Use of AHRQ’s Prevention and Pediatric Quality Indicators in MCO

Rate Setting

Pennsylvania Office of Medical Assistance Programs (OMAP)

David K. Kelley MD,MPA

Chief Medical Officer, OMAP

c-dakelley@state.pa.us

Pennsylvania Medical Assistance• Provides health care coverage to over 2.0 million

consumers (14% of the Commonwealth’s population)

• Operates a capitated managed care program - HealthChoices® - in 25 urban and suburban counties covering 1.1 million consumers

• Operates a managed FFS program in 42 rural counties for 290,000 consumers- Access Plus

ERIE

CRAWFORDWARREN

FOREST

McKEANPOTTER

CAMERONELKVENANGO

MERCER

BEDFORD

BLAIR

SOMERSET

CAMBRANINDIANA

JEFFERSON

CLINTON

LYCOMING

SULLIVAN

TIOGA BRADFORD

WAYNE

WYOMING

PIKE

LUZERNE

MONROE

SCHUYLKILL

CARBON

LEHIGH

COLUMBIA

BUCKS

BERKS

CHESTER

LANCASTER

MONTGOMERY

YORK

LEBANON PERRY

CUMBERLAND

DAUPHINJUNIATAMIF

FLIN

UNION

SNYDER

CENTRE

ADAMS

FRANKLINFULTON

HUNTINGDON

CLEARFIELD UPMC

CLARION

LACKAWANNA

MONTOUR+

PHILADELPHIA

DELAWARE

SUSQUEHANNA

LAWRENCE

BUTLER

ARMSTRONG

FAYETTE

WESTMORELAND

ALLEGHENY

BEAVER

WASHINGTON

Mandatory Managed Care - HealthChoices

Service Areas

GREENE

NORTHAMPTON

ACCESS Plus and Voluntary Managed Care (where available)

Medicaid Value Based Purchasing • Efficiency adjustments to Managed Care

Organization (MCO) rate setting– Inpatient– Emergency Department– Pharmacy– TPL/COB

• MCO pay for performance• Nonpayment for related readmissions within 14 days• Reduced or no payment for preventable serious

adverse events

Why Inpatient Care• Hospital costs account for 32% of MCO

expenditures• Cost-effective and appropriate use of hospital

services is a cornerstone of a well run efficient MCO

• Quality driven outpatient care management leads to fewer admissions

• Goal is to identify potentially preventable hospitalizations using PQIs and PDIs

Inpatient Efficiency Adjustments

• Prevention Quality Indicators (14)• Pediatric Quality Indicators (5)• Other Ambulatory Care Sensitive Conditions

– Cellulitis– Pelvic inflammatory disease– Ear, nose, throat conditions

• C-section mix adjustment

Prevention Quality Indicators (PQIs)

• Diabetes- – uncontrolled diabetes– short-term complications– long-term complications– lower extremity

amputation• Perforated Appendix• Chronic Obstructive

Pulmonary Disease

• Hypertension• Congestive Heart

Failure • Low Birth Weight• Dehydration• Bacterial Pneumonia• Urinary Tract Infection• Angina• Adult Asthma

Pediatric Quality Indicators (PDIs)

• Asthma

• Diabetes Short-term Complications

• Gastroenteritis

• Perforated Appendix

• Urinary Tract Infection

Adjustments

• Applied PQI and PDI exclusions

• Minimum duration of member enrollment

• Removed the sickest 25% using risk adjusted CDPS© scores

• Made an additional 50% credibility reduction in preventable costs in part to account for psych-social issues

Congestive Heart Failure • Preventable admissions- 2,581• Total dollars spent- $20.7 million• Removal of members not enrolled minimum of 4

months with MCO• Removal of “sickest quartile” • Admissions after enrollment adjustment and risk

assessment- 1,470• Dollars spent after enrollment and risk adjustment-

$10.6 million• Dollars spent after 50% credibility factor- $5.3

million

Inpatient Efficiency Adjustments

• Similar analysis done for 17 PQIs and 5 PDIs• Excluded Low Birth Weight PQI• Total PQI/PDI dollars- $30.3 million

– Asthma (PQI 15, PDI 14)- $8.0 million– CHF (PQI 08)- $5.3 million– Diabetes (PQI 01,03,14,16, PDI 15)- $4.9 million– Pneumonia (PQI 11)- $4.3 million– COPD (PQI)- $2.6 million

Inpatient Efficiency Adjustments

• Over 20,000 PQI/PDI admissions

• Over $153.9 million spent on preventable admissions

• Preventable admissions consume 13.7% of inpatient costs

• DPW adjusted 2.7% of inpatient spend ($30.3 million) from the MCO rates

Admissions Rates• Asthma

– 2007 Admits per 1000 member months= 4.49– 2008 Admits per 1000 member months= 4.51

• CHF – 2007 Admits per 1000 member months= 18.17– 2008 Admits per 1000 member months= 17.74

• Diabetes– 2007 Admits per 1000 member months= 5.33– 2008 Admits per 1000 member months= 5.58

• COPD– 2007 Admits per 1000 member months= 5.91– 2008 Admits per 1000 member months= 7.61

Conclusions-PQI Efficiency Adjustments

• Transparency- PQIs/PDIs in the public domain

• Can be used to evaluate the health system’s coordination of outpatient care to prevent hospitalizations

• PQI/PDI efficiency adjustments can focus MCOs on targeted care management strategies

• Purchaser value in not paying for preventable inpatient stays