If I Ran the Zoo: Quality Measures in Accountable Care and the Fit with Integrative Health and Medicine. Jim Whedon, DC, MS Research Working Group, ACCAHC

What is Quality in Health Care? In 2001, the Institute of Medicine (IOM) issued the report, Crossing the Quality Chasm: A New Health System for the 21st Century The IOM report was a call to action to address deficiencies in the quality of US health care. The IOM identified 6 domains for defining quality. High quality health care must be: Safe Effective Patient-centered Timely Efficient Equitable

What is Quality in Health Care? The Agency for Healthcare Research and Quality (AHRQ) Government agency charged with improving the quality of US health care Quality Health Care = “Doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results.”

Measuring Quality in Health Care How does the Agency for Healthcare Research and Quality measure quality? AHRQ has developed standardized measures of health care quality known as Quality Indicators, which are organized into four modules : Prevention Quality Inpatient Quality Patient Safety Pediatric Quality AHRQ Quality Indicators (QIs) make use of hospital inpatient administrative data, and are based upon measures used in AHRQ’s Healthcare Cost and Utilization Project (HCUP), a nationwide collection of US hospital care data. .

Measuring Quality in Health Care The National Committee for Quality Assurance (NCQA) A non-profit dedicated to improving health care quality. NCQA has developed health care quality standards: The Healthcare Effectiveness Data and Information Set (HEDIS)

Measuring Quality in Health Care HEDIS The Healthcare Effectiveness Data and Information Set (HEDIS) used by more than 90 percent of health plans in the United States Domains: Effectiveness Access and Availability Experience of Care Utilization Also measures specific for: Wellness and Health Promotion Accountable Care Organizations

Measuring Quality in Accountable Care Organizations (ACOs) The National Committee for Quality Assurance (NCQA) NCQA ACO Pilot Program HEDIS Quality Measures are developed by a consensus-driven process, informed by public comment and pilot testing (under development) The Centers for Medicare and Medicaid Services (CMS) Medicare Shared Savings Program Pioneer ACO Program 33 ACO quality measures: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO- Shared-Savings-Program-Quality-Measures.pdf http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO- NarrativeMeasures-Specs.pdf http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/PQRS/GPRO_Web_Interface.html

Quality Measures for Accountable Care Organizations: NCQA ACO Pilot Program Topic Measures Prevention and Screening Weight Assessment for Children/Adolescents - BMI 2-18 Years of Age Adult BMI Assessment Colorectal Cancer Screening Cervical Cancer Screening Breast Cancer Screening Chlamydia Screening in Women Childhood Immunization Status Immunizations for Adolescents Care for Older Adults Cardiovascular Controlling High Blood Pressure Cholesterol Management for Patients with Cardiovascular Conditions Disease Modifying Anti-Rheumatic Drug (DMARD) Use of Rheumatoid Arthritis Musculoskeletal Osteoporosis Management in Women Who Had a Fracture Use of Imaging Studies for Low Back Pain Follow-Up Care for Children Prescribed ADHD Medication Follow-Up After Hospitalization for Mental Illness Behavioral Health Antidepressant Medication Management Initiation and Engagement for Alcohol and Other Drug Dependence Treatment Annual Monitoring for Patients on Persistent Medications Diabetes Diabetes Measure Suite (7 rates) Medication Management Respiratory Appropriate Medications for People With Asthma Appropriate Testing for Children with Upper Respiratory Infection Appropriate Testing for Children With Pharyngitis Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Use of Spirometry Testing in Assessment and Diagnosis of COPD Potentially Harmful Drug-Disease Interactions in the Elderly Use of High-Risk Medications in the Elderly Medication Reconciliation Post Discharge Utilization All-Cause Readmissions .

Quality Measures for Accountable Care Organizations: Medicare Domain Measure Description Patient/Caregiver Experience ACO #1 Getting Timely Care, Appointments, and Information ACO #2 How Well Your Doctors Communicate ACO #3 Patients’ Rating of Doctor ACO #4 Access to Specialists ACO #5 Health Promotion and Education ACO #6 Shared Decision Making ACO #7 Health Status/Functional Status Care Coordination/Patient Safety ACO #8 Risk Standardized, All Condition Readmissions ACO #9 ASC Admissions: COPD or Asthma in Older Adults ACO #10 ASC Admission: Heart Failure ACO #11 Percent of PCPs who Qualified for EHR Incentive Payment ACO #12 Medication Reconciliation ACO #13 Falls: Screening for Fall Risk Preventive Health ACO #14 Influenza Immunization ACO #15 Pneumococcal Vaccination ACO #16 Adult Weight Screening and Follow-up ACO #17 Tobacco Use Assessment and Cessation Intervention ACO #18 Depression Screening ACO #19 Colorectal Cancer Screening ACO #20 Mammography Screening ACO #21 Proportion of Adults who had blood pressure screened in past 2 years At-Risk Population Diabetes Diabetes Composite ACO #22 – 26 ACO #22. Hemoglobin A1c Control (HbA1c) (<8 percent) ACO #23 ACO #23. Low Density Lipoprotein (LDL) (<100 mg/dL) ACO #24. ACO #24. Blood Pressure (BP) < 140/90 ACO #25. ACO #25. Tobacco Non Use ACO #26. ACO #26. Aspirin Use ACO #27 Percent of beneficiaries with diabetes whose HbA1c in poor control At-Risk Population Hypertension ACO #28. Percent of beneficiaries with hypertension whose BP < 140/90 At-Risk Population IVD ACO #29 Percent of beneficiaries with IVD with complete lipid profile and LDL ACO #30 Percent of beneficiaries with IVD who use Aspirin or other antithrombotic At-Risk Population HF ACO #31 Beta-Blocker Therapy for LVSD At-Risk Population CAD CAD Composite ACO #32 – 33 ACO #32. Drug Therapy for Lowering LDL Cholesterol ACO #33. ACO #33. ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or LVSD .

Are CMS Quality Measures Consistent with the Principles & Practices of Integrative Health Care? EXCERPTS FROM: 2014 Coronary Artery Disease Module Narrative Measure Specification for GPRO Web Interface Use ONLY GPRO CAD-2 (NQF 0074): Composite (All or Nothing Scoring): Coronary Artery Disease (CAD): Lipid Control The CAD Composite measure consists of CAD-2 and CAD-7. DESCRIPTION: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result < 100 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a documented plan of care to achieve LDL-C < 100 mg/dL, including at a minimum the prescription of a statin DENOMINATOR: All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period NUMERATOR: Patients who have a LDL-C result < 100 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a documented plan of care to achieve LDL-C < 100 mg/dL, including at a minimum the prescription of a statin. Documented plan of care - Includes the prescription of a statin and may also include: documentation of discussion of lifestyle modifications (diet, exercise) or scheduled re-assessment of LDL-C Prescribed - May include prescription given to the patient for a statin at one or more visits within the measurement period OR patient already taking a statin as documented in current medication list RATIONALE: Managing LDL-C to less than 100 mg/dL through use of statins reduces risk of cardiovascular events. CLINICAL RECOMMENDATION STATEMENTS: Reduction of LDL-C to less than 70 mg/dL or high-dose statin therapy is reasonable. (Class IIa Statins should be considered as first-line drugs when LDL-lowering drugs are indicated to achieve LDL treatment goals. .

Are CMS Quality Measures Consistent with the Principles & Practices of Integrative Health Care? Which measures would you keep? Which ones would you drop? Would you introduce new measures?

Quality Measures for Accountable Integrative Health Care Do we need quality measures for integrative health? What quality issues currently exist in integrative health? How does integrative health contribute to better quality healthcare? What criteria should be used to identify potential quality measures? (evidence, safety, patient-centeredness, health creation vs. condition treatment) What process should be used for development of quality measures?