Oregon Health Authority Quality and Health Outcomes Committee AGENDA
MEETING INFORMATION Meeting Date: March 13, 2017 Location: HSB Building Room 137A‐D, Salem, OR Parking: Map ◦ Phone: 503‐378‐5090 x0 Call in information: Toll free dial‐in: 888‐278‐0296 Participant Code: 310477 All meeting materials are posted on the QHOC website. Clinical Director Workgroup Time Topic Owner Materials -Speaker’s Contact Sheet (2) Welcome / -January Meeting Notes (2 – 12) 9:00 a.m. Mark Bradshaw Announcements -PH Update (13 – 14) -BH Directors Meeting Minutes (15 – 17) 9:10 a.m. Legislative Update Brian Nieubuurt -CCO and OHP Bills (18 – 20) Safina Koreishi 9:20 a.m. PH Modernization -Presentation (21 – 27) Cara Biddlecom 9:40 a.m. QHOC Planning Mark Bradshaw -Charter (28 – 29) 10:00 a.m. HERC Update Cat Livingston -HERC Materials (30 – 78) -Letter to FFS Providers re: Back Line Changes (79 – LARC and Back 80) 10:30 a.m. Implementation Check- Kim Wentz -Tapering Resource Guide (81 – 82) in -LARC Letter to Hospitals (83 – 84) -LARC Billing Tips (85) 10:45 a.m. BREAK Learning Collaborative -Agenda (86) -Panelist Bios (87) 11:00 a.m. OHIT: EDIE/PreManage -Presentations (88 – 114) -BH Care Coordination Process (115) 12:30 p.m. LUNCH Quality and Performance Improvement Session Jennifer QPI Update – 1:00 p.m. Johnstun Lisa Introductions Bui -Pre-Survey (116 - 118) 1:10 p.m. Measurement Training Colleen Reuland -Presentation (117 – 143) Transition to Small 2:10 p.m. All Table exercise 2:15 p.m. Small table Exercise All 2:45 p.m. Debrief All
Upcoming April QHOC: Chronic Use Opioid Statewide Performance Improvement Project
Chair contact info: [email protected] OHA contact info: [email protected] Topics may be subject to change due to availability SALEM CAPITOL MALL AREA
D STREET 810 830 850 870
Archives North Mall Building Parrish Heritage Middle 880 Park 885 School 796 N
North State Mall Lands Building HIGH STREET CHURCH STREET WINTER STREET COTTAGE STREET Office
Building Railroad Pacific Southern S
Veterans Building <<<<-----SUMMER STREET CAPITOL STREET ----->>>> Employ. 605 Agri- Employment Orange Salem Cottage culture Building Lot Office Pkg Lot Building UNION STREET Dept. of ODOT Mill Energy Creek Bldg. Barbara Roberts Green Lot Human Services Public Utility Movie Land Building Comm. Building <<<<----- MARION STREET Yellow Lot Safeway (gravel) Macy's Revenue Building Red Lot STREET 12TH STREET 13TH Park & Pay Daily
Parking Real Estate CENTER STREET ----->>>> 1144 McDonalds Center Labor & Trans- Industries portation Building Building 1133 Chemeketa Lane >>> ng Structure t Lane<<< t i i CHEMEKETA STREET
Salem Transit State Public Station Library Service Chemeketa Customer Service 1158 - 1178 Building Building Office <<
Justice Building Marion County Commerce Courthouse Willson Park State Capitol Building Building Structure Supreme Robertson Executive Parking Executive Building Executive Court Building WAVERLY ST WAVERLY STATE STREET ----->>>>
General Services Willamette University Campus Building FERRY STREET FERRY STREET 1202 / 1240 WINTER STREET Ferry Ferry Street Str.
State of Oregon Meters - OK to use Agency issued one-day permit
Capitol Mall Structure Meters - OK to use Agency Issued one-day permit
Yellow Lot & Ferry Structure Rooftop Visitor Spaces - OK to use Agency issued one-day permit
Daily_permit.xlsx - 5/01/14
March 2017 QHOC Packet - Page 1 SPEAKER CONTACT SHEET QHOC – March 2017
AGENDA TOPIC SPEAKER CONTACT INFO Legislative Update Brian Nieubuurt [email protected] PH Modernization Safina Koreishi [email protected] Cara Biddlecom [email protected] HERC Update Cat Livingston, MD, MPH [email protected] LARC & Back Implementation Kim Wentz, MD, MBA [email protected] Checkin Learning Collaborative: Susan Kirchoff, RN [email protected] OHIT: EDIE/PreManage Lisa Parks, QMHP [email protected] Liz Whitworth, MPH [email protected] Daniela Onofrei, BSN, [email protected] RN‐BC Susan Otter [email protected] Kristen Bork [email protected] Britteny Matero [email protected] Susan Kirchoff, RN [email protected] Lisa Parks, QMHP [email protected] Liz Whitworth, MPH [email protected] Daniela Onofrei, BSN, [email protected] RN‐BC QPI Update Jennifer Johnstun [email protected] Measurement Training Colleen Reuland
QHOC CHAIRS Medical Mark Bradshaw, MD [email protected] Behavioral Health Athena Goldberg [email protected] Oral Health Dayna Steringer [email protected] Quality Jennifer Johnstun [email protected]
OHA LEADS Medical Kim Wentz, MD [email protected] Behavioral Health Royce Bowlin, MS, CPRP [email protected] Oral Health Bruce Austin [email protected] Quality Lisa Bui [email protected]
QHOC Website: http://www.oregon.gov/oha/hpa/csi/Pages/Quality‐and‐Health‐Outcomes‐Committee.aspx
Questions: [email protected] or call Lisa Bui at 971‐673‐3397
March 2017 QHOC Packet - Page 2 Quality & Health Outcomes Committee (QHOC)
February 13, 2017 Meeting Notes
Chair- Mark Bradshaw (All Care) Co-Chairs- Jennifer Johnstun (Primary Health)
Attendees: (in person) Anne Alftine (JCC); Susan Arbor (OHA/HSD); Katie Beck (OHA);Carla Bennett (WVCH); Maggie Bennington-Davis (HealthShare); Tara Bergeron (Tuality); Amanda Blodgett (CHA); Summer Boslaugh (OHA/TC); Royce Bowlin (OHA); Stuart Bradley (WVCH); Mark Bradshaw (All Care); Lisa Bui (OHA/TC); Barbara Carey (Health Share); Jody Carson (HealthInsight); Roger Citron (OHA/OSU); Cheryl Cohen (Health Share); Laurence Colman (GOBHI); Coleen Connolly (Trillium); Donna Erbs (HealthInsight); Leslie Ford (CPCCO/GOBHI); Mike Franz (PacificSource); Ruth Galster (UHA); Bennett Garner (FamilyCare); David Geels (WOAH/Coos Co MH);Athena Goldberg (AllCare); Walter Hardin (Tuality); Jenna Harms (Yamhill CCO); Hank Hickman (OHA/HSD); Todd Jacobsen (GOBHI); Charmaine Kinney (Mult. Co./Health Share); Alison Little (PacificSource); Cat Livingston (HERC); Deborah Loy (Capitol Dental); Andrew Luther (OHMS); Ruth McBride (Primary Health); Laura McKeane(AllCare); Kevin McLean (FamilyCare); Jamilah Mooney (WOAH); Tracy Muday (WOAH); Chris Norman (OHA); Bhavesh Rajani (Yamhill CCO); Ariel Smits (OHA/HERC); Debbie Standridge (UHA); Dayna Steringer (DK Strategies); Anna Stern (WVCH); Melanie Tong (Washington Co.); Alison Tonje (OHA); Jennifer Valentine (OHA); Anna Warner (WOAH); Kim Wentz (OHA/HSD) Mark Whitaker (Providence); Eryn Womack (IHN); Amarissa Wooden (WOAH/NBMC) ; Cheryl Youk (Trillium)
By phone: Cynthia Ackerman (AllCare); Ellen Altman (IHN/CCO); Leah Dungey (PacificSource); Kevin Ewanchyna (IHN/CCO); Kerrie Fowler (UHA); Cynthia Lacro (EOCCO); Nicole Merrithew (CareOregon); Corinne Thayer (ODS Dental)
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February 13, 2017 QHOC Meeting Notes ‐ DRAFT March 2017 QHOC Packet - Page 3
Quality & Health Outcomes Committee (QHOC)
February 13, 2017 Meeting Notes
CLINICAL DIRECTORS SESSION
Introductions/ Announcements: Announcements . Dr. Wentz introduced Royce Bowlin as OHA’s Behavioral Health Director;
Mark Bradshaw: . Two surveys have been sent out- 1) What we want to see in the learning collaborative 2) QHOC needs
Lisa Bui: . Handouts on Dual Eligibles from Jennifer Valentine; . There will be a Transformation Conference held March . The Transformation Conference has been scheduled for March 17, 2017; . There have been 15 responses to the survey sent in regard to what folks want to see in the Learning Collaboratives. May resend the survey link; . Sarah Bartlemann is no longer with us in OHA.
Metrics Update . The committee has removed the claims-based SBIRT measure from the 2017 incentive measure set; . SB440- applications received and waiting for appointment.
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February 13, 2017 QHOC Meeting Notes ‐ DRAFT March 2017 QHOC Packet - Page 4 Quality & Health Outcomes Committee (QHOC)
February 13, 2017 Meeting Notes
Pharmacy & There have been two meetings since the last time QHOC met. Therapeutics Update- Roger November meeting: Citron . DUR PA criteria; . Opioid analgesics- PA criteria for short/long acting. Exempt patients with terminal diagnosis; . MS glance rebate- use Copaxin instead;
January meeting: . OHA request PA for Suboxone for initial therapies; . Discussed Trexone; . Removal of PA for POS pharmacy claims; . Oral agent added; . Hormone replacement (generic);
The next P & T Committee meeting will be March 23, 2017. There will be discussion on sedatives. Public comment will be accepted.
Hep-C Case . Risk Corridor in effect January 1, 2017; Management . This was in draft November-December 2016 with one month for feedback. More feedback is requested today for Jim Rickards;
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February 13, 2017 QHOC Meeting Notes ‐ DRAFT March 2017 QHOC Packet - Page 5 Quality & Health Outcomes Committee (QHOC)
February 13, 2017 Meeting Notes
Implementation . Incorporates FFS goals- adherence, mitigate variance, eliminate gaps, and check in improve patient experience; . SER data vs. value-based purchasing; . Use actuarial services; . Define exactly what we need; . No process for reporting; . Discussed implementation and road bumps.
HERC Update- . Discussed new format; Cat Livingston EbGS: and Ariel Smits . 50 Coverage Guidance’s. Update as needed for re-review or significant changes in process; . Corticosteroid injections; . Prenatal Genetic testing; HTAS: . Dr. Wally Shaffer is back and assisting; . 3D Mammography; VbBS: . Residential Mental Health was on an inappropriate line and has been moved; . HCPC’s; . G codes;
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February 13, 2017 QHOC Meeting Notes ‐ DRAFT March 2017 QHOC Packet - Page 6 Quality & Health Outcomes Committee (QHOC)
February 13, 2017 Meeting Notes
. Skin Substitute codes- no Coverage Guidance just a Guideline Note; . Definition of “habilitative”; . Uncomplicated inguinal hernias; . Obesity; . Non-prenatal genetic testing; . Back surgery guidelines. Guidelines: . Computer aided mammography; . Complicated hernias; . GN 37- surgical intervention for conditions of the back and spine other than scoliosis. Discussed central spinal stenosis. Recommend wording into positive. Other: . Obesity and overweight- access to counseling, balloon procedure, any other problems? . Non-invasive liver test; . Saccaral joint fusion; . Biennial report with obesity. OHAP: Have met recently and discussed- . Coding changes that will take effect October 1, 2017; . Multisector- for early childhood caries prevention; . Biennial review- adding coverage for a crown. Expected January 1, 2018.
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February 13, 2017 QHOC Meeting Notes ‐ DRAFT March 2017 QHOC Packet - Page 7 Quality & Health Outcomes Committee (QHOC)
February 13, 2017 Meeting Notes
LARC Benefit . HERC approved guideline note effective 1/1/2017; Implementation- . Immediate postpartum long acting contraceptives; Kim Wentz . Benefits to planned pregnancy; . Why is immediate postpartum LARC an important option? . Postpartum IUD safety; . Policy barriers: advocating for access; . Immediate postpartum LARC in Oregon; . OHSU cohort study; . Hospital; . Quality and reimbursement strategies for Oregon FFS Medicaid; . Barriers; . Chief barrier: billing bundled inpatient delivery claim and LARC claim on same day; . Themes; . FFS approach; . FFS work plan; . Quality Strategies to consider.
Also discussed: . LARC Coverage Guidance; . Grade informed framework;
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February 13, 2017 QHOC Meeting Notes ‐ DRAFT March 2017 QHOC Packet - Page 8 Quality & Health Outcomes Committee (QHOC)
February 13, 2017 Meeting Notes
. Guideline Note 162; . HERC Letter; . LARC Update; . CMS letter: planning services and supplies; . Improving access to LARC contraception.
Back Guideline No problems or discussion raised. check in
JOINT LEARNING COLLABORATIVE SESSION
Applied Behavioral Analysis
QUALITY AND PERFORMANCE IMPROVEMENT SESSION
QPI Update and . Jennifer Johnstun is in Washington D.C.; Introductions- . The SBIRT measure for 2017 has been taken out; . Sarah Bartlemann is no longer with OHA; . Metrics and Scoring TAG- there is a TAG plan with a focus on oral health. During February we will be looking at metric consolidation;
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February 13, 2017 QHOC Meeting Notes ‐ DRAFT March 2017 QHOC Packet - Page 9 Quality & Health Outcomes Committee (QHOC)
February 13, 2017 Meeting Notes
. A website has been set up for OHA/CSI where you can find the statewide PIP documents and a website with the exclusion list; . PIP Quarterly reports- technical assistance is being set up as needed.
Health Insight . Statewide PIP- your reports should be back in a couple of weeks. This one update gets the scoring. Discussed the request for run charts; . In April the status of the statewide PIP will be known; . Discussed success and barriers.
Complaints & . Talk about grievances Excell file. Discussed column C and collapsing Grievances information into one cell. For Access, the information can be put into two columns. Having a drop down was discussed.
Questions (page 192) were then discussed as a group with the following comments/fixes: . In answer to 1, the request is to make changes; . On 2. (a) It was asked if you could copy and paste, and pivot and tally. The answer is yes; . There is approval for 2. (b);
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February 13, 2017 QHOC Meeting Notes ‐ DRAFT March 2017 QHOC Packet - Page 10 Quality & Health Outcomes Committee (QHOC)
February 13, 2017 Meeting Notes
. 2. (c) Columns G, H, and I are ok; . 2. (d) auto calculations can be set up; . 2. (e) yes on auto feed; . 2. (f) yes but let’s pause; . 2. (g) pause and take back for clarification; . 3.(a) place in under creation date; . 4. Pause yes but there are nuances.
Discussed having OHA hosted training. A webinar is preferred as consistency is the goal and it can be reused for future trainings.
2017 QAPI . Intro to QAPI; . 2017 OHA CCO QAPI review team; . 2017 timeline for Quality Strategy Review; . Why we do this work; . QAPI federal requirements; . CCO contractual QAPI requirements; . CCO contract QAPI activities;
T Plan/Quality . Where is quality and transformation going? Strategy-
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February 13, 2017 Meeting Notes
Lisa Bui . Purpose; . Key functions: 2017 schedule; . Current state; . Transformation plan; . QAPI; . Proposed assumptions for new plan; . Proposed Deliverables schedule; . Summary- Triple Aim.
In the discussion following, there was concern that the January timeline was too restrictive. A mid-March date was proposed for every year
NEXT MEETING: Salem - HSB Conference Room 137 A-D March 13, 2017 Toll free dial-in: 888-278-0296 Participant Code: 310477 Parking: Map Office: 503-378-5090 x0
Pg. 10 February 13, 2017 QHOC Meeting Notes ‐ DRAFT March 2017 QHOC Packet - Page 12 PUBLIC HEALTH DIVISION Office of the State Public Health Director
Kate Brown, Governor
800 NE Oregon St., Ste. 930 Portland, OR 97232-2195 Voice: 971-673-1222 FAX: 971-673-1299 Quality and Health Outcomes Committee Public Health Division updates – March 2017
Public health modernization – Oregon Health Authority released the Statewide Public Health Modernization Plan in February. This plan describes the long-term strategy for modernizing the public health system, and it contains the work plan for the next two years. The Statewide Public Health Modernization Plan is available at: https://public.health.oregon.gov/About/TaskForce/Documents/statewidemodernizationplan .pdf. For more information, contact Sara Beaudrault at (971) 673-0432 or [email protected].
Oregon Stroke Care Committee Report the to the 2017 Legislature – February 2017 The Oregon Stroke Care Committee was established by the 2013 Oregon State Legislature Senate Bill 375. The Oregon Health Authority Public Health Division supports the activities of the committee. This second legislative report reviews the committee activities and makes recommendations to improve stroke care in Oregon. The most recent Get with the Guidelines data from 17 of 19 stroke centers from 2010 through 2015 indicate that acute stroke care is improving across the following measures: The time it took patients to receive medication to dissolve blood clots decreased by nearly 30 minutes; The percentage of patients that received clot-dissolving therapies increased by 40 percent; and The percent of potential stroke patient notifications by Emergency Medical Services to hospitals prior to arrival more than doubled to nearly 65 percent. The report is available at: www.healthoregon.org/hdsp. For more information, contact Patricia Schoonmaker at (971) 673-1081 or [email protected].
March is colorectal cancer awareness month – the best test is the one that gets done! 1. Increasing colorectal cancer screening is a public health priority. Colorectal cancer continues to be the 2nd leading cause of cancer deaths of men and women in Oregon. One of two cancers are diagnosed at late stage (Oregon State Cancer Registry 2013). The Cancer You Can Prevent was created by the Oregon Health Authority to share the voices of Oregonians who have been screened to encourage others to get screened. Campaign brochure and poster templates can be tailored with local photos and logos for use by CCOs or clinics in support of patient reminder systems. For more information, visit thecanceryoucanprevent.org. Or contact Patricia Schoonmaker at (971) 673-1081 or [email protected].
March 2017 QHOC Packet - Page 13 2. Take the 80% by 2018 National Colorectal Cancer Roundtable Pledge. Join the 16 organizations in Oregon that have taken the pledge. Learn how your organization can join this national and Oregon movement to advance screening toward 80% by 2018 by engaging primary care providers, hospitals, insurers, employers, community organizations, gastroenterologists and endoscopists, women’s health providers, cancer survivors and families, and cancer coalitions, please visit http://nccrt.org/tools/80-percent-by-2018/. For more information, contact Patricia Schoonmaker at (971)-673-1081 or [email protected].
March 2017 QHOC Packet - Page 14 CCO Behavioral Health Directors Meeting Minutes Monday February 13th, 2017 1:00 – 3:00 pm
Attendees: Athena Goldberg, Mike Franz, Jill Archer, Bruce Abel, Todd Jacobson, Laurence Colman, Gregory Brigham, Bennett Garner, Ron Lagergen, David Geels, Cheryl Cohen, Alfredo Soto, Cindy Becker, Margaret Terry, Karen Weiner, Theresa Heidt, and Heather Hartmann, Royce Bowlin
On Phone: Pam Hyde
USDOJ settlement ‐ discussion with Pam Hyde on developed Oregon Performance Plan. Pam is the Independent consultant monitoring the USDOJ settlement and Oregon/OHA efforts to meet the objectives.
. Pam asked us about general comments/feedback from directors about the plan; what targets may be harder to achieve etc. Disc that some items could likely be met be only attending to few urban areas and ignoring rural communities. This may not be ideal but could be option. Discd ACT teams as an example where rural impl may be harder than urban
. Disc on meeting housing metrics ‐ scatter site, integrated housing as being potentially hardest to meet. Oregon is tracking other supportive housing options as well but due to housing shortage at all levels makes meeting metrics even more difficult. Some disc whether things like rent subsidies are options esp if only available in time limited manner. Royce agreed to look into this.
. Disc on who’s accountable for the Oregon Performance Plan and how it will be passed on to CMHP’s and CCO’s. Royce/Pam disc how they are being incorporated into OARs, CCO/CMHP contracts and performance requirements. While the State is ultimately responsible for the whole OPP ‐ CCOs and CMHP
March 2017 QHOC Packet - Page 15 will be a part of the mechanisms along with OSH that help the State meet the particulars
. Peer delivered services need to increase by 40% over the next two years within the OPP which will largely involve CCO’s role. Current 2015 baseline data report shows a significant improvement in meeting this and other objectives. Directors pointed out that a number of peer delivered services have been funded for a number of years outside the new structure now in place. Oregon is not getting credit for these currently and moving to current Peer funding strategies may threaten their existence – this may include Clubhouse and drop in centers or individuals that do not possess the Peer certifications.
. Any thoughts on Acute Care or Psychiatric placements? BH Directors – 7 day follow up is one that cannot be met in some areas and with increased % requirements it may be disincentive when CCO see it is not a meet‐able target. There are other areas that coordination and rules are granting allowances.
ABA discussion ‐review letter to OHA/HERC requesting clarity in guidance for use: . Reviewed collaborative memo to Don Ross. Cheryl opened discussion up for feedback on document – addressing any issues, such as lack of medical appropriateness listed in any of the OAR’s.\ . Some programs are looking at the evaluation and basing their determination of eligibility on that evaluation and their standards. However, the concern is that the OAR has no medical criteria. . Clarification: ASD needs a standardized tool to assess, and this will be changed in current rule. It's the stereotypic behavior that allows for observation.\ . Dr. Fombonne was asked ‐ is it reasonable to expect that a CCO be allowed to try an alternate service before trying the most intense and costly? Dr. Fombonnes’ current perspective is who’s going to benefit the most from the intervention, not who needs it the most.
This will be ongoing discussion and more recommendations to be made.
March 2017 QHOC Packet - Page 16 Behavioral Health Collaborative updates: . Next Steps: Royce – people support (not all) the initial recommendation of the finance and governance – Standards of care and competence, IT, and workforce. Now meeting with the tribes and determining whether they will be involved in statewide process or would prefer to develop their own plan. The current phase is implementation. Tearing pieces apart and compartmentalizing them to fit work groups. Have 30 days to create a vision of implementation – developing this work plan at OHA/HSD. Does not anticipate any legislative changes to the BHC process or desired outcomes.
. Concern is that many of these changes and pending implementation requirements are not coming with new funding? ANS: OHA/HSD is looking at how current work requirements could be performed differently. Better utilizing the current allocation distributed to CCO’s and CMHP’s. OHA/HSD is also looking at how they support their own internal design and operations.
a. Will be tying the work being done with OPP to the work of the BHC.
Next Meeting – Date: March 13, 2017; 1pm to 3pm; Barbara Roberts Human Services Building/Room 456.
March 2017 QHOC Packet - Page 17 Bill # Relating to Introduced by Key Provisions Proponents Committee Status CCO Bills SB 233 Relating to coordinated care organizations Senate Human Services Requires OHA to make readily available to public: (1) documentation FamilyCare Senate Health Care Bill not yet scheduled submitted to CMS in seeking approval of global budgets; (2) all documents, data and health care utliization data considered in setting global budgets
Requires OHA to determine health services covered by global budget no more than once every 12 months, unless required by federal law
Establishes criteria for setting global budgets
Allows CCOs to global budget by filing appeal with DCBS
Requires DCBS to review appealed global budget de novo
SB 234 Relating to coordinated care organization Senate Human Services Requires Oregon Health Authority to renew coordinated care organization FamilyCare Senate Health Care Bill not yet scheduled contracts with the Oregon Health Authority contract for another five‐year term if specified conditions are met.
SB 236 Relating to coordinated care organizations Senate Human Services Limits discretion of Oregon Health Authority with respect to contracts with FamilyCare Senate Health Care Bill not yet scheduled and rules concerning coordinated care organizations and imposes new requirements.
Imposes requirements on authority for rulemaking and collaborating with coordinated care organizations.
Imposes additional responsibilities on Oregon Health Policy Board in oversight of authority, Health Evidence Review Commission and Office for Oregon Health Policy and Research.
Requires Department of Consumer and Business Services to certify global budget before budget may take effect. SB 273 Modifies requirements for coordinated care organizations in 2018 and 2023. Senate Health Care Bill not yet scheduled
Beginning in 2023, requires coordinated care organizations to be community‐based nonprofit organizations, to have membership of governing body that reflects local control and to distribute at least 80 percent of payments to providers using alternative payment methodologies.
March 2017 QHOC Packet - Page 18 HB 2122 House Health Care 1st Public Hearing, Monday 2/27 Creates Community Escrow Fund in State Treasury to hold coordinated care Relating to coordinated care organizations Rep. Greenlick organization restricted reserves. Rep. Greenlick
Requires Oregon Health Policy Board to adopt minimum criteria for continuation of contracts with coordinated care organization.
Requires coordinated care organizations seeking to contract with Oregon Health Authority in 2018 to present plan for moving toward 2023 requirements and to explain steps taken to innovate health care delivery (NOTE: Wrong Dates) HB 2300 Relating to prescription drug coverage for Governor Brown for OHA Requires costs of mental health drugs to be taken into consideration in OHA; CCOs House Health Care 1st Public Hearing on 3/3 (OHA Bill) medical assistance recipients determining global budgets for coordinated care organizations
HB 2675 Relating to community health improvement Rep. Nosse Requires community health improvement plans adopted by coordinated Reps. Rayfield, Buehler, House Health Care Passed by Committee on 3/1 plans care organizations and community advisory councils to focus on and Kennemer, Keny‐Guyer, develop strategy for integrating physical, behavioral and oral health care Kotek, Malstrom and services Senator Monnes Anderson SB 994 Relating to requirements for coordinated care Sen. Roblan Requires OHA to renew contract with CCO if: COHO Senate Health Care Bill not yet scheduled organizations ‐ CCO is community‐based ‐ Is not in material breach of its contract ‐ Has achieved a score of at least 80% on quality measures ‐ Has earned at least 80% of available incentive payments
Adds additional requirements for reserves and medical loss ratio maintanence
Prohibits OHA from establishing a regional entity or any other type of intermediary entity that exercies control over a CCO
Other Bills of Note SB 558/ Relating to improving the health of Oregon Multiple legislators Governor Brown; multiple Health Care Committee Senate Bill passed 3/7; House Bill HB 2726 Children Requires Oregon Health Authority to convene work group to advise and stakeholder groups scheduled for work session 3/8 assist in implementing targeted outreach and marketing for Health Care for All Oregon Children program. Permits all children residing in Oregon and meeting financial eligibility requirements to enroll in program. Requires authority, in collaboration with Department of Consumer and Business Services if necessary, to seek necessary federal approval or waiver of federal requirements to secure federal financial participation in costs of outreach and marketing and in expansion of eligibility for program. Declares emergency, effective on passage. HB 2303 Relating to health policy Governor Brown for OHA Modifies date by which coordinated care organization must report to OHA House Health Care Heard on 2/8; (OHA Bill) Oregon Health Authority proportion of total medical costs allocated to OHA proposing amendments primary care. Removes obsolete references to Office for Oregon Health Policy and Research. Creates Health Policy and Analytics Division of Oregon Health Authority.
March 2017 QHOC Packet - Page 19 HB 2507 Relating to financial disclosures by certain Rep. Barnhart Requires contract between Oregon Health Authority and coordinated care Rep. Barnhart House Revenue Bill not yet scheduled private entities organization, and contract between public charter school and private entity that provides educational or administrative services, to require coordinated care organization or private entity to disclose tax information and submit to audit by Secretary of State
HB 2580 Relating to medical assistance Rep. Rayfield Rep. Rayfield; Rep. Olson House Health Care PH on 2/20; amendments Exempts foster children and homeless youth from requirement to enroll in forthcoming coordinated care organization in order to receive medical assistance. HB 2723 Relating to hippotherapy Rep. Sollman Prohibits exclusion of hippotherapy from services provided in medical House Health Care Work session on 3/10 assistance HB 2882 Relating to dental care organizations Reps. Nosse and Keny‐ Requires governing body of coordinated care organization to include Reps. Nosse, Keny‐Guyer, House Health Care Bill not yet scheduled Guyer representative from at least one dental care organization that serves Greenlick, Hack, Hayden, members of coordinated care organization. Kennemer; Senators Knopp, Monnes Anderson, Steiner Hayward; DCOs HB 2981 Relating to medical eligibity determinations House Health Care Requires Oregon Health Authority to report specified information on Coalition for a Healthy Awaiting Referral Bill not yet scheduled quarterly basis about processing of applications for medical assistance and Oregon (COHO) for renewals of medical assistance
Placeholder Bills HB 2834 Relating to health care
Requires Oregon Health Authority to conduct study of effectiveness of House Health Care House Health Care House Health Care Oregon Integrated and Coordinated Health Care Delivery System in ****Placeholder bills**** HB 2835 Relating to medical assistance improving health outcomes for medical assistance recipients HB 2836 Relating to health SB 858 Relating to health care Senate Health Care Senate Health Care Senate Health Care
March 2017 QHOC Packet - Page 20 Modernization Oregon’s Public Health System
Safina Koreishi, MD Cara Biddlecom March 13, 2017
PUBLIC HEALTH DIVISION Office of the State Public Health Director
Public health modernization updates
• The role of the Public Health Advisory Board • The Statewide Public Health Modernization Plan • Local public health modernization meetings • House Bill 2310
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March 2017 QHOC Packet - Page 21 3
The public health system, now and in the future Today Moving forward Significant gaps in public health Foundational level of service capacity provided based on provided for everyone where you live
Programs hindered by limited Programs supported by diverse and inflexible funding funding sources that allow local needs to be met
Public health system designed to Public health is accountable for provide individual level services the health of the community
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March 2017 QHOC Packet - Page 22 The Public Health Advisory Board
• Is the accountable body for governmental public health in Oregon • Reports to the Oregon Health Policy Board • Has oversight of public health modernization and the implementation of the State Health Improvement Plan • Is responsible for developing public health accountability measures
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Statewide Public Health Modernization Plan
Priority 1: Improve the public health system’s capacity to provide foundational public health programs for every person in Oregon
Priority 2: Align and coordinate public health and early learning, CCOs, hospitals and other health partners and stakeholders for collective impact on health improvements
Priority 3: Demonstrate progress toward improved health outcomes through accountability metrics and ongoing evaluation
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March 2017 QHOC Packet - Page 23 Opportunities for shared responsibility and collective impact to improve health CCOs Public Health
Communicable Physical health disease control Environmental Behavioral health CHA/ health Oral health CHIPs Assessment and Health Case epidemiology management equity Policy & planning Prevention & health promotion Access to clinical preventive services
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Local public health modernization meetings
• Funded by the Robert Wood Johnson Foundation (RWJF) • Proposes to identify unknown barriers to implementing public health modernization • Work with state and local communities to develop a roadmap and tools to support moving forward with a new model for public health in Oregon
March 2017 QHOC Packet - Page 24 Critical Questions
What is Public Health Modernization?
How will Oregon benefit from a modernized Public Health System?
How can we work together to achieve a modernized health system?
What are the main opportunities and challenges to achieving modernization?
What help does your community need to take the next steps forward with modernization?
Attendees at Meetings
• Total of 453 people attended the 10 statewide meetings. • Attendees at the meetings included representatives from: – Local health departments – Local Boards of County Commissioners – Community Based Organizations – Coordinated Care Organizations – Hospitals – School districts – Tribal health centers – Emergency management – State universities and community colleges
March 2017 QHOC Packet - Page 25 COLUMBIA CLATSOP Astoria WALLOWA UMATILLA TILLAMOOK Portland MORROW Pendleton UNION GILLIAM YAMHILL CLACKAMAS The Dalles
WASCO
POLKSalem MARION LINCOLN WHEELER BAKER JEFFERSON GRANT LINN
BENTON Albany Redmond CROOK
LANE DESCHUTES
COOS Burns Coos BayDOUGLAS LAKE HARNEY MALHEUR
KLAMATH CURRY
JOSEPHINE JACKSONMedford
AIMHI Statewide Meetings
Opportunities for shared responsibility and collective impact to improve health CCOs Public Health
Communicable Physical health disease control Environmental Behavioral health CHA/ health Oral health CHIPs Assessment and Health Case epidemiology management equity Policy & planning Prevention & health promotion Access to clinical preventive services
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March 2017 QHOC Packet - Page 26 www.healthoregon.org/modernization
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March 2017 QHOC Packet - Page 27 CHARTER (Updated 07/13/2015, Approved 8/10/2015) Oregon Health Authority | Quality and Health Outcomes Committee
Background Since 1993, the Quality Health Outcomes Committee (QHOC), formerly known as the Medicaid Medical Directors meeting and the Quality and Performance Improvement Workgroups, served as the forum for communication of the clinical and quality aspects of implementation of the Oregon Health Plan (OHP) with statewide health systems serving the Medicaid population. In 2013, in compliance with the 1115 Waiver, QHOC added learning collaboratives to share best practice implementation of the quality incentive measures and overall health transformation. Purpose Provide a forum for community leadership in physical, behavioral, oral, and population health for the Oregon Health Plan population Develop community improvement strategies from identified trends in quality and compliance Serves a liaison and consultation role to the OHA for clinical and quality aspects of implementation of the Oregon Health Plan, including a focus on clinical guidance, benefits implementation, and quality assurance policies. Identify integrated approaches and strategies to improve health outcomes Provide a mechanism for community programs to reach Coordinated Care Organization (CCO) clinical leadership for policy and implementation issues that support the quality delivery of health care across the spectrum of care. Share best practice to community partners for issues and concerns regarding quality initiatives Principles QHOC promotes integration, efficient working relationships, data driven decision making Maximizes the in-person learning experience while also recognizing the commitment of time and resources Coordinating clinical community efforts towards achieving the Triple Aim (Better health, better care, and lower cost) is the primary goal Scope QHOC brings together clinical leadership from CCOs and their community partners across the state to coordinate and lead quality improvement efforts and support the implementation of innovative health care practices throughout the state. Membership, Roles & Responsibilities Project Sponsor(s) Oregon Health Authority Leadership: Tracy Muday, MD, QHOC Medical Director Chair Barbara Carey, QHOC Quality Program Chair Members: Medical directors and quality managers from each CCO Dental health and behavioral health directors of the CCOs OHA Staff: OHA representatives from Medicaid Assistance Program, Transformation Center staff and the Office of the Chief Medical Officer
QHOC Charter | July 13, 2015 Page 1
March 2017 QHOC Packet - Page 28 Key OHA Staff Resources: Medicaid Medicaid Director Quality Improvement Director Quality Assurance Manager Meeting Support Staff Leadership Responsibilities Facilitate meeting Collaborative agenda development with key OHA staff Field QHOC member questions and concerns Leadership Term QHOC chairs are nominated and voted by the full membership with terms lasting one year with the option of a second year. Key Responsibilities Key Responsibilities: Review, discuss, provide input on changes, and advice regarding clinical policy implementation for HERC, Pharmacy and Therapeutics Committee, MAP and other relevant OHA programs. Support community clinical and population health initiatives and standards Sharing best practices and approaches amongst CCOs and with OHA Evaluate waiver-required External Quality Review Organization (EQRO) findings and Statewide performance improvement projects status and implementation review Quality metrics monitoring and performance improvement plans Advise and provide consultation to OHA Quality Strategy development, implementation and review Collaboratively develop and improve best practices for contractual quality expectations reporting between CCOs and OHA; following the Center for Medicare and Medicaid Services’ regulations Key Stakeholders Health System Members Coordinated Care Organizations Community Partners Oregon Health Authority Center for Medicare & Medicaid Services Meeting Format Frequency: Meetings occur monthly in Salem, Oregon (telecom also available) Format: Integrated morning session for clinical leadership with a joint learning collaborative mid-morning with both clinical and quality leaders. Breakout afternoon session for role specific workgroups (behavioral health directors, quality managers) Materials: QHOC briefing book is distributed monthly with agenda posted to OHA QHOC website no later than 2 weeks prior to meeting Charter Review & Modification Annual Review (at a minimum), beginning July 2015
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March 2017 QHOC Packet - Page 29 Value‐based Benefits Subcommittee Recommendations Summary For Presentation to: Health Evidence Review Commission on March 9, 2017
For specific coding recommendations and guideline wording, please see the text of the 2/2/17 VbBS minutes.
RECOMMENDED CODE MOVEMENT (effective 10/1/2017) Several dental procedures were added to covered lines Various straightforward coding changes were made Procedure codes for fecal microbiota transplant were added to a covered line with a new guideline to clarify coverage Procedure codes for cholecystectomy were added to the pancreatitis line and removed from the intestinal ileus line Limited coverage for tympanostomy tubes and adenoidectomy was added for high‐risk children with hearing loss due to chronic otitis media older than age 5, with coverage limited through age 7 in the chronic otitis media with effusion guideline Adenoidectomy procedure codes were added to the covered line for hearing loss in children age 5 and under to clarify coverage
ITEMS CONSIDERED BUT NO RECOMMENDATIONS FOR CHANGES MADE Digital breast tomosynthesis (3D mammography) for breast cancer screening in average‐ risk women was considered for inclusion on the Prioritized List, but was found to have a lack of evidence to support use and was kept on the Services Recommended for Non‐ Coverage Table No changes were made to the bariatric surgery guideline section regarding marijuana use
RECOMMENDED GUIDELINE CHANGES (effective 10/1/2017) The dental guideline regarding wisdom tooth extraction was revised to clarify coverage The guideline defining significant injuries to joints was modified to include meniscal injuries A new guideline was adopted to define cholecystitis
2018 BIENNIEAL REVIEW CHANGES (effective 1/1/2018) Two lines with injuries to major blood vessels were merged and codes from a third line were moved to the new line to consolidate all diagnosis and treatment codes for major blood vessel injuries
Value‐based Benefits Subcommittee Summary Recommendations, 2/2/2017 March 2017 QHOC Packet - Page 30 VALUE‐BASED BENEFITS SUBCOMMITTEE Clackamas Community College Wilsonville Training Center, Rooms 111‐112 Wilsonville, Oregon February 2, 2017 8:00 AM – 1:00 PM
Members Present: Kevin Olson, MD, Chair; Susan Williams, MD, Vice‐Chair (via phone); Mark Gibson; Irene Croswell, RPh (via phone until 10:45, then in person); Holly Jo Hodges, MD (via phone).
Members Absent: Vern Saboe, DC; Gary Allen, DMD; David Pollack, MD.
Staff Present: Darren Coffman; Ariel Smits, MD, MPH; Cat Livingston, MD, MPH; Jason Gingerich; Denise Taray, RN; Wally Shaffer, MD; Daphne Peck (via phone).
Also Attending: Jesse Little and Kim Wentz, MD, MPH, (Oregon Health Authority); Adam Obley, MD, MPH (OHSU Center for Evidence‐based Policy), Scott Pohlman, Hologic; Chandler Schaab and Jennifer Valley (Stoney Girl Gardens); Cindy Fletcher (Komen Oregon and SW Washington).
Roll Call/Minutes Approval/Staff Report
The meeting was called to order at 8:00 am and roll was called. Minutes from the November 10, 2016 VbBS meeting were reviewed and approved without changes.
Taray summarized a letter from the Oregon Pain Commission discouraging the Health Evidence Review Commission (HERC) from using a pain scale in guidelines, due to the subjective nature of a patient’s scoring. A patient should not be denied a therapy because he or she gave a lower subjective pain score. Functional measures are preferred to be used to determine how much the pain is affecting an individual.
Smits reviewed the most recently published errata; there was no discussion.
Smits pointed out the final changes made to the Prioritized List (code changes and guideline changes) around sacroiliac joint fusion which were highlighted in the November 2016 minutes and had been previously approved by the VbBS/HERC leadership. These changes were slightly more extensive than what the VbBS had instructed staff to do, but were felt to be within the intent of the VbBS and no further changes were suggested.
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March 2017 QHOC Packet - Page 31 Topic: Advisory Panel Reports
Discussion: Smits pointed out the Oral Health Advisory Panel (OHAP) meeting minutes in the packet. There was a separate document outlining the suggested changes to the Prioritized List from OHAP. There was no discussion about these changes.
Recommended Actions: 1) Effective October 1, 2017 a. Add K02 series (Dental caries) to line 349 DENTAL CONDITIONS (EG. SEVERE CARIES, INFECTION) Treatment: ORAL SURGERY (I.E. EXTRACTIONS AND OTHER INTRAORAL SURGICAL PROCEDURES) b. Add D7210 (Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated) to line 349 DENTAL CONDITIONS (EG. SEVERE CARIES, INFECTION) Treatment: ORAL SURGERY (I.E. EXTRACTIONS AND OTHER INTRAORAL SURGICAL PROCEDURES) c. Modify GN34 as shown in Appendix A 2) Effective January 1, 2018 a. Add CDT D6100 (Implant removal, by report) to line 349 DENTAL CONDITIONS (EG. SEVERE CARIES, INFECTION) Treatment: ORAL SURGERY (I.E. EXTRACTIONS AND OTHER INTRAORAL SURGICAL PROCEDURES) b. Add D5221‐D5222 (Immediate partial denture – resin base) to line 457 DENTAL CONDITIONS (EG. MISSING TEETH, PROSTHESIS FAILURE) Treatment: REMOVABLE PROSTHODONTICS (E.G. FULL AND PARTIAL DENTURES, RELINES) and remove from line 594 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH) Treatment: ADVANCED RESTORATIVE‐ELECTIVE (INLAYS, ONLAYS, GOLD FOIL AND HIGH NOBLE METAL RESTORATIONS). MOTION: To approve the recommendations stated in the OHAP recommendations. CARRIES 5‐0.
Topic: Straightforward/Consent Agenda
Discussion: Smits said a question had been raised about the CPT 44300 code entry (Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression)) and requested that this code not be included in the vote for this section. Staff will work to clarify the recommendation on this code and bring back to a future meeting. There was no further discussion about the consent agenda items.
Recommended Actions: 1) Add CPT 41015‐41018 (Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth) to line 210 SUPERFICIAL ABSCESSES AND CELLULITIS
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2) Add CPT 14301 (Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm) to line 172 COMPLICATED HERNIAS; UNCOMPLICATED INGUINAL HERNIA IN CHILDREN AGE 18 AND UNDER; PERSISTENT HYDROCELE 3) Add CPT 15734 (Muscle, myocutaneous, or fasciocutaneous flap; trunk) to line 172 COMPLICATED HERNIAS; UNCOMPLICATED INGUINAL HERNIA IN CHILDREN AGE 18 AND UNDER; PERSISTENT HYDROCELE 4) Add CPT 43270 (Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s)) to line 60 ULCERS, GASTRITIS, DUODENITIS, AND GI HEMORRHAGE 5) Remove ICD‐10 K51.4 (Inflammatory polyps of colon without complications) from line 32 REGIONAL ENTERITIS, IDIOPATHIC PROCTOCOLITIS, ULCERATION OF INTESTINE and add to line 170 ANAL, RECTAL AND COLONIC POLYPS 6) Add CPT 43270 (Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s)) to line 60 ULCERS, GASTRITIS, DUODENITIS, AND GI HEMORRHAGE 7) Add CPT 44346 (Revision of colostomy; with repair of paracolostomy hernia) to line 172 COMPLICATED HERNIAS; UNCOMPLICATED INGUINAL HERNIA IN CHILDREN AGE 18 AND UNDER; PERSISTENT HYDROCELE 8) Remove CPT 21210 (Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)) from line 305 CLEFT PALATE AND/OR CLEFT LIP 9) Add ICD‐10 Z15.01 (Genetic susceptibility to malignant neoplasm of breast) and Z15.02 (Genetic susceptibility to malignant neoplasm of ovary) to line 195 CANCER OF BREAST; AT HIGH RISK OF BREAST CANCER 10) Add CPT 43281‐43283 (Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed, with or without mesh; Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty)) to line 172 COMPLICATED HERNIAS; UNCOMPLICATED INGUINAL HERNIA IN CHILDREN AGE 18 AND UNDER; PERSISTENT HYDROCELE
MOTION: To approve the recommendations stated in the consent agenda. CARRIES 5‐0.
Topic: 2018 Biennial Review: Injuries to Blood Vessels
Discussion: Smits introduced the staff summary document and recommendations. The general consensus of the VbBS was to create one line for major blood vessel injuries as a cleaner solution. Williams said there are very different outcomes for injuries to major vessels of the abdomen/chest due to the high risk of death or major morbidity from these injuries. However, it was brought up that repair of major thoracic/abdominal vessels are effective when there is the ability to stabilize the patient long enough to do such repair; therefore the repair is effective when done. The decision was to create one line for all major blood vessel injuries.
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Livingston pointed out that a few minor blood vessel injury codes were listed for inclusion on line 82 in the staff recommendation document. It was agreed that staff should review all the codes listed for inclusion on the new line and suggest moving superficial vessel injuries to a lower line. Staff will bring back these recommendations as a straightforward item to the March VbBS meeting.
Recommended Actions: These changes are all effective January 1, 2018 1) Add CPT 35207 (Repair blood vessel, direct; hand, finger) to line 294 CRUSH AND OTHER INJURIES OF DIGITS 2) Change the title of line 135 CRUSH INJURIES OTHER THAN DIGITS; COMPARTMENT SYNDROME; INJURIES TO BLOOD VESSEL(S) OF THE NECK a. Remove the following ICD‐10 codes from line 135 and leave on other current line(s): i. S45 (Injury of blood vessels at shoulder and upper arm level) ii. S55 (Injury of blood vessels at forearm level) iii. S65.0‐S65.3, S65.8‐S65.9 (Injury of blood vessels at wrist and hand level) iv. S75 (Injury of blood vessels at high and thigh level) v. S85 (Injury of blood vessels at lower leg level) vi. S95 (Injury of blood vessels at ankle and foot level) b. Remove the following blood vessel repair CPT codes from line 135: i. 35206 Repair blood vessel, direct; upper extremity ii. 35207 Repair blood vessel, direct; hand, finger iii. 35236 Repair blood vessel with vein graft; upper extremity iv. 35266 Repair blood vessel with graft other than vein; upper extremity v. 35521 Bypass graft, with vein; axillary‐femoral vi. 37618 Ligation, major artery (eg, post‐traumatic, rupture); extremity 3) Merge line 281 INJURY TO BLOOD VESSELS OF THE THORACIC CAVITY and line 82 INJURY TO MAJOR BLOOD VESSELS OF EXTREMITIES and prioritize the new line to line 82. The title of the new line will be 82 INJURY TO MAJOR BLOOD VESSELS OF EXTREMITIES AND NECK a. Include all ICD‐10 and CPT codes currently appearing on lines 82 and 281 b. Remove the following ICD‐10 codes from line 135 and add to new line 82: i. S09.0XXA, S09.0XXD (Injury of blood vessels of head, not elsewhere classified) ii. S27.9XXA, S27.9XXD (Injury of unspecified intrathoracic organ) iii. S35.00XA, S35.00XD, S35.01XA, S35.01XD, S35.02XA, S35.02XD, S35.09XA, S35.09XD (injury of abdominal aorta) iv. S35.10XA, S35.10XD, S35.11XA, S35.11XD, S35.12XA, S35.12XD, S35.19XA, S35.19XD (injury of inferior vena cava) v. S35.211A, S35.211D, S35.212A, S35.212D, S35.218A, S35.218D, S35.219A, S35.219D, S35.221A, S35.221D, S35.222A, S35.222D, S35.228A, S35.228D, S35.229A, S35.229D, S35.231A, S35.231D, S35.232A, S35.232D, S35.238A, S35.238D, S35.239A, S35.239D, S35.291A,
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March 2017 QHOC Packet - Page 34 S35.291D, S35.292A, S35.292D, S35.298A, S35.298D, S35.299A, S35.299D (injury of celiac/inferior mesenteric/superior mesenteric artery) vi. S35.311A, S35.311D, S35.318A, S35.318D, S35.319A, S35.319D, S35.321A, S35.321D, S35.328A, S35.328D, S35.329A, S35.329D, S35.331A, S35.331D, S35.338A, S35.338D, S35.339A, S35.339D, S35.341A, S35.341D, S35.348A, S35.348D, S35.349A, S35.349 (injury of portal/splenic/superior mesenteric/inferior mesenteric vein) vii. S35.401A, S35.401D, S35.402A, S35.402D, S35.403A, S35.403D, S35.404A, S35.404D, S35.405A, S35.405D, S35.406A, S35.406D, S35.411A, S35.411D, S35.412A, S35.412D, S35.413A, S35.413D, S35.414A, S35.414D, S35.415A, S35.415D, S35.416A, S35.416D, S35.491A, S35.491D, S35.492A, S35.492D, S35.493A, S35.493D, S35.494A, S35.494D, S35.495A, S35.495D, S35.496A, S35.496D (injury of renal artery/vein) viii. S35.50XA, S35.50XD, S35.511A, S35.511D, S35.512A, S35.512D, S35.513A, S35.513D, S35.514A, S35.514D, S35.515A, S35.515D, S35.516A, S35.516D, S35.531A, S35.531D, S35.532A, S35.532D, S35.533A, S35.533D, S35.534A, S35.534D, S35.535A, S35.535D, S35.536A, S35.536D (Injury of iliac artery/vein, uterine artery/vein, other vessels of lower abdomen or pelvis) c. Remove ICD‐10 S65.4 (injury of blood vessel of thumb) and S65.5 (injury of blood vessel of finger) from line 82 i. Remain on line 294 CRUSH AND OTHER INJURIES OF DIGITS
MOTION: To approve the code change, line name changes, and line merging recommendations as presented. CARRIES 5‐0.
Topic: 2018 Biennial Review: Secondary and Ill Defined Malignancies
Discussion: Smits reviewed the summary document. There was discussion about whether it was more appropriate to code for the primary cancer or for the distant metastases. The answer appears to depend on what is being treated. If the primary cancer is being treated with surgery, chemotherapy, etc. then that diagnosis code is used. If a distant metastases is being treated with radiation, then frequently the diagnosis code for the metastasis is used. For OHP, Taray said when a claim has both the diagnosis code for the primary cancer as well as the code for the metastasis, the claims system only sees the first code and will deny the claim if that code is for a secondary metastasis on line 595 SECONDARY AND ILL‐DEFINED MALIGNANT NEOPLASMS.
The discussion turned to the issue of the effectiveness of the treatment for the secondary cancer, which depends on the primary cancer. For example, colon cancer metastatic to the lung has a very different treatment effectiveness and prognosis than breast cancer metastatic to the lung. It is hard to lump secondary cancers metastatic to an organ onto the
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same line as the primary cancer of that organ, because of the very different biology of that cancer, with very different treatments and outcomes. There is also cancers with unknown primaries, which have treatment paradigms of their own.
Gingerich said a recent data run found many claims for radiation therapy and other types of therapies for diagnoses on line 595. If treatment were for palliation (e.g. radiation to a painful bony metastasis), then the palliative care statement of intent applies. HSD staff said the Statement of Intent (SOI) 1: Palliative Care cannot be entered in the claims system, so these claims typically denied.
Taray said many of the diagnosis codes on line 595 are very vague and could be put in the HSD Undefined File. Some codes might also be put in the Diagnostic Workup File to allow some testing to try to get a better diagnosis.
Olson suggested creating a line for cancers of unknown primary; there are studies that look at outcomes for patients in this category. The very vague malignant neoplasm diagnoses might also go on such a line.
Williams said some of the diagnosis codes on line 595 make sense to move, for example the head and neck lymph nodes diagnoses might go onto a head and neck cancer line. She advocated keeping line 595 for vague diagnosis and for rare cancers with very poor outcomes even with treatment, such as splenic cancer.
Olson suggested creating a small work group to look at the diagnoses on this line and decide which might be more appropriate to move to other lines. For example, the secondary bone cancer diagnoses might be appropriate to move to the bone cancer line to allow radiation therapy.
Wentz said no claims for diagnoses on line 595 get paid for unless they are appealed. The palliative care statement of intent cannot be added to the claims process, but can be taken into account during appeals.
There was some discussion that many of the claims for line 595 appear to be from radiation facilities. Treatment for painful bony metastases should be covered. The Commission does not want to create administrative barriers to this type of palliative care. There was some thought about making a line for palliative radiation. However, it was thought that it would take some time to create such a line, and it likely would not take effect until the next biennial review cycle in 2020. Taray said the Oregon Pain Commission had a workgroup looking at updating the Statement of Intent 1 language to make more clear which palliative care services were covered. This might help clarify coverage for palliation for diagnoses on line 595.
The subcommittee decided to have staff review codes on line 595 as well as denied claims to see what “low hanging fruit” could be easily addressed and bring back to a future
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meeting. Staff may have discussions with Olson to facilitate addressing the most pressing issues regarding diagnoses on line 595 using the existing line structure.
Staff will also look into whether palliative radiation is being covered and, if not, what barriers need to be removed. One idea was to have staff consider moving bone metastases to the bone cancer line with a guideline limiting services to palliative radiation.
Recommended Actions: 1) Staff to work with Olson on addressing problematic diagnoses on line 595 and bringing back suggested changes to a future VbBS meeting
Topic: Coverage Guidance: Digital Breast Tomosynthesis (3D Mammography) for Breast Cancer Screening in Average‐risk Women
Discussion: Shaffer reviewed the summary document. Public testimony was heard from Scott Holman, from Hologic (manufacturer of Digital Breast Tomosynthesis (DBT)). Mr. Holman gave a handout on estimated cost saving for Medicaid with DBT. This handout included estimates of 20% of eligible Medicaid women getting screening and 25% of that group getting DBT would result in a $8.14 savings per woman screened (reducing cost of recall and cancer treatment).
Olson asked if there was evidence that breast cancer is actually detected earlier with DBT. Holman replied that yes, more low‐stage cancers are found with DBT. Obley noted that there is no published literature showing change in stage of cancer detected with DBT. He noted that with minimal recall reduction (2.3%), costs actually increase by $5 per member per month (PMPM). Obley argued that if you take out reduced costs from earlier stage detection from the manufacturer model, then it is not cost savings in any scenario.
Holman said DBT is an improved version of mammography with lower false positives. Short‐ term reduction in costs from not having to investigate false positives is cost savings. He said 27 states currently cover DBT for Medicaid. He also noted that the Medicaid population has a lower rate of screening, so it is more important to have a more accurate mammogram when they are screened.
The VbBS decision was to accept the staff recommendation to continue to include DBT on the Services Recommended for Non‐Coverage Table.
Recommended Actions: 1) Keep CPT 77063 (Screening digital breast tomosynthesis; bilateral) on the Services Recommended for Non‐Coverage Table
MOTION: To approve the recommendations for no change. CARRIES 5‐0.
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March 2017 QHOC Packet - Page 37 Topic: Fecal Microbiota Transplant for Recurrent C Difficile Infection
Discussion: Smits introduced the summary document. Livingston asked if there should be any wording in the proposed guideline about mode of administration. Smits responded that the evidence base used various modes of administration and at this time she did not recommend limiting it to any particular mode. This might change as the technology develops. The subcommittee decided to include the suggested guideline note.
Recommended Actions: 1) Add CPT 44705 (Preparation of fecal microbiota for instillation, including assessment of donor specimen) to line 150 ENTERIC INFECTIONS AND OTHER BACTERIAL FOOD POISONING and remove from the Services Recommended for Non‐Coverage Table 2) Add HCPCS G0455 (Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen) to line 150 ENTERIC INFECTIONS AND OTHER BACTERIAL FOOD POISONING and remove from the Services Recommended for Non‐Coverage Table 3) Adopt a new Guideline Note for line 150 as shown in Appendix B
MOTION: To approve the coding and guideline note changes as presented. CARRIES 5‐0.
Topic: Coverage of Cholecystectomy for Gallstones
Discussion: Smits reviewed the summary document. The group discussed whether to require 2 or 3 items for diagnosis of cholecystitis and decided that 2 was sufficient.
The group discussed whether to include biliary colic on the covered upper line. Gibson noted that the evidence for coverage of biliary colic was poor. Hodges said she did not agree with moving biliary colic alone without any other sign of problems to the covered line. Olson said there is no evidence about the natural history of what happens when recurrent biliary pain is not treated. The studies presented are all retrospective. Gibson suggested that the CCOs consider treatment of recurrent biliary colic as an exception.
The subcommittee felt that all biliary colic, including recurrent colic, should be included on the lower gallstone line. There was discussion about how to word this in the guideline; the decision was to change the name of the lower line to include “biliary colic.”
Recommended Actions: 1) Add the following cholecystectomy CPT codes to line 199 ACUTE PANCREATITIS for pairing with gallstone pancreatitis (ICD10 K85.1) a. 47562 (Laparoscopy, surgical; cholecystectomy) b. 47563 (Laparoscopy, surgical; cholecystectomy with cholangiography) c. 47564 (Laparoscopy, surgical; cholecystectomy with exploration of common duct)
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d. 47600‐47620 (Cholecystectomy) 2) Remove 47562 (Laparoscopy, surgical; cholecystectomy) from line 311 PARALYTIC ILEUS 3) Change the name of line 645 GALLSTONES WITHOUT CHOLECYSTITIS; BILIARY COLIC 4) Adopt a new guideline note for lines 59 and 645 as shown in Appendix B
MOTION: To approve the coding, line name change and guideline note changes as amended. CARRIES 5‐0.
Topic: Meniscal Injuries
Discussion: Smits introduced the summary document. Williams said she agreed with the staff recommendations. There was no other discussion.
Recommended Actions: 1) Guideline Note 98 was modified as shown in Appendix A
MOTION: To recommend the guideline note changes as presented. CARRIES 5‐0.
Topic: Chronic otitis media (COM) with hearing loss
Discussion: Smits reviewed the summary document and staff recommendations.
Testimony was heard from Kim Wentz, MD, speaking as a pediatrician. She testified that the staff evidence review did not recognize the difficulty in measuring and detecting long‐term outcomes on behavior, school performance, etc. in children. For children, short‐term benefits are very important; hearing loss during a critical developmental period may have significant impact, including on cognitive and social development. Preventive treatment in kids has a much greater return on investment than preventive treatment in adults due to the developmental needs of kids. Medicaid children are already at a disadvantage due to issues around low income. Denying this treatment is another strike against them. This is one area where she recommends deferring the decision to ear‐nose and throat doctors (ENTs), who are the experts. Wentz also said the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) component of Medicaid applies to children to age 21. She implied that EPSDT might require treatment of hearing loss from COM. She did note that the OHP EPSDT waiver does allow use of the Prioritized List. She added that pressure equalization (PE) tubes are a relatively low cost intervention (~$1100).
The subcommittee discussion centered on the lack of evidence of significant benefit of treatment. There was discussion about whether the guideline should specify that coverage is through age 7, to reflect the evidence base presented. Williams said such specification was not needed due to the very narrow group of children already included for coverage in the guideline. However, the majority felt that the evidence should be reflected in the
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March 2017 QHOC Packet - Page 39 guideline and wording was added to specify that coverage was only through age 7. Because this benefit will be limited to children through age 7, the CPT codes for adenoidectomy for children age 12 and older were not added to line 450.
Additional edits were made to the guideline to clarify that adenoidectomy was included for children aged 4 and older (rather than over 3 years) with their second set of tubes.
There was minimal discussion about whether to allow adenoidectomy with the first set of PE tubes.
Recommended Actions: 1) Add adenoidectomy CPT codes to lines 316 HEARING LOSS ‐ AGE 5 OR UNDER a. CPT 42830 Adenoidectomy, primary; younger than age 12 b. CPT 42835 Adenoidectomy, secondary; younger than age 12 c. Add tympanostomy tube placement codes to line 450 HEARING LOSS ‐ OVER AGE OF FIVE i. CPT 69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia ii. CPT 69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia d. Add adenoidectomy codes to line 450 HEARING LOSS ‐ OVER AGE OF FIVE for young children i. CPT 42830 Adenoidectomy, primary; younger than age 12 ii. CPT 42835 Adenoidectomy, secondary; younger than age 12 e. Guideline Note 51 was amended as shown in Appendix A
MOTION: To approve the coding and guideline note changes as amended. CARRIES 5‐0.
Topic: Preventive services guideline edits
Discussion: Livingston introduced the summary document. There was no discussion.
Recommended Actions: 1) Amend Guideline Note 106 as shown in Appendix A
MOTION: To recommend the guideline note changes as presented. CARRIES 5‐0.
Topic: Bariatric Surgery Guideline
Discussion: Smits reviewed the summary document. Public testimony was heard from Jennifer Valley, a cannabis grower and breeder. Ms. Valley testified about her own experience with the benefits of cannabis oil for treatment of cancer. She notes that
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March 2017 QHOC Packet - Page 40 research into the impacts of cannabis are limited by federal rules. She testified that cannabis oil helps lower opioid use. She would like cannabis oil covered for pain, diabetes, cancer, and seizures for OHP patients. She would also like studies done on outcomes of medical marijuana.
Livingston pointed the VbBS members to the Institute of Medicine study on medical marijuana. Staff noted that there is an issue with using Medicaid money to pay for marijuana; such payment is not allowed since marijuana is federally still classified as a Schedule 1 controlled substance.
There was minimal discussion about the staff recommendations to not change the bariatric surgery guideline regarding marijuana use. Abuse of and dependence on marijuana will still be a contraindication to surgery, but not casual use.
Recommended Actions: 1) No changes were made to Guideline Note 8 BARIATRIC SURGERY
MOTION: To make no changes to Guideline Note 8. CARRIES 5‐0.
Public Comment:
No additional public comment was received
Issues for next meeting:
None carried forward from this meeting
Next meeting:
March 9, 2017 at Clackamas Community College, Wilsonville Training Center, Wilsonville, Oregon, Rooms 111‐112.
Adjournment:
The meeting adjourned at 12:15 PM.
Value‐based Benefits Subcommittee Minutes, 2/2/2017 Page 12
March 2017 QHOC Packet - Page 41 Appendix A Revised Guideline Notes
GUIDELINE NOTE 34, ORAL SURGERY EXTRACTION OF IMPACTED WISDOM TEETH Line 349 Treatment only for symptomatic dental pain, infection, bleeding or swelling (D7220, D7230, D7240, D7241, D7250). Extraction of impacted wisdom teeth (D7220, D7230, D7240, D7241, D7250) is only included on this line when there is 1) evidence of pathology. Such pathology includes unrestorable caries, non‐treatable pulpal and/or periapical pathology, cellulitis, abscess and osteomyelitis, internal/external resorption of the tooth or adjacent teeth, fracture of tooth, disease of follicle including cyst/tumor, tooth/teeth impeding surgery or reconstructive jaw surgery, and when a tooth is involved in or within the field of tumor resection OR 2) two or more episodes of pericoronitis OR 3) severe pain directly related to the impacted tooth that does not respond to conservative treatment a. extraction for pain or discomfort related to normal tooth eruption or for non‐ specific symptoms such as “headaches” or “jaw pain” is not considered medically or dentally necessary for treatment.
GUIDELINE NOTE 51, CHRONIC OTITIS MEDIA WITH EFFUSION Lines 316,450,479 Antibiotic and other medication therapy (including antihistamines, decongestants, and nasal steroids) are not indicated for children with chronic otitis media with effusion (OME) (without another appropriate diagnosis).
Patients with specific higher risk conditions (including craniofacial anomalies, Down’s syndrome, and cleft palate, or documented speech and language delay) along with hearing loss and chronic otitis media with effusion are intended to be included on Line 316 or line 450 for children up through and including age 7. Otherwise hearing loss associated with chronic otitis media with effusion (without those specific higher risk conditions) is only included on Line 479.
For coverage to be considered on either Line 316, Line 450 or Line 479, there should be a 3 to 6 month watchful waiting period after diagnosis of otitis media with effusion, and if documented hearing loss is greater than or equal to 25dB in the better hearing ear, tympanostomy surgery may be indicated, given short‐ but not long‐ term improvement in hearing. Formal audiometry is indicated for children with chronic OME present for 3 months or longer. Children with language delay, learning problems, or significant hearing loss should have hearing testing upon diagnosis. Children with chronic OME who are not at risk for language delay (such as those with hearing loss <25dB in the better hearing ear) or developmental delay (should be reexamined at 3‐ to 6‐month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected.
Value‐based Benefits Subcommittee Minutes, 2/2/2017 Appendix A March 2017 QHOC Packet - Page 42 Appendix A Revised Guideline Notes
Adenoidectomy is not indicated at the time of first pressure equalization tube insertion. It may be indicated in children aged 4 and older over 3 years who are having their second set of tubes.
GUIDELINE NOTE 98, SIGNIFICANT INJURIES TO LIGAMENTS AND TENDONS AND MENISCI Lines 381,436,611 Significant injuries to ligaments and/or tendons and/or menisci are those that result in clinically demonstrable joint instability or mechanical interference with motion. Significant injuries are covered on Line 381 or Line 436; non‐significant injuries are included on Line 611.
GUIDELINE NOTE 106, PREVENTIVE SERVICES Line 3 Included on this line are the following preventive services: as required by federal law: 1. US Preventive Services Task Force (USPSTF) “A” and “B” Recommendations in effect and issued prior to January 1, 2016: http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf‐a‐and‐b‐ recommendations/ a. USPSTF “D” recommendations are not included on this line or any other line of the Prioritized List 2. American Academy of Pediatrics (AAP) Bright Futures Guidelines: http://brightfutures.aap.org. Periodicity schedule available at http://www.aap.org/en‐us/professional‐resources/practice‐ support/Periodicity/Periodicity%20Schedule_FINAL.pdf. 3. Health Resources and Services Administration (HRSA) Women’s Preventive Services ‐ Required Health Plan Coverage Guidelines: As retrieved from http://www.hrsa.gov/womensguidelines/ on 1/1/2017. 4. Immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP): http://www.cdc.gov/vaccines/schedules/hcp/index.html
USPSTF “D” recommendations are included on line 625, PREVENTION SERVICES WITH LIMITED OR NO EVIDENCE OF EFFECTIVENESS.
Value‐based Benefits Subcommittee Minutes, 2/2/2017 Appendix A March 2017 QHOC Packet - Page 43 Appendix B New Guideline Notes
GUIDELINE XXX, FECAL MICROBIOTA TRANSPLANT Line 150 Fecal microbiota transplant (FMT; CPT 44705, HCPCS G0455) is included on this line for treatment of recurrent C difficile infection only.
GUIDELINE NOTE XXX, CHOLECYSTITIS Lines 59, 645 Cholecystitis is defined as the presence of right upper quadrant abdominal pain, mass, tenderness or a positive Murphy’s sign, AND 1) Evidence of inflammation (for example: fever, elevated white blood cell count, elevated C reactive protein), OR 2) Ultrasound findings characteristic of acute cholecystitis (for example: gallbladder wall thickening) or non‐visualization of the gall bladder on oral cholecystegram or HIDA scan, or gallbladder ejection fraction of < 35%
ICD‐10 K82.8 (Other specified diseases of gallbladder) is included on line 59 when the patient has 1) Porcelain gallbladder, or 2) Gallbladder dyskinesia with a gallbladder ejection fraction <35%. Otherwise, K82.8 is included on line 645.
Value‐based Benefits Subcommittee Minutes, 2/2/2017 B March 2017 QHOC Packet - Page 44
HEALTH EVIDENCE REVIEW COMMISSION (HERC)
COVERAGE GUIDANCE: DIGITAL BREAST TOMOSYNTHESIS (3D MAMMOGRAPHY) FOR BREAST CANCER SCREENING IN AVERAGE RISK WOMEN For HERC Meeting 3/9/2017
HERC Coverage Guidance Digital breast tomosynthesis for breast cancer screening in average risk women is not recommended for coverage (weak recommendation).
Note: Definitions for strength of recommendation are provided in Appendix A GRADE Informed Framework Element Description. RATIONALE FOR DEVELOPMENT OF COVERAGE GUIDANCES AND MULTISECTOR INTERVENTION REPORTS Coverage guidances are developed to inform coverage recommendations for public and private health plans in Oregon as they seek to improve patient experience of care, population health, and the cost- effectiveness of health care. In the era of the Affordable Care Act and health system transformation, reaching these goals may require a focus on population-based health interventions from a variety of sectors as well as individually focused clinical care. Multisector intervention reports will be developed to address these population-based health interventions or other types of interventions that happen outside of the typical clinical setting. The HERC selects topics for its reports to guide public and private payers based on the following principles: Represents a significant burden of disease or health problem Represents important uncertainty with regard to effectiveness or harms Represents important variation or controversy in implementation or practice Represents high costs or significant economic impact Topic is of high public interest Our reports are based on a review of the relevant research applicable to the intervention(s) in question. For coverage guidances, which focus on clinical interventions and modes of care, evidence is evaluated using an adaptation of the GRADE methodology. For more information on coverage guidance methodology, see Appendix A. Multisector interventions can be effective ways to prevent, treat, or manage disease at a population level. For some conditions, the HERC has reviewed evidence and identified effective interventions, but has not made coverage recommendations, as many of these policies are implemented in settings beyond traditional health care delivery systems.
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March 2017 QHOC Packet - Page 45 MINUTES
Evidence‐based Guidelines Subcommittee Clackamas Community College Wilsonville Training Center, Rooms 111‐112 29353 SW Town Center Loop E Wilsonville, Oregon 97070 February 2, 2017 2:00‐5:00pm
Members Present: Wiley Chan, MD, Chair; Eric Stecker, MD, MPH (by phone), Vice‐Chair; Beth Westbrook, PsyD (by phone); Alison Little, MD, MPH; Kim Tippens, ND, MSAOM, MPH (by phone); George Waldmann, MD (by phone).
Members Absent: None
Staff Present: Darren Coffman; Cat Livingston, MD, MPH; Jason Gingerich.
Also Attending: Adam Obley, MD, Val King MD, MPH, and Craig Mosbaek (OHSU Center for Evidence‐ based Policy), Devan Kansagara, MD (Veteran’s Administration), Jessie Little (OHA), Kim Mauer (Bayer), Sandy Christiansen (OHSU), Tracy Titus and David Sibell (OHSU/Spine Intervention Society), Brian Mitchel (OHSU/VA/Oregon Society of Anesthesiologists), Norm Cohen (OHSU), Jordan Johnson (OHSU), Sydney Rose (OHSU), Timothy Grabe (attorney), Mark Wilburn (patient), Carol Wilborn (patient), Martha Sevchik, Larry McKnight.
1. CALL TO ORDER
Wiley Chan called the meeting of the Evidence‐based Guidelines Subcommittee (EbGS) to order at 2:00 pm.
2. MINUTES REVIEW
Minutes from the November 3, 2017 meeting were reviewed and approved 6‐0.
3. STAFF REPORT
Coffman welcomed physician Devan Kansagara to attend as an observer. He has been nominated to the subcommittee and his nomination will be considered at the March HERC meeting. Kansagara he runs the evidence‐based services program at the Portland Veteran’s Administration office.
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March 2017 QHOC Packet - Page 46
Livingston said that the Health Technology Assessment Subcommittee (HTAS) will be reviewing the draft scope statement for CardioMEMS. This is a timing issue; EbGS will not formally review the scope statement but the actual coverage guidance would be developed by EbGS.
4. New Topics
Adam Obley began reviewing the draft scope statements.
Opportunistic Salpingectomy for Ovarian Cancer Prevention Obley also reviewed public comment suggesting that the surgical technique may be an important factor as many times modern laparoscopic techniques result in a partial (rather than full) salpingectomy. Chan asked about outcomes related to contraception. Obley said the focus here is the cancer prevention, as it is often offered along with a planned tubal ligation. Little suggested that under Key Question 2 regarding factors which may affect effectiveness, the question be changed to consider the type of pelvic surgery as well as the indication for which it is being considered.
Colorectal Screening Modalities Kansagara suggested the subcommittee add FIT testing as a comparator. Others agreed. Obley also confirmed that cost effectiveness of various strategies will be considered and that USPSTF is not actively looking at these now, having recently completed its review. Livingston explained that the USPSTF made an A recommendation for screening, listing several tests without ranking them individually. Kansagara asked about data regarding patient attendance for various screening strategies. Obley said this will be addressed in Contextual Question 2, looking at whether offering multiple options affects adherence. Stecker asked about screening intervals. Obley said that for most of the tests, all there will be is expert opinion. Livingston said that it would be helpful to know the recommended interval for each test, even if it is based only on expert opinion.
Urine Drug Testing Obley noted that he doesn’t expect to find a lot of evidence on this topic, with guidelines and expert opinion most likely to inform the recommendation. Westbrook asked about other testing modalities other than urine drug testing, such as hair testing. Obley said that urine testing is most commonly used, and the focus is on whether screening tests are underused and whether the quantitative tests are overused and the appropriate frequency for testing, but we wouldn’t be looking at hair testing. Kansagara asked to add “dose of prescribed opioid” under Key Question 3. Little asked about methadone clinics and treatment programs. Patients in these programs are currently excluded from scope, but after further discussion the subcommittee decided to strike the exclusion and to add a subpoint to Key Question 3 regarding dose proscribed. Waldman suggested adding cannabanoids as a type of drug tested as a subpoint under Key Question 3.
Livinsgton said that in other states they have found that these tests add up to millions. For instance, quantitative tests costing $100 per drug might be used for marijuana, but not change treatment decisions due to marijuana’s legal status in Oregon. A subcommittee member also asked the subcommittee to look at observed versus unobserved testing as a factor, which may affect effectiveness.
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March 2017 QHOC Packet - Page 47
Livingston received some comments from Quest Laboratories about this testing, clarifying the different kinds of tests available.
Chan invited public testimony. Dr. David Sibell from OHSU offered comment (disclosing no conflicts of interest) and said that despite marijuana being legalized under state law, from the point of view of people issuing Drug Enforcement Administration licenses, it is not a grey area since marijuana is still a controlled substance. He said it is a violation of federal law to prescribe a controlled substance to someone who is known to be diverting a controlled substance, and as long as marijuana remains a schedule 1 drug at the federal level, it will be diversion no matter how it is being used. The prior administration did not enforce this, but the current administration may decide to. Thus, from the perspective of a prescriber, the drug needs to be considered illicit. He said at OHSU there is a tacit understanding that if providers are prescribing a controlled substance, and find marijuana, they will stop prescribing the other substance. Based on that feedback the subcommittee listed marijuana with other illicit substances.
Multisector Interventions for Prevention of Unintended Pregnancy Livingston reviewed the draft scope statement and public comments. Kansagara said his understanding is that the evidence shows that long‐acting reversible contraceptives have the best rates of effectiveness, and asked how this finding might be addressed within the draft scope. Livingston noted that Key Question 2(h) addresses type of contraception. Livingston said based on her knowledge, access to LARC is associated with decreased abortion rates and other things. These questions will allow us to compare strategies promoting different forms of contraception. Chan noted that this review won’t be a comparative effectiveness study of the technologies themselves, but the health systems and public health interventions related to them.
Kansagara said a colleague has researched this and that patient acceptability is an important factor with different interventions. Livingston said that how that impacts uptake of contraception is important but we wouldn’t look at that as an outcome in itself. For instance, if you have a program that offers LARCs, but 50% of the population does not want LARCs, this would be an important factor. Kansagara said he has heard there is substantial variability in patient acceptability for LARC. Based on discussion, Key Question 2 was modified to include acceptability of contraceptive methods to patients.
Stecker suggested that income be added as a modulator of effectiveness. He said it’s a little different than access to health care coverage. His recommendation was incorporated by replacing “educational level and income” to “socioeconomic status”. Livingston suggested adding cultural background to the item about race and ethnicity.
Discussion turned to whether mistimed pregnancy is the same as unintended pregnancy. Livingston said it is a subcategory of unintended pregnancy. After brief discussion the parenthetical statement regarding the outcome of unintended pregnancy was removed, including references to teenage pregnancy, mistimed pregnancy and birth spacing.
At Tippins’ suggestion, number of children in the home was added to the key question factor of parity.
A motion was made to approve the draft scope statements as amended (see Appendix A). Motion approved 6‐0.
EbGS 2‐2‐2017 Minutes Page 3
March 2017 QHOC Packet - Page 48 5. Low Back Pain: Corticosteroid Injections
Adam Obley reviewed the public comments to the draft coverage guidance and the public comment disposition. Livingston introduced Tim Keenen and Janna Friedly, who serve as ad hoc experts for this topic. Chan invited public comment.
Kim Mauer offered testimony. She read a letter from Roger Chou, lead author of the systematic review which served as a basis for the coverage guidance. Chou’s letter highlighted the finding of the review that for patients with radiculopathy, steroid injections are associated with relatively modest benefits, principally a short‐term reduction in pain after several weeks. The impact on pain is not that far out of line with other treatments for low back pain. He does not believe that pain relief should be ignored as it is important for quality of life. He said that, for patients with radiculopathy, the evidence is stronger for epidural steroid injections than for anything else. He said that surgery is the only other evidence‐based treatment for radiculopathy, so a trial of an epidural steroid injection for these patients would be a reasonable option.
Livingston said that Dr. Chou was invited to serve as an expert for this coverage guidance, but he was unavailable. Mauer said that he had wanted to be present for this meeting. Chan noted that pain was not selected as an important outcome because we want to incorporate the effect that pain would have on function. That is the reason this effect was not called out. Obley agreed that evidence for epidural steroid injections is stronger than for other interventions.
Sandy Christianson, assistant professor at OHSU, offered testimony on behalf of Dr. Steven Cohen, a professor of anesthesiology, neurology, physical medicine and rehabilitation at Johns Hopkins University (among other titles). His letter referenced presidents, generals and famous doctors who have received epidural steroid injections, and gave the opinion that patients feel better after receiving these injections. The letter said that despite the incomplete, short‐term benefit, other treatments are inadequate as well.
Tracy Titus offered her comments as a patient. She said that people who haven’t had chronic pain have difficulty understanding the impact of not being able to do everyday activities like carrying groceries or bending down or walking down stairs. She also noted the impact on families of patients as well as on their social life. She said she has had neck, back and brain surgery. The injections only last a short period of time, sometimes a bit longer, but they allow her to participate in social activities and daily activities like shopping for groceries.
David Sibell, professor at OHSU and member of the Spine Intervention Society, spoke next. He presented articles and described them by saying that transforaminal epidural steroid injections have clinical and statistical effectiveness in the treatment of radiculopathy when using the appropriate technique. Using other forms of the procedure and giving the injections for other indications is not effective. Failing to pay attention to pain as a variable whose primary effect is pain relief is inappropriate. He said safety has improved over the last decade, eliminating the risks of arterial injection by using imaging guidance.
Little asked whether the studies were evaluated. Obley said he hadn’t had a chance to review the studies provided, but the Chou review had a question about whether the effectiveness varied by approach and found insufficient evidence. He also said that there was a 2014 randomized trial of image‐
EbGS 2‐2‐2017 Minutes Page 4
March 2017 QHOC Packet - Page 49 guidance steroid injections with lidocaine versus lidocaine with saline. Patients had similar conditions, including imaging‐proven L4‐L5 or L5‐S1 disc herniation with unilateral radiculitis. All patients had fluouroscopically‐guided transforaminal injections. While all patients showed improved pain scores, there was not a difference between the two groups. Little asked Sibell what he believes the correct method is. He said for lumbar radiculopathy, the correct technique is to use transforaminal injections with dexamethasone, which appears to be as effective as other steroids, but is safer. Obley said there are comparisons of different approaches and steroids in the coverage guidance, and that he agreed complications are rare.
Brian Mitchell, a physician‐anesthesiologist at the Portland Veteran’s Administration hospital, with no conflicts of interest, said that he does not perform these procedures. He added that we are in the midst of an opioid crisis, with 91 people dying of an overdose every day in the United States, with over 505 dying in Oregon in 2015. He cited a CDC guideline which said that epidural steroid injections can provide short‐term improvement, saying that access to this procedure could help fight opioid overuse and abuse.
Chan said that the evidence shows no reduction in opioids and surgery. If the studies are bad, we need better studies.
Jordan Johnson, a pain medicine fellow at OHSU said he had no conflicts of interest. He expressed concern about dropping coverage for these procedures. He said these procedures are helpful for certain patients. He said he understands that not every patient gets a benefit but that some patients do show improvement in function. In addition he said future OHSU residents and fellows may have less training in this procedure if coverage is reduced.
Tim Grabe, a Multnomah circuit court arbitrator, spoke next. As an attorney he has represented both insurance companies and patients. He said that in the legal world this treatment is accepted. When insurance companies don’t want to pay for the injections, they tend to lose in arbitration and dollars flow back to the Oregon Health Plan after this treatment is provided.
Martha Sevick testified that she has experienced pain relief and improvements in her function in daily life like for many patients. More detailed, controlled studies may be needed to show these kinds of improvements. She said that each pain patient is different, which is why observational and clinical evidence is important. The patient’s ability to move and function in society must be considered. She said that the injections can help patients live with fewer opiates. Injections are less risky than surgery, and they allow her to participate in volunteer activities.
Livingston invited Keenen and Friedly to offer testimony. Keenen said that he graduated 37 years ago and many treatments come and go. He was a member of the HTAS previously and kyphoplasty was not recommended but there was a compromise to allow coverage in limited circumstances. Steroid injections are similar. If he sees pain in a dermatomal distribution that correlates to an MRI finding he knows that the natural history is for the pain to improve without surgery and that a transforaminal injection to the cervical or lumbar spine can allow the patient to weather the pain and get better without surgery. He expressed understanding of the limitations of the studies that have been presented. There is validity in many of their conclusion but there is also efficacy in these treatments. He said injecting facets or injecting anything for back pain doesn’t work. But with radicular pain correlated to an MRI finding with a dermatomal pattern, it can have a dramatic effect. That said, for patients who have
EbGS 2‐2‐2017 Minutes Page 5
March 2017 QHOC Packet - Page 50 an injection and who experience only 2‐3 days of relief, no more injections should be done. He would like to see the indications limitated.
Chan asked him how to narrow the indications. Keenen said it is a challenge. Based on commercial insurance, there needs to be a duration of symptoms (3‐6 weeks) before an injection is considered, then a payer might require a radiological report that specifies the location of the nerve root compression as well as the cause (such as stenosis or disc herniation). He said the number of injections should also be limited. With chronic pain, a documented increase in function should be required. Assessing improved function can be challenging. He agreed that transforaminal injections are superior to other approaches.
Kansagara asked whether other types of injections were ever appropriate. Keenen said a transforaminal injection targets a specific nerve root, while the translaminar would affect other areas. A translaminar injection might be done “to make people not hurt,” but a transforaminal injection is a better diagnostic and therapeutic procedure.
Friedly described her background as a physiatrist and researcher who does not perform these procedures. She echoed Chou’s comments that steroid injections do provide a modest short‐term improvement in pain for people with herniated disc causing radiculopathy. Functional improvements have not been demonstrated. She said that observational evidence is problematic, so focusing on trials with control groups is important. She said that for repeat injections, the systemic effects of steroids need to be considered, along with the risk of infection.
Chan reviewed the evidence‐based process, which focuses on randomized trials because of the issues with observational studies. He did say that he wonders whether pain should have been considered as an outcome for the studies. Despite the observational evidence and personal experience, he said he doesn’t believe we can conclude that steroid injections reduce opioid use or reduce the rates of surgery, despite the observational evidence and personal experience. However he said he didn’t want people going away thinking that the subcommittee doesn’t care about pain. Tippins said she would support including pain.
Friedly highlighted that the finding of modest improvement in short‐term pain only applied to the population with herniated discs and radiculopathy. This condition has a favorable natural history, so observational trials or experience can lead to the perception of greater effectiveness than is actually the case. She also noted that chronic back pain has a variety of factors including depression, anxiety, fear/avoidance, coping skills and insomnia, which should not be ignored. There is a lot of evidence about which patients will not do well with injections, and it focuses around these biopsychosocial issues. It is important to consider these contextual factors when thinking about these treatments.
Chan noted that bringing pain in as an outcome would require re‐examining the evidence. Obley said that pain was included in the Chou review, so staff could summarize the information from the Chou review. He read excerpts from the review, which included a finding with moderate strength of evidence for a modest reduction in pain at immediate follow‐up and no difference at short, medium or long‐term intervals. Friedly said that, at short‐term follow‐up, for all the studies, it did not meet the pre‐defined threshold. The criticism of that analysis is that older studies using different techniques are included in this analysis. If you pull out a specific newer study, there would be a benefit. There is a difference of opinion about whether these studies should be included together. Chan asked whether the difference in the pain finding was clinically important. Obley asked what the predefined threshold for clinical significance is. Friedly said that it is usually 15 or 20 points on a 100‐point scale, or 1.5‐2 points on a 10‐
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March 2017 QHOC Packet - Page 51 point scale. In this case the finding was a reduction of 7.55 points on a 100‐point scale, which does not exceed the predefined threshold. Chan observed that the argument for a clinically significant difference in pain was limited to a single study, despite low heterogeneity with other studies. Friedly said that people point to the single study as the gold standard. Where people get mixed up with the evidence is that when there is a comparison with lidocaine and even with saline, both groups improve at short‐term and even long‐term follow‐up. There is a lot of argument about whether lidocaine injections are a true placebo or an active treatment. People consider that studies which we consider as negative studies are positive because they could be considered as comparisons of active treatments rather than placebo‐ controlled trials. That said, there is no good data that it is an active treatment. She said the gold‐ standard study cited by proponents shows that lidocaine did worse than the other control groups of the study, which are not considered active treatments.
Livingston reviewed other edits to the values and preferences, especially the strong preference for epidural steroid injections. She also requested feedback on possible criteria for coverage if there does turn out to be a recommendation for coverage. Little asked that the analysis clarify whether radicular pain was from herniated disc versus foraminal stenosis. Keenen said that MRI/CT documentation of nerve compression would help. He also said at six weeks the primary care physician could refer to a pain specialist and expressed concern that patients would be unlikely to receive interdisciplinary pain treatment in such a short timeframe. Chan suggested that multidisciplinary approaches might be continued when the steroid injection is offered. After discussion, the group decided against requiring any specific type of multidisciplinary treatment. Based on expert testimony the subcommittee decided that imaging guidance might be required.
After extensive discussion, the subcommittee requested that Obley create an evidence table showing pain and functional outcomes for the 8 or so individual studies already reviewed, in Chou or the draft coverage guidance, for patients with radiculopathy, including whether the radiculopathy was caused by a herniated disk or foraminal stenosis, the inclusion criteria, the approach used and whether imaging guidance was used.
7. ADJOURNMENT
The meeting was adjourned at 5:00 pm. The next meeting is scheduled for April 6, 2017 from 2:00‐5:00 pm at Clackamas Community College, Wilsonville Training Center, Rooms 111‐112, 29353 SW Town Center Loop E, Wilsonville, Oregon 97070.
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March 2017 QHOC Packet - Page 52 APPENDIX A
DRAFT SCOPE STATEMENT FOR HERC COVERAGE GUIDANCE
COLORECTAL CANCER SCREENING MODALITIES
Population Adults age 50 and older with average risk of colorectal cancer description Population scoping notes: Excludes high risk, such as first degree relative with colorectal cancer, known predisposing mutations (AFP, HNPCC) or inflammatory bowel disease
Intervention(s) Computed tomographic colonography, fecal DNA testing, serum test for Sept9, colonoscopy with chromoendoscopy
Intervention exclusions: Double‐contrast barium enema, camera pill
Comparator(s) Colonoscopy, flexible sigmoidoscopy (with or without fecal occult blood testing), fecal occult blood testing, other listed interventions, FIT testing
Outcome(s) Critical: Colorectal cancer incidence, all‐cause mortality, colorectal cancer morbidity (up to five) Important: Diagnostic test characteristics, harms
Considered but not selected for GRADE Table: Quality of life
Key questions What is the comparative effectiveness of colorectal cancer screening modalities?
How does the comparative effectiveness of colorectal cancer screening modalities vary by: a. Age b. Gender c. Race or ethnicity d. Patient adherence/acceptance of test e. Screening interval
What are the harms of colorectal cancer screening?
Contextual What are the optimal screening intervals for each modality? questions What is the comparative effectiveness of offering various colorectal cancer screening modalities in underscreened populations?
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March 2017 QHOC Packet - PageA-1 53 APPENDIX A
CHANGE LOG
Date Change Rationale
1/13/2017 Changed critical outcomes from morbidity and Consistent with other coverage mortality to all‐cause mortality and colorectal guidances; allows committee to cancer morbidity, removed quality of life. examine whether there is a reduction in all‐cause mortality
1/13/2017 Changed outcome of operating characteristics to Clarify that this outcome refers diagnostic test characteristics to diagnostic accuracy rather than patient outcomes, which are address elsewhere.
2/2/2017 Added FIT testing to list of comparators Clarify that this is included at EbGS Request
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March 2017 QHOC Packet - PageA-2 54 APPENDIX A
SCOPE STATEMENT FOR HERC MULTISECTOR INTERVENTION REPORT
PREVENTION OF UNINTENDED PREGNANCIES
Population Adolescents and adults of reproductive age description Population scoping notes: None
Intervention(s) Contraception education, abstinence education, other educational interventions (e.g., parenting practice), strategies to improve access to contraception (e.g., 12 month birth control dispensing, OTC birth control dispensing, clinic on‐site provision and same‐day access to contraception, pharmacist prescribing of contraceptives), change in copays and coinsurance, mass media, social marketing or education campaigns, financial incentives (e.g., metrics, reduction of financial barriers)
Intervention exclusions: None
Comparator(s) Other listed interventions, no specific intervention
Outcome(s) Critical: Unintended pregnancy rate, abortion rate,perinatal morbidity (e.g., (up to five) prematurity, low birth weight), impact on social indicators (educational or income status of women and families)
Important: Use of effective methods of contraception, costs/expenditures, rate of sexually transmitted infections
Considered but not selected for GRADE Table:
Key questions What is the comparative effectiveness and harms of the interventions for reducing unintended pregnancy?
How do the effectiveness or harms of interventions vary by: a. Age (e.g., adolescents vs. adults) b. Parity/number of children at home c. Socioeconomic status d. Comorbidities e. Setting (e.g., school, clinic, community, hospital) f. Race/ethnicity/cultural background g. Presence of co‐occurring interventions h. Type of contraception i. Access to and type of health care coverage j. Acceptability of contraceptive methods to patients What are the most cost‐effective strategies to reduce unintended pregnancy?
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March 2017 QHOC Packet - PageA-3 55 APPENDIX A
CHANGE LOG
Date Change Rationale
1/13/2017 Add other educational interventions, reduction of Include a fuller range of financial barriers and pharmacist‐prescribed interventions and factors which contraception as an intervention may affect outcomes.
Edited Key Question 2 to include type of contraception provided as well as the access to and type of health care coverage
1/23/2017 Deleted “more” in the outcome of “use of more Public comment effective methods of contraception”
Added additional characteristics to key question 2 (parity, educational level, and comorbidities).
Changed the language in KQ2 from “type of contraception being promoted/provided”, to “type of contraception being evaluated.”
1/24/2017 Edited interventions for clarity, added educational Staff clarifications programs. Added mistimed pregnancy as an outcome, added educational/income status of families (not just women), changed Key question 2 (h) to type of contraception.
2/2/2017 Removed parentheticals from outcome of EbGS clarifications unintended pregnancy.
Clarified key questions at EbGS Request.
Sources used for scoping
1. Oringanje C et al. Interventions for preventing unintended pregnancies among adolescents. Cochrane Database of Systematic Reviews 2016, Issue 2. 2. The Community Guide. https://www.thecommunityguide.org/topic/hivaids‐stis‐and‐pregnancy 3. Colorado Family Planning Initiative. https://www.colorado.gov/pacific/cdphe/reducing‐ unintended‐pregnancy 4. Guttmacher Institute. State facts about unintended pregnancy: Oregon. 2013.
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March 2017 QHOC Packet - PageA-4 56 APPENDIX A
DRAFT SCOPE STATEMENT FOR HERC COVERAGE GUIDANCE
OPPORTUNISTIC SALPINGECTOMY FOR OVARIAN CANCER PREVENTION
Population Women at average risk of ovarian cancer undergoing pelvic surgery description Population scoping notes: None
Intervention(s) Opportunistic salpingectomy
Intervention exclusions: None
Comparator(s) No intervention, oral contraceptive pills
Outcome(s) Critical: Ovarian cancer incidence, mortality and morbidity, ovarian function (e.g., (up to five) premature menopause)
Important: Operative time and length of hospital stay, harms
Considered but not selected for GRADE Table:
Key questions What is the comparative effectiveness of an opportunistic salpingectomy for the prevention of ovarian cancer?
How does the comparative effectiveness of opportunistic salpingectomy vary by: a. Age b. Race or ethnicity c. Patient history, including previous pelvic surgeries d. Baseline risk within an average‐risk screening population (as ascertained by risk assessment tools) e. Type of and indication for pelvic surgery f. Laparascopic versus open approach g. Total vs. partial salpingectomy
What are the harms of an opportunistic salpingectomy?
2/27/17
March 2017 QHOC Packet - PageA-5 57 APPENDIX A
CHANGE LOG
Date Change Rationale
1/13/2017 Added subpoints to KQ for surgical approach and Public comment suggests more total versus partial salpingectomy difficult access with laparascopic approach may result in less tissue removal and therefore, reduced effectiveness,
2/2/2017 Changed K.Q. 2 to include type of and indication for EbGS request pelvic surgery.
2/27/17
March 2017 QHOC Packet - PageA-6 58 APPENDIX A
SCOPE STATEMENT FOR HERC COVERAGE GUIDANCE
URINE DRUG TESTING
Population Patients receiving opioids for chronic pain and patients with substance use disorder description Population scoping notes: None
Intervention(s) Urine drug testing (screening and confirmatory testing, qualitative and quantitative, individual drug assays and panels of tests)
Intervention exclusions: None
Comparator(s) Standardized risk assessment tools, no testing, other interventions
Outcome(s) Critical: Overdose and death, identification of diversion, identification of other (up to five) substance use disorders
Important: Test performance characteristics, change in management of chronic pain or substance use disorder
Considered but not selected for GRADE Table: None
Key questions 1. What is the comparative effectiveness of qualitative versus quantitative and screening versus diagnostic urine drug testing?
2. What is the comparative effectiveness of different testing strategies?
3. How does the comparative effectiveness vary by: a. Underlying patient risk b. Presence of comorbid conditions c. Presence of multiple controlled substances d. Type of drug tested (e.g., illicit such as cocaine and methamphetamines, cannabinoids; licit such as alcohol, or prescription only such as benzodiazpenes) e. Frequency of testing f. Observed versus unobserved testing g. Dose of prescribed opioid medication Contextual What is the cost‐effectiveness of the different screening/diagnostic test questions strategies?
What is the effectiveness of urine drug testing in patients receive acute treatment (e.g. in an urgent care or emergency department setting) in patients who also meet the population criteria?
2/27/17
March 2017 QHOC Packet - PageA-7 59 APPENDIX A
CHANGE LOG
Date Change Rationale
2/2/2017 Removed exclusion of patients in opioid treatment EbGS request. programs. Cannabinoids remain illicit Edited Key Question 2 to include cannabinoids as an under federal law, and illicit substance, and added observed versus prescribers are subject to unobserved testing and dose of prescribed opioid federal law in terms of licensing medication to the list of factors under KQ 2 which to prescribe controlled may affect effectiveness. substances.
2/27/17
March 2017 QHOC Packet - PageA-8 60 MINUTES
Health Technology Assessment Subcommittee Clackamas Community College Wilsonville Training Center, Rooms 210 29353 SW Town Center Loop E Wilsonville, Oregon 97070 February 16, 2017 1:00‐4:00pm
Members Present: Derrick Sorweide, DO (Chair); Som Saha, MD, MPH (Vice‐Chair); Leda Garside, RN, MBA; Mark Bradshaw, MD (by phone), Chris Labhart.
Members Absent: Vinay Prasad , MD.
Staff Present: Darren Coffman; Cat Livingston, MD, MPH; Jason Gingerich.
Also Attending: Adam Obley, MD, Val King MD, MPH & Craig Mosbaek (OHSU Center for Evidence‐ based Policy); Kathryn Schable (OHSU); Cindy Fletcher (Susan G. Komen); Renee Taylor (Dexcom); Susie Rice (Juvenile Diabetes Research Foundation); Joannie Kono (OHSU); Jessica Castle (OHSU); Katie Woods (OHSU); Melinda Pierce (OHSU); Gloria Tapice (Salud), Leif Bruce.
1. CALL TO ORDER
Derrick Sorweide called the meeting of the Health Technology Assessment Subcommittee (HTAS) to order at 1:00 pm.
2. MINUTES REVIEW
Minutes from the 12/1/2016 meeting were reviewed and approved 4‐0 (Garside not present).
3. STAFF REPORT
Coffman introducted Dr. Kathryn Schabel, who was recommended by Dr. Farris to replace him as an orthopedist on HTAS. She would have been considered for appointment at the January HERC meeting, but it was cancelled due to weather. HERC will now consider this at their March meeting. She introduced herself as an orthopedist with a focus on hip and knee replacements.
Shaffer reported that the Artificial Disc Replacement topic may be brought back to a future meeting, as Washington’s Health Technology Assessment program will likely support coverage of two‐level artificial disc replacements. Washington’s decision may come as soon as next month. Based on that review, either a slight edit involving two‐level disc replacement or a complete new coverage guidance may come before the subcommittee.
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4. New topics for 2017
The subcommittee reviewed the draft scope statements provided in the meeting materials. They remained unchanged, except as noted.
Acellular dermal matrix for breast reconstruction There was no discussion.
CardioMEMS for heart failure monitoring Obley suggested changing the population to include all patients with heart failure, and include a question about whether the effect differs in patients with preserved versus reduced ejection fraction. The subcommittee decided to recommend the topic despite public comment suggesting that Oregon defer to Medicare, as many patients not eligible for Medicare do have heart failure.
Hepatic artery infusion pump chemotherapy There was no discussion.
Gene expression profiling for breast cancer Shaffer explained that this topic and the next will be split out from the previous coverage guidance on Biomarker Tests of Cancer Tissue for Progonsis and Potential Reponse to Treatment. Sorweide asked whether there would be a difference when the tumor is primary or recurrent. Obley said it is typically done after a primary resection.
Gene expression profiling for prostate cancer The subcommittee discussed the public comments in the meeting packet but made no changes.
A motion was made to approve the scope statements as amended for review by the HERC. See Appendix A for the approved scope statements. Motion approved 4‐0 (Abstained: Garside).
5. Breast Cancer Screening for Women at Above‐Average Risk of Breast Cancer
Coffman introduced Dr. Kari Thomas and Dr. Linda Humphrey, the appointed experts on this topic.
Obley reviewed the draft coverage guidance. Shaffer reviewed the GRADE‐informed framework elements, including the values and preferences and other factors which may influence the coverage recommendation. He said that some of the criteria in the recommendations don’t come directly from the evidence but are consistent with clinical guidelines.
For the question about patients with known mutations or suspected mutations based on family history, Thomas said that they recommend that screening start as young as age 25 if a woman’s mother had breast cancer at an early age or those who had mantle radiation. Saha and Sorweide suggested that women under 30 meeting the American College of Radiology criteria could apply for an exception. Saha asked about whether for patients who can’t get an MRI, other screening modalities may be appropriate. He asked whether ultrasound adds accuracy for these patients. Thomas said no, but they do recommend breast‐specific gamma imaging. Though not ideal because of the radiation involved, it is acceptable for high‐risk patients who cannot have an MRI. Obley said that he found no evidence meeting the inclusion
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criteria for breast‐specific gamma imaging, but that some guidelines favored this intervention in the situations Thomas described. The subcommittee discussed adding language around this and decided that situations like these could be handled as exceptions.
Labhart asked about access to MRI in rural areas. Thomas said that specific MRI technology and software is required, so it is unlikely this service would be available in rural areas. She said there is one in Bend, but she’s not sure whether there was one on the coast.
For patients with both a personal history and family history, Shaffer said that the recommendation is based on operating characteristics. Obley said there is divergence in professional guidelines, with the American Cancer Society finding insufficient evidence while other organization recommends other strategies. Thomas said that for women already receiving a mammogram there is no additional benefit for ultrasound. Obley, however, said that Table 2 of the coverage guidance (from the NICE review) shows additional benefit, despite a reduction in specificity.
Based on discussion, the subcommittee edited the recommendation to clarify that regular annual mammography is recommended as baseline for all populations.
Shaffer asked about whether for surveillance after breast cancer, there might be a recommendation for more frequent screening. Thomas said there is not, but sometimes the mammograms and MRIs will be staggered so that a screening is performed approximately twice a year. Humphrey agreed.
Humphrey and Thomas discussed whether, in this population, an exam would be screening or surveillance. Humphrey said she would see it as surveillance. Thomas explained that a diagnostic mammogram is billed differently and the patient is informed of the results immediately; in a screening mammogram this is not the case. In her practice some patients or providers prefer a screening mammogram and others prefer a diagnostic one. After discussion the subcommittee decided not to characterize the mammogram as screening, diagnostic or surveillance in order to reduce confusion.
For women with a history of chest irradiation, Shaffer said that the recommendation is based on the fact that each modality detects cancers not detected by other modalities. Thomas and Humphrey both recommended changing the recommendation to allow coverage beginning at age 25. The recommendation was changed to allow for coverage beginning 8 years after radiation exposure or at age 25, whichever is later.
For women with dense breasts, discussion focused on the poor interrater reliability of breast density as well as the fact that women’s breast density changes over time. Thomas said if this should be recommended at all, it should be in women with extremely dense breasts.
There was limited discussion of the recommendations against coverage for breast CT scanning as well as breast‐specific gamma imaging.
A motion was made to post the draft coverage guidance as modified for a 30‐day public comment period. Motion approved 5‐0.
HTAS 2‐16‐2017 Minutes Page 3
March 2017 QHOC Packet - Page 63 DRAFT HERC Coverage Guidance Annual screening mammography and annual screening MRI are recommended for coverage for women at above‐average risk of breast cancer (weak recommendation). This coverage, beginning at 30 years of age, includes women who have one or more of the following: Greater than 20% lifetime risk of breast cancer BRCA1 or BRCA2 gene mutation, or who have not been tested for BRCA but have a first‐degree relative who is a BRCA carrier a personal history or a first‐degree relative diagnosed with Bannayan‐Riley‐Ruvalcaba syndrome, Cowden syndrome, or Li‐Fraumeni syndrome
For women with a history of high dose chest radiation before the age of 30, annual screening MRI and annual screening mammography are recommended for coverage beginning 8 years after radiation exposure or at age 25, whichever is later (weak recommendation).
For women with both a personal history and a family history of breast cancer, annual mammography, annual breast MRI and annual breast ultrasound are recommended for coverage (weak recommendation).
For women with increased breast density, supplemental screening with breast ultrasound, MRI, or digital breast tomosynthesis is not recommended for coverage (weak recommendation).
Breast PET‐CT scanning and breast‐specific gamma imaging are not recommended for coverage for breast cancer screening in any risk group (strong recommendation).
6. Continuous Glucose Monitoring
Coffman introduce Dr. Katie Woods, a pediatric oncologist from OHSU as the appointed expert for pediatric oncology for this topic. The subcommittee was still searching for an expert for adult endocrinologist, though Dr. Jessica Castle was present. Castle is a diabetologist at OHSU. She doesn’t have any financial conflicts of interest though her research does use Dexcom products.
Adam Obley reviewed a presentation on the draft coverage guidance. Shaffer noted that this coverage guidance would serve as a replacement to a coverage guidance approved in 2013. The older coverage guidance recommends coverage of continuous glucose monitors (retrospective and real‐time) for patients with type 1 diabetes (of any age), when an insulin pump is being initiated, considered or utilized and only for patients with HbA1c over 8%. The current draft expands coverage for adults (not requiring that it be used in conjunction with insulin pumps) and eliminates coverage for children as well as coverage of retrospective monitors.
For adults with type 1 diabetes the recommendation would remove the requirement related to pumps, and is based on observed reduction in HbA1c levels. There is some question about the clinical significance of reductions but a large quantity of studies points to a reduction with a large potential impact on the population at risk. He said most professional societies recommend CGM and other payers
HTAS 2‐16‐2017 Minutes Page 4
March 2017 QHOC Packet - Page 64 allow some coverage for patients with type 1 diabetes. He said that the retrospective monitor is used by the patient for a few days and brought back to the clinic. Insufficient evidence was found to support this intervention.
Saha asked about the reasons for using the lower threshold for clinical significance of ‐0.3% (versus ‐0.5% previously) as well as the fact that the aggregated effect size of ‐0.3% includes patient with and without pumps. He is concerned that if the patients using pumps showed better results than the ‐0.3%, the patients not using pumps must not have experienced a significant difference. Obley said that recent studies for patients using insulin injections have showed higher levels of effectiveness of ‐0.6% and ‐0.43%. He also said that for use of continuous glucose monitors in pregnant women, the NICE review found only two studies.
Castle said that newer products are more accurate, so the focus should be on the more recent data. The newer studies show more benefit with injections as well as with a pump. She also argued for covering patients with an HbA1c over 7.0%, since the American Diabetes Association recommends HbA1c of 7.0% as a coverage threshold. She said older studies don’t show improvements in hypoglycemia but newer ones do for certain patients. She suggested recommending coverage for patients with frequent hypoglycemia but good HbA1c or with hypoglycemia unawareness.
With respect to her recommendation to lower the HbA1c threshold to 7.0%, Saha said that one of the main consumers for the coverage guidances are the state Medicaid program and that, with limited funds, the state Medicaid program sometimes cannot pay for benefits at the margin. Sometimes the HERC has to make compromises since every dollar we spend takes away dollars for other services.
She also expressed concern that the requirement to show good adherence may deny coverage from patients who may benefit. For instance, some patients travel from far away, and patient adherence during a short trial may not reflect longer‐term use. She agreed that there isn’t evidence to cover CGM for pregnant women. However she argued that the same logic should apply. During pregnancy, the target HbA1c is 6.0%, so there is additional risk for hypoglycemia.
Obley said that the evidence on adherence is variable. Some studies showed that 50% adherence produce the same effects as 70% adherence. He also said some studies required patients to take a test to show that they understood its use. Castle said there is significant training provided when a patient starts with a CGM.
In discussion about a trial period, members of the audience also suggested that it would add cost and that some providers may not have the ability to do such a trial. After discussion, the subcommittee changed the recommendation to require 50% use of the device, measured at the first follow‐up visit. Woods said that much of the cost of using these devices is related to replacement sensors and supplies. After the initial device purchase, there would not be additional costs if the patients didn’t use the device.
Castle also expressed concern about the requirement for severe hypoglycemia, as the ADA definition of severe includes a loss of consciousness. Typically a monitor may be appropriate for patients experiencing frequent, but less severe, hypoglycemia to prevent the occurrence of severe events which could lead to death.
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Saha observed that the evidence did not show a reduction in hypoglycemic events. An audience member testified that this is because of the short duration of the studies. Obley said that in addition, you could regard hypoglycemia as an outcome in itself, or as a balancing measure that would allow more aggressive treatment to lower HbA1c with less fear of hypoglycemic events. Hypoglycemic events were rare in the studies and there was not a statistically significant difference between groups, which is not to say that there would not have been with longer followup.
At Sorweide’s direction, the word “robust” was removed from the description of the diabetes education requirement and a clause added to specify comprehensive education specific to the device. Shaffer said that the word was used to indicate specific education on the CGM. Kono, a diabetes educator, said that the education is usually provided in conjunction with the prescription of the device and after screening to ensure the patient can use the device.
Castle suggested clarifying for a woman with type 1 diabetes who becomes pregnant, she should not lose access to the CGM. Members of the subcommittee agreed this was an oversight.
Discussion shifted to patients with type 2 diabetes. Shaffer said that there were fewer studies and smaller numbers of people in those studies. Coverage criteria from other payers are not consistent and well‐developed. Due to the limited evidence and absence of information about which patients may benefit, the draft recommendation is for noncoverage. Saha said the link to long‐term outcomes is weaker for patients with type 2 diabetes. Obley noted that many of the existing trials included heterogeneous groups of patients, including those on multiple daily insulin injections along with those on oral medications. Though one review separated those populations, there was no sensitivity analysis.
For children and adolescents with type 1 diabetes, Shaffer reviewed the recommendation against coverage. Woods said she was upset to see the recommendation against coverage. She said the devices are extremely popular from the patient perspective and to physicians. She said that there has been a big change in adherence over the past few years since the devices have improved so much. The benefit is greatest in young children where hypoglycemia unawareness is a huge concern. With children the goal is the lowest possible HbA1c without the parents being up all night managing or monitoring the patient’s hypoglycemia. Pierce, a pediatric endocrinologist, said that with children, less severe levels of hypoglycemia than those typically used as outcomes in the studies can be a concern as they affect development. Based on this testimony the subcommittee asked Obley to search for data linking hypoglycemia levels to neurocognitive outcomes. Pierce said that the larger studies focus on children over the age of 8, when younger children are actually likely to benefit the most. Obley said that a small review in 2017 stratifield between ages less than 12 and 12‐15. Woods also highlighted the parental quality of life. The success of children with type 1 diabetes depends on the ability of parents to care for their condition, and these devices facilitate care. She believes there is data to show that as parental quality of life improves, the children do better as well. Obley said he thinks it is unlikely there will be a randomized trial that could evaluate that. Woods said that it may be difficult to conduct such a study as the devices are so popular.
Bruce, the parent of a diabetic child, provided testimony that their daughter’s device provides quality of life and peace of mind. Without such a device it’s impossible to leave the child with a babysitter or family member. It gives them the peace of mind to sleep through the night without checking blood sugar. They also use it to monitor as she participates in sports and grows and develop. Woods added that with the Dexcom G5, you can monitor the child’s blood sugar at school. She said there was a trial
HTAS 2‐16‐2017 Minutes Page 6
March 2017 QHOC Packet - Page 66 demonstrating improved school attendance among child with this device. Obley agreed, with the caveat that this outcome was shown in children with 70% adherence.
Sorweide said there is very little data. Saha agreed that there is limited data, but these are children who we know will have long‐term complications. In the past HERC has treated children with long‐term conditions differently. The subcommittee asked staff to find the research that has been discussed and revise the recommendation and GRADE‐informed framework accordingly.
Susan Rice testified on behalf of the Juvenile Diabetes Research Foundation and referenced their clinical trials which are included in the study. She expressed satisfaction with the direction of the discussion during the meeting.
7. ADJOURNMENT
The meeting was adjourned at 4:00 pm. The next meeting is scheduled for April 20, 2017 from 1:00‐ 4:00 pm at Clackamas Community College, Wilsonville Training Center, Rooms 111‐112, 29353 SW Town Center Loop E, Wilsonville, Oregon 97070.
HTAS 2‐16‐2017 Minutes Page 7
March 2017 QHOC Packet - Page 67 SCOPE STATEMENT FOR HERC COVERAGE GUIDANCE
ACELLULAR DERMAL MATRIX FOR POST‐MASTECTOMY BREAST RECONSTRUCTION
Population Patients undergoing breast post‐mastectomy reconstruction description Population scoping notes: None
Intervention(s) Acellular dermal matrix for breast reconstruction
Intervention exclusions: None
Comparator(s) Breast reconstruction using implants only (direct‐to‐implant reconstruction and two‐stage reconstruction), breast reconstruction using patient’s own tissue (flap procedures), breast reconstruction using a combination of implants and flap procedures
Outcome(s) Critical: Complete wound healing, time to complete wound healing (up to five) Important: Quality of life, patient satisfaction, adverse events
Considered but not selected for GRADE Table:
Key questions What is the comparative effectiveness of acellular dermal matrix for breast reconstruction?
How does the comparative effectiveness of acellular dermal matrix for breast reconstruction vary by: a. Age b. Race or ethnicity c. BMI d. Smoking status e. Comorbid conditions f. Breast size g. Reason for mastectomy h. Extent and complexity of reconstruction i. Use of neoadjuvant or adjuvant chemoradiation j. Intraoperative expander fill volume k. Timing of surgery (e.g., in relation to mastectomy)
What are the harms of acellular dermal matrix for breast reconstruction?
3/1/17
March 2017 QHOC Packet - Page 68
CHANGE LOG
Date Change Rationale
1/31/2017 Changed “cosmesis” outcome to “patient Cosmesis is only one factor satisfaction” influencing satisfaction.
3/1/17
March 2017 QHOC Packet - Page 69 For internal use only:
Experts (appointed or informally consulted)
Data needs
How was topic discovered
Reports available from core sources
3/1/17
March 2017 QHOC Packet - Page 70 SCOPE STATEMENT FOR HERC COVERAGE GUIDANCE
CARDIOMEMS™ FOR HEART FAILURE MONITORING
Population Adults with chronic systolic heart failure description Population scoping notes: None
Intervention(s) CardioMEMSTM heart failure monitoring system
Intervention exclusions: None
Comparator(s) Usual care (e.g., daily weight measurements, symptom reporting, frequent encounters), heart rate variability monitors, intrathoracic impedance monitors
Outcome(s) Critical: All‐cause mortality, cardiovascular mortality, heart failure‐related (up to five) hospitalizations
Important: Quality of life, harms
Considered but not selected for GRADE Table:
Key questions What is the comparative effectiveness of CardioMEMS™ for the management of patients with chronic systolic heart failure?
How does the comparative effectiveness of CardioMEMS™ vary by: a. Age b. Gender c. Race or ethnicity d. Comorbid medical conditions e. Prior and current treatments f. Previous hospitalization for acute decompensated heart failure g. Heart failure etiology h. Treatment setting (inpatient/outpatient) i. Patient adherence to prior treatment and monitoring plans j. New York Heart Association class/American College of Cardiology stage
What are the harms of CardioMEMS™?
CHANGE LOG
Date Change Rationale
m/d/yyyy
3/1/17
March 2017 QHOC Packet - Page 71 SCOPE STATEMENT FOR HERC COVERAGE GUIDANCE
GENOME EXPRESSION PROFILING FOR BREAST CANCER
(Update to a portion of the existing coverage guidance on Biomarker Tests of Cancer Tissue for Prognosis and Potential Response to Treatment)
Population Women diagnosed with early‐stage breast cancer description Population scoping notes: None
Intervention(s) Genome expression profiling on cancer tissue
Intervention exclusions: None
Comparator(s) Usual care, immunohistochemical assays, genome expression profiling tests compared to each other
Outcome(s) Critical: Breast cancer morbidity, breast cancer mortality (up to five) Important: Quality of life, harms, change in management of breast cancer
Considered but not selected for GRADE Table: Analytic validity, clinical validity
Key questions What is the comparative effectiveness of genome expression profiling in early stage breast cancer?
How does the comparative effectiveness of genome expression profiling vary by: a. Age b. Race or ethnicity c. Patient and family history d. Cancer characteristics (e.g., tumor size, tumor grade, type of tumor, nodal status, hormone receptor status, HER2 status, proliferation rate, cancer stage) e. Menopausal status
What are the harms of genome expression profiling for breast cancer?
CHANGE LOG
Date Change Rationale
m/d/yyyy
3/1/17
March 2017 QHOC Packet - Page 72
SCOPE STATEMENT FOR HERC COVERAGE GUIDANCE
GENOME EXPRESSION PROFILING FOR PROSTATE CANCER
(Update to a portion of the existing coverage guidance on Biomarker Tests of Cancer Tissue for Prognosis and Potential Response to Treatment)
Population Men with prostate cancer description Population scoping notes: None
Intervention(s) Genome expression profiling on cancer tissue
Intervention exclusions: None
Comparator(s) Usual care, other methods of risk stratification (e.g., Gleason score, tumor stage, PSA values), genome expression profiling tests compared to each other
Outcome(s) Critical: Prostate cancer morbidity, prostate cancer mortality (up to five) Important: Quality of life, harms , change in management of prostate cancer
Considered but not selected for GRADE Table: Analytic validity, clinical validity
Key questions What is the comparative effectiveness of genome expression profiling for prostate cancer?
How does the comparative effectiveness of genome expression profiling for prostate cancer vary by: a. Age b. Race or ethnicity c. Patient and family history d. Prior treatments and response e. Life expectancy f. Clinical‐pathologic characteristics (e.g., PSA level, tumor size, type of tumor, Gleason score, proliferation rate, cancer stage)
What are the harms of genome expression profiling for prostate cancer?
CHANGE LOG
Date Change Rationale
m/d/yyyy
3/1/17
March 2017 QHOC Packet - Page 73 SCOPE STATEMENT FOR HERC COVERAGE GUIDANCE
HEPATIC ARTERY INFUSION PUMP CHEMOTHERAPY
Population Patients who meet criteria to receive chemotherapy for primary or metastatic description cancers of the liver
Population scoping notes: None
Intervention(s) Chemotherapy delivered by hepatic artery infusion pump
Intervention exclusions:
Comparator(s) Systemic chemotherapy, transarterial chemoembolization, Y‐90 microspheres, partial hepatectomy/resection
Outcome(s) Critical: Overall survival, progression‐free survival, cancer‐specific morbidity (up to five) Important: Quality of life, harms
Considered but not selected for GRADE Table:
Key questions What is the comparative effectiveness of hepatic artery infusion pump chemotherapy?
Does the comparative effectiveness of hepatic artery infusion pump chemotherapy vary by: a. Age b. Gender c. Race or ethnicity d. Cancer type/stage/grade e. Type of chemotherapy/dose/regimen f. Prior treatments and response g. Concurrent treatment modalities h. Other comorbidities i. Co‐morbid liver disease
What are the harms of hepatic artery infusion pump chemotherapy?
CHANGE LOG
Date Change Rationale
m/d/yyyy
3/1/17
March 2017 QHOC Packet - Page 74 AGENDA VALUE-BASED BENEFITS SUBCOMMITTEE March 9, 2017 9:00am - 1:00pm Clackamas Community College Wilsonville Training Center, Rooms 111-112 Wilsonville, Oregon A working lunch will be served at approximately 12:00 PM All times are approximate
I. Call to Order, Roll Call, Approval of Minutes – Kevin Olson 9:00 AM
II. Staff report – Ariel Smits, Cat Livingston, Darren Coffman 9:05 AM A. Errata B. Information desired for May review of opioid/back pain changes
III. Straightforward/Consent agenda – Ariel Smits, Cat Livingston 9:15 AM A. Consent table B. Minor newborn conditions C. Screening colonoscopy with polyp removal D. Straightforward Coding Changes--Injuries to Major Blood Vessels E. Preventive services guideline lead screening edits
IV. 2018 Biennial Review 9:25 AM A. Prioritization of novel treatments with marginal clinical benefit, low cost- effectiveness and/or high cost
Break 10:30 AM
V. New discussion items 10:45 AM A. Pharmacogenetics testing for medications for psychiatric disorders B. Pharmacist medication management guideline C. Breast reduction for macromastia as treatment for neck and back pain D. Elective surgery guideline and electronic cigarettes E. Non-specific pain diagnoses F. MRI for MS progression
VI. Public comment 12:55 PM
VII. Adjournment – Kevin Olson 1:00 PM
Health Evidence Review Commission (503) 373-1985 March 2017 QHOC Packet - Page 75 AGENDA HEALTH EVIDENCE REVIEW COMMISSION Wilsonville Training Center, Rooms 111-112 March 9, 2017 1:30-4:30 pm (All agenda items are subject to change and times listed are approximate)
Action # Time Item Presenter Item 1 1:30 PM Call to Order Som Saha 2 1:35 PM Approval of Minutes (11/10/16) Som Saha X 3 1:40 PM Director’s Report Darren Coffman
Value-based Benefits Subcommittee Report Darren Coffman • Prioritization of novel treatments with marginal clinical 4 1:45 PM Ariel Smits X benefit, low cost-effectiveness and/or high cost • Approval of 2018-19 Biennial Prioritized List Cat Livingston Digital Breast Tomosynthesis (3D Mammography) for Breast Cancer Screening in Average Risk Women Adam Obley 5 2:45 PM X • Coverage Guidance Wally Shaffer • Prioritized List changes Coverage Guidance Monitoring (Rescan) Process • EbGS topics o Prenatal genetic testing o Chronic otitis media with effusion in children o Non-pharmacologic interventions for treatment- resistant depression o Imaging for low back pain o Low back pain: non-pharmacologic noninvasive interventions o Low back pain: minimally invasive & non-corticosteroid percutaneous interventions o Low back pain: pharmacologic & herbal therapies o Planned cesarean birth Cat Livingston o Routine ultrasound in pregnancy 6 3:30 PM Wally Shaffer X o Neuroimaging for mild cognitive impairment/dementia HTAS topics Adam Obley o Hyperbaric oxygen therapy for chronic wounds & burns o Artificial disk replacement o Hip resurfacing o MRI for breast cancer screening o Lumbar discography o Viscosupplementation for osteoarthritis of knee o Osteoporosis screening by DXA o Osteoporosis monitoring by DXA o Hip procedures for FAI syndrome o Treatment of obstructive sleep apnea in adults o knee arthroscopy in patients w/osteoarthritis o upper endoscopy for GERD
March 2017 QHOC Packet - Page 76 AGENDA Review of Proposed New Coverage Guidance & Multisector Intervention Topics Coverage Guidance Topics o Opportunistic salpingectomy for ovarian cancer prevention o Colon cancer screening modalities o Urine drug testing Cat Livingston 7 3:50 PM o Acellular dermal matrix for breast reconstruction Wally Shaffer X o Hepatic artery infusion pump chemotherapy Adam Obley o CardioMEMS for heart failure monitoring o Gene expression profiling for breast cancer o Gene expression profiling for prostate cancer o Artificial disc replacement Multisector Intervention Topics o Prevention of unintended pregnancy Cat Livingston 8 4:10 PM Prioritization of Coverage Guidance Topics X Wally Shaffer Next Steps 9 4:20 PM Schedule next meeting – May 18, 2017 Wilsonville Training Som Saha Center, Rooms 111-112 10 4:30 PM Adjournment Som Saha
Note: Public comment will be taken on each topic per HERC policy at the time at which that topic is discussed. Public comment on a topic not appearing on the agenda will be taken at the end of the meeting.
March 2017 QHOC Packet - Page 77 ANCILLARY GUIDELINE A4, SMOKING CESSATION AND ELECTIVE SURGICAL PROCEDURES Smoking cessation is required prior to elective surgical procedures for active tobacco users. Cessation is required for at least 4 weeks prior to the procedure and requires objective evidence of abstinence from smoking prior to the procedure.
Elective surgical procedures in this guideline are defined as surgical procedures which are flexible in their scheduling because they do not pose an imminent threat nor require immediate attention within 1 month. Reproductive, cancer‐related and diagnostic procedures are excluded from this guideline.
The well‐studied tests for confirmation of smoking cessation include cotinine levels and exhaled carbon monoxide testing. However, cotinine levels may be positive in nicotine replacement therapy (NRT) users (which is not a contraindication to elective surgery coverage). In patients using NRT the following alternatives to urine cotinine to demonstrate smoking cessation may be considered: Exhaled carbon monoxide testing (well studied) Anabasine or anatabine testing
Certain procedures, such as lung volume reduction surgery, bariatric surgery, erectile dysfunction surgery, and spinal fusion have 6 month tobacco abstinence requirements. See Guideline Notes 8, 100, 112 and 159.
March 2017 QHOC Packet - Page 78 HEALTH SYSTEMS DIVISION
Kate Brown, Governor 500 Summer St NE E44 Salem, OR, 97301 Date: March 8, 2017 Voice: 1-800-336-6016 FAX: 503-945-6873 To: Oregon Health Plan (OHP) fee-for-service providers TTY: 711 www.oregon.gov/OHA/healthplan
From: James Rickards, M.D., M.B.A., chief medical officer Office of Clinical Services Improvement, Health Policy and Analytics Division
Kim Wentz, M.D., M.P.H., Medicaid medical director Trevor Douglass, D.C., M.P.H., Provider Clinical Support manager Health Systems Division
Subject: OHP fee-for-service coverage of back and spine pain diagnosis and treatment
This letter is to inform you of OHP coverage guidelines for back and spine pain diagnosis and treatment, including new restrictions on opioid medications for chronic pain. The Oregon Health Evidence Review Commission (HERC) adopted new Guideline Notes and reorganized the Prioritized List lines addressing back and spine conditions to allow coverage of evidence-based, safe and effective therapies for back and spine pain. The current Prioritized List and Guideline Notes prioritize therapies such as chiropractic and osteopathic manipulation, physical therapy, acupuncture, cognitive behavioral therapy, graded exercise therapy, interdisciplinary pain management, yoga, and massage––and a treatment plan to stay active and return to previous function––over ineffective surgeries and narcotics.
These changes are based on new evidence, including a bio-psycho-social model of chronic pain that’s designed to help patients manage their pain with less reliance on medications with high potential harm, and more reliance on developing self-efficacy and resuming normal activities.
What prompted these changes? There continues to be an epidemic in Oregon of prescription opiate misuse, dependency and overdose leading to hospitalizations and deaths. Visits for back pain are very common for OHP members, over 60 percent of Medicaid patients seeking care for back pain in 2013 received prescription opioids, and evidence of the efficacy of chronic opioid therapy for back pain is lacking.
HERC conducted reviews finding evidence that various non-narcotic and non-surgical therapies are safer and more effective for back conditions. However, because the back conditions “line” previously was below the funding line, these therapies were historically not covered by Oregon Medicaid. Patients with back pain without neuropathy were limited to primary care visits and medications, including narcotics.
What should providers do going forward? Please refer to the current Prioritized List and Guideline Notes when developing treatment plans for OHP members with conditions of the back and spine.
March 2017 QHOC Packet - Page 79 17-150 Guideline Note 56 follows a step-wise approach based on the bio-psycho-social model of health. ─ Patients should first be assessed for red flag symptoms and signs requiring immediate diagnostic testing. ─ Patients without evidence of potentially serious conditions should be assessed using a validated assessment tool such as STarT Back, in order to determine their risk for poor functional prognosis based on psychosocial indicators. ─ Patients who are determined to be at low risk are eligible for a package of previously unfunded therapies such as manipulation, acupuncture, PT/OT, and if available, massage. ─ Patients who are determined to be at medium- or high-risk on the validated assessment tool are eligible for a more extensive package of previously unfunded therapies. These include the same therapies as for low-risk patients as well as cognitive behavioral therapy, yoga, supervised exercise therapy, and intensive interdisciplinary rehabilitation. Guideline Note 60 restricts use of opioids and requires a treatment plan for tapering patients off of opioids by January 1, 2018. To learn more about tapering patients off opioids, please read our resource guide. Guideline Note 37 removes or restricts coverage of treatments shown to be ineffective. These include mechanical traction, transcutaneous electrical nerve stimulation, certain surgeries for spinal stenosis; certain epidural, facet joint, and other steroid injections, botulinum toxin injection, and more.
Please ensure that care is coordinated with other providers using a common treatment plan. At certain levels of utilization (i.e., number of visits for therapies), treatment will require prior authorization. Reviewers will look for this common treatment plan, and evidence of functional improvement, in order to authorize further treatment.
Where can I find details about the new coverage? View the new or revised lines and Guideline Notes here: http://www.oregon.gov/oha/herc/Pages/Searchable-List.aspx
View information about reducing opioid overdose and misuse here: https://public.health.oregon.gov/PreventionWellness/SubstanceUse/opioids/Pages/index.aspx
Questions? If you have any questions about this announcement, contact the OHP Prioritized List and Code Pairing Hotline at 800-393-9855.
Thank you for your continued support of the Oregon Health Plan and the services you provide to our members.
March 2017 QHOC Packet - Page 80 HEALTH SYSTEMS DIVISION Provider Services
Resources for tapering Oregon Health Plan (OHP) members with chronic pain off prescription opioids
For patients with chronic pain from diagnoses of the back and spine, Guideline Note 60 of the current Prioritized List of Health Services requires OHP providers to develop treatment plans to taper patients off prescription opioids with a quit date no later than January 1, 2018. Treatment plans must include non-pharmacologic treatment strategies for managing the patient’s pain. If a patient has developed dependence and/or addiction related to their opioid use, treatment is available on Line 4 of the Prioritized List (Substance Use Disorder). This includes Medication-Assisted Treatment (MAT).
The Oregon Health Authority has developed this resource guide to help OHP providers and their patients make this change.
Prescribing opioids for chronic pain, including tapering and discontinuation Centers for Disease Control and Prevention (CDC) guideline Oregon Prescription Drug Monitoring Program health care provider resources: Guidelines, clinical tools and resources for patients Oregon Pain Guidance Group: The Opioid Prescribers Guidelines and Tools for Professionals Providers' Clinical Support System for Opioid Therapies (PCSS-O): This website offers education and training on the safe and effective use of opioids for treatment of chronic pain, as well as the safe and effective treatment of opioid use disorder.
Tapering guidelines and tools These tools are available on the Oregon Pain Guidance Group website at http://www.oregonpainguidance.org/: Practical Tools to Successfully Taper Table of Tapering Approaches Tapering guidelines start on page 41 in The Opioid Prescribers Guidelines Tapering flow sheets for opioids and benzodiazepines Opioid Withdrawal Attenuation Cocktail
Other tapering tools: CDC Pocket Guide: Tapering Opioids for Chronic Pain Washington State Opioid Taper Plan Calculator Tapering Long-Term Opioid Therapy in Chronic Non-cancer Pain
Medication-Assisted Treatment (MAT) Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders. MAT resources from the Substance Abuse and Mental Health Services Administration (SAMHSA) for clinical practices, consumers and families March 2017 QHOC Packet - Page 81 Resources for tapering off prescription opioids Last updated 03/06/2017 SAMHSA Division of Pharmacologic Therapies (DPT): Learn how DPT works to oversee medication-assisted treatment (MAT) for substance use disorders. Behavioral health treatment services locator for substance use disorder American Association for the Treatment of Opioid Dependence Providers' Clinical Support System for MAT (PCSS-MAT): This website offers education, training and guidance related to using MAT to treat opioid use disorder. MATx mobile app: This free app supports practitioners currently providing MAT, as well as those who plan to in the future. Oregon-specific MAT resources Addiction Technology Transfer Center Network
Provider-patient communication tools Turn the Tide: The Surgeon General’s call to end the opioid crisis. This website offers tools, treatment options and patient resources to support tapering, including: Having a difficult conversation and Words that work: How to start the tapering discussion with your patients The Pain Treatment Toolbox
Oregon Pain Guidance Group tools: Difficult conversations— Real-life examples and helpful hints Medical risks of long-term opioid use Patient Treatment Agreements
Oregon Prescription Controlled Substances Toolkit
Resources for patients undergoing tapering Oregon Pain Guidance community resources: Portland Metro and Southern Oregon STOMP (Structuring Your Own Management of Pain) brochure developed by Swedish Hospital in Seattle Living Well with Chronic Conditions: This six-week workshop provides tools for living with chronic pain.
March 2017 QHOC Packet - Page 82
Resources for tapering off prescription opioids Last updated 03/06/2017 HEALTH SYSTEMS DIVISION
Kate Brown, Governor 500 Summer St NE E44 Salem, OR, 97301 Date: March 8, 2017 Voice: 1-800-336-6016 FAX: 503-945-6873 To: Oregon Health Plan hospitals TTY: 711 www.oregon.gov/OHA/healthplan From: Don Ross, Physical and Oral Health Programs manager Integrated Health Programs, Health Systems Division
Subject: Fee-for-service billing for long-acting reversible contraception (LARC) devices inserted at delivery
Effective January 1, 2017, the Oregon Health Authority (OHA) will pay DRG hospitals the Outpatient Prospective Payment System (OPPS) rate for LARC devices and insertion provided immediately postpartum to Oregon Health Plan fee-for-service (FFS) members.
This does not change OHA’s postpartum LARC reimbursement for Type A/B and Critical Access Hospitals.
Why is this happening? Long-acting reversible contraception (LARC) devices such as IUDs and contraceptive implants are shown to be safe and highly beneficial when inserted immediately postpartum. Guideline Note 162 of the current Prioritized List of Health Services approves OHP coverage of postpartum LARC insertion effective January 1, 2017.
Until now, fee-for-service payment to DRG hospitals for postpartum LARC insertion was bundled into the MS- DRG delivery payment, which did not address the cost of this added service. DRG hospitals can now bill separately to receive full reimbursement for the cost of postpartum LARC insertion.
OHA already pays Type A/B and Critical Access Hospitals based on the cost of the services they provide.
What should you do? To bill OHA for LARC devices inserted immediately postpartum, please follow the instructions in our new billing guide. DRG hospitals will bill for the LARC insertion and device on a separate outpatient claim. Type A/B and Critical Access Hospitals will continue to bill for the delivery, LARC insertion and device on the same inpatient claim.
For coordinated care organization (CCO) members, the hospital is paid based upon their provider agreement with the CCO. To learn about billing and reimbursement for LARC services to CCO members, please contact the member’s CCO.
To learn more about LARC coverage recommendations, please read the Health Evidence Review Commission’s Coverage Guidance for Timing of Long-Acting Reversible Contraceptive Placement.
March 2017 QHOC Packet - Page 83 17-149 Questions? If you have any questions about this announcement, contact the Provider Services Unit at [email protected] or call 1-800-336-6016. We are available Monday through Friday between 8 a.m. and 5 p.m. (including lunch hours).
Thank you for your continued support of the Oregon Health Plan and the services you provide to our members!
March 2017 QHOC Packet - Page 84 HEALTH SYSTEMS DIVISION Provider Services
Fee-for-service (FFS) billing for postpartum long-acting reversible contraception (LARC) services
Long-acting reversible contraception (LARC) devices such as IUDs and contraceptive implants are shown to be safe and highly beneficial when inserted immediately postpartum. Guideline Note 162 of the current Prioritized List of Health Services approves Oregon Health Plan (OHP) coverage of postpartum LARC insertion effective January 1, 2017.
This fact sheet explains how to bill the Oregon Health Authority (OHA) for postpartum LARC services provided to fee-for-service (open-card) members.
For coordinated care organization (CCO) members, the hospital is paid based upon their provider agreement with the CCO. To learn about billing and reimbursement for LARC services to CCO members, please contact the member’s CCO.
Type A/B Critical Access Hospitals (CAH) Type A/B CAHs will continue to bill the delivery, insertion and device on the same inpatient claim.
Bill for the insertion as follows: Diagnosis code: Z30430 Procedure code: 0UH97HZ, 0UH98HZ, 0UHC7HZ, 0UHC8HZ
To bill for the device, list the revenue code for the device.
DRG hospitals DRG hospitals can unbundle the LARC device and insertion from the inpatient delivery claim and bill for the device and insertion as an outpatient service. OHA will pay for the service at the OPPS rate.
Bill for the insertion as follows: Diagnosis code: Z30430 Procedure code: 58300 (Insertion of IUD) or 11981 (Insertion of Implant)
To bill for the device, use the contraceptive HCPC codes and report the corresponding NDC. To learn more about NDC reporting, read our NDC billing tips. J7297 (Liletta) J7300 (Paragard) J7306 (Levonorgestrel) J7298 (Mirena) J7301 (Skyla) J7307 (Implanon/Nexplanon)
OHA’s FFS claim system suspends inpatient and outpatient claims that share the same dates of service, provider(s) and patient information. OHA has developed criteria to ensure that LARC claims do not suspend for these reasons.
March 2017 QHOC Packet - Page 85 Billing OHP for LARC services Last updated 03/03/2017 Statewide CCO Learning Collaborative: OHIT Programs: Emergency Department Information Exchange (EDIE)/PreManage
Quality and Health Outcomes Committee Meeting Human Services Building, 500 Summer St NE, Salem, OR, Rm 137A‐D March 13, 2017 11 a.m.–12:30 p.m.
Toll‐free conference line: 888‐278‐0296 Participant code: 310477
Session Objectives Participants will: Understand health information exchange resources available from OHA Office of Health Information Technology Understand EDIE/PreManage resources available Understand how EDIE/PreManage is being used to enhance care coordination
1. Introductions ‐ Lisa Bui
2. Health information exchange resources available from OHA/OHIT) Overview of health information technology goals, priorities, role of OHIT and HIE environment ‐ Susan Otter HIE Onboarding Program ‐ Kristin Bork
3. Panel: Best practices for using HIE to connect patients to care – Lisa Bui Overview of EDIE and PreManage and their value ‐ Susan Kirchoff State Medicaid PreManage subscription ‐ Britteny Matero Behavioral health perspective ‐ Options Counseling and Family Services, Salem ‐Lisa Parks o Value, use and experience implementing PreManage in behavioral health CCO implementation: Care Oregon ‐ Liz Whitworth o CCO role in implementing and championing EDIE/PreManage; benefits to CCO Primary Care perspective Providence Medical Group—Daniela Onofrei o Value, use and experience implementing PreManage in primary care settings Panel Q&A
4. Closing remarks – Susan Otter
March 2017 QHOC Packet - Page 86 CCO Learning Collaborative: March 13, 2017 OHIT: EDIE/PreManage
Panelist Bios
Susan Kirchoff, RN [email protected] Susan is a consultant with the Oregon Health Leadership Council and is leading the EDIE/PreManage statewide initiative. Susan has previously served in leadership roles in a CCO, primary care and emergency services. She is passionate about providing high quality, coordinated care for high risk, vulnerable individuals.
Lisa Parks, QMHP [email protected] Lisa Parks is the quality improvement assistant for Options Counseling and Family Services. Her organization was an early adopter of PreManage and she is responsible for implementation, policy writing and oversight of PreManage.
Liz Whitworth, MPH [email protected] Liz Whitworth currently serves as PreManage project manager for CareOregon. In that role, she supports the care coordination teams using PreManage and assists the network team in engaging clinic partners with PreManage adoption. Previously, she worked with the Oregon Healthcare Quality Corporation (QCorp) and the Oregon Perinatal Collaborative to launch the Oregon Maternal Data Center.
Daniela Onofrei, BSN, RN‐BC [email protected] Daniela has been a RN for 13 years. She began her case management career in the hospital in cardiac rehab. She transitioned to primary care case management in 2014 at Providence Medical Group.
March 2017 QHOC Packet - Page 87 Health Information Exchange in Oregon
Susan Otter, Director of Health IT
QHOC March 13, 2017
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How does Health IT support CCOs and the coordinated care model? • Selected characteristics of the coordinated care model – Care coordination and population management throughout the system – Integration of physical, behavioral, oral health – Accountability, quality improvement, and metrics – Alternative payment methodologies – Patient engagement • Coordinated care model relies on access to patient information and the health IT infrastructure to share and analyze data
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March 2017 QHOC Packet - Page 88 Opportunity in Oregon: Medicaid priorities
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Goals of HIT‐Optimized Health Care
1. Sharing Patient 2. Using Aggregated 3. Patient Access to Information Across Data for System Their Own Health the Care Team Improvement Information • Providers have • Systems (health • Individuals and their access to systems, CCOs, families access their meaningful, timely, health plans) clinical information relevant and effectively and and use it as a tool to actionable patient efficiently collect and improve their health information to use aggregated and engage with their coordinate and clinical data for providers. deliver “whole quality improvement, person” care. population management and incentivizing health and prevention.
March 2017 QHOC Packet - Page 89 HIE Coverage in Oregon • Reliance eHealth Collaborative (formerly Jefferson HIE) • IHN‐CCO’s Regional Health Information Collaborative (RHIC) • PreManage and the Emergency Department Information Exchange (EDIE) • Advantage Dental Information Network (ADIN) • Mercy HIE (developing) • Direct secure messaging –in EHRs, HIEs and CareAccord • Vendor driven networks and federal agency networks • Private efforts, hosted EHRs, etc.
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Adoption of hospital notifications by CCOs, hospitals, and ACT teams
March 2017 QHOC Packet - Page 90 Regional HIEs by county
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CCOs and Non‐Private HIE CCO Reliance RHIC PreManage Other AllCare X In progress Cascade Health Alliance X In progress Columbia Pacific X Eastern Oregon X FamilyCare, Inc. X Health Share of Oregon X Intercommunity Health Network X Jackson Care Connect X X Pacific Source, Central Oregon X X Pacific Source, Columbia Gorge X X PrimaryHealth of Josephine Co. X Trillium X Umpqua Health Alliance In progress Mercy Western Oregon Advanced Health In progress Willamette Valley Community Health X Yamhill Community Care X
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March 2017 QHOC Packet - Page 91 HIE Onboarding Program Background
Kristin Bork, Lead Policy Analyst
CMS State Medicaid Director Letter 16‐003
• HITECH 90% federal funding now available to support the onboarding of a broader range of Medicaid providers to an HIE entity or interoperable system • Onboarding includes: – Legal activities, including establishment of user agreements – Technical development activities – Configuration – Testing – Workflow integration – Training – Post onboarding support (less than one year)
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March 2017 QHOC Packet - Page 92 CMS State Medicaid Director Letter 16‐003 (cont.)
• Providers now included are: 1. Medicaid providers who are eligible for Medicaid EHR Incentive Program (Physicians, Dentists, NPs, and PAs in certain settings) 2. And those providers they need to communicate with to meet Meaningful Use, such as: • Behavioral health, including substance use treatment • Long‐term services & supports • Home health • Correctional health • Laboratory • Pharmacy • Emergency medical services • Public health providers
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Goals of Oregon’s HIE Onboarding Program
Support Medicaid providers connecting to HIEs, through 2021, with the help of 90% HITECH federal funds and 10% general funds, by: 1) Accelerating HIE and filling gaps for critical Medicaid providers’ ability to coordinate care through connecting to HIE entities 2) Incentivizing cross‐organizational HIE by supporting Oregon’s HIE entities that make up its network of networks by funding onboarding for critical Medicaid providers 3) Establishing and formalizing the Oregon HIE network of networks by ensuring HIE entities in Oregon are able to support HITOC’s HIE objectives and OHA’s Medicaid objectives by setting criteria that entities would need to meet to be eligible for funding
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March 2017 QHOC Packet - Page 93 Fundamental Principles of the HIE Onboarding Program
• Support meaningful (trusted, relevant, actionable, and timely) health information exchange that patients and providers value and participate in actively • Support state and Medicaid objectives • Align with HITOC’s HIE strategic plan and vision • Assess periodically to confirm priorities and adjust to changes in the environment
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Draft Programmatic Parameters • Program will be implemented through 2021 • Federal and state funding will be available for each year as OHA has the required 10% match in budget; will vary from year to year • Scale of total program depends on funding • OHA will select HIEs via RFA/RFP, which will include criteria that HIE entities must meet in order to qualify • Contracts will include oversight by OHA and reporting requirements • Program may have multiple phases with different priorities (may run concurrently) • Program will use milestone‐based payments, and may reimburse actual costs (with a cap), a set amount, and/or incentive‐like payments • Will periodically evaluate and adjust program as we learn
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March 2017 QHOC Packet - Page 94 Draft Phase I Provider Priorities
Provider Type Specific Providers Covered Behavioral health Community Mental Health Programs, Certified Community Behavioral Health Centers, behavioral health homes, ACT teams, mobile crisis teams Oral health Clinics contracted with Medicaid DCOs serving CCO members and Fee for Service population Critical physical health Medicaid providers who participate in: PCPCH, FQHCs (incl. FQHC APM), RHCs, CPC+, tribal health, equity‐focused clinics, corrections health Major trading partners in Major trading partners, including those at interstate behavioral, oral, and borders, and especially those that affect the value of HIE critical physical health for smaller and rural/frontier providers
*Roadmap for later phases includes LTSS, social services, and other critical Medicaid providers
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HIE Onboarding Program Tentative Schedule
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March 2017 QHOC Packet - Page 95 PreManage Progress Report Quality and Health Outcomes Committee March 13, 2017
PreManage Adoption-Health Plans
• Kaiser Permanente NW • Humana • PacificSource • Regence-Cambia • Providence Health Plan • Moda Health • Tuality Health Alliance • Atrio
March 2017 QHOC Packet - Page 96 PreManage Adoption - Providers
Clinics (sample) Behavioral Health & Specialty • Providence Medical Group • GOBHI • Legacy Medical Group (by May • Options Counseling (Salem 2017) area) • Silverton Health (soon to be • Cascadia Behavioral Health Legacy) • Lifeworks NW • NW Primary Care • Morrison Child & Family Services • Tuality Clinics • Western Psychological • Portland Clinic Community Paramedicine: • St. Charles Family Care • Mercy Flights • Santiam Medical Group • Tri-County 911 • Pacific Medical Group Specialty: FQHCs: • Compass Oncology • Mosaic Medical • Hematology Oncology of Salem • Virginia Garcia (Spring) • Central City Concern Long-Term Care: • Outside In • OHA AAA/APD Pilot (6 sites) now • One Community Health live
Statewide Collaboration
. EDIE Governance Board . EDIE Operations Committee: • Care Recommendations Work Group • Data/Analytics Work Group • Product Development
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March 2017 QHOC Packet - Page 97 Community Collaboration
Regional Adoption of PreManage • Create shared goals and areas of focus across CCO’s, Health Plans, Hospitals, Primary Care and other provider organizations in a specific community • Clarify roles and responsibilities to reduce duplication and increase cross organizational care coordination • Develop agreements on standard workflows across the community Communities of Practice • Opportunities for specific user groups (e.g. Behavioral Health, Dental) to share best practices, develop workflows and align efforts
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EDIE/PreManage-Success to Date
• EDIE widely viewed by ED providers as a very useful tool • Commercial health plans and CCO’s are finding the notifications very helpful to their internal care management processes as well as coordination with their provider network • Behavioral health adoption has spread rapidly and the information is being utilized to manage ED and IP transitions in care • Community adoption is accelerating cross organizational care coordination for high risk high utilizing individuals
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March 2017 QHOC Packet - Page 98 2017 Priorities Decrease ED visits for high utilizing patients . Increase use of care recommendations . Expand cross organizational care coordination Enhance dissemination of information and resources to support improvement efforts . Analyze and distribute aggregated data reports . Increase sharing of EDIE/PreManage best practices and workflows Leverage use of EDIE/PreManage Technology to support healthcare transformation . Integrate PDMP/EDIE notifications . Expand cross organizational care coordination for mental health transitions in care 23 |
EDIE/PreManage- Issues/Challenges
• Competing organizational priorities challenge focus on coordinated efforts to reduce ED utilization • PreManage adoption and meaningful use in primary care has taken longer than anticipated • Working together across systems to identify roles, responsibilities and workflows are time consuming
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March 2017 QHOC Packet - Page 99 Next Steps • Identify and support strategies to accelerate adoption in primary care practices • Promote and support the community adoption model to facilitate optimal use of EDIE/PreManage tools for cross organizational care coordination • Encourage inclusion of all relevant payers and parts of the care continuum in the conversation as they adopt PreManage (e.g. Behavioral Health, Long Term Care) to identify roles, responsibilities, workflows and communication • Broadly communicate best practices and workflows and provide tools for new organizations adopting PreManage to accelerate adoption
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Statewide Medicaid PreManage Subscription
Britteny Matero, HIE Program Manager
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March 2017 QHOC Packet - Page 100 State coordinated efforts • OHA is leveraging enhanced federal match (75/25) to fund a (voluntary) PreManage subscription for the Medicaid program • Current subscription runs through July 31, 2018 • Subscription covers: – Base package for key care coordinators for Medicaid members • CCOs, including behavioral health and dental partners – CCOs can add “PreManage Complete” at their own cost to extend a PreManage subscription to key practices • Fee‐for‐service contractor (KEPRO) • Assertive Community Treatment (ACT) teams • Other OHA/DHS Care Managers, current pilot for long‐term care (e.g., APD, AAA offices) – Medicaid EDIE data for OHA analytics purposes – HTPP metrics work related to EDIE
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PreManage Progress
Organization Onboarded In Process Not Started CCOs • Columbia Pacific • AllCare • IHN CCO • Eastern Oregon CCO • Cascade Health • Primary Health of • FamilyCare Alliance Josephine County • HealthShare • Umpqua Health • Jackson Care Connect Alliance • PacificSource—Central • Western Oregon Oregon Advanced Health • PacificSource—Gorge CCO • Trillium • Willamette Valley Community Health • Yamhill DCOs • Advantage Dental • Access Dental • Family Dental Care • CareOregon Dental Plan • Kaiser • Capitol Dental • Willamette • Managed Care Dental • ODS
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March 2017 QHOC Packet - Page 101 PreManage Progress
Organization Onboarded In Process ACT Teams • Benton County Mental Health • New Directions • Cascadia Fact • Telecare Oregon • Central City Concern • Clackamas Lake Road Clinic • Coos County Mental Health • Laurel Hill • Marion County • Outside In • Polk County Mental Health • Sequoia Mental Health Services • Symmetry Care • Wallowa Valley Center for Wellness • Yamhill County Health and Human Services
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PreManage Progress
Organization Onboarded
AAA/APD • APD ‐ District 10, Crook, Deschutes and Jefferson Counties • NorthWest Senior & Disability Services 100% live with • Multnomah County Aging, Disability and Veterans Services • CMT pilot APD ‐ District 6, Douglas County • APD ‐ District 10, Deschutes, Crook, Jefferson • APD – District 15, Clackamas County • APD ‐ District 16, Washington and Columbia Counties
Behavioral Health • GOHBI Organizations
Other • KEPRO (supporting Medicaid fee‐for‐service population) • Reliance eHealth Collaborative (formerly Jefferson HIE)
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March 2017 QHOC Packet - Page 102 Future Activities
• EDIE connection to Prescription Drug Monitoring Program (PDMP)
– Note: PreManage will not include PDMP data/connection at this time • AAA/APD Pilot completion
– Long‐term care service and support roll‐out • Behavioral Health program expansion
– Assertive Community Treatment teams (new)
– Community Mental Health Programs & Mobile Crisis Units
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Lisa Parks QMHP Quality Improvement Assistant Options Counseling, Salem
March 2017 QHOC Packet - Page 103 CCO role in Implementing and Championing EDIE/PreManage Quality and Health Outcomes Committee Meeting Human Services Building, 500 Summer St NE, Salem, OR, Rm 137A-D March 13, 2017 11 a.m.–12:30 p.m.
March 2017 QHOC Packet - Page 104 CareOregon PreManage Implementation
• CareOregon as Health Plan: – Meet CMS regulatory requirements – Standardize and improve care coordination and planning—physical, behavioral, dental – Optimize member and provider engagement • CareOregon as CCO: – YCCO (administration only) – HealthShare – Jackson Care Connect – Columbia Pacific CCO
Health Plan Teams Using PreManage
• Transitional Care & Outreach • Health Resilience Program (HRP) • Exceptional Needs Care Coordination (ENCC) • Community Health • Pharmacy • Dental • Health Services Operations •Health Outcomes
March 2017 QHOC Packet - Page 105 Health Plan Team PreManage Goals
• Timely care coordination & follow up • Timely intervention with ED providers to divert inappropriate admissions • Case finding for program outreach & intervention • Team coordination across shared members • Streamlining operations/finance reporting & processes • Improved analytics reporting
CareOregon as CCO: Areas of Focus
• Sponsoring clinic onboarding: – Currently outreaching to ~40 clinic systems representing ~60 clinic sites for PreManage onboarding and support – ~25% of clinic ‘Live’ with PreManage – Identifying interested clinics for ‘deeper’ PreManage collaborative work – OHLC assisting w/ community collaborative work in CCO regions
March 2017 QHOC Packet - Page 106 CareOregon as CCO: Areas of Focus
• Supporting care coordination work: – Avoidable ED visits (YCCO) – High utilizer and ‘Amenable’ ED visits (ColPac CCO) – Community mental health care coordination (ColPac and GOBHI) – EMS provider care coordination (JCC) – Transitions of care for IP discharges (All) – Non-urgent dental-related activity and DCO coordination (All)
Other Uses in Development
• Using PreManage census data for trend/analytic reports • Coordinating w/ clinic partners to expand use of Care Recommendations • Exploring sharing of key PreManage groups across CCO and clinic portals: – CCO Metrics and Medicare Stars Gaps in Care – Care Coordination program information
March 2017 QHOC Packet - Page 107 Questions
• Amit Shah, [email protected]
• Liz Whitworth, [email protected]
PREMANAGE FOR CASE MANAGERS
Daniela Onofrei, BSN, RN‐BC PMG Care Management Supervisor
March 2017 QHOC Packet - Page 108 PMG Cohorts
PMG Cohorts (cont’d)
March 2017 QHOC Packet - Page 109 Referrals and Groups
Patients by ED Visit Frequency
March 2017 QHOC Packet - Page 110 Patients by ED Visit Frequency PDF
Cohorts –IP Encounters
March 2017 QHOC Packet - Page 111 Census Page
Cohort: IP Readmission in 30 Days
March 2017 QHOC Packet - Page 112 Patient Example: Care History
Patient Example: Care Guidelines
March 2017 QHOC Packet - Page 113 March 2017 QHOC Packet - Page 114 QUALITY CARE COORDINATOR PREMANAGE
IMPROVEMENT SERVICES OF OREGON, LLC - OPTIONS COUNSELING SUPPORT PLAN CARE PREMANAGE admission anddischarge information for anyindividuals admitted for psychiatric reasons. In eachOptions office anidentified user will begranted accessthePreManage alert system. This tailored alert will allow thatidentified user toreview relevant psychiatric hospital units, thusgiving Options theinformation neededtoprovide quick targeted individual follow-up behavioral health care. The PreManage Electronic client record system provides real-time care andnotification for individuals entering theemergency department andinpatient discharge information Patient presents Review relevant admission and to ED Notification sentto identified care coordinator(s) No further inquiry or health-related visit? documentation is Is this amental warranted. No Yes appointments have Search theECR to been scheduled follow-up care determine if Follow upwith client byphoneor face toface.Direct client toNPA or Care Coordinator toschedule Appointments already Medication only appointment scheduled? client? Yes Yes Shared with permission by : Lisa Parks, Options Counseling of Oregon, LLC Oregon, of Counseling Options Parks, Lisa : by permission with Shared No PreManage for real-time Contact client to Enter follow-up appointment in follow-up care transparency appointment. schedule a March 2017 QHOCPacket -Page115 No Monitor and evaluate outcomes Enter all info in memo chart in ECR. Last reviewed 11.16.2016 reviewed Last supervisor will visit history to Primary staff, be notified re psychiatrist individuals and ED March 13th QHOC Presentation
Pre‐survey:
Today we are going to be talking metrics, how they are an integral component of your performance improvement projects (PIP), and how you can incorporate them into your reporting.
This anonymous survey will help us understand your baseline understanding and use of metrics.
1. The PIP reporting template has a section focused on clarifying the outcome measures and data collection plan. How often do you complete each component of that section (Baseline, baseline data, improvement target, improvement date, benchmark, national standard, frequency of data collection)?
______Never ______Sometimes ______Usually ______Always
2. The PIP reporting template asks you to identify process and balance measures for your efforts. How would you rate your knowledge about what a process and balance measure is?
_____ Not very knowledgeable ______Somewhat knowledgeable ______Knowledgeable ______Very Knowledgeable
3. The last page of the PIP reporting template notes that you can attach documents that describe your improvement plan and the related metrics. Please indicate whether you have created and provided the following in previous reports: Run Charts ___ No ____Yes Driver Diagram ___ No ____Yes Measurement Plan ___ No ____Yes
March 2017 QHOC Packet - Page 116 QHOC ‐ EVALUATION SURVEY OF OPIP PRESENTATION
Thank you for attending the OPIP Presentation at the QHOC title Metrics 101 – Way to Integrate Measures Into Your Performance Improvement Project. Please share your feedback, which we will use to help plan future events.
1. Please assess the overall value of the presentation to ensuring that metrics are a component of your performance improvement project reporting.
___ Very valuable
___ Valuable
___ Neutral
___ Limited value
___ Not valuable
2. Please rate your knowledge of the difference between outcome, process and balance measures.
___ Not very knowledgeable ____Somewhat knowledgeable _____Knowledgeable ____ Very Knowledgeable
3. As a result of my participation in this presentation, I plan to (select all that apply):
___ Use driver diagram or logic model to map out my performance improvement project
___ Identify a family or set of metrics to gauge my PIP efforts that includes an outcome, process and balance measure
___ Display data collected in a visual format such as an annoted run chart
___ Collect qualitative and quantitative information about the interventions we collect
___ Other (please specify)
______
___ None of the above
4. Within our small work group session, how did you improve your measurement plan related to the Opioid Prescribing PIP: (If you feel you did not improve your measurement work plan, identify barriers and supports you need)
______
______
______
______
______
5. What was the most helpful aspect of the presentation and work session today?
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March 2017 QHOC Packet - Page 117 6. How could the presentation or support provided be improved?
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7. What topics remain unclear? What additional assistance do you need?
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8. Additional comments:
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March 2017 QHOC Packet - Page 118 Measurement 101: Why Metrics Are an Integral Part of Improvement & How to Incorporate Them Into Your PIP Reporting Strategies
Colleen Reuland Director Oregon Pediatric Improvement Partnership March 13th, 2017
Complete Your Pre‐Survey In Your Packet
March 2017 QHOC Packet - Page 119 Agenda
• Background on OPIP and our experience with quality measurement and improvement • Setting the Context: Why and how are metrics an integral component of improvement efforts? • Key factors to consider in designing a measurement plan as part of your performance improvement project – General parameters – Types of metrics to consider, importance of a “family” or set of metrics – Operationalizing metrics – Reporting metrics • Pulling it all together –value of driver diagrams/logic models to ensure alignment of efforts with the aim • Example of how this would be applied for a PIP focused on the Adolescent Well‐Visit Measure (AWV) • Applying what was discussed today: – Small Table Exercise to Specify Metrics Related to Your QI Efforts Focused on Opioid Safety: Reducing Prescribing of High Morphine Equivalent Doses • Complete the Evaluation Survey
Oregon Pediatric Improvement Partnership (OPIP)
• OPIP supports a meaningful, long‐term collaboration of stakeholders invested in child health care quality, with the common purpose of improving the health of the children and youth of Oregon. • OPIP staff and projects focus on building health and improving outcomes for children and youth by: 1) Collaborating in quality measurement and improvement activities; 2) Supporting evidence‐guided quality activities; 3) Incorporating the patient and family voice into quality efforts; and 4) Informing policies that support optimal health and development • OPIP uses a population based approach –starting with the child/family – Work with the multiple kinds of providers who serve children • Primarily contract and grant funded – TA Bank provider for CCOs – External quality review‐like organization, facilitated a PIP with 8 MCOs • Based out of Oregon Health & Science University (OHSU), Pediatrics Department
March 2017 QHOC Packet - Page 120 My Primary Objective‐ To Be Helpful
I know there is a wide range of experience in the room!
• For some of you this may be the first time you have heard these things • For others, this is a helpful review of concepts you already know and work with regularly • Please ask questions as you have them, and let me know as you have topics you would like to discuss as we go‐ the intention here is for me to be helpful! Let me know how best to accomplish that
Metrics Are an Integral Part of Improvement
• Measurement is a critical piece of improvement, as it allows you as a quality improvement (QI) team to: – Understand current performance = Your Baseline Rate – Set goals for your future performance = Your Improvement Target – Monitor the effects of the changes you are making (your interventions) = Interim Data Collection (e.g. Quarterly data Collection, Frequency of Data Collection)
Words in Blue Map to PIP Progress Reports
March 2017 QHOC Packet - Page 121 Model for Improvement
What are we trying to Aim Statement accomplish? How will we know that a change is an improvement? Measurement is a critical What changes can we make that part of this will result in improvement? process as you can’t know WHAT and IF you are going to improve if Act Plan you don’t track it Study Do
The Model for Improvement was developed by Associates in Process Improvement. © 2004 Institute for Healthcare Improvement
March 2017 QHOC Packet - Page 122 Key Strategies OPIP Uses When Working with Partners to Create Effective Aim Statements
• Three components of an effective aim statement: what, how much, by when
• State the aim clearly
• Include numerical goals that are clearly tied to the population and outcome of focus
• Avoid aim drift
• Be prepared to refocus the aim
Measures Are a Critical Part of a “SMART” Aim Statement • Specific
• Measureable
• Achievable
• Realistic
• Time‐Specific
March 2017 QHOC Packet - Page 123 Example: Immunizations
Initial AIM: – Reduce the number of ALERT sheets received by the office by 50% within 12 months.
Second phase AIM: – Increase 2‐year‐old immunization rates by 4% by June of 2010.
Developmental Screening
• To improve developmental disability and autism screening in pediatric practices, in accordance with AAP policy statements and Bright Futures guidelines.
• To improve physician understanding and utilization of standardized developmental screening tools.
• To educate pediatric physicians in proper documentation, coding, and billing.
• To improve provider knowledge of, and referral to, community resources, particularly Early Intervention.
March 2017 QHOC Packet - Page 124 Developmental Screening
Within 9 months of developmental screening implementation:
• ASQ will be routinely administered to 75% of 9, 18, and 24 month olds. • MCHAT will be routinely administered to 75% of 18 and 24 month olds.
March 2017 QHOC Packet - Page 125 Peeling the Onion of an Improvement Project The PDSA Cycle
Key Questions for Designing Improvement Strategies With Associated Metrics
Current Desired Outcomes Outcomes (Baseline • What are the processes or activities that (Target Rates) have impact on the outcomes? (DRIVERS) Rates) • How are these processes currently being implemented? Is implementation stable and reliable? • What interventions on the process will have an impact on the outcome? (PROCESS MEASURES)
• If this intervention is implemented, what impact will it have on other parts of the systems? (BALANCING Measures)
March 2017 QHOC Packet - Page 126 Importance of Measurement Plan As You Design and Improvement Plan: Some Keys to Consider
• Each part of your improvement plan should measured and assessed relative to the outcome • Value of “family” or set of metrics that provide information on the system as a whole, and the impact, or unintended impact, of improvement efforts. Three most common types of metrics: – Outcome – Process – Balancing • Indicator vs Measure – Indicator is a count – Measure has numerator and denominator • Numerator: Did it happen • Denominator: Total it should have happened to
Types of Metrics to Gauge Improvement • Outcome – Measure the results and system performance – The end results of your improvement project – Your target state • Process – The individual workings of the system; the things you do – Capture the changes your QI efforts make to the inputs or steps (DRIVERS) that contribute to the outcomes – Sound process metrics ensure that the activities directly contribute to the outcomes • The WHO and the WHAT of your AIM Statement • Balance – Assess other part of the systems that are related – Ensures that if changes are made to one part of the system, it doesn’t cause intended problems in another part of the system
March 2017 QHOC Packet - Page 127 Important Factors to Consider as You Operationalize Metrics
Get into the details • Operational definition –define each part, including scoring • HOW data will be collected • Sampling –who is measured and how do you identify them • Reporting –how it will be visually shown
Value and importance of metrics that can give a sense of scale • Counts (indicators) o Often count a numerator –what happened, but not what should have happened, so it can sometimes be difficult to gauge impact on outcome • Proportions or Percentages (measures) o Numerator –Who got it: Indicator of focus o Denominator –Who should have received it: Population or Volume
Important Factors to Consider As You Operationalize Metrics
• Examination and plotting data over time o Pre/Post –Only show Baseline and Follow‐up and no relation to when improvement efforts began o Run charts with annotations of when interventions implemented
• Tool for You: http://www.ihi.org/resources/Pages/Tools/RunChart.aspx
March 2017 QHOC Packet - Page 128 Source: https://www.medicaid.gov/medicaid/quality‐of‐care/downloads/qi‐101‐webinar3‐slides.pdf
March 2017 QHOC Packet - Page 129 Pulling It All Together
Aligning Efforts and Metrics to the Aim: Using Driver Diagrams and Logic Models in Planning and Implementation
March 2017 QHOC Packet - Page 130 Tools That Can Help You Design Improvement Efforts that Aligned with the Aim and Sound Metrics
1. Driver Diagrams 2. Logic Model
Tool #1: Driver Diagrams
– Visual display of the improvement efforts – Causal pathway from improvement efforts to the AIM, requires you to think of the connection – The primary drivers, sometimes referred to as “key drivers,” are the system components or factors which contribute directly to achieving the aim. • Secondary drivers are actions, interventions necessary to achieve the primary drivers. • Secondary drivers should be used to identify changes that can be tested in order to affect the primary drivers. – Each driver should be able to be measured, and most drivers should align with specific process measures.
Source: https://innovation.cms.gov/files/x/hciatwoaimsdrvrs.pdf
March 2017 QHOC Packet - Page 131 Source: https://innovation.cms.gov/files/x/hciatwoaimsdrvrs.pdf
Source: https://innovation.cms.gov/files/x/hciatwoaimsdrvrs.pdf
March 2017 QHOC Packet - Page 132 Developmental Driver Diagram of Developmental Screening
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Source: http://www.ohioadolescenthealth.org/uploads/3/1/1/9/31199847/region_v_adolescent_health_series‐ understanding_the_adolescent_well‐care_visit.pdf
March 2017 QHOC Packet - Page 133 Tool #2: Logic Models
• Logic models illustrate how your specific activities are intended to produce particular results (your aim). • Key Parts: 1. Inputs – resources invested 2. Outputs‐ Specific activities 3. Outcomes –Results of each activity • Visual diagram forces you to ensure that the boxes are connected and that the activities are directly linked to the proposed outcome
• Online resources: http://www.wkkf.org/resource‐directory/resource/2006/02/wk‐kellogg‐ foundation‐logic‐model‐development‐guide http://www.uwex.edu/ces/pdande/evaluation/evallogicmodelworksheets.html
Outputs Outcomes Inputs Activities } Participation Short Medium Long
Outcomes Outputs Outputs Inputs: Activities: Participation: Short term What do you Examples: Examples: invest? • Specific • Number of Staff? Outcomes things you do participants Training? • Conduct • WHO you Resources? Mid‐term trainings reached • Curriculum • Facilitated Outcomes Meetings Long term
Free template for you to use: http://fyi.uwex.edu/programdevelopment/logic‐models/bibliography/
March 2017 QHOC Packet - Page 134 Keys to Using These Models: Identify Specific Strategies Used to Achieve the Aim
• Remember: The aim clarifies what, how much, by when relative to the outcome
• In designing your improvement plan you are identifying 1. Specific interventions you will implement 2. For each of those activities, metrics that will help you gauge the impact of those activities What was implemented? For whom? Relationship of the activity to the aim the specific WHAT, HOW MUCH, and BY WHEN
Metrics Demonstrating Intervention Effectiveness
Beyond outcome and process metrics noted, consider metrics of the specific intervention
1) Quantitative metrics o Quantify your intervention o Involve numerical counts Example: Number of clinics trained
2) Qualitative metrics o Often is the “story” behind the numbers o Interviews, and observing and recording behaviors o Feedback from participants of impact. E.g. What are providers, families, and patients saying? Example: Feedback obtained from attendees about the training about their perceptions of the impact the training will have; Notes from your improvement specialist site visit and their interviews with the clinic staff
March 2017 QHOC Packet - Page 135 Fictitious Example of a PIP Focused on Adolescent Well‐Visit
From A Driver Diagram to Metrics
Fictitious Example of a CCO’s PIP Driver Diagram
Primary Drivers Interventions to Address Drivers
Primary Care Provider Provision of Trainings to clinics on Bright Futures High‐Quality Adolescent aligned well‐visits By January 2018, Well‐Child Care we will increase the AWV rate from 20% to 35% of Training to SBHCs on well‐visits, continuously Convenient Access to SBHC outreach to youth in school enrolled youth Care at a SBHC to access 12‐21 receiving a well‐child visit
Adolescent Knowledge Member education about about Well‐Visits importance of well‐visits
March 2017 QHOC Packet - Page 136 By January 2018, we will increase the AWV rate from 20% to 35% of continuously enrolled youth 12‐21 receiving a well‐child visit
• Baseline Data: Rate for 16 Calendar Year • Improvement Target: 35% by January 2017 • Benchmark: State Benchmark – 62.0% • National Standard: National NCQA Rates • Frequency of Data Collection: • Monthly Tracking of Well‐Visits, Annotated Run Chart By Improvement Interventions. The LINE on the chart would show your well‐visit rate, looking back across the year. o Annotate charts to note when the interventions were implemented 1. Training of clinics 2. SBHC clinic engagement 3. Member mailing
March 2017 QHOC Packet - Page 137 ‐‐ Clinic Level Screening Rates
‐‐ Other Access Measures for Those Clinics, E.g. Well‐Child Rates for Young Kids ‐‐ Time to Third Appoints
‐‐ Adolescent SBIRT Metrics for the Clinics, Given Part of Quality AWV
Fictitious Example of a CCO’s PIP Driver Diagram
Primary Drivers Interventions to Address Drivers
Primary Care Provider Provision of Trainings to clinics on Bright Futures High‐Quality Adolescent aligned well‐visits By January 2018, we Well‐Child Care will increase the AWV rate from 20% to 35% of Training to SBHCs on well‐visits, continuously Convenient Access to SBHC outreach to youth in school enrolled youth Care at a SBHC to access 12‐21 receiving a well‐child visit
Adolescent Knowledge Member education about about Well‐Visits importance of well‐visits
March 2017 QHOC Packet - Page 138 Examples of Metrics to Gauge Improvement Interventions
Primary Drivers Interventions to Address Drivers
Primary Care Provider Trainings to clinics on Bright Futures Provision of aligned well‐visits High‐Quality Adolescent Well‐Child Care • Number of clinics trained (Quantitative) By January 2018, we • Number of adolescent members will increase the 12‐21 attributed to the clinics adolescent well‐visit • Monthly/Quarterly reporting of rate by 5% AWV rates for clinics. Annotated run chart of well‐visit rates that notes when training occurred (Outcome) • Assessment of well‐child rates for young children in same clinic (Balance) • Monthly site visit, report from clinics about barriers (Qualitative)
Trainings to clinics • Number of clinics trained (Quantitative) on Bright Futures • Number of adolescent members 12‐21 attributed to the aligned well‐visits clinics • Monthly/Quarterly reporting of AWV rates for clinics. Annotated run chart of well‐visit rates that notes when training occurred (Outcome) • Assessment of well‐child rates for young children in same clinic (Balance) • Monthly site visit, report from clinics about barriers (Qualitative)
March 2017 QHOC Packet - Page 139 Examples of Metrics to Gauge Improvement Interventions
Primary Drivers Interventions to Address Drivers
Training to SBHCS on well‐visits, By January 2018, we Convenient Access to SBHC outreach to youth in school will increase the Care at a SBHC adolescent well‐visit • Number of SBHC engaged rate by 5% (Quantitative) • Number of adolescent clients in zip code for the school • Monthly/Quarterly reporting of increase in AWV by SBHC. Annotated run chart (Outcome) • Assessment of well‐child care rates in primary care clinics in region(Balance)
Examples of Metrics to Gauge Improvement Interventions
• Number of adolescents to whom a mailing was sent (Process) By January 2018, we • Proportion adolescents who will increase the received the education adolescent well‐visit information (not returned) rate by 5% • For adolescents who received a mailing, tracking on access of well‐child care (Outcome)
Adolescent Knowledge Member education about about Well‐Visits importance of well‐visits
March 2017 QHOC Packet - Page 140 Enough talking….. let’s apply these models to your work
Exercise to Specify Metrics Related to Your QI Efforts Focused on Opioid Safety: Reducing Prescribing of High Morphine Equivalent Doses
Step 1: Map Out Your Aim, Primary Drivers and Your Interventions Related to Your QI Efforts Focused on Opioid Safety: Reducing Prescribing of High Morphine Equivalent Doses
Primary Drivers You Have INTERVENTIONS Identified to Prescribing of High WITHIN YOUR PIP Morphine Equivalent Doses
What, how much, by when
What is your baseline? What is your target?
March 2017 QHOC Packet - Page 141 Clarifying Measurement Plan
• Each part of your improvement plan should measured and assessed relative to the outcome
• Value of “family” or set of metrics that provide information on the system as a whole and the impact, or unintended impact, of improvement efforts. Three most common types of metrics: – Outcome – Process – Balancing
Key to Designing Improvement Strategies With Associated Metrics
Current Desired Outcomes Outcomes (Baseline • What are the processes or activities that (Target Rates) have impact on the outcomes? (DRIVERS) Rates) • How are these processes currently being implemented? Is implementation stable and reliable? • What interventions on the process will have an impact on the outcome? (PROCESS MEASURES)
• If this intervention is implemented, what impact will it have on other parts of the systems? (BALANCING Measures)
March 2017 QHOC Packet - Page 142 Small Table Debrief
• What went well? • What was tricky or hard to figure out? Where could we support you more? • Sharing your brainstorming related to your opiod prescribing PIP: – Examples of outcome measures? – Examples of process measures? – Examples of balance measures?
Complete Your Evaluation Survey – THANK YOU!
March 2017 QHOC Packet - Page 143