Measurement and Reporting

Value-Based Payment Reform Academy states
Value-Based Payment Reform Academy states

The National Academy for State Health Policy (NASHP) designed this toolkit to support states interested in developing value-based payment (VBP) methodologies for federally qualified health centers (FQHCs). The following section on measuring performance discusses key considerations and promising strategies based on lessons learned from states during NASHP’s Value-Based Payment Reform Academy.

Key considerations to measure performance include:

  • •  Consider a diverse set of process, structural, and outcome measures to track both practice transformation and quality improvement;
  • •  Align measures (both in selection and measure specifications) across state initiatives to enable policymakers and providers to focus on key priorities;
  • •  Select measures that create accountability for practices to improve patients’ overall health; and
  • •  Track changes in how and what care is delivered.

Background

Tying payment to quality is an essential feature of VBP methodologies. Different types of quality measures can be tied to payment, including outcome, process, structural, and patient experience measures.[i] Measures may be state-driven or nationally-validated through organizations such as the National Quality Forum or the Consumer Assessment of Healthcare Providers and Systems (CAHPS).

Examples of Different Types of Performance Measures

Process measures: Measures that assess whether an action took place.

  • •  NQF 0032: Percent of female patients age 21-64 that received cervical cancer screening
  • •  NQF 0057: Percent of diabetes patients age 18-75 that received a HbA1c test

Structural measures: Measures conditions or infrastructure of a practice.

  • •  Patient-centered medical home certification
  • •  Adoption of electronic health records

Outcome measures: Measures results of health care services provided to patients.

  • •  NQF 0059: Percent of diabetes patients 18-75 that has HbA1c levels over 9% indicating poor control
  • •  NQF 0711: Percent of patients 18 and older that show remission of depression within six months

Patient experience measures: Measures how patients perceive their care.

  • •  CAHPS question: How quickly could you get an appointment?
  • •  CAHPS question: How often has the provider’s office talked to you about your prescriptions with you?

Source: National Quality Forum. “ABCs of Measurement.” Accessed November 15, 2017. https://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx, as seen in Rachel Yalowich and Kitty Purington, Utilizing Measures in Value-Based Purchasing to Incentivize Integrated Care (Portland, ME: National Academy for State Health Policy, 2017).

Key Considerations

Consider a diverse set of process, structural, and outcome measures to track both practice transformation and quality improvement.
Process and structural measures can help states understand whether VBP methodologies improve clinic capacity (e.g., the presence of multi-disciplinary care teams) and increasing uptake of key practices (e.g., follow-up after hospital admissions). Outcome measures, which indicate changes in individual or population health, are multifactorial and can take time to improve. States may want to decrease the number of structural and process measures and increase the number of outcome measures over time, as system transformation and quality improvement capacity matures.

When selecting measures, it is important to consider that some FQHCs may need to transform their coding and billing practices and/or add new staff to ensure they accurately capture all the services they provide. Complete utilization data is necessary for Medicaid to accurately measure practice performance on selected cost and quality measures. Under the Prospective Payment System (PPS), FQHCs receive reimbursement as long as they provide at least one eligible service that generates a billable encounter. Some Academy states expressed concern that FQHCs may not be capturing all services rendered during one encounter or that all services may not be included in the claim to Medicaid or managed care plans.

2017 UDS Clinical Performance Measures

  • •  Diabetes: Hemoglobin A1c poor control
  • •  Controlling high blood pressure
  • •  Low birth weight
  • •  Early entry into prenatal care
  • •  Childhood Immunization Status (CIS)
  • •  Cervical cancer screening
  • •  Weight assessment and counseling for nutrition and physical activity for children and adolescents
  • •  Body mass index (BMI) screening and follow-up
  • •  Tobacco use: Screening and cessation intervention
  • •  Use of appropriate medications for asthma
  • •  Coronary artery disease (CAD): lipid therapy
  • •  Vascular disease (IVD): Use of aspirin or another antiplatelet
  • •  Colorectal cancer screening
  • •  Screening for depression and follow-up plan
  • •  HIV linkage to care
  • •  Dental sealants for children ages 6-9

Source: Health Resources & Services Administration, “Uniform Data System (UDS) Resources,” accessed September 29, 2017, https://bphc.hrsa.gov/datareporting/reporting/index.html.

Align measures (both in selection and measure specifications) across state initiatives to enable policymakers and providers to focus on key priorities. States engaged in other Medicaid VBP and delivery system transformation work, such as patient-centered medical homes, health homes, and accountable care organizations will have measurement strategies in place that can be leveraged. Aligning measures across programs can send a consistent message to providers on a state’s quality improvement priorities and reduce provider burden. When selecting measures, states can draw from the Centers for Medicare & Medicaid Services (CMS) Adult and Child Core sets. FQHCs also report on 16 clinical quality measures to the Uniform Data System —Health Resources and Services Administration’s (HRSA) health center measure set — another potential resource that state policymakers can consider using to maximize both state and clinic resources.

Moreover, the use of consistent measurement specifications (key definitions, numerators, denominators, etc.) across programs can also reduce the burden on providers and Medicaid staff to track, analyze, and report on FQHC performance on these measures. Many of HRSA’s UDS measures have been revised to align with CMS measure specifications for 2017.[ii]

  • Washington, DC has nine measures for its FQHC pay-for-performance methodology. Four of the nine measures align with its Health Home program for Medicaid beneficiaries with three or more chronic conditions.
  • Oregon requires that FQHCs participating in its FQHC APM Pilot report on a set of seven measures that align with Coordinated Care Organization (CCO) measures.[iii] While these measures are not tied directly to FQHC payments under the pilot, the state reports that because of this alignment FQHCs have been able to focus their quality improvement efforts on measures that are important to CCOs. This has allowed some FQHCs to negotiate other VBP arrangements with CCOs.[iv]
  • Washington State aligned quality measures used in its FQHC VBP methodology with those in its Apple Health managed care program.[v]

Select measures that create accountability for practices to improve patients’ overall health. By changing how care is delivered, FQHCs have the capacity to impact cost and quality for services they provide directly (such as improving diabetes management), and for patient outcomes that involve the broader health system (such as reducing unnecessary emergency department utilization). States can help promote this accountability by selecting a diverse set of measures that includes primary care prevention and chronic care measures, as well as outcome measures that indicate improved care management and coordination, such as decreased emergency department utilization and inpatient readmissions. Early discussions with stakeholders about these issues is critical to developing a shared vision of accountability for health care outcomes.

  • Washington, DC includes a diverse mix of access and process measures as well as outcome measures, such as preventable hospitalizations and reduced inpatient readmissions, in its FQHC pay-for-performance methodology.[vi]
  • One of Minnesota’s Integrated Health Partnerships (IHPs), the FQHC Urban Health Network (FUHN), is an ACO consisting of 10 FQHCs. Like other IHPs, they are accountable for reducing total cost of care and improving quality. Illustrating the impact that FQHCs can have across the system of care, FUHN was able to decrease emergency department visits among its attributed patients by 27 percent between 2012 and 2015.[vii] 
Oregon Care STEPs

New visit types

  • • Home visit billable encounter*
  • • E-visit*
  • • Telemedicine encounter*
  • • Telephone visit*
  • • Home visit non-billable encounter

Coordination and integration

  • • Information management
  • • Coordinating care: Dental
  • • Clinical follow-up and transitions
  • • Warm hand-off
  • • Transportation assistance

Education, wellness, and community support

  • • Health education supportive counseling
  • • Education provided in a group setting
  • • Support group participant
  • • Exercise class participant

Outreach and engagement

  • • Flowsheet-screening tools*
  • • Panel management outreach
  • • Case management
  • • Accessing community resource

*Denotes an encounter that is automatically recorded as a Care STEP in the patient’s electronic health record.

Track changes in how and what care is delivered.
As noted earlier, FQHCs may not be in the practice of documenting all services provided in each patient encounter in their own payment systems or in Medicaid claims. To monitor underutilization and assess changes in how care is delivered, some states track utilization of non-billable patient contacts, such as patient outreach (phone calls, text messages, use of electronic health record online patient portal), care coordination, and group visits or patient education. Oregon measures these interactions with patients, which it calls Care STEPs. While certain encounters are recorded automatically, Oregon providers manually document the majority of the Care STEPs in their FQHCs’ electronic health record systems.[viii] FQHCs submit Care STEPS reports to the state quarterly.[ix] Colorado is planning to incorporate similar measures in the VBP methodology it is developing.

For more resources about measuring and reporting FQHC performance within VBP methodologies, see the resources tab. To view additional information about developing a VBP methodology for FQHCs, return to the toolkit home.


[i] National Quality Forum. “The ABCs of Measurement.” Accessed September 29, 2017. https://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx.

[ii] Heath Resources & Services Administration. “2017 Reporting Requirement.” Accessed November 20, 2017. https://bphc.hrsa.gov/datareporting/reporting/2017udsreportingrequirements.pdf.

[iii] Craig Hostetler, Don Ross, and Sherlyn Dahl. “Lessons From Oregon’s FQHC Alternative Payment Methodology Pilot.” PowerPoint, National Academy for State Health Policy Value-Based Payment Reform Academy Kick-Off Meeting, June 14, 2016. https://nashp.org/wp-content/uploads/2017/11/Oregon-APCM-Overview_2016.pdf.

[iv] Communication between authors and Don Ross. Oregon Health Authority. June 14, 2017.

[v] Gary Swan. “Healthier Washington and Washington’s FQHC APM” [PowerPoint Presentation]. July 24, 2017. https://nashp.org/wp-content/uploads/2017/11/WA-HCA-FQHC-VBP-Alignment_2017.pdf.

[vi] District of Columbia Department of Health Care Finance. Notice of Emergency and Proposed Rulemaking, Governing Medicaid Reimbursement for Federally Qualified Health Centers. October 6, 2017. Accessed May 3, 2018. https://www.dcregs.dc.gov/Common/DCMR/SectionList.aspx?SectionNumber=29-4502.

[vii] Deanna Mills. “FUHN’S Journey: MN DHS’s Integrated Health Partnership” [PowerPoint Presentation]. July 25, 2017. https://nashp.org/wp-content/uploads/2017/11/MN-FUHN_Shared-Savings-Overview_2017.pdf.

[viii] Laura Sisulak. “Clinic Readiness, Preparation, and Support” [PowerPoint Presentation]. July 26, 2017. https://nashp.org/wp-content/uploads/2017/11/OPCA_FQHC-Resources-and-Supports_-2017.pdf.

[ix] Oregon Health Authority. Oregon Health Plan Section 1115 Quarterly Report (Salem, Oregon: Oregon Health Authority, 2017). http://www.oregon.gov/oha/HPA/HP-Medicaid-1115-Waiver/1115Waiver/First%20Quarter%202017.pdf.