Texas DSRIP Category 3
February 24, 2014
Summary
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Components of Category 3
Valuation
Reporting by demonstration year
Selecting outcome measures
Technical assistance and additional resources
Timelines
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Components of Category 3
RHP Planning Protocol
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Framework
Outcome measures
Alternate improvement activities
Compendium
Tools (e.g. surveys) appendix
Key information on measures
• Measure type (P4P or P4R)
• Stand-alone or non-standalone
• Measure specifications (definitions for how to report)
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Framework
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All providers are required to verify or select Category 3 outcome
measures for each Category 1 or 2 project.
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If you want to keep your originally proposed Category 3 outcomes for
a project and they are on the current Category 3 menu, you may do so.
Providers will continue to choose either at least 1 standalone
measure or 3 non-standalone measures for each project.
Each measure is designated as Pay for Performance (P4P) or Pay
for Reporting (P4R).
A Category 1 or 2 project may have a mix of P4P and P4R
measures.
P4P measures are required, if appropriate to the Category 1 or 2
project and provider can meet specification requirements.
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If a provider cannot use a P4P measure for a Category 1 or 2 project a
P4R measure may be used.
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Framework, 2
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Some measures require prior authorization.
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All P4R require prior authorization. If you had previously selected the
measure for a project, this constitutes prior authorization.
Certain P4P measures are grandfathered for providers that have
already selected them for a project, but may not be newly selected.
If a provider needs to use a P4R measure, alternate
improvement activities are required in DY 5.
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Framework, 3
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All measures, P4P and P4R, must be reported to
specifications (any approved modifications are noted in the
menu and compendium).
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In most cases, denominators will be broader than the patients served in
the Category 1 or 2 project.
CMS has allowed providers to tailor denominators to appropriate
subsets.
The DSRIP monitoring contractor will verify that providers
are conforming to measure specifications.
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Framework, 4
DY 4
DY 5
P4P outcome measures
P4R outcome measures
(require prior authorization)
50% P4R/
50% P4P
100% P4R on measure
100% P4P
50% P4R on measure
50% P4P on population-focused
priority measure or stretch
activity
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Framework, 5
Decision tree
1. Review revised Category 3 menu (spreadsheet) to determine the
measure(s) that best fits a Category 1 or 2 project.
2. Is there a P4P measure appropriate to your Cat 1 or 2 project that you
can report to specifications?
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If YES, select P4P.
3. If the answer to #2 is NO, select a P4R measure along with an
alternate improvement activity
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Reporting on achievement related to a population-focused priority
measure is the preferred activity, if a provider can report to
specifications.
If a provider cannot use a population-focused priority measure, then
the provider selects a stretch activity.
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Framework, 6
If your originally proposed Category 3 outcomes for a
project are on the revised menu, and you can report
them to specifications, you may keep them, but check
the revised menu to see if the IT # has changed (and fill
in the required info on the Category 3 selection tool).
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Framework, 7
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HHSC and CMS will review Category 3 selections to
determine:
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If a P4P measure could have been selected and/or
If a P4R measure is needed, and the provider selects a
stretch activity, whether a population-focused priority
measure could be used instead of a stretch activity in
DY 5.
HHSC encourages providers to seek technical assistance
prior to submitting Category 3 selections regarding
which Category 3 measure(s) may fit a Category 1 or 2
project.
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Outcome Measures
Key outcome measure information
• Organized by outcome domain (OD)
• Measure type designated as P4P or P4R; some require PA
(Prior Authorization)
• Target setting is IOS (Improvement Over Self) or QISMC
(Quality Improvement System for Managed Care)
methodology if benchmark information is available
• Standalone (SA) or Non-standalone (NSA)
• Measure specifications (definitions) include: Identical,
Modified, or Custom
• Appropriate care setting as identified in measure
specifications
• Benchmark information
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Outcome Measures, 2
Measure specifications are included in the menu in three forms:
Identical, Modified, or Custom (as designated by HHSC/CMS)
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Identical measures – These measure specifications are included in the
Category 3 menu as described by the measure steward.
Modified measures – These measure specifications have been slightly
modified to reflect DSRIP provider focus (e.g. HEDIS measures included,
with revisions to language describing population [member  patient]).
Custom measures – These measures are based on clinical guidelines
and/or standard measurement definitions (e.g. prevalence) and were
created to accommodate approved DSRIP projects when there was no
existing evidence-based measure available.
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Care Settings
• Types of care settings include: Ambulatory, Inpatient, Both,
Emergency Department
• These setting designations describe where and from what types of data
the measure is validated for collection. E.g., HbA1c control measure
is an ambulatory sensitive measure and is not appropriate for acute
hospitalization episodes. All cause readmissions is an inpatient setting
measure as the denominator includes all patient discharges and the
benchmark reflects this type of data. As such, the measure is not
written for collection in the ambulatory setting.
• Providers should review the setting designations to make sure
the measure setting fits the project setting and/or aligns with
the types of data available to the provider.
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Target Setting
QISMC methodology
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Nationally recognized “Quality Improvement System for
Managed Care”
“Hybrid” method: high performance levels (HPLs) are 90th
percentile and minimum performance levels (MPLs) are 25th or
10th percentile of state or national benchmarks.
Benchmarks are a “proxy” for performance and may not be an
exact match to the population or delivery system.
If baseline is at MPL or above, achievement level is 10% gap
reduction between baseline and HPL in DY 4 and 20% in DY 5.
If baseline is below MPL, target is MPL in DY 4 and 10% gap
reduction between MPL and HPL in DY 5.
If provider’s baseline is above the HPL, the provider works with
HHSC to select a new outcome.
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Target Setting, 2
• Improvement Over Self (IOS)
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Used for P4P measures without QISMC benchmarks (90th/25th
percentiles)
5% improvement over baseline in DY 4
10% improvement over baseline in DY 5
For all P4P measures (QSMIC and IOS), HHSC will work
with CMS on policies for a provider to request lower
achievement levels in certain instances.
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A provider may request a lower achievement level based on a big
difference between the size of the project and the denominator or
complexity of project population.
Requests to deviate from the standard achievement levels will occur
with DY 3 October reporting; more details will be provided by then.
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Alternate Improvement Activities
• Used with P4R measures.
• P4R requires prior authorization.
• 1st option is to select a Population-Focused
Priority measure specific to provider type.
• If a provider cannot report a PopulationFocused Priority measure to specifications,
then it may select a “stretch” activity.
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Population-Focused Priority
Measures
• Hospitals – subset of potentially preventable admission and
readmission measures (PPAs and PPRs)
• Community Mental Health Centers
• Academic Health Science Centers
Lists available on HHSC waiver website
http://www.hhsc.state.tx.us/1115-Waiver-Guideline.shtml
Tailoring of denominators cannot be used for these measures as there is not a
specific intervention population. These measures are not tied to a Category 1
or 2 project but are intended to reflect improvement priorities across all of a
provider’s DSRIP projects.
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Stretch Activities
Link to list:
http://www.hhsc.state.tx.us/1115-Waiver-Guideline.shtml
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The selected stretch activity should relate to the type of P4R
measure and/or provider type, such as measure validation or
ability to exchange information with other providers in order
to report to specifications.
HHSC has specified documentation required for reporting for
each stretch activity.
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Compendium Content
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Detailed measure specifications
Whether measure requires prior authorization
DSRIP approved modifications
Measurement period guidance
Benchmarks
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Tools Appendix
• Describes additional information about the
tools (e.g., surveys) used in the Category 3
menu
• Intended populations for use
• Administration and scoring guidelines
• Validity and reliability testing of the tools (when
available)
• Resources to obtain the tool and how to request
additional information from the tool developer
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Valuation
DY 3-5 Category 3 valuation will be determined as
follows:
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HHSC totals up the provider funds allocated to Category 3 for
each DY in DY 3, 4 and 5 and also totals up the provider’s
Category 1 and 2 projects.
Each provider decides what percentage of its total Category 3
funds will go toward a given Category 1 or 2 project (this
single percentage will be applied to the funds allocated for
each DY).
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Valuation, 2
DY 3-5 Category 3 valuation (continued)
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Once the provider decides the percentage of its funds to
allocate to each Category 1 or 2 project for DY 3-5 for
Category 3, based on the number of outcomes selected for
that project, HHSC will allocate an equal amount of Category
3 funds to each outcome measure in a given demonstration
year
Funding then will be equally distributed between milestones
for each measure in a given DY (such as for a P4P measure in
DY 4, 50% of the DY 4 funds for that measure will go to
reporting and 50% for measure improvement)
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Valuation, 3
Category 3 valuation distribution minimums
• Divide the total number of Category 1 and 2 DSRIP
projects into 100. Example: 5 Category 1 and 2 DSRIP
projects = 100/5 = 20. If the provider divides its Category
3 funds equally across the 5 Category 1 or 2 projects, each
of those projects would be allocated 20% of its Category 3
funding.
– Within the provider selection tool, this equal
distribution will be the default allocation displayed.
Providers are able to modify this amount as long as the
minimum is still met.
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Valuation, 4
Category 3 valuation distribution minimums (continued)
• A provider must allocate at least 50% of that “average” Category
3 funding to each Category 1 or 2 project, e.g. 50%*20% = 10%.
• Across its 5 Category 1 or 2 projects, in this example, the
provider must allocate at least 10% of its Category 3 funds to
each Category 1 or 2 project, and in total the percentages
allocated across the 5 Category 1 or 2 projects must equal 100%.
– CMS encourages providers to consider the relative Category 1 or 2
valuation of each project when deciding the amount of Category 3
funds to allocate to a project.
– If a provider has Category 1 or 2 project valuations that vary
greatly and needs to go below the minimum % specified in its
workbook to have proportional Category 3 valuation, it should
contact HHSC to request a revised workbook.
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DY 3 Reporting
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Two process milestones will be used in DY 3.
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50% of the Category 3 allocation for each outcome
measure will be available for April 2014 reporting based
on providers submitting a status report.
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50% of the Category 3 allocation will be reported in
October 2014 for providers submitting/validating baseline
rates – baselines will be reported for both P4P and P4R
measures.
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A certification will be required with submission of baseline rates
from the head quality officer of the provider organization or
another executive level officer. This will also be required for DY 4
and 5 reporting.
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DY 2 Carry-forward
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For those providers that had DY 2 achievement that was
carried forward into DY 3, providers will still have to
demonstrate that achievement to receive DY 2 payment.
To demonstrate DY 2 achievement, providers will have two
options
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(Recommended) Submit DY 2 status report in DY 3. Providers will
simply fill out DY 2 status report and submit it in addition to the DY3
status report
Document achievement of DY 2 process milestone (e.g., project
planning, validation of data systems, etc.) and submit during DY 3
reporting.
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DY 4 Reporting
P4P Measures
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50% of funding available to earn for successful reporting to
specifications
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Carry forward applies
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Partial payment does not apply
50% of funding available for reaching achievement level
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Standard performance is 10% with QISMC
methodology or 5% IOS over baseline reported in DY 3
October reporting
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Carry forward applies
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Partial payment applies
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DY 4 Reporting, 2
P4R Measures
• 100% of funding available to earn through
successful reporting to specifications
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Carry forward applies
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Partial payment does not apply
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DY 5 Reporting
P4P Measures
• 100% of funding available for reaching target
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Standard performance is 20% with QISMC methodology
or 10% IOS over baseline reported in DY 3 October
reporting
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Carry forward applies
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Partial payment applies
• Performance target based on % over baseline set by
October 2014, not from DY 4 reporting
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DY 5 Reporting, 2
P4R Measures
• 50% of funding available to earn through successful reporting
to specifications
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Carry forward applies, partial payment does not apply
50% of funding available to earn through alternate
improvement activity
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Population-focused priority measure is outcome improvement
target
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20% achievement with QISMC, 10% IOS over baseline
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Carry forward and partial payment apply
Stretch activity is process milestone
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Carry forward applies, partial payment does not apply
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Category 3 Partial Payment
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Providers may receive partial payment for making progress
towards, but not fully achieving, an outcome improvement
target. The partial payment would equal 25%, 50% or 75% of
the achievement value of the outcome improvement target.
Based on the progress reported, each outcome improvement
target will be categorized as follows to determine the total
achievement value percentage:
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Full achievement (value = 1)
At least 75 % achievement (value = .75)
At least 50% achievement (value = .5)
At least 25% achievement (value = .25)
Less than 25% achievement (value = 0)
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Category 3 Partial Payment, 2
Example:
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Outcome improvement target for 5% IOS in DY 4 and 10% IOS in
DY 5 over baseline.
In DY 4, the provider achieved a 3% improvement, short of its goal
of 5%.
For partial payment, the provider would be reimbursed 50% of the
incentive payment associated with the target, because achievement
was 60%.
The performing provider may earn the remaining DY 4 incentive
payment in DY 5.
In DY 5, this provider can earn remaining DY 4 funds for reporting
additional achievement above 60% (either at least 75% or 100%) as
“carry forward.”
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Selecting Measures
• The provider selection tool will replace the Category 3 narratives in the
RHP Plan. Providers will have the opportunity to update the Category 1
or 2 narrative with the updated Category 3 selection.
• Providers may select P4R measure(s) only if a P4P measure is not
available and a P4R measure is more appropriate for the project.
• HHSC must prior authorize use of P4R, which will occur once
providers have submitted selected measures.
• HHSC will review all P4R measures to determine if a P4P measure
could be selected.
• For providers already approved by CMS for use of a P4R measure that
was on the original Category 3 menu (does not include “Other”
measures proposed) for a specific Category 1 or 2 project, that original
approval constitutes Prior Authorization.
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Selecting Measures, 2
• All providers will either verify measures already selected, change
measures previously selected or select measures for those Category 3
projects with a previously to be determined (TBD) designation using
the numbering in the revised menu.
• Some “Other” outcome measures initially proposed are now on the menu
and can be selected.
• “Other” outcome measures initially proposed that are not included in the
revised Category 3 menu must be replaced.
• If a provider had stated during Phase 1 that they would replace or add
an additional measure to Patient Satisfaction to maintain valuation, this
must be done in March.
• Each provider should review its Category 1 or 2 milestones to select
Category 3 outcome measures that do not overlap with Category 1 or 2
milestones (providers can request TA from HHSC as needed). If there
is a concern around overlap, the provider will have the opportunity to
revise its Category 1 or 2 milestones during the next plan modification
opportunity (scheduled for this summer).
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Selecting Measures, 3
• For OD 6 and 10, it is recommended that providers use
these tool measures complemented with another measure,
and not as single outcomes.
• Some P4P measures that were on the original Category 3
menu are designated for PA because they are not
considered the strongest P4P measures.
• Providers that originally proposed these measures for a particular
project may keep them (grandfathered).
• Providers may not newly select these measures for use.
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Selecting Measures, 4
• Providers must select for each Category 1 or 2 project at least
1 standalone or 3 non-standalone measures.
• Non-standalone measures can cross domains.
• In the tool, providers can either choose to keep, delete or
replace existing measures as well as add up to 3 additional
measures associated with each Category 1 or 2 project.
• Providers will have the opportunity to tailor the denominator
to reflect a target population that best aligns with the Cat 1 or 2
project through the use of approved denominator subsets.
• Appropriate “facility level” populations or subsets can be selected as
follows as appropriate to the measure: payer source
(Medicaid/indigent), target condition, age, race/ethnicity, gender or
facility(ies) where services are delivered.
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Selection Tool – Tab 2
Category 3 Historical Valuation
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First section is identifying information and has some cells for
providers to populate (yellow cells).
Second section describes historical Category 3 allocation amounts for
DY3 – DY5 by Category 1 or 2 project. This is to allow providers to
see where the total Category 3 funding was previously allocated. No
action needed from providers in this section.
Last section contains detail about the outcomes historically proposed
for each Category 1 and 2 project including prior valuation for each
Category 3 project and relevant Phase 1 review comments.
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Providers will indicate for each Category 1 or 2 project which outcomes
they will be retaining, replacing or deleting (yellow cells).
Providers also will have the option to add up to three additional outcomes
to the number previously proposed.
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Selection Tool - Tab 3
<Category 1 or 2 project ID> Outcome detail.
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Each Category 1 or 2 project has a separate tab for outcome detail that is prepopulated based on the provider’s responses in the first tab.
Brief measure specifications will be populated for each outcome.
Provider will use this tab to:
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Provide rationale for outcome selection
Request denominator subsets
Indicate alternate improvement activities for P4R measures
Indicate if there is potential overlap between outcome and Category 1 or 2 project
milestones. (HHSC will work with providers to resolve potential overlap issues.)
Indicate baseline availability and proposed measurement period.
Optional forecasting for P4P measures to determine what DY4 and DY5
performance goals may be. **This is just a guide and actual goals will be
determined in October based on baseline submissions and final benchmark rates.
Provider will respond to all yellow cells, with the exception of the
optional forecasting section, for a complete Category 3 submission.
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Selection Tool - Tab 4
Category 3 valuation
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Contains information around the new Category 3 allocations.
Providers will indicate, for each Category 1 or 2 project, what
percentage of the total Category 3 amount to allocate to the outcomes
associated with that project.
The tool will default with equal allocations to each Cat 1 or 2 project,
however, providers may change these percentages, adhering to the
minimum requirement of 50% of the average percentage listed.
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Contact HHSC to request an exception to this minimum based on Cat 1 / 2 values.
Providers are encouraged to take into account the Category 1 or 2
valuation of each project when deciding Category 3 valuation.
After provider has indicated % allocation, the tool will populate DY 35 values for each of the outcomes and milestones associated with the
project.
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Selection Tool - Tab 5
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Category 3 IGT data
• This tab will list current IGT entities for each project as
well as allow providers to make any changes to the IGT
entities for any of the listed Category 3 projects.
Note: All Category 3 projects (current, replacement, and 3year projects) are included in the selection tool. If a project
does not receive CMS approval, HHSC will proportionally
adjust the Category 3 funding associated with the provider’s
remaining Category 1 or 2 projects.
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Selection Tool- Tab 1
Progress Tracker
• Indicator to providers that required fields are
populated for each of the tabs within the Selection
tool.
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Will change to green and state ‘Complete’ when
required fields are completed.
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Helpful Resources
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Provider selection tool - this is how providers will select and HHSC and CMS will
review and approve Category 3 outcomes.
Companion - describes the mechanics of Category 3 in greater detail as well as
walks providers through the process of selecting outcomes.
Compendium - detailed measure specifications for each outcome. Providers must
review these specifications for their selected outcome to determine the appropriate
inclusion and exclusion codes for the measure.
Decision tree - visual representation of the outcome selection process.
Risk adjusting document - contains a high level description of risk adjusting
methodologies that may be used for the Category 3 outcomes that require risk
adjusting.
Denominator one pager - brief description of working with outcome denominators,
including denominator subsets and collecting outcomes on intervention populations.
Reporting templates for DY3 - April status report and October baseline report.
Updated RHP Planning Protocol – date TBD.
Updated PFM Protocol – date TBD.
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Technical Assistance
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For measure specifications, please review compendium
information.
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The RHP Anchors and provider associations have been
involved in the development and mechanics of Category 3.
Providers are encouraged to reach out to these groups for
assistance.
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For assistance with specific tools, provider may wish to
reach out to the tool developer - contact info is listed in the
tools appendix and compendium.
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Providers may also reach out to like provider types to
discuss understanding of measure specifications as well as
data availability.
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Technical Assistance, 2
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Providers may also reach out to the HHSC team through the Waiver
mailbox. We ask that providers include “Category 3” in the subject line
using following designations so that the emails can be triaged
appropriately:
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Category 3 – selection tool
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Category 3 – select measure(s) to fit Cat 1 or 2 project
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Category 3 – population-focused priority measures
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Category 3 – stretch activities
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Category 3 – achievement methodology
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Category 3 – data collection processes
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Category 3 – tools/surveys
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Category 3 – other
HHSC anticipates a large volume of TA requests, so responses may take
several days.
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Review Process and Timelines
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Provider selection – March 10, 2014
HHSC’s initial feedback will be specific to measures
requiring PA – goal of April 1, 2014
DY 3 April Reporting – status template will provide
information to inform HHSC review and additional
feedback will occur as needed
DY 3 October reporting – baselines and any proposed
exceptions to standard achievement levels for outcome
targets based on guidelines under development. DY4 and
DY5 performance goals will also be determined at this
time.
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Contact information
• Find updated materials:
• http://www.hhsc.state.tx.us/1115-waiver.shtml
• Submit questions to:
• TXHealthcareTransformation@hhsc.state.tx.us
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