Medicaid Redesign and Evaluation of Quality Measures and Population Indicators

December 31, 2012 NYS Department of Health, Office of Quality and Patient Safety
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OVERVIEW:

The Department has undertaken a series of reform activities to facilitate the provision of high quality health care in the most efficient and effective manner for Medicaid enrollees. Many projects have been initiated through activities associated with the Medicaid Redesign Team. The Department will evaluate the impact of these initiatives on the quality of health care. The evaluation will involve monitoring quality measures and health indicators through the next decade to determine whether care has improved, remained consistent, or has not been unintentionally negatively impacted by changes stemming from these initiatives. Employing the construct of the triple aims to define quality, the indicators included in the evaluation will reflect the goals of:

  1. improving care,
  2. improving health and
  3. reducing costs.

Two series of quality indicators were selected: Medicaid Quality of Care Measures (Table 1) and New York State Population Health Indicators (Table 2). The following tables reflect the quality measures and indicators which will be used for evaluation in the coming ten years. Several principles were used to select the measures: 1) Measures were taken from national quality measurement sets whenever possible to allow benchmarking to national results; 2) Several areas with gaps in the availability of existing measures were noted and the Department will continue to monitor new indicators for gap areas. If the exploratory work identifies additional measures to include, they will be added; and 3) Changes in the national quality measurement sets will be incorporated into New York's collection system and may affect measures in this list.

TABLE 1 MEDICAID QUALITY OF CARE MEASURES:

Table 1 includes a description of each measure, the results for the three most current calendar years available and performance goals for each measure. 2013 performance goals are based on an incremental improvement of 5% of the difference between the most recent year's performance and the goal for the measure, with the same incremental improvement added to the subsequent benchmark years. Results will be updated as new information becomes available annually. In addition to this 'dashboard' presentation of results, the Department will provide a report with more in-depth analyses including performance by age, gender, disability status, race and ethnicity, and geography whenever applicable.

AIM 1: Improving Care
Number Health Care
Priority Area
Quality Measure Measure Description NYS Medicaid Performance by Measurement Year NYS Medicaid Performance Goals
2009 2010 2011 2013 2015 2017 2020
1 Preventive Care Chlamydia screening (Ages 16–24) The percentage of sexually active young women, ages 16 through 24, who had at least one test for Chlamydia during the measurement year. 67 68 71 72 74 75 77
2 Preventive Care Childhood immunizations (Combination 3–4312314) The percentage of two–year old´s who were fully immunized. The HEDIS specifications for fully immunized consisted of the following vaccines: 4 Diphtheria/Tetanus/Pertussis, 3 Polio, 1 Measles/Mumps/Rubella, 2 H Influenza type B, 3 Hepatitis B, 1 Varicella, and 4 pneumococcal. 73 Rotated 74 75 77 78 79
3 Preventive Care Annual dental visit for children (Ages 2–21) The percentage of children and adolescents ages 2 through 21 years, who had at least one preventive dental visit within the measurement year. 51 53 54 56 59 61 63
4 Preventive Care Annual dental visit for adults (Ages 22–64) The percentage of adults ages 22 through 64 years, who had at least one preventive dental visit within the measurement year. Not available Not available TBD TBD TBD TBD TBD
5 Women´s Health Cervical Cancer Screening The percentage of women between the ages of 21 and 64 who had a Pap test within the measurement year or the two years prior. Rotated 72 71 72 74 75 77
6 Women´s Health Frequency of Ongoing Prenatal Care – 81 to 100% of visits The percentage of women who received 81 percent or more of the expected number of prenatal care visits, adjusted for gestational age and month the member enrolled in the health plan. Rotated 74 Rotated 75 77 78 79
7 Women´s Health Low Birth Weight Deliveries (*A low rate is desirable) The percentage of live infants weighing less than 2500 grams among all deliveries by women continuously enrolled in a plan for 10 or more months. 7.0 7.0 2011 birth data not yet available 6.7 6.3 6.0 5.6
8 Chronic Care Follow up care for children prescribed ADHD medication – Initiation The percentage of children, ages 6 to 12 years, with a new prescription for ADHD medication and who had one follow–up visit with a prescribing practitioner within the 30 days after starting the medication. 56 58 59 61 63 65 67
9 Chronic Care Follow up care for children prescribed ADHD medication – Continuation The percentage of children, ages 6 to 12 years, with a new prescription for ADHD medication who remained on the medication for 7 months and who, in addition to the visit in the Initiation Phase, had at least 2 follow–up visits in the 9–month period after the initiation phase. 62 64 66 68 69 71 73
10 Chronic Care Medication Management for People with Asthma – 50% of Treatment Period The percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate asthma controller medications for at least 50% of the treatment period. Not available Not available 59 61 63 65 67
11 Chronic Care Medication Management for People with Asthma – 75% of Treatment Period The percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate asthma controller medications for at least 75% of the treatment period. Not available Not available NCQA Suppressed TBD TBD TBD TBD
12 Chronic Care Comprehensive diabetes care – HbA1c control (<8.0) The percentage of members, ages 18 to 75, with diabetes whose most recent HbA1c control (<8.0%). 55 Rotated 58 60 62 64 66
13 Chronic Care Comprehensive diabetes care – LDL– c control (<100mg/dL) The percentage of members, ages 18 to 75, with diabetes whose most recent level of bad cholesterol was below the recommended level (LDL–C <100 mg/dL). 44 Rotated 47 50 52 55 58
14 Chronic Care Controlling high blood pressure for persons with hypertension The percentage of members, ages 18 to 85 years, who have hypertension and whose blood pressure was adequately controlled (below 140/90). Rotated 67 Rotated 69 70 72 74
15 Chronic Care Comprehensive Care for People Living with HIV/AIDS: Engaged in Care Percentage of members (ages 2 to 64) living with HIV/AIDS who received two outpatient visits with primary care with one visit in the first six months and one visit in the second six months. 67 80 84 85 86 86 87
16 Chronic Care Comprehensive Care for People Living with HIV/AIDS: Viral Load Monitoring Percentage of members (ages 2 to 64) living with HIV/AIDS who received one viral load monitoring test in the first six months and one test in the second six months. 47 58 64 66 68 69 71
17 Chronic Care Comprehensive Care for People Living with HIV/AIDS: Syphilis Screening Percentage of members (ages 19 to 64) living with HIV/AIDS who received at least one Syphilis screening during the measurement year. 54 58 66 68 69 71 73
18 Mental Health Follow Up after Hospitalization for MH – within 7 days The percentage of discharges, for members ages 6 years and older, who were seen on an ambulatory basis or who were in intermediate treatment with a mental health provider within 7 days of discharge. 68 70 72 73 75 76 78
19 Mental Health Follow Up after Hospitalization for MH – within 30 days The percentage of discharges, for members ages 6 years and older, who were seen on an ambulatory basis or who were in intermediate treatment with a mental health provider within 30 days of discharge. 80 85 83 84 85 86 86
20 Mental Health Proportion of Schizophrenia Patients With Long– Term Utilization of Antipsychotic Medications The percentage of patients, ages 24–64, with a principal diagnosis of schizophrenia (in inpatient stay, an ED visit or at least two outpatient visits) and who has an index dispensing event of an antipsychotic medication and who were dispensed antipsychotic medication to supply 80% or more of the proportion of days covered (PDC) during the treatment period. Not available Not available 44 47 50 52 55
21 Substance Abuse Initiation of Alcohol and Other Drug Dependence The percentage of members who, after the first new episode of alcohol or drug dependence, initiate treatment within 14 days of the diagnosis. Not available Not available TBD TBD TBD TBD TBD
22 Substance Abuse Engagement of Alcohol and Other Drug Dependence The percentage of members who, after the first new episode of alcohol or drug dependence, initiated treatment and had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit. Not available Not available TBD TBD TBD TBD TBD
23 Substance Abuse F/U after Hospitalization for Substance Abuse within 7 days The percentage of discharges for alcohol and chemical dependency conditions, which were seen on an ambulatory basis or were in intermediate treatment with a chemical treatment and other qualified providers within 7 days of discharge. Not available Not available TBD TBD TBD TBD TBD
24 Substance Abuse F/U after Hospitalization for Substance Abuse within 30 days The percentage of discharges for alcohol and chemical dependency conditions, which were seen on an ambulatory basis or were in intermediate treatment with a chemical treatment and other qualified providers within 30 days of discharge. Not available Not available TBD TBD TBD TBD TBD
25 Long Term Care Advance Directives Determination (Do Not Resuscitate) Percentage of MLTC members who have made a determination of Do Not Resuscitate status defined as either ´in place´ or ´not in place´. (Numerator does not include ´no selection´) Not available Not available TBD TBD TBD TBD TBD
26 Long Term Care Flu Shot Percentage of MLTC members who received an influenza vaccination in the past year. 83 72 72 73 75 76 78
27 Primary Care Percent of enrollees in PCMH Percentage of Medicaid Managed Care enrollees assigned to a primary care physician practicing in a patient–centered medical home (PCMH). Not available 20 45 48 51 53 56
28 Health Care Reform Percent of High Cost/High Need Cases in Health Homes Percentage of Medicaid Fee–for–Service (FFS) recipients and Medicaid Managed Care (MMC) enrollees identified as High Cost/High Need cases that were enrolled in a Health Home. Not available Not available TBD TBD TBD TBD TBD
29 Health Care Reform Percent of Uninsured Percentage of New Yorkers who are uninsured, including those who are eligible for Medicaid but uninsured. Not available Not available TBD TBD TBD TBD TBD
AIM 2: Improving Health
Number Health Care
Priority Area
Quality Measure Measure Description NYS Medicaid Performance by Measurement Year NYS Medicaid Performance Goals
2009 2010 2011 2013 2015 2017 2020
1 Preventive Care Weight Assessment and Counseling for Children and Adolescents – BMI Percentile The percentage of children and adolescents ages 3–17 who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation during the measurement year. 51 65 73 74 76 77 78
2 Preventive Care Weight Assessment and Counseling for Children and Adolescents – Nutrition The percentage of children and adolescents ages 3–17 who had an outpatient visit with a PCP or OB/GYN and who had evidence of counseling for nutrition during the measurement year. 61 71 77 78 79 80 82
3 Preventive Care Weight Assessment and Counseling for Children and Adolescents – Physical Activity The percentage of children and adolescents ages 3–17 who had an outpatient visit with a PCP or OB/GYN and who had evidence of counseling for physical activity during the measurement year. 48 58 66 68 69 71 73
4 Preventive Care Adult BMI Assessment The percentage of members, 18 – 74 years of age, who had an outpatient visit and whose body mass index (BMI) was documented insuring the measurement year or the year prior. 55 70 Rotated 72 73 75 76
5 Chronic Care Use of Tobacco Cessation Strategies The percentage of estimated smokers using tobacco cessation products or services (includes medications, counseling or classes and OTC products). Not available 15 17 21 25 29 34
6 Long Term Care Fall Prevention Percentage of MLTC members who did not have any falls requiring medical intervention during the measurement period. 51 52 53 55 58 60 62
7 Long Term Care Disruptive/Intense Daily Pain (*A low rate is desirable) Percentage of MLTC members who experience daily intense pain or pain that disrupts daily activity. 10 12 11 10 10 9 9
8 Long Term Care Injury Prevention Percentage of MLTC members who did not experience any injuries, including hip fracture, other fracture, 2nd and 3rd degree burns, or unexplained injuries during the measurement period. Not available Not available TBD TBD TBD TBD TBD
9 Patient Perspective Getting care quickly The percentage of members responding, "usually" or "always" when asked a set of questions to identify if, in the last 6 months, they received appointments for routine and urgent care as quickly as they thought needed. 77 (Adult 4.0H) Not Collected 76 (Adult 4.0H) 77 78 80 81
10 Patient Perspective Getting needed care The percentage of members responding "usually or "always" when asked a set of questions to identify if, in the last 6 months, they were able to easily get appointments with specialists, and to get care, tests and treatment through the health plan. 74 (Adult 4.0H) Not Collected 75 (Adult 4.0H) 76 78 79 80
11 Patient Perspective Care coordination The percentage who responded "usually" or "always" when asked how often their personal doctor seemed informed and up–to–date about care they received from other doctors or health providers. 74 (Adult 4.0H) Not Collected 68 (Adult 4.0H) 70 71 73 74
AIM 3: Reducing Costs
Number Health Care
Priority Area
Quality Measure Measure Description NYS Medicaid Performance by Measurement Year NYS Medicaid Performance Goals
2009 2010 2011 2013 2015 2017 2020
1 Preventable Events Potentially Preventable Hospitalizations (*a low rate is desirable) Percentage of hospital admissions which are potentially avoidable. Not available Not available TBD TBD TBD TBD TBD
2 Preventable Events Potentially Preventable Readmissions (*a low rate is desirable) Percentage of hospital readmissions within 14 days of discharge that might have been prevented. Not available Not available TBD TBD TBD TBD TBD
3 Preventable Events Potentially Avoidable ER Visits (*a low rate is desirable) Percentage of ER visits for ambulatory sensitive conditions that could have been potentially treatable by primary care. Not available Not available TBD TBD TBD TBD TBD
4 Health Care Reform Medicaid Spending within Global Cap   Not available Not available TBD TBD TBD TBD TBD
5 Health Care Reform Percent Eligibility Determination done at State Level   Not available Not available TBD TBD TBD TBD TBD

Rotated = Measure is collected every other year.
Not available data = Measure introduced after the calendar year and results not available.
Not collected = Survey administered on biennial basis; collection did not occur for the measurement year.
Adult 4.0H = Consumer Assessment of Health Care Providers and Systems (CAHPS®), Medicaid Adult survey, version 4.0H.
TBD = To be determined.

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Number Health Care Priority Area Measure Description NYS Performance Benchmarks
2010 2013 2017 2020
AIM 1 Improving Care
1 Preventive Care Incidence of children <72 months old with confirmed blood levels >= 10ug/dl (per 1,000) (*a low rate is desirable) 11.1 10.8 10.5 9.9
2 Birth Outcomes Percent early prenatal care (First Trimester) 73.3 74.4 75.5 77.9
3 Birth Outcomes Percent low birth weight deliveries (*a low rate is desirable) 8.2 8.2 7.9 7.8
4 Birth Outcomes Percent preterm births (*a low rate is desirable) 12.3 11.9 11.5 11.1
5 Birth Outcomes Percent unintended pregnancy (*a low rate is desirable) 29.6 28.6 27.6 26.6
6 Preventive Care Percent of adults (65 and older) receiving seasonal flu vaccine 68.3 69.9 71.6 75.0
7 Preventive Care Percent of adults (65 and older) receiving pneumococcal vaccine 66.1 67.8 69.5 73.0
8 Preventive Care Percent of adults 50 years and older who receive colorectal cancer screening based on recent guidelines 68.0 69.5 71.4 73.0
AIM 2 Improving Health
9 Obesity Percent of WIC children (ages 2–4) who are obese (*a low rate is desirable) 13.1 12.8 12.4 12.1
10 Obesity Percent of public school children in NY state reported to Student Weight Status Category Reporting System who are obese (*a low rate is desirable) 17.6 17.2 16.7 16.3
11 Obesity Percent of public school children in NYC represented in the NYC Fitnessgram who are obese (*a low rate is desirable) 20.7 20.3 19.7 19.3
12 HIV Prevention New Diagnosis of HIV (per 100,000) (*a low rate is desirable) 21.3 20.8 20.2 19.2
13 Tobacco Percent tobacco use (cigarettes, cigars, smokeless tobacco) by high school age students (*a low rate is desirable) 21.2 18.5 15.0 12.3
14 Tobacco Percent cigarette smoking by adults (*a low rate is desirable) 18.1 16.8 15.0 13.7
AIM 3 Reducing Costs
15 Diabetes Preventable Hospitalizations (PQIs) for short term complications of diabetes, age 6–17 (per 100,00) (*a low rate is desirable) 3.4≠ 3.3 3.1 2.9
16 Diabetes Preventable Hospitalizations (PQIs) for short term complications of diabetes, age 18+ (per 100,000) (*a low rate is desirable) 5.6≠ 5.3 4.9 4.5
17 Asthma Emergency Department Visit – all ages (per 10,000) (*a low rate is desirable) 83.4≠ 79.8 75.1 72.0
18 CVD Heart Attack Hospitalizations – all ages (per 10,000) (*a low rate is desirable) 16.0# 15.3 14.4 13.7

PQIs = Preventive Quality Indicators
– baseline data (2007 to 2009)
# – baseline data (age–adjusted 2010)

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