The National Academy for State Health Policy (NASHP) designed this toolkit to support states interested in developing a value-based alternative payment methodology (APM) 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.
|Types of Performance Measures, with Examples
Process Measures: Measures that assess whether an action took place.
Structural Measures: Measures conditions or infrastructure of a practice.
Outcome Measures: Measures results of health care services provided to patients.
Patient Experience Measures: Measures how patients perceive their care.
Source: National Quality Forum. “ABCs of Measurement.” Accessed November 15, 2017. https://www.qualityforum.org/
Key considerations for measuring 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.
- Track changes in how and what care is being delivered.
Tying payment to quality is an essential feature of value-based APMs. When developing APMs, there are different types of quality measures that can be tied to payment, including outcome, process, structural, and patient experience measures (see text box).[i] Measures may be state-driven or nationally-validated through organizations such as the National Quality Forum[ii] or the Consumer Assessment of Healthcare Providers and Systems (CAHPS).[iii]
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 APMs are improving 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 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 are accurately capturing all the services they are providing. Complete utilization data is necessary for Medicaid to accurately measure practice performance on selected cost and quality measures. Under PPS, FQHCs received reimbursement as long as they provided at least one service that generated a patient encounter, which did not incentivize FQHCs to capture all services rendered.
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 value-based payment and delivery system transformation work, such as patient-centered medical homes (PCMHs), health homes,[iv] and accountable care organizations (ACOs)[v] will have measurement strategies in place that can be leveraged. Aligning measures across programs can send a consistent message to providers on quality improvement priorities. When selecting FQHC APM measures, states can draw from the Centers for Medicare & Medicaid Services (CMS) Adult[vi] and Child[vii] 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[viii]—another potential resource that state policymakers can consider to maximize both state and clinic resources (see text box).
Moreover, the use of consistent measurement specifications (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.[ix]
- The District of Columbia has nine measures for its FQHC pay-for-performance program. 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 APM Pilot report on a set of seven metrics that align with Coordinated Care Organization (CCO) metrics.[x],[xi] These metrics are not tied directly to FQHC payment under this APM. Because of this alignment, FQHCs are able to focus their quality improvement efforts on metrics that are important to CCOs, which has allowed some FQHCs to negotiate other value-based payment models with CCOs.[xii]
- Washington aligned its FQHC APM quality metrics with those in its Apple Health managed care program.[xiii]
|2017 UDS Clinical Performance Measures:
Source: Health Resources & Services Administration, “Uniform Data System (UDS) Resources,” accessed September 29, 2017, https://bphc.hrsa.gov/datareporting/reporting/index.html.
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 provided directly by the FQHC (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.
- The District of Columbia includes a diverse mix of FQHC access and process measures, as well as outcome measures, such as preventable hospitalizations and reduced inpatient readmissions, in its FQHC pay-for-performance program.[xiv]
- One of Minnesota’s IHPs, the FQHC Urban Health Network (FUHN), is an ACO consisting of 10 FQHCs. Like other IHPs they are held accountable for reducing total cost of care and improving quality. Between 2012 and 2015, FUHN decreased emergency department visits among its attributed patients by 27 percent,[xv] highlighting that FQHCs can support patients to improve health outcomes and seek care in appropriate settings.
|Oregon Care STEPsNew Visit Types
Coordination and Integration
Education, Wellness, and Community Support
Outreach and Engagement
*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 being delivered.
As states adopt value-based APMs that move away from an underlying fee-for-service (FFS) methodology toward a population-based APM, they may lose some detail on service utilization provided by FFS claims data. 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.[xvi] While certain encounters are recorded automatically, Oregon providers manually document the majority of Care STEP measures in the FQHC’s electronic health record systems (see text box).[xvii] FQHCs submit a Care STEPS report to the state quarterly.[xviii] Colorado is developing similar measures that will be incorporated into its population-based PMPM APM.
For more resources about measuring and reporting FQHC performance within a value-based APM, see the resources tab. To view additional information about developing a value-based APM 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
[ii] National Quality Forum. “Home Page.” Accessed September 29, 2017. https://www.qualityforum.org/Home.aspx.
[iii] Agency for Healthcare Research and Quality. “CAHPS Home Page.” Accessed September 29, 2017. https://www.ahrq.gov/cahps/index.html.
[iv] National Academy for State Health Policy. “State Delivery System and Payment Reform Map.” Accessed September 29, 2017. https://nashp.org/state-delivery-system-payment-reform-map/.
[v] Center for Health Care Strategies, Inc. “Medicaid ACOs: State Activity Map.” Accessed September 29, 2017, https://www.chcs.org/resource/medicaid-aco-state-update/.
[vi] Centers for Medicare & Medicaid Services, “2017 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set),” accessed September 29, 2017, https://www.medicaid.gov/medicaid/quality-of-care/downloads/2017-adult-core-set.pdf.
[vii] Centers for Medicare & Medicaid Services, “2017 Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set),” accessed September 29, 2017, https://www.medicaid.gov/medicaid/quality-of-care/downloads/2017-child-core-set.pdf.
[viii] Health Resources & Services Administration, “Uniform Data System (UDS) Resources,” accessed September 29, 2017, https://bphc.hrsa.gov/datareporting/reporting/index.html.
[ix] Heath Resources & Services Administration. “2017 Reporting Requirement.” Accessed November 20, 2017. https://bphc.hrsa.gov/datareporting/reporting/2017udsreportingrequirements.pdf.
[x] 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, 2017. **NASHP Communications – please insert link to this from the toolkit once available.**
[xi] Oregon Health Authority. “Oregon Health Authority Measure Sets.” July 2017. https://www.oregon.gov/oha/HPA/ANALYTICS/CCOData/2018%20Measures.pdf.
[xii] Communication with Don Ross, OHA. June 14, 2017.
[xiii] Gary Swan. “Healthier Washington and Washington’s FQHC APM.” PowerPoint, National Academy for State Heatlh Policy Value-Based Payment Reform Academy Closing Meeting, July 24, 2017. **NASHP Communications – please insert link to this from the toolkit once available.**
[xiv] 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. https://www.dcregs.dc.gov/Common/DCMR/SectionList.aspx?SectionNumber=29-4502.
[xv] Deanna Mills. “FUHN’S Journey: MN DHS’s Integrated Health Partnership.” PowerPoint, National Academy for State Health Policy’s Value-Based Payment Reform Academy Closing Meeting, July 26, 2017.
[xvi] Oregon Primary Care Association, APCM Care STEPS Report: Care and Services That Engage Patients (Portland, OR: Oregon Primary Care Association, 2017). (link)
[xvii] Veenu Aulakh and Brenda Solórzano. “The Future is Now: Value-Based Care in the Healthcare Safety Net.” Lecture, Oregon-California Learning Exchange, Oakland, California, March 29, 2016. https://www.careinnovations.org/uploads/OrCaX_Master_Presentation_Deck_March_29_2016.pdf
[xviii] Oregon Health Authority, Oregon Health Plan Section 1115 Quarterly Report (Salem, Oregon: Oregon Health Authority, 2017) https://www.oregon.gov/oha/HPA/HP-Medicaid-1115-Waiver/1115Waiver/First%20Quarter%202017.pdf