Protecting, maintaining and improving the health of all Minnesotans Date:
May 23, 2011
To:
Rapid Response Team Members
From:
Katie Burns, Health Economics Program
Subject:
Composite Quality Measure Design
Thank you for your feedback on the design of the composite quality measure for provider peer
grouping. This memo summarizes MDH’s decisions on the methodological issues for which we
sought your input as well as several other issues RRT members raised in their comments.
Combining Individual Measures into Subcomposites
Some RRT members suggested we take a different approach with respect to how we will
combine individual quality measures into a subcomposite measure in the interests of being more
consistent with emerging market approaches. Based on their feedback, we will use an approach
that combines key characteristics of alternative models put forth by CMS under the final Hospital
Value-Based Purchasing Rules and proposed Accountable Care Organization rules. Both
methodologies use a point system in which providers are required to meet a certain threshold of
performance (an “achievement threshold) to earn points on a particular quality measure and
where a maximum number of points may be earned by providers performing near the top of the
peer group (the “benchmark”) for a particular measure. Essentially, we have decided to use the
Hospital Value-Based Purchasing point system with the ACO minimum threshold of
performance for earning points on a specific measure.
Under our hybrid model, points would be allocated according to the following method:
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Assign 0 to 10 points based on performance relative to peer group benchmarks:
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receive 0 points if rate is below “achievement threshold” (thirtieth percentile of peer
group performance)
receive 10 points if rate is above “benchmark” (mean of top decile of peer group
performance)
receive 1-9 points otherwise, where points are assigned as follows:
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[9 * ((rate –threshold)/(benchmark–threshold))] + .5
rounded to next whole number
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Treat “topped out” measures (measures for which performance is almost uniformly very
high) differently to recognize high performance on the measure. We are testing different
definitions of “topped out” measures and methods for awarding points on those measures.
In order to support quality improvement activities at the provider level, we will include each
provider’s absolute rate on each measure along with the points earned on each measure in the
reporting of PPG results.
Treatment of Missing Data
As outlined in our initial memo, we will require that a provider have data for at least one
measure in each subcomposite in order to be included in the PPG analysis. We will not impute
any measures for the physician clinic analysis or for prospective payment hospitals. We will
impute measures for Critical Access Hospitals, provided that CAH has at least some cases for a
given measure but does not meet the minimum number of observations needed. A hospital’s own
results will count toward its score for an individual measure in proportion to the number of
patients for which it has data on that measure. The balance of a hospital’s imputed score will be
the statewide average among Critical Access Hospitals for that measure. Imputation will only
occur for those measures for which a meaningful peer group average can be calculated.
We are integrating existing community standards related to minimum numbers of observations
needed for use and reporting of quality measures in PPG. These thresholds vary among relevant
measure sets and are outlined in greater detail in our initial memo.
Calculation of HEDIS measures
We heard significant concern expressed about assigning HEDIS medical group results to
affiliated physician clinics to facilitate clinic-level peer grouping. To address this concern, MDH
intends to calculate some HEDIS measures based on claims data at the clinic level. Out of 11
HEDIS measures included in MDH’s Quality Report issued in November 2010, seven are based
on administrative data, while the remaining four are calculated using both claims and medical
record data. Of the seven exclusively claims-based measures, MDH intends to calculate the
following six at the clinic level:
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Appropriate Treatment for Children with Upper Respiratory Infection
Appropriate Testing for Children with Pharyngitis
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Breast Cancer Screening
Chlamydia Screening
Use of Appropriate Medications for People with Asthma
The seventh measure (Cervical Cancer Screening) requires more years of data than what MDH
currently has. We will also calculate this seventh measure in the second round of peer grouping,
when we have an additional year of claims data in the all-payer claims database. We intend to
use medical group level results for affiliated clinics for the remaining four HEDIS measures.
Inclusion of Specific Quality Measures and Subcomposite Categories
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Use of “All or None” Composite Measures and Component Parts
Some RRT members expressed significant concern about MDH’s plan to use both composite
measures (e.g., Optimal Diabetes Care) as well as their component parts. In response to
those concerns, MDH has decided to use only the individual measures on which these
composite measures are based for both physician clinics and hospitals.
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Health Information Technology Adoption
One RRT member suggested that we include measures related to adoption of health
information technology. Our existing data source for HIT adoption is the completion of a
required HIT survey for hospitals and physician clinics. While this is a useful data source,
we have not contemplated how to meaningfully integrate HIT survey data into the PPG
analysis and are unsure about whether the data has been sufficiently analyzed to be used for
this purpose. We will revisit the inclusion of HIT survey data in future iterations of PPG.
Patient Experience
In our original memo, we proposed including patient experience data as part of the composite
quality measure for prospective payment system hospitals and excluding it for Critical Access
Hospitals as it is not uniformly available among this latter type of hospitals as hospitals with
fewer than 500 discharges per year are not required to measure patient experience under state
administrative rules. We made this recommendation out of concern that we not have different
subcomposite categories between Critical Access Hospitals.
We have decided to adopt a different approach for reporting patient experience information.
Patient experience will be reportedly separately from the quality measure composite results. We
believe this is a middle ground approach that will allow us to maintain a consistent methodology
across providers and support the value of measuring, using, and reporting data on patient
experience. The points that would have counted toward patient experience will instead be shifted
to the “process of care” subcomposite category and increase the weight of that subcomposite
from 15 percent to 30 percent.
Composite Measure of Cost and Quality
MDH has received feedback at several points in the methodological development process that
PPG will be most helpful to consumers, providers, and purchasers if cost and quality information
are presented simultaneously rather than merged into a numerical score. MDH accepts this
recommendation and will present peer grouping information in a two dimensional “scatterplot”
format.