABG), or percutaneous coronary interventions (PCI) from January 1 to November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year, who had a LDL-C screening and LDL-C control (less than 100 mg/dl) http://www.qualitymeasures.ahrq.gov/content.aspx?id=38868&search =Percutaneous+Coronary+Intervention+ 12
Controlling high blood pressure NQF ID 0018 The percentage of members 18 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year. http://www.qualityforum.org/qps/measuredetails.aspx?standardid=1 236&print=1&entityTypeID=1 Diabetes Care: HbA1c control <8.0% NQF ID 0575 Percentage of patients 18-75 years of age with diabetes (type 1 or 2) who had HbA1c <8.0% http://www.qualityforum.org/qps/measuredetails.aspx?standardid=9 44&print=1&entityTypeID=1 13
Follow-Up care for children prescribed ADHD medication: Initiation Phase & Continuation and Maintenance Phase NQF ID 0108 Percentage of children 6-12 years of age and newly dispensed a medication for ADHS who had appropriate follow-up care. Two rates are reported: Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-day initiation phase Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. http://www.qualityforum.org/qps/measuredetails.aspx?standardid=8 57&print=1&entityTypeID=1 HPV Vaccination for female adolescents NQF ID 1959 Percentage of female adolescents 13 years of age who had three doses of the human papillomavirus (HPV) vaccine by their 13th birthday http://www.qualityforum.org/qps/measuredetails.aspx?standardid=1 959&print=1&entityTypeID=1 14
Immunizations for Adolescents NQF ID 1407 The percentage of adolescents who turned 13 years of age in the measurement year who had recommended immunizations by their 13th birthday http://www.qualityforum.org/qps/measuredetails.aspx?standardid=1 407&print=1&entityTypeID=1 Medication management for people with asthma / (Ages 5-18) NQF ID 1799 The percentage of members 5-64 (or 5-18 for Child-only QRS) years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported: The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period. The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period. http://www.qualityforum.org/qps/measuredetails.aspx?standardid=1 799&print=1&entityTypeID=1 15
Plan All-Cause Readmissions NQF ID 1768 For members 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories: Count of Index Hospital Stays (IHS) (denominator) Count of 30-Day Readmissions (numerator) Average Adjusted Probability of Readmission Observed Readmission (Numerator/Denominator) Total Variance http://www.qualityforum.org/qps/measuredetails.aspx?standardid=1 768&print=1&entityTypeID=1 Relative resource use for people with cardiovascular conditions inpatient facility index NQF ID 1558 The risk-adjusted relative resource use by health plan members with significant cardiovascular conditions/events (AMI, CABG, PCI, ischemic vascular disease) during the measurement year Despite inpatient designation Pharmacy is listed under ambulatory service resources http://www.qualityforum.org/qps/measuredetails.aspx?standardid=1 558&print=1&entityTypeID=1 16
Relative resource use for people with diabetes inpatient facility index NQF ID 1557 The risk-adjusted relative resource use by health plan members 18-75 years of age who were identified as having diabetes (type 1 and type 2) during the measurement year. Despite inpatient designation Pharmacy is listed under ambulatory service resources http://www.qualityforum.org/qps/measuredetails.aspx?standardid=1 557&print=1&entityTypeID=1 How to Contact CMS When commenting need to refer to file code CMS-3288-NC 4 ways to comment by January 24, 2014 by 5:00pm EST: Electronically - You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the "Submit a comment instructions. Regular Mail: Centers for Medicare & Medicaid Services Department of Health and Human Services, Attention: CMS-3288-NC P.O. Box 8010 Baltimore, MD 21244-8010 Express or overnight mail: Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-3288-NC Mail Stop C4-26-05 7500 Security Boulevard Baltimore, MD 21244-1850 Hand Delivery 17
Need for Additional Webinar? Separate webinar to comment on Measure Applications Partnership (MAP) Pre-Rulemaking Report? available for public comment through January 27, 2014 The 2014 MAP Pre-Rulemaking Report provides recommendations on measures under consideration by HHS for twenty clinician, hospital, and post-acute care/long-term care performance measurement programs Questions Email comments to AMCP: tsega@amcp.org 18
How to Ask A Question Raise your hand to ask verbally Or, type your question in the Questions area References Patient Protection and Affordable Care Act; Exchanges and qualified health plans, quality rating system (QRS), framework measures and methodology; Notice with comment, 78 Federal Register 223 (19 November 2013), pp. 69418-69426. H.R. 3590--111th Congress: Patient Protection and Affordable Care Act. www.govtrack.us. 2009. January 7, 2014 http://www.govtrack.us/congress/bills/111/hr3590 http://www.ahrq.gov/workingforquality/nqs/principles.htm http://www.cms.gov/medicare/health-plans/healthplansgeninfo/downloads/2013-call-letter.pdf 19