Feb. 2 marked the official launch of North Carolina’s State Transformation Collaborative (STC). State healthcare leaders met at Duke University’s Fuqua School of Business to discuss strategies around quality measure alignment, health equity, investment in primary care, and creating the data infrastructure to allow stakeholders to measure progress.
In December 2021, CMS Administrator Chiquita Brooks-LaSure announced the launch of the state-based initiative for the Health Care Payment Learning & Action Network (LAN) to accelerate the movement toward advanced payment models. The State Transformation Collaborative program is starting in Arkansas, California, Colorado and North Carolina.
Kate Davidson, director of the Learning and Diffusion Group at the Center for Medicare & Medicaid Innovation, led off the meeting by giving the federal perspective. “At the Innovation Center, we've delivered a lot of models that have had a multi-payer alignment strategy in the past, and quite frankly, we've learned a lot about what doesn't work,” she said. “We've learned a lot about where we should go next in terms of creating flexibilities in our models and how we can support pulling together commercial payers with Medicare Advantage payers and Medicaid payers as well. We know that if we align too loosely that we send mixed signals to providers and unintentionally increase their administrative burden. I hear from providers all the time that they're signing into multiple portals in order to access their data, which really just means they're receiving a fragmented look at their entire patient population. So we need to change that and aligning around quality measures is one concrete way we can support alignment.”
Davidson also said that CMS realizes that “when we align too strictly, or we put too many parameters around joining one of the Innovation Center models, we actually stifle innovation. We've been talking with a lot of stakeholders about how we can create a path forward where we're directionally aligning around the really key design features that are important to reduce administrative burden and support providers to create that less-fragmented, seamless, coordinated care.”
CMMI also has learned, she said, that all healthcare is local. “And for a long time, we were really trying to think about multi-payer alignment from the national perspective. But we have to consider that relationships are a part of everything that we do. We think that the State Transformation Collaborative offers an opportunity for CMS and other national payers to learn from states, from providers, from regional payers and others in the community about what you need in order to support a broader adoption of value-based care and accountable care.”
Fourteen contracts and 158 quality measures
Mark Gwynne, D.O., president of the UNC Health Alliance, spoke about the importance of aligning quality measures and some of the work his organization has done to whittle them down.
The UNC Health Alliance is the University of North Carolina's clinically integrated network involved in Next Generation and MSSP accountable care organizations. UNC Health Alliance has a network of over 6,500 employed and independent providers, 16 hospitals and 35 post-acute providers.
“We looked at all of the quality measure sets across our 14 contracts and there were 158 different measures. There's not a single provider in the state that can pay attention to 158 different measures,” Gwynne said. “But what they can pay attention to is 10 or five really important measures that have good evidence that front-line care teams care about and that through my lens have a financial implication for our network and help support further work. Providers can also focus on how to redesign care around hypertension, not necessarily what is the exact threshold of a hypertension measure that will achieve financial results, Gwynne explained. “So we took all 158 measures and narrowed it down to the top 20 based on those three criteria: evidence base, what our front-line care teams care about, and what the financial implication will be across our portfolio, and that's what we focus on. Every year we whittle that down to 10, and we focus on 10 a year across our network. That's doable. We can then translate that into how we support providers and practices. We can alter our EMR for point-of-care decision support to support those efforts. That's actually doable. And we've been doing that for the past three to four years very effectively.”
Within the broad concept of health equity, Gwynne said, it has been valuable to narrow it down to something that's actionable. “We've had a really nice partnership with Blue Cross Blue Shield over the past year. Between April and December, we focused on three areas: diabetes control, hypertension control and colorectal cancer screening, and we agreed on how we are going to define disparities, how we are going to define populations and the goals. In nine months, we reduced diabetes disparities by 25 percent, hypertension disparities by 25 percent, and for this particular population, our colorectal cancer screening rates for our BIPOC populations are actually greater than our white population. This is doable. It's a concentrated effort, and we've learned a tremendous amount.”
Short-term actions, long-term goals
Rebecca Whitaker, Ph.D., M.S.P.H., research director for North Carolina Health Care Transformation at the Duke-Margolis Center for Health Policy, spoke about some key goals the STC has identified through early stakeholder feedback: improving population health, advancing health equity, enhancing the patient experience, relieving provider burden and reducing healthcare costs.
“We aim to work toward these goals by strengthening coordinated and accountable primary care, by aligning on quality measures, enhancing health equity data, and improving data infrastructure,” Whitaker said. “Taken together, we hope that these strategies will be early steps toward this overarching vision. By securing and implementing an agreed path forward for alignment and action, we can make progress both within Medicaid but also beyond Medicaid, including in the Medicare space, Medicare Advantage and commercial payers as well.” She said that following the meeting and discussion, a goal was to have a sense of the priority areas for short-term actions — things that the stakeholders can do together over the next six to 12 months through the North Carolina STC. Progress on longer-term goals can build on this foundational short-term work, she said.
Speaking about the strategy of aligning on quality measurement, Whitaker said that starting with alignment on existing quality measures could build a pathway for future work to modify those priority measures and incorporate new measures, especially patient-reported ones. Some short-term action steps include a focus on aligning quality measures across key population groups —pediatrics, adults, and older adults, starting with some existing measures where there is agreement that persistent disparities exist, and using that aligned priority measure set to measure and identify disparities. “We heard a lot of interest in leveraging aligned quality measures to reduce disparities through coordinated action, which is a lot more achievable if we're focused on the same priorities and measuring things in the same way.” There are several state examples on promoting accountability for reducing disparities in California and Rhode Island, as well as in Oregon, Louisiana, and Massachusetts, she added.
Finally, in order to make meaningful progress on advancing health equity, Whitaker said they heard from stakeholders about the need to develop standardized approaches to the direct collection of health equity data, which would include race, ethnicity, language, sexual orientation, gender identity, disability, social drivers of health, and as well as to establish some learning collaboratives to facilitate implementation and use of these data.
“From there, we can apply a valid and reliable set of aligned health equity data to identify disparities and help drive multi-stakeholder collaboration to reduce gaps in services and improve clinical outcomes,” she said. “So in the short term, we certainly heard about the need to start with what we have and improve the data that we currently have by standardizing data storage formats and the way that we're reporting data by different population groups. Those sound really boring and mundane, perhaps, but are really critical to the future work.”
