1. Overview of 2006 Quality Assurance Activities Maryland Department of Health and Mental Hygiene November 30, 2006

2. 2 Overview  2006 Quality review activities: Systems Performance Review Healthy Kids Quality Monitoring Program Enrollee Satisfaction Survey Health Plan Employer Data and Information Set (HEDIS) Value-Based Purchasing Performance Measures Consumer Report Card Performance Improvement Projects

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 2005 SPR consisted of 12 standards including 1 new standard for Fraud and Abuse.  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  The Department rotated one standard for 2005, Outreach Plan, because all of the MCOs had previously met the minimum compliance rate (100%.)  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 Performance Standard Description MCO Aggregate CY 2005 AGMDIAHFCJMSMPCPPMCOUHC 1Systematic Process 100% 2Governing Body 96%*100%80%*100% 95%*100% 3 Oversight of Delegated Entities 84%100%64%*100% 57%*86%* 4Credentialing 99%*100%99%*100%99%* 100% 5Enrollee Rights 99%*100% 96%* 100% 6Availability and Access 100% 7Utilization Review 96%*97%*89%*100%97%*87%*100% 8Continuity of Care 98%*100%88%*100% 9Health Education Plan100% 10Outreach PlanExempt 11Claims Payment100% 12 Fraud and Abuse (Baseline) 74%75%86%100%79%54%43%85%

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. Note: due to a change in the sampling methodology, the minimum compliance rate per component was decreased to 70% and 2005 results are considered baseline.

7. 7 Healthy Kids Audit Results MCO Health & Developmental History Comprehensive Physical Examination Laboratory Tests Immunizations Health Education/ Anticipatory Guidance Composite Score AGM79%93%71%91%82%86% DIA95% 75%92%90%93% HFC84%96%77%91%90%89% JMS93%99%93%94%96% MPC86%96%80%92%88%90% PPMCO85%94%77%92%87%89% UHC81%92%72%92%84%87% Aggregate 85%95%78%92%88%89%

8. 8 Healthy Kids Audit Results

9. 9  DHMH conducts an enrollee satisfaction survey annually using the Consumer Assessment of Health Care Providers and Systems (CAHPS®) survey instruments designed for the Medicaid adult and child managed care population.  DHMH uses a NCQA certified CAHPS vendor, The Myers Group, 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 2006 – The CAHPS survey was mailed to 1350 adults and 3,490 children in each MCO. Sample size is determined by NCQA protocol. – Follow-up phone calls were made to interview members who did not respond by mail.  Response rates varied by MCO ranging from 23% to 34% for adults and 20% to 33% 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 7.9 for children. Enrollee Satisfaction Surveys (continued)

11. 11  The Health Plan Employer Data and Information Set is a standardized set of performance measures developed by NCQA and CMS to measure managed care performance.  Each year NCQA updates the measurement set based on the latest available information.  The Department contracts with an NCQA certified HEDIS auditor, HealthCareData.Com, to audit and report on MCO 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

12. 12 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 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 Access/Availability of Care Children’s Access to Primary Care Practitioners Adults’ Access to Preventive/Ambulatory Health Services Prenatal and Postpartum Care Claims Timeliness Call Answer Timeliness Call Abandonment Health Plan Stability Practitioner Turnover HEDIS Performance Measures  For 2006, MCOs were required to report their performance on 19 HEDIS measures.

13. 13  Overall, the MCOs have made significant improvement in their HEDIS scores over the last 3 years. HEDIS Performance Measures (continued)

14. 14  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 11 measures cover all important dimensions of MCO performance:  Access to Care  Quality of Care  Administration (MCO structure and operations)  7 of the 11 measures are HEDIS measures and the remaining 4 are Maryland specific. Value-Based Purchasing

15. 15  Targets for each measure have been established based on 3 levels of performance:  Below minimum compliance (disincentive)  Neutral  Optimum compliance (incentive)  These target levels are established based on several methodologies:  The latest National Medicaid HEDIS benchmarks for the HEDIS measures  Past performance by HealthChoice MCOs  Regulatory requirements or legislative mandates.  As a result of legislation passed in 2003, any funds available for incentive payments were redirected to fund MedBank. Therefore, any incentives earned by the MCOs could only be used to offset their disincentives. Value-Based Purchasing (continued)

16. 16 Value-Based Purchasing (continued) Performance Measure2005 Target MCO AGMDIAHFCJMSMPCPPMCOUHC Incentive (I); Neutral (N); Disincentive (D) Well-child visits for children ages 3–6 Incentive: >68% Neutral: 61%–68% Disincentive: <61% 79.5% (I) 48.7% (D) 65.9% (N) 84.4% (I) 69.7% (I) 70.3% (I) 69.7% (I) Dental services for children ages 4–20 Incentive: >60% Neutral: 40%–60% Disincentive: <40% 45.4% (N) 29.8% (D) 48.6% (N) 45.2% (N) 45.3% (N) 48.4% (N) 43.5% (N) Ambulatory care services for SSI adults Incentive: >86% Neutral: 72%–86% Disincentive: <72% 75.4% (N) 65.0% (D) 80.8% (N) 83.1% (N) 79.2% (N) 82.2% (N) 77.7% (N) Ambulatory care services for SSI children Incentive: >77% Neutral: 63%–77% Disincentive: <63% 67.9% (N) 47.6% (D) 74.0% (N) 72.7% (N) 71.8% (N) 73.5% (N) 65.6% (N) Timeliness of prenatal care Incentive: >89% Neutral: 72%–89% Disincentive: <72% 94.1% (I) 68.2% (D) 90.3% (I) 82.9% (N) 85.2% (N) 82.5% (N) 89.9% (I) Cervical cancer screening for women ages 21–64 Incentive: >77% Neutral: 47%–77% Disincentive: <47% 68.1% (N) 36.8% (D) 61.1% (N) 71.3% (N) 62.4% (N) 58.4% (N) 57.4% (N) Lead screenings for children ages 12–23 months Incentive: >53% Neutral: 41%–53% Disincentive: <41% 51.1% (N) 38.7% (D) 52.4% (N) 55.9% (I) 52.4% (N) 53.4% (I) 43.7% (N) Eye exams for diabetics Incentive: >64% Neutral: 42%–64% Disincentive: <42% 76.2% (I) 9.7% (D) 66.2% (I) 74.1% (I) 50.1% (N) 52.3% (N) 54.7% (N) Childhood immunization status—Combo 2 Incentive: >68% Neutral: 50%–68% Disincentive: <50% 88.2% (I) NA 74.2% (I) 77.4% (I) 69.8% (I) 79.6% (I) 71.0% (I) Practitioner turnoverN/A6.7%2.4%7.2%9.5%3.7%2.1%8.4% Claims timelinessN/A94.2%97.6%98.6%98.5%95.8%90.4%93.8%

17. 17 Consumer Report Card  This is the fourth 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 2007 Consumer Report Card is currently in the process of being completed. The presentation and the methodology are the same as for the 2006 Report Card.

18. 18 Performance Improvement Projects  Currently have 2 Performance Improvement Projects ongoing that MCOs are required to conduct:  Improve the Delivery of Prenatal/Postpartum Care  Improve Screening for Chronic Kidney Disease  Both projects are 3 years in duration and consist of:  Submission of data collection and analysis plan  Baseline measurement of data  Intervention development and implementation  Re-measurement of data

19. 19 Performance Improvement Projects  For Prenatal/Postpartum: 5 MCOs improved their scores from 2004-2005.  For CKD Measure 1 “HEDIS, Kidney Disease Monitored Rate”: 3 MCOs improved their scores from 2004-2005.  For CKD Measure 2 “Hypertensive members receiving at least one serum creatinine”: 4 MCOs improved their scores from 2004-2005.

20. 20 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”