Performance Measures 101 Health Services Advisory Group March 28, 2007 3:00 p.m.–4:00 p.m. Presenter: Peggy Ketterer, RN, BSN, CHCAExecutive Director, EQRO Services
Balanced Budget Act (BBA) of 1997 42CFR438.240 States must require each managed care organization (MCO) and pre-paid inpatient health plan (PIHP) to annually measure and report performance to the state using standardized measures.
Balanced Budget Act (BBA) of 1997 (cont) 42CFR438.356 The BBA also requires that states contract with an EQRO for an annual independent review of each MCO and PIHP to evaluate the quality and timeliness of, and access to, health care services provided to Medicaid enrollees.
Balanced Budget Act (BBA) of 1997 42CFR438.358 States must ensure that the performance measures are validated annually through the external quality review process.
Performance Measures What is a Performance Measure? A quantitative measurement by which goals are established and performance is assessed.
Performance Measures (cont) Performance Measure Characteristics: • Standardized • Clearly defined • Meaningful and timely • Results in comparable data
Performance Measures (cont) Why measure performance? To obtain solid data to evaluate performance and make decisions on what improvements are necessary.
Performance Measures Key Roles: • States identify measures and data submission format • MCOs and PIHPs collect, calculate, and submit performance measure data to the State using required submission format • Performance measures are validated annually by the EQRO following required CMS protocols
Calculation and Reporting of Performance Measures Performance Measure Calculation: A Brief Overview
Calculation and Reporting of Performance Measures Step 1: Identify necessary data sources and data elements for reporting the selected measures • Membership/enrollment data • Claims/encounter data • Other administrative data (if available), i.e., disease management database, kept appointment database
Calculation and Reporting of Performance Measures Step 2: Prepare data set • Extract data • Clean data (valid variables, formats) • Verify completeness and accuracy • Establish data element to link data sources (unique member ID)
Calculation and Reporting of Performance Measures Step 3: Produce source code to calculate measures • Calculate continuous enrollment and anchor date • Determine member age and gender • Include diagnosis and procedure codes needed to identify service events • Exclusion logic
Calculation and Reporting of Performance Measures Step 4: Calculate measures administratively • Run source code • Examine output files • Review preliminary administrative results
Calculation and Reporting of Performance Measures Step 5: Hybrid Sampling (if applicable) • Supplement administrative data with medical record pursuit • HEDIS-like methodology preferable (411 sample) • Systematic sampling
Calculation and Reporting of Performance Measures Step 6: Collect medical record data • Use standardized criteria • Tools • Instructions • Establish a sound process for monitoring data collection accuracy (inter-rater reliability, over-reads)
Calculation and Reporting of Performance Measures Step 7: Combine administrative and medical record data • Logic for duplicates • Methodology for integration into reporting repository
Calculation and Reporting of Performance Measures Step 8: Validate results • Review calculated rates for reasonability • Examine data output file and verify with source data (membership and encounter data)
Calculation and Reporting of Performance Measures (cont) Step 9:Submit Performance Measure reports to the state • Utilize state-specified format
Calculation and Reporting of Performance Measures Hybrid/MRR – Negative Aspects • Typically more expensive • More burdensome to capture data • May not always increase administrative rate drastically
Diagram of a Performance Measure • Written Description • Calculation (the percentage of X who had Y) • Eligible Population Criteria • Numerator Event Criteria • Exclusion Criteria • Reporting Format
Written Description Example for PMHPs: The percentage of discharges of members 6 years of age or older who were hospitalized for treatment of selected mental health disorders and who were seen on an outpatient basis or were in intermediate treatment with a mental health provider.
Written Description Example for NHDPs: This measure summarizes utilization of long term care services and acute care services in the following categories: • Units of case management/1000 member months • Units of private duty nursing/1000 member months • Units of physical, occupational, and speech therapy/1000 member months • Inpatient days/1000 member months
Calculation Example for PMHPs: Two calculations will be generated: • The percentage of discharges for members who had an outpatient or intermediate mental health visit on the date of discharge, up to 30 days after hospital discharge and • The percentage of discharges for members who had an outpatient or intermediate mental health visit on the date of discharge, up to seven days after hospital discharge
Calculation Example for NHDPs: Long Term Care Services - each category counts encounters between a NHDP provider and enrollee, which includes each occurrence/unit as identified by specified encounter data service types. Acute Care Services – This category counts total discharges, days, and ALOS for all inpatient stays.
Eligible Population Criteria Example for PMHPs: • Specifies any age, continuous enrollment (CE), and event/diagnosis requirements. • Age: 6 years or older as of the date of discharge • CE: Date of discharge through 30 days after discharge • Event/diagnosis: Discharged from an inpatient setting of an acute care facility with specific principal diagnosis codes indicating a mental health disorder
Eligible Population Criteria Example for NHDPs: • Specifies member months calculation instructions • Member months: for each month of enrollment, each enrollee contributes one member month (i.e. one year of enrollment equals 12 member months) • May be stratified by age or gender
Numerator Event Criteria Example for PMHPs: • An outpatient mental health encounter or intermediate treatment with a mental health provider within the specified time period. • CPT, HCPCS, and revenue codes are listed to identify qualifying visit type.
Numerator Event Criteria Example for NHDPs: • Specifies rules for counting services/units • Lists the type of services by description or service code for each category • For acute care services, specifies UB-92 type of bill codes and rules for calculating ALOS
Exclusion Criteria Example for PMHPs/NHDPs: • Specifies certain diagnoses or circumstances that would qualify for an exclusion
Reporting Format Example for PMHPs: • Identifies the data elements necessary for reporting (i.e. eligible population, numerator events, rate) • Includes a grid for entering data elements
Reporting Format Example for NHDPs: • Identifies the data elements necessary for reporting (i.e. number of services, number of services by category per 1000 member months, number of discharges, discharges/1000 member months, ALOS ) • Includes a grid for entering data elements
Performance Measure Development • Specifications are typically selected or developed by the State with input from the MCOs. • Specifications that are developed by the State may require modifications, clarifications, and further refinement after first year of reporting. • Specifications and measure results should be re-evaluated annually to ensure they are comparable, valid, and meaningful.
Open Discussion Questions and Answers