1. Performance Measures 101 Presenter: Peggy Ketterer, RN, BSN, CHCA Executive Director, EQRO Services Health Services Advisory Group March 28, 2007 3:00 p.m.–4:00 p.m.

2. Balanced Budget Act (BBA) of 1997

3. 42CFR438.240 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) 42CFR438.356 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 42CFR438.358 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 what improvements are necessary.

9. Performance Measures 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. Step 1: Identify necessary data sources and data elements for reporting the selected measures Membership/enrollment data Claims/encounter data Other administrative data (if available), i.e., disease management database, kept appointment database Calculation and Reporting of Performance Measures

12. Step 2: Prepare data set Extract data Clean data (valid variables, formats) Verify completeness and accuracy Establish data element to link data sources (unique member ID) Calculation and Reporting of Performance Measures

13. Step 3: Produce source code to calculate measures Calculate continuous enrollment and anchor date Determine member age and gender Include diagnosis and procedure codes needed to identify service events Exclusion logic Calculation and Reporting of Performance Measures

14. Step 4: Calculate measures administratively Run source code Examine output files Review preliminary administrative results Calculation and Reporting of Performance Measures

15. Step 5: Hybrid Sampling (if applicable) Supplement administrative data with medical record pursuit HEDIS-like methodology preferable (411 sample) Systematic sampling Calculation and Reporting of Performance Measures

16. Step 6: Collect medical record data Use standardized criteria –Tools –Instructions Establish a sound process for monitoring data collection accuracy (inter-rater reliability, over-reads) Calculation and Reporting of Performance Measures

17. Step 7: Combine administrative and medical record data Logic for duplicates Methodology for integration into reporting repository Calculation and Reporting of Performance Measures

18. Step 8: Validate results Review calculated rates for reasonability Examine data output file and verify with source data (membership and encounter data) Calculation and Reporting of Performance Measures

19. Step 9: Submit Performance Measure reports to the state Utilize state-specified format Calculation and Reporting of Performance Measures (cont)

20. Hybrid/MRR – Negative Aspects Typically more expensive More burdensome to capture data May not always increase administrative rate drastically Calculation and Reporting of Performance Measures

21. Written Description Calculation (the percentage of X who had Y) Eligible Population Criteria Numerator Event Criteria Exclusion Criteria Reporting Format Diagram of a Performance Measure

22. Example for PMHPs: The percentage of discharges of members 6 years of age or older who were hospitalized for treatment of selected mental health disorders and who were seen on an outpatient basis or were in intermediate treatment with a mental health provider. Written Description

23. Example for NHDPs: This measure summarizes utilization of long term care services and acute care services in the following categories: Units of case management/1000 member months Units of private duty nursing/1000 member months Units of physical, occupational, and speech therapy/1000 member months Inpatient days/1000 member months Written Description

24. Example for PMHPs: Two calculations will be generated: The percentage of discharges for members who had an outpatient or intermediate mental health visit on the date of discharge, up to 30 days after hospital discharge and The percentage of discharges for members who had an outpatient or intermediate mental health visit on the date of discharge, up to seven days after hospital discharge Calculation

25. Example for NHDPs: Long Term Care Services - each category counts encounters between a NHDP provider and enrollee, which includes each occurrence/unit as identified by specified encounter data service types. Acute Care Services – This category counts total discharges, days, and ALOS for all inpatient stays. Calculation

26. Example for PMHPs: Specifies any age, continuous enrollment (CE), and event/diagnosis requirements. Age: 6 years or older as of the date of discharge CE: Date of discharge through 30 days after discharge Event/diagnosis: Discharged from an inpatient setting of an acute care facility with specific principal diagnosis codes indicating a mental health disorder Eligible Population Criteria

27. Example for NHDPs: Specifies member months calculation instructions Member months: for each month of enrollment, each enrollee contributes one member month (i.e. one year of enrollment equals 12 member months) May be stratified by age or gender Eligible Population Criteria

28. Example for PMHPs: An outpatient mental health encounter or intermediate treatment with a mental health provider within the specified time period. CPT, HCPCS, and revenue codes are listed to identify qualifying visit type. Numerator Event Criteria

29. Example for NHDPs: Specifies rules for counting services/units Lists the type of services by description or service code for each category For acute care services, specifies UB-92 type of bill codes and rules for calculating ALOS Numerator Event Criteria

30. Example for PMHPs/NHDPs: Specifies certain diagnoses or circumstances that would qualify for an exclusion Exclusion Criteria

31. Example for PMHPs: Identifies the data elements necessary for reporting (i.e. eligible population, numerator events, rate) Includes a grid for entering data elements Reporting Format

32. Example for NHDPs: Identifies the data elements necessary for reporting (i.e. number of services, number of services by category per 1000 member months, number of discharges, discharges/1000 member months, ALOS ) Includes a grid for entering data elements Reporting Format

33. 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 re- evaluated annually to ensure they are comparable, valid, and meaningful. Performance Measure Development

34. Questions and Answers Open Discussion