Wendy Talbot MPH, CHCA Project Manager, Audits Validation and Analysis of Performance Measures and Results for all MCOs

Balanced Budget Act (BBA) 1997 The BBA requires that: States contract with an EQRO EQRO conducts annual independent review of each managed care organization (MCO) and pre-paid inpatient health plan (PIHP) Evaluates quality, access, and timeliness of health care services provided to Medicaid enrollees

BBA (cont) Validation of Performance Measures is one of the required activities that an EQRO performs.

Validation of Performance Measures (PMs) What is a Performance Measure? A quantitative measurement by which goals are established and performance is assessed.

Validation of PMs (cont) Performance Measure Characteristics: Standardized Clearly defined Meaningful and timely Results in comparable data

Validation of PMs (cont) Why measure performance? To obtain solid data to evaluate performance and make decisions on what improvements are necessary.

Validation of PMs (cont) Final AHCA Required Performance Measures for Measurement Year 1: –Non-Reform HMOs/PSNs – 10 HEDIS –Reform HMOs/PSNs – 10 HEDIS & 2 Agency-developed –PMHPs – 3 Agency-developed –CWPMHP – 2 Agency-developed –NHDPs – 4 Agency-developed

Validation of Performance Measures HMOs/PSNs

HMOs/PSNs HEDIS Audits Plans underwent HEDIS compliance audits in Spring HMOs and 6 PSNs –12 Non-Reform HMOs –10 Reform HMOs –1 Non-Reform PSN –6 Reform PSNs Measures: –10 HEDIS (Non-Reform & Reform) –2 Agency-Defined (Reform)

Measures HEDIS –Well-Child Visits in the First Fifteen Months of Life (W15) –Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34) –Adolescent Well Care Visits (AWC) –Annual Dental Visits (ADV) –Cervical Cancer Screening (CCS) –Prenatal and Postpartum Care (PPC)

Measures HEDIS (cont) –Controlling High Blood Pressure (CBP) –Comprehensive Diabetes Care (CDC) –Follow-Up After Hospitalization for Mental Illness (FUH) –Ambulatory Care (AMB) Agency-Defined –Smoking Cessation (SMO) –Use of Beta Agonist (UBE)

Audit Findings R = Report –Reportable rate or numeric result NA = Denominator <30 –HMO/PSN followed specifications but denominator was too small to report

Audit Findings (cont) NB = No Benefit –HMO/PSN did not offer health benefit required by the measure NR = Not Report –Rate was materially biased or plan chose not to report

Measure Specific Findings

Validation Findings Non-Reform HMOs RNANBNR W W AWC12000 ADV2073 CCS12000 PPC11100 CBP11100 CDC11100 FUH10200 AMB12000

Validation Findings Reform HMOs RNANBNR W W AWC9100 ADV8002 CCS9100 PPC7300 CBP8200 CDC8200 FUH7300 AMB9100 SMO3700 UBE2602

Validation Findings PSNs RNANBNR W W AWC7000 ADV7000 CCS*5000 PPC5200 CBP*5100 CDC5200 FUH4210 AMB7000 SMO*†3200 UBE*†4200 *Not required to be reported by PSNs who’s populations are specific to children † Reported by Reform PSNs only

Results

Analytics Comparative –Florida 2008 weighted average compared to the national 2007 Medicaid 50th percentile –Florida 2008 weighted average compared to the 2007 weighted average Distribution –Range of HMO/PSN reported rates

Comparison Graphs

Distribution Graphs 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Measure 1Measure 2 Highest Plan RateWeighted AverageLowest Plan Rate Highest Rate Lowest Rate FL Weighted Average High Outlier Low Outlier

Pediatric Care

There were no significant specification changes in 2008 to any of the Pediatric Care measures –Well-Child Visits in the First Fifteen Months of Life –Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life –Adolescent Well-Care Visits –Annual Dental Visits

Pediatric Care Well Child Visits in the First Fifteen Months of Life –Zero Visits (reverse measure) 2008 FL Non-Reform weighted average improved by 0.7 percentage point from the 2006 rate 2008 FL Non-Reform weighted average was greater than the national HEDIS 50 th percentile The 2008 FL Reform weighted average was greater than the national HEDIS 90 th percentile (Note: with reverse measure – lower is better)

Pediatric Care Well Child Visits in the First Fifteen Months of Life –Six or More Visits 2008 FL Non-Reform weighted average improved by 2.5 percentage points from the 2006 rate 2008 FL Non-Reform weighted average was lower than the national HEDIS 25 th percentile 2008 FL Reform weighted average ranked below the national HEDIS 25 th percentile

Pediatric Care Well Child Visits in the 3rd, 4th, 5th, & 6th Years of Life & Adolescent Well- Care Visits 2008 FL Non-Reform weighted average improved when compared to the 2006 rate 2008 FL Non-Reform weighted average ranked higher than the national HEDIS 50 th percentile 2008 FL Reform weighted average also ranked higher than the national HEDIS 50 th percentile

Pediatric Care Adolescent Well-Care Visits 2008 FL Non-Reform weighted average decreased from FL Non-Reform weighted average ranked just below the national HEDIS 50 th percentile 2008 FL Reform weighted average ranked above the national HEDIS 50 th percentile

Pediatric Care Annual Dental Visits 2008 FL Non-Reform weighted average ranked below national HEDIS 10 th percentile 2008 FL Reform weighted average also ranked below the national HEDIS 10 th percentile

Pediatric Care Comparative Results – Non-Reform Inverse measure

Pediatric Care Range of 2008 Rates – Non-Reform

Pediatric Care Comparative Results – Reform Inverse measure Compared to 2007 National HEDIS 50th Percentile Annual Dental Visits, Combined Adolescent Well-Care Visits Well-Child 3rd-6th Years of Life Well-Child 1st 15 Months of Life, 6+ Visits Well-Child 1st 15 Months of Life, Zero Visits -30%-20%-10%0%10% Inverse measure

Pediatric Care Range of 2008 Rates – Reform

Pediatric Care Improvement efforts to consider include: –Provider report cards –Missed opportunities –Research to determine if missing service data are due to capitated providers –Have high performers present best practices

Women’s Care

There were no significant specification changes in 2008 to any of the Women’s Care measures –Cervical Cancer Screening –Prenatal and Postpartum Care

Women’s Care Cervical Cancer Screening –2008 FL Non-Reform weighted average had a slight increase over the 2007 weighted average – 2008 FL Non-Reform weighted average ranked below the national HEDIS Medicaid 25 th percentile –2008 FL Reform weighted average ranked below the national HEDIS Medicaid 10 th percentile

Women’s Care Prenatal and Postpartum Care –Timeliness of Prenatal Care 2008 FL Non-Reform weighted average increased by 8.2 percentage points compared to the 2007 rate 2008 FL Non-Reform weighted average ranked above the national HEDIS 10 th percentile 2008 FL Reform weighted average ranked below the national HEDIS 10 th percentile

Women’s Care Prenatal and Postpartum Care –Postpartum Care 2008 FL Non-Reform weighted average ranked just below the national HEDIS 50 th percentile 2008 FL Reform weighted average ranked below the national HEDIS 25 th percentile

Women’s Care Comparative Results – Non-Reform

Women’s Care Range of 2008 Rates – Non-Reform

Women’s Care Comparative Results – Reform

Women’s Care Range of 2008 Rates – Reform

Women’s Care Improvement efforts to consider include: –Research challenges or barriers to obtaining service evidence from: Lab results Missing detail on global bills Mammography data –Provider education if issues are identified (e.g. not performing postpartum visit in appropriate timeframe)

Living with Illness

There were no significant specification changes in 2008 to any of the Living with Illness measures –Comprehensive Diabetes Care –Controlling High Blood Pressure (removed age stratification) –Follow-Up After Hospitalization for a Mental Illness

Living with Illness Comprehensive Diabetes Care –HbA1c Testing 2008 FL Non-Reform weighted average ranked above the 25 th percentile 2008 FL Reform weighted average ranked above the 50 th percentile –HbA1c Poor Control (reverse measure) 2008 FL Non-Reform weighted average ranked above the 50 th percentile 2008 FL Reform weighted average ranked above the 50th percentile

Living with Illness Comprehensive Diabetes Care –HbA1c Good Control 2008 FL Non-Reform weighted average ranked above the 50 th percentile 2008 FL Reform weighted average ranked above the 50th percentile

Living with Illness Comprehensive Diabetes Care –LDL-C Screening 2008 FL Non-Reform weighted average ranked above the 50 th percentile 2008 FL Reform weighted average ranked above the 75 th percentile –LDL-C < FL Non-Reform weighted average ranked above the 25 th percentile 2008 FL Reform weighted average ranked above the 25 th percentile

Living with Illness Comprehensive Diabetes Care –Eye Exams 2008 FL Non-Reform weighted average ranked below the 25 th percentile 2008 FL Reform weighted average ranked below the 25 th percentile –Nephropathy 2008 FL Non-Reform weighted average ranked above the 50 th percentile 2008 FL Reform weighted average ranked above the 50 th percentile

Living with Illness Controlling High Blood Pressure 2008 FL Non-Reform weighted average increased by 6.5 percentage points from the 2007 weighted average 2008 FL Non-Reform weighted average ranked above the national HEDIS Medicaid 25 th percentile 2008 FL Reform weighted average ranked below the national HEDIS Medicaid 25 th percentile

Living with Illness Follow-Up After Hospitalization for a Mental Illness –30-Day Rate 2008 FL Non-Reform weighted average ranked below the 25 th percentile 2008 FL Reform weighted average ranked below the 25 th percentile

Living with Illness Follow-Up After Hospitalization for a Mental Illness –7-Day Rate 2008 FL Non-Reform weighted average ranked above the 25 th percentile 2008 FL Reform weighted average ranked below the 25 th percentile

Living With Illness Comparative Results – Non-Reform

Living with Illness – Diabetes Care Range of 2008 Rates – Non-Reform

Living with Illness Range of 2008 Rates – Non-Reform, cont’d

Living With Illness Comparative Results – Reform

Living with Illness – Diabetes Care Range of 2008 Rates – Reform

Living with Illness Range of 2008 Rates – Reform, cont’d

Living With Illness Improvement efforts to consider include: –Research barriers to obtaining complete lab and pharmacy data –Provider education on clinical guidelines if necessary –Provider report cards or incentives for high performers

Performance Measure Validation (PMV) PMHPs/CWPMHP

PMHPs/CWPMHP PMV Audits Site visits occurred May-June PMHPs and 1 CWPMHP 3 Measures –Follow-up within seven days after acute care discharge for a mental health diagnosis (PMHP1) –Thirty-day readmission rate (PMHP2) –Number of enrollees admitted to State mental health treatment facilities* (PMHP3) *CWPMHP was not required to report this measure

Measure Specific Findings

Follow-Up Within Seven Days After Acute Care Discharge for a Mental Health Diagnosis 5 out of 5 PMHPs received Fully Compliant for this measure 1 out of 1 CWPMHP received Fully Compliant for this measure 3 numerators reported for measure –Follow-Up with Mental Health Practitioner –Follow-Up with Mental Health Practitioner/Case Manager –Follow-Up with Case Manager

PMHP1 Rate Ranges Follow-up with a mental health practitioner: –10.98% to 31.22% Follow-up with a mental health practitioner and/or case manager: –11.82% to 55.18% Follow-up with case manager: –3.98% to 42.81%

Thirty-day Readmission Rate 5 out of 5 PMHPs received Fully Compliant for this measure 1 out of 1 CWPMHP received Fully Compliant for this measure

PMHP2 Rate Range Thirty-day readmission rate: –15.67% to 30.22%

Number of Enrollees Admitted to State Mental Health Treatment Facilities 4 out of 5 PMHPs received Substantially Compliant for this measure 1 PMHP received Not Valid for this measure CWPMHP was not required to report this measure

PMHP3 Rate Range Number of enrollees admitted to state mental health treatment facilities: –0.00% to 0.12%* * Data for this measure were obtained from a third party and HSAG was unable to validate the original source data to ensure the reported rates were accurate

Overall Findings All PMHPs and the CWPMHP were able to report valid rates for two out of three measures Overall performance was average, with room for improvement PMHPs did not have access to all of the data necessary to calculate certain measures - this should be considered when selecting future measures

Performance Measure Validation (PMV) NHDPs

NHDP PMV Audit Onsite audits occurred October- November NHDPs 4 measures –Disenrollment Rate –Retention Rate –Voluntary Disenrollment Rate –Average Length of Enrollment before Voluntary Disenrollment

Preliminary Findings Review of documentation and interviews with key staff revealed measures were being calculated correctly Source code review indicated specifications were being followed No final determination on rates until final rates are submitted in 2009

Next Steps Rates due to AHCA/DOEA and HSAG March 2, 2009 Draft reports due to AHCA/DOEA on March 16, 2009 Final reports due to AHCA/DOEA on April 21, 2009

Questions?