1. External Quality Review Quarterly Meeting Wednesday, September 26, 2007 1:00 p.m. – 3:00 p.m. WELCOME!

2. EQR Quarterly Meeting  Welcome to all participants  Overview of agenda  Webinar do’s and don’ts  Evaluation Forms

3. PIP Validation Activities for Year Two 1:15 p.m. – 1:30 p.m. Presenter: Cheryl Neel, RN, MPH, CPHQ Manager, Performance Improvement Projects

4. Overview PIP Activities Completed Important Dates PIP Submission Tips

5. PIP Activities Completed

6. Webinar PIP Trainings PMHPs on August 21, 2007 NHDPs on August 22, 2007 HMOs/PSNs on August 22, 2007

7. Purpose of PIP Webinar Trainings Provided technical assistance for activities either Partially Met or Not Met overall for the 2006-2007 validation cycle Instructed on how to submit PIPs Provided resources Addressed PIP questions and issues

8. PIP Statement of Intent (SOI) HSAG received SOI submissions from: 17 HMOs (Reform and Non-reform) 6 PSNs 8 PMHPs 12 NHDPs

9. PIP Frequently Asked Questions FAQ on myfloridaeqro.com Updated for the 2007-2008 validation cycle Includes FAQs for collaborative PIPs Examples of FAQs  What are some resources I can use in conducting my PIP?  Where can I find benchmarking information for Medicaid programs?  What is a collaborative PIP?

10. PIP Submission Letters  Letters sent on September 6, 2007 Included:  2007-2008 PIP validation timeline  PIP topics selected for validation  PIP study form for new PIPs  Completion instructions

11. PIP Topics Selected Examples: HMO  Cultural & Linguistic  Member Satisfaction PSN  Cultural and Linguistic  Dental Care

12. PIP Topics Selected Examples: PMHP  Encounters/Claims Lag  Readmissions NHDP  Influenza Vaccination  Wound Care

13. Important Dates

14. PIP Submissions Due to HSAG All selected PIP submissions* are due Friday, October 5, 2007 *NHDP Collaborative PIPs due Friday, November 2, 2007

15. PIP Submission Tips

16. Previously Submitted PIPs For ongoing PIPs, use the same PIP Study Form that was submitted for previous year’s validation cycle. Highlight, bold, or add text in a different color, and date any new information that is added to the existing PIP Study Form. Strikethrough and date any information that no longer applies to the PIP study submission. Ensure all Partially Met and Not Met evaluation elements from the previous validation cycle have been addressed in the documentation.

17. All PIP Submissions ‣ Complete demographic page of PIP Study Form. ‣ Only complete the PIP Study Form as far as the PIP has progressed. ‣ Be sure to include all attachments referenced in the PIP Study Form (e.g. manual data collection tool, instructions, etc.)

18. HSAG Contacts for PIP Questions  Cheryl Neel –cneel@hsag.comcneel@hsag.com –602.745.6201  Denise Driscoll –ddriscoll@hsag.comddriscoll@hsag.com –602.745.6260

19. Update on the Collaborative PIP Initiatives 1:30 p.m. – 1:45 p.m. Presenter: Peggy Ketterer, RN, BSN, CHCA Executive Director, EQRO Services

20. Collaborative PIPs EQRO Year 1 (FY 2006-2007) HSAG validated 81 PIPs HSAG identified potential collaborative topics within the Annual Strategic Report

21. Collaborative PIPs EQRO Year 1 (FY 2006-2007) HSAG recommended three topics: Well-Child Visits (zero visits numerator) for HMOs/PSNs Follow-Up After Hospitalization for Mental Illness for PMHPs Fall Prevention for NHDPs

22. Collaborative PIPs EQRO Year 2 (FY 2007-2008) HSAG held collaborative PIP kick- off meetings in June with HMOs/PSNs, PMHPs, and NHDPs. As a result of the kick-off meetings, the topics were modified or refined.

23. Collaborative PIPs Final collaborative PIP topics: Well-Child Visits (Six or More Visits numerator) for HMOs/PSNs Follow-Up within Seven Days after Acute Care Discharge for a Mental Health Diagnosis for PMHPs Retention Rate for NHDPs

24. Collaborative PIPs Current status: Monthly conference calls are held with all participants Documentation requirements for each PIP activity are discussed Host MCOs are responsible for facilitating the meeting and preparing meeting minutes

25. Collaborative PIPs Current status: The study question has been identified for each collaborative Study indicators have been identified for the HMO/PSN and PMHP PIPs All MCOs are responsible for completing customized PIP forms

26. Collaborative PIPs Validation activities: HSAG is validating two PIPs per MCO Collaborative PIPs will be validated (as one of the two selected PIPs per MCO) If an MCO is not participating in the collaborative, two other PIPs will be selected for validation

27. Collaborative PIPs Validation activities: Collaborative PIPs will be validated as far as they have progressed to date. Additional evaluation elements will be considered “not applicable” for this validation cycle.

28. Collaborative PIPs Validation activities: HSAG will produce a report for each PIP selected for validation, including the collaborative PIPs. The reports have been streamlined to be more concise and less repetitive.

29. Collaborative PIPs Collaborative PIP Report: HSAG prepared the draft Statewide Collaborative Methodology Report for PIPs in August, 2007 The report describes the background, purpose, and status of the collaborative, as well as HSAG’s role in facilitating the progression of the PIPs

30. Collaborative PIPs Collaborative PIP Information: HSAG has posted the meeting minutes, agendas, conference call schedules, and FAQs on www.myfloridaeqro.com

31. Collaborative PIPs Questions?

32. Validation of Performance Measures and HEDIS Strategic Analysis FY 2007/2008 Wendy Talbot, MPH Project Leader, State and Corporate Services

33. Performance Measure Validation Process HSAG, in collaboration with AHCA, has determined which MCOs can undergo validation activities –Non-reform populations only for Year 2 To be eligible for validation activities, an MCO must report standardized performance measures

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

35. Performance Measure Validation Process On September 10, 2007, a document request letter was forwarded to the HMOs. The letter requested the following items: –HMO-completed 2007 Baseline Assessment Tool (BAT) or updates to their 2006 BAT –Final health plan quality indicator data file in AHCA-required format –Completion of additional questions on the information system capabilities assessment tool (ISCAT) Requested items are due to HSAG on or before October 19, 2007

36. Performance Measure Validation Process Step One: Review BAT and ISCAT additional questions to assess systems capabilities Step Two: Review quality data indicator file for reasonability and evaluation of HMO performance Step Three: Compile measure-specific validation findings based on CMS protocols Step Four: Draft report of the results of the validation of performance measures activity

37. Performance Measure Validation Process Validation of Performance Measure report –Draft to AHCA November 30, 2007 –Final to AHCA January 11, 2008

38. HEDIS Strategic Analysis Objectives –Verify that the HMO’s HEDIS production processes conform with technical specifications –Measure the HMO’s Information Systems capabilities –Evaluate the HMO’s ability to process medical, member, and provider data in order to accurately report HEDIS data –Ensure accurate and reliable publicly reported data

39. HEDIS Strategic Analysis No HMO-specific reports in Year 2, only Statewide Aggregate Statewide Aggregate report will include: – Comparisons to national benchmarks – Comparisons to 2006 rates – Calculation of the state weighted average – Ranking of HMOs – Identification of overall program strengths and areas for improvement

40. Reported Measures Dimensions of Care –Women’s Care Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening in Women Timeliness of Prenatal Care –Living With Illness Use of Appropriate Medication for People with Asthma Comprehensive Diabetes Care Controlling High Blood Pressure

41. HEDIS Strategic Analysis Strategic Aggregate report –Draft to AHCA January 30, 2008 –Final to AHCA March 5, 2008

42. QUESTIONS?

43. 2007/2008 Focused Study 1:55 p.m. – 2:05 p.m. Marilea Rose, RN, BA Associate Director, State and Corporate Services

44. HSAG will be conducting one focused study on the following topic: To what extent do the outpatient behavioral health authorization processes, medical necessity criterion, and timeliness of authorizations vary across MCOs and by service category.

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

46. 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.

47. Focused Study Activities What are the project steps? Step 1: Procure MCO information via survey method Step 2: Conduct desk review of survey responses and supporting documentation (policies and procedures) Step 3: Evaluate MCO self reported timeliness of authorizations Step 4: Prepare report

48. A survey will be sent to the MCOs to collect study information Survey will be similar to the Special Health Care Needs survey used for the 2006/2007 focused study Tentative timeframe to send the survey to the MCOs is mid-November Tentative timeframe for returning the survey to HSAG is mid-December

49. What types of information will the survey collect from the MCOs? Authorization policies and procedures What initiates a request for authorization Staff credentials required to authorize various services Number of units authorized for initial requests for services Process to obtain continued authorization Timeliness standards for authorizations Medical necessity criterion

50. Questions and Answers

51. Overview of EQR Technical Report for 2006/2007 2:05 p.m. – 2:25 p.m. Presenter: Peggy Ketterer, RN, BSN, CHCA Executive Director, EQRO Services

52. 2006-2007 EQR Technical Report Required annually by the Balanced Budget Act of 1997 (BBA) Includes conclusions regarding the quality and timeliness of, and access to, care furnished by contracted MCOs and PIHPs

53. 2006-2007 EQR Technical Report Summarizes the activities and findings from the first year of the EQR contract Includes summary findings by MCO type (HMO, PSN, PMHP, and NHDP) as well as overall conclusions and recommendations

54. 2006-2007 EQR Technical Report Data used to evaluate performance included: Validation of PIP results Validation of performance measure results Consumer satisfaction survey data

55. 2006-2007 EQR Technical Report Data used to evaluate performance (cont’d): HEDIS ® results Results of Adolescent Well-Care Focused Study HEDIS ® is a registered trademark of the National Committee for Quality Assurance (NCQA)

56. 2006-2007 EQR Technical Report Other EQR activities: There were several EQR activities that were not intended to produce findings that could be used for comparisons A summary of these activities, along with the final outcome, was addressed in the report

57. 2006-2007 EQR Technical Report Other EQR activities: Technical assistance on enrollee race, ethnicity, and primary household language Value-based purchasing methodologies Evaluation of AHCA quality strategy Dissemination of education (quarterly meetings, website, trainings)

58. 2006-2007 EQR Technical Report HMO Findings: Most objective data available to evaluate performance PIPs–Nine percent received Met validation status, 43 percent received a Partially Met status, and 47 percent received a Not Met validation status

59. 2006-2007 EQR Technical Report HMO Findings (cont’d): Performance Measures–above average performance on asthma measures, average performance on breast cancer and Chlamydia screening measures, and below average performance on well-child care measures.

60. 2006-2007 EQR Technical Report HMO Findings (cont’d): Consumer satisfaction surveys (CAHPS ® )–mixed results, no observable patterns seen Focused Study (Adolescent Well- Care)–generally low performance statewide CAHPS ® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

61. 2006-2007 EQR Technical Report PMHP Findings: Limited objective data to evaluate PIPs–Most PIPs received a Partially Met validation status, with one receiving a Not Met status Consumer satisfaction surveys– unable to use for comparison purposes

62. 2006-2007 EQR Technical Report PSN Findings: Limited objective data to evaluate Consumer satisfaction surveys– unable to use for comparison purposes Focused Study (Adolescent Well- Care)–performance generally consistent with statewide average

63. 2006-2007 EQR Technical Report NHDP Findings: Limited objective data to evaluate PIPs–Most PIPs received a Not Met validation status, with two PIPs receiving a Partially Met status Consumer satisfaction surveys– unable to use for comparison purposes

64. 2006-2007 EQR Technical Report Assessment of MCO Strengths and Weaknesses: HSAG developed a methodology to identify strengths and weaknesses in performance in key EQR areas Used objective data (PIPs, performance measure results, consumer survey performance, and focused study results)

65. 2006-2007 EQR Technical Report Assessment of MCO Strengths and Weaknesses: HEDIS measures that exceeded the high performance level (national 90 th percentile) were considered a strength for the MCO HEDIS measures that fell below the low performance level (national 25 th percentile) were considered a weakness for the MCO

66. 2006-2007 EQR Technical Report Assessment of MCO Strengths and Weaknesses: CAHPS ® measures that were statistically higher than the state mean were considered a strength for the MCO CAHPS ® measures that were statistically lower than the state mean were considered a weakness for the MCO CAHPS ® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

67. 2006-2007 EQR Technical Report Assessment of MCO Strengths and Weaknesses: Adolescent well-care clinical indicators that were statistically higher than the overall MCO aggregate rate were considered a strength for the MCO Adolescent well-care clinical indicators that were statistically lower than the overall MCO aggregate rate were considered a weakness for the MCO

68. 2006-2007 EQR Technical Report Assessment of MCO Strengths and Weaknesses: Within the technical report, HSAG prepared a set of tables displaying each MCO’s strengths and weakness based on the methodology Strengths and weaknesses were also grouped into categories of quality, timeliness, and access to care

69. 2006-2007 EQR Technical Report Overall Conclusions and Recommendations: Most objective data addressed only quality of services Unable to draw overall conclusions based on the first year of data Expect more objective data and the ability to compare performance in FY 2007-2008

70. 2006-2007 EQR Technical Report Overall Conclusions and Recommendations: Recommendations included introducing standardized performance measures and consumer satisfaction surveys for all MCO types Need to add indicators or measures that address timeliness and access to care.

71. 2006-2007 EQR Technical Report Questions?

72. Florida Medicaid Quality Strategy 2:25 p.m. – 2:40 p.m. Linda Macdonald, MS Senior Management Analyst II AHCA Margaret deHesse, RN, BSN Executive Director, State and Corporate Services HSAG

73. Quality Strategy AHCA Development 1.Background 2.Goals and Objectives EQRO Review 1.Findings 2.Recommendations

74. Quality Strategy EQR Findings: 1.The Quality Strategy was generally compliant with the CMS requirements and toolkit 2.High level of detail was included 3.The Quality Strategy should be further enhanced to better align with federal regulations and to improve its overall effectiveness

75. Quality Strategy Recommendations 1.Enhance methods/process for gathering enrollee/stakeholder feedback 2.Add details/methodology regarding conducting annual quality review 3.Explicitly state the term of the EQRO contract 4.List the standards and activities that will be monitored through Medicare or an accreditation review

76. Quality Strategy Recommendations Continued 5.Describe the work being done in the area of race/ethnicity and primary language 6.Include statements about vision, values, and guiding principles 7.Set performance measurement benchmarks and improvement goals

77. Questions and Answers

78. Upcoming EQR Activities 2:40 p.m. – 2:50 p.m. Peggy Ketterer, RN, BSN, CHCA Executive Director, EQRO Services

79. Upcoming EQR activities MARK YOUR CALENDARS!!!! Next quarterly meeting is scheduled for Wednesday, January 16, 2008. The meeting will be a full day, onsite at the AHCA offices.

80. Upcoming EQR activities Validation of PIPs: Submission date for selected PIP forms and documentation is Friday, October 5, 2007 For NHDPs only, collaborative PIP form is due to HSAG by Friday, November 2, 2007

81. Upcoming EQR activities Collaborative PIPs: HMO/PSN conference call is Tuesday, October 16 th at 10:00 a.m. PMHP conference call is Thursday, October 25 th at 11:00 a.m. NHDP conference call is Thursday, October 18 th at 2:00 p.m.

82. Upcoming EQR activities Validation of Performance Measures: Request for documentation for HMOs was sent out on September 10, 2007 Documentation is due to HSAG on Friday, October 19th, 2007 Requested items: HEDIS BAT, ISCAT questions, HEDIS data file, audit report

83. Upcoming EQR activities Focused Study–Behavioral Health Authorizations: Document request will be sent to all participating HMOs, PSNs, and PMHPs Requested documentation will include completion of a questionnaire, policies and procedures, and authorization forms

84. Upcoming EQR activities Questions?

85. External Quality Review Quarterly Meeting THANK YOU FOR YOUR PARTICIPATION!