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Overview of 2007 Quality Assurance Activities

Overview of 2007 Quality Assurance Activities

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Overview of 2007 Quality Assurance Activities

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  1. Overview of 2007 Quality Assurance Activities Maryland Department of Health and Mental Hygiene November 29, 2007

  2. Overview • 2007 Quality review activities: • Systems Performance Review • Healthy Kids Quality Monitoring Program • Enrollee Satisfaction Survey • Healthcare Effectiveness Data and Information Set (HEDIS) • Value-Based Purchasing Performance Measures • Consumer Report Card • Performance Improvement Projects 2

  3. Systems Performance Review • Federal law requires that all State Medicaid Programs use an External Quality Review Organization (EQRO) to conduct an annual Systems Performance Review (SPR) of all managed care organizations (MCO). • The Department contracts with Delmarva Foundation to conduct the SPR. • The 2006 SPR consisted of 9 standards. • Each MCO is rated separately on compliance with each standard. • Criteria used for each standard is reviewed and updated annually by the Department based on EQRO recommendations. 3

  4. System Performance Review (continued) • The Department rotated two standards for 2006, Outreach Plan and Health Education because all of the MCOs had previously met the minimum compliance rate (100%.) • For 2006, the minimum compliance rate for all standards was 100% except Oversight of Delegated Entities at 90% and Fraud and Abuse at 70%. • For any standard or any components of a standard that do not meet the minimum compliance level, MCOs are responsible for implementing an approved corrective action plan. 4

  5. Systems Performance Review

  6. Healthy Kids Quality Monitoring Program • Monitoring is performed by a team of nurses who also review and certify providers for EPSDT services. • Through medical record reviews, the nurses rate each MCO’s performance on compliance with the 5 major EPSDT components: • Health and Developmental History. • Comprehensive Physical Exam. • Laboratory Tests. • Immunizations. • Health Education. • Data results are reviewed and validated by the EQRO and are included in the SPR report. • All MCOs exceeded the minimum composite compliance rate of 85%. • All MCOs met or exceeded the 70% compliance rate for each of the 5 components of the review. 6

  7. Healthy Kids Audit Results

  8. Healthy Kids Audit Results

  9. Enrollee Satisfaction Surveys • DHMH conducts an enrollee satisfaction survey annually using the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey instruments designed to evaluate members’ satisfaction with their health plans. • DHMH uses an NCQA certified CAHPS vendor to conduct the survey and compile the results. • Surveys include question sets covering: • Enrollment and coverage • Access to and utilization of healthcare • Communication and interaction with providers • Interaction with MCO administration • Self perceived health status 9

  10. Enrollee Satisfaction Surveys (continued) • In 2007 • 11,362 CAHPS Medicaid Adult Surveys and 13,958 CAHPS Medicaid Child with Chronic Care Condition (CCC) Surveys were mailed. There were 2,850 adult responses and 4,867child responses. • Follow-up phone calls were made to interview members who did not respond by mail. • Response rates varied by MCO ranging from 21% to 35% for adults and 15% to 29% for children. • Based on ratings of 0 to 10 where 10 is the best, the lowest MCO score in any rating is 7.4 for adults and 6.4 for children. 10

  11. Provider Satisfaction Surveys • DHMH conducts an annual provider satisfaction survey to assess provider satisfaction with various aspects of HealthChoice. • DHMH uses an NCQA certified HEDIS survey vendor to conduct the survey and compile the results. • Historically, response rates have been low and it is believed that a shorter survey in combination with telephone follow-up may help to increase provider survey participation beginning in 2008.

  12. Provider Satisfaction Surveys (continued) • Survey topics include: • Finance Issues • Customer Service/Provider Relations • No-Show HealthChoice Appointments • Coordination of Care and Case Management • Utilization Management • Overall Satisfaction • In 2007 • A mail-only survey administration methodology was utilized to survey a random sample of Primary Care Providers (PCPs) from each of the seven MCOs. From a total aggregate of 5,309 PCPs, 248 responses were received yielding a total aggregate response rate of 6.1%

  13. HEDIS Performance Measures • The Healthcare Effectiveness Data and Information Set is a standardized set of performance measures developed by NCQA and CMS to measure managed care performance and assess opportunities for improvements in quality of care. • Each year NCQA updates the measurement set based on the latest information available. • The Department contracts with an NCQA certified HEDIS vendor to audit and report the MCOs’ scores. • MCOs use claim and encounter data to produce each measure. However, for some measures, MCOs are allowed to supplement incomplete data with medical record reviews. 13

  14. HEDIS Performance Measures • For 2007, MCOs were required to report their performance on 20 HEDIS measures. Access/Availability of Care • Children and Adolescents’ Access to Primary Care Practitioners • Adults’ Access to Preventive/Ambulatory Health Services • Prenatal and Postpartum Care • Call Answer Timeliness • Call Abandonment Effectiveness of Care • Childhood Immunization Status • Adolescent Immunization Status • Breast Cancer Screening • Cervical Cancer Screening • Comprehensive Diabetes Care • Use of Appropriate Medications for People with Asthma • Appropriate Treatment for Children with Upper Respiratory Infection (NEW) • Appropriate Testing for Children with Pharyngitis (NEW) • Chlamydia Screening in Women (NEW) Use Of Services • Frequency of Ongoing Prenatal Care • Well-Child Visits in the First 15 Months of Life • Well-Child Visits in the Third, Fourth, Fifth and Sixth Year of Life • Adolescent Well-care Visits • Discharge and Average Length of Stay- Maternity Care • Births and Average Length of Stay, Newborns 14

  15. HEDIS Performance Measures (continued) • The 2007 HEDIS audits had an increase in the number of DHMH measures that had to be reported. Three measures added provided information on preventative services provided to HealthChoice members. • These measures were: • Chlamydia Screening in women, • Appropriate Testing for Children with Pharyngitis, • Appropriate Treatment for Children with Upper Respiratory Infection. • Overall, the MCOs continue to show improvement in their HEDIS scores over the last 4 years. 15

  16. Department of Health and Mental Hygiene

  17. MCOs:Benchmarks: AGM = AMERIGROUP Maryland, Inc. NMH = National Medicaid HEDIS Mean HFC = Helix Family Choice, Inc. MARR = Maryland Average Reportable Rate DIA = Diamond Plan - the Medicaid product line of Coventry Health Care MMA = Maryland MCO Average JMS = Jai Medical Systems Managed Care Organization, Inc MPC = Maryland Physicians Care PP = Priority Partners UHC = UnitedHealthcare of the Mid-Atlantic, Inc. Report Indicators: NR = Not Reportable NA = Not Applicable

  18. Value-Based Purchasing • Value Based Purchasing is a set of performance measures based on current HealthChoice monitoring activities. • The goal of our Value Based Purchasing strategy is to improve MCO performance by providing monetary incentives and disincentives. • These 10 measures cover all important dimensions of MCO performance: • Access to Care • Quality of Care • Administration (MCO structure and operations) • 5 of the 10 measures are HEDIS measures and 5 are Maryland specific. 20

  19. Value-Based Purchasing (continued) • Targets for each measure have been established based on 3 levels of performance: • Disincentive: For any measure that the MCO does not meet the minimum target, a disincentive of 1/9 of 1/2 percent of the total capitation paid to the MCO during the measurement year will be collected. • Neutral • Incentive: For any measure that the MCO exceeds the minimum target, the MCO shall be paid an incentive payment of up to 1/9 of 1/2 percent of the total capitation amount paid to the MCO during the measurement year. 21

  20. Value-Based Purchasing (continued)

  21. Consumer Report Card • This is the fifth year that we have produced a HealthChoice Consumer Report Card. • Since its inception, the Department has been contracting with the NCQA (through the EQRO contract) to develop the methodology and calculate the MCOs’ scores. • The 6 performance areas rated in the Report Card are calculated compiling 30-40 measures from HEDIS, Value Based Purchasing, and the Satisfaction Survey. • The Consumer Report Card is included in all enrollment packets. 23

  22. Performance Improvement Projects • Currently have 2 Performance Improvement Projects ongoing that MCOs are required to conduct: • Improve Screening for Chronic Kidney Disease • Improve Cervical Cancer Screening (Began July 2007) Improving the Delivery of Prenatal/Postpartum Care was completed in 2007. • PIPs consist of: • Submission of data collection and analysis plan • Baseline measurement of data • Intervention development and implementation • Re-measurement of data 24

  23. Performance Improvement Projects • For Prenatal/Postpartum: All MCOs improved their scores from baseline in 2004 to final in 2007. • For CKD Measure 1 “HEDIS, Kidney Disease Monitored Rate”: All MCOs improved their scores from 2005-2006. (Diamond Plan was not required to participate in 2006 due to insufficient membership size). • For CKD Measure 2 “Hypertensive members receiving at least one serum creatinine”: 2 MCOs improved their scores, 3 MCOs remained relatively the same, and 1 MCO had a small score decrease from 2005-2006. (Diamond Plan was not required to participate in 2006 due to insufficient membership size). 25

  24. Where to find complete information ? DEPARTMENT OF HEALTH AND MENTAL HYGIENE WEBPAGE Select “Medical Care Programs”, “HealthChoice Managed Care”, “HealthChoice Quality Assurance Activities” 26