1. Overview of 2007 Quality Assurance Activities Maryland Department of Health and Mental Hygiene November 29, 2007

2. 2 2 Overview  2007 Quality review activities: Systems Performance Review Healthy Kids Quality Monitoring Program Enrollee Satisfaction Survey Healthcare Effectiveness Data and Information Set (HEDIS) Value-Based Purchasing Performance Measures Consumer Report Card Performance Improvement Projects

3. 3 3  Federal law requires that all State Medicaid Programs use an External Quality Review Organization (EQRO) to conduct an annual Systems Performance Review (SPR) of all managed care organizations (MCO).  The Department contracts with Delmarva Foundation to conduct the SPR.  The 2006 SPR consisted of 9 standards.  Each MCO is rated separately on compliance with each standard.  Criteria used for each standard is reviewed and updated annually by the Department based on EQRO recommendations. Systems Performance Review

4. 4 4  The Department rotated two standards for 2006, Outreach Plan and Health Education because all of the MCOs had previously met the minimum compliance rate (100%.)  For 2006, the minimum compliance rate for all standards was 100% except Oversight of Delegated Entities at 90% and Fraud and Abuse at 70%.  For any standard or any components of a standard that do not meet the minimum compliance level, MCOs are responsible for implementing an approved corrective action plan. System Performance Review (continued)

5. 5 Systems Performance Review Standards MCO Aggregate CY 2005 MCO Aggregate CY 2006 AGMDIAHFCJMSMPCPPMCOUHC Systematic Process 100% Governing Body 96%*100% Oversight of Delegated Entities 84%82%*79%* 93%100%71%*79%*75%* Credentialing 99%*97%*96%*97%*100%90%*99%* Enrollee Rights 99%*98%*100%93%*100% 98%*95%*97%* Availability and Access 100% Utilization Review 96%*95%*100%88%*100% 92%*95%*92%* Continuity of Care 98%* 100%88%*100% Fraud and Abuse 74%94%100%95%100% 89%71%

6. 6 6 Healthy Kids Quality Monitoring Program  Monitoring is performed by a team of nurses who also review and certify providers for EPSDT services.  Through medical record reviews, the nurses rate each MCO’s performance on compliance with the 5 major EPSDT components: 1.Health and Developmental History. 2.Comprehensive Physical Exam. 3.Laboratory Tests. 4.Immunizations. 5.Health Education.  Data results are reviewed and validated by the EQRO and are included in the SPR report.  All MCOs exceeded the minimum composite compliance rate of 85%.  All MCOs met or exceeded the 70% compliance rate for each of the 5 components of the review.

7. 7 Healthy Kids Audit Results MCO Health & Developmental History Comprehensive Physical Examination Laboratory Tests Immunizations Health Education/ Anticipatory Guidance Composite Score AGM90%94%77%95%87%91% DIA87%95%77%87%88%89% HFC88%96%75%94%91% JMS94%98%94% 96% MPC88%97%83%94%90%92% PPMCO89%96%75%95%91% UHC86%93%72%93%86%88% Aggregate Score 89%95%79%94%90%91%

8. 8 Healthy Kids Audit Results

9. 9 9  DHMH conducts an enrollee satisfaction survey annually using the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey instruments designed to evaluate members’ satisfaction with their health plans.  DHMH uses an NCQA certified CAHPS vendor to conduct the survey and compile the results.  Surveys include question sets covering:  Enrollment and coverage  Access to and utilization of healthcare  Communication and interaction with providers  Interaction with MCO administration  Self perceived health status Enrollee Satisfaction Surveys

10. 10  In 2007 –11,362 CAHPS Medicaid Adult Surveys and 13,958 CAHPS Medicaid Child with Chronic Care Condition (CCC) Surveys were mailed. There were 2,850 adult responses and 4,867 child responses. – Follow-up phone calls were made to interview members who did not respond by mail.  Response rates varied by MCO ranging from 21% to 35% for adults and 15% to 29% for children.  Based on ratings of 0 to 10 where 10 is the best, the lowest MCO score in any rating is 7.4 for adults and 6.4 for children. Enrollee Satisfaction Surveys (continued)

11. 11 Provider Satisfaction Surveys  DHMH conducts an annual provider satisfaction survey to assess provider satisfaction with various aspects of HealthChoice.  DHMH uses an NCQA certified HEDIS survey vendor to conduct the survey and compile the results.  Historically, response rates have been low and it is believed that a shorter survey in combination with telephone follow-up may help to increase provider survey participation beginning in 2008.

12. 12 Provider Satisfaction Surveys (continued)  Survey topics include: Finance Issues Customer Service/Provider Relations No-Show HealthChoice Appointments Coordination of Care and Case Management Utilization Management Overall Satisfaction  In 2007 A mail-only survey administration methodology was utilized to survey a random sample of Primary Care Providers (PCPs) from each of the seven MCOs. From a total aggregate of 5,309 PCPs, 248 responses were received yielding a total aggregate response rate of 6.1%

13. 13  The Healthcare Effectiveness Data and Information Set is a standardized set of performance measures developed by NCQA and CMS to measure managed care performance and assess opportunities for improvements in quality of care.  Each year NCQA updates the measurement set based on the latest information available.  The Department contracts with an NCQA certified HEDIS vendor to audit and report the MCOs’ scores.  MCOs use claim and encounter data to produce each measure. However, for some measures, MCOs are allowed to supplement incomplete data with medical record reviews. HEDIS Performance Measures

14. 14 Effectiveness of Care Childhood Immunization Status Adolescent 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 (NEW) Appropriate Testing for Children with Pharyngitis (NEW) Chlamydia Screening in Women (NEW) 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 Discharge and Average Length of Stay- Maternity Care Births and Average Length of Stay, Newborns 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 HEDIS Performance Measures  For 2007, MCOs were required to report their performance on 20 HEDIS measures.

15. 15  The 2007 HEDIS audits had an increase in the number of DHMH measures that had to be reported. Three measures added provided information on preventative services provided to HealthChoice members.  These measures were: Chlamydia Screening in women, Appropriate Testing for Children with Pharyngitis, Appropriate Treatment for Children with Upper Respiratory Infection.  Overall, the MCOs continue to show improvement in their HEDIS scores over the last 4 years. HEDIS Performance Measures (continued)

16. 16 Department of Health and Mental Hygiene

17. 17 MCOs: Benchmarks: AGM = AMERIGROUP Maryland, Inc. NMH = National Medicaid HEDIS Mean HFC = Helix Family Choice, Inc. MARR = Maryland Average Reportable Rate DIA = Diamond Plan - the Medicaid product line of Coventry Health Care MMA = Maryland MCO Average JMS = Jai Medical Systems Managed Care Organization, Inc MPC = Maryland Physicians Care PP = Priority Partners UHC = UnitedHealthcare of the Mid-Atlantic, Inc. Report Indicators: NR = Not Reportable NA = Not Applicable

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20. 20  Value Based Purchasing is a set of performance measures based on current HealthChoice monitoring activities.  The goal of our Value Based Purchasing strategy is to improve MCO performance by providing monetary incentives and disincentives.  These 10 measures cover all important dimensions of MCO performance:  Access to Care  Quality of Care  Administration (MCO structure and operations)  5 of the 10 measures are HEDIS measures and 5 are Maryland specific. Value-Based Purchasing

21. 21  Targets for each measure have been established based on 3 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. Value-Based Purchasing (continued)

22. 22 Value-Based Purchasing (continued) Performance 2006 Target MCO MeasuresAGMDIAHFCJMSMPCPPMCOUHC Incentive (I); Neutral (N); Disincentive (D) Well-child visits for children ages 3–6 Incentive: >80% Neutral: 73%–80% Disincentive: <73% 80.2% (I) 69.4% (D) 73.7% (N) 88.1% (I) 76.2% (N) 72.7% (D) 80.5% (I) Dental services for children ages 4–20 Incentive: >47% Neutral: 40%–47% Disincentive: <40% 42.2% (N) 31.1% (D) 51.8% (I) 48.3% (I) 46.9% (N) 49.5% (I) 46.5% (N) Ambulatory care services for SSI adults Incentive: >83% Neutral: 79%–83% Disincentive: <79% 75.8% (D) 69.1% (D) 79.1% (N) 83.5% (I) 78.9% (D) 82.0% (N) 76.5% (D) Ambulatory care services for SSI children Incentive: >77% Neutral: 70%–77% Disincentive: <70% 70.3% (N) 69.5% (D) 76.7% (N) 75.2% (N) 74.3% (N) 72.8% (N) 66.6% (D) Timeliness of prenatal care Incentive: >90% Neutral: 85%–90% Disincentive: <85% 97.5% (I) 88.9% (N) 90.0% (N) 87.7% (N) 86.9% (N) 86.6% (N) 88.0% (N) Cervical cancer screening for women ages 21–64 Incentive: >67% Neutral: 61%–67% Disincentive: <61% 71.1% (I) 43.6% (D) 58.2% (D) 77.7% (I) 61.8% (N) 63.0% (N) 61.2% (N) Lead screenings for children ages 12–23 months Incentive: >52% Neutral: 46%–52% Disincentive: <46% 52.1% (I) 40.4% (D) 54.7% (I) 62.5% (I) 51.5% (N) 54.4% (I) 44.2% (D) Eye exams for diabetics Incentive: >57% Neutral: 50%–57% Disincentive: <50% 73.2% (I) 42.9% (D) 62.7% (I) 72.0% (I) 53.6% (N) 54.7% (N) 56.9% (N) Childhood immunization status— Combo 2 Incentive: >80% Neutral: 69%–80% Disincentive: <69% 87.5% (I) 74.1% (N) 81.3% (I) 75.0% (N) 71.1% (N) 82.0% (I) 73.5% (N) Claims TimelinessN/A98.4%97.4%98.3%98.4%95.7%86.7%97.9%

23. 23 Consumer Report Card  This is the fifth year that we have produced a HealthChoice Consumer Report Card.  Since its inception, the Department has been contracting with the NCQA (through the EQRO contract) to develop the methodology and calculate the MCOs’ scores.  The 6 performance areas rated in the Report Card are calculated compiling 30-40 measures from HEDIS, Value Based Purchasing, and the Satisfaction Survey.  The Consumer Report Card is included in all enrollment packets.

24. 24 Performance Improvement Projects  Currently have 2 Performance Improvement Projects ongoing that MCOs are required to conduct:  Improve Screening for Chronic Kidney Disease  Improve Cervical Cancer Screening (Began July 2007) Improving the Delivery of Prenatal/Postpartum Care was completed in 2007.  PIPs consist of:  Submission of data collection and analysis plan  Baseline measurement of data  Intervention development and implementation  Re-measurement of data

25. 25 Performance Improvement Projects  For Prenatal/Postpartum: All MCOs improved their scores from baseline in 2004 to final in 2007.  For CKD Measure 1 “HEDIS, Kidney Disease Monitored Rate”: All MCOs improved their scores from 2005-2006. (Diamond Plan was not required to participate in 2006 due to insufficient membership size).  For CKD Measure 2 “Hypertensive members receiving at least one serum creatinine”: 2 MCOs improved their scores, 3 MCOs remained relatively the same, and 1 MCO had a small score decrease from 2005-2006. (Diamond Plan was not required to participate in 2006 due to insufficient membership size).

26. 26 Where to find complete information ? D EPARTMENT OF H EALTH AND M ENTAL H YGIENE WEBPAGE http://www.dhmh.state.md.us/ Select “Medical Care Programs”, “HealthChoice Managed Care”, “HealthChoice Quality Assurance Activities”