AHRQ National Advisory Council Subcommittee (SNAC) on Children's Healthcare Quality Measures for Medicaid and CHIP Programs

On this page:

1. CHIPRA Quality Measures: NAC Subcommittee Discussion
2. CHIPRA—Title IV
3. CMS, AHRQ, NAC, and Subcommittee Roles
4. Key Players for SNAC Work
5. Subcommittee Charge
6. Timeline to January 1 Posting for Public Comment
7. Key Points about Process (I)
8. Key Points about Process (II)
9. SNAC Nomination and Scoring Process
10. Key Features of the SNAC Public Process
11. Conceptual Framework for Scope of Core Measurement Set
12. Consensus on Criteria Definitions
13. Consensus on Criteria Definitions (continued)
14. Consensus on Criteria Definitions (continued)
15. Consensus on Criteria Definitions (continued)
16. SNAC Recommended Quality Measures (continued)
17. Recommended Topics by Rank (per SNAC priority score) (I)
18. Recommended Topics by Rank (per SNAC priority score) (II)
19. Recommended Topics by Rank (per SNAC priority score) (III)
20. Multiple Conditions Represented
21. Measure Areas by CHIPRA Legislative Topic
22. Most Measures Focus on Prevention/Health Promotion
23. Most Measures Cross All or Most Age Groups
24. All but One Measure is for Ambulatory Settings
25. Topics by Data Source
26. Major Issues Identified by the SNAC (I)
27. Major Issues Identified by the SNAC (II)
28. Other Factors of Interest (I)
29. Other Factors of Interest (II)
30. Discussion Questions

Slide 1. CHIPRA Quality Measures: NAC Subcommittee Discussion

November 13, 2009
National Advisory Committee Meeting
Kathleen Lohr, PhD
Timothy Brei, MD

Slide 2. CHIPRA—Title IV

Image: The upper half of the first page of the document for 123 STAT. 72 Public Law 111–3—FEB. 4, 2009, Title IV: Strengthening Quality of Care and Health Outcomes.

Slide 3. CMS, AHRQ, NAC, and Subcommittee Roles

Image: Chart shows the relationship between the Secretary of the Department of Health & Human Services (HHS), the AHRQ National Advisory Council (NAC), the Subcommittee on Children's Healthcare Quality Measures for Medicaid and CHIP Programs, the Director of the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Medicare and Medicaid Services (CMS).

Slide 4. Key Players for SNAC Work

SNAC Co-Chairs:

• Jeffrey Schiff, MD, MBA Minnesota Department of Human Services.
• Rita Mangione-Smith, MD, MPH, University of Washington.

AHRQ Staff:

• Denise Dougherty, PhD, Senior Advisor, Child Health and Quality Improvement.

NAC Members:

• Timothy Brei, MD, FAAP.
• Kathleen Lohr, PhD.

Members:

• Another ~ 20 experts from clinical, Medicaid, CHIP, quality measurement, research, and policy fields.

Slide 5. Subcommittee Charge

Identify initial core health care quality measurement set for Medicaid and CHIP programs and in doing this

• Provide guidance on criteria for identification of initial core set.
• Provide guidance on a strategy for identifying additional measures in use for consideration.
• Review and apply criteria to compilation of measures currently in use by Medicaid/CHIP.

Slide 6. Timeline to January 1 Posting for Public Comment

Image: A timeline shows the following events:

• January 2009: Law passed, Centers for Medicare and Medicaid Services-Agency for Healthcare Research and Quality (CMS-AHRQ) partnership established.
• July 2009: Subcommittee Meeting #1.
• September 2009: Subcommittee Meeting #2.
• October 2009: First full draft of initial core set for Federal review.
• November 2009: Revised draft to Secretary.
• December 2009: Revisions if needed.
• Final for posting (Dec. 18).

Slide 7. Key Points about Process (I)

• Three major criteria for selection of measures
      - Validity.
      - Feasibility.
      - Importance.
• Philosophically, preferred to leave an "empty chair" than to recommend quality measures that simply were too weak.
• Sought breadth where possible.
• Sought familiarity with or use of measures on part of Medicaid programs and/or SCHIP programs.
• Recognized nothing was going to be perfect.

Slide 8. Key Points about Process (II)

Slide 9. SNAC Nomination and Scoring Process

• Initial measure identification.
• Delphi I—Validity and Feasibility.
• SNAC definitions of
      - Validity.
      - Feasibility (with reliability).
      - Importance.
• Understanding of a "core, grounded, and parsimonious" set.
• Broad measure nomination.
• Delphi II—VFI.
• Ranking process.
• Final vote.
• SNAC key issues.

Slide 10. Key Features of the SNAC Public Process

• Transparent.
• Multiple stakeholders per CHIPRA.
• Public comment including public nominations of measures.
• Focused on measures in use per CHIPRA.
• Evidence-informed (per CHIPRA) SNAC Delphi processes June and August.

Slide 11. Conceptual Framework for Scope of Core Measurement Set

Grounded → Intermediate → Aspirational
Measures      Measures          Measures

• Consensus of the subcommittee to focus on choosing grounded measures.
• Grounded: N ≈ 10-25, currently feasible, many already in place.
• Intermediate category: N = ?, good specifications, some states already using them.
• Aspirational: needed measures to fill in the gaps.

Slide 12. Consensus on Criteria Definitions

• Validity

  • Measures must be supported by scientific evidence or, where evidence is insufficient, by expert consensus.
  • Measures must support a link from structure to process to outcomes.
  • The measure must represent an aspect of care that is under the control of health care providers and systems.
  • The measure should truly assess what it purports to measure.
  • Measures supported by evidence from unpublished data should be considered for inclusion.

Slide 13. Consensus on Criteria Definitions (continued)

• Feasibility
  • The data necessary to score the measure must be available to state Medicaid and CHIP programs.
       — Administrative data, medical records data, survey data.
  • Detailed specifications must be available for the measure that allow for reliable and unbiased scoring of the measure across states and institutions.

Slide 14. Consensus on Criteria Definitions (continued)

• Importance
  • The measure should be actionable.
  • Cost of the condition to the nation should be high.
  • Health care systems are clearly accountable for the quality problem assessed by the measure.
  • The extent of the quality problem should be substantial.
  • There should be documented variation in performance on the measure.
  • The measure should be representative of a class of quality problems: "sentinel measure" of QOC provided for preventive care, mental health care, or dental care, etc.

Slide 15. Consensus on Criteria Definitions (continued)

• Importance (continuted)
  • The measure assesses an aspect of health care where there are known disparities.
  • The core set should represent a balanced portfolio of measures and be consistent with the intent of the legislation.
  • Improving on performance for the core set of measures should have the potential to transform care for our nation's children.

Slide 16. SNAC Recommended Quality Measures (continued)

by Ranking based on SNAC Priority Scores, Legislative Topic, Condition, Age Group, Setting, Source of Data.

Slide 17. Recommended Topics by Rank (per SNAC priority score) (I)

• 1 Immunizations for 2 year-olds (National Committee for Quality Assurance [NCQA] measure).
• 2 Frequency of ongoing prenatal care (NCQA measure).
• 2 Emergency Department Utilization—Average number of emergency room visits per member per reporting period.
• 3 Annual number of asthma patients (> 1 year-old) with > 1 asthma-related ER visit (S/AL Medicaid Program).
• 4 Body Mass Index documentation 2-18 year olds (NCQA measure).
• 5 Well-Child Visits (three NCQA measures): (1) first 15 months of life; (2) third, fourth, fifth and sixth years of life; (3) Adolescent.
• 6 Total eligibles receiving preventive dental services (EPSDT measure).
• 7 Adolescent immunization (NCQA revised for 2010).
• 8 HEDIS CAHPS 4.0 including supplements for children with chronic conditions and Medicaid Plans.
• 9 Timeliness of prenatal care (NCQA measure).

Slide 18. Recommended Topics by Rank (per SNAC priority score) (II)

• 10 % of live births weighing less than 2,500 grams.
• 11 Rates of screening using standardized screening tools for potential delays in social and emotional development.
• 12 Follow-up care for children prescribed attention-deficit/hyperactivity disorder (ADHD) (Medication Continuation and Maintenance Phase—National Committee for Quality Assurance [NCQA] measure).
• 13 Annual dental visit (NCQA measure).
• 13 Child and adolescent Major Depressive Disorder (MDD)—suicide risk assessment.
• 13 Annual hemoglobin A1C testing (all children and adolescents diagnosed with diabetes).

Slide 19. Recommended Topics by Rank (per SNAC priority score) (III)

• 14 Chlamydia screening 16-20 year-old females (National Committee for Quality Assurance [NCQA] measure).
• 14 Followup after hospitalization for mental illness (NCQA measure).
• 16 Cesarean rate for low-risk first birth women.
• 16 Access to primary care practitioners, by age and total.
• 16 Use of clinician & group primary care CAHPS survey for practitioners participating in Medicaid and CHIP (CAHPS family of measures).
• 17 Total EPSDT eligibles who received dental treatment services (EPSDT).
• 17 Pediatric catheter-associated blood stream infection rates (PICU/NICU).
• 18 Pharyngitis: appropriate testing (NCQA measure).
• 18 Otitis media with effusion: avoidance of inappropriate use of systemic antimicrobials.

Slide 20. Multiple Conditions Represented

Slide 21. Measure Areas by CHIPRA Legislative Topic

Slide 22. Most Measures Focus on Prevention/Health Promotion

Image: Bar graph shows the following types of care:

• Prevention/Health Promotion: 12
• Acute: 5
• Chronic: 5
• FEC: 2
• Available: 1

Slide 23. Most Measures Cross All or Most Age Groups

Image: Bar graph shows the following age groups:

• Perinatal: 3
• 0-2: 3
• 0-3: 1
• 6-Adolescent: 6
• All: 10

Note: SNAC voted to include all well-child visits (ages 15 mos-13 y) as one measure. Perinatal measures are for babies; they are not counted separately here as adolescent measures.

Slide 24. All but One Measure is for Ambulatory Settings

Image: Bar graph shows the following settings:

• AMB [Ambulatory]: 24
• Inpatient: 1

Note: Ambulatory includes Emergency department; dental care; specialty care.

Slide 25. Topics by Data Source

Image: Bar graph shows the following topics by data source:

• Admin: 10
• Hybrid: 9
• Survey: 2
• Birth +: 2
• Other: 2

Note: Admin = Admin only; Hybrid = admin + chart.
Birth + = Medicaid enrollment plus birth certificate data.
Other refers to 2 dental EPSDT measures.

Slide 26. Major Issues Identified by the SNAC (I)

• Standardization of duration of enrollment measures.
• Standardization of the denominator across measures.
• Expansion of use of measures for the whole Medicaid/ CHIP population.
• Improved disparities reporting.

Slide 27. Major Issues Identified by the SNAC (II)

• "Empty chairs"
  1. Most integrated health care system (medical home).
  2. Specialty care.
  3. Inpatient care.
  4. Care for substance abuse.
  5. Mental health treatment.
  6. Measures of integration of care with services outside of the health care system.
  7. Health outcomes.

Slide 28. Other Factors of Interest (I)

• Quality assessment and improvement for federal(insurance) programs is hard, complicated.
• Issues are very broad: e.g., including dental, mental health, prevention, populations, settings, etc ...
• Medicaid and CHIP programs differ markedly in what they already do and likely can do at the moment.
• Wide range of
  • Probable funding from their states.
  • Access to data now and/or what is now reported to them.
  • Types of health care systems that deliver care (managed care plans v mostly private practice or whatever).
  • Centralized v. decentralized ways the programs are administered in different states.

Slide 29. Other Factors of Interest (II)

• The CHIPRA quality measurement activity is voluntary at the moment
  but
• Skepticism that things will stay that way and not become mandatory
  so
• SNAC wanted to be careful about numbers of measures, complexity, and other factors.

Slide 30. Discussion Questions

• Comments on the recommended core set or the SNAC process?
• A model for the Subcommittees of the future?
• NAC interest in next phases of AHRQ CHIPRA work?
• Other?