external quality review quarterly meeting tuesday, january 9, 2007 1:00 p.m. – 3:00 p.m
TRANSCRIPT
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
FC=Fully Compliant SC=Substantially Compliant
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
FC=Fully Compliant SC=Substantially Compliant
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
HMO Performance Measures
Pediatric CareWomen’s
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
HMO Performance Measures
Pediatric CareWomen’s
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
Breast Cancer Screening
Cervical Cancer Screening
HMO Performance Measures
Pediatric CareWomen’s
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
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”
Update on Focused Study Activities – Adolescent Well-Care –
MCOs included in this study:– HMOs
– PSN
– MediPass
(NHDPs and PMHPs not appropriate for inclusion)
Update on Focused Study Activities – Adolescent Well-Care –
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)
Update on Focused Study Activities – Adolescent Well-Care –
Methodology OverviewMethodology Overview
Update on Focused Study Activities – Adolescent Well-Care –
Focused Study Objective– To provide baseline results of adolescent
EPSDT indicators for targeting interventions and improving performance
Update on Focused Study Activities – Adolescent Well-Care –
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
Update on Focused Study Activities – Adolescent Well-Care –
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
Update on Focused Study Activities – Adolescent Well-Care –
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
Update on Focused Study Activities – Adolescent Well-Care –
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.
Update on Focused Study Activities – Adolescent Well-Care –
Medical Record Procurement– Submission dates
• December 15, 2006
• January 15, 2007
• February 15, 2007 (FINAL SUBMISSION DATE)
Update on Focused Study Activities – Adolescent Well-Care –
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.
Update on Focused Study Activities – Adolescent Well-Care –
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)
Update on Focused Study Activities – Adolescent Well-Care –
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
Update on Focused Study Activities – Special Health Care
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.
Update on Focused Study Activities – Special Health Care
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.
Update on Focused Study Activities – Special Health Care
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.
Update on Focused Study Activities – Special Health Care
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.