One Care Quality Monitoring and
Measurement
Presented by
Edith G. Walsh
2016 National Health Policy Conference
February 2, 2016
Washington, DC
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www.rti.org
One Care Overview
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One Care is the Massachusetts demonstration under the CMS
Financial Alignment Initiative, started in October, 2013.
Goals are to alleviate fragmentation of care, improve service
coordination, enhance quality of care, and reduce costs.
Key objectives are to improve the beneficiary experience in
accessing care, deliver person-centered care, promote
independence in the community.
The Medicare-Medicaid Plans participate in 3-way contracts with
CMS and Massachusetts Medicaid (MassHealth) to deliver the full
range of benefits and provide care coordination.
A Contract Management Team, including representatives from the
MassHealth Provider and Plan unit, MassHealth central policy office,
CMS regional office Medicare and Medicaid staff, and MedicareMedicaid Coordination Office (MMCO) works together and meets
regularly with each plan.
Target Population, Enrollment, and Special Features
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Full benefit Medicare-Medicaid beneficiaries age 21–65 are eligible
to enroll.
Eligible beneficiaries can opt out or select a plan; if neither are
selected, they may be auto-enrolled. They are also able to disenroll
at will.
Particular focus is placed on addressing the needs of people with
serious mental illness. New diversionary services are offered.
Expanded services and new community-based services are offered,
and plans have the option to provide flexible benefits.
Plans are operating in 9 of the 14 counties. Three plans participated
for the first 2 years, but one dropped out at the end of the second
year (9/30/15). At that time, there were over 17,000 enrollees;
current enrollment is about 13,000.
Quality Monitoring and Measurement is a Shared
Responsibility
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The Commonwealth and CMS are responsible for monitoring
individual plan performance and various quality measures
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Core measures required of all capitation model demonstrations that
address access, assessment, care coordination, enrollee protection,
organization structure and staffing, performance and quality improvement,
provider network, systems and service utilization.
– State-specific measures, focused primarily on long-term care services and
supports and care coordination.
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Plans are also required to meet Medicare Advantage reporting
requirements such as HEDIS, CAHPS, and HOS.
RTI International is responsible for evaluating demonstration-level
quality.
Examples of Measures Collected by Massachusetts
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Core measures required of all demonstrations:
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Members with assessments completed with 90 days
– Total number of members enrolled for 90 days or more with completed assessments
– Grievances and Appeals
– ER visit rates for behavioral health diagnoses
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Massachusetts-specific measures:
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All demonstration measures (core and state-specific) can be found online:
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Members with care plans completed within 90 days of assessment
Members with documented discussion of care goals
Members with LTSS needs who have an LTS coordinator
Number of critical incident and abuse reports
Congestive heart failure admission rates
https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-MedicaidCoordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/InformationandGuidanceforPlans.html
RTI Quality Monitoring and Analysis Overview
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Ongoing monitoring analyses to track quarterly changes in selected
quality measures
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Annual descriptive analyses of quality for demonstration eligible,
enrollees, subgroups and comparison group results looking at
baseline and demonstration period trends
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Multivariate difference-in-differences analyses of quality using a
comparison group
Ongoing Quality Monitoring
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MassHealth submits information quarterly about their quality
monitoring and quality improvement work, results of any analyses,
focus groups, and surveys. RTI staff conduct quarterly phone calls
with MassHealth to discuss the quarterly data submission and gain
further details about demonstration developments.
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RTI staff conduct annual site visits, meeting with MassHealth
officials, health plans, stakeholders and CMS members of the CMT.
RTI staff are also conducting a series of focus groups.
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RTI submits quarterly reports to CMS that are also shared with
MassHealth; information from these reports will be incorporated into
annual reports.
Annual Reports
Annual reports
 Will include data analyses for One Care and for comparison areas,
examining trends
 Will also include beneficiary experience information gleaned from
focus groups conducted by RTI and MassHealth, CAHPS data, and
other sources
 Will summarize information from site visits, focus groups, and studies
and quality reports from MassHealth and other entities.
 Final analyses
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Will use difference-in-differences approach to evaluate outcomes for
beneficiaries overall, and for subgroups
Quality Measures: Screening and Preventive Care
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Immunization rates (influenza and pneumococcal)
Adult BMI assessment (HEDIS)
Breast cancer screening
Screening for Fall Risk
Controlling high blood pressure (HEDIS)
Comprehensive diabetes care: selected components—HbA1c
control, LDL-C control, retinal eye exam (HEDIS)
Annual monitoring for patients on persistent medications (HEDIS)
Quality Measures: Acute Medical Care
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Ambulatory Care Sensitive Condition hospitalization rates (overall,
and chronic composite)
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Avoidable emergency department visits
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All cause 30-day hospital readmission rates
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Cardiac rehabilitation following hospitalization for AMI, angina,
CABG, PCI, CVA
Quality Measures: Behavioral Health and Long-term Care
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Initiation and engagement of alcohol and other drug dependence
treatment
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Admissions with a primary diagnosis of a serious mental illness or
substance use disorder
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Follow-up after hospitalization for mental illness (within 30 days, and
within 7 days of discharge)
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Screening for clinical depression and follow-up
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Antidepressant medication management (HEDIS)
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Percent of high-risk long-stay nursing facility residents with pressure
ulcers (MDS analysis)
For More Information
One Care evaluation plan:
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https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-andMedicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/Downloads/MassEvalPlan.pdf
Aggregate evaluation plan:
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https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-andMedicaid-Coordination/Medicare-Medicaid-CoordinationOffice/FinancialAlignmentInitiative/Downloads/EvalPlanFullReport.pdf
Edith G. Walsh, RTI International: ewalsh@rti.org
William Clark and Daniel Lehman, CMS: William.clark@cms.hhs.gov,
Daniel.lehman@cms.hhs.gov
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