1. Briefing on NQF MAP Duals Workgroup NQF SDS Trial Period
Special Needs Plans (SNP) Alliance Meeting

2. Agenda MAP Dual Eligible Beneficiaries Workgroup Role
MAP Duals Family of Measures Updates
NQF Risk Adjustment Background
SDS Perspectives
NQF Policy change
Trial Period

3. MAP Dual Eligible Beneficiaries Workgroup
Dual Eligible Beneficiaries Workgroup provides:
Balanced expertise for CMS and other Federal partners
Strategy for performance measurement
High-impact quality improvement opportunities
Identification of best available measures for the population
Prioritization of measure gaps
Ideas for new measures to fill gaps
Guidance on applying measures to vulnerable populations
Pre-rulemaking input to HHS on measures for defined programs and settings of care

4. MAP Structure

5. Person-Centered Look at Measurement Programs
A single consumer interacts with many measures over time…

6. Current MAP Measure Selection Criteria
NQF-endorsed measures are required for program measure sets, unless no relevant endorsed measures are available to achieve a critical program objective
Program measure set adequately addresses each of the National Quality Strategy’s three aims
Program measure set is responsive to specific program goals and requirements
Program measure set includes an appropriate mix of measure types
Program measure set enables measurement of person- and family- centered care and services
Program measure set includes considerations for healthcare disparities and cultural competency
Program measure set promotes parsimony and alignment
A key component of the National Quality Strategy is to “address the abundance of clinical quality measures… get to measures that matter and minimize provider burden.” U.S. Department of Health and Human Services (HHS). National Strategy for Quality Improvement in Healthcare. Washington, DC: HHS, 2011.

7. Updating the Family of Measures
Overview of current Family of Measures
58 NQF-endorsed, 2 no longer endorsed
Variety of measure types
39 process
10 outcome
5 patient reported outcome or consumer experience
3 composite
1 cost/resource use
14 with e-Measures available
Measures are applicable across a variety of care settings and levels of analysis
It's important to highlight that not all are intended for use in any one program. Fit-for-purpose is important and the family functions like a menu or pick list.
Measures identified as best-available to address quality issues across the continuum of care for dual eligible beneficiaries and high-need subgroups
Intended as a resource to assist the field in the selection of measures for programs, to promote alignment, and define high-priority gaps
Current family has 58 measures
Variety of measure types, care settings, levels of analysis
Increasing use in federal programs
Workgroup considered updates at March meeting

8. MAP Priority Gap Areas for Dual Eligible Beneficiaries
Goal-directed, person-centered care planning and implementation
Shared decisionmaking
Systems to coordinate acute care, long-term services and supports, and nonmedical community resources
Beneficiary sense of control/autonomy/self-determination
Psychosocial needs
Community integration/inclusion and participation
Optimal functioning (e.g., improving when possible, maintaining, managing decline)

9. New measures added to the MAP Duals Family
The workgroup voted to include 11 Behavioral Health measures, 1 Care Coordination measure, and 5 Admission and Readmission measures.

10. New measures added to the MAP Duals Family
NQF # Title
0104 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
*replaced #0111: Bipolar Disorder: Appraisal for risk of suicide
2380 Rehospitalization During the First 30 Days of Home Health
2456 Medication Reconciliation: Number of Unintentional Medication Discrepancies per Patient
2502 All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation Facilities (IRFs)
2505 Emergency Department Use without Hospital Readmission During the First 30 Days of Home Health
2510 Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)
2512 All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Long- Term Care Hospitals (LTCHs)
2597 Substance Use Screening and Intervention Composite

11. New measures added to the MAP Duals Family Health Plan Measures
NQF # Title
2599 Alcohol Screening and Follow-up for People with Serious Mental Illness
2600 Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other Drug Dependence
2601 Body Mass Index Screening and Follow-Up for People with Serious Mental Illness
2602 Controlling High Blood Pressure for People with Serious Mental Illness
2603 Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Testing
2604 Diabetes Care for People with Serious Mental Illness: Medical Attention for Nephropathy
2605 Follow-up after Discharge from the Emergency Department for Mental Health or Alcohol or Other Drug Dependence
2606 Diabetes Care for People with Serious Mental Illness: Blood Pressure Control (<140/90 mm Hg)
2607 Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
2608 Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Control (<8.0%)
2609 Diabetes Care for People with Serious Mental Illness: Eye Exam

12. MAP Continues to Advance the Agenda of Person-Centered Care
Themes to Expect in Forthcoming MAP Report (August 2015)
Improving alignment of measures across reporting requirements
Findings from interviews with key informants about the measure use experience and which measures are most effective in improving care
Strategies health plans and providers are using to engage beneficiaries as partners in their care and reduce disparities
Trauma-informed care, multi-disciplinary teams, etc

13. Risk Adjustment for Socioeconomic Status (SES) and Other Demographic Factors Briefing

14. Background
NQF has been working to identify and examine issues related to risk-adjusting measures for socioeconomic status (SES) or related demographic factors
What are sociodemographic status (SDS) factors?
Sociodemographic status refers to a variety of socioeconomic (e.g., income, education, occupation) and demographic factors (e.g., age, primary language, household income, zip code).
What is risk adjustment?
Risk adjustment is a statistical approach that allows patient-related factors (e.g., comorbidity and illness severity) to be taken into account when computing performance measure scores, thereby improving the ability to make fair and correct conclusions about quality. Although there are various ways to risk-adjust, the most common method is use of multivariable statistical models.

15. Background Why risk adjust?
Patients are not randomly assigned to healthcare units and the characteristics of the patients treated varies across healthcare unit
Avoid incorrect inferences
In the context of comparative performance assessment, the general question being addressed is:
How would the performance of measured entities compare if, hypothetically, they had the same mix of patients?
Key considerations
Association with the outcome
Association with the exposure (healthcare unit)
Not affected by the exposure or outcome
If precede the exposure to the healthcare unit –i.e., present at the start of care, it cannot be affected by healthcare unit or the outcome
Do not adjust for:
Treatment variables
Variables between healthcare unit treatment and the outcome, e.g., complication

16. Background Why consider adjustment for SDS?
Overall quality has improved, but disparities have not
Growing evidence regarding role of SDS factors on many outcomes
Evidence-based interventions that could help close the gap require additional resources  
Stratification has largely failed to materialize
Shift from process to outcomes reporting
Higher financial stakes has heightened concern, especially for safety net providers

17. Views on Adjustment for Sociodemographic Factors
Oppose
- Some providers may deliver worse quality care to disadvantaged patients
- Adjustment could make meaningful differences in quality disappear
- Worse outcomes could be expected
No expectation to improve
Implies or sets a different standard
- Lack of adequate data for SDS adjustment
- Prefer payment approach to help safety net
SUPPORT
- Risk adjustment allows for comparative performance
- A performance score alone (whether or not adjusted for SDS factors) cannot identify disparities.
- Hospitals caring for the disadvantaged are already being penalized.
- No evidence that disparities would be reduced through further negative financial incentives.
- Lack of adjustment would continue to create a disincentive to care for the poor.
Adjusting for sociodemographic factors will mask disparities
Adjusting for sociodemographic factors is necessary to avoid making incorrect inferences in the context of comparative performance assessment

18. SDS Expert Panel
To consider and address these issues, NQF convened an SDS Expert Panel to consider if, when, and how outcome performance measures should be adjusted for SES or related demographic factors
The Expert Panel was composed of multiple stakeholders with a variety of experiences related to outcome measurement and disparities
The Panel’s recommendations were presented for public comment and modified in response to comments received

19. SDS Expert Panel: Core Principles
Outcome performance measurement is critical to the aims of the National Quality Strategy.
Disparities in health and healthcare should be identified and reduced.
Performance measurement should not lead to increased disparities in health and healthcare.
Outcomes may be influenced by patient health status, clinical, and sociodemographic factors, in addition to the quality and effectiveness of healthcare services, treatments, and interventions.

20. SDS Expert Panel: Core Principles (cont.)
When used in accountability applications, performance measures that are influenced by factors other than the care received, particularly outcomes, need to be adjusted for relevant differences in case mix to avoid incorrect inferences about performance.
Risk adjustment may be constrained by data limitations and data collection burden.
The methods, factors, and rationale for risk adjustment should be transparent.

21. NQF Policy Change: Trial Period
The Panel recommended, and the NQF Board approved, a two-year trial period prior to a permanent change in NQF policy.
Under the new policy, adjustment of measures for SDS factors is no longer prohibited.
During the trial period, if SDS adjustment is determined to be appropriate for a given measure, NQF will endorse one measure with specifications to compute:
SDS-adjusted measure
Non-SDS version of the measure (clinically adjusted only)
Stratification of the non-SDS-adjusted version
Prior to the trial period, NQF had prohibited consideration of sociodemographic factors in risk adjustment, preferring stratification based on these variables

22. NQF Policy Change: Trial Period (cont.)
Each measure must be assessed individually to determine if SDS adjustment is appropriate.
Not all outcomes should be adjusted for SDS factors (e.g., central line infection would not be adjusted)
Need conceptual basis (logical rationale, theory) and empirical evidence
The recommendations apply to any level of analysis including health plans, facilities, and individual clinicians.

23. Guidelines for Selecting Risk Factors
Clinical/conceptual relationship with the outcome of interest
Empirical association with the outcome of interest
Variation in prevalence of the factor across the measured entities
Present at the start of care
Is not an indicator or characteristic of the care provided (e.g., treatments, expertise of staff)
Resistant to manipulation or gaming
Accurate data that can be reliably and feasibly captured
Contribution of unique variation in the outcome (i.e., not redundant)
Potentially, improvement of the risk model (e.g., risk model metrics of discrimination, calibration)
Potentially, face validity and acceptability

24. Implications of Trial Period for Measure Consideration and Evaluation
Newly-submitted measures
ALL measures submitted to NQF after April 1, 2015 will be considered part of the trial period, and Standing Committees may consider whether such measures are appropriately adjusted for SDS factors as part of their evaluation.
Previously-endorsed measures
Measures undergoing endorsement maintenance review during the trial period will also be considered “fair game” for consideration of SDS adjustment.
Other paths for evaluation of SDS adjustment for endorsed measures:
Ad hoc requests
Conditional endorsement (e.g., Readmissions, Cost & Resource Use)

25. Evaluation of Trial Period
To evaluate the success of the trial period – and the appropriateness of the change in policy to allow SDS adjustment – NQF will focus on a number of indicators, including but not limited to:
Number/types of measures submitted with SDS adjustment, and the outcome of those evaluations
Number/types of measures with requests for ad hoc review related to SDS adjustment
What SDS factors and variables were analyzed
The extent to which SDS adjustment follows accepted methods as outlined in the Expert Panel report
In addition, NQF will solicit feedback from stakeholders on the impact of the trial period.

26. Evaluation of Trial Period (cont.)
Longer-term questions for evaluating the impact of SDS adjustment may include:
The availability of data on SDS variables, and the quality of that data
How healthcare entities react to SDS-adjusted scores and stratified data for improvement
How purchasers and payers use SDS-adjusted scores in accountability programs
Whether SDS adjustment has any impact on disparities
While these questions are largely out of NQF’s control, NQF will work with stakeholders and the Disparities Standing Committee to explore ways of gaining insight into these longer-term issues.

27. Resources
For more information, please contact Project Webpage: Risk Adjustment for Socioeconomic Status or other Sociodemographic Factors:

28. Discussion