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

External
Quality Review Organization
(EQRO) Kick-Off Meeting
Agency for Health Care
Administration (AHCA)
Tuesday, June 27, 2006
10 a.m. – 2:30 p.m.
Health Services Advisory
Group (HSAG)
Health Services Advisory Group
Federal Division
• Quality Improvement Organization (QIO) for AZ
Medicare
State and Corporate Division
• External Quality Review Organization (EQRO)
Surveys, Research and Analysis Division
• Certified Consumer Assessment of Health Plans
Survey (CAHPS) vendor
www.hsag.com
HSAG History
• Founded in 1979
• Became AZ PRO (now a Quality
Improvement Organization, or QIO) in
1984
• Began working in the Medicaid quality
arena in 1983
• Performs EQR activities in 11 states
• Over 21% of national Medicaid population
Where does HSAG provide EQR
services?
Florida Medical Quality
Assurance, Inc.
(FMQAI)
FMQAI
• Incorporated in Florida in 1992
• Medicare Quality Improvement
Organization (QIO) for the State of
Florida
• ESRD Network 7 federal contractor
Presentation Outline
• Overview of Balanced Budget Act of
1997 (BBA)
• Overview of Florida EQRO activities
• Dissemination of EQRO information
• MCO roles and responsibilities
• Questions and Answers
Balanced Budget Act of 1997
(BBA)
Balanced Budget Act (BBA) of 1997
The BBA requires states with Medicaid
managed care programs to implement
certain standards and business practices
pertaining to:
• Member Rights and Responsibilities
• Quality Assessment and Performance
Improvement
• Grievance and Appeals System
Balanced Budget Act (BBA) of 1997
(cont)
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•
•
•
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Access and Availability of Services
Practice Guidelines
Utilization Review
Contracts and Delegation
Providers
Balanced Budget Act (BBA) of 1997
(cont)
The BBA also requires that states
contract with an EQRO for an annual
independent review of each managed
care organization (MCO) and pre-paid
inpatient health plan (PIHP) to evaluate
the quality and timeliness of, and access
to, health care services provided to
Medicaid enrollees.
Balanced Budget Act (BBA) of 1997
(cont)
EQR activities must be performed
consistent with the BBA protocols.
www.cms.hhs.gov/medicaid/managedcare
EQR Mandatory Activities
• EQR services required by Balanced
Budget Act of 1997:
– Monitoring Medicaid managed care
organizations and prepaid inpatient health
plans
– Validating performance improvement
projects (PIPs)
– Validating performance measures
– (EQR Technical Report)
Optional EQR Activities
• Optional EQR activities include:
– Validating encounter data
– Conducting focused studies
– Administering or validating member or
provider surveys
– Calculating performance measures
– Providing technical assistance
Overview of Florida EQRO
Activities
Overview of EQR Activities
in Florida
• Validation of PIPs
• Validation of performance measures
• Review of compliance with access,
structural, and operations standards
• Strategic reports on consumer-reported
surveys
• Strategic HEDIS® analysis reports
HEDIS® is a registered trademark of the National Committee for Quality Assurance
(NCQA)
Overview of EQR Activities
in Florida (cont’d)
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Technical assistance
Value-based purchasing methodologies
Evaluation of AHCA quality strategy
Focused studies
Dissemination of EQR information
EQRO Technical Report
Description of
Florida EQR Activities
Validation of Performance
Improvement Projects
•Assess and improve processes
•Improve outcomes of care
•Typically consists of a baseline, an
intervention period, and a remeasurement
Validation of Performance Improvement
Projects
HSAG validates PIPs:
• According to CMS protocol
• Using a PIP tool based on the protocol
The result is a final validation finding of
the degree of confidence in the results
(high, low, no confidence)
Validation of Performance Measures
Performance measures:
• Are quantitative measurements by which
goals are established and performance is
assessed
• Calculated by MCOs
• May be HEDIS® measures, state-developed,
or MCO-developed
• Validated by HSAG following CMS protocol
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Validation of Performance Measures
In Florida:
• Most MCOs report HEDIS and undergo a
HEDIS Compliance AuditTM
• Other MCOs (such as PMHPs, and most
NHDPs) collect non-HEDIS performance
measures, which will undergo validation
by HSAG
HEDIS® Compliance Audit is a registered trademark of the National Committee for Quality Assurance
(NCQA)
Review of Compliance with Access,
Structure, and Operations Standards
Key tasks:
• Obtain information on compliance
reviews
• Evaluate AHCA and DOEA compliance
audit process
• Select sample of three audits/conduct
on-site visit to validate results
• Prepare report of findings
Strategic Reports of Consumer-Reported
Surveys
Key tasks:
• Obtain survey data
• Perform exploratory analysis
• Prepare report
– Identify alternative scoring methods
– Discuss approaches for improvement
– Recommend improvements for scoring
algorithm
Strategic HEDIS Analysis Reports
Key tasks:
• Obtain HEDIS data
• Perform analysis
• Produce MCO-specific reports
• Produce Strategic Analysis Report
Technical Assistance: Enrollee Race/Ethnicity
and Primary Household Language Information
Key tasks:
• Review current practices
• Examine data management processes
• Identify barriers
• Develop recommendations
• Prepare report
Value-Based Purchasing Methodologies
Key tasks:
• Review current agency practice
• Perform literature review
• Investigate other states’ approaches
• Develop a definition of superior
performance
• Recommend scoring/weighting
methodologies
• Technical assistance
Evaluation of AHCA Quality Strategy
Key tasks:
• Review quality strategy
• Review other states’ quality strategies
for lessons learned
• Prepare report
Focused Studies
Key tasks:
• Design study, methodology
• Select sample
• Collect data
• Perform analysis
• Prepare report of findings
Focused Studies
Selected Topics for FY 06-07:
• Adolescent Well-Care
• Identification and Assessment of
Individuals with Special Health Care
Needs
Dissemination of EQR Information
Key tasks:
• Develop a communication plan to keep
key stakeholders involved and informed
• Conduct quarterly meetings
• Prepare meeting agendas, materials,
and summaries
EQR Technical Report
Key tasks:
• Develop report outline
• Compile EQR findings from all
applicable activities
• Perform analysis
• Prepare technical report
Dissemination of EQRO
Information
Dissemination of EQRO Information
EQRO Website:
www.myfloridaeqro.com
Website functions:
• Updates on activities
• Secure file transfer protocol (FTP) site
• Frequently asked questions (not available
yet)
• Reminders of upcoming due dates
• Links to other websites
Dissemination of EQRO Information
Quarterly MCO Meetings
• Onsite or via Webinar
• Updates on activities
• Review of most recent EQR reports
• Sharing of best practices
• Technical assistance
Dissemination of EQRO Information
Email Communication
• Letters describing activities
• Questions/answers
• Reminders of upcoming due dates
• Use of mailing lists for group messages
Dissemination of EQRO Information
Phone communications
• Conference calls
• Questions/answers
MCO Roles and Responsibilities
related to EQRO Activities
MCO Roles and Responsibilities
Validation of Performance
Improvement Projects
Validation of PIPs
MCO Roles and Responsibilities
• Provide basic information on the PIPs
that are currently underway using the
“Statement of Intent” document
• Indicate technical assistance needs on
HSAG’s “technical assistance
assessment survey”
• Complete the PIP form and provide
supportive documentation for each PIP
selected for validation
Validation of PIPs
MCO Roles and Responsibilities
• Review HSAG’s completed PIP tool and
PIP report, providing feedback and
comments
• Participate in PIP technical assistance
activities as they become available
Note: The PIP validation process is an
annual activity.
Project Activity by Month
Validation of Performance Improvement Projects (PIPs)
Task
PIPs
May
Jun
Jul
7/06 – 10/06
Request PIP
Documentation
Aug
Sep
Oct
11/06 – 12/06
Perform individual
PIP Analysis
7/06 – 10/06
Develop Annual Plan for
Technical Assistance
Nov
Dec Jan Feb Mar Apr May Jun
07
12/06 – 2/07
Prepare Annual
Validation Summary
Report
1/07 – 4/07
Prepare Annual
Strategic Report
Ongoing
Technical Assistance to Agency, MediPass, and MCOs
Ongoing
Prepare Quarterly Status Reports on Technical Assistance
Validation of Performance
Measures
Validation of Performance Measures
MCO Roles and Responsibilities
• HMOs provide 2006 HEDIS® Baseline
Assessment Tool (BAT), Data
Submission Tool (DST), and Final Audit
Report to HSAG
• HMOs complete and forward
supplemental questions document to
HSAG
• Establish a contact person if questions
arise from the HSAG review team
Validation of Performance Measures
MCO Roles and Responsibilities
For MCOs that do not currently undergo
an independent audit:
• HSAG will evaluate what performance
measures are collected and whether
they can be validated
• PSN and some MCOs will undergo the
validation activities, including a site visit
• Other MCOs should participate in
technical assistance opportunities as
they become available
Project Activity by Month
Validation of Performance Measures (PMVs)
Task
May
Jun
Jul
Aug Sep Oct Nov Dec Jan
07
PMVs
6/06
Request
Documentation
7/06
Receive MCO
documentation
8/06 – 9/06
Complete
Site Visit(s)
10/06 – 12/06
Prepare Report
Feb
Mar
Apr
May
Focused Studies
Focused Studies
MCO Roles and Responsibilities
• Provide data and/or information, if needed
If study design requires medical records:
• Receive list of sample cases
• Identify appropriate providers
• Collect medical records
• Forward medical records to Tampa office
• Provide status reports of medical record
pursuit
Project Activity by Month
Focused Studies
Task
Focused
Studies
Jun
Jul
Aug Sep Oct
7/06 –8/06
Develop
Study
Criteria for
Each Study
8/06
Identify
Study
Populations
and Select
Samples
Nov
Dec Jan
07
10/06 – 12/06
Collect Medical Records
Feb
Mar
Apr
May Jun
2/07 – 3/07
Analyze Electronic
and Medical
Abstraction Data
12/06 – 2/07
Abstract Medical
Records
3/07 – 6/07
Prepare Reports
Questions and Answers