Performance Measures 101 March 30, 2012 Presenter: Wendy Talbot, MPH, CHCA Associate Director, Audits (HSAG) State and Corporate Services

Overview Balanced Budget Act (BBA) of 1997 Performance Measures Calculation and Reporting Performance Measurement Development Open Discussion/Questions and Answers

Balanced Budget Act (BBA) of 1997 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.

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.

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

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

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

Performance Measures (cont.) Why measure performance? To obtain solid data to evaluate performance and make decisions on which improvements are necessary.

Performance Measures (cont.) 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

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

Calculation and Reporting of Performance Measures (cont.) Identify necessary data sources and data elements for reporting the selected measures: Membership/enrollment data Claims/encounter data Other administrative data (if available) e.g., disease management database, kept appointment database

Calculation and Reporting of Performance Measures (cont.) 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 (cont.) Calculate continuous enrollment and anchor date Determine member age and gender Include diagnosis and procedure codes needed to identify service events Create exclusion logic

Calculation and Reporting of Performance Measures (cont.) Examine output files Review preliminary administrative results

Calculation and Reporting of Performance Measures (cont.) Establish a sound process for monitoring data collection accuracy (interrater reliability, over-reads) Develop logic to identify duplicates Develop methodology for integration into reporting repository

Calculation and Reporting of Performance Measures (cont.) Review calculated rates for reasonability Examine data output file and verify with source data (membership and encounter data) Use state-specified format

Performance Measure Development Specifications are typically selected or developed by the State with input from the MCOs Specifications that are developed by the State may require modifications, clarifications, and further refinement after first year of reporting Specifications and measure results should be reevaluated annually to ensure they are comparable, valid, and meaningful

Open Discussion Questions and Answers