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

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

3. Balanced Budget Act (BBA) of 1997
42CFR 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.

4. Balanced Budget Act (BBA) of 1997 (cont.)
42CFR 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.

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

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

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

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

9. 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

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

11. 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

12. 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)

13. 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

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

15. 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

16. 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

17. 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

18. Open Discussion
Questions and Answers