Transcript Overview of 2004-2005 External Quality Review (EQR) Activities

Overview of 2007
Performance Measure Validation
Findings and
HEDIS Results
Presented by:
Wendy Talbot, MPH, CHCA
January 16, 2008
Presentation Overview
I.
Performance Measure Validation
a. Process
b. Findings and Recommendations
c. Questions
II.
HEDIS Results
a. Results and Recommendations by
Dimension of Care
b. 2008 HEDIS Changes
c. Questions
Performance Measure Validation
Objectives
– Evaluate accuracy
of data collected
– Determine the
extent to which each
measure calculated
followed established
specifications
– Utilize process
consistent with CMS
protocol
Validation Activities
•
•
•
•
•
•
•
•
•
NCQA-licensed audit organization
Pre-on-site call/meeting
BAT review
AHCA-specific measure set validation
Source code/certified software review
Primary source review
Convenience sample validation (if applicable)
Medical Record Review
Health Plan Quality Indicator Data File
Review
Validation Activities Findings
• Used a certified software vendor:
– 10 out of 12 HMOs
• Convenience sample validation:
– 4 HMOs had a convenience sample
– 3 HMOs were exempt
– Was not specified in final audit report whether one
was required or performed for 5 HMOs
• Medical record review validation
– 11 HMOs
– 1 HMO did not use the hybrid method
• All other validation activities were fulfilled
Audit Findings
• R = Report
– Reportable rate or numeric result for HEDIS
measures
• NA = Not Applicable
– The HMO followed the specifications but the
denominator was too small to report a valid rate
(<30)
• NB = No Benefit
– The HMO did not offer the health benefits required
by the measure
• NR = Not Report
– The HMO calculated the measure but the rate was
materially biased or the HMO chose not to report
the measure
Audit Findings
• Breast Cancer Screening
– 42-51 Years
• R = 10 HMOs
• NA = 2 HMOs
– 52-69 Years
• R = 10 HMOs
• NA = 2 HMOs
– Combined
• R = 10 HMOs
• NA = 2 HMOs
• Timeliness of Prenatal Care
• R = 11 HMOs
• NR = 1 HMO
Audit Findings
• Cervical Cancer Screening
• R = 12 HMOs
• Chlamydia Screening
– 16-20 Years
• R = 11 HMOs
• NA = 1 HMO
– 21-25 Years
• R = 11 HMOs
• NA = 1 HMO
– Combined
• R = 12 HMOs
Audit Findings
• Appropriate Medications for People with
Asthma
– 5-9 Years
• R = 9 HMOs
• NA = 3 HMOs
– 10-17 Years
• R = 8 HMOs
• NA = 4 HMOs
– 18-56 Years
• R = 8 HMOs
• NA = 4 HMOs
– Combined
• R = 10 HMOs
• NA = 2 HMOs
Audit Findings
• Comprehensive Diabetes Care
– LDL-C Screening
• R = 10 HMOs
• NA = 2 HMOs
– LDL-C Testing
• R = 10 HMOs
• NA = 2 HMOs
– Eye Exams
• R = 9 HMOs
• NA = 2 HMOs
• NR = 1 HMO
– Nephropathy
• R = 10 HMOs
• NA = 2 HMOs
Audit Findings
• Controlling High Blood Pressure
– 18-45 Years
• R = 7 HMOs
• NA = 1 HMO
• NR = 4 HMOs
– 46-85 Years
• R = 7 HMOs
• NA = 1 HMO
• NR = 4 HMOs
– Combined
• R = 7 HMOs
• NA = 1 HMO
• NR = 4 HMOs
IS Standards
• IS 1.0—Sound Coding Methods for Medical Data
• IS 2.0—Data Capture, Transfer, & Entry—Medical Data
• IS 3.0—Data Capture, Transfer, and Entry—Membership
Data
• IS 4.0—Data Capture, Transfer, and Entry—Practitioner
Data
• IS 5.0—Data Integration Required to Meet the Demands
of Accurate HEDIS Reporting
• IS 6.0—Control Procedures that Support HEDIS
Reporting Integrity
IS 1.0—Sound Coding Methods for Medical Data
Findings
1
2
3
4
5
6
7
8
9
10
11
12
IS 1.0
FC
SC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC=Fully Compliant
IS 2.0
FC
NR
SC
FC
FC
FC
SC
FC
FC
FC
SC
NR
IS 3.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
IS 4.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC=Substantially Compliant
IS 5.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
IS 6.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
FC
NR=Not Report
IS 1.0 Issues –
Two HMOs received a
substantially compliant on
this standard because
they were not capturing
CPT II codes and internal
audits of claims
examiners was not
sufficient.
IS 2.0—Data Capture, Transfer, & Entry—Medical
Data
Findings
1
2
3
4
5
6
7
8
9
10
11
12
IS 1.0
FC
SC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC=Fully Compliant
IS 2.0
FC
NR
SC
FC
FC
FC
SC
FC
FC
FC
SC
NR
IS 3.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
IS 4.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC=Substantially Compliant
IS 5.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
IS 6.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
FC
NR=Not Report
IS 2.0 Issues –
Three HMOs received a
substantially compliant on
this standard due to
issues with data entry
processes and data
transmissions.
Two HMOs received a not
report for this standard
due to problems identified
with their medical record
process.
IS 3.0—Data Capture, Transfer, and Entry—
Membership Data
Findings
1
2
3
4
5
6
7
8
9
10
11
12
IS 1.0
FC
SC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC=Fully Compliant
IS 2.0
FC
NR
SC
FC
FC
FC
SC
FC
FC
FC
SC
NR
IS 3.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
IS 4.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC=Substantially Compliant
IS 5.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
IS 6.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
FC
NR=Not Report
IS 3.0 Issues –
One HMO received a
substantially compliant on
this standard because
there were no policies
and procedures in place
for receiving Medicaid
enrollment files.
IS 4.0—Data Capture, Transfer, and Entry—
Practitioner Data
Findings
1
2
3
4
5
6
7
8
9
10
11
12
IS 1.0
FC
SC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC=Fully Compliant
IS 2.0
FC
NR
SC
FC
FC
FC
SC
FC
FC
FC
SC
NR
IS 3.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
IS 4.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC=Substantially Compliant
IS 5.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
IS 6.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
FC
NR=Not Report
IS 4.0 Issues No issues, all HMOs were
fully compliant with this
standard.
IS 5.0—Data Integration Required to Meet the
Demands of Accurate HEDIS Reporting
Findings
1
2
3
4
5
6
7
8
9
10
11
12
IS 1.0
FC
SC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC=Fully Compliant
IS 2.0
FC
NR
SC
FC
FC
FC
SC
FC
FC
FC
SC
NR
IS 3.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
IS 4.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC=Substantially Compliant
IS 5.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
IS 6.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
FC
NR=Not Report
IS 5.0 Issues No issues, all HMOs were
fully compliant with this
standard.
IS 6.0—Control Procedures that Support HEDIS
Reporting Integrity
Findings
1
2
3
4
5
6
7
8
9
10
11
12
IS 1.0
FC
SC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC=Fully Compliant
IS 2.0
FC
NR
SC
FC
FC
FC
SC
FC
FC
FC
SC
NR
IS 3.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
IS 4.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC=Substantially Compliant
IS 5.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
FC
IS 6.0
FC
FC
FC
FC
FC
FC
FC
FC
FC
SC
FC
FC
NR=Not Report
IS 6.0 Issues –
One HMO received a
substantially compliant on
this standard because
NCQA specifications were
not followed for sample
size production and oversample percentages.
Recommendations—HMOs
• Monitor all vendors who are
contracted to work with data;
specifically medical record
vendors
• Develop and implement
policies and procedure for
data entry validation,
regardless of the amount of
manual data entry performed
• Develop procedures to
ensure all data files are
consistent and accurate
Recommendations—AHCA
• Require a predetermined file
layout for submitting data
• Consider using the NCQA
IDSS data submission tool
• Have HMOs submit Final
Audit reports and Audit
Designation reports to AHCA
as soon as they receive them
to eliminate confusion in the
reporting process
• Have auditors validate the
actual data files being
submitted to AHCA
QUESTIONS?
Florida Medicaid
HEDIS 2007 Results
Dimensions of Care
• Women’s Care
• Living with Illness
Analytics
Comparative
– Florida 2007 weighted average compared
to the national 2006 Medicaid 50th
percentile
– Florida 2007 weighted averages compared
to Florida 2006 weighted averages (when
applicable)
Distribution
– Range of MHP reported rates
Distribution Graphs
100%
Highest Rate
90%
High
Outlier
80%
FL Weighted
Average
70%
60%
Low
Outlier
50%
40%
Lowest Rate
30%
20%
10%
0%
Measure 1
Highest Plan Rate
Measure 2
Weighted Average
Lowest Plan Rate
Florida 2007 Results Compared to
National Benchmarks
7
6
Number of Weighted Average Rates
6
5
5
4
3
3
2
1
1
0
0
0
0 TO 10
10 TO 25
25 TO 50
50 TO 75
2006 National Medicaid Percentile Range
75 TO 90
90 TO 100
Women’s Care
Women’s Care
• 2007 Measures
– Breast Cancer Screening
• Ages 42-51 Years
• Ages 52-69 Years
• Combined
– Cervical Cancer Screening
– Chlamydia Screening
• Ages 16-20 Years
• Ages 21-25 Years
• Combined
– Prenatal and Postpartum Care
• Timeliness of Prenatal Care
Women’s Care
• In 2006, only Breast Cancer Screening
and Chlamydia Screening were
reported by the HMOs.
• Starting in 2007:
– Breast Cancer Screening measure was
reported in three cohorts and the lower age
limit was raised to 40 years of age
– The lower age limit for Cervical Cancer
Screening was raised to 21 years of age
Women’s Care
Overall performance for the
Women’s Care dimension continued
to be below average to average.
Women’s Care
• Breast Cancer Screening—Ages 52-69 Years
findings:
– 10 HMOs reported a rate for this measure; two
HMOs were unable to report rates due to
insufficient sample sizes
– Nine had rates below the national HEDIS 2006
50th percentile
– Four of the HMOs had rates below the low
performance level (LPL)
– The 2007 Florida Medicaid weighted average
decreased by 1 percentage point compared to the
2006 weighted average
Women’s Care
• Cervical Cancer Screening findings:
– 12 HMOs reported a rate for this measure
– All 12 HMOs’ rates were below the national
HEDIS 2006 50th percentile
– 10 of the HMOs reported rates below the
LPL
– The 2007 weighted average of 55.8
percent was below the LPL of 59.7 percent
Women’s Care
• Chlamydia Screening in Women—
Combined findings:
– 12 HMOs reported a rate for this measure
– Four HMOs reported rates above the
national HEDIS 2006 50th percentile
– Two HMOs reported rates below the LPL
– The 2007 weighted average was 1.5
percentage points below the 2006
weighted average
Women’s Care
• Timeliness to Prenatal Care findings:
– 11 HMOs reported a rate for this measure;
one HMO reported an NR for the measure
– All 11 of the HMOs reported rates below
the LPL
– The 2007 weighted average of 63.4
percent was below the LPL of 74.2 percent
Women’s Care
Range of 2007 Rates
80%
70%
60%
50%
40%
30%
20%
10%
0%
Breast Cancer
Screening, 42-51
Years
Breast Cancer
Screening, 52-69
Years
Breast Cancer
Screening,
Com bined
Highest Plan Rate
Cervical Cancer
Screening
Chlam ydia
Chlam ydia
Screening, 16-20 Screening, 21-25
Years
Years
FL Weighted Average
Chlam ydia
Screening,
Com bined
Lowest Plan Rate
Tim eliness of
Prenatal Care
Women’s Care
• Improvement efforts to be considered
for the Breast Cancer Screening
measure include:
– Increase efforts to target younger women
for mammograms
– Educate on the importance of early
detection
– Work to ensure complete administrative
data
Women’s Care
• Improvement efforts to consider for the
Cervical Cancer Screening and
Chlamydia Screening measures
include:
– Educate women on the importance of
screening
– Identify barriers to accessing care and
services
Women’s Care
• Improvement efforts to consider for the
Timeliness to Prenatal Care measure
include:
– Ensure complete data through the use of
medical record review, especially for plans
that utilize global billing for maternity
services
– Educate on the importance of prenatal care
Women’s Care
• Missed opportunities could be examined
to identify barriers to improvement and
target specific interventions
• High performing HMOs should share
best practices with other HMOs
Living with Illness
Living with Illness
• 2007 Measures:
– Use of Appropriate Medications for People with
Asthma
•
•
•
•
Ages 5-9 Years
Ages 10-17 Years
Ages 18-56 Years
Combined
– Comprehensive Diabetes Care
•
•
•
•
LDL-C Screening
LDL-C Controlled
Eye Exams
Medical Attention for Diabetic Nephropathy
– Controlling High Blood Pressure
• Ages 18-52 Years
• Ages 46-85 Years
• Combined
Living with Illness
• In 2006, only Use of Appropriate Medications
of People with Asthma was reported by the
HMOs
• Starting in 2007:
– Controlling High Blood Pressure measure
was reported in three cohorts and the
lower age limit was decreased to 18 years
of age
– There were changes to several indicators
in the Comprehensive Diabetes Care
measure
Living with Illness
The overall statewide results in the Living
With Illness dimension were average to
below average, with the exception of
Comprehensive Diabetes Care—Medical
Attention for Diabetic Nephropathy, which
was above average.
Living with Illness
• Appropriate Use of Medications for
People with Asthma—Combined
findings:
– Nine HMOs reported a rate for this
measure; three HMOs had an insufficient
sample size to report the measure
– Four HMOs reported rates above the
national HEDIS 2006 50th percentile
– One HMO reported a rate below the LPL
Living with Illness
• Comprehensive Diabetes Care findings:
– LDL-C Screening
• No HMOs reported rates above the national
HEDIS 50th percentile
• Eight of the 10 HMOs reported a rate below the
LPL
– LDL-C Testing
• One HMO reported a rate above the national
HEDIS 50th percentile
• Two of the 10 HMOs reported a rate below the
LPL
Living with Illness
• Comprehensive Diabetes Care findings
continued:
– Eye Exams
• No HMOs reported a rate above the national
HEDIS 50th percentile
• Two if the nine HMOs reported a rate below the
LPL
– Medical Attention for Diabetic Nephropathy
• Eight of the 10 HMOs reported a rate above the
HPL
• One HMO reported a rate below the LPL
Living with Illness
• Controlling High Blood Pressure—Ages
46-85 Years findings:
– Seven HMOs reported a rate for this
measure; one had an insufficient sample
size to report the measure, and four
reported an NR
– None of the HMOs reported a rate above
the LPL
Living with Illness
Range of 2007 Rates
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Diabetes Care-Eye Exam
Diabetes Care-LDL Screening Diabetes Care-LDL level <100
Highest Plan Rate
FL Weighted Average
Lowest Plan Rate
Diabetes Care-Nephropathy
Living with Illness
Range of 2007 Rates, cont.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Asthm a, 5-9
Years
Asthm a, 10-17
Years
Highest Plan Rate
Asthm a, 18-56
Years
Asthm a,
Com bined Rate
Controlling High Controlling High Controlling High
Blood Pressure, Blood Pressure, Blood Pressure,
16-45 Years
46-85 Years
Com bined
FL Weighted Average
Lowest Plan Rate
Living with Illness
• Improvement efforts to consider for
Appropriate Medications for People with
Asthma include:
– Ensure pharmacy data are complete
– Educate providers on the guidelines of
asthma treatment
Living with Illness
• Improvement efforts to consider for
Comprehensive Diabetes Care include:
– Educate members on the importance of
diabetes management care
– Ensure vendor data, such as lab and
pharmacy, are complete
– Work to improve administrative data to
minimize the burden of medical record
review
Living with Illness
• Improvement efforts to consider for
Controlling High Blood Pressure
include:
– Changes were made to the 2007 technical
specifications, HMOs should ensure all
changes were implemented
– Monitor medical record review processes
to ensure the measure is being captured
according to specifications
Living with Illness
• Missed opportunities could be examined
to identify barriers to improvement and
target specific interventions
• High performing HMOs should share
best practices with other HMOs
Changes to HEDIS 2008
Summary of Changes
in HEDIS 2008
• New HEDIS measures
• Changes to existing measures
• Retired measures
HEDIS 2008 New Measures
• Lead Screening in Children (LSC)
• Pharmacotherapy Management of
COPD Exacerbation (PCE)
• RRU – Cardiovascular Conditions
(RCA)
• RRU – Uncomplicated Hypertension
(RHY)
• RRU – COPD (RCO)
Changes to Existing Measures
• Childhood Immunization Status (CIS) –
clarified numerator evidence for antigen
compliance
• Persistence of Beta-Blocker Treatment
After A Heart Attack (PBH) – decreased
lower age limit to 18 years of age
Changes to Existing Measures, cont’d
• Avoidance of Antibiotic Treatment in Adults
with Acute Bronchitis (AAB) – Inverted the
measure rate so that a higher rate is
better, and renamed the measure formerly
called Inappropriate Antibiotic Treatment
for Adults with Acute Bronchitis
• Use of High-Risk Medications in the
Elderly (DAE) – renamed measure that
was formally called Drugs to be Avoided in
the Elderly
Retired Measures
• Adolescent Immunization Status
• Beta-Blocker Treatment After a Heart
Attack
• Discharges and ALOS – Maternity
• Births and ALOS – Newborns
• Mental Health Utilization – Inpatient
Discharges and ALOS
• Chemical Dependency Utilization –
Inpatient Discharges and ALOS
Questions?
2007-2008 Focused Study
Behavioral Health Prior
Authorizations
Peggy Ketterer, RN, BSN, CHCA
Executive Director, State and Corporate Services
Marilea Rose, RN, BA
Associate Director, State and Corporate Services
The purpose of the study is to
determine:
•
How behavioral health authorization
processes vary between MCOs
•
How medical necessity criterion vary
between MCOs
•
How timeliness of authorizations vary
across MCOs
Who will participate in the study?
•HMOs
•PSNs
•PMHPs
Focused Study Activity
Step 1: Procure behavioral health
information from MCOs
• 25 out of 26 MCOs have submitted
behavioral health documents
• HSAG has completed a cursory review
and in process of requesting additional
information from MCOs
Focused Study Activity
Step 2: Conduct desk review
• HSAG is currently compiling and
categorizing MCO survey responses
• HSAG conducted informal interviews
with a limited number of providers to
gather preliminary information regarding
potential barriers
Focused Study Activity
Step 3: Evaluate self-reported
timeliness of authorization
• Data submission file layout for
timeliness data is being designed
• HSAG is preparing MCO data request
letter
• HSAG is finalizing MCO instructions for
calculating timeliness indicators
Focused Study Activity
Step 3: Evaluate self-reported
timeliness of authorization (cont’d)
Key Dates:
• Data request letters will be sent to the
MCOs on 1/31/08
• Timeliness data is due back to HSAG
on 3/7/08
Focused Study Activity
Step 4: Report Preparation
• Report outline is being drafted
• HSAG will present findings, summary of
common practices
• HSAG will provide recommendations for
improvement of the process, consider
standardization
Questions and Answers
Upcoming EQR Activities
Contract Year Two
2:45 p.m. – 3:30 p.m.
Peggy Ketterer, RN, BSN, CHCA
Executive Director, EQRO Services
Upcoming EQR activities
MARK YOUR CALENDARS!!!!
The next EQR Quarterly Meetings
are scheduled as follows:
Wednesday, March 26, 2008 (Webinar)
Wednesday, June 18, 2008 (AHCA
Offices)
Wednesday, September 24, 2008
(Webinar)
Performance Improvement Projects
(PIPs)
• PIP validation process is targeted for
completion in March, 2008.
• MCOs will be given the opportunity to
review HSAG’s completed PIP tool and
summary grid and provide feedback and
comments.
Performance Improvement Projects
(PIPs)
• Collaborative PIPs – HMOs/PSNs
• The well-child visits collaborative PIP is on
two separate tracks: reform and nonreform plans. Non-reform plans have
collected baseline data and are completing
the causal/barrier analysis and intervention
planning phase. Reform plans will be
collecting baseline data (HEDIS® 2008),
available June, 2008.
HEDIS is a registered trademark of the National Committee for Quality
Assurance (NCQA)
Performance Improvement Projects
(PIPs)
• Collaborative PIPs – PMHPs
• Topic: Follow-up Within 7 Days After an
Acute Care Discharge for a Mental Health
Diagnosis.
• PMHPs will be collecting baseline data on
calendar year 2007, which will be available
in June, 2008.
Performance Improvement Projects
(PIPs)
• Collaborative PIPs – NHDPs
• Topic: Retention Rate
• NHDPs will begin collecting baseline data
quarterly and will prepare a 2008 calendar
year roll-up rate.
Performance Measures
Non-reform HMOs:
• Validation of Performance Measures
Report is targeted to be finalized in
January, 2008.
• HEDIS 2007 Strategic Analysis Report
will be provided to AHCA as a draft in
January, 2008. The report is targeted to
be finalized in March, 2008.
Performance Measures
Reform HMOs/PSNs:
• HEDIS 2008 data will be analyzed and
reported on during the next contract
year (2008-2009).
Performance Measures
PMHPs:
• PMHPs will be collecting and reporting
performance measure data on calendar
year 2007 to AHCA in July, 2008.
• HSAG will conduct the validation of
performance measures activities
concurrently during the data collection
and reporting cycle.
Performance Measures
NHDPs:
• NHDPs have begun to collect
performance measure data quarterly
(Jan – Mar 2008).
• HSAG will conduct the validation of
performance measures activity in the
early part of the next contract year
(2008-2009).
Focused Study
Behavioral Health Authorizations
• HMOs, PSNs, and PMHPs have
completed the MCO survey document
describing their authorization
processes.
• HSAG will forward a request for
timeliness data to the participating
MCOs on January 31, 2008. Timeliness
data should be submitted to HSAG by
March 7, 2008.
• Draft focused study report is targeted
for submission to AHCA in May, 2008.
Upcoming EQR activities
•Quarterly EQR meetings (webinar
and onsite at AHCA offices in
Tallahassee)
•Other meetings (including
Collaborative PIP meetings and
technical assistance sessions) will be
scheduled in conjunction with the
quarterly meetings
QUESTIONS???
THANK YOU FOR YOUR
PARTICIPATION!