Validation of Performance Measures for PMHPs

1. 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

2. Balanced Budget Act (BBA) of 1997

3. 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.

4. 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.

5. Balanced Budget Act (BBA) of 1997 42CFR438.358 States must ensure that the performance measures are validated annually through the external quality review process.

6. Performance Measures Performance Measure Characteristics: • Standardized • Clearly defined • Meaningful and timely • Results in comparable data

7. 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

8. Calculation and Reporting of Performance Measures Performance Measure Calculation: A Brief Overview

9. 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

10. 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)

11. 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

12. Calculation and Reporting of Performance Measures Step 4: Calculate measures administratively • Run source code • Examine output files • Review preliminary administrative results

13. 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)

14. Calculation and Reporting of Performance Measures (cont) Step 9:Submit Performance Measure reports to the state • Utilize state-specified format

15. 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

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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

22. Reporting Format • Identifies the data elements necessary for reporting (i.e. eligible population, numerator events, rate) • Includes a grid for entering data elements

23. Validation Activities Three Main Phases: • Pre-On-Site • On-Site • Post-On-Site

24. 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

25. 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

26. 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

27. 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

28. 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

29. Open Discussion Questions and Answers