External Quality Review Quarterly Meeting Tuesday, January 9, 2007 1:00 p.m. – 3:00 p.m.

ExternalQuality Review

Quarterly Meeting

Tuesday, January 9, 2007

1:00 p.m. – 3:00 p.m.

Welcome and Logistics

Introductions and roll-callWebinar logisticsDo’s and don’tsPost-meeting survey

Welcome and Logistics

Today’s agendaPIP validation update and summary of preliminary

findingsPreliminary findings on the validation of

performance measuresPreliminary findings on the HEDIS strategic reports Update on focused studiesSummary of technical assistance on enrollee race,

ethnicity, and primary languageUpcoming EQR activitiesQuestions and Answers

Performance Improvement Projects (PIPs) Update

1:20 p.m. – 1:30 p.m.

Cheryl L. Neel, RN, MPH, CPHQManager, Performance Improvement Projects

Presentation Overview

• PIP Update

– Submissions

– Review Process

– PIP Review Process Update

• PIP Studies

– Reform versus Non-reform Members

• PIP Technical Assistance

PIP Submissions

Update: November 3rd Submission Date

– Total studies submitted=86

HMO studies– Total submitted=58 (represents 14 HMOs entities)

NHDP studies– Total submitted=20 (represents 10 NHDP entities)

PMHP– Total submitted=8 (represents 2 PMHP entities)

PIP Review Process

– All PIP studies are independently reviewed by, at a minimum, a clinician and a statistician.

– Scored results are compiled and any discrepancies are identified from the independent reviews.

– PIP Validation Tools are finalized.– PIP Validation Reports are completed.

PIP Review Process

Update: Observations

– If non-compliance noted in one MCO study it was likely that similar issue was found in additional submitted studies.

Reform versus Non-reform

PIP study populations that include reform and non-reform members:– Future PIP submissions will need to have

results separated, if the study includes both populations.

Technical Assistance (TA)

Update: Annual TA Plan submitted to AHCA for

final review and approval. Will be available soon on the website

(www.myfloridaeqro.com).

Questions and Answerson PIP activities?

Preliminary Findings - Validation of Performance Measures

1:30 p.m. – 1:50 p.m.

Raj Shrestha, MPH, MBA, CHCADirector, Audits/Private Projects

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

Performance Measure Validation

MCOs undergoing validation activities:– Must have collected and reported standardized

performance measures.

– HMOs – collected and submitted HEDIS measures in October, 2006.

– PSN – collecting HEDIS measures, will undergo validation of 2006 performance measure data.

– PMHPs and NHDPs – TA will be provided to AHCA/DOEA for the development of standardized performance measures.

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

Validation Activities Findings

9 out of 11 HMOs had a full audit 9 out of 11 HMOs used a certified software

vendor 4 HMOs did not need a convenience sample

validation All other validation activities were fulfilled

Audit Designations

R = Report Measure fully or substantially compliant with

HEDIS specifications. The reported rate may also be “N/A” indicating the denominator was too small (<30) to report a valid rate.

NR = Not ReportMeasure deviated from HEDIS specifications

such that the reported rate was significantly biased or if an HMO chose not to report.

Audit Findings

• All HMOs received an “R” designation which means they are valid and reportable.

• Not Applicable Audit Designations: Breast Cancer Screening: (2 HMOs) Asthma 5-9: (2 HMOs) Asthma 10-17: (4 HMOs) Asthma 18-56: (5 HMOs) Asthma Combined: (2 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 Findings

• There were four instances where the HMOs were found to be “Substantially Compliant”.

• None of these IS capabilities issues lead to a “Not Report.”

IS Findings

IS 1.0 Issues—Online edits permit processing to occur when codes are not fully valid.

FC=Fully Compliant SC=Substantially Compliant

IS Findings


IS 2.0 Issues—AHCA’s requirements for claims processing not met.

Oversight of medical record vendor and data completeness studies were not performed.

No formal process to ensure data validity.

IS Findings


IS 4.0 Issues—Internal and external audits of provider data and reconciliation processes between separate provider databases were not implemented.

Recommendations—HMOs

Assess and devise ways to improve administrative data completeness

Monitor individual provider’s submission rates by provider type to look for potential submission issues

Recommendations—AHCA When adding measures consider:

– Additional burden to HMOs

– Data sources needed to collect measures

– Administrative measures that are less labor-intensive and costly

– Whether the measure adds value

Preliminary Findings – HEDIS Strategic Reports

1:50 p.m. – 2:00 p.m.

Raj Shrestha, MPH, MBA, CHCADirector, Audits/Private Projects

HMO Performance Measures

Pediatric CareWomen’s

CareLiving With

Illness



CareLiving With

Illness

Well-Child Visits in the First 15 Months of Life

Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life

Adolescent Well-Care Visits



CareLiving With

Illness




Breast Cancer Screening

Cervical Cancer Screening



CareLiving With

Illness




Breast Cancer Screening

Cervical Cancer Screening

Use of Appropriate Medications for People With Asthma

HMO-Specific Reports

Reports includes:– A performance-level analysis, which shows HMOs’ results

relative to national Medicaid performance levels.

– Comparison of each HMO’s performance to the statewide weighted average.

– An audit analysis indicating any HEDIS data collection or reporting issues identified through the audit process.

Draft reports to AHCA December 13, 2006

Aggregate Report

Reports includes:– A weighted average comparison of the Florida Medicaid 2006

results to the national HEDIS 2005 Medicaid 50th percentiles.

– A performance profile analysis of the overall Florida Medicaid 2006 results and a summary of health plan performance relative to the Florida Medicaid performance.

– A health plan ranking analysis relative to the Florida Medicaid performance levels.

– A data collection analysis of the potential impact of data collection methodology on reported rates.

Currently, finishing draft aggregate report—due to AHCA January 18, 2006.

QUESTIONS?

Update on Focused Study Activities

2:00 p.m. – 2:20 p.m.

Thomas Miller, MADirector, State and Corporate Analysis

David Mabb, MS, CHCASenior Director, Statistical Evaluation

Update on Focused Study Activities

HSAG is currently conducting two focused studies on the following topics:Adolescent Well-CareIdentification of Individuals with Special Health Care Needs

Update on Focused Study Activities – Adolescent Well-Care –

Presentation Overview– Timeline review

– Methodology overview

– Medical record procurement update

– Upcoming activities – “What to Expect”


MCOs included in this study:– HMOs

– PSN

– MediPass

(NHDPs and PMHPs not appropriate for inclusion)


Focused Study TimelineFocused Study Timeline

1- Develop study methodology and study indicators (July – November)

2- Identify eligible population & select study sample (October - November)

3- Develop medical record abstraction tool and instructions (October-December)

4- Procure selected members’ medical records(November - February)

5- Abstract member medical records and collect study data (January - March)

6- Analyze data and report findings (March – April)

7- Draft report and recommendations (April - June)


Methodology OverviewMethodology Overview


Focused Study Objective– To provide baseline results of adolescent

EPSDT indicators for targeting interventions and improving performance


Focused Study Indicators– Based on the Florida Medicaid Child Health

Check-up Coverage and Limitations Handbook

– Includes the following:• Adolescent well-care visits• Health history • Developmental assessment• Comprehensive physical examination• Health education• Vision assessment and referrals


Focused Study Indicators, con’t• Hearing assessment and referrals

• Nutritional assessment

• Dental assessment and referrals

• Immunization assessment

• Laboratory tests

• Diagnosis and treatment

• Referrals

• Care coordination


Sampling Methodology– Eligible population

• Medicaid enrolled members 11 through 20 years of age as of June 30, 2006

• Continuously enrolled in the same MCO between July 1, 2005 and June 30, 2006– Only one 1-month gap in enrollment

• Anchor date for enrollment: June 30, 2006


Sampling Methodology– Sample

• Random sample of 411 cases– Stratified by age group (11-14 yrs, 15-18 yrs, 19-20 yrs)

– 137 cases per age group per MCO

• Oversample of 21 cases (5 percent)

Note: Rates reported at the MCO or aggregate statewide level will be weighted according to the proportional representation of each age group and MCO.


Medical Record Procurement– Submission dates

• December 15, 2006

• January 15, 2007

• February 15, 2007 (FINAL SUBMISSION DATE)


Tracking Sheet Status Number Percent

1- Tracking sheet not received 5,189 92.4%

2- Tracking sheet received 427 7.6%

A- Medical record submitted 120 28.1%

B- No medical record submitted 307 71.9%

• No visits during study period 40 13.0%

• Provider refused to release record 6 2.0%

• Unable to locate medical record 8 2.6%

• Other 253 82.4%

* Shaded areas are associated with different denominators.


Medical Record Procurement– Process Notes

• Copies and faxes distort the barcode on the cover sheet

• Make sure the cover sheet is attached to the top of medical record

• Submit cover sheets only once• Reminder – 2nd Submission date is approaching

(January 15)


Upcoming Activities– Final submission of medical records

– Completion of medical record abstraction

– Analysis

– Reporting of findings and recommendations

Update on Focused Study Activities –Special Health Care

NeedsIdentification of Individuals with Special Health Care Needs:– Study methodology has been approved by

AHCA

– Study indicators being identified

Update on Focused Study Activities – Special Health Care

Needs

MCOs included in the study:HMOsPSNPMHPs


Needs

NHDPs have a very high majority of individuals with special health care needs. Due to the primary purposes of the study, HSAG and AHCA determined NHDPs should not be included in the focused study.


NeedsWhat to expect?The study methodology calls for a request for information document be completed by the MCOs indicating their process and policies for identifying individuals with special health care needs.


NeedsWhat to expect?HSAG will request member-level data on individuals identified as having special health care needs.Conducted via the administrative method – anticipate no medical record review.


NeedsWhat to expect?Proposed methodology involves MCOs “re-running” the population using a standardized approach to identify special health care needsMethodology will be similar for PMHPs, but have different criteria for identification

Update on Special Needs Focused Study Activities

General time frames:Analyze identification of individuals with special health care needs data –January– April 2007 (includes initial analysis and remeasurement)

Prepare draft report for AHCA - May 2007

Questions and Answers

Technical Assistance on Enrollee Race, Ethnicity, and Primary

Household Language Information

2:20 p.m. – 2:35 p.m.

Susan Jentz, MSStatistician

BBA Requirements for Race, Ethnicity, and Language

States must ensure that they have procedures in place to identify the race, ethnicity, and primary language spoken of each Medicaid enrollee.

This information must be provided to the MCO and PIHP for each Medicaid enrollee at the time of enrollment.

Source: 42 CFR §438.204

Methodology

Kick-off Meeting Regulatory Review Data Collection, Review, and Analysis Interviews Report Development

Findings onRace, Ethnicity, and Primary Language

Data Collection and Transmission

Race, ethnicity, and language data are collected when Medicaid enrollees are determined to be eligible.

At present, these data are not submitted to the MCOs.

Recommendations onRace, Ethnicity, and Primary Language

Data Collection and Transmission

HSAG is producing a report that identifies specific changes to the systems used to collect race, ethnicity, and language data.

Recommendations will also be made regarding the type of categories to collect, as well as the process for transmitting these data to the MCOs.

Upcoming EQR Activities

2:35 p.m. – 2:50 p.m.

Peggy Ketterer, RN, BSN, CHCAExecutive Director, EQRO Services

Upcoming EQR activities

Next quarterly meeting – tentative for March 2007PIP validation reportsHMO HEDIS analysis reportsSpecial health care needs data requestsWebsite/portal FTP change

Questions and Answers

Thank you for participating

You have two options for completing the evaluation survey.

Option One: Complete your online survey immediately following the webinar.

Option Two: Log on to www.myfloridaeqro.com, print off the survey, and fax to HSAG.

http://www.myfloridaeqro.com/

External Quality Review Quarterly Meeting Tuesday, January 9, 2007 1:00 p.m. – 3:00 p.m.

Documents

Transcript of External Quality Review Quarterly Meeting Tuesday, January 9, 2007 1:00 p.m. – 3:00 p.m.