Developing Innovative Quality Metrics In Value-based Care

Most nationally vetted clinical performance measures are provider-centric, based on billable in-person services, and unable to capture more patient-centered, flexible services such as visits with expanded care teams and virtual telehealth encounters. PRIME (Public Hospital Redesign and Incentives in Medi-Cal), part of California’s Medi-Cal 2020 waiver, provides pioneering and frontline contributions to the performance measurement landscape through its “Innovative Metrics.”

PRIME, an ambitious five year pay-for-performance program for 53 health systems, seeks to transform care delivery for underserved populations to be more equitable, coordinated, patient-centered, team-based, and value driven. To measure these new approaches to care, twenty-two “Innovative Metrics” (listed below) were conceptualized to meet the diverse PRIME project objectives, ranging from assessing and managing chronic pain to measuring specialty care expertise referrals. These metrics are quickly transformed to be functional, mature, and stable enough for PRIME’s pay-for-performance setting. At the core of the process, public hospital and health care system subject matter experts, including several members of national quality advisory bodies, serve as volunteer measure stewards by overseeing changes to the metric and answering questions from PRIME entities.

These metrics undergo a rigorous multi-year testing and vetting process, governed by the California Department of Health Care Services (DHCS) and implemented by the California Health Care Safety Net Institute (SNI) in collaboration with DHCS and the National Committee for Quality Assurance (NCQA). SNI annually facilitates three rounds of steward specification revisions, analysis and feedback by NCQA, DHCS, and reporting health systems (which includes the public health care systems and district municipal hospitals). These comprehensive revisions culminate in final specifications that incorporate formative, responsive measure feedback.

With continued stewardship, these tested metrics represent new models of care that can enable health care systems nationwide to provide more innovative, value-based, patient-centric care. SNI looks forward to sharing progress and learnings with the national quality improvement community.

Check out SNI’s poster on PRIME’s innovative metrics shared at the CMS 2019 Annual Quality Conference on January 30.

List of PRIME Innovative Metrics (as of Year 4):

1. Abnormal results follow-up: % of abnormal results with appropriate and timely documentation and follow-up
2. Adherence to medications for individuals prescribed high cost pharmaceuticals
3. Ambulatory palliative team established
4. Assessment and management of chronic pain (Use of annual opioid agreement form and annual toxicology screen)
5. BIRADS (Breast Imaging Reporting and Data System) to biopsy
6. Comprehensive medical evaluation following foster youth replacement in foster care
7. Documentation of medication reconciliation in the medical record for patients taking high cost pharmaceuticals
8. High-cost pharmaceutical ordering protocols
9. Measuring What Matters (MWM) #8 – treatment preferences (Outpatient)
10. National Healthcare Safety Network (NHSN) Antimicrobial Use Measure (Variation)
11. Palliative care service offered at time of diagnosis of advanced illness
12. Patients with chronic pain on long term opioid therapy checked in PDMPs (Prescription Drug Monitoring Programs)
13. Peri-operative prophylactic antibiotics administered after surgical closure
14. Primary care redesign metrics stratified by Race, Ethnicity, and Language (REAL) categories and Sexual Orientation and Gender Identity (SOGI)
15. REAL and/or SOGI disparity reduction
16. REAL data completeness
17. Receipt of appropriate follow-up for abnormal CRC (ColoRectal Cancer) screening
18. Request for specialty care expertise turnaround time
19. Sexual Orientation/Gender Identity (SO/GI) data completeness
20. Specialty care touches: Specialty expertise requests managed via non-face to face specialty encounters
21. Treatment of chronic non-malignant pain with multi-modal therapy
22. Use of imaging Studies for low back pain (red flags, no time limit)