Measure Name Description Numerator Denominator Data Source Reporting Frequency

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1 Appendix 2 to Attachment 7: Specifications QHP Issuers shall use the following metrics to establish baseline s for Attachment 7 requirements and demonstrate improvement on each of these s over time. These metrics were reported in the Certification or in subsequent requests and must be reported according to the table below. Additionally, QHP Issuers must report these metrics as necessary upon s request. and QHP Issuers shall work collaboratively during the term of this Agreement to enhance these specifications to further define the requirements. Metric Self-Reported Racial or Ethnic Identity Racial or Ethnic Identity Diabetes Care: HbA1c Control < 8.0% (NQF 0575) CBP Controlling High Blood Pressure (NQF 0018) Measure Name Description Numerator Denominator Data Source Report self-identifying racial and ethnic group through the enrollment application, web site registration, health assessment, reported at provider site, etc. Report racial and ethnic identity based on selfreport or proxy methodology (i.e. zip code or surname analysis, or both) who self-identified a racial or ethnic group. with racial and ethnic group identified QRS administrative HbA1c Control <8.0% QRS Controlling High Blood Pressure Total hip for. Exclude actively selecting an option to decline selfreport (e.g. decline to state or prefer not to say ). Total hip for Comprehensive Diabetes Care (NQF 0731) Data (enrollment) Data (enrollment) and clinical Clinical Applications for evalue8 RFI QHP Issuer DRAFT RECOMMENDATION April 14, 2016 Appendix 2 to Attachment 7

2 Asthma Medication Ratio Ages 5-85 (NQF 1800) Antidepressant Medication Management (NQF 0105) Depression Response at Twelve Months- Progress Towards Remission (NQF 1885) Diabetes Hospitalization Hybrid Measure Measure Name Description Numerator Denominator Data Source Combine the following AHRQ PQI measures for the Diabetes Hospitalization Hybrid Measure: PQI #1 Diabetes Short-Term Complications Admissions Rate PQI #3 Diabetes Long-Term Complications Admissions Rate PQI #14 - Uncontrolled Diabetes Admission Rate HEDIS Asthma Medication Ratio QRS Antidepressant Medication Management MN Community Combine AHRQ measure PQI #1, 3, 14, 16 Controlling High Blood Pressure HEDIS eligible Asthma Medication Ratio Antidepressant Medication Management MN Community denominator Comprehensive Diabetes Care (NQF 0731) and clinical and prior Pharmacy Annually May 1 of prior April 30 Clinical QHP Issuer DRAFT RECOMMENDATION April 14, 2016 Appendix 2 to Attachment 7

3 Measure Name Description Numerator Denominator Data Source PQI #16 Lower-Extremity Amputation among Patients with Diabetes Rate Hypertension Hospitalization Hybrid Measure Combine the following AHRQ PQI measures for the Hypertension Hospitalization Hybrid Measure: PQI #7 Hypertension Admission Rate PQI #8 Heart Failure Admission Rate PQI #13 Angina Without Procedure Admission Rate Combine AHRQ measure PQI #7, 8, 13 Controlling High Blood Pressure Asthma Hospitalization Hybrid Measure Combine the following AHRQ PQI measures for the Hypertension Hospitalization Hybrid Measure: PQI #5 COPD or Asthma in Older Adults Admission Rate PQI #11: Bacterial Pneumonia Admission Rate PQI 15 Asthma in Younger Adults Admission Rate Combine AHRQ measure PQI #5, 11, 15. Exclude COPD codes from PQI #5. HEDIS eligible Asthma Medication Ratio. Use age range of 18 s and older. QHP Issuer DRAFT RECOMMENDATION April 14, 2016 Appendix 2 to Attachment 7

4 Primary Care Physician Selection Primary Care Payment Strategies Primary Care Payment Strategies Membership Attributed to IHMs Measure Name Description Numerator Denominator Data Source Report by product in the health plan s business with a personal care physician (PCP) Report the number and percentage of attributed to providers for whom a payment strategy is deployed to adopt accessible, -driven, team-based care with accountability for improving triple aim metrics Report the number and percentage of attributed to providers for whom a payment strategy is deployed to adopt accessible, -driven, team-based care with accountability for improving triple aim metrics Report the number and percentage of in each product who are managed under an IHM who have selected or were assigned to a PCP attributed to a provider with a payment reform strategy attributed to a provider with a payment reform strategy managed under an IHM Total hip Total hip Total hip Total hip / financial / financial / financial Quarterly January 1 (quarterly reporting periods to be defined upon request by ) / quarterly reports as requested 2018 and and 2019 QHP Issuer DRAFT RECOMMENDATION April 14, 2016 Appendix 2 to Attachment 7

5 Membership Attributed to IHMs Hospitals reporting to CMQCC Hospitals meeting CalSIM goal for C-sections NTSV C- rate for each hospital Payment strategies for maternity services Opioid Adverse Events (Patients Treated with Naloxone) CAUTI Rate for small- Measure Name Description Numerator Denominator Data Source Report the number and percentage of in each product who are managed under an IHM Report hospital participation in CMQCC Report hospital performance for meeting CalSIM NTSV C- goal For the plan s of providing maternity services, report each hospital name, location, product (HMO, PPO, EPO), and NTSV C- rate Report number of paid under each type of payment strategy for maternity services and the denominator (total number of ) Report rate for each hospital: Opioid-related ADE caused by medical error and/or adverse drug reactions Rate Calculation: (Numerator / Denominator) x 100 Target-setting approach: six months historical for baseline; 25th percentile figure from PfP Campaign (e.g., based on AHA/HRET Hospital Engagement ) Report rate for below TBD denominator threshold: managed under an IHM reporting to CMQCC meeting CalSIM goal of NTSV C- rate at or below 23.9 percent NTSV C- deliveries paid under payment strategy or each payment strategy s treated with an opioid who received naloxone Total hip providing maternity services in providing maternity services in NTSV deliveries providing maternity services s who received an opioid (top 5-10 prescribed) / financial /CMQCC participant list /clinical submitted to CMQCC /clinical submitted to CMQCC /financial Clinical (medical record review, incident reporting systems, pharmacy reporting system) ; HQI proposed National Healthcare QHP Issuer DRAFT RECOMMENDATION April 14, 2016 Appendix 2 to Attachment 7

6 Measure Name Description Numerator Denominator Data Source denominator CAUTI Rate All Tracked Units - to evaluate improvement Rate Calculation: (Numerator / Denominator) x 1,000 healthcareassociated CAUTIs for all indwelling urinary catheter Safety (NHSN) or Partnership for Patients and prior CAUTI SIR for all excluding smalldenominator Urinary Catheter Utilization Ratio historical for baseline Report SIR for each hospital excluding small-denominator : CAUTI Standardized Infection Ration (SIR) All Tracked Units Relative performance Rate Calculation: Numerator / Denominator historical for baseline Report rate for each hospital: Urinary Catheter Utilization Ratio All Tracked Units Rate Calculation: (Numerator / Denominator) x 100 observed healthcareassociated CAUTIs for all indwelling urinary catheter predicted healthcareassociated CAUTIs for all (determined by NHSN) bed NHSN or Partnership for Patients NHSN or Partnership for Patients CLABSI Rate for smalldenominator CLABSI SIR for all excluding smalldenominator Lower ratios are generally associated with better performance and may also impact the CAUTI rate Report rate for each hospital below TBD denominator threshold: CLABSI Rate All Tracked Units Rate Calculation: (Numerator / Denominator) x 1,000 Target-Setting Approach: Twelve or twenty-four months historical for baseline (various possible sources: NHSN, 2013 CHART, 2014 CDPH) Report SIR for each hospital excluding small-denominator : CLABSI SIR All Tracked Units observed healthcareassociated CLABSIs for all observed CLABSIs for all central line expected CLABSIs for all NHSN, Department of Public Health (CDPH), or Partnership for Patients and prior QHP Issuer DRAFT RECOMMENDATION April 14, 2016 Appendix 2 to Attachment 7

7 Central Line Utilization Ratio Measure Name Description Numerator Denominator Data Source Rate Calculation: Numerator / Denominator historical for baseline (various possible sources: NHSN, 2013 CHART, 2014 CDPH) Report rate for each hospital: Central Line Utilization Ratio All Tracked Units Rate Calculation: (Numerator / Denominator) 100 central line (determined by NHSN) bed C. Diff Rate for smalldenominator Lower ratios are generally associated with better performance and may also impact the CLABSI rate Report rate for each hospital below TBD denominator threshold: Lab-Identified C. Diff Rate Rate Calculation: (Numerator / Denominator) 1,000 hospital-onset C. diff lab identified events for all bed and prior C. Diff SIR for all excluding smalldenominator SSI-Colon Rate for smalldenominator historical for baseline (various possible sources: NHSN, 2013 CHART, 2014 CDPH) Report SIR for each hospital excluding small-denominator : Lab-Identified C. Diff SIR Rate Calculation: Numerator / Denominator Target Setting Approach: Twelve months historical for baseline (various possible sources: NHSN, 2013 CHART, 2014 CDPH) Report rate for each hospital below TBD denominator threshold: Colon Surgery SSI Rate Rate Calculation: (Numerator / Denominator) 100 observed hospital-onset C. diff lab identified events for all SSIs related to colon surgeries (based on NHSN definition) expected hospital-onset cases of C. diff for all tracked units Inpatients having the colon procedures included in the NHSN operative procedure category and prior QHP Issuer DRAFT RECOMMENDATION April 14, 2016 Appendix 2 to Attachment 7

8 Measure Name Description Numerator Denominator Data Source SSI-Colon SIR for all excluding smalldenominator Hospital Reimbursement at Risk for Quality Performance Hospitals with Reimbursement at Risk for Quality Performance Members Using Wellness Benefit Members obese who are participating in a weight management program Members tobacco dependent who are participating in a smoking Target-Setting Approach: Twelve or twenty-four months historical for baseline (various possible sources: NHSN, 2013 CHART, 2014 CDPH) Report SIR for each hospital excluding small-denominator :: Colon Surgery SSI SIR Rate Calculation: Numerator / Denominator historical for baseline (various possible sources: NHSN, 2013 CHART, 2014 CDPH) Report the percentage of hospital performance at risk for quality performance (metrics may include but are not limited to HACs, readmissions, patient satisfaction, etc.) Report the number and percentage of with reimbursement at risk for quality performance (metrics may include but are not limited to HACs, readmission, patient satisfaction, etc.) Report the number and percentage of who have a preventive care visit ($0 member cost share) Report the number of obese who are participating in weight management programs Report the number of tobacco-dependent who are participating in smoking cessation programs observed SSIs for colon surgeries (based on NHSN definition) Hospital payment dollars tied to quality performance Hospitals with payment tied to quality performance Members incurring at least one preventive care visit/service obese who are participating in weight management program tobacco dependent participating in smoking predicted SSIs for colon surgeries (determined by NHSN definition) Total hospital payment dollars Total hip across all lines of hip excluding Medicare obese tobacco dependent Financial /financial Claim/ encounter Claims/ encounter Claims/ encounter Certification evalue8 RFI evalue8 RFI QHP Issuer DRAFT RECOMMENDATION April 14, 2016 Appendix 2 to Attachment 7

9 Measure Name Description Numerator Denominator Data Source cessation program cessation program QHP Issuer DRAFT RECOMMENDATION April 14, 2016 Appendix 2 to Attachment 7