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

Validation and Analysis of
Performance Measures and
Results for all MCOs
Wendy Talbot MPH, CHCA
Project Manager, Audits
Balanced Budget Act (BBA) 1997
The BBA requires that:
• States contract with an EQRO
• EQRO conducts annual independent
review of each managed care
organization (MCO) and pre-paid
inpatient health plan (PIHP)
• Evaluates quality, access, and
timeliness of health care services
provided to Medicaid enrollees
BBA (cont)
Validation of Performance Measures
is one of the required activities
that an EQRO performs.
Validation of Performance Measures
(PMs)
What is a Performance Measure?
A quantitative measurement by which
goals are established and performance is
assessed.
Validation of PMs (cont)
Performance Measure Characteristics:
•
•
•
•
Standardized
Clearly defined
Meaningful and timely
Results in comparable data
Validation of PMs (cont)
Why measure performance?
To obtain solid data to evaluate
performance and make decisions on what
improvements are necessary.
Validation of PMs (cont)
Final AHCA Required Performance
Measures for Measurement Year 1:
– Non-Reform HMOs/PSNs – 10 HEDIS
– Reform HMOs/PSNs – 10 HEDIS & 2
Agency-developed
– PMHPs – 3 Agency-developed
– CWPMHP – 2 Agency-developed
– NHDPs – 4 Agency-developed
Validation of Performance
Measures
HMOs/PSNs
HMOs/PSNs HEDIS Audits
• Plans underwent HEDIS compliance
audits in Spring 2008
• 13 HMOs and 6 PSNs
– 12 Non-Reform HMOs
– 10 Reform HMOs
– 1 Non-Reform PSN
– 6 Reform PSNs
• Measures:
– 10 HEDIS (Non-Reform & Reform)
– 2 Agency-Defined (Reform)
Measures
• HEDIS
– Well-Child Visits in the First Fifteen
Months of Life (W15)
– Well-Child Visits in the Third, Fourth, Fifth,
and Sixth Years of Life (W34)
– Adolescent Well Care Visits (AWC)
– Annual Dental Visits (ADV)
– Cervical Cancer Screening (CCS)
– Prenatal and Postpartum Care (PPC)
Measures
• HEDIS (cont)
– Controlling High Blood Pressure (CBP)
– Comprehensive Diabetes Care (CDC)
– Follow-Up After Hospitalization for Mental
Illness (FUH)
– Ambulatory Care (AMB)
• Agency-Defined
– Smoking Cessation (SMO)
– Use of Beta Agonist (UBE)
Audit Findings
• R = Report
– Reportable rate or numeric result
• NA = Denominator <30
– HMO/PSN followed specifications but
denominator was too small to report
Audit Findings (cont)
• NB = No Benefit
– HMO/PSN did not offer health benefit
required by the measure
• NR = Not Report
– Rate was materially biased or plan chose
not to report
Measure Specific Findings
Validation Findings
Non-Reform HMOs
R
NA
NB
NR
W15
12
0
0
0
W34
12
0
0
0
AWC
12
0
0
0
ADV
2
0
7
3
CCS
12
0
0
0
PPC
11
1
0
0
CBP
11
1
0
0
CDC
11
1
0
0
FUH
10
2
0
0
AMB
12
0
0
0
Validation Findings
Reform HMOs
W15
W34
AWC
ADV
CCS
PPC
CBP
CDC
FUH
AMB
SMO
UBE
R
6
9
9
8
9
7
8
8
7
9
3
2
NA
4
1
1
0
1
3
2
2
3
1
7
6
NB
0
0
0
0
0
0
0
0
0
0
0
0
NR
0
0
0
2
0
0
0
0
0
0
0
2
Validation Findings
PSNs
W15
W34
AWC
ADV
CCS*
PPC
CBP*
CDC
FUH
AMB
SMO*†
UBE*†
R
4
7
7
7
5
5
5
5
4
7
3
4
NA
3
0
0
0
0
2
1
2
2
0
2
2
*Not required to be reported by PSNs who’s populations are specific to children
† Reported by Reform PSNs only
NB
0
0
0
0
0
0
0
0
1
0
0
0
NR
0
0
0
0
0
0
0
0
0
0
0
0
Results
Analytics
Comparative
– Florida 2008 weighted average
compared to the national 2007
Medicaid 50th percentile
– Florida 2008 weighted average
compared to the 2007 weighted
average
Distribution
– Range of HMO/PSN reported rates
Comparison Graphs
2008 FL Weighted Average Compared
to 2007 NCQA
Medicaid 50th Percentile
2008 FL Weighted Average
Compared to
2007 FL Weighted Average
-15%
-10%
-5%
0%
5%
10%
15%
20%
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
Pediatric Care
Pediatric Care
There were no significant specification
changes in 2008 to any of the Pediatric
Care measures
– Well-Child Visits in the First Fifteen Months
of Life
– Well-Child Visits in the Third, Fourth, Fifth,
and Sixth Years of Life
– Adolescent Well-Care Visits
– Annual Dental Visits
Pediatric Care
Well Child Visits in the First Fifteen
Months of Life
– Zero Visits (reverse measure)
• 2008 FL Non-Reform weighted average improved
by 0.7 percentage point from the 2006 rate
• 2008 FL Non-Reform weighted average was
greater than the national HEDIS 50th percentile
• The 2008 FL Reform weighted average was
greater than the national HEDIS 90th percentile
(Note: with reverse measure – lower is better)
Pediatric Care
Well Child Visits in the First Fifteen
Months of Life
– Six or More Visits
• 2008 FL Non-Reform weighted average improved
by 2.5 percentage points from the 2006 rate
• 2008 FL Non-Reform weighted average was
lower than the national HEDIS 25th percentile
• 2008 FL Reform weighted average ranked below
the national HEDIS 25th percentile
Pediatric Care
Well Child Visits in the 3rd, 4th, 5th, &
6th Years of Life & Adolescent WellCare Visits
• 2008 FL Non-Reform weighted average
improved when compared to the 2006 rate
• 2008 FL Non-Reform weighted average ranked
higher than the national HEDIS 50th percentile
• 2008 FL Reform weighted average also ranked
higher than the national HEDIS 50th percentile
Pediatric Care
Adolescent Well-Care Visits
• 2008 FL Non-Reform weighted average
decreased from 2006
• 2008 FL Non-Reform weighted average ranked
just below the national HEDIS 50th percentile
• 2008 FL Reform weighted average ranked
above the national HEDIS 50th percentile
Pediatric Care
Annual Dental Visits
• 2008 FL Non-Reform weighted average ranked
below national HEDIS 10th percentile
• 2008 FL Reform weighted average also ranked
below the national HEDIS 10th percentile
Pediatric Care
Comparative Results – Non-Reform
Inverse measure
Well-Child 1st 15 Months of Life, Zero Visits
Well-Child 1st 15 Months of Life, 6+ Visits
Well-Child 3rd-6th Years of Life
Adolescent Well-Care Visits
Annual Dental Visits, Combined
-40%
-30%
-20%
-10%
0%
Compared to 2007 National HEDIS 50th Percentile
10%
Pediatric Care
Range of 2008 Rates – Non-Reform
Pediatric Care
Comparative Results – Reform
Inversemeasure
measure
Inverse
Well-Child 1st 15 Months of Life, Zero Visits
Well-Child 1st 15 Months of Life, 6+ Visits
Well-Child 3rd-6th Years of Life
Adolescent Well-Care Visits
Annual Dental Visits, Combined
-30%
-20%
-10%
0%
Compared to 2007 National HEDIS 50th Percentile
10%
Pediatric Care
Range of 2008 Rates – Reform
Pediatric Care
Improvement efforts to consider include:
– Provider report cards
– Missed opportunities
– Research to determine if missing service
data are due to capitated providers
– Have high performers present best
practices
Women’s Care
Women’s Care
There were no significant specification
changes in 2008 to any of the Women’s
Care measures
– Cervical Cancer Screening
– Prenatal and Postpartum Care
Women’s Care
Cervical Cancer Screening
– 2008 FL Non-Reform weighted average had a
slight increase over the 2007 weighted average
– 2008 FL Non-Reform weighted average ranked
below the national HEDIS Medicaid 25th percentile
– 2008 FL Reform weighted average ranked below
the national HEDIS Medicaid 10th percentile
Women’s Care
Prenatal and Postpartum Care
– Timeliness of Prenatal Care
• 2008 FL Non-Reform weighted average
increased by 8.2 percentage points compared
to the 2007 rate
• 2008 FL Non-Reform weighted average ranked
above the national HEDIS 10th percentile
• 2008 FL Reform weighted average ranked
below the national HEDIS 10th percentile
Women’s Care
Prenatal and Postpartum Care
– Postpartum Care
• 2008 FL Non-Reform weighted average ranked
just below the national HEDIS 50th percentile
• 2008 FL Reform weighted average ranked
below the national HEDIS 25th percentile
Women’s Care
Comparative Results – Non-Reform
Cervical Cancer Screening
Timeliness of Prenatal Care
Postpartum Care
-15%
-10%
-5%
0%
5%
10%
Com pared to 2007 National HEDIS 50th Percentile
Com pared to 2007 Florida Medicaid Weighted Average
Women’s Care
Range of 2008 Rates – Non-Reform
Women’s Care
Comparative Results – Reform
Cervical Cancer Screening
Timeliness of Prenatal Care
Postpartum Care
-20%
-15%
-10%
-5%
0%
5%
Compared to 2007 National HEDIS 50th Percentile
Women’s Care
Range of 2008 Rates – Reform
Women’s Care
Improvement efforts to consider include:
– Research challenges or barriers to obtaining
service evidence from:
• Lab results
• Missing detail on global bills
• Mammography data
– Provider education if issues are identified
(e.g. not performing postpartum visit in
appropriate timeframe)
Living with Illness
Living with Illness
There were no significant specification
changes in 2008 to any of the Living with
Illness measures
– Comprehensive Diabetes Care
– Controlling High Blood Pressure (removed age
stratification)
– Follow-Up After Hospitalization for a Mental Illness
Living with Illness
Comprehensive Diabetes Care
– HbA1c Testing
• 2008 FL Non-Reform weighted average ranked
above the 25th percentile
• 2008 FL Reform weighted average ranked
above the 50th percentile
– HbA1c Poor Control (reverse measure)
• 2008 FL Non-Reform weighted average ranked
above the 50th percentile
• 2008 FL Reform weighted average ranked
above the 50th percentile
Living with Illness
Comprehensive Diabetes Care
– HbA1c Good Control
• 2008 FL Non-Reform weighted average ranked
above the 50th percentile
• 2008 FL Reform weighted average ranked
above the 50th percentile
Living with Illness
Comprehensive Diabetes Care
– LDL-C Screening
• 2008 FL Non-Reform weighted average ranked
above the 50th percentile
• 2008 FL Reform weighted average ranked
above the 75th percentile
– LDL-C <100
• 2008 FL Non-Reform weighted average ranked
above the 25th percentile
• 2008 FL Reform weighted average ranked
above the 25th percentile
Living with Illness
Comprehensive Diabetes Care
– Eye Exams
• 2008 FL Non-Reform weighted average ranked
below the 25th percentile
• 2008 FL Reform weighted average ranked
below the 25th percentile
– Nephropathy
• 2008 FL Non-Reform weighted average ranked
above the 50th percentile
• 2008 FL Reform weighted average ranked
above the 50th percentile
Living with Illness
Controlling High Blood Pressure
• 2008 FL Non-Reform weighted average
increased by 6.5 percentage points from the
2007 weighted average
• 2008 FL Non-Reform weighted average ranked
above the national HEDIS Medicaid 25th
percentile
• 2008 FL Reform weighted average ranked
below the national HEDIS Medicaid 25th
percentile
Living with Illness
Follow-Up After Hospitalization for
a Mental Illness
– 30-Day Rate
• 2008 FL Non-Reform weighted average ranked
below the 25th percentile
• 2008 FL Reform weighted average ranked
below the 25th percentile
Living with Illness
Follow-Up After Hospitalization for
a Mental Illness
– 7-Day Rate
• 2008 FL Non-Reform weighted average ranked
above the 25th percentile
• 2008 FL Reform weighted average ranked
below the 25th percentile
Living With Illness
Comparative Results – Non-Reform
Diabetes Care, HbA1c Testing
Diabetes Care, Poor HbA1c Control – REVERSE MEASURE
Diabetes Care, Good HbA1c Control
Diabetes Care, LDL-C Screening
Diabetes Care, LDL-C Level <100
Diabetes Care, Eye Exam
Diabetes Care, Nephropathy
Controlling High Blood Pressure, Combined
Follow-Up After Hospitalization for Mental Illness, 30 Days
Follow-Up After Hospitalization for Mental Illness, 7 Days
-20%
-15%
-10%
-5%
0%
5%
Compared to 2007 National HEDIS 50th Percentile
Compared to 2007 Florida Medicaid Weighted Average
10%
Living with Illness – Diabetes Care
Range of 2008 Rates – Non-Reform
100%
90%
80%
70%
Reverse
Measure
60%
50%
40%
30%
20%
10%
0%
Diabetes Care,
HbA1c Testing
Diabetes Care, Poor Diabetes Care, Good Diabetes, Care Eye Diabetes Care, LDL Diabetes Care, LDL
HbA1c Cntrl
HbA1c Cntrl
Exam
Screening
Level <100
Highest Plan Rate
FL Weighted Average
Lowest Plan Rate
Diabetes Care,
Nephropathy
Living with Illness
Range of 2008 Rates – Non-Reform, cont’d
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Controlling High Blood Pressure,
Combined
Follow-Up After Mental Illness, 30-day
Highest Plan Rate
FL Weighted Average
Follow-Up After Mental Illness, 7-day
Lowest Plan Rate
Living With Illness
Comparative Results – Reform
Diabetes Care, HbA1c Testing
Diabetes Care, Poor HbA1c Control – REVERSE MEASURE
Diabetes Care, Good HbA1c Control
Diabetes Care, LDL-C Screening
Diabetes Care, LDL-C Level <100
Diabetes Care, Eye Exam
Diabetes Care, Nephropathy
Controlling High Blood Pressure, Combined
Follow-Up After Hospitalization for Mental Illness, 30 Days
Follow-Up After Hospitalization for Mental Illness, 7 Days
-25%
-20%
-15%
-10%
-5%
0%
5%
Compared to 2007 National HEDIS 50th Percentile
10%
Living with Illness – Diabetes Care
Range of 2008 Rates – Reform
Living with Illness
Range of 2008 Rates – Reform, cont’d
Living With Illness
Improvement efforts to consider include:
– Research barriers to obtaining complete
lab and pharmacy data
– Provider education on clinical guidelines if
necessary
– Provider report cards or incentives for high
performers
Performance Measure
Validation (PMV)
PMHPs/CWPMHP
PMHPs/CWPMHP PMV Audits
• Site visits occurred May-June 2008
• 5 PMHPs and 1 CWPMHP
• 3 Measures
– Follow-up within seven days after acute
care discharge for a mental health
diagnosis (PMHP1)
– Thirty-day readmission rate (PMHP2)
– Number of enrollees admitted to State
mental health treatment facilities* (PMHP3)
*CWPMHP was not required to report this measure
Measure Specific Findings
Follow-Up Within Seven Days After Acute
Care Discharge for a Mental Health Diagnosis
• 5 out of 5 PMHPs received Fully
Compliant for this measure
• 1 out of 1 CWPMHP received Fully
Compliant for this measure
• 3 numerators reported for measure
– Follow-Up with Mental Health Practitioner
– Follow-Up with Mental Health
Practitioner/Case Manager
– Follow-Up with Case Manager
PMHP1 Rate Ranges
• Follow-up with a mental health
practitioner:
– 10.98% to 31.22%
• Follow-up with a mental health
practitioner and/or case manager:
– 11.82% to 55.18%
• Follow-up with case manager:
– 3.98% to 42.81%
Thirty-day Readmission Rate
• 5 out of 5 PMHPs received Fully
Compliant for this measure
• 1 out of 1 CWPMHP received Fully
Compliant for this measure
PMHP2 Rate Range
• Thirty-day readmission rate:
– 15.67% to 30.22%
Number of Enrollees Admitted to State Mental
Health Treatment Facilities
• 4 out of 5 PMHPs received Substantially
Compliant for this measure
• 1 PMHP received Not Valid for this
measure
• CWPMHP was not required to report
this measure
PMHP3 Rate Range
• Number of enrollees admitted to
state mental health treatment
facilities:
– 0.00% to 0.12%*
* Data for this measure were obtained from
a third party and HSAG was unable to
validate the original source data to ensure
the reported rates were accurate
Overall Findings
• All PMHPs and the CWPMHP were able
to report valid rates for two out of three
measures
• Overall performance was average, with
room for improvement
• PMHPs did not have access to all of the
data necessary to calculate certain
measures - this should be considered
when selecting future measures
Performance Measure
Validation (PMV)
NHDPs
NHDP PMV Audit
• Onsite audits occurred OctoberNovember 2008
• 13 NHDPs
• 4 measures
– Disenrollment Rate
– Retention Rate
– Voluntary Disenrollment Rate
– Average Length of Enrollment before
Voluntary Disenrollment
Preliminary Findings
• Review of documentation and
interviews with key staff revealed
measures were being calculated
correctly
• Source code review indicated
specifications were being followed
• No final determination on rates until final
rates are submitted in 2009
Next Steps
• Rates due to AHCA/DOEA and HSAG
March 2, 2009
• Draft reports due to AHCA/DOEA on
March 16, 2009
• Final reports due to AHCA/DOEA on
April 21, 2009
Questions?