1. Presented by: Wendy Talbot, MPH, CHCA January 16, 2008 Overview of 2007 Performance Measure Validation Findings and HEDIS Results

2. Presentation Overview I.Performance Measure Validation a. Process b. Findings and Recommendations c. Questions II.HEDIS Results a.Results and Recommendations by Dimension of Care b.2008 HEDIS Changes c.Questions

3. Performance Measure Validation Objectives –Evaluate accuracy of data collected –Determine the extent to which each measure calculated followed established specifications –Utilize process consistent with CMS protocol

4. NCQA-licensed audit organization Pre-on-site call/meeting BAT review AHCA-specific measure set validation Source code/certified software review Primary source review Convenience sample validation (if applicable) Medical Record Review Health Plan Quality Indicator Data File Review Validation Activities

5. Validation Activities Findings Used a certified software vendor: –10 out of 12 HMOs Convenience sample validation: –4 HMOs had a convenience sample –3 HMOs were exempt –Was not specified in final audit report whether one was required or performed for 5 HMOs Medical record review validation –11 HMOs –1 HMO did not use the hybrid method All other validation activities were fulfilled

6. Audit Findings R = Report –Reportable rate or numeric result for HEDIS measures NA = Not Applicable –The HMO followed the specifications but the denominator was too small to report a valid rate (<30) NB = No Benefit –The HMO did not offer the health benefits required by the measure NR = Not Report –The HMO calculated the measure but the rate was materially biased or the HMO chose not to report the measure

7. Audit Findings Breast Cancer Screening –42-51 Years R = 10 HMOs NA = 2 HMOs –52-69 Years R = 10 HMOs NA = 2 HMOs –Combined R = 10 HMOs NA = 2 HMOs Timeliness of Prenatal Care R = 11 HMOs NR = 1 HMO

8. Audit Findings Cervical Cancer Screening R = 12 HMOs Chlamydia Screening –16-20 Years R = 11 HMOs NA = 1 HMO –21-25 Years R = 11 HMOs NA = 1 HMO –Combined R = 12 HMOs

9. Audit Findings Appropriate Medications for People with Asthma –5-9 Years R = 9 HMOs NA = 3 HMOs –10-17 Years R = 8 HMOs NA = 4 HMOs –18-56 Years R = 8 HMOs NA = 4 HMOs –Combined R = 10 HMOs NA = 2 HMOs

10. Audit Findings Comprehensive Diabetes Care –LDL-C Screening R = 10 HMOs NA = 2 HMOs –LDL-C Testing R = 10 HMOs NA = 2 HMOs –Eye Exams R = 9 HMOs NA = 2 HMOs NR = 1 HMO –Nephropathy R = 10 HMOs NA = 2 HMOs

11. Audit Findings Controlling High Blood Pressure –18-45 Years R = 7 HMOs NA = 1 HMO NR = 4 HMOs –46-85 Years R = 7 HMOs NA = 1 HMO NR = 4 HMOs –Combined R = 7 HMOs NA = 1 HMO NR = 4 HMOs

12. IS Standards IS 1.0—Sound Coding Methods for Medical Data IS 2.0—Data Capture, Transfer, & Entry—Medical Data IS 3.0—Data Capture, Transfer, and Entry—Membership Data IS 4.0—Data Capture, Transfer, and Entry—Practitioner Data IS 5.0—Data Integration Required to Meet the Demands of Accurate HEDIS Reporting IS 6.0—Control Procedures that Support HEDIS Reporting Integrity

13. IS 1.0—Sound Coding Methods for Medical Data Findings IS 1.0 Issues – Two HMOs received a substantially compliant on this standard because they were not capturing CPT II codes and internal audits of claims examiners was not sufficient. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

14. IS 2.0—Data Capture, Transfer, & Entry—Medical Data Findings IS 2.0 Issues – Three HMOs received a substantially compliant on this standard due to issues with data entry processes and data transmissions. Two HMOs received a not report for this standard due to problems identified with their medical record process. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

15. IS 3.0—Data Capture, Transfer, and Entry— Membership Data Findings IS 3.0 Issues – One HMO received a substantially compliant on this standard because there were no policies and procedures in place for receiving Medicaid enrollment files. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

16. IS 4.0—Data Capture, Transfer, and Entry— Practitioner Data Findings IS 4.0 Issues - No issues, all HMOs were fully compliant with this standard. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

17. IS 5.0—Data Integration Required to Meet the Demands of Accurate HEDIS Reporting Findings IS 5.0 Issues - No issues, all HMOs were fully compliant with this standard. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

18. IS 6.0—Control Procedures that Support HEDIS Reporting Integrity Findings IS 6.0 Issues – One HMO received a substantially compliant on this standard because NCQA specifications were not followed for sample size production and over- sample percentages. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

19. Recommendations—HMOs Monitor all vendors who are contracted to work with data; specifically medical record vendors Develop and implement policies and procedure for data entry validation, regardless of the amount of manual data entry performed Develop procedures to ensure all data files are consistent and accurate

20. Recommendations—AHCA Require a predetermined file layout for submitting data Consider using the NCQA IDSS data submission tool Have HMOs submit Final Audit reports and Audit Designation reports to AHCA as soon as they receive them to eliminate confusion in the reporting process Have auditors validate the actual data files being submitted to AHCA

21. QUESTIONS?

22. Florida Medicaid HEDIS 2007 Results

23. Dimensions of Care Women’s Care Living with Illness

24. Analytics Comparative –Florida 2007 weighted average compared to the national 2006 Medicaid 50 th percentile –Florida 2007 weighted averages compared to Florida 2006 weighted averages (when applicable) Distribution –Range of MHP reported rates

25. Distribution Graphs 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Measure 1Measure 2 Highest Plan RateWeighted AverageLowest Plan Rate Highest Rate Lowest Rate FL Weighted Average High Outlier Low Outlier

26. Florida 2007 Results Compared to National Benchmarks

27. Women’s Care

28. 2007 Measures –Breast Cancer Screening Ages 42-51 Years Ages 52-69 Years Combined –Cervical Cancer Screening –Chlamydia Screening Ages 16-20 Years Ages 21-25 Years Combined –Prenatal and Postpartum Care Timeliness of Prenatal Care

29. Women’s Care In 2006, only Breast Cancer Screening and Chlamydia Screening were reported by the HMOs. Starting in 2007: –Breast Cancer Screening measure was reported in three cohorts and the lower age limit was raised to 40 years of age –The lower age limit for Cervical Cancer Screening was raised to 21 years of age

30. Women’s Care Overall performance for the Women’s Care dimension continued to be below average to average.

31. Women’s Care Breast Cancer Screening—Ages 52-69 Years findings: –10 HMOs reported a rate for this measure; two HMOs were unable to report rates due to insufficient sample sizes –Nine had rates below the national HEDIS 2006 50 th percentile –Four of the HMOs had rates below the low performance level (LPL) –The 2007 Florida Medicaid weighted average decreased by 1 percentage point compared to the 2006 weighted average

32. Women’s Care Cervical Cancer Screening findings: –12 HMOs reported a rate for this measure –All 12 HMOs’ rates were below the national HEDIS 2006 50 th percentile –10 of the HMOs reported rates below the LPL –The 2007 weighted average of 55.8 percent was below the LPL of 59.7 percent

33. Women’s Care Chlamydia Screening in Women— Combined findings: –12 HMOs reported a rate for this measure –Four HMOs reported rates above the national HEDIS 2006 50 th percentile –Two HMOs reported rates below the LPL –The 2007 weighted average was 1.5 percentage points below the 2006 weighted average

34. Women’s Care Timeliness to Prenatal Care findings: –11 HMOs reported a rate for this measure; one HMO reported an NR for the measure –All 11 of the HMOs reported rates below the LPL –The 2007 weighted average of 63.4 percent was below the LPL of 74.2 percent

35. Women’s Care Range of 2007 Rates

36. Women’s Care Improvement efforts to be considered for the Breast Cancer Screening measure include: –Increase efforts to target younger women for mammograms –Educate on the importance of early detection –Work to ensure complete administrative data

37. Women’s Care Improvement efforts to consider for the Cervical Cancer Screening and Chlamydia Screening measures include: –Educate women on the importance of screening –Identify barriers to accessing care and services

38. Women’s Care Improvement efforts to consider for the Timeliness to Prenatal Care measure include: –Ensure complete data through the use of medical record review, especially for plans that utilize global billing for maternity services –Educate on the importance of prenatal care

39. Women’s Care Missed opportunities could be examined to identify barriers to improvement and target specific interventions High performing HMOs should share best practices with other HMOs

40. Living with Illness

41. 2007 Measures: –Use of Appropriate Medications for People with Asthma Ages 5-9 Years Ages 10-17 Years Ages 18-56 Years Combined –Comprehensive Diabetes Care LDL-C Screening LDL-C Controlled Eye Exams Medical Attention for Diabetic Nephropathy –Controlling High Blood Pressure Ages 18-52 Years Ages 46-85 Years Combined

42. Living with Illness In 2006, only Use of Appropriate Medications of People with Asthma was reported by the HMOs Starting in 2007: –Controlling High Blood Pressure measure was reported in three cohorts and the lower age limit was decreased to 18 years of age –There were changes to several indicators in the Comprehensive Diabetes Care measure

43. Living with Illness The overall statewide results in the Living With Illness dimension were average to below average, with the exception of Comprehensive Diabetes Care—Medical Attention for Diabetic Nephropathy, which was above average.

44. Appropriate Use of Medications for People with Asthma—Combined findings: –Nine HMOs reported a rate for this measure; three HMOs had an insufficient sample size to report the measure –Four HMOs reported rates above the national HEDIS 2006 50 th percentile –One HMO reported a rate below the LPL Living with Illness

45. Comprehensive Diabetes Care findings: –LDL-C Screening No HMOs reported rates above the national HEDIS 50 th percentile Eight of the 10 HMOs reported a rate below the LPL –LDL-C Testing One HMO reported a rate above the national HEDIS 50 th percentile Two of the 10 HMOs reported a rate below the LPL

46. Living with Illness Comprehensive Diabetes Care findings continued: –Eye Exams No HMOs reported a rate above the national HEDIS 50 th percentile Two if the nine HMOs reported a rate below the LPL –Medical Attention for Diabetic Nephropathy Eight of the 10 HMOs reported a rate above the HPL One HMO reported a rate below the LPL

47. Living with Illness Controlling High Blood Pressure—Ages 46-85 Years findings: –Seven HMOs reported a rate for this measure; one had an insufficient sample size to report the measure, and four reported an NR –None of the HMOs reported a rate above the LPL

48. Living with Illness Range of 2007 Rates

49. Living with Illness Range of 2007 Rates, cont.

50. Living with Illness Improvement efforts to consider for Appropriate Medications for People with Asthma include: –Ensure pharmacy data are complete –Educate providers on the guidelines of asthma treatment

51. Living with Illness Improvement efforts to consider for Comprehensive Diabetes Care include: –Educate members on the importance of diabetes management care –Ensure vendor data, such as lab and pharmacy, are complete –Work to improve administrative data to minimize the burden of medical record review

52. Living with Illness Improvement efforts to consider for Controlling High Blood Pressure include: –Changes were made to the 2007 technical specifications, HMOs should ensure all changes were implemented –Monitor medical record review processes to ensure the measure is being captured according to specifications

53. Living with Illness Missed opportunities could be examined to identify barriers to improvement and target specific interventions High performing HMOs should share best practices with other HMOs

54. Changes to HEDIS 2008

55. Summary of Changes in HEDIS 2008 New HEDIS measures Changes to existing measures Retired measures

56. HEDIS 2008 New Measures Lead Screening in Children (LSC) Pharmacotherapy Management of COPD Exacerbation (PCE) RRU – Cardiovascular Conditions (RCA) RRU – Uncomplicated Hypertension (RHY) RRU – COPD (RCO)

57. Changes to Existing Measures Childhood Immunization Status (CIS) – clarified numerator evidence for antigen compliance Persistence of Beta-Blocker Treatment After A Heart Attack (PBH) – decreased lower age limit to 18 years of age

58. Changes to Existing Measures, cont’d Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) – Inverted the measure rate so that a higher rate is better, and renamed the measure formerly called Inappropriate Antibiotic Treatment for Adults with Acute Bronchitis Use of High-Risk Medications in the Elderly (DAE) – renamed measure that was formally called Drugs to be Avoided in the Elderly

59. Retired Measures Adolescent Immunization Status Beta-Blocker Treatment After a Heart Attack Discharges and ALOS – Maternity Births and ALOS – Newborns Mental Health Utilization – Inpatient Discharges and ALOS Chemical Dependency Utilization – Inpatient Discharges and ALOS

60. Questions?

61. 2007-2008 Focused Study Behavioral Health Prior Authorizations Peggy Ketterer, RN, BSN, CHCA Executive Director, State and Corporate Services Marilea Rose, RN, BA Associate Director, State and Corporate Services

62. The purpose of the study is to determine: How behavioral health authorization processes vary between MCOs How medical necessity criterion vary between MCOs How timeliness of authorizations vary across MCOs

63. Who will participate in the study? HMOs PSNs PMHPs

64. Focused Study Activity Step 1: Procure behavioral health information from MCOs 25 out of 26 MCOs have submitted behavioral health documents HSAG has completed a cursory review and in process of requesting additional information from MCOs

65. Focused Study Activity Step 2: Conduct desk review HSAG is currently compiling and categorizing MCO survey responses HSAG conducted informal interviews with a limited number of providers to gather preliminary information regarding potential barriers

66. Focused Study Activity Step 3: Evaluate self-reported timeliness of authorization Data submission file layout for timeliness data is being designed HSAG is preparing MCO data request letter HSAG is finalizing MCO instructions for calculating timeliness indicators

67. Focused Study Activity Step 3: Evaluate self-reported timeliness of authorization (cont’d) Key Dates: Data request letters will be sent to the MCOs on 1/31/08 Timeliness data is due back to HSAG on 3/7/08

68. Focused Study Activity Step 4: Report Preparation Report outline is being drafted HSAG will present findings, summary of common practices HSAG will provide recommendations for improvement of the process, consider standardization

69. Questions and Answers

70. Upcoming EQR Activities Contract Year Two 2:45 p.m. – 3:30 p.m. Peggy Ketterer, RN, BSN, CHCA Executive Director, EQRO Services

71. Upcoming EQR activities MARK YOUR CALENDARS!!!! The next EQR Quarterly Meetings are scheduled as follows: Wednesday, March 26, 2008 (Webinar) Wednesday, June 18, 2008 (AHCA Offices) Wednesday, September 24, 2008 (Webinar)

72. Performance Improvement Projects (PIPs) PIP validation process is targeted for completion in March, 2008. MCOs will be given the opportunity to review HSAG’s completed PIP tool and summary grid and provide feedback and comments.

73. Performance Improvement Projects (PIPs) Collaborative PIPs – HMOs/PSNs The well-child visits collaborative PIP is on two separate tracks: reform and non- reform plans. Non-reform plans have collected baseline data and are completing the causal/barrier analysis and intervention planning phase. Reform plans will be collecting baseline data (HEDIS ® 2008), available June, 2008. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA)

74. Performance Improvement Projects (PIPs) Collaborative PIPs – PMHPs Topic: Follow-up Within 7 Days After an Acute Care Discharge for a Mental Health Diagnosis. PMHPs will be collecting baseline data on calendar year 2007, which will be available in June, 2008.

75. Performance Improvement Projects (PIPs) Collaborative PIPs – NHDPs Topic: Retention Rate NHDPs will begin collecting baseline data quarterly and will prepare a 2008 calendar year roll-up rate.

76. Performance Measures Non-reform HMOs: Validation of Performance Measures Report is targeted to be finalized in January, 2008. HEDIS 2007 Strategic Analysis Report will be provided to AHCA as a draft in January, 2008. The report is targeted to be finalized in March, 2008.

77. Performance Measures Reform HMOs/PSNs: HEDIS 2008 data will be analyzed and reported on during the next contract year (2008-2009).

78. Performance Measures PMHPs: PMHPs will be collecting and reporting performance measure data on calendar year 2007 to AHCA in July, 2008. HSAG will conduct the validation of performance measures activities concurrently during the data collection and reporting cycle.

79. Performance Measures NHDPs: NHDPs have begun to collect performance measure data quarterly (Jan – Mar 2008). HSAG will conduct the validation of performance measures activity in the early part of the next contract year (2008-2009).

80. Focused Study Behavioral Health Authorizations HMOs, PSNs, and PMHPs have completed the MCO survey document describing their authorization processes. HSAG will forward a request for timeliness data to the participating MCOs on January 31, 2008. Timeliness data should be submitted to HSAG by March 7, 2008. Draft focused study report is targeted for submission to AHCA in May, 2008.

81. Upcoming EQR activities Quarterly EQR meetings (webinar and onsite at AHCA offices in Tallahassee) Other meetings (including Collaborative PIP meetings and technical assistance sessions) will be scheduled in conjunction with the quarterly meetings

82. QUESTIONS???

83. THANK YOU FOR YOUR PARTICIPATION!