Welcome to today's webinar. My name is Rajesh Garg. This webinar is co-hosted by the ADA's Healthcare Delivery and Quality Improvement Interest Group and the Primary Care Interest Groups. Just a little bit about myself. I'm currently a professor of medicine at the UCLA's School of Medicine in Los Angeles. I head the diabetes section at Harvard UCLA Medical Center. I'm also the current chair of ADHS at CDQI, which is Healthcare Delivery and Quality Improvement. I have spent the last two decades trying to improve the quality of diabetes care, both in the outpatient setting and in the inpatient setting. I'm currently on several ADA committees and ACE committees, and so we try to see how we can further improve diabetes care. I'm here with my colleague, Azita Zahir, and I'll let her introduce herself. Thank you, Rajesh. Hello, everyone. I'm very much delighted to be part of today's conversation and webinar. My name is Azita Zahir, and I'm a chair-elect of the Primary Care Interest Group of ADA. To share a little bit about myself, I'm trained as a pharmacist. Also, I received training on regulatory and compliance in pharmaceutical care. Currently, I work as clinical pharmacist with Lakeside Medical Group, part of Heritage Provider Network in Southern California, and I manage diabetic patients in collaboration with Primary Care Division of the Lakeside. I'm looking forward to today's conversation and engaging distinguished panelists and our audience. Thank you for joining us. So, here is a glance at today's agenda. We'll provide introductions and a few announcements, and then we'll have two really great speakers from NCQA. We have been waiting for them for several months, and finally, we got them, and then there will be time for a few question-and-answers. There will be time for a few question-and-answers, and you can type your questions or put it in the chat. So, the presenters will be taking questions from the audience at the end of the event. Please don't wait until the end of the session to send your questions. Go ahead and type it in the Q&A box in your control panel. Please be sure to use the Q&A box and not the chat function for the questions. During this announcement segment, we will use the chat box to send the important links, and you can use this place to chat with other attendees. Another benefit of ADA membership is connecting with the members of the interest group on Diabetes Pro-Member Forum, continue conversation about the topics covered in this webinar. Please see the link in the chat now. All right. So, finally, it's my distinct pleasure to introduce our panelists today. Dr. Caroline Plonk, she is a highly accomplished pediatrician. She was a professor of medicine at New York Langone Hospital Health System before she joined NCQA, and she has been a member of the Langone Hospital Health System before she joined NCQA. And before that, she was, I think, at University of Michigan, where she was professor and assistant dean of population health, and she was leading Medicare, managed care, ACOs, and several programs and new initiatives which she has, you know, led over the years. She has contributed quite a bit to national policy on system redesign and quality of care for older adults, and we are really happy that we have this opportunity to listen to Dr. Plonk. Our second speaker is Emily Hubbard. Emily is a senior research associate at the NCQA's Chronic Disease, Chronic Condition Center, and she is focusing on digital quality measure to enhance diabetes, kidney, and prenatal care. She has been there with NCQA for about six years, and she has led initiatives like Digital Quality Summit, A Type 2 Diabetes and Heart Failure Roundtable Discussion, and Kidney Health Toolkit. Emily holds dual bachelor's degree in anthropology and public and non-profit administration from Grand Valley State University, and she is also pursuing her MPH in epidemiology at the George Washington University. So, it's really, we are looking forward to this webinar. I'll hand it over to Dr. Plonk. Okay, great. Thank you very much, Dr. Garg, and hello, everyone. Good afternoon. So, I guess we can start the slides. There we go. So, we're going to be talking about best practices in measuring diabetes care. Next slide. And I'll be talking a little bit about NCQA and measurement science to sort of level set and set some background. And then we'll be talking about HEDIS. Everybody's interested in HEDIS for diabetes. We'll talk about that. And then Emily will be talking about the Diabetes Recognition Program for clinicians that several of you may be familiar with and how we're updating it. So, next slide. So, let's talk a little bit about measurement science to sort of level set. Many people joining today may be interested in measurement. Next slide. So, what is NCQA? You've probably heard of it. NCQA is sort of a nonprofit agency with the mission to improve the quality of healthcare. And we do three things. We do measures to assess healthcare quality and guide performance improvement through our HEDIS program and other quality measurement programs. We accredit organizations, particularly health plans, as well as ACOs and other systems. You may have heard of patient-centered medical home. And so, we have accreditation. And then we recognize providers and practices that deliver high-quality care, especially through our Diabetes Recognition Program. Next slide. We're going to focus mostly on measures today. That's why we have that little highlight. So, NCQA and HEDIS are pretty important. You've heard of HEDIS, which stands for Healthcare Effectiveness Data and Information Set. It basically covers health plans, 235 million people. So, a lot of people, 72% of people with health insurance are covered by an NCQA-accredited plan. Many clinicians, nearly 60,000, work in an NCQA-recognized medical practice. And 11,700 practices and entities are accredited or recognized by NCQA. So, they have a pretty big reach throughout the country. Next slide. So, now I want to talk a little bit about measurement science. And I think everybody here probably knows about this. But just so you know, how do we get to measures? How do we get to HEDIS measures? How do we get to the measures in the DRP program? Well, first, you have to have evidence. And our researchers, our clinicians, learning health systems, other entities, NIH, CDC, develop the evidence. Then we get guidelines. And guidelines, ADA, of course, puts out guidelines every January. So, usually clinicians, other societies, the university, the U.S. Preventative Services Task Force, they give the guidelines, which talks about the evidence. So, taking the evidence through the guidelines, there are measure developers. And NCQA is a longstanding, over 35 years, measure developer. But other people, other entities in the country, develop measures too. CMS, CDC, Joint Commission, which you may have heard for with hospitals. There are other policy groups and companies and clinicians and societies that develop measures. So, with all these people developing measures, how do we know the measures are good and standardized? And that's where this fourth column comes in, measure endorsement. In the day, you may have heard of something called the National Quality Forum, or NQF, that used to endorse measures. And they get endorsed mostly for CMS, the Center for Medicaid Services that runs Medicare and Medicaid. They get endorsed for CMS and also for payers. Now, an entity called Battelle won the contract from CMS. So, these measures, these contractors, NQF or Battelle, assemble a group of experts to look at all the measures that are developed by all these groups to see if they meet standards, if they're high-quality measures. So, that's the endorsement process. And once that happens, it's the groups that use the measures. And that's, for example, NCQA, we use it in our health plan accreditation, and we use them in our products, in our recognition products. CMS uses the measures. Some of you may have heard of STARS, or you may have heard of Medicaid core sets. CMS uses the measures. The CDC will use the measures. The Leapfrog Group, the Joint Commission, states will use the measures. So, you get measures, but then they have to get used in programs. Okay, next slide. Another important thing that we'll talk about a little bit today is level of accountability. For example, to start at the bottom, you may know about the MIPS program, the QPP program. This is an eCQM program. That's where clinicians and practices are held accountable for the quality of care. But above that is plans, and that's where NCQA mostly operates, although we do do some measures at the clinician level of accountability, which Emily will be talking about. But much of HEDIS is for plans or large health systems. Then sometimes payers, like states, like CMS or the federal government, might hold states accountable. So, there are several levels of accountability. Whenever you talk about a measure, you always say, where is the accountable entity? Who's accountable for this measure? Next slide. Another thing that many people may have heard of is what type of measure? What's the quality framework? We talk about structure, process, and outcome. Structures are what needs to be in place for high-quality care. For example, in a practice, you need to have qualifications. You have to have operational methodology. You have to have a QI infrastructure. If you don't have the structure in place, you can't do quality care. So, that's a structure. Usually, we use standards to identify high-quality structures. Sometimes, we use measures. But most of the measures that people are familiar with and that people listening are familiar with are process measures. Process measures often come from claims. For example, I'm a geriatrician. Functional assessment. Is someone able to feed themselves? Is someone able to walk? That's a functional assessment. That's a process. We just assess it. Or chronic disease management. Did someone go to the eye doctor? Some with diabetes go to the eye doctor. That's a process. Are we monitoring medications? Are we using safe medicines? Advanced care planning. Are people having an advanced care plan? Care coordination. Are doctors talking to each other? Measures about this are process measures. Now, the whole world loves outcome measures, but outcome measures are hard to do. If you imagine for diabetes, for example, the outcome you want, for example, is good treatment of diabetes leads to fewer strokes. But there are so many things on the way to fewer strokes in so many years, it's really very hard to come up with an outcome measure related to a process measure. We have to go back to the evidence and studies that have shown a link between process and outcome. Usually in the real world, outcome measures are utilization and cost. You may be very familiar with utilization of emergency room for people with diabetes, utilization of hospital, readmissions for older adults. These are often the so-called outcome measures. Another type of outcome measures are person experience, the patient experience. You may have heard of the CAPS measures, for example, where a person is asked, did the doctor listen to them? Did they get the right medicines, et cetera? Sometimes we also do quality of life. But that's an important thing to think about, structure, process, and outcome measures. Next slide. Finally, and we'll think about desirable outcomes for measures. There's often a question, where did the HEDIS measures come from? Why did you pick those measures? Why are they there? Then we have to have, measures have desirable attributes. We say, well, what's a good measure? What has to be relevant? It has to be meaningful. It has to enhance health. It has to be variable. It has to have a financial impact of improvement. Then it also has to be feasible. It has to be specified precisely. We have to be able to do it. The data has to be there. It can't be too expensive to do. Then, of course, the most important attributes of a measure is the scientific soundness. Is it based on evidence? Is the process linked to an outcome? Is the measure accurate, reliable, and valid? We often say that not all good ideas make good measures. You have to have enough sample size. There has to be strong evidence. You have to be able, the measure has to be accurate and reliable. Not all good ideas make a good measure. Now, I'm going to talk a little bit about some background in HEDIS before we get to diabetes and HEDIS. Remember, HEDIS is mostly for health plans. That's what it's called, Healthcare Effectiveness Data and Information Set. It's a tool used by 90 percent of America's health plans, as I just said. There are four general areas where HEDIS measures fall, preventative care, chronic disease management, where diabetes obviously would fall, care coordination, and behavioral health. Emily and I work with chronic disease management, care coordination, and a little bit in the preventative world. We do a lot of the work around many of the domains of HEDIS measures. Next slide. This shows where all the HEDIS measures are in the states. Most states require some type of HEDIS reporting for their health plans to be certified in that state. It shows the wide reach. Next slide. Another point about how does a measure get into HEDIS? At NCQA, again, we look at the evidence, we look at how feasible are, but we work through stakeholder input. Some of the people on this call may have worked with us on our committees. We have measurement advisory panels and expert work groups. We get public comment. Even though our staff, people like Emily and me, come up with measures and we design them, we always go to the stakeholders to see how we're doing and to see if it makes sense. Then NCQA also has voting committees. They vote and say, okay, the measures that you came up with based on what you heard from your stakeholders make sense. They're good enough to be HEDIS measures. Finally, it has to go to the NCQA board of directors before an idea ends up as a HEDIS measure. Next slide. Now what we're here for, diabetes. Here are the diabetes measures that are in HEDIS. I'm sure people who are listening have heard of these. They've been around for some time. This just shows, and you can see the little characters on the side of them where they can be in the diabetes recognition program that we're going to talk about later. They can be in eCQMs, which is in a MIPS measure. You can see first glycemic status assessment has to be under eight or over nine. We don't want it over nine. We do want it under eight. This is measured by A1C or glucose management index. Then blood pressure control, of course. You can see age 18 to 75, less than 140 over 90. Eye exam, retinal exam for diabetes retinopathy. Kidney health evaluation, where we look at kidney function through albumin creatinine ratio. Statin therapy, statins dispensed and the person adhered to. There's a new one that you may not have heard of yet, and it's only for Medicare patients. It's emergency department visits for hypoglycemia in older adults. Obviously in that one, lower is better. We want fewer people to have hypoglycemia ED visits. We're now working on a measure about amputation prevention, which is related to the foot exam measure, but takes into account the higher risk population. I'll let you take a look at these. While you're taking a look at them, think about where the data comes from. The glycemic status assessment, blood pressure control, really that comes from the chart, right? We don't have claims for what the blood pressure is. Well, we sort of do, but it's not very helpful. So you really want to look in the chart. What is the blood pressure? What is the A1C or GMI? The other measures, however, eye exam, kidney, statin, and even emergency, you can imagine that those are claims-based. You get a bill for the eye exam. You get a bill for the creatinine albumin. So we have claims-based, but we also have clinical measures. And also the foot exam coming up, that also is clinical. You have to look in the chart to see if the doc or the clinician looked at the feet. Okay, so these are the HEDIS measures that are related to diabetes. Next slide. And this is sort of what I was talking. This talks about how we identify what patients have diabetes, because remember, this is a plan level measure. So we're looking at a health plan, like Blue Cross of, you know, Blue Cross of Michigan or something. We're looking who in that health plan has diabetes. And this is how we figure it out. Through claims or encounter data, they have to have at least two diagnoses of different dates of service, or we can use a pharmacy criteria that they're dispensed at least one diabetes medication, and they have one diagnosis. So this is how we use, we pick out the people with diabetes who are in the denominator of the measure. Okay, next slide. And here's the sort of interesting slide that I think you'll all be very, want to pay some attention to. This is performance of all those HEDIS diabetes measures. And you can see it's over the last few years. If you look at the colors, the yellow is commercial, the light blue is Medicaid, and the purple is Medicare. And you can see the years are 21, 22, and 2023. And let's look at blood pressure control. Right, we're seeing around 60, 60 some percent, and it hasn't changed much, hasn't improved much from 21 to 23. But that's the measure of blood pressure control for all the people with diabetes, millions and millions of people that are in health plans that have, do HEDIS measures. Same thing with glycemic status under eight. It's interesting how Medicaid's a little worse, Medicare's a little better, oddly. Glycemic status greater than nine, obviously lower is better there, you want a lower number. And again, Medicare is lower, you can see the performance. And I'll just let you take a look at it, statin therapy, kidney health, eye exams. The statin therapy, people are probably doing the best, but it's a bit disappointing that with glycemic status under eight and blood pressure control, we're still hovering around between 50 and 60% around the country for diabetes management. And these are people with health insurance, you know, working people, well, and Medicaid and Medicare. So that is performance. And if people have questions, I will be addressing them after the talk. Next slide, please. And I put this slide in here because I'm gonna start to talk about what's coming up, what's coming up in the future. So as I was mentioning, you know, some of the parameters we wanna look at, like glycemic control and blood pressure, they're best gotten by reviewing the chart. But, and we call that, in HEDIS, we call that a hybrid measure because many of our measures are administrative, we're looking at claims, you know, do you have a bill for C and I, you know, getting an eye exam? But for some things we have to review the chart. Well, we're getting away from reviewing the chart. You know, most, we have electronic EHRs and there's certified EHRs, and there's the Office of the National Coordinator about what has to be in the EHR and how the data has to be standardized. So not only NCQA, but all the measure developers were going to digital measures. And chart review for this clinical information is not gonna happen anymore. And so we're transitioning. We're transitioning from this current state where you would review the chart to see the, review the chart to see the A1C, to where we're transitioning where it has to be done from standardized data by a computer. So we're no more chart review, no more sampling in the entire population, everybody with diabetes, what is their A1C, for example, what is their blood pressure? And so we have this intermediate state where we're sort of figuring out how the standardized data works and eventually there'll be a future state where everything is a digital quality measure and that also implies interoperability. So no matter what chart you have, you'll be able, that chart will be able to talk to another type of EHR. So the EHRs will be able to talk to each other. So this is a whole long discussion anyway, but I just wanted to introduce it because it's coming up and we're getting away. You'll hear when Emily talks about it, even in practices, we're getting away from chart review for measures. So the next slide. Another thing that's coming up, I just wanna give you a little bit of a preview and Emily will be talking about it more, is continuous glucose monitoring. As most of you know, evidence is accumulating that CGM improves outcomes, especially for type one patients and for people on daily insulin therapy and ADA has guidelines for type two. So we're exploring CGM in other populations, but we know that access is uneven related to insurance. But we know, if you look at the right side there, there is improvement in A1C with accumulating evidence. There's decreased hypoglycemia and there may even be some behavioral and utilization outcomes with increased patient satisfaction. But there's a problem with data capture. Anybody who's been a clinician, I remember myself looking at the ambulatory glucose profile. The CGM devices, they can upload data to the cloud or they have proprietary information that the patients can see it on their phone, but it doesn't hook to the EHR. So if you wanted to make a quality measure about CGM use, it's very hard to do it because it doesn't hook to the EHR yet. And people are working on them. Epic is working on that with some of the companies that do CGMs, but so far it's data capture remains a bit of a challenge, but it's coming. Next slide. The last thing that's, okay, this just shows the transition that right now we have with the only parameter from CGM that we're using is a glucose management indicator, which is related to the A1C. And right now we sort of are pulling it from the ambulatory glucose profile, although I think it's also can be shown in the lab values. But our short-term goal is to have in the diabetes recognition program to try to assess how it's being used, but eventually we want to put it in HEDIS and we want to look at the things that we really care about with CGM, like time and range or time under range or time below range. Okay, next slide. I think that's the last thing I'm going to talk about is something else that's coming up through HEDIS and through other measures. And of course, you all know what I'm talking about, the cardiovascular kidney metabolic syndrome. We've certainly known about this for many years. We know that this is a health disorder where obesity, diabetes, CKD, cardiovascular disease they're all related, we've known this for many years. There's a combined risk. People have a risk for one, they tend to have a risk for another and these things sort of pile up and they become expensive and they increase morbidity and they can certainly have much more impact in certain disadvantaged population or when combined with other social determinants of health problems. So we're interested in developing a quality framework where we can somehow think about this combined risk instead of an individual measure for each thing like a measure for obesity, a measure for CKD, a measure for cardiovascular, a measure for diabetes. How can we think of a combined risk within a quality framework? So NCQA is going to be doing a convening with multiple experts and try to think about is there a better way to assess and lead to better quality for all the people in the United States that have this combined risk? So I think I'm going to stop here and I'm going to turn it over to Emily who's going to talk about our recognition program for clinicians. Thanks, Caroline. Yeah, so just to emphasize that the measures that Caroline walked through already were for our HEDIS product, which is used by health plans. And so I'm going to shift us into talking about a product that is used at the clinician level so that separate level of accountability. So our diabetes recognition program was launched in 1997 to recognize clinicians delivering high quality diabetes care. The purpose of this program is to strengthen clinical accountability structures to help improve outcomes for adults with diabetes. So this is a long standing program of NCQAs, but we are currently working on a refresh of this program in which our goals are to update and digitize the program measures, update scoring, modernize its infrastructure and automate its processes. So I'll walk us through a little bit of what those updates look like. I want to acknowledge that the refresh of the diabetes recognition program is supported by the Leona M. and Harry B. Helmsley Charitable Trust and Precision HQ or AQ. And the refresh you can see is shifting us from what the program used to be historically into these updates on the right. So this includes updating the existing measure set to make sure that any guideline updates are incorporated into the existing measures. We're also working on developing and including new measures which we'll get to. We are moving the measures from paper-based to digital with a transition period as providers work towards that digital capability. We're moving recognition from every three years to an annual submission recognizing single measurement periods. We're also moving the program to our program called QPASS. You may be familiar with this if you've done other programs at NCQA. This is just the program that we use across our other recognition and accreditation programs. So standardizing that platform. We are enabling digital submissions providers who again are on that pathway, but recognizing that not everyone is quite there. So we are still enabling manual submission, manual collection, but starting to shift the program towards that digital perspective. And we're also moving from a convenient sample to a population-based or random sample. So the Diabetes Recognition Program is unique from our other recognition programs and accreditation programs in that it's measures-based. So we're strictly using a set of measures to assess recognition. So you can see the existing measure set on the left. A lot of this is going to overlap with what you saw in HEDIS so glycemic status assessment, blood pressure control, eye exam, foot exam, kidney health evaluation and smoking and tobacco use screening and follow-up. And on the right are three new measures we are currently working on developing for proposed inclusion in the program. So that includes statin therapy prescription, depression screening and follow-up as well as continuous glucose monitoring utilization. So for CGM utilization, this isn't something that we're going to hold providers or clinicians accountable for on how well they perform on it. This is a measure that's a bit different and that it's more of gathering information and understanding when and how CGM is being utilized. So we're looking at two groups. The first is type one diabetes and the second is type two diabetes who meet the ADA guidelines for CGM use. So again, just trying to understand CGM use before we shift into something like an accountability measure. I mentioned that a lot of these overlap with what we showed is included in HEDIS. So many of these measures are derivatives of the HEDIS health plan measures and they're aligned as much as possible to reduce reporting burden across those different levels of accountability. But there are some minor nuances just given the data that's available at the clinician level versus the plan level. So for example, in HEDIS our statin measure assesses whether statins were dispensed and whether there was adherence because health plans have access to that prescription fill information. However, in this clinician level diabetes recognition program, our proposed statin measure will assess whether statins were prescribed because that's more aligned the data accessible to clinicians. We are, let's see. And then I also wanted to note that there are two measures here that are in the recognition program that are not yet in HEDIS and that includes the foot examination and the CGM utilization measure. So while we're implementing these at the provider level, NCQA is interested in exploring these for potential use at the health plan level in the future. So sort of what we're thinking about coming down the line. And just like Caroline explained for our HEDIS diabetes definition, this is our recognition program clinician level diabetes definition. It's a bit different. And so if you're familiar with eCQM measures you may notice that it aligns actually with how we define diabetes at the eCQM level. So this is looking for patients 18 to 75 who had a qualifying visit during the measurement period and had a diagnosis of diabetes in the first half of the measurement period. So this is essentially in the program looking to see that they are adults with diabetes with contact with the practice during the calendar year that we're measuring. And this is used in all measures in the recognition program, old and new. And then speaking of new measures, the three that I mentioned were recently tested with practice sites and we wanted to share some key takeaways from that. So we tested the three new measures with 12 sites that had variation by region, practice type, size, and type of electronic data source. We gather both quantitative and qualitative information to inform the use of these in the diabetes recognition program. And from that, we found that both statin therapy prescription and depression screening and follow-up showed high performance with opportunity for improvement. And the CGM utilization measure showed moderate utilization with substantial variation across those diabetes groups and providers. And then all three of these measures showed moderate to high sensitivity, specificity, and feasibility when we tested. We also received feedback from sites around overall challenges. This was our focus in qualitative testing. So the primary challenge that came out of this and was identified was barriers to querying data from EHRs. So this included compatibility issues, documentation processes, and report limitations. But this didn't necessarily come as a surprise. We recognize that practices experience the same challenges with implementing digital measures and digital processes that we see for entities across industry. And also just want to acknowledge that these challenges are specific to relying solely on electronic extraction, which was something we did test when working with the sites. But the diabetes recognition program is still in this transition. So it's not restricted to electronic extraction and clinicians seeking recognition can still utilize manual extraction in their data submission. So we're still sort of, again, in that transition, understanding what some of these barriers are so that we can think about this as we continue to move the program to being digitally enabled. I forgot to mention, so I'm glad I have it here, that we did receive support for the three new measures from our panels and committees that Caroline mentioned earlier. And so the next step is gathering public comment feedback. So these are currently open for public comment. We've included them within what's called our HEDIS public comment period, which focuses on measures. So there's sort of a special item included this period. This is something that anyone on this call, anyone can participate in, and it's open until this Thursday. So we appreciate any and all feedback on the inclusion of these three new measures into the program. If you're interested, we'll be sharing these slides so you can access this link, but it's also right on our NCQA website. And lastly, for the recognition program is that Helmsley Charitable Trust is providing funding for applicants, clinicians seeking recognition. So if you scan this QR code, you can see how you or your clinicians can have their application fees covered if you're interested in pursuing recognition through the diabetes recognition program. I will hold this slide for just a moment in case anyone's trying to grab that QR code with their phone camera. Okay. So that is it for my section. I just want to know, we'll come, I'm going to come back to this slide, but I just want a quick note that we've also included additional resources. So when these slides are shared, there's additional resources at the end of the presentation that may be of interest to you, and those are things around white papers, our HEDIS website, our recognition program website. So some slides with some summaries, and then also a final slide with website links for your access. I'll pop back to the questions and we'll go from there. Okay. Thank you very much both. It was very interesting and there are a couple of questions here in the Q&A box and also one in chat. One of the participants is asking, reviewing the list of HEDIS measures, I'm wondering what discussion has been regarding adding something about offering education? I recognize not all good ideas make good measures, but the evidence is a strong linking education with clinical improvement. The NHS in the United Kingdom added a measure, adults with type 2 diabetes are offered a structured education program at diagnosis. Can this be added in the United States? If so, how soon? What do we have to do to bring enough evidence to justify that? Emily, you wanna do that one? Sure. So I will say that, and Caroline can jump in if I miss anything, but with the diabetes recognition program, so not HEDIS, which you mentioned in your question, but the diabetes recognition program is an interesting use case for this because our recognition programs and accreditation programs often include standards. And standards are something that we've thought about potentially incorporating into the recognition program and education is a fantastic thing that could be addressed through standards. So standards look at things like processes, procedures, what do you have in place? And so whether you are offering and have an education program in place is something that would fit well within that standard structure. But again, something that we, we're not developing at this time, but have considered for inclusion. In terms of HEDIS measures, I know that we've looked at education resources for other populations like chronic kidney disease. And so I think that it's something, well, Caroline, why don't I defer to you and see if there's anything for HEDIS that you wanna add? Yeah, I don't think that we've looked at education for at the health plan level yet. As Emily pointed out, we have actually considered it quite a bit and we have an educator on our committee on our diabetes expert panels to make sure to try to figure out how we address it. I do think if we do it through measures or standards, we'll do it on the provider side first because it's a little tricky to do it on the plan side. And probably there's not enough billing for it. We might not be able to find it even though theoretically everybody should be getting it. But I think it is a good suggestion. We probably would see how it performs on the provider side, on the clinician side. And if it seems that it's useful, that it's driving better care, that it's improving quality, we would definitely start thinking about it for HEDIS. And as you remember, I was talking about CKM and sort of this unified risk. There's also the same issue with education for chronic kidney disease. So there's a benefit for it, it's not being used, providers are not billing for it, and the benefit may not be quite as good as we want it to be, so it's analogous. And I can imagine as we do this combined risk framework, we may end up thinking about education for lifestyle, diabetes certified, diabetes education, kidney education, and sort of putting it together to give it a little bit more heft and a way to drive quality for this combined risk that so many people face. So hopefully that helps. I have a question about the process of picking up the HEDIS measures. Like who picks them, what criteria to be used? For example, you showed that hypoglycemia, admission for hypoglycemia is one of the criteria at the system level, but why not DKA? It seems to be more relevant, at least to many people it will seem to be. Hypoglycemia hospitalization is also important, but I think DKA, why not DKA? It's also in one of the questions. That's a very good question. And part of that actually is sample size because as you know, as everyone knows, the number of people that have type one diabetes or insulin requiring diabetes, where they would go into ketoacidosis is small. So we could certainly pick that up, I think on the provider side, if we were working with practices and endocrinology practices that have a lot of type one diabetes people or people that absolutely require insulin, whether it's type one or other genetic problems or whatever. So, but at the plan level, I think we might end up having sample size problems because it's very hard to find type one people with diabetes because in a big population of the United States, luckily for the world, there are type two sort of dwarfs type one. So in ketoacidosis is a little bit more relevant in that area, even though I know you could have hyperosmolar and things like that. But that is something that we certainly will consider because one of the, we are very interested in the type one population. We haven't been that before, but again, through the diabetes recognition program and through work with other clinician level of accountability, as opposed to the plan level, we are very interested in the type one population. We're working with people around the country that work with that population and think about quality for that population. And so we may end up thinking about the ketoacidosis measure at the clinician level in the future, if that makes sense. Yeah, but I'll go back to my question, like who proposes, what's the process? That's a good question. That's a really good question. And like, how does a measure get developed or endohedis? And it really comes from, there are a variety of reasons. Some of the, and a lot of the reasons happened 15 years ago when this all started, that we have some guideline driven measures for major diseases. That sort of started about 15 years ago. And so there's sort of a historical piece to this, like what did the diabetes community think were important measures back in 2005? What did the geriatric community think were important measures? What did the cardiovascular community think were important measures? So the way that measures, the way that we decide what's a HEDIS measure usually comes from a change in guideline and it comes from stakeholders who tell us. Remember, we said that we have a tremendous amount of measurement advisory committees and expert work groups that work with us. And our board comes from, our board is also multiple stakeholders, CEOs of health plans, CEOs of health systems, academics, policymakers. So we get the ideas for a measure from gaps that are really generally because it comes from our stakeholders. Just like you, just like somebody here saying, why don't we have education as a measure? That is sort of how it happens. And so we have a certain number of stakeholders that we hear it from multiple sources. There is evidence, it meets standards. As I said, it looks like it's something that can become a measure. That's, and that's how historically these have happened, usually from sort of external influences and the evidence is available. I will just keep going on the same point. Is there a process to update those measures periodically? Yes. As in diabetes, things change so fast. Every year we are updating the standards of care. And is there a collaboration with the ADA on that? And most of our HEDIS measures are updated every three to five years because guidelines change. And we do, for the measures that relate to the quality of care or care effectiveness for major diseases, like the ADA, we look at the ADA guidelines every year. We have ADA members on our committees. So yes, and all, and we routinely evaluate measures about every three to five years. And some measures we throw out, because some measures we call it retired. Some measures get retired. Sometimes they top out. Some, you know, people learn how to do it and there's, we're not gonna see any more quality. Sometimes the evidence changes, the guidelines change. They're sort of just old fashioned measures that don't really move the quality needle anymore. So we retire measures also. Thank you. Ajita, you want to read questions from the chat? Definitely. I go back to the Q&A box and then I address the chat box questions. The question disappeared unfortunately from the Q&A. It looks like, I can see it in the answered section. That was answered already. Oh, I see, I see. Okay, I go back to the answer. Okay, I go back to the question. The attendee is asking, as you likely know, ADA has its own recognition program for diabetes education programs that meet national quality education standards. This could cause some confusion. I'm thinking that maybe NCQA recognized diabetes program should show they know how to find, to find ADA recognized education program and they are asking for your talk. So, yeah, that's a great point. And we've realized that as well. And we actually have representatives from these other education programs on our expert panel. And we've had discussions around this. So if we were to consider something like a standard for education, for diabetes education, we've talked about, you know, acknowledging that we don't want to duplicate programs that are already in existence. We would wanna make sure that anything we put into our program worked hand in hand with those existing programs in some way. So we do have those representatives working with us to make sure that we're thinking about how we can fit within the larger landscape of diabetes education programs. Thank you. Thank you. In the chat box, we have a question. They are asking, is there a threshold for percentage of patient meeting the A1C and blood pressure measures? But clinician recognition. Yeah, so here this is more about benchmarking, right? And so we don't have thresholds, but we'll have thresholds in the recognition program. I'm actually gonna show the first, this is the first slide in our additional resources. It may be a lot to take in right now, but this walks you through the current scoring process for the recognition program. So there's, each measure has a set performance threshold. And then for, as a clinician, if your patient population meets that threshold, then you receive the differential points for each measure. And as we think about incorporating three new measures, these will likely update, especially the point structure, because we need to fit three more measures in. So this is currently what's in use in the program. And so it was for the A1C. So each A1C measure has its own threshold. So for example, glycemic status assessment, less than 8%. In order to receive those 15 allotted points, 65% of your patients would need to have their glycemic status, either A1C or GMI, below 8%. And so that, then we would look at that for each measure. And that's how, once we add up the points, we would allot recognition to those clinicians that achieve it. Thank you very much. Again, there is a question about education. If education was a standard, every provider would discuss and offer. If driven by measures, I think you would see the benefit and ROI. And the same participant is asking, also with increasing usage of SGLT2s, you have more of DKA now. I don't know if there is any discussion of looking at the DKA as one of the measures. Not yet, not quite. Not yet. Okay. And then, is there a CDE or diabetes educator part of the panel or group in the NCQA? I don't think so on our board. I'd have to look. I don't think on our board. Definitely on our expert committees. But I don't think on the board. So, the other thought I have, because it is criteria and this NCQA have been there for, I have in my whole life, career. But has anyone looked at those who the healthcare systems who achieve those goals, do they have better outcomes? Or I haven't really seen any papers on that, any publications, whether achieving it is, or fulfilling criteria for recognition or better outcomes leads to better outcomes, cardiovascular or diabetes complications. Do you know if there is any evidence of that? We would love to know, right? But first of all, chronic disease outcomes take years and years to really develop. So, it's hard to know. And secondly, it's hard to know without a control group, because HEDIS has been with everybody. So, you can't sort of can't measure what didn't happen. We don't know what would have happened if HEDIS didn't exist. But so, that's a really interesting question. No, but those who achieve and those who don't achieve are at a risk. Yeah, and I don't know what research has been done. I'm not a health services researcher. You may not be either. So, I don't exactly know how, because one thing that happens is plans change. Like a plan will be very good for a couple of years and it'll go down. Another plan will be good for a couple of years. So, I don't know how consistently plans are high performers. We have looked at that in some small areas, for example, in antibiotics. We work with the Pew Charitable Fund to figure out plans that are doing very well in antibiotic stewardship. And do they continue to do well? And what are their best practices? And how do they, and if they're doing well in stewardship, how does that relate to their antibiotic use? And how do the measures interrelate sort of a validity study on antibiotics? So, we have sometimes done that in certain constricted areas, but I don't know if we've done that particularly for diabetes. But it'd be very interesting to know how plans move, because they're not always the same. A plan that's good one year may not be that good the next year. And so, what happened and why? And so, I don't think it's understood that well, quite frankly. There's sort of the global thing as well as a more patient level outcome. I don't think either one of us understood the way we would love it to be. Questions in the chat, in the QA? QA, yes. I work both the outpatient and inpatient consultation for new and established diabetics. Any resource for identifying inpatient quality measure? Unfortunately, that's not in my fund of knowledge. NCQA really works in the ambulatory arena. So, I know that there may well be inpatient measures, but I don't know them. So, sorry about that. I can't answer that. Just to jump in from the ADA side. So, the ADA along with Leapfrog have created those inpatient quality metrics. And ADA and Leapfrog together collaborating and have been recognizing hospitals for inpatient quality measures. Thank you. And there is one more question. With the new ADA SOC phenotyping, the difference or early intervention with a stage one and stage two type one diabetes, they are saying that it's a newer concept, which is getting into practice. Has there been any thought about people who are diagnosed as type two diabetes? Is there any thought to identify people who are misdiagnosed? Yeah, I'm not completely sure I understand the question. I understand the first part of the question. We're very interested in that because we understand that, again, there'll be a sample size problem if one really wanted to do a measure, but maybe it would be more relevant when we focus on stage one type one. But the idea that we can prevent type one or we can influence the development of type one because of the new information and how it can be staged. I was lucky enough to participate in a seminar on that with some type one experts, and I thought it was very interesting. And we're really looking into that and we're in the national conversation about the new information on developing type one. But I don't understand how that relates to the second question. So I'm confused. I think the question says that there may be misdiagnosis between type one and type two. So I don't know how- I thought there were a way to handle that. Yeah. I guess I'm not quite, since I'm not a diabetologist, I'm not understanding that relationship there. I certainly know that there are people with type one who also get type two. I've had those patients. I certainly know as a geriatrician, there are people who are older that have type one, that get type one. So I know that too, but I'm not completely sure how that relates to this question. So I can't help there. Sorry. Is there any- Sorry, fine. Sorry, for the prevention of diabetes, like we know that diabetes prevention programs have been around for a long time, maybe in 2002. And so it has been pretty hard to implement those, the diabetes prevention programs from pre-diabetes to diabetes. Is there any discussion that has happened to identify any quality metric for that? Yeah, we are very interested in screening for people with diabetes and prevention of diabetes. We're very interested in that. And we had been talking about that with the CDC because they have one of the DPP prevention programs. They have been a little frustrated about the uptake, as you know, and we're very interested in that. I think through our new CKD convening and our new ideas of trying to get a framework for this coordinated risk with people with obesity and diabetes and CKD. So I think we may look towards that even more, but yes, we are very interested in that whole process. Adita? Sure, and I just wanted to say that I think they clarified the question. They are talking about misdiagnosing as type 2 diabetes and later find out type 1. And there is one other comment. They are saying that so studying this information has a metric in future. I'm sorry. I think, so their question is around, would we ever measure, I think, this idea of identifying those who are misdiagnosed with type 2? And I think for when we think about our measures, especially HEDIS, this wouldn't impact the denominator, the population that feeds into our measures. I don't know that we would look at a metric that follows the diagnosis, but we would potentially look at some validation of how we're identifying those with type 2 versus type 1 diabetes in the future, especially if we start to think about measures that are specific to a type diabetes. So I think that we would probably approach it from that perspective. All right, we have one minute left. Anyone else? Okay. Dr. Clement asks if there is an ADA member or ADA person on the board of NCQA, or will it help to have more closer collaboration with ADA? I think historically NCQA has had a pretty close collaboration with ADA. In fact, I think, Emily, I can't remember if you told us this, the history of our diabetes recognition program, it started with ADA. So NCQA and ADA did it together. So I think there's always been a close relationship and the composition of the board is sort of above my pay grade, but I think that's a very excellent idea. And I think that when NCQA recruits new board members, they look for experts all over, and we are very interested in this whole area at this point. So who knows? Good idea. We are interested in it too, to collaborate on the ADA side. All right, thank you so much. I think we are- Thank you. I really appreciate the NCQA panel. Thank you. Thank you, everybody. Appreciate it.

Healthcare Delivery

Quality Improvement

Diabetes Care

Rajesh Garg

NCQA

HEDIS

Digital Measures

Continuous Glucose Monitoring

Cardiovascular Kidney Metabolic Syndrome

Diabetes Recognition Program

ADA Collaboration