Validation and Analysis of Performance Measures and Results for all MCOs

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Validation and Analysis of Performance Measures
and Results for all MCOs
Wendy Talbot MPH, CHCA Project Manager, Audits
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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

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BBA (cont)

• Validation of Performance Measures
• is one of the required activities
• that an EQRO performs.

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Validation of Performance Measures (PMs)

• What is a Performance Measure?
• A quantitative measurement by which goals are
  established and performance is assessed.

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Validation of PMs (cont)

• Performance Measure Characteristics
• Standardized
• Clearly defined
• Meaningful and timely
• Results in comparable data

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Validation of PMs (cont)

• Why measure performance?
• To obtain solid data to evaluate performance and
  make decisions on what improvements are
  necessary.

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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

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Validation of Performance Measures HMOs/PSNs
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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)

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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)

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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)

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Audit Findings

• R Report
• Reportable rate or numeric result
• NA Denominator lt30
• HMO/PSN followed specifications but denominator
  was too small to report

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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

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Measure Specific Findings
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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
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Validation Findings Reform HMOs
R NA NB NR
W15 6 4 0 0
W34 9 1 0 0
AWC 9 1 0 0
ADV 8 0 0 2
CCS 9 1 0 0
PPC 7 3 0 0
CBP 8 2 0 0
CDC 8 2 0 0
FUH 7 3 0 0
AMB 9 1 0 0
SMO 3 7 0 0
UBE 2 6 0 2
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Validation Findings PSNs
R NA NB NR
W15 4 3 0 0
W34 7 0 0 0
AWC 7 0 0 0
ADV 7 0 0 0
CCS 5 0 0 0
PPC 5 2 0 0
CBP 5 1 0 0
CDC 5 2 0 0
FUH 4 2 1 0
AMB 7 0 0 0
SMO 3 2 0 0
UBE 4 2 0 0
Not required to be reported by PSNs whos
populations are specific to children Reported
by Reform PSNs only
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Results
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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

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Comparison Graphs
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Distribution Graphs
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• Pediatric Care

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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

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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)

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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

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Pediatric Care

• Well Child Visits in the 3rd, 4th, 5th, 6th
  Years of Life Adolescent Well-Care 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

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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

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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

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Pediatric CareComparative Results Non-Reform
Inverse measure
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Pediatric Care Range of 2008 Rates Non-Reform
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Pediatric CareComparative Results Reform
Inverse measure
Inverse measure
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Pediatric Care Range of 2008 Rates Reform
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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

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• Womens Care

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Womens Care

• There were no significant specification changes
  in 2008 to any of the Womens Care measures
• Cervical Cancer Screening
• Prenatal and Postpartum Care

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Womens 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

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Womens 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

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Womens 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

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Womens CareComparative Results Non-Reform
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Womens CareRange of 2008 Rates Non-Reform
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Womens CareComparative Results Reform
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Womens CareRange of 2008 Rates Reform
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Womens 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)

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• Living with Illness

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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

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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

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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

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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 lt100
• 2008 FL Non-Reform weighted average ranked above
  the 25th percentile
• 2008 FL Reform weighted average ranked above the
  25th percentile

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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

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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

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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

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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

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Living With IllnessComparative Results
Non-Reform
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Living with Illness Diabetes CareRange of 2008
Rates Non-Reform
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Living with IllnessRange of 2008 Rates
Non-Reform, contd
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Living With IllnessComparative Results Reform
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Living with Illness Diabetes CareRange of 2008
Rates Reform
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Living with IllnessRange of 2008 Rates Reform,
contd
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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

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Performance Measure Validation (PMV)PMHPs/CWPMHP
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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

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Measure Specific Findings
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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

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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

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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

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PMHP2 Rate Range

• Thirty-day readmission rate
• 15.67 to 30.22

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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

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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

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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

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Performance Measure Validation (PMV)NHDPs
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NHDP PMV Audit

• Onsite audits occurred October-November 2008
• 13 NHDPs
• 4 measures
• Disenrollment Rate
• Retention Rate
• Voluntary Disenrollment Rate
• Average Length of Enrollment before Voluntary
  Disenrollment

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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

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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

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Questions?