External Quality Review Quarterly Meeting Tuesday, January 9, :00 p.m. – 3:00 p.m.

Welcome and Logistics  Introductions and roll-call  Webinar logistics  Do’s and don’ts  Post-meeting survey

Welcome and Logistics Today’s agenda  PIP validation update and summary of preliminary findings  Preliminary findings on the validation of performance measures  Preliminary findings on the HEDIS strategic reports  Update on focused studies  Summary of technical assistance on enrollee race, ethnicity, and primary language  Upcoming EQR activities  Questions and Answers

Performance Improvement Projects (PIPs) Update 1:20 p.m. – 1:30 p.m. Cheryl L. Neel, RN, MPH, CPHQ Manager, 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 3 rd 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 (

Questions and Answers on PIP activities?

Preliminary Findings - Validation of Performance Measures 1:30 p.m. – 1:50 p.m. Raj Shrestha, MPH, MBA, CHCA Director, 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, –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 Report Measure 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, CHCA Director, Audits/Private Projects

HMO Performance Measures Pediatric Care Women’s Care Living With Illness

HMO Performance Measures Pediatric Care Women’s Care Living 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 Care Women’s Care Living 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 Care Women’s Care Living 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, MA Director, State and Corporate Analysis David Mabb, MS, CHCA Senior Director, Statistical Evaluation

Update on Focused Study Activities HSAG is currently conducting two focused studies on the following topics:  Adolescent Well-Care  Identification 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 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 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, yrs, 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 StatusNumberPercent 1- Tracking sheet not received5, % 2- Tracking sheet received4277.6% A- Medical record submitted % B- No medical record submitted % No visits during study period4013.0% Provider refused to release record62.0% Unable to locate medical record82.6% Other % * 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 – 2 nd 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 Needs Identification 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:  HMOs  PSN  PMHPs

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 Needs What 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 Needs What 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 Needs What to expect?  Proposed methodology involves MCOs “re-running” the population using a standardized approach to identify special health care needs  Methodology 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, MS Statistician

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 §

Methodology  Kick-off Meeting  Regulatory Review  Data Collection, Review, and Analysis  Interviews  Report Development

Findings on Race, 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 on Race, 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, CHCA Executive Director, EQRO Services

Upcoming EQR activities  Next quarterly meeting – tentative for March 2007  PIP validation reports  HMO HEDIS analysis reports  Special health care needs data requests  Website/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 print off the survey, and fax to HSAG.