Overview of 2008 Quality Assurance Activities Maryland Department of Health and Mental Hygiene November 20, 2008

2 Overview 2008 Quality review activities: Systems Performance Review Healthy Kids Quality Monitoring Program Enrollee Satisfaction Survey Provider Satisfaction Survey Healthcare Effectiveness Data and Information Set (HEDIS) Value-Based Purchasing Performance Measures Consumer Report Card Performance Improvement Projects Performance Measure Validation

3 Systems Performance Review Since March 2003, CMS has required states to assess quality of care for Medicaid beneficiaries in managed care programs through review activities of the managed care organizations, including a review of organizational and structural performance, e.g. a Systems Performance Review (SPR). An External Quality Review Organization (EQRO) must carry out the tasks for the Medicaid program to determine the degree of compliance with regulations, and provide quality assurance oversight. The Department contracts with the Delmarva Foundation for Medical Care to conduct the SPR. The 2007 SPR consisted of 10 standards. The Department returned the Outreach Plan standard as an active assessment area.

4 System Performance Review (continued) The criteria applied to each standard is reviewed and updated annually by the Department, to ensure compliance with any new regulations and to incorporate mutually agreed upon recommendations of the EQRO. Each MCO was rated separately on compliance with each standard. The minimum compliance rate was set for all standards at 100%, with the exception of the Fraud and Abuse standard, which increased 10 points from the previous year, to 80%. For any standard, or components of a standard that did not meet the minimum compliance level, the MCO was required to develop and implement an approved Corrective Action Plan (CAP).

5 Systems Performance Review Standards MCO Aggregate CY 2006 MCO Aggregate CY 2007 ACCDIAMSFCJMSMPCPPMCOUHC Systematic Process100% Governing Body100% Oversight of Delegated Entities82%*98%*100%86%*100% Credentialing97%*96%*95%*93%*100% 96%* 95%* Enrollee Rights98%*99%*100%97%*100% 95%*100% Availability and Access100% Utilization Review95%*94%*98%*83%*100%98%* 89%*93%* Continuity of Care98%*100% Fraud and Abuse94%96%100%92%100% 95%87%* Outreach PlanEXEMPT95%*100%75%*100% 96%*100%93%*

6 EPSDT Record Reviews The medical record reviews of approximately 2,800 children under the age of 21 were performed this year by the state’s EQRO, Delmarva Foundation for Medical Care. Nurse reviewers audited each MCO’s performance for adherence to the EPSDT standards in 5 major components: 1. Health and Developmental History 2. Comprehensive Physical Exam 3. Laboratory Tests 4. Immunizations 5. Health Education Data results will not be available until close of the year secondary to changes in this year’s audit process.

7 Enrollee Satisfaction Surveys DHMH conducts an enrollee satisfaction survey annually using the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey instruments designed to evaluate member’s satisfaction with their health plans. DHMH uses Widener-Burrows & Associates, Inc. (WB&A), an NCQA certified CAHPS vendor, to conduct the survey and compile the results. The enrollees are contacted by WB&A between February and May of each year to learn of their experiences with service delivery in their HealthChoice MCO. Surveys include question sets covering: Getting Needed Care Getting Care Quickly Shared Decision-making How Well Doctors Communicate Self perceived health status

8 Enrollee Satisfaction Surveys (continued) In 2008, CAHPS surveys were mailed to 11,901 Medicaid adults and 18,842 Medicaid children and children with chronic care conditions (CCC). Returned were 3,582 adult and 3,586 child responses (1,894 responses represented CCC). Follow- up phone calls were made to interview members who did not respond by mail. Response rates varied by MCO, ranging from 26% to 35% for adults, to 18% to 31% for children (an increase from last year). Based on a rating scale of 0 to 10 where 10 is best, MCO satisfaction by adults ranged from 6.1 to 8.1. The highest satisfaction was found in Shared Decision- making, How Well Doctors Communicated, and Coordination of Care. MCO satisfaction by parents of children in service scored 7.3 to 8.9. Highest satisfaction was with the Courteousness and Helpfulness of Office Staff, How Well Doctors Communicated, and Getting Care Quickly. Caretakers of Children with Chronic Disease gave similar high ratings to these areas.

9 Provider Satisfaction Surveys DHMH conducts an annual provider survey to assess satisfaction with various aspects of HealthChoice. WB&A conducts the survey for the Department, and issues a final report. A random sample of Primary Care Providers (PCPs) from each of the seven MCOs are chosen. From an aggregate of 4,313 mailed surveys, 556 responses were received, raising the response rate from last year to 12.9%. This is likely a result of telephone follow-up conducted in 2008.

10 Provider Satisfaction Surveys (continued) Satisfaction survey topics included: No-Show HealthChoice Appointments Overall Satisfaction Finance Issues Customer Service/Provider Relations Coordination of Care and Case Management Utilization Management In 2008, providers’ satisfaction overall was measured to be 64%. Seventy-three percent would recommend HealthChoice to their patients, and 68% said they would recommend the program to other physicians.

11 HEDIS Performance Measures The Healthcare Effectiveness Data and Information Set (HEDIS) is a standardized set of performance measures developed by the National Committee for Quality Assurance (NCQA) to measure health plan performance for comparison among health systems. This standardized tool is used by more than 90% of health plans across the country. Health plans also use the information as a basis for strategic planning. Each element is evaluated at least every three years by NCQA on the basis of continued desirability, statistical analysis, audit review results, and user comments. Subsequently, NCQA releases yearly updates to the measurement set. The Department contracts with HealthcareData Company, LLC, an NCQA certified HEDIS vendor, to audit and report HealthChoice MCOs’ scores. MCOs use claims and encounter data to calculate each measure. For some measures, MCOs are allowed to supplement incomplete data with medical record reviews.

12 HEDIS Performance Measures For 2008, MCOs were required to report their performance on 18 HEDIS measures. Effectiveness of Care -Childhood Immunization Status -Breast Cancer Screening -Cervical Cancer Screening -Comprehensive Diabetes Care -Use of Appropriate -Medications for People with Asthma -Appropriate Treatment for Children with Upper Respiratory Infection -Appropriate Testing for Children with Pharyngitis -Chlamydia Screening in Women Access/Availability of Care -Children and Adolescents’ Access to Primary Care Practitioners -Adults’ Access to Preventive/Ambulatory Health Services -Prenatal and Postpartum Care -Call Answer Timeliness -Call Abandonment Use Of Services -Frequency of Ongoing Prenatal Care -Well-Child Visits in the First 15 Months of Life -Well-Child Visits in the Third, Fourth, Fifth and Sixth Year of Life -Adolescent Well-Care Visits -Ambulatory Care (NEW)

13 HEDIS Performance Measures (continued) HEDIS 2008 for HealthChoice MCOs required two fewer measures to be reported. Three measures were removed from the previous year (Adolescent Immunization Status, Discharge and Average Length of Stay-Maternity Care, and Births and Average Length of Stay-Newborns). Ambulatory Care was added from the Use of Service Category and was a test measure this year; it will be reportable for the HEDIS 2009 audit. The MCOs continue to show overall improvement in their HEDIS scores each year and for many measures. The Maryland average remains higher than the National Medicaid Mean.

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18 Value-Based Purchasing Value Based Purchasing is a set of performance measures selected from current HealthChoice monitoring activities. The goal of our Value Based Purchasing strategy is to improve MCO performance by providing monetary incentives and disincentives. These nine measures cover important dimensions of MCO performance: Access to Care Quality of Care 5 of the 9 measures are HEDIS measures and 4 are selected by the Department from Maryland Medicaid HealthChoice Encounter Data.

19 Value-Based Purchasing (continued) Targets for each measure have been established based on three levels of performance: Disincentive: For any measure that the MCO does not meet the minimum target, a disincentive of 1/9 of 1/2 percent of the total capitation paid to the MCO during the measurement year will be collected. Neutral Incentive: For any measure that the MCO exceeds the minimum target, the MCO shall be paid an incentive payment of up to 1/9 of 1/2 percent of the total capitation amount paid to the MCO during the measurement year.

20 Value Based Purchasing-Department of Health and Mental Hygiene

21 Consumer Report Card This will be the sixth year of production for our HealthChoice Consumer Report Card. Since its inception, the Department has been contracting with the NCQA via the EQRO contract to develop the methodology and calculate the MCOs’ scores. The 6 performance areas rated in the Report Card are calculated compiling measures from HEDIS, Value Based Purchasing, and the Satisfaction Survey. The Consumer Report Card is included in all enrollment packets.

22 Performance Improvement Projects The MCOs are currently responsible for 2 Performance Improvement Projects (PIPs). Each PIP is at least three years in duration. The current PIPs are: Chronic Kidney Disease (CKD) Cervical Cancer Screening (CCS) Activities must be designed by each MCO that are intended to achieve measurable improvement in processes, and outcomes of care. PIPs consist of: Identifying Quality of Care measures/indicators Measuring baseline performance of these measures Developing interventions; implementing the strategies Re-measurement of performance Analyzing and reporting results

23 Performance Improvement Projects Calendar Year 2007 was the baseline year for Cervical Cancer Screening. The MCOs have developed interventions and implemented their health care improvement strategies during Performance re- measurement will occur in 2009 of Calendar Year 2008 results. For CKD Measure 1, “Monitoring for Diabetic Nephropathy” (HEDIS measure), 4 MCOs improved their scores from the prior year (2-5%). The Diamond Plan began the project this year, and submitted their baseline measurement. Two MCOs saw a reduction in the monitoring rate (3-4%). For CKD Measure 2, “Hypertensive members receiving at least one serum creatinine”, 3 MCOs improved their scores, 3 MCOs had a decline in performance during CY 2007, and the Diamond Plan measured their baseline performance for comparison to CY 2008 performance data.

24 Where to find complete information ? DEPARTMENT OF HEALTH AND MENTAL HYGIENE Select “Medical Care Programs”, “HealthChoice Managed Care”, “HealthChoice Quality Assurance Activities”