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Spine Measure Redesign Recommendations Approved by MARC

In March, MNCM’s Measurement and Reporting Committee (MARC) approved several recommendations for the redesign of the spine surgery measures. Consideration of redesign was sparked by a request from the Centers for Medicare & Medicaid Services (CMS) who have adopted six MNCM spine measures into the Quality Payment Program. The evolution of these measures offered an opportunity for benchmarking capability and stability.

The spine measure redesign workgroup, led by Paul Huddleston from Mayo Clinic, reached consensus on several redesign recommendations that will enhance measure use and reporting.

The scope of work included three tasks:

  1. Consider a target-based measure construct for measures of functional status and pain
  2. Expand the denominator for the discectomy/laminotomy population
  3. Discuss the usability/value of the quality of life measures with PROMIS Global-10

After several meetings with thorough discussion, review of extensive data analysis and numerous constructs, the workgroup reached consensus on the following recommendations:

Modify the current measure constructs for functional status, back pain, and leg pain

Recalculation of existing data (no change in elements submitted).

  • Functional status is less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI).
  • Back pain is less than or equal to 3.0 OR a change of 5.0 points or greater on the VAS Pain scale.
  • Leg pain is less than or equal to 3.0 OR a change of 5.0 points or greater on the VAS Pain scale.
  • Patients who are not assessed remain in the denominator and are counted as not meeting the target.
  • MARC requests additional monitoring of average pre-op scores as a proxy for appropriateness.

Expand the discectomy/laminotomy denominator population

It is very likely that medical groups are not using CPT codes to determine which patients to administer pre-operative assessments to; proceed forward with expanded denominator definition and delay public reporting.

  • Expansion of denominator from single CPT code 63030 to include all the following discectomy/laminectomy CPT procedure codes: 63005, 63012, 63017, 63030, 63042, and 63047. No narrowing by diagnosis. Name changed to discectomy/ laminectomy to reflect expanded population.
  • Add the same exclusions currently used for the lumbar fusion population; spine related cancer, fracture or infection and scoliosis (neuromuscular, idiopathic, or congenital).
  • No submission for discectomy/laminectomy 2018 dates of procedure. Submit 2019 dates of procedure in 2020 for private reporting.
  • Change in submission timeframe more appropriate for this measure with a shorter assessment period.

MARC, a subcommittee of the MNCM Board of Directors, approved these amended recommendations March 13, 2019. Measure changes pending final Board approval in May 2019.

For more information, please refer to the summary report and measurement specification example.

Feedback about these changes will be accepted at until Friday, April 12, 2019. Questions can be directed to


MNCM Welcomes Dr. Anne Pearson as New Board Member

Dr. Anne PearsonMNCM is pleased to welcome Anne Pearson, MD, CPE as the newest members of its Board of Directors.
Anne Pearson is the Vice President, Medical Director of Provider Integration at Fairview Health Services. In her role, Dr. Pearson is responsible for the integration of two legacy medical groups comprised of 1,400 employed providers. In addition to her leadership role, Dr. Pearson is a family medicine physician. She sees patients at the HealthEast clinic in Vadnais Heights.

Dr. Pearson attended the Loyola Stritch School of Medicine in Chicago and completed her residency in family medicine at the University of Minnesota. She is an experienced medical leader who has served in a variety of roles including site medical director, regional medical director, and vice president of the HealthEast Medical Group/executive medical director for primary care. In 2014, Dr. Pearson become a Certified Physician Executive (CPE) through the American Association of Physician Leaders. In 2017, she received her Lean Bronze Certification.

Dr. Pearson served on the HealthEast System Board of Directors for six years and is currently on the Board for the Community Health Network, an Accountable Care Organization (ACO).

Dr. Pearson has a passion for improving quality and patient experience. She has chaired the ambulatory quality committee at HealthEast and served on the quality committee of the Board. She been a part of care redesign work at HealthEast and Fairview and is also part of the customer experience team at Fairview. Much of her focus has been guiding providers to put the patient at the center of improvement work including a focus on achieving quality outcomes, advancing access work, and partnering to think differently about how our care teams work together to serve patients.


MNCM Welcomes New Measurement Reporting Committee (MARC) Co-Chair

MNCM is pleased to welcome Rahshana Price-Isuk, MD as the new co-chair of MARC. Dr. Price-Isuk is a board-certified practicing family physician and medical director at Neighborhood Healthsource, an urban primary care clinic system in Minneapolis organized as a Federally Qualified Health Center with a mission to provide affordable, quality health care to underserved communities. She has been an actively engaged MARC member for over six years. She joins Howard Epstein, MD, senior VP & Chief Medical Officer at PreferredOne who serves as the other co-chair.


MNCM Adopts 2019 Slate of Measures for Public Reporting

In December, MNCM’s Measurement and Reporting Committee and its board of directors approved the slate of measures for public reporting in 2019. The measures listed on the 2019 slate are similar to last year with a few updates. First, the Controlling High Blood Pressure HEDIS measure will not be publicly reported in 2019 due to substantial changes to the measure specifications; public reporting will resume in 2020. In 2020, adolescents will be added to the suite of depression outcome measures reported in 2020 and the new Symptom Control During Chemotherapy measure will also be reported. To view the 2019 slate, click here.


Clinic and Provider Registration and Direct Data Submission Deadlines

All eligible Minnesota clinics and providers are required to register and update their information in MNCM’s data portal. Although the deadline has passed, you may still register.

Instructions are available from the MNCM Data Portal Resources tab. Registration is a prerequisite to submitting data for the clinical quality measures in 2019. Measures submitted in Cycle A will be wrapping up in February.

More on Clinic and Provider Registration and Direct Data Submission Deadlines »


MNCM Releases Report on Quality of Care for Chronic Conditions; Preventative Care Report Coming Soon

In December, MNCM released the second in a series of topic reports, “Quality of Care for Chronic Conditions in Minnesota.” This report presents data collected in 2018 on quality measures for chronic disease care, including comparisons by medical group and clinic. While Minnesota has some of the best health indicators in the country, measurement results show a pattern of wide variation in health care quality overall and significantly different outcomes among some patient populations. View the report here.

The third in our new report series focuses on preventive health screening measures and is expected to be released at the end of January.

These reports bring together performance results on both quality and health equity for measures relevant in each category. The series is intended to provide a user-friendly view of measure results to highlight the wealth of data that MNCM collects, engage stakeholder audiences more effectively and catalyze improvement. Watch for the press release soon!


MNCM is Seeking Workgroup Members for Cost Measure Development Group

MNCM is investigating the feasibility and value of adding an episodes of care cost measure to the current Cost and Utilization suite of measures that is produced annually and is convening a workgroup to advise this project. The scope of the workgroup’s discussion will include risk adjustment, attribution and reporting options. Recommendations will be delivered to the Cost Technical Advisory Group and to the Measurement and Reporting Committee (MARC).

We are looking primarily for medical group participants. No technical expertise in episodes of care is required.

The time commitment is 6-9 months with virtual monthly meetings. If you are interested or have questions, please contact Gunnar Nelson at by February 7.


MNCM in the News

MN Community Measurement’s second topical report – “Quality of Care for Chronic Conditions” – was featured on Minnesota Public Radio (MPR) in a piece titled Report: Treatment quality varies widely for expensive chronic conditions. The report was also featured in the Star Tribune in a piece titled Clinics’ grades go down slightly in Minnesota. The articles draw attention to the importance of measuring chronic conditions. With approximately 60% of adults in the U.S. struggling with a chronic condition, treating them makes up a vast majority of the nation’s health care spending.


MNCM 2019 Leadership and Board Announcements

On December 13, the MNCM board of directors approved the election of Beth Averbeck, MD, Senior Medical Director of Primary Care at HealthPartners, as MNCM Board Chair. The board also approved the election of Mark Matthias, MD, Vice President of Medical Affairs and Acute Care Division at CentraCare to serve as MNCM Vice Chair. Both officers will serve in their appointed roles for two-year terms.

MNCM board members continuing to serve in 2019 include:

  • Joseph Bianco, MD, Director, Primary Care, Essentia Health
  • Cara Broich, RN, CPHQ, Senior Director, Quality and Clinical Advancement, Medica
  • Jon Christianson, PhD, James A. Hamilton Chair in Health Policy, School of Public Health, U of M
  • Kevin Croston, MD, Chief Executive Officer, North Memorial Health
  • Howard Epstein, MD, SFHM, Executive Vice President and Chief Medical Officer, PreferredOne
  • Bentley Graves, Director, Health Care and Transportation, Minnesota Chamber of Commerce
  • David Homans, MD, Minnesota Hospital Association Representative
  • Deb Krause, Vice President, Minnesota Health Action Group
  • Mariam Mohamed, Consumer Representative
  • Dan Trajano, MD, MBA, Senior Medical Director, BlueCross BlueShield of Minnesota
  • Mary Ellen Wells, FACHE, Consumer Representative
  • Brian Whited, MD, MBA, Vice Chair-Operations, Mayo Clinic Health System
  • Pam Houg, Office Manager, Minnesota Council of Health Plans (ex officio)
  • Lawrence Massa, President, Minnesota Hospital Association (ex officio)
  • Claire Neely, MD, President and Chief Executive Officer, Institute for Clinical Systems Improvement (ex officio)
  • Jim Schowalter, President and Chief Executive Officer, Minnesota Council of Health Plans (ex officio)
  • Janet Silversmith, Chief Executive Officer, Minnesota Medical Association (ex officio)
  • Julie Sonier, President, MN Community Measurement (ex officio)

The MNCM board of directors represents the breadth and depth of the many stakeholder groups we are proud to serve and we extend our thanks to them for their service to our community.

Beth Averbeck Beth Averbeck, MD
HealthPartners Medical Group
Senior Medical Director of Primary Care

Dr. Averbeck is an executive physician leader with extensive experience in organizational culture, clinical operations, governance, quality improvement, measure development, and physician resilience. She joined HealthPartners in 1992 as a practicing internist and is now responsible for HealthPartners primary care practice overseeing 400 clinicians in over 40 practice locations. She maintains a clinical practice in geriatrics.

Her leadership in redesigning ambulatory care has been recognized by the American Medical Group Association (AMGA) which named HealthPartners Medical Group the recipient of the Acclaim Award, its highest honor, in 2006 and 2012. In 2010, Dr. Averbeck and her team were honored with an Acclaim Award honoree for their work reducing health disparities.

Dr. Averbeck earned a bachelor’s degree at St. Olaf College in Northfield, Minnesota, and earned a Doctor of Medicine from the University of Minnesota Medical School. She serves on the boards of Minnesota Community Measurement, the Institute for Clinical Systems Improvement, and the American Medical Group Association.


Mark MatthiasMark Matthias, MD
CentraCare Health
Vice President of Medical Affairs and Acute Care Division

Mark joined St. Cloud Hospital in 2011 as Vice President of Medical Affairs and in October 2015 became Vice President of Medical Affairs and Acute Care Division.

He trained at the University of Minnesota Medical School and completed his residency in Family Practice and Community Health at Methodist Hospital in St. Louis Park. Mark has been a physician leader in Mankato, Hutchinson, and Willmar.


MN Community Measurement Releases Report on Quality of Care for Chronic Conditions

MN Community Measurement (MNCM) has released a new report highlighting quality of care for chronic conditions. The report, “Quality of Care for Chronic Conditions,” presents data collected by MNCM in 2018 on quality measures for chronic disease care, including comparisons by medical group and clinic.

Key Findings of the Report

While Minnesota has some of the best health indicators in the country, measurement results show a pattern of wide variation in health care quality overall and significantly different outcomes among some patient populations. Key findings of the report include:

  • Statewide results for all chronic condition measures have been relatively stable over the last three years but show continued room for improvement. See page 8 of the report.
  • Rates are, on average, significantly better for patients with chronic conditions who live in metro areas. For example, patients with asthma who live in small town or rural areas have the lowest rates. See page 10 of the report.
  • In general, measures of how well chronic conditions are managed mostly improve with age. For example, the highest rates occur among people age 60 and older with ischemic vascular disease. See page 11 of the report.
  • Outcome rates vary by race and Hispanic ethnicity. In general, rates for diabetes vascular and asthma are lower for American Indians, African Americans, and Hispanics. See page 13 of the report.

The report also presents results by gender and language.

The measures were developed or selected for their potential to reduce the modifiable risks and complications associated with these conditions. National and state statistics illustrate the need for improvement in care.

  • Roughly 151 million adults in the United States are physically, emotionally, and financially affected by chronic disease.
  • 60 percent of adults in the United States have a chronic disease and 40 percent of adults have two or more. This number is predicted to increase rapidly in future years.
  • Chronic diseases such as diabetes, heart disease, stroke, or cancer are leading causes of death and disability in the United States.
  • In Minnesota, those diagnosed with chronic conditions accounted for 83 percent of all medical spending in the state in 2012, with an average of $12,800 in health care spending per person.

Although statewide rates have been relatively stable, the report also illustrates substantial variation across health care providers (page 9 of the report). MN Community Measurement President Julie Sonier says, “The reason we do this work is to provide health care decision makers with information that can be used to improve health outcomes. Many health care providers in Minnesota have been very successful in this effort, and we should look to spread these stories of success.”

Measurement Matters

Andrea Walsh, president and chief executive officer of HealthPartners, one of the highest performing medical groups across most measures in Minnesota, says that data drives progress.

“High quality care doesn’t just happen. It’s a continual process that’s guided by data to drive improvement and innovation across our system so that we can better serve patients,” she explains. “This report recognizes the work we’ve done to improve treatment of chronic conditions and pushes us to do better, especially our focus in reducing health disparities among diverse racial and ethnic communities.”

Read the full report.