Measuring Quality and Value in Medicaid

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Measuring Quality and Value in Medicaid

• Patrick Roohan, Director
• Division of Quality and Evaluation
• Office of Health Insurance Programs
• New York State Department of Health
• November 13, 2008

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Agenda

• Medicaid Reform in NYS
• Measuring Quality
• NYs Quality Incentive
• What is Value?
• Tying Payment and Quality

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Medicaid Reform

• Governor Pattersons initiative to have Medicaid
  patient-focused
• Emphasize quality of care
• Get better value
• Rightsize the payment system

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Measuring QualityMedicaid Managed Care

• Begin measurement in 1995 to monitor the program
• In 1998 plans were directed to specific areas for
  improvement
• In 2000, plans with high scores on quality
  received more members due to auto-assignment
• In 2002, plans with high scores on quality
  receive more money through the Quality Incentive
  

Increasing Levels Of Accountability
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Reporting Performance

• Commitment early on to produce results and
  publicly release information
• Annual Report
• eQARR
• Consumer Guides

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Managed Care Plan Performance
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eQARR
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Medicaid Consumer Guides
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Plan-Directed Quality ImprovementQuality
Performance Matrix

• First developed in 1998, the QI Matrix targets
  measures that are in most need of improvement
• Based on two dimensions
• Plan performance compared to statewide averages
• Plan performance over time
• Uses QARR performance measures

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Plan-Directed Quality Improvement Quality
Performance Matrix

• Measures targeted are either below the statewide
  average and/or have a decreasing trend over time.
  
• Annually, plans are responsible for
• A root cause analysis, and
• An action plan for each measure in need of
  improvement
• Roohan et al, The Quality Performance Matrix New
  York States Model for Targeting Quality
  Improvement in Managed Care Plans, Quality
  Management in Health Care 2002, 10(2) 39-46

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Plan-Directed Quality Improvement Quality
Performance Matrix
Trend Increasing No Trend Trend Decreasing
Below At Statewide Ave Above
Statewide Average
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The Quality Incentive

• Initiated in 2002
• NYs Pay for Performance Program for Medicaid

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What are the Goals of the Quality Incentive?

• Business case for investing in quality
• Empower medical directors/QI staff with CFOs,
  COOs, CEOs
• Accelerate improvement
• Align with other P4P initiatives
• Health plan initiated
• Private payors (Bridges to Excellence)

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Quality Incentive

• Quality Incentive and Quality Weight in
  Auto-assignment
• implemented in fall of 02. Plans initially
  could earn up to 1 in additional premium. That
  amount was increased to 3.
• DOH also directs enrollees who do not choose a
  plan to high performing plans.

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Quality IncentiveMethodology

• HEDIS/QARR data counts 2/3 (10 measures)
• CAHPS data
• Compliance
• The Benchmark 75th percentile from two years
  previous measurement for HEDIS/QARR
• Above statewide average for CAHPS
• Measures change annually with rotation/priorities
• Plans can earn 3, 2.25, 1.5, .75 or no
  additional premium depending on their overall
  score

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Quality Incentive2008 Results (based on 2007
data)

• Winners
• 3 plans - 3
• 3 plans - 2.25
• 6 plans - 1.5
• 8 plans - .75

• Losers
• 3 plans
• No Quality Incentive
• -and-
• No quality preference in auto-assignment

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Quality IncentiveTracking the Money

• How do plans use Incentive funds?
• Build plan infrastructure (Information system
  upgrades, additional clinical staff, programmers,
  provider relations)
• Pass down to network physicians
• Member Incentives
• Hire consultants
• Use to defray rate cuts (general funds)
• Specific quality improvement activities

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Results to Date

• Four major trends/findings
• Rates of performance for almost all measures have
  increased over time
• In a study of MMC and FFS, MMC outperformed FFS
  in all but one of 21 measures
• The gap between commercial managed care and MMC
  has decreased over time, and MMC exceeds
  commercial managed care on some measures
• New York State exceeds almost all national
  benchmarks for MMC quality

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Medicaid Managed Care Trends Over Time 2001-2007
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Medicaid Managed Care Compared to Medicaid
Fee-for-Service
Based on a Study conducted in 2000
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Medicaid Managed Care Compared to Commercial
Managed Care
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What is Value?

• Value is getting the best quality for the lowest
  cost
• VALUE QUALITY / COST

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Tying Payment to Quality

• NYS implemented a risk adjusted payment system
  for Medicaid managed care in April 2008
• Uses Clinical Risk Groups (CRGs)
• Uses for Premium Groups
• SSI, TANF Adults, TANF children and Family Health
  Plus

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Description of Clinical Risk Groups (CRGs)

• CRGs are a categorical clinical model which
  assign each member of a population to a single
  mutually exclusive risk category. Each CRG is
  clinically meaningful and provides the basis for
  the prediction of health care utilization and
  cost.

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CRGs are Conceptually Simple

• CRGs use standard demographic, diagnostic,
  procedure, and pharmacy data - whether from
  claims, computerized medical records, or some
  other source.
• The process of assigning a CRG uses a clinically
  based hierarchical model.
• Each individual is assigned to a single, mutually
  exclusive clinically defined group which is in
  one of nine health statuses.

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The 9 CRG Statuses (ACRG3)

• Catastrophic Conditions
• Dominant, Metastatic and Complicated Malignancies
• Dominant Chronic Disease in Three or More Organ
  Systems
• Significant Chronic Disease in Multiple Organ
  Systems
• Single Dominant or Moderate Chronic Disease
• Minor Chronic Disease in Multiple Organ Systems
• Single Minor Chronic Disease
• Significant Acute Disease
• Healthy

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Aggregated CRGs

• The 1108 CRGs are consolidated into three tiers
  of aggregation (ACRGs)
• Each successive tier of aggregation has fewer
  base CRGs
• CRG 1108
• ACRG1 446
• ACRG2 181
• ACRG3 44
• Severity levels are maintained

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Examples of Diabetes Severity Leveling Factors
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CRG Payment Weights NY Medicaid TANF Adult

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CRG Payment Weights Medicare
Slide courtesy of
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CRG Payment Weights Medicare -- DM, CHF and COPD
Slide courtesy of
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How do we Connect Payment and Quality?

• Encourage CRG-level reduction in
• Hospitalizations, including Preventable Quality
  Indicator (PQI) hospitalizations
• ER Visits
• Reduce the variation among plans
• Monitor Disease Progression

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Medicare Admits Per 1000 by CRG
Slide courtesy of
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Disease Progression from 2003 to 2004 for Level 1
Diabetics in 2003
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Future InitiativesMedicaid Fee for Service

• Begun the process to measure quality in Medicaid
  FFS
• Hospital quality measurement
• Create Medicaid FFS QARR
• Payment reform tied to quality when possible
• Investment in outpatient care
• Selective Contracting
• Stop paying for never events

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Future InitiativesMedicaid FFS and MC

• Primary care standards
• Investigating NCQA Medical Home
• Prenatal care standards
• Reduce payment for hospitals with high potential
  preventable complication rates (PPCs) or high
  potentially preventable readmission rates (PPRs)
• Aligning fiscal and quality goals of the program