You are on page 1of 8

TECHNICAL ASSISTANCE

TOOL | September 2014

Quality Measurement Approaches of State Medicaid


Accountable Care Organization Programs

tatesinterestedinusinganaccountablecareorganization(ACO)
modelmustthinkcriticallyaboutwhichmetricsarebestsuited
Qualitymeasurementisanintegralcomponent
toencourageenhancedaccessandcarecoordinationandpromote
oftheaccountablecareorganization(ACO)
provideraccountabilityfortheseoutcomes.Thereisconsiderable
model,usedbystatestopromotebetteraccess
andoutcomesforbroadpopulationsof
varietyinstateMedicaidACOmeasurementapproaches,relatedto
Medicaidbeneficiaries.Thisresourcepresents
eachstatesaccess,quality,clinical,andcostgoals.Common
thequalitymeasures,andrelatedreportingand
measurementareasinclude:(1)chroniccondition(e.g.,asthma,
paymentapproaches,ofACOprogramsinsix
diabetes)processesandoutcomes;(2)emergencydepartmentuse;
states:Colorado,Maine,Minnesota,New
(3)inpatientadmissionandreadmission;(4)wellchildvisits;(5)
Jersey,Oregon,andVermont.
patientexperience;and(6)behavioralhealth.Tosupportcollection,
statesoftenemploymeasuresthatalignwiththosecollectedfor
otherprogramspursuingsimilargoals,suchasbehavioralhealthintegrationandhealthhomes.States
typicallyseektomirrorthescopeandreportingrequirementsofMeaningfulUse,CHIPRA,aAdultCore,
andMedicareACOmeasuresetsandalsousemeasuresdevelopedand/orendorsedbynational
performancemeasurementauthorities(e.g.,NationalCommitteeforQualityAssurance,National
QualityForum,AgencyforHealthcareResearchandQuality).
QualitymeasurerequirementsforACOscanrangefromsimplecollectionandreportingtoadvanced
expectationsinvolvingachievementthresholds,benchmarkcomparisons,and/orratesof
improvementovertime.Methodologiestocalculateperformancebasedpaymentscanrangesimilarly
incomplexity.ParticipationofACOsinqualitymeasurementisoftenfacilitatedbytheinitialinclusion
ofclaimsbasedmeasuresandthephasinginofmoredemandingelements,suchasthecollectionof
nonclaimsbased(e.g.,clinical)measuresorrigorousperformancetargetstiedtohigherfinancial
reward.
StatesdevelopingACOqualitymeasurementstrategiescanborrowfromtheapproachesofsixstates
intheCenterforHealthCareStrategies(CHCS)MedicaidACOLearningCollaborative:Colorado,
Maine,Minnesota,NewJersey,Oregon,andVermont.WithsupportfromTheCommonwealthFund,
CHCShasbeenworkingwiththesestatestoaccelerateMedicaidACOplanningandimplementation.
ThechartonthefollowingpagespresentsthequalitymeasuresofeachstatesMedicaidACOprogram
andkeydetails,includingmeasuredomains,reportingrequirements,andcontingenciesrelatedto
payment.
Thisresourcedrawsfromstatespecificdocuments,suchasMedicaidACOsolicitations(e.g.,requests
forinformation/proposals/applications),stateplanamendments,andwaivers,aswellasresearch
conductedbyRachelBonheimoftheWoodrowWilsonSchool,PrincetonUniversity.

ChildrensHealthInsuranceProgramReauthorizationAct.

MadepossiblethroughsupportfromTheCommonwealthFund.

2TechnicalAssistanceTool|QualityMeasurementApproachesofMedicaidAccountableCareOrganizations

Colorado Accountable Care Collaborative


RegionalCareCoordinationOrganizations(RCCOs),theleadorganizationsinColoradosAccountableCareCollaborative(ACC)program,arerequiredtocollectandreportfourqualitymeasures,allofwhich
aretiedtopayment.QuarterlyincentivepaymentsaremadewhentheRCCOmeetsorexceedsthestatesqualitytarget,calculatedbasedonregionwideperformanceonthesamemeasures.

COLORADO
MeasureDomain

CoreMeasures(TiedtoPayment)

All

Emergencydepartment(ED)visitsper1,000fulltimeenrollees(FTEs)
Hospitalreadmissionsper1,000FTEs
Outpatientserviceutilizations/MRI,CTscans,andtestsper1,000FTEs
Wellchildvisitsper1,000FTEs

Maine Accountable Communities


AccountableCommunities(AC)inMainearerequiredtoreport16corequalitymeasuresandfiveelectivemeasures.Allcoremeasuresandthreeelectivemeasures(pertheACschoosing)arelinkedto
payment.Therearefiveadditionalmeasuresformonitoringandevaluation,whicharerequiredtobereportedbutnotlinkedtopayment.Toqualifyforsharedsavings,anACmustscorearateof30percent
foratleast70percentofmeasuresineachdomain(excludingpatient/caregiverexperience).TheportionofthesavingsanACwillreceiveisdeterminedbyitsperformancecomparedtostateornational
Medicaidbenchmarksonselectmeasures.

MAINE
MeasureDomain

CoreMeasures(TiedtoPayment)

CareCoordination/
PatientSafety

NonemergentEDuse
Pediatricqualitycomposite(PDI#92)
EHRprogramincentivepaymentprogram
Planallcausereadmission
Preventionqualitychroniccompositeforadults(PQI#92)

ChronicCare/
AtRiskPopulations

Asthma
Medicationmanagementadults
BehavioralHealth
Followupafterhospitalizationformentalillness
Initiationandengagementofalcoholandotherdrugdependence
treatment
Diabetes
Glucosecontrol(HbA1ccontrol)adults
Eyecare

Patient/Caregiver
Experience

ClinicianandgroupCAHPS

PreventiveHealth

Adolescent(1221years)wellcarevisits
Developmentalscreeningfirstthreeyearsoflife
Wellchildvisits(015months)
Wellchildvisits(36years)
Wellchildvisits(711years)

Advancingaccess,quality,andcosteffectivenessinpubliclyfinancedcare|www.chcs.org

ElectiveMeasures

Monitoring/Evaluation

Cardiovascularhealthscreeningfor
peoplewithschizophreniaorbipolar
disorderwhoareprescribed
antipsychoticmedications
Imagingforlowerbackpain

Useofhighriskmedicationintheelderly

COPD
Useofspirometrytestinginthe
assessmentanddiagnosisofCOPD
Diabetes
HbA1cTestingadults
Nephropathy

BehavioralHealth
Outofhomeplacementforchildrenand
adults
Diabetes
Glucosecontrol(HbA1ccontrol)
children
HbA1ctestingchildren

Breastcancerscreening

3TechnicalAssistanceTool|QualityMeasurementApproachesofMedicaidAccountableCareOrganizations

Minnesota Integrated Health Partnerships


MinnesotasIntegratedHealthPartnerships(IHP)arerequiredtoreport36measures.Thesemeasuresscoreas10compositemeasures,comprisedofeightclinicalmeasuresandtwopatientexperience
measures.Compositescomprisebundlesofmeasurestoindicatemoreclinicallymeaningfuloutcomesfordomainssuchasdiabetes,asthma,orvascularcare.Theclinicalandpatientexperiencemeasures
includebothclinicandhospitallevelmetrics.
EachIHPsportionofsharedsavingsistiedtoitsperformanceonthe10coremeasures.Theclinicalmeasuresareassigned75percentofqualityperformanceweightandthepatientexperiencemeasures
areassigned25percent.DistributionofsharedsavingsisscaledoverthecourseofanIHPsinvolvementintheprogram:

Firstyear:IHPreceivesamaximumof25percentofsharedsavingsforreportingthecoremeasures.
Secondyear:IHPreceivesaportionofsharedsavingsrelativetoitsperformanceoncoremeasures.
Thirdyear:IHPcanreceiveuptoamaximumof50percentofsharedsavings,basedonperformanceonthecoremeasures.

Inthesecondandthirdperformanceyears,themeasuresareassessedforachievementandimprovement,respectively.Pointsareawardedonaslidingscalebasedonpredefinedthresholdsandrelative
improvementcomparedtobaseline.Theremainderofavailablesharedsavings(e.g.,beyond50percentinthirdyear)isnotcontingentonqualitymeasureperformance.

MINNESOTA
MeasureDomain

CoreMeasures(TiedtoPayment)

Clinical

Pneumonia:initialantibioticselection(hospital)
Asthma
Optimalasthmacarecomposite:child/adolescent
Optimalasthmacarecomposite:adult
Homemanagementplanforcareforasthma(hospital)
BehavioralHealth
Depressionremissionatsixmonths
Cardiovascular
Optimalvascularcarecomposite(LDLcontrol,bloodpressurecontrol,tobaccocessation,aspirinuse)
Heartfailure:leftventricularfailure(LVF)assessment(hospital)
Diabetes
Optimaldiabetescarecomposite(HbA1ccontrol,LDLcontrol,bloodpressurecontrol,tobaccocessation,aspirinuse)

PatientExperience

ClinicianandGroupCAHPS
HospitalCAHPS

Advancingaccess,quality,andcosteffectivenessinpubliclyfinancedcare|www.chcs.org

4TechnicalAssistanceTool|QualityMeasurementApproachesofMedicaidAccountableCareOrganizations

New Jersey Medicaid ACO Demonstration Project


NewJerseyrequiresACOstomeasureandreportacoresetof21qualitymeasuresacrosssixdomains:(1)AcuteCare;(2)BehavioralHealth;(3)ChronicConditions;(4)PatientExperience;(5)Prevention
andEffectivenessofCare;and(6)ResourceandUtilization.Someofthesemetricsareonlyrequiredtobecollectedinyear2ofthedemonstration.NewJerseyalsorequiresACOstoreportsixvoluntary
qualitymeasures.Whilethereportingofsixmeasuresismandatory,theACOsvoluntarilyselectthesemeasures,includingonemeasurefromalistof14Prevention/EffectivenessofCaremeasuresandfive
measuresfromalistof25chronicconditionsprovidedbythestate.Inadditiontothecoreandvoluntarymeasures,thestaterequiresACOstoreportsixdemonstrationqualitymeasures.EachACOs
performanceonthecoreandvoluntarymeasuresistiedtothestatescalculationofitsgainsharingpayment,whilethedemonstrationmeasuresarenottiedtopayment.

NEWJERSEY
MeasureDomain

CoreMeasures(TiedtoPayment)

VoluntaryMeasures(TiedtoPayment)

AcuteCare

RespiratorySyncytialVirusinneonates<35weeks

N/A

Initiationandengagementofalcoholandotherdrug
dependencetreatment
Antidepressantmedicationmanagement

N/A

Annualmonitoringforpatientsonpersistent
medications(year2)
AnnualHIV/AIDSmedicalvisit

CardiovascularDisease
Cholesterolmanagementforpatientswithcardiovascularconditions
Controllinghighbloodpressure
CompletelipidpanelandLDLcontrol
Useofaspirinoranotherantithrombic
Betablockertherapyforleftventricularsystolicdysfunction
DrugtherapyforloweringLDLcholesterol
ACEorARBtherapyforpatientswithCADorLVSD
Diabetes
HbA1ctesting
HbA1cpoorcontrol>9
HbA1ccontrol<8
LDLscreening
LDLcontrol<100
Neuropathymonitoring
Bloodpressurecontrol<140/80
Eyeexam
Respiratory
Useofappropriatemedicationsforpeoplewithasthma
Medicationmanagementforpeoplewithasthma
UseofspirometrytestinginassessmentanddiagnosisofCOPD
PharmacotherapyofCOPDexacerbation
Resource/Utilization
30dayreadmissionratefollowingacutemyocardialinfarction
30dayreadmissionratefollowingheartfailure
30dayreadmissionratefollowingpneumonia
COPDadmissionrate
CHFadmissionrate
Adultasthmaadmissionrate

BehavioralHealth

ChronicConditions

Advancingaccess,quality,andcosteffectivenessinpubliclyfinancedcare|www.chcs.org

Demonstration

Followupafter
hospitalizationformental
illness
Medicationreconciliation
(year2)
Mentalhealthutilization
Transportation
Referrals/connectionsto
socialsupports(housing,
food)
Identificationofalcoholand
otherdrugservices

5TechnicalAssistanceTool|QualityMeasurementApproachesofMedicaidAccountableCareOrganizations

NEWJERSEY

MeasureDomain

CoreMeasures(TiedtoPayment)

VoluntaryMeasures(TiedtoPayment)

PatientExperience

Gettingtimelycare,appointmentsand,information
Howwellyourdoctorcommunicates
Patientsratingofdoctor
Accesstospecialists
Healthpromotionandeducation
Shareddecisionmaking
Healthstatus/functionalstatus

N/A

Preventionand
EffectivenessofCare

Screeningforclinicaldepressionandfollowupplan
Annualdentalvisit

ResourceandUtilization

Emergencydepartmentvisits
Inpatientreadmissionwithin30days
Preventablehospitalizations
Providervisitwithin7daysofhospitaldischarge
ReturntoEDwithin7daysofhospitaldischarge

N/A

Advancingaccess,quality,andcosteffectivenessinpubliclyfinancedcare|www.chcs.org

Childhoodimmunizationstatus
Adolescentimmunization
Wellchildvisitsfirst15months
Wellchildvisits3,4,5,&6
Adolescentwellcare
Weightassessmentandcounselingforchildrenandadolescents
Frequencyofongoingprenatalcare
Medicalassistancewithsmokingandtobaccousecessation
Cervicalcancerscreening
Colorectalcancerscreening
Tobaccoscreeningandcessation
Breastcancerscreening
Chlamydiascreeninginwomen2124
Prenatalandpostpartumcare

Demonstration

6TechnicalAssistanceTool|QualityMeasurementApproachesofMedicaidAccountableCareOrganizations

Oregon Coordinated Care Organizations


Oregonhasdesignated33corequalitymeasuresforitsCoordinatedCareOrganizations(CCOs),17ofwhicharelinkedtoaCCOsqualitypoolpayment,and16ofwhichareusedforstatemonitoring.The
statehasestablishedfundsinaqualityincentivepool,whichcomprisetwopercentofaggregatedpaymentsfromallCCOs.AnindividualCCOmayreceiveamaximumpaymentoftwopercentofitsactual
payments,contingentonqualityperformance.Therearetwophasesbywhichthequalityincentivepoolfundsaredistributed.

Firstphase:EachCCOsportionofthemaximumqualitypoolpaymentisrelativetothenumberofmeasuresforwhichitdemonstratesanimprovementoveritsownbaselineorreachesa
benchmarkdefinedbythestate.For13ofthemeasures,performanceisratedonapass/failbasis.Forthreeclinicalmeasures(diabetesbloodsugarcontrol,hypertensioncontrol,anddepression
screeningmeasures),performanceisratedbasedonmeasurementandreportingactivities,notonperformance.ThePatientCenteredPrimaryCareHome(PCPCH)enrollmentmeasureisratedona
slidingscale.IfaCCOmeetsthetargetsonatleast75percentofmeasures(oneofwhichmustbeelectronichealthrecordadoption),andreachesamilestonescoreonPCPCHenrollment,itwill
receive100percentofqualitypoolfundsavailabletoit.
Secondphase:Ifthereareleftoverfundsinthequalityincentivepool,thesearedistributedtoCCOsthatmeetperformancebenchmarksonchallengemeasurementsthatfocusoncare
integrationandpatientoutcomes.ThesemetricsareHbA1cpoorcontrol,screeningforclinicaldepressionandfollowup,PCPCHenrollment,andalcoholorothersubstancemisuse.

OREGON
MeasureDomain

CoreMeasures(TiedtoPayment)

Monitoring

AtRiskPopulations

Children
FollowupcareforchildrenprescribedADHDmedication
Mentalandphysicalhealthassessmentwithin60daysforchildrenin
DHScustody
PregnantWomen
Timelinessofprenatalcare
Electivedelivery

Children
Appropriatetestingforchildrenwithpharyngitis
PregnantWomen
Postpartumcarerate

CareCoordination/PatientSafety

ChronicCare

BehavioralHealth
Alcoholorothersubstancemisuse
Followupafterhospitalizationformentalillness
Diabetes
HbA1cpoorcontrol
Hypertension
Controllinghighbloodpressure

Asthma
Adultasthmaadmissionrate
Cardiovascular
COPDadmission
Congestiveheartfailureadmissionrate
Diabetes
HbA1ctesting
LDLCscreening
Shorttermcomplicationadmissionrate

Patient/CaregiverExperience

CAHPSadultandchildcomposites

Childandadolescentaccesstoprimarycarepractitioners
ProvideraccessquestionsfromthePhysicianWorkforceSurvey

PreventiveHealth

Screeningforclinicaldepressionandfollowup
Colorectalcancerscreening
Developmentalscreeninginthefirst36monthsoflife
Adolescentwellcarevisits

Wellchildvisitsinthefirst15monthsoflife
Childhoodimmunizationstatus
Immunizationforadolescents
Medicalassistancewithsmokingandtobaccousecessation
Chlamydiascreeninginwomenages1624
Cervicalcancerscreening

OutpatientandEDutilization
PatientCenteredPrimaryCareHomeenrollment
EHRadoption

Advancingaccess,quality,andcosteffectivenessinpubliclyfinancedcare|www.chcs.org

Planallcausereadmissions

7TechnicalAssistanceTool|QualityMeasurementApproachesofMedicaidAccountableCareOrganizations

Vermont Medicaid ACO Shared Savings Program


Thestatehasidentified28corequalitymeasuresforreportinginyearoneofitsACOdemonstration,eightofwhicharelinkedtopayment.Thereareanadditional23monitoringandevaluation
measures,whicharerequiredforreporting,butnottiedtopayment.ACOsarenotrequiredtoreportmonitoringandevaluationmetrics,butthestatetracksthemtoseeiftheyareaffectedbyACOactivity.
DistributionofsharedsavingsiscontingentonanACOmeetingaqualitythreshold(gate)of35percentofeligiblepointsontheeightmeasureslinkedtopayment.Oncethisisachieved,75percentofthe
sharedsavingsisguaranteed.Thescaleofpaymentisbasedonascoringmethodology(ladder),bywhichtheACOcanearnupto100percentofsavingsifatleast60percentofeligiblepointsontheeight
measuresareacquired.Vermontmayaddanadditional23pendingmeasurestothecorequalitymeasureset,pendingapprovalfromtheGreenMountainCareBoard.

VERMONT
MeasureDomain

CoreMeasures(TiedtoPayment)

Claims

Allcausereadmission
Adolescentwellcarevisit
Cholesterolmanagementforpatientswith
cardiovascularconditions(LDLscreeningonly)
Followupafterhospitalizationformentalillness,7day
Initiationandengagementofalcoholandotherdrug
dependencetreatment
Avoidanceofantibiotictreatmentforadultswithacute
bronchitis
Chlamydiascreeninginwomen
Developmentalscreeninginthefirstthreeyearsoflife

CoreMeasures(ReportingOnly)

PatientExperience/Survey

Accesstocarecomposite
Communicationcomposite
Shareddecisionmakingcomposite
Selfmanagementsupportcomposite
Comprehensivenesscomposite
Officestaffcomposite
Informationcomposite
Coordinationofcarecomposite
Specialistcarecomposite

N/A

Advancingaccess,quality,andcosteffectivenessinpubliclyfinancedcare|www.chcs.org

Diabetescomposite(D5):
HbA1ccontrol(<8percent)
Diabetescomposite(D5)(allor
nothingscoring):low
Densitylipoprotein(<100)
Bloodpressure<140/90
Tobaccononuse
Aspirinuse
Diabetesmellitus:HbA1Cpoorcontrol(>9
percent)
Colorectalcancerscreening
Depressionscreeningandfollowup
Adultweight(BMI)screeningandfollowup
Childhoodimmunizationstatus(combo10)
Pediatricweightassessmentandcounseling

N/A

N/A

Ambulatorycaresensitiveconditions:COPD
admissions
Mammography/Breastcancerscreening
Rateofhospitalizationforambulatorycare
sensitiveconditions:PQIcomposite
Appropriatetestingforchildrenwith
pharyngitis

Clinical

Monitoring/Evaluation
Appropriatemedicationsforpeople
withasthma
Comprehensivediabetescare:eye
examsfordiabetics
Comprehensivediabetescare:medical
attentionfornephropathy
Useofspirometrytestinginthe
assessmentanddiagnosisofCOPD
Followupcareforchildrenprescribed
ADHDmedication
Antidepressantmedication
management

AnnualDentalVisit

8TechnicalAssistanceTool|QualityMeasurementApproachesofMedicaidAccountableCareOrganizations

VERMONT
MeasureDomain

CoreMeasures(TiedtoPayment)

CoreMeasures(ReportingOnly)

Monitoring/Evaluation

StateLevelMonitoring

N/A

N/A

TotalCostofCare
ResourceUtilizationIndex
Ambulatorysurgery/1,000
Average#ofprescriptionsPMPM
AvoidableEDvisitsNYUalgorithm
AmbulatoryCare(EDrateonly)
EDUtilizationforAmbulatoryCare
SensitiveConditions
Genericdispensingrate
Highendimaging/1,000
InpatientUtilizationGeneral
Hospital/AcuteCare
Primarycarevisits/1,000
SNFDays/1,000
Specialtyvisits/1,000
Schoolcompletionrate
Unemploymentrate
Familyevaluationofhospicecaresurvey

ABOUT THE CENTER FOR HEALTH CARE STRATEGIES


TheCenterforHealthCareStrategies(CHCS)isanonprofithealthpolicyresourcecenterdedicatedtoadvancinghealthcareaccess,quality,andcosteffectivenessinpublicly
financedcare.CHCSworkswithstateandfederalagencies,healthplans,providers,andconsumergroupstodevelopinnovativeprogramsthatbetterservepeoplewith
complexandhighcosthealthcareneeds.Formoreinformation,visitwww.chcs.org.

Advancingaccess,quality,andcosteffectivenessinpubliclyfinancedcare|www.chcs.org