The Significant Lack of Alignment
Across State and Regional Health
Measure Sets:
An Analysis of 48 State and Regional
Measure Sets, Resource Document
Kate Reinhalter Bazinsky
Michael Bailit
September 10, 2013
Executive summary
 The are many state/regional performance measures for
providers in use today.
– 1367 measures identified across 48 measure sets.
 Unfortunately, current state and regional measure sets are
not aligned.
– Only 20% of all measures were used by more than one program.
 Non-alignment persists despite the tendency to use
standard, NQF-endorsed and/or HEDIS measures.
– Although 59% of the measures come from standard sources, they
are selecting different subsets of these standard measures for use.
– The most frequently used measure was only used by 63% of the
programs.
2
Executive summary (cont’d)
 With few exceptions, regardless of how we analyzed the
data, the programs’ measures were not aligned.
– This lack of alignment persists across programs of the same type
and for the same purpose.
– Medicaid MCOs are the exception and use far more of the same
measures than any other type of program. This is partially because
they rely almost exclusively on HEDIS measures.
– We also found that California has more alignment. This may be due
to our sample or the work the state has done to align measures.
 While many programs use measures from the same
domains, they are not selecting the same measures within
these domains.
– This suggests that simply specifying the domains from which
programs should select measures will not facilitate measure set
alignment.
3
Executive summary (cont’d)
 Even when the measures are “the same,” the programs
often modify the traditional specifications for the standard
measures.
– 83% of the measure sets contained at least one modified measure.
– Two of the programs modified every single measure and six of the
programs modified at least 50% of their measures.
 Many programs create their own “homegrown” measures.
– 40% of the programs created their own homegrown measures.
– Some of these may be measure concepts, rather than measures
that are ready to be implemented
 Unfortunately most of these homegrown measures do not
represent true innovation in the measures space.
– There appears to be a need for new standardized measures in the
areas of self-management, cost, and care management and
coordination.
4
Conclusions
 Bottom line: Measures sets appear to be developed
independently without an eye towards alignment with
other sets.
 The diversity in measures allows states and regions
interested in creating measure sets to select measures
that they believe best meet their local needs. Even
the few who seek to create alignment struggle due to a
paucity of tools to facilitate such alignment.
 The result is “measure chaos” for providers subject to
multiple measure sets and related accountability
expectations and performance incentives. Mixed
signals make it difficult for providers to focus their
quality improvement efforts.
5
Purpose
 Goal: Paint a picture of the measures landscape across
states and regions to inform development of the
emerging Buying Value measure set.
 Process: Identify and collect 48 measure sets used by
25 states for a range of purposes and conduct a multipronged analysis:
– Provide basic summary information to describe the 48 measure
sets
– Provide an overview of the measures included in the 48
measure sets
– Analyze the non-NQF endorsed measures
– Analyze the measures by measure set type
– Analyze the measures by measure set purpose
– Analyze the measures by domain/ clinical areas
– Assess the extent of alignment within the states of CA and MA
6
Methodology
 We used a convenience sample of measure sets from
states, by requesting assistance from our contacts in
states and by:
– Obtaining sets through state websites:
• Patient-Centered Medical Home (PCMH) projects
• Accountable Care Organization (ACO) projects
• CMS’ Comprehensive Primary Care Initiative (CPCI)
– Soliciting sets from the Buying Value measures work group
 We also included measure sets from specific regional
collaboratives.
 We have not surveyed every state, nor have we
captured all of the sets used by the studied states.
 We did not include any hospital measures sets in our
analysis.
– Excluded 53 hospital measures from the analysis
7
Methodology (cont’d)
 Organized the measures by:
–
–
–
–
–
–
–
Measure steward
NQF status/ number
Age of the population of interest
Program type (e.g., ACO, PCMH, health home)
Program purpose (e.g., payment or reporting)
Domain (used the NQS tagging taxonomy)
Clinical areas of interest (used NQF taxonomy detail)
 Unduplicated the total measures list to identify the
“distinct” measures
–If a measure showed up in multiple measure sets, we only counted
it once.
– If a program used a measure multiple times (variations on a theme)
we also only counted it once.
8
Methodology (cont’d)
 Assessed whether the measure is standard, modified,
homegrown or undetermined.
• If we did not have access to the specifications, but the
measure appeared to be standard through combination of
steward and title or NQF#, we considered it to be a
“standard” measure. This approach is likely to underestimate
the number of modified measures.
• We labeled measures “modified” if they were standard
measures with a change to the traditional specifications.
• We labeled measures “homegrown” if they were were
indicated on the source document as having been created by
the developer of the measure set.
• We labeled measures “undetermined” if the source of the
measure was unclear. Some of these measures may be
“homegrown” while others may be drawn from niche sources.
9
Table of contents
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical
area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
10
1. Overview of measure sets
 Goal: provide some basic summary information to
describe the group of measures sets and answer the
following questions:
1. How many measures are included across the measure
sets?
2. How many measures are included in the average measure
set?
11
Measure sets by state
 Reviewed 48
measure sets
used by 25
states.
 Intentionally
gave a closer
look at two
states: CA and
MA.
1. AR
11.ME (2)
2. CA (7) 12.MI
3. CO
13.MN (2)
4. FL
14.MO (3)
5. IA (2) 15.MT
6. ID
16.NY
7. IL
17.OH
8. LA
18.OK
9. MA (8) 19.OR
10.MD
20.PA (4)
21.RI
22.TX
23.UT (2)
24.WA
25.WI
Note: If we reviewed more than one measure set from a state, the
number of sets included in the analysis is noted above.
12
Program types

Note: these categories are meant to be mutually exclusive. Each
measure set was only included in one category.
 ACO: Measure sets used by states to evaluate Accountable Care
Organizations. Organizations of providers that agree to be
accountable for the clinical care and cost of a specific attributed
population
 Alignment Initiative: Measure sets created by statewide initiatives
in an attempt to align the various measures being used throughout
the state by various payers or entities
 Commercial Plans: Measure sets used by states to evaluate
insurers serving commercial members
 Duals: Measure sets used by state Medicaid agencies in programs
serving beneficiaries who are dually eligible for Medicare and
Medicaid
 Exchange: Measure sets used to assess plan performance in a
state-operated marketplace for individuals buying health insurance
13
coverage
Program types (cont’d)
 Medicaid: Measure sets used by states to evaluate the Medicaid
agency performance
 Medicaid MCO: Measure sets used by state Medicaid agencies to
assess performance of their contracted managed care organizations
 Medicaid BH MCO: Measure sets used by state Medicaid agencies
to assess performance of their contracted behavioral health managed
care organizations
 PCMH: Measure sets used by patient-centered medical home
initiatives
 Other Provider: Measure sets used by states to assess performance
at the provider level, but are not for assessing ACO, PCMH or Health
Home initiatives
 Regional Collaboratives: A coalition of organizations coordinating
measurement efforts at a regional level, often with the purpose of
supporting health and health care improvement in the geographic
area
14
Measure sets by program type
14
13
12
10
8
6
4
2
6
5
3
3
3
3
3
2
2
2
2
1
0
15
Measure sets by purpose
25
20
Defining Terms
22
Reporting: measure sets used for
performance reporting, this reporting
may be public or may be for internal use
only
19
15
10
5
0
5
2
Payment: measure sets used for
payment distribution to providers (e.g.,
pay for performance, shared savings,
etc.)
Reporting and Other: measure sets
used for reporting and an additional nonpayment purpose, such as tiering
providers or contract management
Alignment: measure sets resulting from
state initiatives to establish a core
measure set for the state
16
Measure sets ranged significantly in size
[max]
108 measures
[avg]
29 measures
[min]
3 measures
Note: This is counting the measures as NQF counts them (or if the
measure was not NQF-endorsed, as the program counted them).
17
Table of contents
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical
area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
18
2. Overview of measures
Goals:
 To describe the measures used across the sets and
answer the following questions:
1.
2.
3.
4.
5.

Are the measures used primarily standard measures?
To what extent are measures NQF-endorsed?
What are the primary sources of the measures?
Into which domains do most of the measures fall?
To what extent do the measures cover all age ranges?
To assess the extent of alignment across the measure
sets
1. To what extent are measures shared?
2. What are the most frequently shared measures?
19
Finding: Many state/regional performance
measures for providers in use today
In total, we identified 1367 measures across the 48 measure
sets
– This is counting the measures as NQF counts them or if the measure
was not NQF-endorsed, as the program counted them
We identified 509 distinct measures
–If a measure showed up in multiple measure sets, we only counted it
once
–If a program used a measure multiple times (variations on a theme)
we also only counted it once
We excluded 53 additional hospital measures from the
analysis.
20
Programs use measures across all of the
domains
Utilization
5%
Treatment and
Secondary
Prevention
33%
Safety
13%
Access,
affordability &
inapprop care
9%
Comm & care
coordination
2%
Health and wellbeing
27%
Personcentered
9%
Total measures by domain
n = 1367
Infrastructure
2%
21
The distinct measures actually are more evenly
distributed across the domains
Utilization
8%
Access,
affordability &
inapprop care
11%
Treatment and
secondary
prevention
28%
Safety
19%
Comm & care
coordination
5%
Health and wellbeing
14%
Personcentered
11%
Distinct measures by domain
n = 509
Infrastructure
4%
22
Most implemented measures are for adults
Adult (18-64)
4%
Adult (65+)
3%
Pediatric and
Adult (0-64)
20%
Pediatric (0-17)
16%
All Adults (18+)
57%
 But there does not
appear to be a deficiency
in the number of measures
that could be used in the
pediatric or the 65+
population.
Measures by age group
n = 1367
23
Finding: Little alignment exists across the
measure sets
 Programs have very few
measures in common or
“sharing” across the
measure sets
Shared*
20%
Not
shared
80%
Number of distinct measures shared by
multiple measure sets
n = 509
 Of the 1367 measures,
509 were “distinct”
measures
 Only 20% of these distinct
measures were used by
more than one program
* By “shared,” we mean that the programs have measures in common
with one another, not that they are working together.
24
How often are the “shared measures” shared?
Not that often…
11-15 sets, 3%
(14 measures)
Measures not
shared 80%
Shared
measures 20%
6-10 sets,
4% (21
measures)
3-5 sets, 4%
(20 measures)
16-30 sets, 4%
(19 measures)
2 sets, 5% (28
measures)
Most measures are
not shared
Only 19 measures
were shared by at
least 1/3 (16+) of the
measure sets
25
Categories of 19 most frequently used
measures
7 Diabetes
Care
•Comprehensive
Diabetes Care
(CDC): LDL-C
Control <100
mg/dL
•CDC: Hemoglobin
A1c (HbA1c)
Control (<8.0%)
•CDC: Medical
Attention for
Nephropathy
•CDC: HbA1c
Testing
•CDC: HbA1c Poor
Control (>9.0%)
•CDC: LDL-C
Screening
4 Other
Chronic
Conditions
1 Mental
Health/Substance Abuse
•Breast Cancer
Screening
•Controlling High
Blood Pressure
•Cervical Cancer
Screening
•Use of
Appropriate
Medications for
People with
Asthma
•Follow-up after
Hospitalization for
Mental Illness
6 Preventative
Care
•Childhood
Immunization
Status
•Colorectal Cancer
Screening
•Weight Assessment
and Counseling for
Children and
Adolescents
•Tobacco Use:
Screening &
Cessation
Intervention
•Cardiovascular
Disease: Blood
Pressure
Management
<140/90 mmHg
•Cholesterol
Management
for Patients with
Cardiovascular
Conditions
1 Patient
Experience
•CAHPS Surveys
(various versions)
•CDC: Eye Exam
26
Finding: Non-alignment persists despite
preference for standard measures
Undetermined
6%
Other
3%
Defining Terms
Standard: measures from a known
source (e.g., NCQA, AHRQ)
Homegrown
15%
Modified: standard measures with a
change to the traditional
specifications
Modified
17%
Homegrown: measures that were
indicated on the source document
as having been created by the
developer of the measure set
Standard
59%
Measures by measure type
n = 1367
Undetermined: measures that were
not indicated as “homegrown”, but
for which the source could not be
identified
Other: a measure bundle or
composite
27
In particular, states show a preference for NQFendorsed measures
Never
NQFendorsed
32%
NQFendorsed
63%
No longer
NQFendorsed
5% Percentage of total measures that are NQFendorsed
n = 1367
28
But looking at the distinct measures, they are
clearly willing to use non-NQF measures
Never
NQFendorsed
64%
NQFendorsed
32%
What are “distinct”
measures?
• If a measure showed up in
multiple measure sets, we
only counted it once (e.g.,
breast cancer screening was
counted 30 times in the total
measures chart since it
appeared in 30 different
measure sets; here it is
counted once)
No longer
NQF- • If a program used a
measure multiple times
endorsed
(variations on a theme) we
4%
also only counted it once
Percentage of distinct measures that are
NQF-endorsed
n = 509
(e.g., MA PCMH used 3
different versions of the
tobacco screening measure;
here it is counted once)
29
NCQA (HEDIS) is clearly the most common
source of measures
Undetermined
6%
Source with
fewer than 20
measures
8%
Homegrown
14%
Other
3%
HEDIS
52%
Resolution
Health
CMS
2%
4%
CAHPS
4%
AHRQ
AMA-PCPI
5%
4%
Total measures by source
n = 1367
30
But only 16% of the distinct measures
come from HEDIS
Undetermined
15%
HEDIS
16%
Homegrown
39%
Resolution
Health
5%
AHRQ
4%
CMS
4%
AMA- PCPRI
4%
In other words, the
81 HEDIS
measures are used
by multiple
programs.
Standard
source with
less than 10
measures
13%
Distinct measures by source
n = 509
31
There is a lot of overlap between NQF
and HEDIS but it is not 100%
NQF
HEDIS
32
Why HEDIS measures are often the first
choice for programs
 HEDIS measures are known and trusted
– They have been available and in use for a long time
– The specifications are widely available and clearly defined
 NCQA offers national and regional benchmark information
– Although information is at the health plan level, programs can get a
sense of how to define “good performance”
– They are already used by most health plans, thus providing some
information about baseline performance relative to the benchmark
 It’s good for the health plans if other programs use HEDIS
– If health plan success is being measured on the basis of the HEDIS
set, the health plans have an interest in getting other parties to
engage in improving scores of those measures
 NCQA regularly updates the specifications in response to
use, feedback and changes in guidelines
– Since another organization is doing this work, it takes the burden
33
off of the program managers
Programs are selecting different subsets of
standard measures
While the programs may be primarily using standard,
NQF-endorsed measures, they are not selecting the
same standard measures
Not one measure was used by every program
– Breast Cancer Screening is the most frequently used measure
and it is used by only 30 of the programs (63%)
Program
C
Program
B
Program
A
Program
D
Program
E
34
Finding: Even shared measures aren’t always
the same - the problem of modification!
 Most state programs modify measures
 23% of the identifiable standardized measures were
modified (237/1051)
 40 of the 48 measure sets modified at least one measure
 Two programs modified every single measure
1. RI PCMH
2. UT Department of Health
 Six programs modified at least 50% of their measures
1.
2.
3.
4.
5.
6.
CA Medi-Cal Managed Care Specialty Plans (67%)
WA PCMH (67%)
MA PCMH (56%)
PA Chronic Care Initiative (56%)
OR Coordinated Care Organizations (53%)
WI Regional Collaborative (51%)
35
Do modifications indicate a problem with
the measure specifications?
 Perhaps… some types of modifications suggest that the
measure deserves a closer look:
–
–
–
–
Adding additional detail to or changing details in the specifications
Eliminating detail from the specifications
Changes in the CPT codes used in the measure specifications
Changes in the source of the data (i.e., from hybrid/clinical records to
claims)
 However, we found that there are many modifications that
programs make that don’t necessarily indicate a
fundamental problem with the measure. For example,
frequent modifications include:
– Reporting only some of the rates/components of the measure (e.g., if the
measure has two components: screening and follow-up, they may only do
the screening component of the measure)
– Narrowing or expanding the age of the population measured
– Applying the measure to a new or sub-population
36
– Applying the measure to an alternative setting
Frequency of modification type
70
60
50
40
30
20
10
0
59
39
31
28
23
17
12
12
8
6
4
4
Note: some of the measures were modified in more than one way and
each modification is represented on this chart
37
Why do organizations modify measures?
 To tailor the measure to a specific program
– If the program is specific to a subpopulation, then the
organization may alter the measure to apply it to the population of
interest
 To make implementation easier
– The systems that the organizations have in place may make an
alternative approach to implementing the measure easier
 To obtain buy-in and consensus on a measure
– Sometimes providers have strong opinions about the particular
CPT codes that should be included in a measure in order to
make it more consistent with their experiences. In order to get
consensus on the measure, the organization may agree to modify
the specifications.
– Sometimes providers are anxious about being evaluated on
particular measure and request changes that they believe reflect
best practice
38
Most frequently modified measures
# programs
modifying
the measure
Measure Name
Steward
NQF #
12
10
Childhood Immunization Status
Use of Appropriate Medications for Asthma
NCQA (HEDIS)
NCQA (HEDIS)
38
36
8
Tobacco Use: Screening & Cessation Intervention
AMA-PCPI
28
7
CDC: Blood Pressure Control (<140/90 mm Hg)
NCQA (HEDIS)
61
7
CDC: Hemoglobin A1c (HbA1c) Control (<8.0%)
NCQA (HEDIS)
575
7
Breast Cancer Screening
31 (no
NCQA (HEDIS)
longer
endorsed)
7
Cholesterol Management for Patients with
Cardiovascular Conditions
NCQA (HEDIS)
NA
6
Controlling High Blood Pressure
NCQA (HEDIS)
18
6
Weight Assessment and Counseling for Nutrition and
Physical Activity for Children/Adolescents
NCQA (HEDIS)
24
6
CDC: Hemoglobin-A1c Testing
NCQA (HEDIS
57
39
Most frequently modified measures (cont’d)
# programs
modifying
the measure
Measure Name
Steward
NQF
#
5
Colorectal Cancer Screening
NCQA (HEDIS)
34
5
CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
NCQA (HEDIS)
59
5
CDC: LDL-C Screening
NCQA (HEDIS)
63
5
CDC: LDL-C Control <100 mg/dL
NCQA (HEDIS)
64
4
Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment: Engagement Only
NCQA (HEDIS)
4
4
CDC: Medical Attention for Nephropathy
NCQA (HEDIS)
62
4
Preventive Care and Screening: Body Mass Index (BMI)
Screening and Follow-Up
CMS
421
4
Frequency of Ongoing Prenatal Care
NCQA (HEDIS) 1391
40
Table of contents
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical
area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
41
Finding: Many programs use nonstandard measures
Undetermined
14%
Homegrown
36%
Standard
46%
Other
4%
Distinct measures by type
n =509
42
Some measures were from “undetermined”
sources
 78 of the measures were from “undetermined” sources
across 12 measure sets
 These measures are in this category due to difficulty
interpreting the source documents.
– Source was not indicated in the source document
– The measure did not include an NQF#
– The measure did not use a recognizable measure name
 11 VT ACO utilization measures are considered
“undetermined” because the specifications for these
measures have not been finalized. They are
undetermined from the program’s perspective.
43
There were 78 undetermined measures
across 12 measure sets
30
26
26
25
20
15
11
10
5
4
2
2
2
1
1
1
1
1
0
69% percent of the undetermined measures come
from two sources.
44
Finding : Many programs create
homegrown measures
What are
“homegrown”
measures?
Undetermined
14%
Homegrown
36%
Standard
46%
Other
4%
Distinct measures by type
n =509
Homegrown measures
are measures that were
indicated on the source
document as having
been created by the
developer of the
measure set.
If a measure was not
clearly attributed to the
developer, the source
was considered to be
“undetermined” rather
than “homegrown.”
45
40% of the programs created at least one
homegrown measure
70
60
50
40
30
20
10
0
65
32
21 21
16
9
6
5
4
3
3
3
2
2
2
1
There were 198 homegrown measures
across 19 measure sets
1
1
1
46
Programs create homegrown measures
across all domains
Access,
affordability,
and
inappropriate
care
17%
Communication and care
coordination
7%
Utilization
17%
Secondary
prevention and
treatment
9%
Health and
well-being
8%
Safety
12%
Person and
family-centered
care
20%
Infrastructure
10%
Homegrown measures by domain
n =198
47
Four basic types of homegrown measures
Provider choice
measures
10%
Unclear as to
why the program
used a
homegrown
measure
14%
Measures that
are specific to
one program
41%
Measures that
attempt to fill a
measurement
gap
35%
Homegrown measures by type
n =198
48
Some homegrown measures that are
specific to one program
 81 programmatic measures: measures related to
infrastructure, utilization, geographic access, and
program oversight
– Percent Eligibility Determination Done at State Level
– Child Psychiatrist Count
– Provider Satisfaction
 These measures are unlikely to become standardized
because they are specific to the management or
structure of a particular program.
49
Other homegrown measures may be
“reinventing the wheel”
 Of these 198 measures, there were 28 measures (14%) for
which it was not readily apparent as to why the program
created the measures, as these measures appeared to
replicate standard measures.
 Perhaps the programs were unaware of the availability of
the standard measures
– Adherence to prescription medications for asthma and/or COPD
(could have used NQF #1799: Medication management for people
with asthma)
– ED appropriate utilization: reduce all ED visits (could have used the
ED rates from the HEDIS Ambulatory Care measure)
– Emergency Department Visits: Previously Diagnosed Asthma
(ages 2 - 17) (could have used NQF# 1381 Asthma Emergency
Department Visits)
– Fall Prevention (could have used NQF #35 Fall Risk Management)
50
A few homegrown measures are designed to
give providers flexibility and options
 20 “provider choice” measures: measures that give
the provider an option with regard to the measurement
tool or outcome
– Quality of Life: provider selects a validated tool
– Percentage of patients 18 years of age and older receiving
depression screening through the use of PHQ-2 or other
approved screening instruments
– Activities of Daily Living: Provider selects a validated
assessment tool
 18 of these measures came from Texas and 2 came
from MA PCMH
 These types of measures could become standardized
but are not traditional measures at this point
51
Some homegrown measures attempt to
fill a measurement gap
 22 care management measures: measures related to care
transitions, care management or patient self-management
– Percent of patients in the highest risk registry who have a
documented self-management goal
– Post-discharge follow-up
 11 cost measures:
– Cost of care: PMPM rolling annual cost total and by service
category
– Cost savings from improved chronic care coordination and
management
 14 unique measures:
– Advance directives determination (Do Not Resuscitate)
– Functional status assessment for knee replacement
– Mental health admissions and readmissions to criminal justice
settings such as jails or prisons
52
Do homegrown measures represent
innovation?
 “Innovative” measures are measures that are not NQF
endorsed and:
a. address an important health care concern that is not
addressed in most state measure sets, e.g.,
•
•
•
•
• Patient self-management
Care coordination
• Procedure-specific quality
Care management/ transitions
concerns
Cost
• Social determinants of health
End-of-life care/ hospice/ palliative care
b. address an issue/condition for which few measures are
commonly employed, e.g.,
•
•
•
•
Dementia
Dental care
Depression
Maternal health
•
•
•
•
Mental health
Pain
Quality of life
Substance abuse
53
Finding #7: Most homegrown measures
are not innovative
Non-innovative
homegrown
measures
149
Innovative
homegrown
measures
53
Innovative
measures
that are
not
homegrown
23
But most innovative measures are
homegrown
Note: The numbers on this slide vary slightly from the others since we have added
the four additional homegrown innovative measures from MN AF4Q.
54
Innovative measures
 We identified 76 innovative measures across 50 measure
sets
– 48 measures sets from the state measure set analysis
– 2 additional regional collaborative measure sets
• Minnesota AF4Q
• Oregon AF4Q
 20 of the measure sets included at least one innovative
measure
–
–
–
–
35% of MA PCMH measures were innovative (17)
31% of MN SQRMS measures were innovative (4)
25% of MA MBHP measures were innovative (2)
16% of TX Delivery System Reform Incentive Program measures
were innovative (17)
 Some of the innovative measures may simply be
“measure concepts” that are not ready for implementation.
55
Examples of innovative measures
 % of hospitalized patients who have clinical, telephonic
or face-to-face follow-up interaction with the care team
within 2 days of discharge during the measurement
month (MA PCMH)
 Patient visits that occur with the selected provider/care
team (ID PCMH)
 Cost savings from improved chronic care coordination
and management (IA dually eligible program)
 Decrease in mental health admissions and readmissions
to criminal justice settings such as jails or prisons (TX
DSRIP)
 Mental and physical health assessment within 60 days
for children in DHS custody (OR CCO)
56
Innovation across the measure sets
18
16
14
12
10
8
6
4
2
0
17 17
6
5
4
4
3
3
3
2
2
2
2
1
1
1
1
1
1
57
There appears to be a need for new
measures in certain areas
16
14
12
10
8
6
4
2
0
15
11
10
7
8
6
4
4
3
3
2
2
2
58
Other measures: Bundles and composites
 Bundles are combinations of measures that use an “allor-nothing” approach. In order to achieve success on the
bundle, the entity must successfully meet the target on
each of the component pieces of the measure.
 Composites are combinations of measures in which the
various components are averaged in some fashion to
yield an overall view of performance on the group of
measures.
 These are considered separate from the modified
measures
59
Other: Some organizations create their
own bundles and composites
 There are two standard bundles that were used by
some programs:
– Optimal Diabetes Care bundle (NQF #729)
– Optimal Vascular Care bundle (NQF #76)
 There were 39 non-standard bundles and composites
used across 6 programs
–
–
–
–
–
–
15 CA Office of the Patient Advocate (HMO)
14 CA Office of the Patient Advocate (PPO)
6 CA Office of the Patient Advocate (medical group)
2 WI Regional Collaborative
1 MA MBHP
1 MN SQRMS
60
Table of contents
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical
area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
61
Finding: Regardless of how we analyzed
the data, the programs were not aligned
 We conducted multiple analyses and found non-alignment
persisted across:
–
–
–
–
Program types
Program purposes
Domains, and
A review of sets within CA and MA
 The only program type that showed alignment was the
Medicaid MCOs
– 62% of their measures were shared
– Only 3 measures out of 42 measures were not HEDIS measures
 California also showed more alignment than usual
– This may be due to state efforts or to the fact that three of the
seven CA measure sets were created by the same entity.
62
4. Analyzing the measures by program type
Goals:
 To analyze the measures by provider type and answer
the following questions:
1. What is the average size of the measure sets by program type?
2. To what extent do programs of the same type use the same
measures?
3. To what extent are the measures NQF-endorsed?
4. What are the most frequently used measures within each
program type?
63
Selected four measure set types for analysis
14
13
12
10
8
6
4
2
6
5
3
3
3
3
3
2
2
2
2
1
0
64
Finding: Not as much sharing within
program type as expected
70%
60%
50%
40%
30%
20%
10%
0%
62%
34%
20%
13%
12%
 We had anticipated
that programs of the
same type would
use the same
measures
 We found that
except for Medicaid
MCOs which share
more than other
types, this was
generally not the
case
65
Summary of program type analysis
Program Type
Average number
of measures in
the set
Number of
distinct
measures
Percent of
distinct
measures NQFendorsed
All measures
29
509
32%
PCMH
20
116
41%
Medicaid MCO
19
42
55%
Other provider
46
222
49%
Regional
collaborative
25
56
64%
66
PCMH measures
 267 measures across 13 measure sets
– Average of 20 measures per set (range: 6-48)
– All of the PCMH programs except for one modified at least
one of its measures
 116 distinct measures
 13 programs located in the following states:
– Idaho, Massachusetts, Maryland, Maine, Michigan,
Minnesota, Missouri, Pennsylvania, Rhode Island,
Washington
67
PCMH: Greater percentage shared but
still many used in only one set
Shared
34%
Not shared
66%
Number of distinct PCMH measures shared
by multiple measure sets
n = 116
68
PCMH: Majority of measures implemented
are NQF-endorsed
Never NQFendorsed
27%
-No longer
NQF
endorsed
5%
NQFendorsed
68%
Percentage of total measures that are NQFendorsed
n = 267
69
PCMH: But less than half of the distinct
measures are NQF-endorsed
NQFendorsed
41%
Never NQFendorsed
55%
No longer
NQFendorsed
4%
Percentage of distinct PCMH measures that
are NQF-endorsed
n = 116
70
Most frequently used PCMH measures
# programs
modifying
the measure
Measure Name
Steward
NQF #
9
CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS)
59
9
Controlling High Blood Pressure
NCQA (HEDIS)
18
9
Tobacco Use: Screening & Cessation Intervention
AMA
28
8
Body Mass Index (BMI) Screening and Follow-Up
CMS
421
8
Cardiovascular Disease: Blood Pressure Management
NCQA (HEDIS)
<140/90 mmHg
61
8
CDC: HbA1c Control (<8.0%)
NCQA (HEDIS)
575
8
Colorectal Cancer Screening
NCQA (HEDIS)
34
8
Use of Appropriate Medications for Asthma
NCQA (HEDIS)
36
7
Breast Cancer Screening
31 (no
NCQA (HEDIS) longer
endorsed)
7
Cardiovascular Disease: LDL Cholesterol
Management <100 mg/dl (CMC)
NCQA (HEDIS)
64
71
Medicaid Managed Care Organization
(MCO) measures
 111 measures across 6 measure sets
– Average of 19 measures per set (range: 6-42)
 42 distinct measures
– All except for 3 homegrown measures come from HEDIS
 All except one program modified measures
 6 Medicaid MCO programs included in analysis:
– California, California (specialty plans), Florida, Illinois,
Massachusetts, Pennsylvania
72
Medicaid MCO: Share more measures than
they don’t share
Not shared
38%
Shared
62%
Number of distinct Medicaid MCO measures
shared by multiple measure sets
n = 42
73
Medicaid MCO: Most of the measures
implemented are NQF-endorsed
Never NQFendorsed
27%
No longer
NQFendorsed
4%
NQFendorsed
69%
Percentage of Medicaid MCO measures that
are NQF-endorsed
n = 111
74
Medicaid MCO: Majority of distinct measures
are also NQF-endorsed
Never NQFendorsed
40%
No longer
NQFendorsed
5%
NQFendorsed
55%
Percentage of distinct Medicaid measures
that are NQF-endorsed
n = 42
75
Most frequently used Medicaid MCO
measures
#
programs
modifying
the
measure
Measure Name
Steward
NQF #
5
Controlling High Blood Pressure
NCQA (HEDIS)
18
4
Adolescent Well-Care Visits
NCQA (HEDIS)
NA
4
Breast Cancer Screening
31 (no
NCQA (HEDIS)
longer
endorsed)
4
CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
NCQA (HEDIS)
59
4
CDC: LDL-C Control <100 mg/dL
NCQA (HEDIS)
64
4
Childhood Immunization Status
NCQA (HEDIS)
38
4
Prenatal and Postpartum Care
NCQA (HEDIS)
1517
4
Well-Child Visits in the 3rd, 4th, 5th, & 6th Years of Life NCQA (HEDIS)
1516
76
Other provider measures
 276 measures across 6 measure sets
– Average of 46 measures per set (range: 5-108)
 222 distinct measures
 All of the provider programs modified at least one of
its measures
 6 Other provider programs included in analysis:
– California, Massachusetts GIC, Massachusetts PCPRI, PA
provider P4P program, TX Delivery System Reform Incentive
Program, and Utah’s Department of Health reporting system
77
Other provider: Very small percentage
shared
Shared
12%
Not shared
88%
Number of distinct provider measures shared
by multiple measure sets
n = 222
78
Other provider: Most of the measures
implemented are NQF-endorsed
Never NQFendorsed
39%
-No longer
NQF
endorsed
7%
NQFendorsed
54%
Percentage of Medicaid measures that are
NQF-endorsed
n = 276
79
Other provider: Just under half of the distinct
measures are NQF-endorsed
Never NQFendorsed
46%
NQFendorsed
49%
-No longer
NQF
endorsed
5% Percentage of distinct provider measures that
are NQF-endorsed
n = 222
80
Other provider: Most frequently used
measures
# programs
modifying
the measure
Measure Name
Steward
NQF #
6
Breast Cancer Screening
31 (no
NCQA (HEDIS) longer
endorsed)
5
Cervical Cancer Screening
NCQA (HEDIS)
32
4
CDC: HbA1c Testing
NCQA (HEDIS)
57
4
CDC: Medical Attention for Nephropathy
NCQA (HEDIS)
62
3
Controlling High Blood Pressure
NCQA (HEDIS)
18
3
Chlamydia Screening in Women
NCQA (HEDIS)
33
3
CDC: LDL-C Screening
NCQA (HEDIS)
63
3
Annual Monitoring for Patients on Persistent
Medications
21 (no
NCQA (HEDIS) longer
endorsed)
3
Cholesterol Management for Patients with
Cardiovascular Conditions (LDL-C Screening & LDL- NCQA (HEDIS)
C Control (< 100 mg/dL))
NA
81
Regional collaborative measures
 75 measures across only 3 studied measure sets
– Average of 25 measures per set (range: 10-37)
 56 distinct measures
 Two out of the three collaboratives modified at least
one of its measures
 3 Regional collaboratives included in the analysis:
– Maine Health Management Coalition, HealthInsight Utah,
Wisconsin Collaborative for Healthcare Quality
82
Regional collaborative: Very small
percentage shared
Shared
13%
Not shared
87%
Number of distinct regional collaborative
measures shared by multiple measure sets
n = 56
83
Regional collaborative: Most of the measures
implemented are NQF-endorsed
No longer
NQFendorsed
2%
Never NQFendorsed
25%
NQFendorsed
73%
Percentage of regional collaborative
measures that are NQF-endorsed
n = 75
84
Regional collaborative: Most distinct
measures are NQF-endorsed
Never NQFendorsed
34%
NQFendorsed
64%
No longer
NQFendorsed
2%
Percentage of distinct regional collaborative
measures that are NQF-endorsed
n = 56
85
7 shared regional collaborative measures
# programs
modifying
the measure
Measure Name
Steward
NQF #
2
CDC: Blood Pressure Control (<140/90 mm Hg)
NCQA (HEDIS)
61
2
CDC: HbA1c Control (<8.0%)
NCQA (HEDIS)
575
2
CDC: Hemoglobin-A1c Testing
NCQA (HEDIS)
57
2
CDC: LDL-C Control <100 mg/dL
NCQA (HEDIS)
64
2
CDC: LDL-C Screening
NCQA (HEDIS)
63
2
CDC: Medical Attention for Nephropathy
NCQA (HEDIS)
62
2
Preventive Care & Screening: Tobacco Use:
Screening & Cessation Intervention
AMA-PCPI
28
86
Conclusions from measure-type analysis
 Surprised that there is not more overlap of measures
within measure set type
 Medicaid MCOs are the exception and share far
more measures than any other type of program.
– This is partially because they rely almost exclusively on the
HEDIS measures.
 The “other provider” focused measures sets tend to
be larger on average and there is less sharing across
the provider measure sets
 The interest in modifying was not limited to one type
 While most of the implemented measures are NQFendorsed, many of the distinct measures used are
not endorsed
87
Table of contents
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical
area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
88
5. Analyzing the measures by program purpose
Goals:
 To analyze the measures by provider purpose and
answer the following questions:
1. What is the average size of the measure sets by program
purpose?
2. To what extent do programs designed for the same purpose use
the same measures?
3. To what extent are the measures NQF endorsed?
4. What are the most frequently used measures within each
program purpose?
89
Selected two measure set purposes for analysis
25
22
19
20
15
10
5
5
2
0
Reporting
Payment (and
reporting)
Reporting and
other purpose
Other
90
Finding: More sharing within reporting
programs than in payment
45%
40%
39%
35%
30%
26%
25%
20%
20%
15%
10%
 We had anticipated
that the payment
programs would use
more similar
measures, but we
found that was not
the case.
5%
0%
Reporting
Payment
All measures
91
Finding: Not as much use of NQF
measures for payment as expected
45%
40%
37%
36%
35%
32%
30%
25%
20%
15%
10%
5%
 We had anticipated
that the payment
programs would use
mostly NQF
endorsed
measures, but we
found that was not
the case.
0%
Reporting
Payment
All measures
92
Summary of program purpose analysis
Program
Type
Number of
programs
included in
category
Average
number of
measures in
the set
Number of
distinct
measures
Percent of
distinct
measures
NQF
endorsed
All measures
48
29
509
32%
Reporting
measures
22
22
157
37%
Payment
measures
19
30
250
36%
93
Measures for reporting
 490 measures across 22 measure sets
– Average of 22 measures per set (range: 5-50)
 157 distinct measures
 82% of the programs modified at least one of their
measures
94
Reporting: More sharing than the general
analysis
Shared
39%
Not shared
61%
Number of distinct reporting measures shared
by multiple measure sets
n = 157
95
Reporting: The majority of implemented
reporting measures are NQF-endorsed
-No longer
NQF
endorsed
7%
Never NQFendorsed
23%
NQFendorsed
70%
Percentage of reporting measures that are
NQF-endorsed
n = 490
96
Reporting: Most of the distinct measures are
not endorsed
NQFendorsed
37%
Never NQFendorsed
57%
-No longer
NQF
endorsed
6%
Percentage of distinct reporting measures
that are NQF-endorsed
n = 157
97
Most frequently used reporting measures
# programs
modifying
the measure
Measure Name
Steward
NQF #
16
CDC: Hemoglobin A1c (HbA1c) Control (<8.0%)
NCQA HEDIS
575
15
CDC: LDL-C Control <100 mg/dL
NCQA HEDIS
64
14
Controlling High Blood Pressure
NCQA HEDIS
18
14
CDC: Blood Pressure Control (<140/90 mm Hg)
NCQA HEDIS
61
14
CDC: Medical Attention for Nephropathy
NCQA HEDIS
62
13
CDC: Hemoglobin-A1c Testing
NCQA HEDIS
57
13
Breast Cancer Screening
31 (no
NCQA HEDIS
longer
endorsed)
12
CDC: LDL-C Screening
NCQA HEDIS
63
11
Cervical Cancer Screening
NCQA HEDIS
32
11
CDC: Eye Exam
NCQA HEDIS
55
98
Measures for payment
 563 measures across 19 measure sets
– Average of 30 measures per set (range: 3-108)
 250 distinct measures
 All except two of the measure sets used for payment
modified at least one of their measures
99
Payment: Shares slightly more than the
general, but less than the reporting
Shared
26%
Not shared
74%
Number of distinct payment measures shared
by multiple measure sets
n = 250
100
Payment: Most implemented measures are
NQF-endorsed
Never NQFendorsed
32%
NQFendorsed
64%
No longer
NQFendorsed
4% Percentage of payment measures that are
NQF-endorsed
n = 563
101
Payment: …but most distinct measures are
not NQF-endorsed
NQFendorsed
36%
Never NQFendorsed
61%
No longer
NQFendorsed
3%
Percentage of distinct payment measures that
are NQ- endorsed
n = 250
102
Most frequently used payment measures
#
programs
modifying
the
measure
Measure Name
Steward
NQF #
13
Breast Cancer Screening
NCQA (HEDIS)
31 (no
longer
endorsed)
12
Controlling High Blood Pressure
NCQA (HEDIS)
18
10
Cervical Cancer Screening
NCQA (HEDIS)
32
10
Follow-Up After Hospitalization for Mental Illness (7
NCQA (HEDIS)
day rate only)
576
9
Use of Appropriate Medications for Asthma
NCQA (HEDIS)
36
9
Childhood Immunization Status
NCQA (HEDIS)
38
NCQA (HEDIS)
59
CMS (PQRI 134)
418
9
9
CDC: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%)
Screening for Clinical Depression and Follow-up
Plan
103
Table of contents
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical
area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
104
Summary of domain analysis
Domain
Access, affordability, and
inappropriate care
Communication and care
coordination
Health and well-being
#of
Total # of
distinct
measures
measures
% of
measures
shared
# of programs
% of distinct
that share the
measures
most
NQFfrequently
endorsed
used measure
120
55
21%
24%
12
32
26
12%
25%
4
371
70
40%
44%
30
Infrastructure
23
20
0
0
0
Person and familycentered care
127
58
5%
12%
16
Safety
Treatment and secondary
prevention
181
95
16%
34%
19
448
143
25%
49%
29
Utilization
65
38
8%
3%
9
105
6. Access, affordability, and inappropriate care
 120 access, affordability, and inappropriate care
(AAIC) measures
– Only 4% were modified
 55 distinct measures
106
AAIC: Many measures used by only one
program
Shared
21%
Not shared
79%
Number of distinct AAIC measures shared by
multiple measure sets
n = 55
107
AAIC: Exactly half of the measures are NQF
endorsed
Never NQFendorsed
50%
NQFendorsed
50%
Percentage of total AAIC measures that are
NQF-endorsed
n = 120
108
AAIC: …but most of the distinct measures are
not endorsed
NQFendorsed
24%
Never NQFendorsed
76%
Percentage of distinct AAIC measures that
are NQF-endorsed
n =55
109
Most frequently used AAIC measures
# programs
modifying
the measure
12
11
10
7
7
6
6
Measure Name
Appropriate Testing for Children With Pharyngitis
Steward
NCQA (HEDIS)
Avoidance of Antibiotic Treatment in Adults with Acute
NCQA (HEDIS)
Bronchitis
Appropriate Treatment for Children with Upper
NCQA (HEDIS)
Respiratory Infections
Child and Adolescent Access to Primary Care
NCQA (HEDIS)
Practitioners (12-14, 25mo-6yr, 7-11, 12-19) HEDIS
Use of Imaging Studies for Low Back Pain
Adult Access to Preventive/Ambulatory Health
Services
Use of Spirometry Testing in the Assessment and
Diagnosis of COPD
NQF #
2
58
69
NA
NCQA (HEDIS)
52
NCQA (HEDIS)
NA
NCQA (HEDIS)
577
4
PC-01 Elective Delivery
The Joint
Commission
469
3
Cesarean Rate for Low-Risk First Birth Women
AHRQ/CHIRPA
NA
3
Third Next Available Appointment
NCQA Standard
NA
110
Communication and care coordination
 32 communication and care coordination measures
– None of the measures were modified
 26 distinct measures
111
Communication: Most distinct measures
used by only one program
Shared
12%
Not shared
88%
Number of distinct communication measures
shared by multiple measure sets
n = 26
112
Communication: Most measures used are not
NQF-endorsed
NQFendorsed
36%
Never NQFendorsed
55%
No longer
NQF endorsed
9%
Percentage of total communication measures
that are NQF-endorsed
n = 33
113
Communication: Most of the distinct measures
are not NQF-endorsed
NQFendorsed
25%
Never NQFendorsed
64%
Percentage of distinct communication
measures that are NQF-endorsed
n = 26
No longer
NQFendorsed
11%
114
Communication measures shared across
programs
# programs
modifying
the measure
Measure Name
Steward
NQF #
Care Transition — Transition Record Transmitted to
Health Care Professional
AMA-PCPI
648
2
3-Item Care Transition Measure (CTM-3)
University of
Colorado Health
Sciences Center
228
2
Medication reconciliation after discharge from an
inpatient facility
NCQA (HEDIS)
97
4
115
Health and well-being measures
 371 health and well-being measures
– None of the measures were modified
 70 distinct measures
116
Health and well-being:
Greater number of measures shared
Shared
40%
Not shared
60%
Number of distinct health and well-being measures
shared by multiple measure sets
n = 70
117
Health and well-being:
Most measures used are NQF-endorsed
Never NQFendorsed
18%
No longer
NQFendorsed
9%
NQFendorsed
73%
Percentage of total health and well-being
measures that are NQF-endorsed
n = 371
118
Health and well-being:
Most of the distinct measures are not endorsed
Never NQFendorsed
50%
NQFendorsed
44%
No longer
NQFendorsed
6%
Percentage of distinct health and well-being
measures that are NQF-endorsed
n = 70
119
Most frequently used health and wellbeing measures
# programs
modifying
the measure
Measure Name
Steward
NQF #
30
Breast Cancer Screening
NCQA (HEDIS)
31 (no
longer
endorsed)
24
Cervical Cancer Screening
NCQA (HEDIS)
32
21
Childhood Immunization Status
NCQA (HEDIS)
38
19
Colorectal Cancer Screening
Preventive Care & Screening: Tobacco Use:
Screening & Cessation Intervention
Weight Assessment & Counseling for Nutrition &
Physical Activity for Children & Adolescents
NCQA (HEDIS)
34
AMA-PCPI
28
NCQA (HEDIS)
24
Chlamydia Screening
NCQA (HEDIS)
33
NCQA (HEDIS)
1517
NCQA (HEDIS)
NA
NCQA (HEDIS)
4
17
17
15
15
14
14
14
Maternity Care: Postpartum Care (PPC), Prenatal
Visit During 1st Trimester (PPC)
Adolescent Well-Care Visits
Initiation and Engagement of Alcohol and Other
Drug Dependence Treatment: Composite
Preventive Care and Screening: Body Mass Index
(BMI) Screening and Follow-Up
CMS
421 120
Infrastructure measures
 23 Infrastructure measures
– None of the measures were modified
– 87% of the measures were homegrown
 20 distinct measures
121
Examples of infrastructure measures
 MO Medicaid managed care - BH measures
– Adult psychiatrist count
– Psychiatric practices contacted to complete survey regarding
patient services, services provided, service availability
 Oregon CCO Incentive Measures Set
– Electronic health record adoption
 NY Medicaid Redesign Initiative
– Percent eligibility determination done at state level
 MiPCT Clinical Metrics
– PCMH registry with decision support & performance reports
122
Infrastructure: No measures shared
Shared
0%
Not shared
100%
Number of distinct Infrastructure measures shared by
multiple measure sets
n = 20
123
Infrastructure:
None of the measures are NQF-endorsed
Never NQFendorsed
100%
Percentage of infrastructure measures that
are NQF-endorsed
n = 23
124
Person and family-centered care measures
 127 person and family-centered care measures
– Only 4% of the measures were modified
 58 distinct measures
125
Person and family-centered care:
Very small number of measures shared
Shared
5%
Not shared
95%
Number of distinct person and family-centered care
measures shared by multiple measure sets
n = 58
126
Person and family-centered care:
Most measures are NQF-endorsed
Never NQFendorsed
40%
NQFendorsed
59%
No longer
NQFendorsed
1% Percentage of total person and family-centered
care measures that are NQF-endorsed
n = 127
127
Person and family-centered care: Most of the
distinct measures are not NQF-endorsed
NQFendorsed
12%
No longer
NQFendorsed
2%
Never NQFendorsed
86%
Percentage of distinct person and familycentered care measures that are NQF-endorsed
n = 58
128
Shared person and family-centered care
measures
#
programs
using the
measure
Measure Name
1
Steward
NQF #
16
CAHPS Survey
AHRQ
YES
2
Hospice and Palliative Care – Treatment
Preferences
University of
North CarolinaChapel Hill
1641
2
Quality of Life survey: choice of tool
NA
NA
1: If a program used one question from a CAHPS survey, we counted it
as using CAHPS. We did not look at the specific surveys or which
questions/composites from the surveys they used.
129
Safety measures
 181 safety measures
– 17% of the measures were modified
 95 distinct measures
130
Safety:
Most measure used by only one program
Shared
16%
Not shared
84%
Number of distinct safety measures shared by multiple
measure sets
n = 95
131
Safety:
Most measures used are NQF-endorsed
Never NQFendorsed
33%
NQFendorsed
55%
No longer
NQFendorsed
12% Percentage of total safety measures that are
NQF-endorsed
n = 181
132
Safety: Most of the distinct measures are not
NQF-endorsed
NQFendorsed
34%
Never NQFendorsed
62%
-No longer
NQF
endorsed
4%
Percentage of distinct safety measures that
are NQF-endorsed
n = 95
133
Most frequently used safety measures
#
programs
using the
measure
19
11
Measure Name
Follow-Up After Hospitalization for Mental Illness
(30 day only)
Annual Monitoring for Patients on Persistent
Medications
Steward
NQF #
NCQA (HEDIS)
576
NCQA (HEDIS)
21 (no longer
endorsed)
NCQA (HEDIS)
1768
9
Plan All-Cause Readmission
6
Chronic Obstructive Pulmonary Disease - Admission
AHRQ (PQI)
Rate
275
6
Heart Failure Admission Rate (PQI 8)
277
6
Pharmacotherapy Management of COPD
Exacerbation (bronchodilator only)
NCQA (HEDIS)
549 (no
longer
endorsed)
5
Medication Management for People With Asthma
NCQA (HEDIS)
1799
4
Asthma in Younger Adults Admission Rate (PQI 15) AHRQ (PQI)
Hospital-Wide All-Cause Unplanned Readmission
Yale/CMS
Measure (HWR)
Diabetes Short-Term Complications Admission Rate AHRQ (PQI)
4
3
AHRQ (PQI)
283
1789
272134
Treatment measures, including treatment
and secondary prevention measures
 448 treatment and secondary prevention measures
– 23% of the measures were modified
 143 distinct measures
135
Treatment and secondary prevention:
Larger percentage shared than in other domains
Shared
25%
Not shared
75%
Number of distinct treatment and secondary prevention
measures shared by multiple measure sets
n = 143
136
Treatment and secondary prevention: Very high
percentage of measures are NQF-endorsed
No longer
NQFendorsed
3%
Never
NQFendorsed
20%
NQFendorsed
77%
Percentage of total treatment and secondary
prevention measures that are NQF-endorsed
n = 448
137
Treatment and secondary prevention: Only half
of distinct measures are NQF-endorsed
Never NQFendorsed
45%
NQFendorsed
49%
-No longer
NQF
endorsed
6%
Percentage of distinct treatment and secondary
prevention measures that are NQF endorsed
n = 143
138
Most frequently used treatment and
secondary prevention measures
#
programs
using the
measure
Measure Name
Steward
NQF #
29
Controlling High Blood Pressure
NCQA (HEDIS)
18
23
CDC: Hemoglobin A1c (HbA1c) Control (<8.0%)
NCQA (HEDIS)
575
23
CDC: LDL-C Control <100 mg/dL
NCQA (HEDIS)
64
21
Use of Appropriate Medications for Asthma
NCQA (HEDIS)
36
20
CDC: Medical Attention for Nephropathy
NCQA (HEDIS)
62
20
CDC: Blood Pressure Control (<140/90 mm Hg)
NCQA (HEDIS)
61
19
CDC: Hemoglobin-A1c Testing
NCQA (HEDIS)
57
18
CDC: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%)
NCQA (HEDIS)
59
17
CDC: LDL-C Screening
NCQA (HEDIS)
63
17
Cholesterol Management for Patients with
Cardiovascular Conditions (LDL-C Screening & LDL- NCQA (HEDIS)
C Control (< 100 mg/dL))
NA
139
Most frequently used treatment and
secondary prevention measures
#
programs
using the
measure
Measure Name
Steward
NQF #
16
CDC: Eye Exam
NCQA (HEDIS)
55
13
Follow-Up Care for Children Prescribed ADHD
Medication
NCQA (HEDIS)
108
13
Antidepressant Medication Management
NCQA (HEDIS)
105
8
Comprehensive Diabetes Care (Composite Measure)NCQA (HEDIS)
731
6
6
6
6
5
Persistence of Beta-Blocker Treatment After a Heart
NCQA (HEDIS)
Attack
Disease Modifying Anti-rheumatic Drug (DMARD)
NCQA (HEDIS)
Therapy in Rheumatoid Arthritis
Diabetes Care Foot Exam
NCQA (HEDIS)
Ischemic Vascular Disease (IVD): Complete Lipid
NCQA (HEDIS)
Profile and LDL-C Control <100 mg/dL
Heart Failure: Angiotensin-Converting Enzyme (ACE)
Inhibitor or Angiotensin Receptor Blocker (ARB)
AMA-PCPI
Therapy for Left Ventricular Systolic Dysfunction
71
54
56
75
81
140
Utilization measures
 65 utilization measures
– 17% of the measures were modified
 38 distinct measures
141
Utilization: Larger percentage not shared than
in other domains
Shared
8%
Not shared
92%
Number of distinct utilization measures shared by
multiple measure sets
n = 38
142
Utilization: Very high percent of measures are
NQF-endorsed
No longer
NQFendorsed
3%
Never
NQFendorsed
20%
NQFendorsed
77%
Percentage of total utilization measures that
are NQF-endorsed
n = 65
143
Utilization: Only one distinct measure is NQFendorsed
NQF
endorsed
3%
Never NQF
endorsed
97%
Percentage of distinct utilization measures that are
NQF endorsed
n = 38
144
Shared utilization measures
#
programs
using the
measure
9
Measure Name
Steward
Ambulatory Care
NCQA (HEDIS)
6
Asthma Emergency Department Visits
Alabama
Medicaid
Agency
2
Mental Health Utilization
NCQA (HEDIS)
NQF #
NA
1381
NA
145
Conclusions from domain analysis
 Programs select measures from the same domains,
with an emphasis on the Treatment and Secondary
Prevention and the Health and Well-being domains
 However, programs are not picking the same
measures within those domains
 Simply specifying the domains from which programs
should select measures will not facilitate measure set
alignment
146
Measures by clinical areas of interest
50
45
40
35
30
25
20
15
10
5
0
44
42
41
40
21
18
17
16
14
12
Distinct measures
147
Summary of clinical areas of interest analysis
# of distinct measures
# of programs that share
the most frequently used
measure
Behavioral health
44
19
Diabetes measures
42
23
Cardiovascular
measures
41
29
Pulmonary/critical care
40
21
Cancer-related
12
30
Clinical area of interest
148
44 behavioral health measures by category
14
13
12
10
9
8
7
7
6
5
4
3
2
0
Serious
Mental
Illness
Alcohol, Behavioral Depression
Substance
Health
Use/Abuse Screening
Tobacco
Use
ADHD
Distinct measures
149
Shared behavioral health measures
#
programs
using the
measure
Measure Name
Steward
NQF #
19
Follow-Up After Hospitalization for Mental Illness
NCQA (HEDIS)
576
17
Preventive Care & Screening: Tobacco Use:
Screening & Cessation Intervention
AMA-PCPI
28
14
Initiation and Engagement of Alcohol and Other
Drug Dependence Treatment
NCQA (HEDIS)
4
13
Antidepressant Medication Management
NCQA (HEDIS)
105
13
Follow-Up Care for Children Prescribed ADHD
Medication
NCQA (HEDIS)
108
12
Screening for Clinical Depression
CMS
418
Depression Remission at Six Months
MN Community
Measurement
NCQA (CAHPS)
2
2
Medical Assistance With Smoking and Tobacco
Use Cessation
711
27
150
Most frequently used diabetes measures
#
programs
using the
measure
Measure Name
Steward
NQF #
23
CDC: LDL-C Control <100 mg/dL
NCQA (HEDIS)
64
23
CDC: Hemoglobin A1c (HbA1c) Control (<8.0%)
NCQA (HEDIS)
575
20
CDC: Blood Pressure Control (<140/90 mm Hg)
NCQA (HEDIS)
61
20
CDC: Medical Attention for Nephropathy
NCQA (HEDIS)
62
19
CDC: Hemoglobin-A1c Testing
NCQA (HEDIS)
57
18
CDC: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA (HEDIS)
59
17
CDC: LDL-C Screening
NCQA (HEDIS)
63
16
CDC: Eye Exam
NCQA (HEDIS)
55
8
Comprehensive Diabetes Care (Composite Measure) NCQA (HEDIS)
731
6
Diabetes Care Foot Exam
56
NCQA (HEDIS)
151
Most frequently used diabetes measures
(cont’d)
#
programs
using the
measure
Measure Name
Steward
NQF #
3
Diabetes Short-Term Complications Admission Rate
(PQI 1)
AHRQ (PQI)
272
3
Uncontrolled Diabetes Admission Rate (PQI 14)
AHRQ (PQI)
638
Optimal diabetes care (ODC) (bundle)
MN Community
Measurement
729
3
2
Diabetes Long Term Complications Admission Rate(PQI 3)
AHRQ (PQI)
274
2
Comprehensive Diabetes Care: Blood Pressure
Control (<140/80 mm Hg)
NCQA (HEDIS)
NA
2
Comprehensive Diabetes Care: Hemoglobin A1c
(HbA1c) Control (<7.0%)
NCQA (HEDIS)
NA
152
41 cardiovascular disease measures by
category
14
12
10
8
6
4
2
0
13
9
8
4
4
3
Distinct measures
153
Shared cardiovascular disease measures
#
programs
using the
measure
29
17
6
6
6
5
4
3
3
2
2
Measure Name
Controlling High Blood Pressure
Cholesterol Management for Patients with
Cardiovascular Conditions
Persistence of Beta-Blocker Treatment After a Heart
Attack
Heart Failure Admission Rate (PQI 8)
Ischemic Vascular Disease (IVD): Complete Lipid
Profile and LDL-C Control <100 mg/dL
Heart Failure: ACE Inhibitor or ARB Therapy for LVSD
Hypertension: Blood Pressure Measurement
Ischemic Vascular Disease (IVD): Use of Aspirin or
Another Antithrombotic
Ischemic Vascular Disease (IVD): Blood Pressure
Control
Heart Failure : Beta-blocker therapy for LVSD
Optimal Vascular Care (OVC) (bundle)
Steward
NQF #
NCQA (HEDIS)
18
NCQA (HEDIS)
NA
NCQA (HEDIS)
71
AHRQ (PQI)
277
NCQA (HEDIS)
75
AMA-PCPI
81
13 (no longer
NCQA (HEDIS)
endorsed)
NCQA (HEDIS)
68
NCQA (HEDIS)
73
AMA-PCPI
MN Community
Measurement
83
76 154
40 pulmonary/critical care measures by
category
30
28
25
20
15
9
10
5
3
0
Asthma
COPD
Pneumonia
Distinct measures
155
Shared pulmonary/critical care measures
#
programs
using the
measure
21
6
6
6
Measure Name
Use of Appropriate Medications for Asthma
Asthma Emergency Department Visits
Steward
NCQA (HEDIS)
Alabama
Medicaid
Agency
NCQA (HEDIS)
Use of Spirometry Testing in the Assessment and
Diagnosis of COPD
Chronic Obstructive Pulmonary Disease - Admission
AHRQ (PQI)
Rate (PQI 5)
NQF #
36
1381
577
275
6
Pharmacotherapy Management of COPD
Exacerbation
549 (no
NCQA (HEDIS)
longer
endorsed)
5
Medication Management for People With Asthma
NCQA (HEDIS)
1799
4
Asthma in Younger Adults Admission Rate (PQI 15)
AHRQ (PQI)
283
3
Optimal Asthma Care
MN Community
Measurement
NA
156
12 cancer-related measures
 Most measures related to cancer screening
 Four shared measures
#
programs
using the
measure
Measure Name
Steward
NQF #
30
Breast Cancer Screening
NCQA (HEDIS)
31 (no longer
endorsed)
24
Cervical Cancer Screening
NCQA (HEDIS)
32
19
Colorectal Cancer Screening
NCQA (HEDIS)
34
2
“Checking for Cancer” Composite: Breast Cancer
Screening, Cervical Cancer Screening, Colorectal
Cancer Screening
NCQA (HEDIS)
NA
157
Table of contents
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical
area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
158
7. Summary of intrastate analysis
State
California
Massachusetts
All measures
# of
% of
# of
Total # of
distinct measures
programs measures
measures
shared
7
8
48
231
334
1367
64
214
509
69%
24%
20%
% of distinct
measures
NQFendorsed
% of
programs
that share
the most
frequently
used
measure
59%
59%
32%
86%
75%
63%
159
California measures
 231 measures across 7 measure sets
– Average of 33 measures per set (range: 6-51)
 64 distinct measures
 All of the CA programs modified at least one of their
measures
 Three of the 7 sets were created by the Office of the
Patient Advocate
160
California: Significantly more alignment
than typical
Not shared
31%
Shared
69%
Number of distinct CA measures shared by
multiple measure sets
n = 64
161
California: Uses mostly NQF measures
Never NQFendorsed
15%
-No longer
NQF
endorsed
8%
NQFendorsed
77%
Percentage of CA measures that are NQFendorsed
n = 276
162
California: Most of the distinct measures are
NQF-endorsed too
Never NQFendorsed
36%
NQFendorsed
59%
No longer
NQFendorsed
5% Percentage of distinct CA measures that are
NQF-endorsed
n = 64
163
Most frequently used CA measures
#
programs
modifying
the
measure
Measure Name
Steward
6
Annual Monitoring for Patients on Persistent
Medications
NCQA
(HEDIS)
6
Avoidance of Antibiotic Treatment in Adults with Acute NCQA
Bronchitis
(HEDIS)
6
Breast Cancer Screening
NCQA
(HEDIS)
6
CDC: Blood Pressure Control (<140/90 mm Hg)
6
CDC: Hemoglobin A1c (HbA1c) Control (<8.0%)
6
CDC: Hemoglobin-A1c Testing
6
CDC: LDL-C Control <100 mg/dL
NCQA
(HEDIS)
NCQA
(HEDIS)
NCQA
(HEDIS)
NCQA
(HEDIS)
NQF #
21 (no
longer
endorsed)
58
31 (no
longer
endorsed)
61
575
57
64
164
Most frequently used CA measures
(cont’d)
# programs
modifying
the measure
6
6
6
6
6
6
Measure Name
Steward
NCQA
(HEDIS)
NCQA
CDC: Medical Attention for Nephropathy
(HEDIS)
NCQA
Cervical Cancer Screening
(HEDIS)
Cholesterol Management for Patients with Cardiovascular NCQA
(HEDIS)
Conditions
NCQA
Controlling High Blood Pressure
(HEDIS)
NCQA
Use of Imaging Studies for Low Back Pain
(HEDIS)
CDC: LDL-C Screening
NQF #
63
62
32
NA
18
52
165
Massachusetts measures
 334 measures across 8 measure sets
– Average of 42 measures per set (range: 8-99)
 214 distinct measures
 6 of the 8 MA sets modified at least one of their
measures
166
Massachusetts: Less alignment than CA
Shared
24%
Not shared
76%
Number of distinct MA measures shared by
multiple measure sets
n = 214
167
Massachusetts: Most measures are NQFendorsed
-No longer
NQF
endorsed
7%
Never NQFendorsed
23%
NQFendorsed
70%
Percentage of MA measures that are NQFendorsed
n = 334
168
Massachusetts: Most of the distinct measures
are NQF-endorsed too
Never NQFendorsed
34%
NQFendorsed
59%
-No longer
NQF
endorsed
7% Percentage of distinct provider measures that
are NQF-endorsed
n = 214
169
Most frequently used MA measures
#
programs
modifying
the
measure
Measure Name
Steward
NCQA
(HEDIS)
6
Breast Cancer Screening
6
Follow-Up After Hospitalization for Mental Illness
6
Use of Appropriate Medications for Asthma
5
Cervical Cancer Screening
5
Initiation and Engagement of Alcohol and Other
Drug Dependence Treatment
NCQA
(HEDIS)
NCQA
(HEDIS)
NCQA
(HEDIS)
NCQA
(HEDIS)
4
Annual Monitoring for Patients on Persistent
Medications
NCQA
(HEDIS)
4
Screening for Clinical Depression
CMS
NQF #
31 (no
longer
endorsed)
576
36
32
4
21 (no
longer
endorsed)
418
170
Intrastate analysis summary
 California has significantly more alignment across its
measure sets when compared to Massachusetts and the
total measures set.
 Part of the reason for the alignment within CA is that three
of the seven measure sets were developed by the same
organization (Office of the Patient Advocate).
 Anecdotally, we have been told that CA has worked to
align its measure sets.
 While MA has work underway to align its measure sets
across the state though the Statewide Quality Committee,
currently there is little alignment within the state.
171
Table of Contents
1. Overview of measure sets
2. Overview of measures
3. Non-standard measures
4. Analysis by measure set type
5. Analysis by measure set purpose
6. Analysis by measure domain/clinical
area
7. Intrastate analysis of CA and MA
8. Conclusions / recommendations
172
Summary of findings
 There are many, many measures in use today.
 Current state and regional measure sets are not aligned.
 Non-alignment persists despite the tendency to use
standard, NQF-endorsed and/or HEDIS measures.
 With few exceptions, regardless of how we analyzed the
data, the programs’ measures were not aligned.
– With the exception of the Medicaid MCO programs, we found
this lack of alignment existed across domains, and programs of
the same type or for the same purpose.
– We also found that California has more alignment. This may be
due to our sample or the work the state has done to align
measures.
173
Summary of findings (cont’d)
 While many programs use measures from the same
domains, they are not selecting the same measures within
these domains.
– This suggests that simply specifying the domains from which
programs should select measures will not facilitate measure set
alignment.
 Even when the measures are “the same,” the programs
often modify the traditional specifications for the standard
measures.
174
Summary of findings (cont’d)
 Many programs create their own “homegrown”
measures.
– Some of these may be measure concepts, rather than
measures that are ready to be implemented
 Unfortunately most of these homegrown measures
do not represent true innovation in the measures
space.
 There appears to be a need for new standardized
measures in the areas of self-management, cost, and
care management and coordination.
175
Conclusions
 Bottom line: Measures sets appear to be developed
independently without an eye towards alignment with
other sets.
 The diversity in measures allows states and regions
interested in creating measure sets to select measures
that they believe best meet their local needs. Even
the few who seek to create alignment struggle due to a
paucity of tools to facilitate such alignment.
 The result is “measure chaos” for providers subject to
multiple measure sets and related accountability
expectations and performance incentives. Mixed
signals make it difficult for providers to focus their
quality improvement efforts.
176
This is only the beginning…
 We anticipate that as states and health systems become
more sophisticated in their use of electronic health
records and health information exchanges, there will be
more opportunities to easily collect clinical data-based
measures and thus increase selection of those types of
measures over the traditional claims-based measures.
 Combining this shifting landscape with the national
movement to increase the number of providers that are
paid for value rather than volume suggests that the
proliferation of new measures and new measure sets is
only in its infancy.
177
A call to action
 In the absence of a fundamental shift in the way in
which new measure sets are created, we should
prepare to see the problem of unaligned measure
sets grow significantly.
178
Recommendations
1. Launch a campaign to raise awareness about the current
lack of alignment across measure sets and the need for a
national measures framework.
– help states and regions interested in creating measure sets
understand why lack of alignment is problematic
2. Communicate with measure stewards to indicate to them
when their measures have been frequently modified and
why this is problematic.
– in particular in the cases in which additional detail has been added,
removed or changed
3. Develop an interactive database of recommended
measures to establish a national measures framework.
–
–
consisting primarily of the standardized measures that are used
most frequently for each population and domain
selecting and/or defining measures for the areas in which there is
179
currently a paucity of standardized measures
Recommendations (cont’d)
4. Provide technical assistance to states to help them select
high-quality measures that both meet their needs and
encourage alignment across programs in their region and
market. This assistance could include:
–
–
–
a measures hotline
learning collaboratives and online question boards, blogs and/or
listservs
benchmarking resources for the recommended measures
selected for inclusion in the interactive measures tool.
5. Acknowledge the areas where measure alignment is
potentially not feasible or desirable.
–
–
different populations of focus
program-specific measures
180
Contact information
Michael Bailit,
MBA
•
•
•
President
mbailit@bailithealth.com
781-599-4700
Kate Bazinsky,
MPH
•
•
•
Senior Consultant
kbazinsky@bailithealth.com
781-599-4704
Appendix
182
Overview of measure sets included in
analysis
State
Name
Type
AR
Arkansas Medicaid
Medicaid
CA
CA Medi-Cal
Managed Care
Division
CA
CA Medi-Cal
Managed Care
Division: Specialty
Plans
CA
# of
measures
NQFendorsed
Modified
Homegrown
14
79%
None
None
Medicaid
22
82%
45%
5%
Medicaid
6
50%
67%
33%
Office of the Patient Commercial
Advocate (HMO)
Plans
50
74%
18%
None
CA
Office of the Patient Commercial
Advocate (Medical
Plans
Group)
25
68%
4%
None
CA
Office of the Patient Other Provider
Advocate (PPO)
44
73%
14%
None
183
Overview of measure sets included in
analysis (cont’d)
State
Name
Type
CA
CALPERS
Commercial
Plans for Public
Employees
# of
measures
NQFendorsed
Modified
Homegrown
33
85%
6%
None
CA
Quality and Network
Management –
Exchange
Quality Reporting
System (QRS)
51
84%
6%
None
CO
Medicaid's
Accountable Care
Collaborative
ACO with
Primary Care
Medical Provider
3
None
33%
None
FL
Medicaid MCO
Procurement
Measures
Medicaid MCO
8
75%
None
None
IA
IA Duals
Duals
31
65%
10%
10%
IA
IA Health Homes
Health Home
12
92%
None
None
184
Overview of measure sets included in
analysis (cont’d)
State
Name
Type
# of
measures
NQFendorsed
Modified
Homegrown
ID
Idaho Medical Home
PCMH
Collaborative
17
59%
12%
None
IL
IL Medicaid MCO
Medicaid MCO
42
88%
12%
None
LA
Coordinated Care
Networks
Medicaid
35
71%
6%
9%
MA
MA Connector
Exchange
9
67%
None
None
MA
MA Duals Project
Duals
42
86%
None
5%
MA
MA GIC
Other Provider
99
60%
16%
None
185
Overview of measure sets included in
analysis (cont’d)
State
Name
Type
MA
MA MBHP
Behavioral
Health MCO P4P
MA
MA MMCO
MA
# of
measures
NQFendorsed
Modified
Homegrown
8
38%
13%
38%
Medicaid
19
79%
11%
None
MA PCPRI
Other Provider
26
96%
4%
None
MA
PCMH
PCMH
48
52%
56%
44%
MA
Statewide Quality
Alignment
Advisory Committee
Initiative
(SQAC)
83
78%
7%
1%
MD
Maryland MultiPayer Pilot Program PCMH
(MMPP)
20
90%
5%
None
186
Overview of measure sets included in
analysis (cont’d)
State
ME
ME
MI
MN
MN
MN
Name
Maine Health
Management
Coalition
Maine's PCMH
Project
The Michigan
Primary Care
Transformation
Project (MiPCT)
MN AF4Q
MN Dept Health
(Medicaid)
Health Care Home
MN SQRMS: MN
Statewide Quality
Reporting and
Measurement
System (SQRMS)
Type
# of
measures
NQFendorsed
Modified
Homegrown
Regional
Collaborative
28
100%
43%
None
PCMH
29
79%
24%
7%
PCMH
36
61%
19%
17%
Innovative
measures only
NA
NA
NA
NA
PCMH
7
86%
None
None
Alignment
Initiative
13
46%
15%
8%
187
Overview of measure sets included in
analysis (cont’d)
State
MO
MO
MO
MT
NY
OH
Name
Type
MO BHMCO
measures
MO Medicaid
Health Home
Missouri Medical
Home Collaborative
(MMHC)
Montana Medical
Home Advisory
Council
Medicaid Redesign
Initiative
Medicaid BH
MCO
SW OH CPCI
# of
measures
NQFendorse
d
Modified
Homegrown
69
3%
4%
94%
Health Home
41
41%
17%
51%
PCMH
9
89%
33%
11%
PCMH
13
92%
8%
None
Medicaid
38
55%
24%
24%
PCMH
21
86%
5%
None
Overview of measure sets included in
analysis (cont’d)
Stat
e
Name
Type
OK
OK Medicaid
Soonercare
PCMH
17
65%
18%
None
OR
CCO's Incentive
Measures Set
ACO
17
65%
53%
24%
PA
Chronic Care
Initiative
PCMH
34
47%
56%
15%
PA
Health Home
Care set
Health
Home
8
75%
None
None
PA
MCO/Vendor P4P
14
64%
29%
None
PA
Provider P4P
13
62%
31%
None
MCO
P4P
Other
Provider
# of
measures
NQFendorsed
Modified
Homegrow
n
Overview of measure sets included in
analysis (cont’d)
State
RI
TX
UT
UT
VT
Name
Type
RI PCMH (CSI)
PCMH
TX Delivery
Other
System Reform
Provider
Incentive Program
Other
UT Dept. of Health
Provider
Regional
Health Insight Utah
Collaborative
VT ACO Measures
ACO
Work Group
# of
measures
NQFendorsed
Modified
Homegrown
10
80%
100%
None
108
35%
2%
30%
5
60%
100%
None
10
100%
None
None
37
54%
11%
None
WA
Multi-payer PCMH PCMH
6
67%
67%
None
WI
WI Regional
Collaborative
10
80%
100%
None
Regional
Collaborative