AIM HEDIS WebinarDECEMBER 18, 2018

This webinar is being recorded.

THE WEBINAR RECORDING, PRESENTATION SLIDES AND

RELATED MATERIALS WILL BE POSTED ON THE AIM WEBSITE

VISIT: WWW.IMMUNIZATIONMANAGERS.ORG/WEBINARS

2

Agenda

Welcome and Housekeeping

The Importance of Quality Measures- Angela K. Shen, ScD, MPH

CAPT(ret) USPHS

California Efforts to Implement New Adult Immunization Performance Measures- Dr. Sarah Royce (CA)

National Quality Landscape- Abby Bownas (AVAC)

Open Discussion/ Q&A

Closing

3

Webinar Tech-Tips 4

Click either:✓ “USE Telephone” for

cell phone or land line OR

✓ “USE Mic & Speakers”for computer audio and voice

Choose EITHER your telephone or your computer’s microphone and speakers.

If you are dialing in on telephone, enter audio pin #yourpin#

www.immunizationmanagers.org

Discussion 5

Type question in

Question Box and AIM

Staff will read your

question to the panelist.

ALL Lines will be unmuted during the

discussion portion of the call.

PLEASE remember to mute your line if

you are not speaking

Mute the line by muting your

phone, or computer mic, or by

clicking the green microphone

button the Go To Webinar control

panel

www.immunizationmanagers.org

Angela K Shen, ScD, MPH

CAPT(ret) USPHS

Adjunct Professor, Drexel Dornsife

School of Public Health

angela.k.shen@gmail.com

6

ASSOCIATION OF IMMUNIZATION MANAGERS WEBINAR

1 8 D E C E M B E R 2 0 1 8

A N G E L A K S H E N , S C D , M P H

C A P T ( R E T ) U S P H S

A D J U N C T P R O F E S S O R - D R E X E L D O R N S I F E S C H O O L O F P U B L I C H E A L T H

A N G E L A . K . S H E N @ G M A I L . C O M

Quality Measurement & 2019 New HEDIS Adult Immunization Measures

Outline

Introduction – Importance of Quality Measurement Why do we have quality measures?

Shift from volume to value in health care delivery

New HEDIS® 2019 adult immunization measures Prenatal Immunization Status

Adult Immunization Status

Electronic Clinical Data System

Adult & Implementation NCQA accredited plans

CMS – Medicare

Medicaid – state by state action

Why do we have quality measures?

Who delivers vaccinations? Health Plans – pay for services

Providers - provide services

Public Health – assures services to all

What are we trying to do with measures? Improve the quality of healthcare across the lifespan through measurement

We can’t improve what we don’t measure

We want measurement to be transparent so measurement will be accepted

Accountability: once we measure we can expect and track progress

Why do we have quality measures? – 2

How does measurement help? Goals, report cards, score cards - strategies that use measurement. As a result:

Process & Procedures (e.g., standing order in workflow, point of care alerts)

Increased access points and personnel (e.g., MAs to administer, specialty clinics, PN during influenza visits)

Technology Automated Process: Registry (bi-directional), Patient Prompts (call in appointment line, reminders, letters)

Why do we have quality measures? - 3

Why? Compliance with policy & legislation – state by state

School IZ requirements

Standards are tied to reimbursement and public reporting Private plans | HEDIS® measures are accountable, transparent, &

rigorously audited; Cover 184 million people (57% population) HEDIS is used to assess the quality of health plans Tool for improving performance – asks how often insurers provide

evidence-based care to support 70+ aspects of health Measures must be meaningful

• Clinically important to patients & clinicians• Feasible (to get & to report)

Medicare | CMS (STARS rating program) – MIPS, ACO Medicaid | Medicaid core set Accreditation | JOINT COMMISSION Other programs | e.g., Office of Personnel Management, Federally

Qualified Health Centers

12

Goal: High value health care

Healthy/low risk

At risk

High risk

Early symptoms

Active disease

generate 20% OF PEOPLE

80% OF COSTS

Slide: Courtesy of NCQA

Measuring immunization is a good example of focusing on prevention

13

This shift is driving an increased focus on preventive services, such as vaccines, which have been shown to improve health outcomes and reduce healthcare spending and utilization over the long-term

The Volume-to-Value Shift Is Creating Opportunities to Incentivize Vaccination

Cost

Quality A key component of defining the value of health products and services

Reducing costs is well understood, but the role of quality continues to evolve

Volume Value

Slide: Courtesy of Avalere

P R E N A T A L I M M U N I Z A T I O N S T A T U S

A D U L T I M M U N I Z A T I O N S T A T U S

( S E E H A N D O U T )

( F O L L O W O N T O F E B 2 2 , 2 0 1 8 P R E S E N T A T I O N )

E L E C T R O N I C C L I N I C A L D A T A S Y S T E M

New HEDIS® 2019 Adult Immunization Measures

HEDIS® Development & Testing

National Committee for Quality Assurance (NCQA) tested and developed Adult immunization status (Adult composite) and Prenatal immunization status (Prenatal composite) measures

Healthcare Effectiveness Data and Information Set (HEDIS), a tool used to assess the quality of care in health plans

Measures are specified using the HEDIS Electronic Clinical Data Systems data collection method This method leverages electronic clinical data for quality measurement

Such data include administrative claims, electronic medical records, case management systems and registries

Measures Added to the 2019 HEDIS® Set

Adult Immunization Status

Percentage of members 19 years of age and older who are up-to-date on recommended routine vaccines for influenza, Td/Tdap, zoster and pneumococcal

Applies to Medicaid, Commercial, Medicare plans

Prenatal Immunization Status

Percentage of deliveries in which women received influenza and Tdap vaccinations

Applies Medicaid and Commercial plans

Major Quality ActivitiesEvidence

Development

Guideline

Development

Measure

Development*

Measure

Endorsement

Measure

Implementation

Develop

evidence base

for effective

treatment

Develop

guidelines for

practitioners

based on

evidence

Develop

performance

measures

based on

guidelines

Ensure

measures are

evidence-

based,

scientifically

sound,

feasible

Use measures

to improve

quality

Example orgs.:

Researchers Advisory Committee on Immunization Practices & others

National Committee for Quality Assurance, Specialty societies

National Quality Forum

Centers for Medicare & Medicaid Services, Clinical Registries, states & others

* Quality measures can be effective tools to compare and monitor health plan performance* Need to balance desirable attributes of importance, scientific acceptability & feasibility* Leveraging health information technology is key

NCQA HEDIS®

A tool used by more than 90 percent of America's health plans to measure

performance on important dimensions of care and service

Existing measures are survey measures; New measures in ECDS gets away from having to conduct field surveys to get this information, by capturing electronic clinical data

Accredited Medicaid and commercial plans are listed here: The 2018-2019 Health Insurance Plan Ratings

Incorporating Quality Measures

Monitor changes in new & existing programs To monitor changes in new and existing programs and payment models (e.g. mandatory

reporting programs, pay for reporting, pay for performance)

Advocate for inclusion of immunization measures in programs

Tying quality measures to payment models Value-based payment structures

Leverage existing payment mechanisms for immunization

Potential programs for measure adoption & implementation: Medicare | health plan, clinical, facility levels

E.g., Merit-Based Incentive Payment System (MIPS), Medicare Shared Savings Program, & Medicare Advantage (MA) – Star Ratings

Medicaid | adult core set, child core set

NQF | Endorsement

19

Opportunities

Advocate for inclusion of immunization to programs and payment models that use quality measures & metrics: Mandatory reporting programs Pay for reporting Pay for performance Value-based purchasing Shared savings programs Incentive arrangements Alternative payment models Accreditation requirements

Archived NAIIS Quality Performance Measure Slides https://www.izsummitpartners.org/naiis-workgroups/quality-and-

performance-measures/

Adult Immunization Quality Measures Landscape

Source: A Shen, NAIIS 2016

Sarah Royce, MD, MPH

Chief, Immunization Branch

Division of Communicable Disease

Control, Center for Infectious Diseases

California Department of Public Health

Sarah.Royce@cdph.ca.gov

22

California efforts to implement new adult immunization performance measures

12/18/2018 AIM meeting

Sarah.Royce@cdph.ca.gov

510 230 3593

Outline

1. How can performance measures help raise coverage levels?

2. Which measure to prioritize?

3. Which organization(s) are highest priority for adopting the measure?

4. Strategies to promote adoption

5. Questions for discussion

24

1. How measurement can drive increased immunization

• Inform quality improvement efforts• How are we doing now? (Baseline)

• Where do we need to improve? How target efforts?

• Did they work?

• Incentives for providers, medical groups, health plans• Pay for Performance

• Public reporting • Feedback to providers can be a powerful motivator

• To inform consumer, employer choice

• Allow consumers (taxpayers) to hold payers, Health Plans accountable

25https://www.thecommunityguide.org/sites/default/files/assets/What-Works-Factsheet-Vaccination.pdf

2. Prioritize Prenatal IZ

• Public health impact in CA• Risk of flu morbidity/mortality in pregnant woman and infants

• Pertussis cases < 4 mos of age

• Even in lower incidence years: ~100 cases and 1-2 deaths/year

• Infants born to women in the Medi-Cal program were 2.5 times more likely to develop pertussis than infants born to privately insured women*

• Performance improvement is needed • Large gaps in prenatal immunization levels

• Medi-Cal disparity

26

*Winter. Pediatric Infectious Disease Journal. 2018Link for “Shelf Talker”in English and Spanish to place in pharmacy aisles: http://eziz.org/resources/pertussis-promo-materials/prenatal-tdap/

27

Reported receipt of Tdap vaccination during pregnancy, Maternal Infant Health Assessment, by insurance status CA, 2016

https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/MIHA-FactSheet2016.pdf

(Called PRAMS in other states)

More reasons to prioritize Prenatal IZ

• Evidence based practices to raise IZ rates are available • Ex. Stocking immunizations on site works

• Barriers are amenable to intervention. In a trace back study, • pregnant women with Medi-Cal were less likely to be appropriately

immunized, even when provider stocked Tdap

• providers cite reimbursement and contracting barriers

• (if don’t stock) referrals not working Barriers to Receipt of Prenatal Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine Among Mothers of Infants Aged <4 Months with Pertussis — California, 2016

• Feasible for Health Plans to implement the measure: aligns with existing maternity care measures, short look back period

28

Adult composite measure, 18-49, 50-64, 65+ years of age• Public health impact in CA/year

• > 100k zoster and 1000’s of pneumococcal cases could be prevented, especially in > 65 year olds (Medicare)

• Millions cases of flu

• Low IZ levels, disparity

• Less feasible: 10 year look back for Td

• Uncertainty of PCV 13 recommendation after 2019

• RZV supply constraints

29

3. Which state level organizations are highest priority for adopting the measure?Medi-Cal, given infant pertussis and maternal Tdap disparities

• Medi-Cal managed care plans (MCPs) • Report performance on a list of measures, rates posted on line

• Are held to minimum performance levels

• Not sufficient to have Medi-Cal contracts requiring Plans to assure ACOG compliance; make adult immunizations available in pharmacies https://files.medi-cal.ca.gov/pubsdoco/medsupply/MediCal_coverage_immunizations_faq.asp

• Need actual prenatal IZ levels to • Hold Plans accountable for assuring immunization of pregnant women

• Focus and inform quality improvement at Plan and provider levels

30

Proposed Medicaid adoption of prenatal immunization measure

• Adding to CMS Core Child Set would help foster state Medicaid adoption now (mandatory in 2024) https://www.medicaid.gov/federal-policy-

guidance/downloads/sho18010.pdf; https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/child-core-set/index.html

• Federally Qualified Health Centers (FQHCs) provide a significant portion of prenatal care in the Medi-Cal program • Medi-Cal managed care plans assess FQHC performance for their members

(even if not required for FQHC reporting to HRSA in the Uniform Data System)

31

Other state level organizations to consider

• Regional Health Improvement Collaborative (RHICs in 30 states)• common measure set

• Health Plan incentive payments to physician groups (Pay for Performance) https://www.iha.org/sites/default/files/resources/fs_amp_commercial_hmo.pdf

• public reporting http://reportcard.opa.ca.gov/rc/medicalgroupcounty.aspx

• CA’s RHIC will test prenatal immunization measure this spring

• NCQA-accredited health plans • Required reporting on a list of measures

• Look up your state’s Health Plans: The 2018-2019 Health Insurance Plan Ratings

All payer claims data base

32

4. Strategies for fostering adoption of measure• Enlist partners to select measure(s) and orgs, test, adopt

• IZ coalition, professional orgs, health systems and plans, Medicaid agency

• Build/convey a strong argument • National Quality Forum criteria for measure selection (See draft sample)

• Find out timing of windows for comment, decisions

• Use Immunization Info System (IIS)• Promote use by Plans, medical groups, providers and pharmacies

• Run coverage rate using HEDIS specifications (AIM can provide)• Example: match with birth certificates to identify pregnant women and determine

weeks gestation at time of immunization (CA, MN, WI studies)

33

Abby L. Bownas

Senior Advisor

NVG LLC

abownas@nvgllc.com

34

AVAC Meeting October 19, 2018

35

Association of Immunization Managers Webinar December 18, 2018

Abby BownasManager,

Adult Vaccine Access Coalition

Adult Vaccine Access Coalition

• AVAC began in 2015• AVAC has brought together over 50

diverse organizations under one umbrella working to bring federal policy changes to increase adult vaccination rates

• Members include vaccine innovators, health care providers, pharmacy, public health, registry, patient and minority health organizations

• AIM is an active member of AVAC!

AVAC Core Areas1. Build. AVAC is committed to improving reporting of adult vaccinations to

immunization registries and encouraging greater utilization of health

information technology to track vaccination status and improve patient

outcomes and care.

2. Access. AVAC aims to improve adult immunization rates among at-risk

populations by reducing financial barriers for patients, reducing

administrative hurdles for providers, and eliminating missed opportunities

for immunization.

3. Measure. AVAC supports the development and adoption of federal

benchmarks and measures to encourage better tracking, better reporting,

and increased adult immunization rates.

AVAC’s Work to Strengthen Adult Immunization Quality Metrics • Comment regularly on federal proposed rulemaking. Fighting against

efforts to eliminate quality measures under a variety of Medicare

payment programs.

• Promote the availability new Adult Immunization Composite Measures

with federal payment programs and provider organizations.

• Advocate for lifespan immunization measures as part of Healthy People

2030 objective development process at DHHS.

Supporting Quality Measures Through the Federal Regulatory Comment Process • There are opportunities to review and provide comments to several proposed rules from

CMS throughout the year.

• Last year, AVAC submitted over a dozen comment letters with the theme of “protecting and preserving” existing measures, as well as proposing the adoption of updated and streamlined immunization quality measures.

• A sample of CMS regulatory comment opportunities:

o Physician Fee Schedule

o CY 2019 Home Health Prospective Payment System

o Hospital Inpatient Prospective Payment

o CMS Skilled Nursing Facilities Quality Reporting Program

o CMS Medicare Advantage and Part D Call letter

Advocating for Next Generation of Adult Immunization Composite Measures• NCQA added the adult immunization composite measure to their

2019 Healthcare Effectiveness Data Information Set (HEDIS) using the new Electronic Clinical Data System (ECDS) reporting domain.

• The measure will now be available for health plans to test as part of their HEDIS data sets. The results of this measure will not be public until after the measure is finalized.

• Measures in the HEDIS ECDS domain are calculated using electronic data from administrative claims, electronic medical records, case management systems and registries.

Opportunities to Advocate for the Adult Immunization Composite Measure• The National Quality Forum (NQF) released its Measures Under Consideration (MUC) on

December 3. These measures are being considered for future use in Medicare.

• Adult Immunization Status Measure (Medicare Shared Savings Program). The MSSP measure -- the MAP voted 68% (15 supported and 4 opposed) to provide conditional support but highlighted concerns with differential timing with measure reporting.

• Adult Immunization Status Measure (Merit-based Incentive Payment System). The MIPS composite measure – MAP voted 89% (17 supported and 2 opposed) to not support the measure with an opportunity for mitigation.

• NQF will release a draft report for public comment on December 21.

• Public comments on draft report due January 10.

Additional Opportunities to Advocate for the Adult Immunization Composite Measure

• Adult Immunization Composite Measure on Medicare Star Ratings Display Page

• FY19 Medicare Advantage Call letter included the adult immunization composite as a “Potential New Measures for 2020 and Beyond.”

• AVAC drafted a memo to CMS urging adoption of HEDIS Composite as part of the FY2020 Medicare Advantage Call Letter (12/12/19)

• Next MA Call letter is expected to be released in Feb 2019

• Opportunity to submit comment in response to draft letter

• Medicaid Adult Core Set (Aug)

• Medicaid Childhood Core Set (maternal immunization composite) (Aug)

Healthy People 2030 Process • HHS Office of Disease Prevention and Healthy Promotion goal to streamline Healthy People

objectives (reduce from 1000 in 2020 to just over 300 for 2030)

• Proposed Objectives for HP2030 released December 4

• Cut immunization measures in half from 2020

• Proposed objectives -https://www.healthypeople.gov/sites/default/files/ObjectivesPublicComment508.pdf

• Elimination of many childhood and adolescent objectives

• Maintains only 2 adult objectives

• Flu (6mos+, core), Tdap (pregnant women, developmental objective)

• Immunization advocates will need to make case for these quality measures!

• Deadline to comment on proposed HP Objectives – January 17

• Expect additional opportunities to comment on other elements of HP2030 in 2019

Healthy People 2030

Healthy People 2030

Ways to Support Adult Immunization Quality Measures

• Submit letters during pubic comment periods

• Provide information and resources to Members of Congress to educate them on how these proposed changes will impact your work in their districts and states

• Share stories with AIM on how quality measures (or removal of measures) will impact your work

AVAC Meeting October 19, 2018

47

Learn more: www.adultvaccinenow.orgFollow: AVAC @AVACNOWEmail AVAC:

abownas@nvgllc.com, lfoster@nvgllc.com

Discussion Questions

• What efforts to implement these new measures are underway or

are you contemplating in your jurisdiction?

• Which measure did/would you prioritize? Why?

• In which health care system in your jurisdiction is it most

important to adopt the measure? Why?

• How would measure adoption help raise immunization rates?

• What organizations can help get the measure adopted? What’s

in it for them?

• How can AIM, NAIIS, CDC help support jurisdiction-level efforts?

48

Reminders

➢ Take the event evaluation that appears at the

end of the webinar.

Your feedback will help us improve!

49