Validation of performance measures for pmhps
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Validation of Performance Measures for PMHPs. Health Services Advisory Group. January 17, 2008 10:00 a.m. –12:00 p.m. Presenter: Peggy Ketterer, RN, BSN, CHCA Executive Director, EQRO Services. Balanced Budget Act (BBA) of 1997. Balanced Budget Act (BBA) of 1997. 42CFR438.240

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Validation of Performance Measures for PMHPs

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Validation of performance measures for pmhps

Validation of Performance Measures for PMHPs

Health Services Advisory Group

January 17, 2008

10:00 a.m.–12:00 p.m.

Presenter:

Peggy Ketterer, RN, BSN, CHCAExecutive Director, EQRO Services


Balanced budget act bba of 1997

Balanced Budget Act (BBA) of 1997


Balanced budget act bba of 19971

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

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 19972

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

Performance Measures

Performance Measure Characteristics:

  • Standardized

  • Clearly defined

  • Meaningful and timely

  • Results in comparable data


Performance measures1

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

Calculation and Reporting of Performance Measures

Performance Measure Calculation:

A Brief Overview


Calculation and reporting of performance measures1

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., inpatient utilization reports, kept appointment database


Calculation and reporting of performance measures2

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 measures3

Calculation and Reporting of Performance Measures

Step 3: Produce source code to calculate measures

  • Calculate continuous enrollment and anchor date

  • Determine member age

  • Include diagnosis and procedure codes needed to identify service events

  • Exclusion logic


Calculation and reporting of performance measures4

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 measures5

Calculation and Reporting of Performance Measures

Step 5: 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

Calculation and Reporting of Performance Measures (cont)

Step 9:Submit Performance Measure reports to the state

  • Utilize state-specified format


Diagram of a performance measure

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

Written Description

The percent of enrollees who were hospitalized for a mental health diagnosis and were discharged to the community from an acute care facility and were seen on an outpatient basis by a mental health practitioner and/or case manager within seven days.


Calculation

Calculation

Three calculations will be generated:

  • The percentage of enrollees who had a follow-up visit with a mental health practitioner

  • The percentage of enrollees who had a follow-up visit with a mental health practitioner and/or case manager

  • The percentage of enrollees who had a follow-up visit with a case manager


Eligible population criteria

Eligible Population Criteria

Specifies any age, continuous enrollment (CE), and event/diagnosis requirements

  • Age: no requirement – all enrollees

  • CE: Date of discharge through 7 days after discharge

  • Event/diagnosis: Discharged to the community from an acute care facility (inpatient or crisis stabilization unit) with specific diagnosis codes indicating a mental health disorder


Exclusion criteria

Exclusion Criteria

Specifies any exclusions

  • Enrollees who died

  • Enrollees who were re-admitted within 7 days of discharge

  • Enrollees whose discharges were followed by readmission or direct transfer


Exclusion criteria1

Exclusion Criteria

Specifies any exclusions (cont’d)

  • Enrollees who receive Florida Assertive Community Treatment services

  • Enrollees who are admitted to hospice, nursing facilities, state mental health facilities, correctional institutions or hospice programs


Numerator event criteria

Numerator Event Criteria

An outpatient follow-up encounter with a mental health practitioner up to seven days after hospital discharge

  • Mental health practitioner definitions are specified

  • Service codes for follow-up encounter are specified


Reporting format

Reporting Format

  • Identifies the data elements necessary for reporting (i.e. eligible population, numerator events, rate)

  • Includes a grid for entering data elements


Validation activities

Validation Activities

Three Main Phases:

  • Pre-On-Site

  • On-Site

  • Post-On-Site


Validation activities1

Validation Activities

Pre-On-Site Activities:

  • Identify measures to be validated

  • Prepare Information System Capabilities Assessment Tool (ISCAT) request

  • Schedule site visits and prepare agendas


Validation activities2

Validation Activities

Pre-On-Site Activities (cont):

  • Receive completed ISCATs from PMHPs

  • Review ISCATs to assess information system integrity and capabilities

  • Conduct pre-on-site conference call with each PMHP


Validation activities3

Validation Activities

On-Site Activities (for each PMHP):

  • Duration – approximately 2 days

  • Conduct opening meeting

  • Complete on-site activities – including systems walkthroughs, demonstrations, and measure specific review

  • Conduct exit conference


Validation activities4

Validation Activities

Post-On-Site Activities:

  • Evaluate corrective actions and follow-up items

  • Determine validation findings for each performance measure

  • Prepare draft report – submit to AHCA and PMHPs for comments

  • Prepare final report


Validation activities proposed timeline

04/11/08

Receive PMHP documentation

03/10/08

Request ISCAT Documentation

05/19/08 – 05/30/08

Conduct Onsite Visits

06/09/08 – 07/11/08

Prepare Report

Validation ActivitiesProposed Timeline


Open discussion

Open Discussion

Questions and Answers


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