1. 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.

2. Health Services Advisory Group (HSAG)

3. 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

4. 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

5. Where does HSAG provide EQR services?

6. Florida Medical Quality Assurance, Inc.
(FMQAI)

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

8. 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

9. Balanced Budget Act of 1997
(BBA)

10. 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

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

12. 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.

13. Balanced Budget Act (BBA) of 1997 (cont)
EQR activities must be performed consistent with the BBA protocols.

14. 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)

15. 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

16. Overview of Florida EQRO Activities

17. 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)

18. 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

19. Description of Florida EQR Activities

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

21. 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)

22. 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)

23. 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)

24. 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

25. 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

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

27. 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

28. 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

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

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

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

32. 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

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

34. Dissemination of EQRO Information

35. Dissemination of EQRO Information
EQRO Website:
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

36. 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

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

38. Dissemination of EQRO Information
Phone communications
Conference calls
Questions/answers

39. MCO Roles and Responsibilities related to EQRO Activities

40. MCO Roles and Responsibilities
Validation of Performance Improvement Projects

41. 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

42. 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.

43. 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

44. Validation of Performance Measures

45. 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

46. 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

47. 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

48. Focused Studies

49. 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

50. 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

51. Questions and Answers