External Quality Review Organization (EQRO) Kick-Off Meeting Agency for Health Care Administration (AHCA) Tuesday, June 27, 2006 10 a.m. – 2:30 p.m.

Health Services Advisory Group (HSAG)

Health Services Advisory Group Federal Division Quality Improvement Organization (QIO) for AZ Medicare State and Corporate Division External Quality Review Organization (EQRO) Surveys, Research and Analysis Division Certified Consumer Assessment of Health Plans Survey (CAHPS) vendor www.hsag.com

HSAG History Founded in 1979 Became AZ PRO (now a Quality Improvement Organization, or QIO) in 1984 Began working in the Medicaid quality arena in 1983 Performs EQR activities in 11 states Over 21% of national Medicaid population

Where does HSAG provide EQR services?

Florida Medical Quality Assurance, Inc. (FMQAI)

FMQAI Incorporated in Florida in 1992 Medicare Quality Improvement Organization (QIO) for the State of Florida ESRD Network 7 federal contractor

Presentation Outline Overview of Balanced Budget Act of 1997 (BBA) Overview of Florida EQRO activities Dissemination of EQRO information MCO roles and responsibilities Questions and Answers

Balanced Budget Act of 1997 (BBA)

Balanced Budget Act (BBA) of 1997 The BBA requires states with Medicaid managed care programs to implement certain standards and business practices pertaining to: Member Rights and Responsibilities Quality Assessment and Performance Improvement Grievance and Appeals System

Balanced Budget Act (BBA) of 1997 (cont) Access and Availability of Services Practice Guidelines Utilization Review Contracts and Delegation Providers

Balanced Budget Act (BBA) of 1997 (cont) The BBA also requires that states contract with an EQRO for an annual independent review of each managed care organization (MCO) and pre-paid inpatient health plan (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) EQR activities must be performed consistent with the BBA protocols. www.cms.hhs.gov/medicaid/managedcare

EQR Mandatory Activities EQR services required by Balanced Budget Act of 1997: Monitoring Medicaid managed care organizations and prepaid inpatient health plans Validating performance improvement projects (PIPs) Validating performance measures (EQR Technical Report)

Optional EQR Activities Optional EQR activities include: Validating encounter data Conducting focused studies Administering or validating member or provider surveys Calculating performance measures Providing technical assistance

Overview of Florida EQRO Activities

Overview of EQR Activities in Florida Validation of PIPs Validation of performance measures Review of compliance with access, structural, and operations standards Strategic reports on consumer-reported surveys Strategic HEDIS® analysis reports HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

Overview of EQR Activities in Florida (cont’d) Technical assistance Value-based purchasing methodologies Evaluation of AHCA quality strategy Focused studies Dissemination of EQR information EQRO Technical Report

Description of Florida EQR Activities

Validation of Performance Improvement Projects Assess and improve processes Improve outcomes of care Typically consists of a baseline, an intervention period, and a remeasurement

Validation of Performance Improvement Projects HSAG validates PIPs: According to CMS protocol Using a PIP tool based on the protocol The result is a final validation finding of the degree of confidence in the results (high, low, no confidence)

Validation of Performance Measures Are quantitative measurements by which goals are established and performance is assessed Calculated by MCOs May be HEDIS® measures, state-developed, or MCO-developed Validated by HSAG following CMS protocol HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

Validation of Performance Measures In Florida: Most MCOs report HEDIS and undergo a HEDIS Compliance AuditTM Other MCOs (such as PMHPs, and most NHDPs) collect non-HEDIS performance measures, which will undergo validation by HSAG HEDIS® Compliance Audit is a registered trademark of the National Committee for Quality Assurance (NCQA)

Review of Compliance with Access, Structure, and Operations Standards Key tasks: Obtain information on compliance reviews Evaluate AHCA and DOEA compliance audit process Select sample of three audits/conduct on-site visit to validate results Prepare report of findings

Strategic Reports of Consumer-Reported Surveys Key tasks: Obtain survey data Perform exploratory analysis Prepare report Identify alternative scoring methods Discuss approaches for improvement Recommend improvements for scoring algorithm

Strategic HEDIS Analysis Reports Key tasks: Obtain HEDIS data Perform analysis Produce MCO-specific reports Produce Strategic Analysis Report

Technical Assistance: Enrollee Race/Ethnicity and Primary Household Language Information Key tasks: Review current practices Examine data management processes Identify barriers Develop recommendations Prepare report

Value-Based Purchasing Methodologies Key tasks: Review current agency practice Perform literature review Investigate other states’ approaches Develop a definition of superior performance Recommend scoring/weighting methodologies Technical assistance

Evaluation of AHCA Quality Strategy Key tasks: Review quality strategy Review other states’ quality strategies for lessons learned Prepare report

Focused Studies Key tasks: Design study, methodology Select sample Collect data Perform analysis Prepare report of findings

Focused Studies Selected Topics for FY 06-07: Adolescent Well-Care Identification and Assessment of Individuals with Special Health Care Needs

Dissemination of EQR Information Key tasks: Develop a communication plan to keep key stakeholders involved and informed Conduct quarterly meetings Prepare meeting agendas, materials, and summaries

EQR Technical Report Key tasks: Develop report outline Compile EQR findings from all applicable activities Perform analysis Prepare technical report

Dissemination of EQRO Information

Dissemination of EQRO Information EQRO Website: www.myfloridaeqro.com Website functions: Updates on activities Secure file transfer protocol (FTP) site Frequently asked questions (not available yet) Reminders of upcoming due dates Links to other websites

Dissemination of EQRO Information Quarterly MCO Meetings Onsite or via Webinar Updates on activities Review of most recent EQR reports Sharing of best practices Technical assistance

Dissemination of EQRO Information Email Communication Letters describing activities Questions/answers Reminders of upcoming due dates Use of mailing lists for group messages

Dissemination of EQRO Information Phone communications Conference calls Questions/answers

MCO Roles and Responsibilities related to EQRO Activities

MCO Roles and Responsibilities Validation of Performance Improvement Projects

Validation of PIPs MCO Roles and Responsibilities Provide basic information on the PIPs that are currently underway using the “Statement of Intent” document Indicate technical assistance needs on HSAG’s “technical assistance assessment survey” Complete the PIP form and provide supportive documentation for each PIP selected for validation

Validation of PIPs MCO Roles and Responsibilities Review HSAG’s completed PIP tool and PIP report, providing feedback and comments Participate in PIP technical assistance activities as they become available Note: The PIP validation process is an annual activity.

Project Activity by Month Validation of Performance Improvement Projects (PIPs) Task May Jun Jul Aug Sep Oct Nov Dec Jan 07 Feb Mar Apr PIPs 7/06 – 10/06 Request PIP Documentation 11/06 – 12/06 Perform individual PIP Analysis 12/06 – 2/07 Prepare Annual Validation Summary Report 1/07 – 4/07 Prepare Annual Strategic Report 7/06 – 10/06 Develop Annual Plan for Technical Assistance Ongoing Technical Assistance to Agency, MediPass, and MCOs Ongoing Prepare Quarterly Status Reports on Technical Assistance

Validation of Performance Measures

Validation of Performance Measures MCO Roles and Responsibilities HMOs provide 2006 HEDIS® Baseline Assessment Tool (BAT), Data Submission Tool (DST), and Final Audit Report to HSAG HMOs complete and forward supplemental questions document to HSAG Establish a contact person if questions arise from the HSAG review team

Validation of Performance Measures MCO Roles and Responsibilities For MCOs that do not currently undergo an independent audit: HSAG will evaluate what performance measures are collected and whether they can be validated PSN and some MCOs will undergo the validation activities, including a site visit Other MCOs should participate in technical assistance opportunities as they become available

Project Activity by Month Validation of Performance Measures (PMVs) Task May Jun Jul Aug Sep Oct Nov Dec Jan 07 Feb Mar Apr PMVs 6/06 Request Documentation 7/06 Receive MCO documentation 8/06 – 9/06 Complete Site Visit(s) 10/06 – 12/06 Prepare Report

Focused Studies

Focused Studies MCO Roles and Responsibilities Provide data and/or information, if needed If study design requires medical records: Receive list of sample cases Identify appropriate providers Collect medical records Forward medical records to Tampa office Provide status reports of medical record pursuit

Project Activity by Month Focused Studies Task Jun Jul Aug Sep Oct Nov Dec Jan 07 Feb Mar Apr May Focused Studies 7/06 –8/06 Develop Study Criteria for Each Study 10/06 – 12/06 Collect Medical Records 2/07 – 3/07 Analyze Electronic and Medical Abstraction Data 8/06 Identify Study Populations and Select Samples 12/06 – 2/07 Abstract Medical Records 3/07 – 6/07 Prepare Reports

Questions and Answers