1. 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

2. 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

3. 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.”

4. 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. .

5. 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)

6. 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

7. 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: Shared-Savings-Program-Quality-Measures.pdf
NarrativeMeasures-Specs.pdf
Instruments/PQRS/GPRO_Web_Interface.html

8. 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 .

9. 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 .

10. Are CMS Quality Measures Consistent with the Principles & Practices of Integrative Health Care?
EXCERPTS FROM: 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. .

11. 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?

12. 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?