A c c o u n t a b l e C a r e P r o g r a m s Tom Valuck, MD, JD - - PowerPoint PPT Presentation

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A c c o u n t a b l e C a r e P r o g r a m s Tom Valuck, MD, JD - - PowerPoint PPT Presentation

Jan 06, 2024 329 likes •640 views

D I S C E R N Q u a l i t y M e a s u r e G a p s i n To d a y s A c c o u n t a b l e C a r e P r o g r a m s Tom Valuck, MD, JD Dis Discern Hea Health th October 30, 2014 1120 11 20 North orth Char Charles Str Street

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D I S C E R N

Dis Discern Hea Health th 11 1120 20 North

  • rth Char

Charles Str Street Suit Suite 20 200 Balti Baltimore, , MD MD 21 21201 201 (41 (410) 54 542-4470 www.d .dis iscernhealth th.c .com

Q u a l i t y M e a s u r e G a p s i n To d a y ’ s A c c o u n t a b l e C a r e P r o g r a m s

Tom Valuck, MD, JD October 30, 2014

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D I S C E R N

Accountable Care Measures for High-Cost Specialty Care and Innovative Treatment You Get What You Pay For: Improving Measures for Accountable Care

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D I S C E R N

Highlights

Gaps in accountable care measure sets cannot be completely addressed with more of the same measure types and measurement strategies currently in use We recommend enhancements that include increased use of outcome, cross-cutting, and patient-reported measures, and new measurement approaches including layered and modular models

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D I S C E R N

Background

Quality measurement, tied to financial incentives, is one of many approaches accountable care programs are using to promote system-wide improvement Accountable care incentives are geared toward controlling cost Focus of measure sets is typically limited to the clinical conditions of a few at-risk populations Measurement influences priorities and care delivery to the potential detriment of patients with conditions outside the scope of measure sets Measure sets need breadth, depth, and new approaches to promote appropriate care across the relevant population

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D I S C E R N

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D I S C E R N

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Saves 417 Hearts, 72 Legs & 745 Pairs of Eyes Each Year

17.8 17.5 10.1 10.1 10.0 8.8 6.5 7.4 7.6 6.3 5.8 5.9 5.1 4.8 4.9 4.6 4.0 4.3 3.3 3.9 3.6 3.3 2.6 2.6 2.6 2.6 68.0 57.4 59.8 56.1 54.5 56.4 53.1 46.9 47.9 48.2 41.0 43.3 41.8 7.8% 12.5% 13.1% 18.4% 10.8% 12.8% 12.7% 17.5% 16.9% 30.5% 39.0% 41.8% 41.9%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Optimal Diabetes % Events/1000 AMI/1000 AMPUTATIONS/ 1000 NEW RETINOPATHY CASES/1000 OPTIMAL DIABETES RATE

HealthPartners’ 32,747 members with diabetes in 2012 suffered 417 fewer heart attacks, 72 fewer leg amputations and 745 people did not experience eye complications compared to what would have happened to the same 32,747 plus members in 2000.

Optimal Diabetes Care

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D I S C E R N

Project Purpose

Examine gaps in accountable care measure sets and available measures for certain conditions Priority focus was gaps for high-priority conditions; that is, conditions that are prevalent and costly Understand the implications of the measure gaps to inform recommendations for improving accountable care measurement

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D I S C E R N

Project Limitations and Clarifications

Quality measurement is one of many tools to promote improvement Lack of measurement does not imply providers will not deliver high quality care Focus is accountable care generally, not only ACOs “Inappropriate care” includes both overuse and underuse of services Project scope includes policy-level solutions and recommendations, but not specific measures for specific conditions or topics Project solutions and recommendations are not meant to suggest that all processes of care for every condition should be measured

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D I S C E R N

Condition Selection

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Primary criteria Prevalence Cost Overall Specialty pharmaceutical Imaging Surgical procedures Hospitalization Secondary criteria Mix of acute and chronic Applicability to all populations No duplication

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D I S C E R N

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Selected Conditions

Asthma ADHD Breast Cancer Chronic Back Pain Chronic Kidney Disease COPD Diabetes Glaucoma Hepatitis C HIV Hypertension Influenza Ischemic Heart Disease Major Depression Multiple Sclerosis Osteoarthritis Osteoporosis Prostate Cancer Rheumatoid Arthritis Stroke

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D I S C E R N

Logic Model

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D I S C E R N

MSSP Direct and Indirect Measures for Selected Conditions

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2 4 6 8 10 12 14 16 18 20 Indirect Direct

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D I S C E R N

NCQA Direct and Indirect Measures for Selected Conditions

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2 4 6 8 10 12 14 16 18 20 Indirect Direct

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D I S C E R N

Direct Available Measures to Fill Gaps, Including Outcome Measures

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5 10 15 20 25 30 35 Process Outcome

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D I S C E R N

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Measure Gaps Ranked by Cost

Tier 1 (Low Cost)

Patient education Screening/immunizations Simple labwork Appt scheduling/follow-up OTC medications Simple imaging

Tier 2 (Medium Cost)

Traditional medications Complex imaging Advanced lab testing Invasive diagnostics Specialist/other referrals

Tier 3 (High Cost)

Surgical procedures Specialty medications Long-term chronic medications Hospitalization

Cost Categories

Tier 1 Tier 2 Tier 3

n = 55 n = 93 n = 116

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D I S C E R N

CAHPS measure set BMI assessment Tobacco cessation Flu and Pneumovax Inpatient admission rates Hospital readmissions Medication reconciliation Hospital readmissions Medication reconciliation

Cross-Cutting Measures and Gaps

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Patient Experience Prevention / Healthy Behaviors Care Coordination Patient Safety Clinical Effectiveness

Shared decision making Patient activation Patient-reported outcomes Nutrition / exercise Genetic testing Environmental risk assessment Specialist referral rates Non-physician referral rates (behavioral and PT/OT therapy) High-risk behavior education Disease transmission education Confirmatory diagnoses Medication adherence Treatment escalation

Use of Available Measures Measure Gaps

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D I S C E R N

Roundtable-Identified Priority Measure Gaps

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  • Mortality, complications, functional status, readmissions

Outcome Measures

  • Medication adherence, avoidance of polypharmacy, patient safety, care coordination

Cross-Cutting Measures

  • Shared decision making, shared care plan documentation/adherence, experience of care, patient-reported outcomes

Measures of Patient Centeredness

  • Overuse measures (low back pain, antibiotic use)

Appropriateness Measures

  • Total cost of care, episode of care, out-of-pocket costs

Cost of Care Measures

  • e.g., Optimal Diabetes Care

Composite Measures

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D I S C E R N

Recommendations

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  • 1. Identify and Prioritize Measure Gaps
  • 2. Use Alternative Measurement

Approaches

  • 3. Use the Most Meaningful Measure

Types

  • 4. Address Barriers to Measurement
  • 5. Assess Opportunities to Continuously

Improve

Most prevalent and costly conditions, unmeasured aspects of care, use of early indicators. Use of alternative models: layering and modular approaches Maximization of preferred measure types:

  • utcomes, cross-cutting, patient-reported

New or optimized data sources, logistical, analytical, systemic challenges Feedback, input from patients, measure set review process

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D I S C E R N

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Types 1 and 2 Diabetes

Rheumatoid Arthritis Multiple Sclerosis

HbA1c Control Gap

Accountable Care Measure Set

Cross Cutting Measures Gap Gap Gap DMARD Use

Existing Quality Measures

Hypo- glycemic Events Measure Gap

Select Available Measures to Fill Gaps

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D I S C E R N

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Types 1 and 2 Diabetes

Rheumatoid Arthritis Multiple Sclerosis

HbA1c Control Gap

Accountable Care Measure Set

Cross Cutting Measures Gap Gap Gap DMARD Use

Existing Quality Measures

Hypo- glycemic Events Measure Gap

Developed Quality Measures

Functional Status Change

Develop Measures to Fill Gaps

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D I S C E R N

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Types 1 and 2 Diabetes

Rheumatoid Arthritis Multiple Sclerosis

HbA1c Control Gap

Accountable Care Measure Set

DMARD Use Access to Specialists Timely Care

Condition- Specific Measures

Cross Cutting Gap Cross-Cutting Measure Gap

Use Cross-Cutting Measures

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D I S C E R N

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Types 1 and 2 Diabetes

Rheumatoid Arthritis Multiple Sclerosis

HbA1c Control Gap

Accountable Care Measure Set

DMARD Use Access to Specialists Timely Care

Condition- Specific Measures

Cross Cutting Gap Cross-Cutting Measure Gap Medication Adherence

Existing or Developed Cross-Cutting Measure

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D I S C E R N

Alternative Measurement Models: Layered Approach

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D I S C E R N

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Diabetes Care

Comp- rehensive Diabetes Care

Hypo- Glycemic Events

System Level

Depression Remission

External Accountability Measure Set Internal Management Measures

Population Level Provider Level

Internal Improvement Measures

Composite Measure

Blood Pressure Test HbA1c Test Tobacco Assess- ment Lipid Panel Depression Screening

Appropriate Use of Anti- Depressants

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D I S C E R N

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Rheumatoid Arthritis Care

Appropriate DMARD Use

System Level

Sed Rate & C-Reactive Protein Tests Serum Creatinine Test Pain Screening

Pain Assessment

Functional Status Change

External Accountability Measure Set Internal Management Measures

Population Level Provider Level

Internal Improvement Measures

Pain Control

Liver Function Test

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D I S C E R N

Alternative Measurement Models: Modular Approach

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D I S C E R N

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Measure Measure Measure Measure Measure Measure Measure Measure Cross Cutting Measure Cross Cutting Measure Cross Cutting Measure General Population ACO Measure Set Condition- Specific Subpopulation Modules

Module 1

Measure

Modular Measurement Approach

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SLIDE 28

D I S C E R N

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HbA1c <8.0% LDL <100 mg/dL BP <140/90 Fall Screening Cancer Screening

Hypogly- cemic Events Depression Remission Amputation Rate Functional Status Change Pain Control Appropriate DMARD Use

Rate of Flare-Ups Approp- riate Pharma Use Functional Status Change Hospital Re- admissions Access to Specialists Medication Adherence

Module 1 (Ex. Diabetes Care) Module 2 (Ex. Rheumatoid Arthritis Care) Module 3 (Ex. Multiple Sclerosis Care)

General Population ACO Measure Set Condition- Specific Subpopulation Modules

AMI Rate Avoidance

  • f RA Prog-

ression

Therapy Referrals

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D I S C E R N

Conclusions

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Gaps exist in current accountable care measure sets These gaps should be addressed through better measures and new approaches to measurement Preferred types of measures to fill gaps include

  • utcome, cross-cutting, and patient reported

measures Strategic approaches to measurement do not necessarily require more measures

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D I S C E R N

Thank you!

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Tom Valuck, MD, JD

tvaluck@discernhealth.com 410-542-4470, ext. 102