Measuring Results

1. Improve health outcomes for adults with diabetes
2. Improve health through the reduction of adult body mass indices
3. Reduce hospital readmission rates and ambulatory care sensitive condition admissions
4. Improve care coordination for individuals with asthma
5. Improve care coordination through timely transmission of transition records
6. Improve preventive care for children
7. Improve treatment of individuals with clinical depression.

Alabama will primarily use Medicaid claims and eligibility data to track the state’s performance specific to these goals.

1. Improved health care access
2. Improved health outcomes for patients
3. Improvements promoting long-term cost savings
4. Enhanced patient satisfaction
5. Enhanced practice satisfaction

• Ratio of preventive visits to expected (10 visits by age 2, 1 every year after);
• ED utilization rates;
• Immunization rates;
• Parent satisfaction;
• Use of a preventative developmental screening code; and
• Provider willingness to take more Medicaid children.

Accountable Care Collaborative (ACC) Program: The primary goals of Colorado’s Accountable Care Collaborative program are to improve health outcomes through a coordinated, client/family-centered system that proactively addresses clients health needs and controlling costs by reducing avoidable, duplicative, variable and inappropriate utilization.
 
The program’s 2012 Annual Report to the legislature, published in Nobember 2012, reported reductions in hospital readmissions and utilization of high-cost imaging services for ACC enrollees compared to non-enrollees. Emergency room utilization also increased less for enrollees than for non-enrollees. The report also found that ACC enrollees with asthma and diabetes are less likely to be hospitalized or readmitted. Colorado estimates that the program has saved the state $30 million in its first year, exceeding the state’s initial estimate of $20 million.
 
 
The Accountable Care Collaborative 2013 Annual Report, released in November 2013, reported additional positive findings, including additional cost savings:

• Reduced hospital readmissions (15-20%) and high cost imaging services utilization (25%) relative to a comparison population;
• Improved chronic disease management, as evidenced by a 22% reduction in hospital admissions among ACC members with COPD who have been enrolled in the program six months or more, compared to those not enrolled, as well as lower rates of exacerbated chronic health conditions such as hypertension (5%) and diabetes (9%) relative to clients not enrolled in the ACC program;
• Emergency room utilization by ACC enrollees increased 1.9%, compared to an increase of 2.9% for those not enrolled; and
• $44 million gross reduction ($6 million net reduction) in total cost of care for clients enrolled in the ACC Program.

• Number of diabetics receiving blood pressure screenings and eye exams
• Inpatient readmissions
• Emergency department utilization
• Medication reconciliation for asthmatics

Pediatric:

• Developmental Screenings
• Recommended well-care visits
• Connection to dental services
• Emergency department utilization

Customized CAHPS-PCMH surveys for both the adult and pediatric populations will include questions to evaluate patient experience with medical homes and the Medicaid provider network.

• Clinical measures, including chronic disease outcome measures and preventive care measures;
• Practice transformation; and
• Patient and provider/staff satisfaction.

For a complete list of required measures, visit the Idaho Medical Home Collaborative Pilot Measures matrix.
 
Beyond this list, some participating payers require reporting on additional measures. For more information, visit the summary of additional requirements for each payer: Blue Cross of Idaho, Pacific Source, and Regence Blue Shield of Idaho. For more information on Idaho Medicaid, see below.
 
ACA Section 2703 State Plan Amendment: Idaho Medicaid is using claims and chart-based process and outcome measures endorsed by the National Quality Forum to track progress on six goals for the state’s health home program:

1. Improve care for diabetes among adults;
2. Improve care for patients with heart disease;
3. Improve care for individuals with mental illness;
4. Improve care for asthma among adults and children;
5. Increase preventive care for adults; and
6. Increase preventive care for children.

For more information on provider reporting requirements in addition to requirements under the IMHC program (see above), see the Idaho Medicaid summary.

• Patient experience of care, as assessed by surveys
• Cost savings, as calculated by actuaries
• Process and clinical outcomes improvements, especially at the population-level
• Provider satisfaction

The Illinois Department of Healthcare and Family Services has announced that Illinois Health Connect saved the state approximately $150 million in fiscal year 2009. The state has also seen increases in developmental screenings, mammograms, and regular adolescent check-ups since implementing the program.
 
The Commonwealth Fund has provided $100,000 in funding for the Robert Graham Center to study the impact of Illinois Health Connect and Your Healthcare Plus (a disease management program). The evaluation will draw on claims data from before and after program implementation, as well as data from Medicaid programs in other states. The grant was announced in 2011. Researchers from the Robert Graham Center presented on findings from this evaluation at the 2012 annual conference of the American Public Health Association, estimating savings for the 2007-2010 period at $531 million.

• Reduction in unjustified variation of utilization and expenditure
• Improvement of safety, timeliness, effectiveness, and efficiency
• Increased patient participation in decision making
• Increased access to evidence-based care in underserved areas
• Cost containment

A draft of the full evaluation design is available here.
 
ACA Section 2703 Health Homes: Iowa is working to measure success toward the state’s two goals for this state plan amendment:

1. Change patient behavior to increase the use of preventative services and increase awareness of appropriate chronic condition management; and
2. Transform provider practices by adopting the patient-centered medical home model to improve population health.

Specific measures, drawn from the National Quality Forum and CHIPRA core measure sets, include hospital admissions and readmissions, emergency department utilization, and skilled nursing facility visits.
 
The state is also tracking the program’s administrative costs, total cost savings, patient outcomes, and patient satisfaction, as well as gathering input from patients and providers on the implementation process and lessons learned.

• Healthcare Effectiveness Data and Information Set (HEDIS);
• Agency for Healthcare Research and Quality Review (AHRQ);
• Consumer Assessment of Healthcare Providers and Systems (CAHPS);
• Children’s Health Insurance Program Reauthorization Act (CHIPRA); and
• Other measures as determined by the Louisiana Department of Health and Hospitals.

For specific measures, please see the networks’ quality companion guide or the appendices for the prepaid and shared savings request for proposals.

1. Reduce inefficient healthcare spending;
2. Improve chronic disease management;
3. Improve preventive care for children; and
4. Ensure evidence-based prescribing.

Specific measures include hospital admissions and readmissions, emergency department utilization, and skilled nursing facility visits.

• Adult prevention and screening;
• Behavioral health (adult and pediatric);
• Pediatric health (excluding behavioral health measures)
• Adult chronic conditions
• Access (adult and pediatric)
• Care coordination (adult and pediatric)

These measures will impact pay for reporting, pay for quality performance, and shared savings payments over the course of the three year initiative. For more information on the selected measures, including impact on payment, see Attachement D of the PCPRI RFA.

• Quarterly narrative and financial reports submitted by each physician organization on progress in achieving MiPCT goals.
• Semi-annual payer reports.
• Financial reports
• Standard audit procedures

• Clinical Quality: The report found that health care home practices performed better than non-health care home practices on a variety of clinical quality measures, including (* indicates statistically significant difference):
  • Colorectal cancer screening*,
  • Asthma care*,
  • Diabetes care*,
  • Vascular care* (percentage of patients with Ischemic Vascular Disease who have optimally managed modifiable risk factors), and
  • Depression follow-up.
• The report notes that all statistically significant results indicated that clinical quality at health care home practices was higher than clinical quality at non-health care home practices. Asthma care showed the largest difference in quality of care (over 20%) between health care homes and non-health care homes.
• Utilization: Medicaid enrollees attributed to health care home practices had significantly fewer emergency department visits than those attributed to non-health care home practices in 2010, 2011, and 2012.
• Cost: Over the three-year evaluation period, the average per-member cost for Medicaid enrollees attributed to health care homes was $2,588, compared to $2,850 for enrollees attributed to non-health care home practices. This represents 9.2% net cost savings.

Minnesota’s Outcomes Measurement Work Group previously developed recommendations for the state’s evaluation, proposing to focus evaluation efforts on clinical quality (especially care for patients with asthma and vascular conditions), patient access to care and experience of care, and cost (especially rates of hospitalizations, readmissions, emergency department use, and total cost of care).

1. Improve health outcomes for persons with mental illness
2. Reduce substance Abuse
3. Increase patient empowerment and self-management
4. Improve coordination of care
5. Improve preventative care
6. Improve diabetes care
7. Improve asthma care
8. Improve cardiovascular care

Missouri will assess quality improvement and clinical outcome measures at both the practice and aggregate levels.
 
ACA Section 2703 Health Homes – Primary Care Health Homes:MOHealthNet will use claims, a disease registry, a web-based electronic medical record, monthly data reports from participating primary care health home practices, and Consumer Assessment of Healthcare Providers and Systems Clinician and Groups (CG-CAHPS) surveys to measure success in eight specific goals specified in their second health home state plan amendment:

1. Improve health outcomes for persons with chronic conditions
2. Improve behavioral healthcare
3. Increase patient empowerment and self-management
4. Improve coordination of care
5. Improve preventative care
6. Improve diabetes care
7. Improve asthma care
8. Improve cardiovascular care

Missouri will assess quality improvement and clinical outcome measures at both the practice and aggregate levels.

• Improved health care access;
• Improved health outcomes for patients;
• Medicaid cost containment;
• Patient satisfaction; and
• Provider satisfaction.

A list of measures for each outcome of interest is available here.
 
In addition, TransforMED collected metrics on the progress of the transformation of the practices through the Patient Experience Assessment Tool (PEAT) and provider/staff surveys.
 
The evaluation for the two-year pilot, competed in November 2013, used analysis of claims data, provider records, and surveys to measure pilot impact on the identified outcomes of interest. Highlights from the evaluation findings include:

• A statistically significant decrease in the rate of overall emergency department visits per 1,000 patients;
• A statistically significant decrease in the number of prescriptions written per 1,000 patients and in spending for prescriptions per 1,000 patients;
• A significant decrease in the percentage of total visits to specialists, and in the rate of visits to specialists per 1,000 patients;
• Improvement in clinical process measures preventive care and chronic disease management, including cancer screenings, tobacco use screenings, body mass index tracking, diabetes control, cholesterol control, and high blood pressure control; and
• Increased patient satisfaction.

Multi-Payer Patient-Centered Medical Home Pilot: The participation agreement for Nebraska’s multi-payer medical home pilot requires participating payers select measures for practice reporting from a mutually agreed-upon list. The lists of adult quality measures and pediatric quality measures are available online.

1. “Whether cost savings are achieved and supporting documentation;
2. Types and rates of health screening;
3. Health outcome measures including but not limited to:
   • emergency room visit rates;
   • hospitalization rates; and
   • avoidable hospital readmission rates, comparing medical home cohorts;
4. At a minimum, two clinical measures; and
5. Satisfaction measures, e.g., CAHPS [Consumer Assessment of Healthcare Providers and Systems] measures.”

Reports are to be made to the Division of Medical Assistance and Health Service (DMAHS) annually.

• improve quality and outcomes
• lower overall health care costs
• improve access; and
• create a new clinically integrated model that can be replicated in other parts of the state.

Statewide Patient-Centered Medical Home Program: Chapter 58 of the Laws of 2009 requires the state health commissioner to report on the Statewide Patient-Centered Medical Home Program’s impact on quality, cost, and outcomes to the legislature and governor by December 31, 2012.
 
In addition, Chapter 59 of the Laws of 2011 requires the state health commissioner to prepare a similar annual report for the effects of regional multi-payer medical home initiatives on Medicaid, Family Health Plus, and Child Health Plus enrollees.
 
ACA Section 2703 Health Homes: New York will use claims and pharmacy data to measure success toward the state’s five goals for this state plan amendment:

1. Reduce utilization associated with preventable inpatient stays;
2. Reduce utilization associated with preventable emergency room visits;
3. Improve outcomes for persons with mental illness and/or substance use disorders;
4. Improve disease-related care for chronic conditions; and
5. Improve preventative care.

New York is also developing a patient experience survey tool that includes elements of AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys and implement learning collaborative with health home providers and high-risk enrollees to discuss program successes, challenges, and lessons learned.

• Medicaid claims data;
• Pharmacy claims data – web-based pharmacy home program;
• Case identification reports – risk stratification;
• Gaps in care analysis reports;
• Customized queries; and
• Baseline measures, ongoing monitoring, and trend analysis.

Furthermore, an informatics center can provide feedback reports at the individual, practice, network and state levels. However, certain data (including substance abuse and HIV data) cannot be included in individual reports.
 
The Brookings Institution will be evaluating the public-private “First in Health” program’s impact on both quality and cost of care.
 
ACA Section 2703 Health Homes:  North Carolina will use claims data, a provider survey, and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient survey to evaluate progress toward the state’s three goals for this state plan amendment:

1. Reduce avoidable emergency department utilization;
2. Reduce avoidable hospitalizations; and
3. Increase integration of primary care and behavioral healthcare.

1. Core clinical outcome metrics;
2. Enhanced clinical outcome metrics;
3. Patient, staff, and student satisfaction survey outcomes;
4. Access to care metrics;
5. Practice operations/financials metrics; and
6. Curriculum/training metrics

For specific measures selected, please see pages 7-8 of the advisory group’s final work product report.
 
ACA Section 2703 State Plan Amendment – Community Behavioral Health Centers (CBHCs): Ohio will use claims data to evaluate progress toward the state’s eight goals for the health home program:

1. Improve cardiovascular care;
2. Improve care coordination;
3. Improve diabetes care;
4. Improve care for persons with asthma;
5. Improve health outcomes for persons with mental illness;
6. Improve preventive care;
7. Reduce substance abuse; and
8. Improve appropriate utilization/site of care.

1. Reduce the rate of potentially avoidable hospital readmissions;
2. Reduce the number of potentially avoidable hospitalizations and increase the ratio of ambulatory care to emergency room visits;
3. Improve care transitions between primary care and inpatient facilities;
4. Improve care transitions for people with mental health conditions; and
5. Improve documentation, tracking, and reporting of health risks and use or preventive services.

The state will also use AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys to measure care coordination and implement learning collaborative with health home providers and high-risk enrollees to discuss program successes, challenges, and lessons learned.

1. Improve care coordination;
2. Improve health outcomes for children and youth with special healthcare needs (CYSHCN);
3. Decrease the occurrence of secondary conditions;
4. Decrease emergency department utilization and inpatient treatment for ambulatory sensitive conditions; and
5. Improve transitions of care between inpatient/residential care and community settings.

The state is also working to develop surveys to measure process outcomes and lessons learned at participating CEDARR Family Centers.
ACA Section 2703 Health Homes – Community Mental Health Organizations (CMHOs): Rhode Island will use claims and encounter data, intake surveys of CMHO clients, chart reviews, and the RHode Island Behavioral Health Online Database to evaluate progress toward the state’s six goals for this state plan amendment:

1. Improve care coordination;
2. Reduce preventable emergency department utilization;
3. Increase preventive services utilization;
4. Improve management of chronic conditions;
5. Improve transitions to community mental health organzation services; and
6. Reduce hospital readmissions.

The state is also collecting data on patient experience of care.
ACA Section 2703 Health Homes – Opioid Treatment Programs (OTPs): Quality improvement and clinical outcomes goals include reduced use of high cost/high use services (pharmacy, lab, residential treatment), reduced rates of drug use and smoking, and increased patient engagement and self-management. The state plan amendment also identifies psychosocial goals, including reduced rates of arrest and incarceration, increased rates of employment, and increased housing stability.

• A quality of care study that includes data on prenatal and newborn care, childhood immunizations, asthma, emergency room utilization, and Early and Periodic Screening Diagnosis & Treatment (EPSDT) examinations;
• A service access study focusing on emergency room service and utilization; appointment availability and scheduling, referrals, follow up care provided, and the timeliness of services;
• A medical record survey to ensure compliance with medical record uniformity of format, legibility and documentation; and
• An administrative survey of administrative policies and procedures.

• Access
• Utilization
• Costs
• Quality
• Outcomes
• Patient and family experience

Project leaders anticipate drawing on Utah’s all-payer claims database to use other practices as controls.

• Clinical Quality: The report found that Blueprint participants experienced better clinical quality on a variety of measures relative to comparison groups (* indicates statistically significant difference for Medicaid populations):
  • Breast cancer screening
  • Cervical cancer screening*
  • Well-child visits and adolescent well-care visits
  • Diabetes care
• Utilization: The report indicates that utilization patterns differ between Blueprint participants and comparison groups. Blueprint participants demonstrated (* indicates statistically significant difference for Medicaid populations):
  • Lower rates of all-cause inpatient hospitalizations*
  • Higher rates of primary care visits*
  • Lower rates of medical and surgical specialty visits*
  • Mixed results for emergency department utilization, with lower rates for the commercial population and higher rates for the Medicaid population
• Cost: Relative to comparison groups, Blueprint participants had lower annual per-member health care expenditures. Relative to comparison groups, the report identifies per-person savings of $586 per commercially insured adult, $386 per commercially insured child, $447 per adult Medicaid enrollees and $200 per pediatric Medicaid enrollee.
  • Medicaid beneficiaries participating in the Blueprint also had lower per-member costs relative to comparison groups, though results were not statistically significant. The 2013 Annual Report found statistically significant reductions in outpatient and pharmacy expenditures and non-statistically significant reductions in inpatient and professional services. Medicaid beneficiaries demonstrated a significant increase in spending on Special Medicaid Services like transportation, case management, dental services, and mental health and substance abuse treatment.

• Increased practice capabilities over time, as measured by the Medical Home Index
• Mixed changes in clinical outcomes, such as the portion of diabetic patients with record of an eye exam
• Improvements in provider satisfaction over time

• Clinical process measures
• Clinical outcome measures
• Utilization
• Cost
• Alignment with Meaningful Use

In the West Virginia Health Improvement Institute’s (WVHII) 2012 annual report, WVHII reported that providers felt the pilot improved their workflows and care planning capabilities. While the costs for patients attributed to the demonstration rose 0.6% over the life of the pilot, costs for practices that did not achieve NCQA recognition rose by 2.0%.

1. Reduce the risk of complicating opportunistic infections and improve health outcomes;
2. Ensure the integration of oral health care and medical health care for HIV patients.

Wisconsin will use public health surveillance data, claims data from the state’s Medicaid Management Information System, and enrollees’ medical records to track the state’s performance on these goals.
 
The state’s Medicaid agency and the Wisconsin Division of Public Health (DPH) will collaboratively assess program implementation.
 
Costs savings will be calculated using a pre/post analysis of Medicaid claims data for health home enrollees, as well as comparing the costs for Medicaid enrollees with HIV that are not participating in the health home program.

1. Tobacco Use Assessment and Cessation Intervention
2. Breast Cancer Screening
3. Cervical Cancer Screening
4. Colorectal Cancer Screening
5. Childhood Immunization Status
6. Diabetes: Hemoglobin A1C Poor Control
7. Diabetes: Blood Pressure Management
8. Diabetes: LDL Management and Control
9. ADHD: Follow-up Care for Children Prescribed Medication.