The National DPP → Quality Metrics
In the health care industry’s drive towards value vs. volume, the importance of quality measures is increasingly vital to success. Quality metrics help ensure that organizational efforts at improving quality and decreasing costs are showing efficacy as determined by the measurement guidance. While there is currently not a prediabetes-focused quality measure, other metrics exist and can be used to help ensure that prediabetes screening activities drive participation into programs leading to a decrease in population type 2 diabetes prevalence.
Current BMI-Focused Measures
Current quality measures have a strong focus on disease management rather than prevention, including type 2 diabetes management. Payers and providers can look to a number of quality measures focused on body mass index (BMI) to help in evaluating the success of the National DPP lifestyle change program.
*NOTE: Measurement standards are not mutually exclusive across measure sets. Some measure sets may be comprised of a subset of metrics from another measure set.
Click below for more information on the each measure set.
- MIPS Quality Measures
- HEDIS Measures
- Core Quality Measures Collaborative (ACO & PCMH / Primary Care Measures)
- 2016 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set)
- NCQA Wellness & Health Promotion (WHP) Performance Measures
- NCQA PCMH Recognition Program
- Patient-Centered Specialty Practice (PCSP) Recognition Program
States could also consider establishing measures that promote screening for potentially high-risk individuals and referrals of these individuals to disease management or prevention-based programs. The CMS measures “Closing the Referral Loop: Receipt of Specialist Report” or “Preventive Care and Screening: Screening for Depression and Follow-Up Plan” provide examples of a measures that can be utilized to enhance the referral process for at-risk individuals.
Development of a Prediabetes Quality Measure
Despite a strong cohort of diabetes management quality measurements currently in place, there is an evident and recognized gap in the development and adoption of prediabetes quality measures. Quality measures should reflect the current state of important health care industry initiatives, and preventive care is a foundational aspect of the shift to value-based care. As such, the development of a prediabetes quality measure will facilitate the promotion of recognizing and decreasing the risk of type 2 diabetes through prevention rather than disease management.
The CDC, American Medical Association (AMA), and Diabetes Advocacy Alliance (DAA) are all committed to utilizing its resources, expertise and reach to prevent type 2 diabetes and to improve health outcomes for those suffering from this disease and are collaborating to develop and recommend a prediabetes quality measure. Together, they are encouraging and moving forward this development through the Prevent Diabetes STAT program.
The Core Quality Measures Collaborative has indicated the potential development of a prediabetes measure for the ACO & PCMH/Primary Care Measures core quality measurements. The Core Quality Measure Collaborative is an organization of leaders from health plans, CMS, the National Quality Forum (NQF), physician organizations, employers, and consumers working together to reach a consensus and alignment on core performance measures across both the public and private sectors.
Additionally, a prediabetes measure can be developed through the CMS MACRA Quality Measure Development Plan finalized under the MACRA final rule. An update and emphasis in preventive quality measures will encourage providers to focus more on diabetes prevention rather than managing costly diabetes patients after development of the disease.
State Quality Strategies
Current Federal regulations require states to develop and maintain a quality strategy aimed at assessing and improving the quality of managed care services offered within a state. Each state who contracts with a managed care organization (MCO) and/or prepaid inpatient health plan (PIHP) is required to gather feedback from key stakeholders, including beneficiaries, provide a public comment period, and provide access to the final quality plan.
In the development of these state-specific quality plans, states make annual decisions on the development or selection of quality metrics that will best meet the need and improve health outcomes of their state’s Medicaid recipients. Processes vary state by state; however, there are potential opportunities to influence the development or selection process to include prevention measures like prediabetes measures.
Below are several state examples of the quality metric selection process:
Louisiana formed the state Quality Committee to oversee and monitor the Medicaid program. MCOs are required to participate on the Quality Committee, are measured on a designated set of quality measures, and may be sanctioned for failing to meet minimum benchmarks. The Quality Committee advises the Louisiana Department of Health on best practices, provider relations, ongoing quality improvement measures and recommendations for changes to Bayou Health’s structure as appropriate. The committee also includes representatives of both the Senate and House Health and Welfare committees.
The State of Maryland develops a multi-faceted Medicaid Quality Strategy through the Office of Health Services Managed Care Administration. Utilizing a public comment process located on the Department of Health and Mental Hygiene website, partnered with inter-departmental collaboration for subject matter expertise, Maryland develops a plan that includes the quality measures MCOs are required to report. Public comments are solicited on the state Medicaid website for one month (e.g., June 1 – June 30, 2015).
Beyond the federal quality strategy requirement, the Minnesota legislature passed a 2008 health reform law that requires the Commissioner of Health to establish a standardized set of quality measures. Health plans are not allowed to require reported metrics beyond the established list. Quality measure review occurs annually and the process must include physicians.
Montana operates Medicaid under a primary care case management model, not an MCO or PIHP model, and is thus not required under federal law to develop a quality strategy plan. The entire Medicaid expansion population in Montana is managed through a private plan, Blue Cross and Blue Shield (BCBS), Montana. Therefore, stakeholders have the opportunity to provide input on measures directly to the state or through BCBS, MT.
Every three years, the New York Department of Health (DoH) reviews the quality strategy and places it on the DoH website for at least 30 days to gather public and stakeholder comments on content and approach.
For over two decades, Oregon has utilized the Health Evidence Review Commission (HERC) to evaluate quality measures and medical evidence. The HERC process relies on transparency and input through a series of public meetings organized to gather information from providers and the public to ensure the decisions made are in the best interest of the patients and taxpayers. HERC develops and publicly provides a prioritized list of health services that guides legislative decisions, as well as evidence based reports on topics that are of interest to payers, providers, and members of the public.
In 2015, the Texas Health and Human Services Commission (HHSC) launched an initiative to conduct quarterly individual calls with each MCO managing Texas Medicaid patients. “The purpose of these quality calls is to maintain an interactive dialogue with MCOs on priority areas related to quality improvement and efficiency in the context of value-based purchasing roadmap designed by HHSC. The central paradigm of the dialogue is focused on measuring the value of healthcare provided to the state beneficiaries, within the healthcare delivery and payment reform led by HHSC.” Additionally, HHSC is required by state law to review and accept clinical initiative, quality, and efficiency improvement suggestions from state legislators, Commissioners of state health and human services agencies, the Medical Care Advisory Committee, the Physician Payment Advisory Committee, and the Electronic Health Information Exchange System Advisory Committee.
Future Implications for Medicaid Managed Care
On April 26, 2016, CMS released a final rule outlining changes and clarifying regulations for state Medicaid managed care programs. Included in these rules is a plan for managed care quality metrics to become standardized, mandatory, more transparent, and align with other insurance markets. Under the new system, states will be required to implement a quality rating system (QRS) and publish standardized quality information for each managed care entity on their website. Although states may seek approval to use an alternative rating system, the main components of the proposed rating model will be determined by CMS and align with the marketplace quality rating system. CMS intends to issue the QRS guidance in 2018 and states will have three years from final publication in the Federal Register to come into compliance with implementation (by 2021).
The United States Preventive Services Task Force (USPSTF) is an independent panel of experts that publishes recommendations for evidence-based clinical preventive services. The Affordable Care Act requires a subset of health plans to cover items and services with a grade A or B USPSTF recommendation without cost-sharing for the relevant member. The counseling requirements referenced in the following recommendations can be met through coverage of the National DPP lifestyle change program. These recommendations will bring additional attention to prediabetes and may create momentum around the development of prediabetes measures as outlined above.
Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening
The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. (This recommendation applies to adults aged 40 to 70 years who are seen in primary care settings and do not have obvious symptoms of diabetes. Persons who have a family history of diabetes, have a history of gestational diabetes or polycystic ovarian syndrome, or are members of certain racial/ethnic groups (that is, African Americans, American Indians or Alaskan Natives, Asian Americans, Hispanics or Latinos, or Native Hawaiians or Pacific Islanders) may be at increased risk for diabetes at a younger age or at a lower body mass index. Clinicians should consider screening earlier in persons with 1 or more of these characteristics.)
Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling
The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. Impaired fasting glucose is listed as one such risk factor.
Coverage of the National DPP lifestyle change program is also indirectly related to two additional USPSTF grade A and B preventive services. These services reference National DPP lifestyle change program inclusion criteria.
Gestational Diabetes Mellitus, Screening
The USPSTF recommends screening for gestational diabetes mellitus (GDM) in asymptomatic pregnant women after 24 weeks of gestation. Note: you cannot participate in the National DPP lifestyle change program if you are pregnant, but you are eligible if you were previously diagnosed with GDM.
Obesity in Adults: Screening and Management
The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. (This recommendation is currently being updated under the title of: Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral and Pharmacotherapy Interventions.)
MACRA QPP Improvement Activities
On November 2, 2017, CMS released the 2018 Quality Payment Program (QPP) Final Rule which establishes required quality reporting for clinicians billing under Medicare Part B. The Medicare Improvement Payment System (MIPS) track of the QPP evaluates clinicians in four performance categories: Quality, Cost, Advancing Care Information, and Improvement Activities. Under the Improvement Activities performance category, CMS has identified two activities directly tied to the National DPP. Clinicians required to report under MIPS and are involved in the National DPP can utilize these measures when reporting under the Improvement Activities performance category.
- For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of medical records with documentation of referring eligible patients with prediabetes to a CDC-recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.
- Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following:
- Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;
- Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target; such as a CDC recognized diabetes prevention program;
- Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions;
- Use panel support tools (registry functionality) to identify services due;
- Use predictive analytical models to predict risk, onset and progression of chronic diseases; or
- Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.