David Pating, MDChief, Addiction MedicineKaiser San FranciscoAssociate Clinical Professor UCSFMember, NQF Behavioral Health Standing Committee

April 27, 2017

National Consensus Standards for Behavioral Health Conditions

…an unofficial introduction

The National Quality Forum: A Unique Role

Unauthorized presentation for demonstration purposes only. 3

Established in 1999, NQF is a non-profit, non-partisan, membership-based organization that brings together public and private sector stakeholders to reach consensus on healthcare performance measurement. The goal is to make healthcare in the U.S. better, safer, and more affordable.

Mission: To lead national collaboration to improve health and healthcare quality through measurement

▪ An Essential Forum▪ Gold Standard for Quality Measurement▪ Leadership in Quality

NQF Activities in Multiple Measurement Areas

4

▪ Performance Measure Endorsement▫ 600+ NQF-endorsed measures across multiple clinical areas▫ 19 empaneled standing committees

▪ Measure Applications Partnership (MAP) ▫ Advises HHS on selecting measures for 20+ federal programs, Medicaid,

and health exchanges

▪ National Quality Partners▫ Convenes stakeholders around critical health and healthcare topics▫ Spurs action on patient safety, early elective deliveries, and other issues

▪ Measurement Science▫ Convenes private and public sector leaders to reach consensus on

complex issues in healthcare performance measurement such as attribution, alignment, sociodemographic status (SDS) adjustment

5

NQF endorsement evaluation

MAP pre-rulemaking

recommendations

NQF evaluation summary provided

to MAP

MUC that has never been through NQF

MUC given conditional support

pending NQF endorsement

MAP feedback on endorsed measures:• Entered into NQF database• Shared with Committee during

maintenance• Ad hoc review if MAP raises any

major issues addressing criteria for endorsement

• NQF outreach to MUC developers in February and during Call for Measures

• Funding proposals include MAP topics

• MAP feedback to Committee

CDP-MAP INTEGRATION – INFORMATION FLOW

Types of Performance Measures

▪ Quality▪ Resource use/cost ▪ Efficiency (combination of quality and resource use)▪ Composite (two or more measures in a single score)

6

NQF endorsement reflects rigorous scientific and evidence-based review for Standardized performance measures are used for comparisons.

Characteristics of Measures

▪ Measures are different from concepts or ideas» Quality of care is an abstract construct» A quality measure is a numeric quantification of healthcare quality

▪ Measures have detailed specifications» What to count (including codes, definitions)» Who is included and/or excluded» When to count» Where to find data» How to compute score

7

Numerators = XDenominators Y

8

Person-Centered Measures

9

▪ 0008: Experience of Care and Health Outcomes (ECHO) Survey (behavioral health, managed care versions) (CMS)*

▪ 0027: Medical Assistance With Smoking and Tobacco Use Cessation (NCQA)*

▪ 0028: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (PCPI Foundation)*

▪ 3185: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (eMeasure) (PCPI Foundation)

▪ 0108: Follow-Up Care for Children Prescribed ADHD Medication (NCQA)*

▪ 0576: Follow-Up After Hospitalization for Mental Illness (NCQA)*

Behavioral Health Portfolio of MUC measures: 4*Measures for maintenance evaluation

▪ 3132: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (eMeasure) (CMS)

▪ 3148: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (CMS)*

▪ 3172: Continuity of Pharmacotherapy for Alcohol Use Disorder (RAND Corporation)

▪ 3175: Continuity of Pharmacotherapy for Opioid Use Disorder (RAND Corporation)

10

NQF currently has more than 50 endorsed measures within the area of behavioral health. Endorsed measures undergo periodic evaluation to maintain endorsement – “maintenance”.

Measure Evaluation Criteria Overview

11

NQF Consensus Development Criteria

▪ Criteria #1: Importance to Measure and Report*

▪ Criteria #2: Scientific Acceptability of Measure Properties*

▪ Criteria #3: Feasibility

▪ Criteria #4: Usability and Use *=(must-pass)

▪ Criteria #5: Comparison to Related or Competing Measures

Final Recommendation for Endorsement/Harmonization

12

Criterion #1: Importance to Measure & Report

13

1. Importance to measure and report - Extent to which the specific measure focus is evidence-based and important to making significant gains in healthcare quality where there is variation in or overall less-than-optimal performance.

1a. Evidence: the measure focus is evidence-based

1b. Opportunity for Improvement: demonstration of quality problems and opportunity for improvement, i.e., data demonstrating considerable variation, or overall less-than-optimal performance, in the quality of care across providers; and/ordisparities in care across population groups

1c. Quality construct and rationale (composite measures only)

Subcriterion 1a: Evidence for Measure Focus

▪ Hierarchical preference for▫ Outcomes linked to evidence-based processes/structures▫ Outcomes of substantial importance with plausible

process/structure relationships▫ Intermediate outcomes▫ Processes/structures

14

Most closely linked to outcomes

Criterion #2: Reliability and Validity– Scientific Acceptability of Measure Properties

15

2a. Reliability (must-pass)2a1. Precise specifications including exclusions 2a2. Reliability testing—data elements or measure score

2b. Validity (must-pass)2b1. Specifications consistent with evidence 2b2. Validity testing—data elements or measure score2b3. Justification of exclusions—relates to evidence2b4. Risk adjustment—typically for outcome/cost/resource use2b5. Identification of differences in performance 2b6. Comparability of data sources/methods2b7. Missing data

Extent to which the measure, as specified, produces consistent (reliable) and credible (valid) results about the quality of health care delivery

Reliability and Validity

16

Assume the center of the target is the true score…

Consistent,

but wrong

Consistent &

correct

Inconsistent &

wrong

Criterion #3: Feasibility

17

Extent to which the required data are readily available, retrievable without undue burden, and can be implemented for performance measurement.

3a: Clinical data generated during care process

3b: Electronic sources

3c: Data collection strategy can be implemented

Criterion #4: Usability and Use

18

Extent to which potential audiences are using or could use performance results for both accountability and performanceimprovement to achieve the goal of high-quality, efficient healthcare for individuals or populations.

4a: Accountability and Transparency

4b: Improvement

4c: Benefits outweigh the harms

4d: Vetting by those being measured and others

Criterion #1: Importance to measure and report Criteria emphasis is different for new vs. maintenance measures

19

New measures Maintenance measures

• Evidence – Quantity, quality,

consistency (QQC)

• Established link for process

measures with outcomes

DECREASED EMPHASIS: Require measure

developer to attest evidence is

unchanged evidence from last evaluation;

Standing Committee to affirm no change

in evidence

IF changes in evidence, the Committee

will evaluate as for new measures

• Gap – opportunity for

improvement, variation, quality

of care across providers

INCREASED EMPHASIS: data on current

performance, gap in care and variation

Criterion #2: Scientific Acceptability

20

New measures Maintenance measures

• Measure specifications are

precise with all information

needed to implement the

measure

NO DIFFERENCE: Require updated

specifications

• Reliability

• Validity (including risk-

adjustment)

DECREASED EMPHASIS: If prior testing

adequate, no need for additional testing at

maintenance with certain exceptions (e.g.,

change in data source, level of analysis, or

setting)

Must address the questions for SDS Trial

Period

Criteria #3-4: Feasibility and Usability and Use

21

New measures Maintenance measures

Feasibility

• Measure feasible, including

eMeasure feasibility assessment

NO DIFFERENCE: Implementation

issues may be more prominent

Usability and Use

• Use: used in accountability

applications and public reporting

INCREASED EMPHASIS: Much

greater focus on measure use and

usefulness, including both impact

and unintended consequences• Usability: impact and unintended

consequences

Recommendation for Endorsement or Endorsement +

22

▪ The Committee votes on whether to recommend a measure for NQF Endorsement

▪ Or “Endorsement +” designation, indicating that the measure exceeds NQF criteria if

▫ Meets evidence criteria without exception▫ Good results on reliability testing of the measure score▫ Good results on empirical validity testing of the measure score

(not just face validity)▫ Well-vetted in real world settings by those being measured and

others in key areas.

▪ Harmonization of related or competing measures

www.qualityforum.org

23

The Business of Making Measures

24

25

26

Busy Clinic - The App!

27

28

29

▪ Peter Briss, MD, MPH, (Co-Chair)

▪ Harold Pincus, MD (Co-Chair)

▪ Robert Atkins, MD, MPH

▪ Mady Chalk, PhD, MSW

▪ Shane Coleman, MD, MPH*

▪ David Einzig, MD

▪ Julie Goldstein Grumet, PhD

▪ Charles Gross, PhD*

▪ Constance Horgan, ScD

▪ Lisa Jensen, DNP, APRN

▪ Dolores (Dodi) Kelleher, MS, DMH

▪ Kraig Knudsen, PhD

▪ Michael R. Lardieri, LCSW

▪ Tami Mark, PhD, MBA

Behavioral Health Standing Committee

30

▪ Raquel Mazon Jeffers, MPH, MIA

▪ Bernadette Melnk, PhD, RN, CPNP/FAANP, FNAP, FAAN

▪ Laurence Miller, MD

▪ Brooke Parish, MD*

▪ David Pating, MD

▪ Vanita Pindolia, PharmD

▪ Rhonda Robinson Beale, MD

▪ Lisa Shea, MD, DFAPA

▪ Andrew Sperling, JD*

▪ Jeffery Susman, MD

▪ Michael Trangle, MD

▪ Bonnie Zima, MD, MPH

▪ Leslie S. Zun, MD, MBA

*indicates new committee member

31

32

Evidence: Gap

33

34

Evidence Validity

35

36

Feasibility

Useability

Review of HEDIS: AOD_IET Measure

The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence* (first visit in calendar year) who received the following:

•Inpatient

•Intensive Outpatient

•Partial Hospitalization

•Outpatient

•Detoxification

•ED Encounter

•Inpatient

•Intensive Outpatient

•Partial Hospitalization

•Outpatient

Index Episode

Start Date

(IESD)

14 days

inclusive Initiation Visit30 days

Two

Engagement

Visits

Primary Focus •Inpatient

•Intensive Outpatient

•Partial Hospitalization

•Outpatient

HEDIS “dependence” definition is very broad and contains almost all alcohol and substance related codes (see appendix)

Unhealthy Drinking In KPNC Primary Care

38

Abstainers

Low-Risk Drinkers

Unhealthy Drinkers

w/out dependence

6.8%

Alcohol Dependent

Institute of Medicine. 1990, and World Health Organization, 2001

Need Specialty

Treatment

Brief Intervention

7.5%

0.8%

20 Most Frequent Dx in Med-FMS 2013

39

Contact: Sue Paulsen QOS 8-428-3264

Diagnoses 2013 # Index Visits % Initiated

1 ALCOHOL ABUSE 2527 12%

2 ALCOHOL DEPENDENCE 2484 9%

3 ALCOHOL USE, EXCESSIVE, NON-DEPENDENT 1454 6%

4 OPIOID DEPENDENCE 905 12%

5 CANNABIS DEPENDENCE 455 6%

6 CANNABIS ABUSE 428 7%

7 SUBSTANCE ABUSE 344 20%

8 ALCOHOL DEPENDENCE, CONTINUOUS 184 9%

9 DRUG DEPENDENCE 165 16%

10 DRUG ABUSE 140 26%

11 ALCOHOLISM 133 19%

12 OPIOID WITHDRAWAL 131 27%

13 DRUG SEEKING BEHAVIOR 125 12%

14 CAFFEINE USE 119 2%

15 ALCOHOL ABUSE, EPISODIC 96 16%

16 OPIOID DEPENDENCE, CONTINUOUS 94 12%

17 CAFFEINE DEPENDENCE 81 5%

18 METHAMPHETAMINE DEPENDENCE 81 11%

19 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE 79 11%

20 POLYSUBSTANCE ABUSE 71 11%

40

HEDIS IET AOD

Approved for CMS: January 1 2014

AUDIT Screening Tool

▪ Alcohol Use Disorders Identification TestDomain Question

Hazardous Alcohol Use (1-3)Dependence Syndromes (4-6)Harmful Alcohol Use (7-10)

AUDIT Score WHO Kaiser<8 (Alc Education) No Action8-15 (Simple Advice) RN Advice>16 (Brief Counsel) LCSW&MD inbasket>20 (Specialist Tx) ------

Rx: Medication Recommendation

1. Naltrexone – Injectable Extended Release (Vivitrol) 380mg IMa. Hold if LFT > 3x normal or recent opioid use. b. If decides against IM, consider oral Naltrexone 50mg daily. (#30)

2. Topiramate – (second choice)a. Start 50mg hs x 1 week, then increase 100mg hs. (#50) b. Reduce dose ½ in renal disease. Caution: sedation.

Bryson WC1, McConnell J, Korthuis PT, McCarty D.“Extended-release naltrexone for alcohol dependence: persistence and healthcare costs and utilization.”, Am J Manag Care. 2011 Jun;17 Suppl 8:S222-34.

Aetna, 2011: XR-NTX (n=211) Disulfiram (1043),Oral NTX (1408), Acamprosate (2479)

“Compared with other medications for alcohol use disorders, XR-NTX is associated with increased days on medication and lower utilization and cost of inpatient and emergency care.”

46

JC SUB 1

47

JC SUB 2

48

JC SUB 3

49

50

51

Curative Factors in Addiction Treatment

Identity & Self-Efficacy

CognitiveSkills Training

Sober Social Networks

A BehavioralProgram of Recovery

Mind/BodyStress Mgt

Anti-Craving Medications

4/27/2017

52

Resilience-based Addiction Treatment

GeneralizedResilienceResources

Cognitive skills(Mastery)

Social Support(Belonging)

Self-Concept(Acceptance)

EmotionalRegulation(Serenity)

Alcoholism

AA/SpiritualityRelationshipsHobby/Passion

Values (Life of Meaning & Purpose)

Anti-Craving Medications

A BehavioralProgram of Recovery

MotivationalInterviewing

QOLAssessment

4/27/2017

53

TEA

BAM

Measuring Progress: TEMT-KP

4/27/2017

57

58

59

Questions?