MLTSS Quality Measures . . .a quick tour of the landscape SNP Alliance, 13th Annual Leadership Forum November 3, 2017 Debra J. Lipson, Senior Fellow

Overview Current MLTSS measure scene Standardized MLTSS measures on the horizon Putting MLTSS measures into use/practice Next steps – how you can help

Current MLTSS Measure Landscape

MLTSS measures already exist YES BUT State Medicaid agencies developed their own LTSS measures for MLTSS plans CMS Financial Alignment Initiative (Dual Demo) measures Nearly all LTSS measures are state specific With the possible exception of “nursing facility diversion” (but not publicly reported last year due to “inconsistencies” in reporting) No standardization across states Most state MLTSS-specific measures have not been tested for validity and reliability and many are not clearly defined or specified No measures specific to MLTSS plans have yet been endorsed by NQF Gaps in some key LTSS domains

Which types of MLTSS Measures are needed? Standardized national measures are medically oriented for the most part HEDIS Medicare Advantage measures Hospitalization for Ambulatory Care Sensitive Conditions (ACSCs) among HCBS users Necessary but insufficient Measure gaps remain for key LTSS domains Rebalancing – greater use of HCBS, less use of institutional care Comprehensive LTSS assessment and care planning Quality of life, community integration (employment, socialization) Integration of medical care and LTSS

Can we use HCBS survey-measures for MLTSS? YES BUT CAHPS HCBS Experience of Care (NQF # 2967) specified for use at the state level, but could be used for MLTSS plans with adjustments National Core Indicator-AD measures under development, designed to be apply to MLTSS Denominator shifts from HCBS waiver participants to MLTSS members who meet minimum and continuous enrollment period requirements NCI-AD is a proprietary survey; some states may not use it and some prefer their own surveys Survey-based measures are important but costly and can be burdensome to members; subject to low response rates

Standardized MLTSS measures on the horizon

It’s easy to develop MLTSS measures YES BUT General consensus on important measure domains and gaps: Rebalancing: greater use of HCBS & less use of institutional care Comprehensive LTSS assessment and person- focused care planning Quality of life Community integration (employment, socialization) Integration of medical care and LTSS Feasibility and data availability among MLTSS plans must be carefully assessed Large differences - and capabilities – of MLTSS plan data systems State contract and reporting requirements complicate efforts to develop standardized measures Quality of life and community integration are subjective concepts Data to risk adjust LTSS outcome measures often not available, or very burdensome to collect

Medicaid Managed Care TA Project, 2012-2013 Sponsor and Partners: CMS, CMCS, Division of Managed Care Plans (DMCP) Mathematica Policy Research and NCQA Goal: Identify key MLTSS measure domains and concepts MLTSS quality processes and outcomes, excluding person-reported outcomes measures to avoid duplicating other efforts (e.g. HCBS experience of care survey) Result: Recommended a set of measure concepts and preliminary measure specifications to be field tested: Assessment and Care Planning Rebalancing/Institutional Utilization Falls Risk Screening, Assessment and Plan of Care

Quality Measure Development and Testing - MLTSS, 2015-2018 Sponsors and Partners: CMS: CCSQ, MMCO, CMCS DQ & CMCS DMCP Mathematica Policy Research and NCQA Goals Conduct field testing of recommended MLTSS measures with health plans Refine and revise measure specifications based on results Obtain TEP review and feedback Seek NQF endorsement, support measure implementation Results to date 4 Assessment and Care Planning measures – next slides 3 Rebalancing/Utilization measures - near end of testing Falls Risk Reduction measure – re-testing revised specifications

MLTSS Comprehensive Assessment Percentage of MLTSS enrollees who receive an in- home (face-to-face) comprehensive assessment within 90 days of enrollment, and updated at least annually ‘Comprehensive’ defined as assessment of 28 elements in 8 domains: Physical functioning, medical conditions, mental and behavioral health, vision/hearing/therapy needs, health risks, social support, care preferences and service use

MLTSS Comprehensive Assessment Majority of enrollees had 11-15 elements of 28 data elements documented Numerator will count documentation of all 9 core elements 9 Core Elements ADLs Current Medications Acute and chronic conditions Cognitive Function Mental Health Status Home Safety Risk Living Arrangement Availability of friend/family caregiver support Current Providers Source: Mathematica analysis of enrollee data from 5 health plans.

MLTSS Comprehensive Care Plan Percentage of MLTSS enrollees who have a comprehensive, person-centered care plan within 120 days of enrollment, and updated at least annually ‘Comprehensive’ includes 20 types of services and supports in 6 domains: Summary of assessed needs Plans to meet medical, functional, cognitive, emotional and social needs Amount, frequency and duration of LTSS services and supports Personal goals and preferences Provider coordination and communication Emergency back-up

MLTSS Comprehensive Care Plan About a quarter (28 percent) of enrollees had 12- 15 data elements documented (of 20 total) Numerator will count documentation of 7 core elements 7 Core Elements Medical needs Functional needs Cognitive needs, List of all services received/expected to receive Beneficiary goal Follow-up and communication schedule Plan for ensuring beneficiary needs are met in case of emergency Source: Mathematica analysis of enrollee data from 5 health plans.

MLTSS: Shared Care Plan Percentage of MLTSS enrollees with a care plan that was shared in whole or in part with key LTSS providers and the primary care provider (PCP) within 30 days of development 30 percent of care plans were shared with a PCP or another key LTSS provider Of those with a shared care plan, 63% were shared within 30 days

MLTSS: Post-Hospital Stay Re-Assessment/Care Plan Update Percentage of inpatient hospital discharges of MLTSS enrollees resulting in updates to the assessment and/or care plan within 30 days of discharge (excluding planned readmissions) 31% of discharges followed by re-assessment within 30 days Only 5.2% had a re-assessment AND care plan update within 30 days Source: Mathematica analysis of enrollee data from 5 health plans.

Rebalancing/Institutional Use Measures Final stages of analyzing field test results for: Admission to an Institution from the Community: Number of admissions to an institution among MLTSS enrollees residing in the community per 1,000 enrollee months 3 Rates: 1. Short-stay admissions (<100 days); 2. Long-stay admissions (100+ days); 3. Total admissions Successful Discharge after Short-Term Stay Percentage of admissions to an institution that result in successful discharge to the community (community residence for 30 or more days) within 100 days of admission Successful Transition after Long-Term Stay The percentage of long-term stay (101 days or more) institutional residents who are successfully transitioned to the community (community residence for 30 or more days) Exploring feasibility of risk-adjustment for clinical conditions

Re-Testing Falls Risk Reduction PQRS (provider-level measure) restricted to people age 65 and older; plan of care limited to Vitamin D supplements and referral for balance/strength/gait training Revised measure for MLTSS enrollees expands age range, and covers a wider set of evidence-based falls risk interventions Three rates: Screening Percentage of MLTSS enrollees who were screened for future fall risk at least once within 12 months. Assessment Percentage of MLTSS enrollees who had a history of falls and had a risk assessment for falls completed within 12 months. Plan of Care Percentage of MLTSS enrollees who had a history of falls and had a plan of care with at least one evidence-based intervention documented within 12 months.

Putting MLTSS Measures into Practice

NQF endorsement is important YES BUT CMS and States turn first to NQF- endorsed measures when creating performance measure sets NQF endorsement ensures that measures meet rigorous evaluation criteria: Importance/relevance to quality Scientific validity and reliability Feasibility Usability Alignment/harmonization with related measures MLTSS Assessment and Care Planning measures will be submitted to NQF for potential endorsement - November 2017 NQF committees are medically- oriented and give more weight to measures with high evidence ratings (multiple studies using experimental design, control groups, etc.) LTSS research less often meets high evidence ratings CMS includes non-NQF endorsed measures in Medicaid Core Sets, Medicare Advantage, MMP Core Set, Nursing Home Compare, and other programs

MLTSS measures found valid and reliable will be used by CMS and States YES BUT CMS, State Medicaid agencies, and MLTSS plans clamoring for standardized, validated LTSS measures For MLTSS For VBP with providers Initially, MLTSS plans may be asked to report the measures and given time to modify data systems to reflect new expectations States are not required to use, or report to CMS, Medicaid quality measures – even those in the Medicaid Core Sets States and MLTSS plans may not adopt or use certain measures if they cannot be properly risk adjusted due to lack of reliable and readily available data CMS MMCO may or may not adopt MLTSS measures for MMPs

Greater Alignment = Greater Use? Across MLTSS programs -- State MLTSS programs, MMPs, FIDE-SNPs, PACE, etc.   With heterogeneity of enrollees and variability in covered benefits covered, could one core set be applicable to all plans? Would different measures for enrollee subgroups help with alignment? Across federal and state payers Some states will follow CMS’ lead Others will continue to use their own measures Across states Nationally standardized measures will help to reduce variation Some states will continue to use “home-grown” measures to address performance domains without standardized measures

Data Collection and Reporting Issues Many data elements required for the new MLTSS measures are not routinely recorded or captured – health plans will need time to re-program data systems and train staff Data elements for the measures may be stored in different places/data sets Burden associated with abstracting data from case management records, which may not have structured fields like those in electronic medical records Random sampling can help lower burden Validation and auditing also needed

Miles to go before we sleep

What’s up next? CMS-Mathematica-NCQA final test data analysis 3 rebalancing/institutional use measures Revised falls risk reduction measure Self-direction offer & take-up measure to be tested soon All measure development efforts subject to results that indicate low reliability, validity or feasibility Measures may be re-specified and re-tested, e.g. Falls Risk Reduction. . . or abandoned Concurrent LTSS & HCBS measure development and testing efforts Need to be specified and tested for MLTSS plans too

How you can help Submit public comments To Mathematica on CMS-sponsored MLTSS measures To NCQA on adding MLTSS measures to HEDIS To NQF on MLTSS measure endorsement decisions Participate in MLTSS measure field tests First in line to assess data collection/reporting feasibility Opportunity to clarify/revise specifications Prepares your plan to implement measures (if adopted) Talk to CMS and State Medicaid agencies Which measures are most important to develop and test Appropriate uses of measures (internal QI, public reporting, P4P, etc.)

Posting draft technical specifications on CMS’ MLTSS website soon: For more information Posting draft technical specifications on CMS’ MLTSS website soon: https://www.medicaid.gov/medicaid/managed- care/ltss/index.html Debra Lipson, Mathematica Policy Research dlipson@mathematica-mpr.com Jessica Ross, Mathematica Policy Research jross@mathematica-mpr.com