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Overview of 2007 Quality Assurance Activities Maryland Department of Health and Mental Hygiene November 29, 2007 Overview 2007 Quality review activities: Systems Performance Review Healthy Kids Quality Monitoring Program Enrollee Satisfaction Survey

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Overview of 2007 Quality Assurance Activities

Maryland Department of

Health and Mental Hygiene

November 29, 2007


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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

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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.

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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.

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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.

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    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

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    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.

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    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.


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    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%


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    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.

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    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

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    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.

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    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


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    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.

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    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.

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    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.

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    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

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    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).

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    Where to find complete information ?

    DEPARTMENT OF HEALTH AND MENTAL HYGIENE

    WEBPAGE

    http://www.dhmh.state.md.us/

    Select “Medical Care Programs”, “HealthChoice Managed Care”, “HealthChoice Quality Assurance Activities”

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