DSRIP Category Cmeasure Specifications: DY7-8

DSRIP Category CMeasure Specifications: DY7-8

Part 1 of 4 - Introduction

Contents

General Overview

Measure Stewards

Measure Maintenance Schedule

DSRIP Specific Population

Reporting Methodology & Sampling

Data Sources

Specifications Definitions

General Overview

Measure Stewards

All of the measures included the finalCategory C menu have beenapproved for use in DSRIP by HHSC and CMS. Often the source of these measures is an authoritative agency around outcome measurement (e.g., AHRQ, NCQA, CDC, NQF), referred to as the "Measure Steward". These measures have been validated and tested to ensure that the outcomes are measuring what they aim to measure. In some cases, where validated measures did not previously exist, innovative measures were created based on evidence-based guidelines and practices. The outcomes are salient to aspects of patient care that reflect better health and satisfaction with services, improved efficiencies in health care delivery and cost savings.

Measure Maintenance Schedule

The measure specificationsversions included in this compendium will be the versions used in DY7-8. If significant clinical guideline changes are made to a measure by the Measure Steward, HHSC may take those updatesinto consideration. Providers should contact HHSC before making any methodology changes that affect how the measure is implemented or the way data is collected that impacts comparison between baseline and performance years.

DSRIP Specific Population

When reporting data for measures in a measure bundle, the eligible denominator population for each measure will be determined by the following process:

Step 1: Determine the DSRIP attributed population—the target population (or pool) for accountability under the DSRIP incentive program -- using the prescribed attribution methodology defined below.

Step 2: Determine the individuals from step one that are included in the measure bundle or measure target population

Step 3: Determine the individuals from the measure bundle target population that meet the measure specific denominator inclusion criteria.

Step 4: Determine payer type for individuals or encounters in the denominator following standardized specifications to determine the all payer, Medicaid, and uninsured rate for each measure.

Step 1: Determine the DSRIP attributed population using the prescribed retroactive attribution methodology defined below based on the provider type indicated in the RHP Plan Submission:

For Hospital organizations and Physician Practices, the DSRIP attributed population includes individuals that meet at least one of the criteria below. Individuals do not need to meet all or multiple criteria to be included.
Medicaid beneficiary attributed to the Performing Provider during the measurement period as determined by assignment to a primary care provider (PCP), medical home, or clinic in the performing providers DSRIP defined system OR
Individuals enrolled in a local coverage program (for example, a county-based indigent care program) assigned to a PCP, medical home, or clinic in the performing providers DSRIP defined system OR
One preventive service provided during the measurement period (value sets of visit type codes for annual wellness visit, preventive care services - initial office visit, preventive care services - established office visit, preventive care individual counseling) OR
One ambulatory encounter during the measurement year and one ambulatory encounter during the year prior to the measurement year OR
Two ambulatory encounters during the measurement year OR
Other populations managed with chronic disease in specialty care clinics in the performing providers DSRIP defined system
One emergency department visit during the measurement year OR
One admission for inpatient or observation status during the measurement year OR
One prenatal or postnatal visit during the measurement year OR
One delivery during the measurement year OR
One dental encounter during the measurement year OR
Enrolled in a palliative care or hospice program during the measurement year OR
Other populations not included above that should be included in a measure bundle target population included in the RHP plan submission and approved by HHSC (for example, individuals enrolled in community based education programs)
For Community Mental Health Centers the DSRIP attributed population includes:
All individuals that meet one of the following criteria during the measurement period:
One encounter with the performing providers system during the measurement year and one encounter during the year prior to the measurement year OR
Two encounters with the performing providers system during the measurement year OR
Otherpopulations defined by the CMHC in the RHP Plan Submission and approved by HHSC
For Local Health Departments the DSRIP attributed population includes:
Individuals with one eligible encounter during the measurement period OR
Other populations defined by the LHD in the RHP Plan Submission and approved by HHSC
Allowable Exclusions for all provider types:
Performing providers may remove from the DSRIP attributed population any individual for which the provider has documentation of any one of the following during the measurement year:
The individual that was previously assigned a PCP, medical home, or clinic with the provider but has changed their care to a PCP, medical home, or clinic that is not with the performing providers DSRIP system.
The patient has had a total time of incarceration during the measurement period that exceeded 45 days.

Steps 2 - 3: Refer to Measure Bundle Target Population and Measure Specifications

Step 4: Determine payer type for individuals or encounters in the denominator

Providers will report each Category C measure stratified by payer type (Medicaid, Uninsured, All-payer), unless otherwise specified in the measure specifications or an exception has been approved in accordance with Program Funding and Mechanics Protocol (PFM) Paragraph 21.
The methodology of determining payer-type stratification is determined based on the unit of measurement (individuals vs. encounters, for example).
Individuals: A unit of measurement is “Individual” if a person can only be counted once in the denominator in a given measurement year. Payer type for DSRIP reporting purposes will be determined by the most recent payer type on record at the end of the reporting period

Step 4: Determine payer type of record for individuals in active patient population based on the most recent payer type on record at the end of the reporting period

OPTIONAL: Providers may choose to align their Medicaid payer type definition with their PPP definition so that any individual with a Medicaid enrolled service at any point in the measurement year may be classified as Medicaid, even if their most recent payer type of record is not Medicaid.

Encounter: A unit of measurement is an “encounter” if a person can be counted in the denominator more than once in a given measurement year. Payer type will be determined by the payertype assigned to the specific qualifying visit or admission.

Step 4: Determine payer type of record for each visit/admission in the denominator

Reporting Methodology & Sampling

Some measures with specifications specific to electronic health records have specifications for both E.H.R. and claims specifications. Providers should choose one reporting method to use (i.e. E.H.R., claims, or registry) and use the corresponding specifications for that method. For DSRIP reporting purposes, E.H.R. reporting is preferred if available.

Providers should use the most complete data available and ensure that the rates reported are representative of the entire population served in a provider’s system. For a measure based on administrative data, all cases that meet the eligible population requirements for the measure must be included.

For measures where all required data elements are not available electronically (E.H.R., claims data, or registry) or are of poor quality, providers may conduct a sample to determine rate for a given performance year. Providers should follow the sampling methodology provided by a given measure steward, or if no sampling methodology is specified, providers should follow the HHSC specific sampling methodology identified below.

-Providers should use available administrative data to determine the denominator population. Sampling should be systematic and random to ensure that all eligible individuals have an equal chance of inclusion. Providers should ensure that the sample used to calculate the measure is representative of the entire eligible population for the measure.

For a measurement period where the denominator size is less than or equal to 75, providers must report on all cases. No sampling is allowed.
For a measurement period where the denominator size is less than or equal to 380 but greater than 75, providers must report on a random sample of not less than 76 cases.
For a measurement period where the denominator size is greater than 380, providers must report on a random sample of cases that is not less than 20% of all cases; however, providers may cap the total sample size at 411 cases.

It is recommended to select an oversample of 10-15% of the sample size for substitution in the event that cases in the original sample are excluded from the measure.

Providers will indicate at the time of reporting if a sampling methodology is used. Providers should maintain records of sampling methodology and random selection.

For any measure that uses sampling, (measure steward specified methodology or HHSC specified methodology), providers may determine Medicaid and uninsured rates based on the initial sample as long as the volume for each payer type is greater than 75. If the initial all-payer sample results in a sample size of less than 75 for either the Medicaid or uninsured payer type or results in a payertype breakdown that is not representative of the eligible denominator population, providers should utilize the HHSC specified methodology to determine the Medicaid rate and uninsured rate.

Data Sources

The data source is specified for each measure as either claims, E.H.R., or other. Providers are responsible for adhering to measure specifications and in cases where a variance from a designated measure source is required due to variances in data sources, providers should keep a record of and such variances to ensure consistency, and make a note of such variances when reporting each measurement year. Providers may opt to use local or proprietary codes or values mapped to the standard codes included in the Category C measure specifications. Providers that use local or proprietary codes must maintain documentation that includes a crosswalk of relevant codes, descriptions, and clinical information if applicable.

Specifications Definitions

The components below are included for each measure, as applicable, in the Category C measure specifications. The measure specifications provide details on how each measure is to be reported. Please note: claims, registry and/or E.H.R. specifications may or may not be included for each measure. These specifications will be included as available.

Measure Description / Brief description/overview of the measure.
DY7/DY8 Program ID / The number designation specific to an individual outcome measure. This reference number is the identifier used in DSRIP projects to indicate a selected measure in DY7 and DY8.
NQF Number / The National Quality Forum (NQF) identifier number assigned to a measure. Not all measures have an NQF number.
Measure Steward / Specifies the organization that endorses or stewards the measure, or the source of clinical guideline or recommendation.
Measure Source / Link and/or source where full measure specification may be found.
Data Source / The data source for which a measure has been specified. Can be claims, E.H.R, or other.
Measure Classification / The classification of a measure (clinical outcome, cancer screening, hospital safety, immunization, quality of life, process, or innovative measure) will be indicated here.
Measure Parts / Indicates how many parts a measure may have (1 part, 2 parts, or 3 parts). If a measure has multiple parts, a performing provider must report on all measure parts using the same baseline measurement period.
Unit of Measurement / The methodology of determining payertype stratification is determined based on the unit of measurement (individuals, vs. encounters, for example) as outlined in the “DSRIP Specific Population” section of this document.
Payer Type Instructions / Some measures will only be reported as one payer type, as indicated here(i.e. Medicaid rate only, or all-payer rate only). Unless otherwise specified, providers are to report on the Medicaid, LIU, and all-payer rates.
Benchmark Description / For pay-for-performance (P4P) measures where a benchmark is available (measures which use the QISMC methodology), the high performance level (HPL) and minimum performance level (MPL) is indicated. These benchmark rates are used as guidelines for measure performance and to incorporate into the calculation of DY7 and DY8 achievement targets. Benchmarks are using the 90th and 25th percentiles of the all lines of business (LOBs) average from the National Quality Compass 2016.
Notes / Measures not eligible for a shortened baseline measurement period will be indicated here.
Additionally, measures eligible for a baseline numerator of zero will be indicated here, as well as the DY7 and DY8 goals for those measures if a baseline numerator of 0 exception is approved
Denominator Description / Description of the total eligible population in which cases (numerator) can be identified (e.g., all adult patients with diabetes).
Denominator Inclusions / Some measures include specific denominator inclusion criteria, with criteria that cases must meet to be included in the denominator.
Denominator Exclusions / Some measures include specific denominator exclusion or exception criteria that would disqualify a case from a denominator. Some measures refer to both exclusions and exceptions. Exclusions are based on information identified in the denominator. Exceptions are based on information identified in the numerator. Both exclusions and exceptions should be removed from the denominator.
Numerator Description / Description of eligible cases for the particular measure (e.g., all patients with an HbA1c > 9.0%).
Numerator Inclusions (Performance Met) / Some measures include specific numerator inclusion criteria, with criteria that cases must meet to be included in the numerator.
Numerator Exclusions (Performance Not Met) / Some measures include specific numerator exclusion criteria that would disqualify a case from a numerator.
DSRIP Specific Modifications / Any modification made for DSRIP reporting purposes will be indicated here.
Additional Information / If applicable, any additional information about the measure will be included here, including guidance on reporting the measure and/or data criteria for E.H.R. measures.

Copyright information

For AMA-PCPI measures:

Physician Performance Measures (Measures) and related data specifications have been developed by the American Medical Association (AMA)-convened Physician Consortium for Performance Improvement® (PCPI®). These performance Measures are not clinical guidelines and do not establish a standard of medical care and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed, or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and the AMA (on behalf of the PCPI). Neither the AMA, PCPI nor its members shall be responsible for any use of the Measures.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND

Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the PCPI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications.

For Minnesota Community Measurement measure:

PHQ-9: Copyright: Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

For National Committee for Quality Assurance (NCQA) measures:

NCQA Notice of Copyright and Disclaimers

These performance measures were developed and are owned by the National Committee for Quality Assurance ("NCQA"). These performance measures are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures. NCQA holds a copyright in this measure and can rescind or alter this measure at any time. Users of the measure shall not have the right to alter, enhance, or otherwise modify the measure, and shall not disassemble, recompile, or reverse engineer the source code or object code relating to the measure. Anyone desiring to use or reproduce the measure without modification for a noncommercial purpose may do so without obtaining any approval from NCQA. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA. Use by health care providers in connection with their own practices is not commercial use. A "commercial use" refers to any sale, license, or distribution of a measure for commercial gain, or incorporation of a measure into any product or service that is sold, licensed, or distributed for OMB 0938-1148

CMS-10398

Other Stewards:

Measure content regarding specific measures may be protected by intellectual property rights which are owned by the Measure Steward or Measure Developer. These materials are not clinical guidelines and do not establish a standard of medical care. The measure content may not be modified by anyone other than the Measure Steward or Measure Developer. The following organizations hold a copyright in these materials and can rescind or alter owned materials at any time:

Agency for Healthcare Research and Quality (AHRQ)
American Academy of Asthma Allergy and Immunology (AAAAI)
American Dental Association (ADA)
American Gastroenterological Association (AGA)
American Heart Association (AHA)/American Stroke Association (ASA)
American Nurses Association (ANA)
American Podiatric Medical Association (APMA)
American Psychiatric Association (APA)
Center for Quality Assessment and Improvement in Mental Health (CQAIMH)
Children’s Hospitals’ Solutions for Patient Safety National Children’s Network
Henry Ford Hospital
Institute for Clinical Systems Improvement (ICSI)
Massachusetts General Hospital (MGH)/Partners HealthCare System
Pharmacy Quality Alliance (PQA)
RAND Corporation
RAND Corporation/University of California, Los Angeles (UCLA)
Substance Abuse and Mental Health Services Administration (SAMHSA)
The Joint Commission
University Hospitals (UH) Cleveland Medical Center
University of Minnesota Rural Health Research Center
University of North Carolina (UNC)-Chapel Hill
US Office of Population Affairs (OPA)
Wisconsin Collaborative for Healthcare Quality (WCHQ)

This material contains content from LOINC®. The LOINC table, LOINC codes, and LOINC panels and forms file are copyright © 1995-2015, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and available at no cost under the license on the LOINC® Terms of Use web page.