Part 4 of 4 Welcome to this presentation on “Quality Measures in Cholesterol and Diabetes Management.” 1

In conclusion, there are many public and private sector initiatives that aim to improve diabetes and cholesterol management by measuring the performance of health plans and providers. The next section will review some of the commonalities and differences between these initiatives. 2

This slide lists some of the more commonly used diabetes measures This slide lists some of the more commonly used diabetes measures. As can be seen from the table, all initiatives include a blood sugar control and LDL-C control measure for patients with diabetes. Most initiatives differentiate poor control (ie, A1C >9%) from control (A1C <8%). Apart from the Five-Star program, all initiatives reviewed here include blood pressure control measures as well.1-5 Note that A1C and LDL-C testing are less generally used as a quality measure. It should be noted that quality targets used here are often less stringent than those used by the American Diabetes Association, which recommends6: A1C <7% Blood pressure <130/80 mm Hg LDL-C <100 mg/dL for patients without overt cardiovascular disease, and <70 mg/dL as an option for patients with overt cardiovascular disease References NCQA. The State of Health Care Quality: Continuous Improvement and the Expansion of Quality Measurement; 2011. http://www.ncqa.org/LinkClick.aspx?fileticket=3MKx7Bok7tg %3d&tabid=1427&mid=5945&forcedownload =true. Accessed January 9, 2012. Centers for Medicare & Medicaid Services. Medicare health and drug plan quality and performance ratings 2012 Part C and Part D technical notes. http://www.scanhealthplan.com/documents/QualityImprovement/ 2012_Tech_Notes_2011_10_11.pdf. Updated October 11, 2011. Accessed October 31, 2011. Anise A. Quality Alliance Steering Committee, Engelberg Center for Health Care Reform. Brookings- Dartmouth accountable care organization initiative. http://www.healthqualityalliance.org/userfiles/Presentation_BD %20ACO%20Initiative.pdf. Accessed January 14, 2012. Centers for Medicare & Medicaid Services. Medicare program; Medicare shared savings program: accountable care organizations. Final rule. Fed Regist. 2011;76(2):67802-67990 (codified at 42 CFR Part 425). http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27461.pdf. Accessed January 13, 2012. Centers for Medicare & Medicaid Services. 2012 Physician Quality Reporting System (Physician Quality Reporting) measures list. https://www.cms.gov/PQRS/15_MeasuresCodes.asp. Published November 11, 2011. Accessed January 9, 2012. American Diabetes Association. Standards of medical care in diabetes-2011. Diabetes Care. 2011;34 (suppl 1):S11-S61. 3

The various quality initiatives reviewed in the presentation address complications of diabetes to a varying extent. The PQRS has the most comprehensive list of measures aimed at monitoring and managing diabetes complications, followed by the Five-Star program and the Medicare shared savings program for accountable care organizations.1-5 References NCQA. The State of Health Care Quality: Continuous Improvement and the Expansion of Quality Measurement; 2011. http://www.ncqa.org/LinkClick.aspx?fileticket=3MKx7Bok7tg %3d&tabid=1427&mid=5945&forcedownload =true. Accessed January 9, 2012. Centers for Medicare & Medicaid Services. Medicare health and drug plan quality and performance ratings 2012 Part C and Part D technical notes. http://www.scanhealthplan.com/ documents/QualityImprovement/2012_Tech_Notes_2011_10_11.pdf. Updated October 11, 2011. Accessed October 31, 2011. Anise A. Quality Alliance Steering Committee, Engelberg Center for Health Care Reform. Brookings-Dartmouth accountable care organization initiative. http://www.healthqualityalliance.org/userfiles/Presentation_BD%20ACO%20Initiative.pdf. Accessed January 14, 2012. Centers for Medicare & Medicaid Services. Medicare program; Medicare shared savings program: accountable care organizations. Final rule. Fed Regist. 2011;76(2):67802-67990 (codified at 42 CFR Part 425). http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/ 2011-27461.pdf. Accessed January 13, 2012. Centers for Medicare & Medicaid Services. 2012 Physician Quality Reporting System (Physician Quality Reporting) measures list. https://www.cms.gov/PQRS/ 15_MeasuresCodes.asp. Published November 11, 2011. Accessed January 9, 2012. 4

Less common goals related to cholesterol management are drug therapy to lower LDL-C in patients with CHD for Medicare ACOs, adherence to cholesterol lowering therapy for health plans in the Five-Star program, and PQRS measures related to general screening and risk stratification, as well as LDL-C control in patients with hypertension.1-5 References NCQA. The State of Health Care Quality: Continuous Improvement and the Expansion of Quality Measurement; 2011. http://www.ncqa.org/LinkClick.aspx?fileticket=3MKx7Bok7tg %3d&tabid=1427&mid=5945&forcedownload=true. Accessed January 9, 2012. Centers for Medicare & Medicaid Services. Medicare health and drug plan quality and performance ratings 2012 Part C and Part D technical notes. http://www.scanhealthplan.com/ documents/QualityImprovement/2012_Tech_Notes_2011_10_11.pdf. Updated October 11, 2011. Accessed October 31, 2011. Anise A. Quality Alliance Steering Committee, Engelberg Center for Health Care Reform. Brookings-Dartmouth accountable care organization initiative. http://www.healthqualityalliance.org/ userfiles/Presentation_BD%20ACO%20Initiative.pdf. Accessed January 14, 2012. Centers for Medicare & Medicaid Services. Medicare program; Medicare shared savings program: accountable care organizations. Final rule. Fed Regist. 2011;76(2):67802-67990 (codified at 42 CFR Part 425). http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011- 27461.pdf. Accessed January 13, 2012. Centers for Medicare & Medicaid Services. 2012 Physician Quality Reporting System (Physician Quality Reporting) measures list. https://www.cms.gov/PQRS/ 15_MeasuresCodes.asp. Published November 11, 2011. Accessed January 9, 2012. 6

Achievement of quality measures becomes increasingly important for all stakeholders. HEDIS and the NCQA formally recognize high-performing health plans, and report cards are in the public domain.1 The Medicare Five-Star program offers health plans public recognition and financial incentives, as well as permitting plans that achieve Five-Star status the added benefit of being allowed to enroll beneficiaries year round.2 Commercial ACOs often work with health plans to develop and implement mutually beneficial financial arrangements. Improvement of quality of care and efficiency of care delivery is often used by ACOs, independent delivery networks and plans in public relations and marketing.3 The Medicare Shared Savings program offers providers recognition and financial incentives.4 PQRS also offers clinicians recognition which will be made public with the launch of the Physician Compare Web site in 2013.5 In addition, financial incentives also enhance the value of the PQRS for providers.5 References NCQA. The State of Health Care Quality: Continuous Improvement and the Expansion of Quality Measurement; 2011. http://www.ncqa.org/LinkClick.aspx?fileticket=3MKx7Bok7tg %3d&tabid=1427&mid=5945&forcedownload =true. Accessed January 9, 2012. Centers for Medicare & Medicaid Services. Announcement of calendar year (CY) 2012 Medicare Advantage capitation rates and Medicare Advantage and Part D payment policies and final call letter. https://www.cms.gov/PrescriptionDrugCovContra/Downloads/Announcement2012final.pdf. Published April 4, 2011. Accessed October 31, 2011. Capgemini Consulting. US health care reform: the emergence of value based purchasing and accountable care organizations. http://www.us.capgemini.com/insights-resources/publications/us-health- care-reform-the-emergence-of-value-based-purchasing-and-accountable-care-organizations/. Accessed December 2, 2011. Centers for Medicare & Medicaid Services. Medicare program; Medicare shared savings program: accountable care organizations. Final rule. Fed Regist. 2011;76(2):67802-67990 (codified at 42 CFR Part 425). http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27461.pdf. Accessed January 13, 2012. Centers for Medicare & Medicaid Services. Proposed changes for calendar year 2012 physician incentive programs. http://www.snm.org/index.cfm?PageID=1110&FileID=199143. Published July 1, 2011. Accessed October 27, 2011. 7

We have seen that hypercholesterolemia and diabetes remain underdiagnosed, undertreated, and frequently uncontrolled. Managing the costs and improving the quality of such highly prevalent diseases like hypercholesterolemia and diabetes care are top priorities for private and public payers alike. We have looked at VBP and seen that the trend toward VBP is driven by a combination of private and public sector initiatives that center around core elements of Improving the quality of care Improving the efficiency of care delivery Limiting the growth in healthcare expenditures Payment reform that rewards plans and providers for high-quality care and/or cost savings All stakeholders, from patients and providers to payers and employers, stand to gain if they work together to achieve quality targets and improve cholesterol and diabetes management. 8