1. Validation of Performance Measures for PMHPs Presenter: Peggy Ketterer, RN, BSN, CHCA Executive Director, EQRO Services Health Services Advisory Group January 17, 2008 10:00 a.m.–12:00 p.m.

2. Balanced Budget Act (BBA) of 1997

3. 42CFR438.240 States must require each managed care organization (MCO) and pre-paid inpatient health plan (PIHP) to annually measure and report performance to the state using standardized measures.

4. Balanced Budget Act (BBA) of 1997 (cont) 42CFR438.356 The BBA also requires that states contract with an EQRO for an annual independent review of each MCO and PIHP to evaluate the quality and timeliness of, and access to, health care services provided to Medicaid enrollees.

5. Balanced Budget Act (BBA) of 1997 42CFR438.358 States must ensure that the performance measures are validated annually through the external quality review process.

6. Performance Measures Performance Measure Characteristics: Standardized Clearly defined Meaningful and timely Results in comparable data

7. Performance Measures Key Roles: States identify measures and data submission format MCOs and PIHPs collect, calculate, and submit performance measure data to the State using required submission format Performance measures are validated annually by the EQRO following required CMS protocols

8. Calculation and Reporting of Performance Measures Performance Measure Calculation: A Brief Overview

9. Step 1: Identify necessary data sources and data elements for reporting the selected measures Membership/enrollment data Claims/encounter data Other administrative data (if available), i.e., inpatient utilization reports, kept appointment database Calculation and Reporting of Performance Measures

10. Step 2: Prepare data set Extract data Clean data (valid variables, formats) Verify completeness and accuracy Establish data element to link data sources (unique member ID) Calculation and Reporting of Performance Measures

11. Step 3: Produce source code to calculate measures Calculate continuous enrollment and anchor date Determine member age Include diagnosis and procedure codes needed to identify service events Exclusion logic Calculation and Reporting of Performance Measures

12. Step 4: Calculate measures administratively Run source code Examine output files Review preliminary administrative results Calculation and Reporting of Performance Measures

13. Step 5: Validate results Review calculated rates for reasonability Examine data output file and verify with source data (membership and encounter data) Calculation and Reporting of Performance Measures

14. Step 9: Submit Performance Measure reports to the state Utilize state-specified format Calculation and Reporting of Performance Measures (cont)

15. Written Description Calculation (the percentage of X who had Y) Eligible Population Criteria Numerator Event Criteria Exclusion Criteria Reporting Format Diagram of a Performance Measure

16. The percent of enrollees who were hospitalized for a mental health diagnosis and were discharged to the community from an acute care facility and were seen on an outpatient basis by a mental health practitioner and/or case manager within seven days. Written Description

17. Three calculations will be generated: The percentage of enrollees who had a follow- up visit with a mental health practitioner The percentage of enrollees who had a follow- up visit with a mental health practitioner and/or case manager The percentage of enrollees who had a follow- up visit with a case manager Calculation

18. Specifies any age, continuous enrollment (CE), and event/diagnosis requirements Age: no requirement – all enrollees CE: Date of discharge through 7 days after discharge Event/diagnosis: Discharged to the community from an acute care facility (inpatient or crisis stabilization unit) with specific diagnosis codes indicating a mental health disorder Eligible Population Criteria

19. Specifies any exclusions Enrollees who died Enrollees who were re-admitted within 7 days of discharge Enrollees whose discharges were followed by readmission or direct transfer Exclusion Criteria

20. Specifies any exclusions (cont’d) Enrollees who receive Florida Assertive Community Treatment services Enrollees who are admitted to hospice, nursing facilities, state mental health facilities, correctional institutions or hospice programs Exclusion Criteria

21. An outpatient follow-up encounter with a mental health practitioner up to seven days after hospital discharge Mental health practitioner definitions are specified Service codes for follow-up encounter are specified Numerator Event Criteria

22. Identifies the data elements necessary for reporting (i.e. eligible population, numerator events, rate) Includes a grid for entering data elements Reporting Format

23. Three Main Phases: Pre-On-Site On-Site Post-On-Site Validation Activities

24. Pre-On-Site Activities: Identify measures to be validated Prepare Information System Capabilities Assessment Tool (ISCAT) request Schedule site visits and prepare agendas

25. Validation Activities Pre-On-Site Activities (cont): Receive completed ISCATs from PMHPs Review ISCATs to assess information system integrity and capabilities Conduct pre-on-site conference call with each PMHP

26. Validation Activities On-Site Activities (for each PMHP): Duration – approximately 2 days Conduct opening meeting Complete on-site activities – including systems walkthroughs, demonstrations, and measure specific review Conduct exit conference

27. Validation Activities Post-On-Site Activities: Evaluate corrective actions and follow-up items Determine validation findings for each performance measure Prepare draft report – submit to AHCA and PMHPs for comments Prepare final report

28. Validation Activities Proposed Timeline Task Jan 2008 Feb 2008 Mar 2008 Apr 2008 May 2008 Jun 2008 Jul 2008 Aug 2008 Validation Performance Measures for PMHPs 05/19/08 – 05/30/08 Conduct Onsite Visits 04/11/08 Receive PMHP documentation 03/10/08 Request ISCAT Documentation 06/09/08 – 07/11/08 Prepare Report

29. Questions and Answers Open Discussion