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Health Care Quality Report Shows Increases in Teen Mental Health Screening and Immunizations for Adolescents

Health Care Quality Report Shows Increases in Teen Mental Health Screening and Immunizations for Adolescents

The number of Minnesota teens receiving a mental health screening increased between 2015 and 2016. Likewise, the number of Minnesota adolescents receiving recommended immunizations also increased from the previous year. These findings, and results of more than 30 individual clinical quality measures, are part of a new report published March 2 by MN Community Measurement (MNCM).

The annual MNCM Health Care Quality Report, now in its 13th edition, compares clinic, medical group and hospital performance on clinical measures related to preventive and chronic care, hospital care and health information technology. An objective of the Health Care Quality Report is to provide reliable information to support medical group quality improvement. An equally important objective is greater health care transparency by sharing results with the public at-large.

The report is at

“This report provides valid and reliable information to help consumers make informed decisions about their health care,” said Jim Chase, MNCM President. “This report also contains actionable, reliable and comparable information for providers to use in their efforts to improve patient care and outcomes.”

Examples of Health Care Quality Report results:

  • The statewide screening rate for Teen Mental Health Screening increased from 40 percent in 2015 to 64 percent in 2016. This is a 24 percentage point increase in adolescent patients receiving mental health and/or depression screening at a well-child visit. This means that 64 out of 100 youth ages 12 through 17 were screened for depression and other mental health conditions at their well child exams. The Teen Mental Health Screening measure notes how many patients age 12 through 17 were screened for social, emotional and behavioral disorders by their primary care provider at a well-child visit.
  • The statewide rate for Immunizations for Adolescents increased from 75 percent in 2015 to 85 percent in 2016. This is a 10 percentage point increase in adolescents receiving immunization. This means 85 of 100 adolescents had their meningococcal and either Tdap or Td vaccines by their 13th birthday. This measure is calculated both on a statewide basis as noted above, and also an average of all medical groups reporting. The rate of Immunizations for Adolescents by all reporting medical groups, and reported on, is 87 percent. The Immunizations for Adolescents measure shows how well Minnesota health care providers performed in keeping adolescents current on meningococcal (meningitis) and either Tdap (tetanus, diphtheria and pertussis) or Td (tetanus and diphtheria) vaccines.

“These results show that when Minnesota providers focus on a particular area, there can be a substantial positive impact,” said Chase.

Additional Health Care Quality Report key results

Two clinical measures showed noticeable improvement in their statewide rates:

  • Pediatric Preventive Care: Overweight Counseling – The statewide rate increased from 85 percent in 2015 to 89 percent in 2016.
  • Optimal Asthma Control – Adults – The statewide rate increased from 52 percent in 2015 to 55 percent in 2016.

Thirteen other clinical measures showed some small improvements in their statewide rates. Measures with increases or noted improvement include Childhood Immunization Status (Combo 3); Chlamydia Screening in Women; Appropriate Testing for Children with Pharyngitis; Appropriate Treatment for Children with Upper Respiratory Infections; Colorectal Cancer Screening; Breast Cancer Screening; Use of Spirometry Testing in the Assessment of Chronic Obstructive Pulmonary Disease; Follow-up Care for Children Prescribed Attention Deficit Hyperactivity Disorder (ADHD) Medication; Total Knee Replacement pre-op and post-op; Spinal Surgery Discectomy/Laminotomy Functional Status; Spinal Surgery Discectomy/Laminotomy pre-op and post-op; Spinal Surgery Lumbar Fusion pre-op and post-op and Maternity Care: C-Section Rate.

Six medical groups achieved rates that were above average for a cluster of primary care measures. Julie Gerndt, MD, is Chief Medical Officer at Mankato Clinic and was not surprised that Mankato Clinic was among the high performing medical groups across Minnesota.

“We expected to do well based on the commitment we made as an organization several years ago to redesign our care model for better patient outcomes,” said Dr. Gerndt. “That work is paying off.”

Park Nicollet Health, HealthPartners Clinics, Mankato Clinic, Stillwater Medical Group, Fairview Health Services and Allina Health each achieved above-average rates on at least half of the primary care clinical measures.

“These results validate that if you keep working at this over time and make it a priority, you can have an impact,” said Dr. Gerndt.

The Health Care Quality Report is organized for ease of use to both the clinician and the public at-large. The report contains easy to read tables for specific conditions or procedures, grouped by large and moderate improvement, increase or decrease. Trends are noted where a trend exists. More than 300 medical groups and 1,600 clinics are registered to submit data to MNCM. The annual Health Care Quality Report is a compilation of all measures publicly reported by MNCM during the year. Individual medical group results are also available year-round at

About Us

MN Community Measurement is a non-profit organization dedicated to improving health by publicly reporting health care information. A trusted source of health care data and public reporting on quality, cost and patient experience since 2003, MNCM works with medical groups, health plans, employers, consumers and state agencies to spur quality improvement, reduce health care costs and maximize value. Learn more at


2017 Health Information Technology (HIT) Ambulatory web survey opens February 15

The 2017 Health Information Technology (HIT) Ambulatory web survey opens February 15, 2017. This survey is an annual reporting requirement established in the Minnesota Statewide Quality Reporting and Measurement System (SQRMS) by the Minnesota Department of Health (MDH) through Minnesota Rules, Chapter 4654. All Minnesota physician clinics must complete the 2017 HIT Ambulatory Clinic Survey between February 15, 2017 and March 16, 2017.

MNCM will post a PDF version of the survey in two locations: under the “Resources” tab in the Data Portal and on the MNCM website at (Submitting Data, Provider Tools, then Online Resources). To reduce data entry time, MNCM highly recommends that respondents gather all responses on a paper copy prior to web entry.  Please note that due to required survey settings, respondents cannot start a web survey entry and then “resume” at a later date. The survey must be completed in one sitting.

Results from the survey are used by MDH, MN e-Health Initiative, MNCM and others to report the status and use of electronic health records, health information exchange, and other health information technology across Minnesota.

Physician clinics will receive an email communication from MNCM with a link to the web version survey in mid-February. Those with questions can contact Dina Wellbrock of MNCM at mailto:wellbrock@mnc.organd (612) 454-4829.


MNCM Measure Re-Endorsed by NQF

The National Quality Forum (NQF) has endorsed four measures related to cardiovascular conditions. Six measures were evaluated against NQF’s endorsement criteria. Among the four measures that received endorsement was the Optimal Vascular Care (OVC) composite measure from MN Community Measurement. Of the endorsed measures, one was a new measure and MNCM’s OVC measure was among three that were re-endorsed. A complete list of NQF cardiovascular measures can be viewed on the project page.


First-in-the-Nation Health Care Cost Comparison Highlights How Minnesota Compares to Other Regions

A first-ever comparison of what commercial insurers are paying for healthcare in different regions shows wide variation in spending. This report is valuable as a first attempt to compare costs across regions.

The report from the Network for Regional Healthcare Improvement (NRHI), a national organization of local groups working to improve healthcare, analyzed spending by commercial health insurance plans in five different regions nationwide (Utah, Maryland, St. Louis, Minnesota and Oregon). Analysts found a $1,080 yearly difference in the amount plans spend, on average, per enrollee, with a high of $369 per-enrollee-per-month in Minnesota and a low of $279 in Maryland.

“Identifying regional differences in healthcare costs is important because high costs are depleting family budgets. Entire communities pay the price as money that could go to schools, housing and other needs are instead eaten up by healthcare costs. This information will enable physicians to identify cost drivers, address them, and get better outcomes. This enables a transformation in healthcare delivery, enabling better care decisions while potentially saving individuals, employers and other private payers hundreds of millions of dollars.” Elizabeth Mitchell, president and CEO of NRHI

Regional variation on medical spending has long been shown to exist in the Medicare market, but differences in the amount commercial insurers pay for care has been difficult to decipher, because multiple insurance plans participate in a single market.  This project was important as a technical learning opportunity about how to standardize reporting across regions.

The data within the report are detailed in From Claims to Clarity: Deriving Actionable Healthcare Cost Benchmarks from Aggregated Commercial Claims Data, which was developed with support from the Robert Wood Johnson Foundation.


MNCM Seeks to Become a CMS Registry to Assist in MIPS Quality Payment Programs

MNCM has made progress in preparing for providing significant value to the community under MACRA. For years, MNCM’s role has been as the central point for quality measurement and data collection and reporting from clinicians to the State and Health Plans for various programs and reporting requirements. Work is now underway to include reporting to CMS for MIPS.

CMS Registry Application

MNCM submitted an application to become a Qualified Clinical Data Registry (QCDR). Currently and in the past, submitting to MNCM has allowed clinicians to attest they are meeting some of their CMS meaningful use requirements. With some modifications to our system, making this transition as a MIPS registry is feasible and a natural next step.

QPP Measures

Several MNCM developed measures have a CMS QPP (Quality Payment Program) number and can be used locally and nation-wide. Additionally, data elements from the Diabetes (A1C) and Vascular (Ischemic IVD) measures also have a QPP number. Specifically:

  • Q113 Colorectal Cancer Screening
  • Q370 Depression Remission at 12 Months*
  • Q371 Depression Utilization of the PHQ-9Tool
  • Q411 Depression Remission at 6 Months*
  • Q398 Optimal Asthma Control*
  • Q001 Diabetes: Hemoglobin A1C* (from ODC measure)
  • Q204 Ischemic IVD (from OVC measure)

*Denotes CMS priority classification “Outcome/High Priority”

Additional QCDR Measures

QCDR’s also have the ability to add additional community measures that may not yet have a QPP number but may also be considered as CMS “credit”. MNCM has asked that the MNCM NQF endorsed measures be included. These are:

  • NQF0729 Optimal Diabetes Care
  • NQF0076 Optimal Vascular Care
  • NQF2643 Lumbar Spine Fusion-Avg. Change in Functional Status Following Procedure
  • NQF2653 Total Knee Replacement-Avg. Change in Functional Status Following Procedure
  • NQF 1885 Depression Response at 12 Months
  • NQF 1884 Depression Response at 6 Months

MNCM is pleased with the progress made so far, and will be providing further detail regarding the registry process and programmatic details. Stay tuned!


Additional Hospital Measures Released

MN Community Measurement (MNCM) recently published new results for two hospital-based health care quality measures and a refresh of five existing readmission measures. This information can be used to compare hospitals within Minnesota with state and national averages.

The results are available at MNCM’s public reporting website

The two quality measures are relatively new composites that are required by Centers for Medicaid and Medicare Services (CMS).

Value Based Purchasing Composite

The Hospital Value-Based Purchasing (VBP) composite measures the performance of acute-care hospitals on the quality of care they provide to Medicare beneficiaries, how closely best clinical practices are followed and how well hospitals enhance patients’ experiences of care during hospital stays.

The VBP measure combines results from different measure components into a single score for a hospital. A hospital score can range between 0 and 100. The statewide score is 46.0. A hospital’s performance rating is a comparison to the statewide score and is noted as “above average” (better), “below average” (worse) or “average” (the same). This information is from patients seen between January 1, 2015 and December 31, 2015.

Hospital Acquired Conditions Composite

One way to measure hospital quality is to see how many patients developed infections or other specific health issues as a result of their hospital stay, such as bloodstream infections, pressure ulcers, surgical complications, kidney damage, blood clots and other serious conditions.

The Hospital Acquired Conditions Composite measure combines results from different measure components into a single rating for the hospital. A hospital score can range between 1 and 10. The statewide score is 4.94. A hospital’s performance rating is a comparison to the statewide score and is noted as “lower than average” (better), “higher than average” (worse) or “average” (the same). This information is from patients seen between January 1, 2015 and December 31, 2015.

Refreshed Data

Additionally, MNCM refreshed data for five readmission measures for the period of July 1, 2012-June 30, 2015. Measures with refreshed data include Chronic Obstructive Pulmonary Disease (COPD), Heart Failure,    Acute Myocardial Infarction (AMI), Pneumonia and Knee or Hip Surgery.

Results for these and other health care quality measures are available at MNCM’s public reporting website


Equity Report Shows Continued Gaps in Health Care for Many Minnesotans

For many Minnesotans, good health can be elusive, especially for people of color and new immigrants. Health care outcomes vary widely based on where a person lives, their race, preferred language or country of origin, according to a new report from MN Community Measurement (MNCM).

The 2016 Health Equity of Care Report pinpoints distinct differences in health care between numerous patient populations and geographic regions across Minnesota. Results in the 2016 Health Equity of Care Report clearly show that some racial, ethnic, language and country of origin groups have consistently poorer health care outcomes than other groups. The report also shows how those rates vary by medical group across the state and gives examples of what groups are doing to improve outcomes for their patients.

“Minnesota is one of the healthiest states in the nation, at the same time we have some clear and persistent inequities in health status,” said Jim Chase, MNCM President. “Patients from specific geographic regions and populations, including those in Greater Minnesota, people of color, people who identify as Hispanic, immigrants and people who do not speak proficient English are less likely to receive preventive screenings and more likely to suffer from negative health outcomes.”

The third annual Health Equity of Care Report released by MNCM provides a new benchmark in understanding health inequity in Minnesota. The report is at

The report’s major findings include:

  • White patients generally had better health care outcomes across most measures and most geographic areas.
  • Patients in Greater Minnesota overall had poorer health outcomes than patients in the 13-county Metro area.
  • Patients born in Asian countries tend to have better outcomes across multiple quality measures and geographic regions than patients in other country of origin groups.
  • Generally, patients from large medical groups in the Metro area had higher rates of optimal care.
  • Across measures and geographic areas, American Indian or Alaska Native and Black or African American patients generally had the lowest health outcomes both statewide and regionally.
  • Hispanic patients generally had poorer health care outcomes than non-Hispanic patients across all quality measures and most geographic regions.
  • Patients born in Laos, Somalia and Mexico generally had poorer outcomes than other groups.
  • Patients who preferred speaking Hmong, Somali and Spanish generally had lower screening and care rates compared to other preferred language groups.

Despite the somewhat stark results, examples of success exist and several such examples are featured in the 2016 Health Equity of Care Report. South Lake Pediatrics is highlighted in the report as one such example for their positive results for numerous populations for the Optimal Asthma Control for Children measure.

“We are very proud of our asthma work,” said Laura Saliterman MD, with South Lake Pediatrics. “A great deal of effort has gone into our asthma program and it has produced great results for our patients.”

The 2016 Health Equity of Care Report contains information collected from patients seen for appointments at medical groups throughout Minnesota, and evaluates health care quality in seven areas. Results for the seven health care quality measures were segmented by race, Hispanic ethnicity, preferred language and country of origin. These measures are further reported at statewide, regional and medical group levels. The seven measures are: Adolescent Mental Health and/or Depression Screening, Adolescent Overweight Counseling, Colorectal Cancer Screening, Optimal Asthma Control for Adults, Optimal Asthma Control for Children, Optimal Diabetes Care and Optimal Vascular Care. The Adolescent Mental Health and/or Depression Screening and Adolescent Overweight Counseling measures are new in the 2016 Health Equity of Care Report.

“To reduce and eliminate the barriers to health equity, we must understand where they exist and their scope,” said Chase.


This report is unique because medical groups across the state report the data in a standardized format, which allows MNCM to compare results across medical groups and regions.

MNCM released The Handbook on the Collection of Race/Ethnicity/Language Data in Medical Groups in 2008. This handbook defined and standardized the information that is to be collected from patients by clinics and medical groups, as well as set best practices for collection and reporting. Since then, Minnesota providers have steadily improved their collection and reporting of race, ethnicity, language and country of origin (REL) data. In 2016, nearly all Minnesota providers submitted REL data to MNCM and most did so using best practices. Only data from medical groups who have successfully demonstrated to MNCM that they follow these best practices is included in the Health Equity of Care Report.

Understanding why the gaps exist from one group to another and what can be done to reduce the barriers to optimal health are the reasons behind the MNCM effort to collect and report this information. Specific questions of why, and what is being done, according to Chase, are questions best answered by the state’s medical groups and others health equity advocates.

“We share this report with the community so that advocates, policymakers, public health professionals, communities of color and medical groups can take the necessary steps toward addressing the unique health concerns of their patients, stakeholders and constituents,” said Chase.

About Us

MN Community Measurement is a non-profit organization dedicated to improving health by publicly reporting health care information. A trusted source of health care data and public reporting on quality, cost and patient experience since 2003, MNCM works with medical groups, health plans, employers, consumers and state agencies to spur quality improvement, reduce health care costs and maximize value. Learn more at



NQF Names Shantanu Agrawal MD, as New President and CEO

The National Quality Forum (NQF) Board of Directors has selected Shantanu Agrawal, MD, as the organization’s new president and chief executive officer (CEO). NQF is a non-profit, non-partisan, public service organization that reviews, endorses and recommends use of standardized health care performance measures. NQF also advises Medicare on measures to include in their value-based purchasing programs with physicians.

Jim Chase, President of MNCM, serves as Vice Chairman of the NQF Board of Directors. Chase joined the NQF Board in January 2014.

“Shantanu understands the importance of advancing quality and patient safety both from the frontlines of medicine and from a national policy perspective,” said Bruce Siegel, MD, MPH, NQF Board chair and president and CEO of America’s Essential Hospitals. “He is the innovative, passionate, focused visionary that NQF needs now to ensure that we respond strategically and effectively to the nation’s changing healthcare landscape.”

A board-certified emergency medicine physician who has worked in both academic and community settings, Dr. Agrawal is the former deputy administrator and director for the Centers for Medicare & Medicaid Services’ (CMS) Center for Program Integrity (CPI). Dr. Agrawal succeeded Helen Darling, NQF interim president and CEO, as of January 30, 2017.

“NQF was created 16 years ago by private- and public-sector leaders out of their shared sense of urgency about the impact of healthcare quality on patient outcomes, workforce productivity, and healthcare costs. These issues, and NQF’s role to address them, are just as urgent today, if not more so,” said Dr. Agrawal.

Dr. Agrawal completed his undergraduate education at Brown University, medical education at Weill Medical College of Cornell University, and clinical training at the Hospital of the University of Pennsylvania. He has a master’s degree in social and political sciences from Cambridge University.


Save the Date – 9.13.17 – for the 2017 MNCM Annual Seminar

Get your datebook, update your smartphone and sync your calendar to “Save The Date” of Wednesday, September 13, 2017, for the MN Community Measurement (MNCM) Annual Seminar.

Plans are underway to build upon the successful 2016 MNCM Annual Seminar (remember Ann Bancroft) and deliver a series of speakers, interactive discussions, networking and professional development opportunities for a wide swath of quality measurement advocates and implementers.

This one-day annual educational event will once again occur at the Earle Brown Heritage Center, just a few miles north of downtown Minneapolis in Brooklyn Center, MN. Stay tuned for additional details about the 2017 topics and featured speakers.

Save the date, September 13, 2017. See you there!


MN Community Measurement Seeks to Become Qualified CMS Registry to Assist with Clinic MACRA Medicare Quality Payment Program Needs

MN Community Measurement (MNCM) is in the process of becoming a CMS qualified registry so that clinics currently submitting data to MNCM on existing MNCM measures can meet their Federal needs to submit results for at least six quality measures* for 2017 performance period for the Merit-based Incentive Payment System (MIPS). MNCM has several measures that are NQF endorsed and currently used in Federal programs such as the Physician Quality Reporting System (PQRS).

Three of the MNCM depression measures and the asthma measure are in MIPS. The components of the diabetes (AIC component) and vascular (aspirin component) measures as well as the colorectal cancer screening measure are also included in MIPS and can be calculated from data currently submitted to the MNCM Data Portal. Other MNCM NFQ endorsed measures are also in the process of being evaluated for MIPS eligibility for Minnesota providers. Much of the work done by the Minnesota community on patient reported outcome measures, such as in depression or post procedural change in function, will become increasingly more important in MIPS. MNCM will be providing more information throughout the first quarter of 2017. Stay tuned!

* The minimum number of measures required in 2017 is six and includes two outcome measures.


Graves Joins MN Community Measurement Board

Bentley GravesMN Community Measurement (MNCM) welcomes Bentley Graves as its newest board member. He is Director of Health Care and Transportation Policy at the Minnesota Chamber of Commerce.  Graves worked for nearly eight years on Capitol Hill in Washington, DC. His policy experience includes work on small business concerns, health care, transportation, taxes, education, foreign affairs, defense, and federal appropriations. Graves graduated cum laude from Hillsdale College in Michigan with a degree in Political Economy, is a member of the Consumer and Small Employer Advisory Committee of MNsure, the state’s health insurance exchange, and a member of the Advisory Panel for Own Your Future, an initiative designed to help Minnesotans prepare for their Long Term Care needs.


MN Community Measurement Publishes 2017 Measures

MN Community Measurement (MNCM) has published the Slate of Measures for Public Reporting in 2017. The complete list can be found on the MNCM website ( and this link.

The annually updated listing of ambulatory and hospital measures was approved by the MNCM Measurement and Reporting Committee (MARC) and the MNCM Board of Directors in December 2016.

One measure was retired, Appropriate Testing for Children with Pharyngitis.

Five measures will be evaluated in 2017 for potential retirement. The five measures to be considered for retirement are Appropriate Treatment for Children with URI (HEDIS measure), Follow-up Care for Children Prescribed ADHD Medication (HEDIS measure), Use of Spirometry Testing in Assessment and Diagnosis of COPD (HEDIS measure), Maternity Care C-Section Rate (DDS measure) and Pediatric Preventative Care Overweight Counseling (DDS measure).