2015 Slate of MNCM Publicly Reported Measures

MN Community Measurement
Slate of MNCM Measures for 2015 Reporting - Final
process
process
process
process
+
+
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●
●
●
●
●
●
●
●
●
●
●
●
SQRMS
process
Colorectal Cancer Screening
Chlamydia Screening in Women
Immunizations for Adolescents
Adolescent Depression/ Mental Health
Screening
Pediatric Overweight Counseling
Adult Healthy Lifestyle/ Risk Reduction
(CTG) – in development
Better Care – Effective and Reliable
+
+
Health Plans
Cervical Cancer Screening
+
BTE-MN
MG
MG
Meaningful Use
process
process
Data Collection
Method
PQRS
Healthy People and Healthy Communities
Breast Cancer Screening
Childhood Imm. Status (Combo 3)
Data Source
ACO
Measure Type
Reported Entity
C = Clinic
MG = Med Group
H = Hospital
NQF endorsed
Endorsement and Use
Key changes
Recommend for
Public
Reporting
in 2015?
AMBULATORY CARE SETTING
Health Plan
Health Plan
Claims
Claims/Chart/registry
●
MG
Health Plan
Claims/chart
●
C, MG
MG
MG
Groups/clinics
Health Plan
Health Plan
DDS
Claims
Claims/Chart/registry
+
●
●
C, MG
Groups/clinics
DDS
●
process
C, MG
Groups/clinics
DDS
outcome
C, MG
Groups/clinics
DDS
Controlling High Blood Pressure
outcome
MG
Health Plan
Claims/Chart
●
Depression - 6 Month Remission
Depression - 6 Month Response
Depression - PHQ-9 Follow-up at 6
Months
Depression - 12 Month Remission
Depression - 12 Month Response
Depression - PHQ-9 Follow-up at 12
Months
Depression - Utilization of PHQ-9
Follow-up Children Prescribed ADHD
Med
outcome
outcome
C, MG
C, MG
Groups/clinics
Groups/clinics
DDS
DDS
◊
◊
process
C, MG
Groups/clinics
DDS
outcome
outcome
C, MG
C, MG
Groups/clinics
Groups/clinics
DDS
DDS
process
C, MG
Groups/clinics
DDS
process
C, MG
Groups/clinics
DDS
◊
●
●
process
MG
Health Plan
Claims
●
●
●
composite
C, MG
Groups/clinics
DDS
Optimal Diabetes Care
composite
Optimal Vascular Care
composite
Spine Surgery – Functional status
outcome
Spine Surgery – Health Related QoL
outcome
Spine Surgery – Pain
outcome
Spirometry Testing Assess/Dx COPD
process
Total Knee Replacement, PRO tool use
process
New concept - TBD
Better Care – Communication and Care Coordination
HIT Survey - Ambulatory
survey
Health Care Homes – Advance Care
process
Planning – on hold
Health Care Homes – Follow Up After
process
Discharge – on hold
Better Care – Patient Centered
Patient Experience CG-CAHPS Survey –
outcome
4 Domains
Better Care – Appropriateness
Approp. Testing Children w/ Pharyngitis
process
Approp. Treatment for Children w/ URI
process
Avoid Antibiotic Adults Acute Bronchitis
process
Maternity Care - C-Section Rate
outcome
Colonoscopy Quality - in development
Affordability
Total Cost of Care
efficiency
Average Unit Price
efficiency
C, MG
C, MG
MG
MG
MG
MG
MG
Groups/clinics
Groups/clinics
Groups/clinics
Groups/clinics
Groups/clinics
Health Plan
Groups/clinics
DDS
DDS
DDS
DDS
DDS
Claims
DDS
Optimal Asthma Control
●
●
●
●
●
●
None
None
Add HPV test;
Hybrid method
None
None
None
Yes
Yes
●
NA
Yes
●
NA
Yes
NA
No
●
●
●
●
●
Yes;
Add’l targets
None
None
None
◊
◊
●
●
●
◊
◊
+
+
+
+
+
+
●
●
●
Yes†
Yes
Yes
Yes
None
None
Yes
None
Yes
None
Yes
Yes
●
Yes, removed
action plan
D4
V3
NA
NA
NA
None
NA
Yes
Yes
Yes
Yes
Yes
Yes
Yes
●
●
●
●
●
●
●
●
●
●
●
●
Yes
Yes
Yes
None
●
+
Yes
Yes
Clinic
Groups/clinics
survey
None
Yes
C, MG
Groups/clinics
DDS
NA
No
C, MG
Groups/clinics
DDS
NA
No
C
Groups/clinics
Survey
●
12 Month
Survey
Yes
MG
MG
MG
MG
Health Plan
Health Plan
Health Plan
Groups/clinics
Groups/clinics
Claims
Claims
Claims
DDS
DDS
●
●
●
None
None
None
No
NA
Yes
Yes
Yes
Yes
TBD
MG
MG
Health Plan
Health Plan
Claims
Claims
●
NA
None
Yes
Yes
outcome
H
outcome
H
MHA
MHA
Hospital claims
Hospital claims
None
None
Yes
Yes
outcome
H
MHA
Medical Record
MHA
Medical Record
MHA
Survey
●
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●
●
●
●
●
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●
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HOSPITALS
CMS – 3 mortality measures
AHRQ Quality Indicators – 8 composite
& mortality measures
Vermont Oxford Network (VON) – 1
NICU measure
CDC’s National Healthcare Safety
Network (NHSN) – 1 CLABSI
HCAHPS Survey -10 Domains
outcome
outcome
H
H
●
●
●
●
●
●
●
●
●
●
●
●
●
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None
None
None
Yes*
Yes*
Yes
Legend: + Partial or Modified ◊ MNCM is measure steward †Consistent with NCQA reporting plan *Results posted on www.mncm.org
NQF - National Quality Forum (endorsed)  HEDIS - Health Effectiveness Data & Information Set  SQRMS - MN Statewide Quality Reporting and Measurement System  PQRS - Physician
Quality Reporting System  MU - Meaningful Use  ACO - Accountable Care Organization Shared Savings Program
List of MNCM’s Previously Retired Measures:
HEDIS measures – completely retired:
• Well Child Visits. This measure was last reported in the 2006 Health Care Quality Report.
Rationale: The HEDIS measure did not align with ICSI guidelines.
•
Cancer Screening Combined. This measure was last reported in the 2010 Health Care Quality Report.
Rationale: Retired when the HEDIS Colorectal Cancer Screening measure was retired because they used the same denominator.
HEDIS measures – retired but replaced with another measure:
• Depression Treatment – Continuous Phase Medication Management. Last reported in the 2006 Health Care
Quality Report. It was replaced with a suite of depression measures.
Rationale: More robust depression measures developed and data collected directly from practices which
made it possible to report results at the clinic level and for results to include all patients.
•
Use of Appropriate Medications for People with Asthma. Last reported in the 2010 Health Care Quality Report.
It was replaced with the Optimal Asthma Care measure.
Rationale: A more robust asthma measure was developed and data was collected directly from practices
which made it possible to report results at the clinic level and for results to include all patients.
•
Colorectal Cancer Screening. Last reported in the 2010 Health Care Quality Report. It was replaced with the
Colorectal Cancer Screening measure.
Rationale: A colorectal cancer screening measure was developed that allowed data to be collected directly
from practices which made it possible to report results at the clinic level and for results to include all patients.
•
Childhood Immunization (Combo 2). This measure was last reported in the 2006 Health Care Quality Report. It
was replaced with the Childhood Immunization (Combo 3) measure.
Rationale: The combo 3 HEDIS measure included the chicken pox vaccine.
Measures Recommended for Retirement in 2015:
Ambulatory Surgery Measures (ASC). The following ASC measures are recommended for retirement due to lack of performance gap,
decreased use (removal from SQRMS) and ASC-specific performance not meeting validation standards for public reporting:
 Timing of Prophylactic IV Antibiotics
 Surgical Site Hair Removal
 Hospital Transfer or Admission
Withdrawn measure development concepts
• HITECH diagnostic imaging. This measure development concept was deemed not feasible due to lack of data source.
• Readmissions. This measure development concept was deemed not feasible due to lack of data source.
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