On May 23, health system leaders gathered to plan the next steps in the North Carolina State Transformation Collaborative’s efforts to improve quality measure alignment, focus on health equity, and create 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 started in Arkansas, California, Colorado and North Carolina.
The May 23 meeting was to discuss a new Alignment Proposal on action areas involving:
• Align quality measures, starting with aligned implementation of a few key measures;
• Improve data sharing infrastructure by meeting organizations where they are and helping progress toward national interoperability standards; and
• Enhance health equity data like race, ethnicity, language through standardized approaches to the collection, sharing, and use of these data.
Rebecca Whitaker, Ph.D., M.S.P.H., research director, North Carolina Health Care Innovation & Medicaid Transformation at the Duke Margolis Institute for Health Policy, outlined the Alignment Proposal.
“What is contained in the Alignment Proposal is really driven from key challenges that we heard with respect to implementing whole-person care and care delivery reforms. Some of those key challenges tie back to different sources of administrative burden,” she explained. “We heard a lot about variability in measures, including in payer and provider contracts. That includes variability not just in the measures themselves, but how those measures are implemented, and the lack of a consistent way to define and measure disparities, which is preventing apples-to-apples comparisons, both within organizations, but also across organizations. Finally, we heard about limitations in data interoperability as a result of some of this variation in measurement, collection and reporting.”
From these challenges, the State Transformation Collaborative sought to identify opportunities and action areas to better reduce burden and enable this movement toward whole-person care.
Both in North Carolina and across across the country, states have tried to align on quality measures, across payer contracts and lines of business. “This is hard work, and I think we see different levels of success,” Whitaker said. “What we are prioritizing through this North Carolina State Transformation Collaborative is actually drilling down on the implementation of the measures themselves and trying to reduce the burden associated with the collection and reporting of measures in payer and provider contracts.”
She explained that they are proposing to start with three key measures: child immunization status, controlling high blood pressure, and hemoglobin A1C control.
“We want to use these measures to identify how we can reduce the burden of reporting of these measures by identifying some multi-stakeholder alignment strategies,” Whitaker said. “We are putting these measures forward because we know that they are common across value-based payment contracts in public and private payer organizations, and they are clinically significant. They're historically pretty challenging to collect and report on, and they're also associated with persistent disparities in our state.”
The second strategy is to improve data-sharing infrastructure — taking those measures as a use case and saying, what are some specific things that can be done to leverage automated reporting tools and streamline the collection of those data to make life easier for provider organizations and payer organizations alike. The intent is to put out a vision for a robust data-sharing ecosystem in North Carolina, while also acknowledging the range of readiness among provider organizations, she said.
“Not everybody is ready to go fast and implement national data interoperability standards. We heard from some primary care organizations that they are not able to participate meaningfully in value-based care contracts because they don't have the resources or their bandwidth to do all the supplemental data feeds to payers,” Whitaker said. “So they're not even participating meaningfully. What can we do to help those organizations?”
There are other organizations that may have more capacity and bandwidth to adopt and implement national interoperability standards, submitting electronic clinical quality data, leveraging bulk FHIR, for example, but may not have the use cases or the incentives to apply those things now.
A third action area is related to enhancing health equity data. “We know that there are persistent disparities in health outcomes across the healthcare system, and we also know that there's pretty significant variation in how organizations collect, share and use health equity data, which makes it challenging to address observed disparities,” she said. “We are going to be convening a health equity data work group later this summer that will aim to accomplish a few things: identifying some leading practices in the collection, sharing, and use of health equity data; establishing some principles for how to guide that work, because we know it's really important to build trust and work with communities and people with experience in this process; as well as explore standardization across organizations and how we are collecting and using these data.”
Role for the HIE to play
During a panel session following Whitaker’s presentation, Sam Thompson, the executive director at the North Carolina Health Information Exchange Authority, spoke about the role the HIE could play in streamlining reporting on quality. “Instead of having each health plan run independent quality measures, submit independent gap reports, and extract clinical data one by one from providers, each in a different format, we can try to push Medicaid and health plans to using a centralized aggregator where providers already have to submit their clinical data, where they already have to go to look at their performance and use that as a venue to present a unified front for the Medicaid side, instead of working with a half-dozen different health plans,” he said. “As tailored plans come online, as the Children’s Health Care Specialty Plan for foster children comes online, the environment only gets more complex. So the hope is that the HIE can make it less complex. We’re doing similar work with social determinants of health data.”
Kristen Dubay, M.P.P., chief of population health for NC Medicaid, spoke about data quality and aligning on quality measures. “We have a data strategy we developed in advance of going live with Medicaid managed care, and as we're reviewing the results of that data strategy and updating measures, we see that the data are not as clean as we expect all the time, because we have this very complex system,” she said. “So as providers are frustrated, we are also frustrated, right? Because we really want to be focusing on what moves the needle for these members and better health outcomes.”
Dubay said when they have these challenges with the data, it delays their efforts. “We're really excited to be working on this with our health information exchange. We'll continue to work on that, and that's also serving as the foundation of a lot of the work we'll be doing. We are going to be seeking feedback from providers and payers, from the community, around our approach at Medicaid for aligning with the Medicare Making Care Primary model, which is rolling out in North Carolina,” she added. “We’re looking at getting input on the design. We're thinking about a standard value-based arrangement that we would have all Medicaid health plans implement, and really aligning that work with the Medicare model. To me, that's an opportunity to reduce provider burden in their payer contracts and in their approach to focusing on incentives and quality improvement across more of their payer contract arrangements.”
