Accountable Care Organization

Episode 44: Exciting Changes to the Quality Heat Map

December 2022

The ACO’s Laura Larssen joins Heather and Mike to discuss measures that have just been added to the MHACO Quality Heat Map, including a first-ever health disparity measure.

Additional Information

Mike: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization. A crispy on the outside, juicy on the inside monthly podcast for health care providers. I'm Mike Clark.

Heather: And I'm Heather Ward. Mike and I are practicing physicians who participate in the MaineHealth ACO.

Mike: This month, we're dedicating our entire episode to some new and interesting developments with the ACO's quality. Heat Map.

Heather: Awesome. Let's get to it.

Mike: Meaty topic.

Heather: For many years now, the ACO has distributed monthly Quality Heat Maps to hundreds of clinical, administrative and population health leaders across the ACO. The Heat Map compares local health system performance on reaching the annual target set for 11 key quality measures.

That's right, Heather. And the cover page of the heat map is kind of a grid where the X-axis includes the 11 measures and the Y-axis includes all the MaineHealth local health systems plus St Mary's. Performance across the measures is shown numerically in each cell and is color-coded. Where the target has not yet been met, the cell is shaded red and where it has, the cell is white.

Nicely described. To actually see the heat map, we'll put an example up on the web page for this episode at Episode 44.

Mike: That'll definitely be helpful, especially for the visual types. But to fill us in on what's behind the red and the white on this fiscal year's heat map is Laura Larssen, program manager at the ACO and our local content expert. Welcome, Laura.

Thank you, Mike. Thanks, Heather. Great to be here.

So let's get right at this. Laura, can you briefly describe the purpose of the heat map and what it measures?

Laura: Yeah. So we have this heat map, in part, to take this giant set of really complex measures that we engage in at the ACO. We have these 16 value-based contracts, and within those value-based contracts, we have over 115 unique quality measures. So can you imagine, Heather, if I came to you in your practice and said, Hey, Dr. Ward, you're only responsible for these 115 quality measures, right?

Heather: That wouldn't fly very well.

Mike: Yeah, that's a nightmare.

It would be a nightmare for all of us. So our job at the ACO is, we really try to take on that complexity, and we take that giant list of measures and we boil it down to this core set of measures that we can take to providers and care teams without totally overwhelming them. So, we look at that whole set of measures and we look at things like the clinical significance, the relevance, how many value-based contracts the measures are in, if it's impactful at the primary care level, and if there's still meaningful opportunity for improvement. So that kind of drills us down into this set of measures, which this year is 11, that make it onto our heat map.

Heather: That was a great explanation. Thank you. I am curious to know what changes the November heat map is going to include for this entire fiscal year. And I understand that some have been retired and some have been added. So what's going to go away?

Laura: Yeah. So in thinking about changes to the heat map, we have this really engaged group of folks that are the quality workgroup who started meeting all the way back in June. And we look at what's currently on the heat map, we look at industry trends, we look at those value-based contracts, and we also look at measures to see, are there measures where our performance has been consistently high for a long time, and we think that those workflows are really well baked in at the practice, so we don't have so much room for improvement anymore. And so we had really robust conversation with that group, clinical leadership, around these measures. So this year, we are retiring three measures and we're adding three measures. We try to keep those changes sort of net neutral, again, so as not to overwhelm providers and care teams. So for fiscal year 23, in this new heat map, we are retiring the well-child visits 0 to 15 months. We are retiring the depression screening and we're retiring the breast cancer screening. And that's certainly not to say that those aren't important measures. We recognize that they are. But again, our performance across the ACO has been consistently very high in those measures. So we look to add some new measures that offer some new opportunities for improvement.

Mike: So that's good news on our performance in the past. But now we're going to be turning our attention to some new measures. What will they be?

Laura: We are, Mike, and I'm really excited about these changes this year. So, we are adding three new measures and we're going to drill down into two of them, I think in a little more detail. But the first is HPV immunization. So that's sort of a swap for that well child, that's another pediatric measure. It's one where we have lots of opportunity for improvement, and it's also one that's included at the MaineHealth system quality dashboard. So we're in alignment with them and I think there's going to be some great resources coming out to support that change. And then the other two additions are Medicare Advantage Aggregate Star score. So this is going to be looking at a star score for a set of clinical measures, and that's going to be pulling that star score in by the local health system level every month. So we'll drill down into that in a little bit more detail. And then that third measure is the health disparities gap. So this is the one I'm actually most excited about. What we've done is we've taken our diabetes poor control measure, so that's patients whose HbA1c is greater than 9%, and we are looking at the difference in the rate of control for patients who have commercial insurance versus patients who have either Medicaid or no insurance. And the gap between that rate of control—so your patients who have commercial insurance, let's say that 18% that are out of control and your aggregate between those other two populations, Medicaid and no insurance, if that's 25%, your health disparities gap is 7%. So that's the difference between the care that those two sets of patients are receiving.

Mike: Wow, those are fascinating and really important measures. And I think the one that I scratch my head the most about is the stars measure. Could you explain that a little bit more?

Yeah, I'd be happy to. I think that this—it is such a different type of measure than what we've had in the past. So it's this role up aggregate measure. And I think as we see Medicare Advantage, that space is growing more and more. It's representing more and more of our overall value-based contracts. Part of the intention in bringing this onto the heat map is to help familiarize providers and care teams with these Medicare Advantage measures. So a lot of the measures are very similar. It's a sort of core set of Medicare Advantage measures. Many of them are the same as what we might see on the heat map. So your colonoscopy screening and your breast cancer screening, lots of the same. There are a few measures that are a little different. So it brings in things like medication adherence and osteoporosis management. And essentially our amazing analytics team at the ACO has built a report in Power BI that aggregates all this data that we're getting from payers in claims as well as our clinical data, and they then are able to show us, by local health system, where are we at in that star rating for each of those measures, and what are the gaps to get to a five-star performance, for example. So I think it's a step toward greater literacy across the ACO and better understanding: What are those MA star measures? How do we impact them? How many patients fall into those different measures for the denominator?

Heather: That's great. Thank you. I'm finally starting to understand it a little bit. There's so much that goes into that one. The one that I'm super curious about is the new health equity measure, and you dove into it a little bit, but I'm wondering if you could just explain better how we came to that, and why are you using patients with Mainecare or uninsured as a comparison to commercial insurance patients?

Laura: Thank you for that question. Heather and I actually love talking about this measure and I'm really excited that we got here. But it did start long, long ago, back in May when we internally started talking about health disparities in our industry. There's just been a lot of chatter about health equity, health disparities, social determinants of health. It's kind of these buzzwords that we keep hearing everywhere. And CMS Innovation Center is talking about embedding health equity in every aspect of their models. And CQA is talking about stratifying these quality measures by race and ethnicity. So, you know, the challenge, first of all, is how do we measure disparities? And then here at MaineHealth, what disparities exist? So as you ask the question about why are we using this health insurance, we started with looking through the lens of race or ethnicity. So that's more of the stereotypical way to stratify these data is by using demographics data. But as we worked with the team at the MaineHealth system level, the feedback that we got was that we probably need about another year before everyone is sort of trained consistently in collecting that information and that we have confidence in being able to use that data. So in lieu of that, we chose to use health insurance as a proxy for socioeconomic status and we're not new in doing that. That's a methodology that's been used by other investigators in those studies. So once we kind of decided that's the lens that we're going to use to look at this, then the MaineHealth Medical Group analytics team did this amazing wizardry, and they took all of our existing heat map measures and they ran them through a report that showed us what are our rates by each different line of business. So we could see, are there disparities between Medicare Advantage and commercial and Medicaid and uninsured? So that was kind of the first glimpse that we had to say, oh, there are disparities. We do see a big change, a big gap, between our uninsured population and our Medicare Advantage population, for example. And so we brought those data to that quality workgroup, and Heather, you were a part of that, and there was actually a lot of engagement and a lot of interest. And I think what I loved about this so much was that the providers who are involved in those conversations, while there's still a lot of sort of uncertainty about how do we move the dial on this, there's just a lot of engagement in saying this is the right thing for us to do. We want to take this step. Even though we have a lot to learn. We want to take this step and start looking at our performance through the view of disparities. And so that was really exciting for me to see just how engaged the providers were as we started to roll this out.

Mike: Thank you for the work the team has done on that and bringing a health equity measure to the forefront for us, it is so important. And finally, I've noticed that several of the targets for the legacy measures have changed. The goalpost is moving a little bit on these. What do we need to know about those?

Laura: That's right, Mike. So every year, we take a look at a number of data sets to see, across the nation, how is performance changing? Because that's what our payer partners, the insurance companies, use when they measure our performance. So they use standard sets for commercial. There's other standard sets for Medicare Advantage. So when we set our targets, we take a formula that takes into account the Medicare Advantage cut points is what they call them, but they're just targets. And then the HEDIS quality measures, which is the quality compass, and we look at those two sets of targets and then that's what we use to set our heat map targets. So it's really interesting to see when we look at previous performance and what this has been based on, some years that they're looking back at a COVID year, for example, the targets went down. So that happened last fiscal year. A lot of our targets on the heat map went down. This fiscal year, we saw a few that were ticking up a little bit. And then there are a few that have stayed pretty static, pretty in line with what they were last year. So I would say in looking at the group that we have now, there's probably three that have ticked up just a little bit, and then there are three that have notched down a little bit. So we're kind of again, net neutral in that space. But it does reflect what's happening nationally with the benchmarks.

Heather: Laura, thanks for all of that information on the new health disparities measure. I'm really curious from a provider standpoint, what can I do to help impact that, when I really have no control over who I bring in and which insurance is there and that sort of thing?

Laura: Yeah. Thank you, Heather. You will probably not be surprised to hear that as we have cascaded this communication to lots of different places, that question has come up a lot. And so I think the intention of bringing this onto the heat map is not necessarily that we expect you, Dr. Heather Ward, to solve health equity for the whole state of Maine. I think we recognize the limitations of quality data to be able to do that. But I think the bigger intention here is to engage leadership and large groups like the Population Health Team, that is really starting to drill down into social determinants, to start to identify what are those factors that are playing in here. Is it that patients don't have transportation to get to appointments? Is it that there's some access issues around their medications or cost barriers? So starting to drill down into, what are the factors that are playing into these disparities, so that we can then build out what needs to happen at the system level to be able to impact and positively influence. And I think that is part of what's generated some of the excitement as we take this out to physicians and committees and leadership. I've actually had a provider say, as we shared this, seeing this on our heat map makes me really proud to be part of MaineHealth, and I love that. I think we all recognize it's just a first step. We know that quality measures can't solve for equity, but we do believe that working with system leadership to address these disparities and address the systems that underlie all of this, I think will be a really good step in the right direction. And I also want to say another thing I'm really proud of is that this is the first time that a measure like this has been brought to the system level, any kind of a disparities measure. And as we meet with payers and insurance companies, they have also told us that we are the first ACO that is measuring this and bringing it to systems consistently like this. So I really think that MaineHealth ACO is a pioneer in this space. I'm really excited that we're taking this step. I think we're going to have a lot to learn this year, and so I'll be really curious to see for fiscal year 24 where we land with this measure.

Heather: Wow. It is so exciting to see that and to be able to start looking at what really, truly underlies the health issues of our communities and hopefully be able to start pointing resources and make a difference in the community or at the community level as opposed to just what happens in the doctor's office.

Laura: Absolutely.

Mike: Okay, so, Laura, I can understand how important the stars are. But why did we decide to bring it onto the heat map this year?

Laura: Yeah. Thank you, Mike. I think it goes back a little bit to what even is Medicare Advantage, what is a star score? And so, as you think about these value-based contracts that we enter into with insurance companies, these insurance companies essentially get grades from CMS every year. So how well did they do in a certain number of areas? And that is things like patient experience and it's areas like pharmacy and improvement. And there's a whole administrative section. But one piece of that pie really revolves around quality measures. And so that's the piece where we have a lot more influence. And so our payer partners are coming to us all the time and saying, Here's your performance in Medicare Advantage. You're landing at a three-star, you're landing at a four-star. And essentially that's just a tier within the Medicare Advantage star system. Every insurance company wants to be a five-star plan. So they're always pushing us to try to get to that five-star tier, which, for example, in breast cancer might be if you're at 77%, you're now at five stars in breast cancer. And all of those scores for all of those individual measures roll up and they get averaged and that becomes a star score. So we at the ACO are pretty familiar. We see our star scores for each of the different insurance companies on the regular as we meet with them monthly. And so we wanted to help encourage sort of more literacy even within the ACO so that we all get comfortable with this language in seeing the Medicare Advantage star scores. And so that was part of the intention of bringing this onto the heat map and starting to use some of those cut points or targets and bring that in alignment with the heat map.

Heather: Okay, Laura, you've just given us a ton of information, so how can providers find out more about our heat map?

Well, there are lots of ways to find out more about the heat map. We did just release the heat map last week, so that should be in folks' inboxes. Within the heat map itself, we do have measure definitions, so you can see sort of a 30,000-foot view within the heat map itself. But if you want to drill down into lots more detail, we have a new version of the Heat Map Quality Metrics Guide, and there was a link to that also in the heat map message that went out last week. And we can include a link to that in our show notes for today. But that gets into each of the measures in a lot more detail. It has links to resources, it has links to studies and evidence-based resources around each of those measures. So that is something that I often refer to as care teams have questions for me. It's a really great resource and of course, you're always welcome to reach out to me as well. I love to geek out on quality measures with folks, so feel free to email me as well.

Mike: Thank you, Laura. Thank you for joining us on the BACON podcast. This is great information that I know will be really important for our listeners.

Laura: Thank you. It was my pleasure to be here.

Thanks for listening to BACON this month. You can find all our episodes on your podcast app and on our web page, And if you have questions, comments or suggestions, we really would love to hear from you. Please email us at That's

Heather: BACON is produced by the MaineHealth Accountable Care Organization with help from the MaineHealth Educational Services. Thanks for joining us. See you next time.

See you next time.