2006 Annual Technical Report

Transcription

1 An independent external quality review of the Minnesota publicly funded managed care programs in accordance with the Balanced Budget Act of 1997 Presented by MPRO October 2007

2 2006 Annual Technical Report October 2007 Report Preparation: Michigan Peer Review Organization (MPRO) Haggerty Road, Suite 100 Farmington Hills, MI For More Information: Robert J. Lloyd, MBA, CPHQ, Manager Health Program Quality Performance Measurement and Quality Improvement PO Box St. Paul, MN Telephone: Fax: ATR Companion Reports: The following ATR companion reports are available on the DHS Web site: ATR Companion Report: TSOC Results MDH Quality Assurance Examination Documents: DHS Performance Measurement and Quality Improvement Studies and Reports: Additional Report Formats: This information is available in other forms to people with disabilities by contacting us at (voice). TDD users can call the Minnesota Relay at 711 or For the Speech-to-Speech Relay (STS), call This document may be reproduced without restriction. Citation of the source is appreciated.

3 CONTENTS EXECUTIVE SUMMARY...I CHAPTER 1: INTRODUCTION... 1 Purpose and Objectives... 1 DHS/MCO Contract Requirements... 2 EQR Activities That Ensure Quality, Timely Health Care... 3 CHAPTER 2: CHANGES TO QUALITY IMPROVEMENT PROGRAMS... 7 DHS and MDH Combine Reviews to Consolidate Oversight Activities... 7 Public Programs Expansions for Seniors and Disabled... 8 Contract Changes to Support QCare CHAPTER 3: KEY FINDINGS SUMMARY Structural Findings Process Findings Outcomes Findings CHAPTER 4: 2004 ATR RECOMMENDATIONS FOLLOW-UP MCO-specific Recommendations CHAPTER 5: MCO FINANCIAL INCENTIVES AND DISINCENTIVES Incentives and Withholds: Challenges CHAPTER 6: MCO-SPECIFIC ANALYSIS Blue Plus FirstPlan of Minnesota (FirstPlan) HealthPartners (HP) Itasca Medical Care (IMCare) Medica Metropolitan Health Plan (MHP) PrimeWest Health System (PrimeWest) South Country Health Alliance (SCHA) UCare Minnesota (UCare) CHAPTER 7: DISCUSSION AND ADVICE TO DHS What is Working Well What to Consider MPRO s Assessment of 2005 ATR Recommendations CHAPTER 8: MCO COMMENTS... 72

4 FirstPlan Of Minnesota (FirstPlan) HealthPartners (HP) South Country Health Alliance (SCHA) UCare Minnesota (UCare) APPENDICES Appendix A Description of Minnesota Health Care Programs Appendix B Supplemental Compliance Requirements Appendix C 2005 through 2007 MCO Performance Improvement Projects Summary Appendix D Managed Care Performance Measures: Appendix E Managed Care Contract Incentive Rates and Payment Amounts Appendix F Withhold Point Summary (F&C Contracts Only) Appendix G Detailed 2004 ATR Responses from MCOs Appendix H MCO HEDIS Performance to Goals TABLES Table 1: MCO Participation in Publicly Funded Managed Care Programs... 3 Table 2: Mandatory EQR-related Activities for Each Contracted MCO... 4 Table 3: Assignment of EQR Activities into Quality, Access, and Timeliness Components... 6 Table 4: Blue Plus Demonstrates 100% Compliance with All TSOC Audit Standards...13 Table 5: FirstPlan Demonstrates 99.3% Compliance with All TSOC Audit Standards...14 Table 6: PrimeWest Demonstrates 99.2% Compliance with All TSOC Audit Standards...15 Table 7: IMCare s Current Audit Demonstrates 95% Compliance with All Standards...16 Table 8: TSOC Audit Results Summary...17 Table 9: QA Exam or Mid-cycle Exam Review Results Summary for IMCare, HP, and Blue Plus...19 Table 10: Project Titles and Goals for Each Proposed PIP by MCO (or Collaborative)...22 Table 11: MCO Grievances and Appeals by Calendar Year (All Product Lines and All Ages)...22 Table 12: MCO Work Plan and Quality Evaluation Commentary...28 Table 13: 2006 Practice Guideline Report Summaries...30 Table 14: 2006 HEDIS Performance Measures...32 Table 15: CAHPS Survey Rating Results by Program...34 Table 16: Composite Area Survey Communication, Waits, and Courteousness...34 Table 17: Composite Area Survey Health Plan Customer Service and Getting Needed Care...35 Table 18: Key Findings for Plans within Programs...36 Table 19: 2006 Voluntary Enrollment Change Rates by MCO...37 Table 20: Composite Responses by Program...38 Table 21: MCO-specific Recommendations...42 Table 22: Well-Child Performance Measures...49 Table 23: Blue Plus s Strengths and Weaknesses...51

5 Table 24: FirstPlan s Strengths and Weaknesses...53 Table 25: HealthPartners s Strengths and Weaknesses...54 Table 26: IMCare s Strengths and Weaknesses...56 Table 27: Medica s Strengths and Weaknesses...57 Table 28: MHP s Strengths and Weaknesses...58 Table 29: PrimeWest s Strengths and Weaknesses...60 Table 30: SCHA s Strengths and Weaknesses...62 Table 31: UCare s Strengths and Weaknesses...63 Table 32: MCO Incentive Rates Table 33: MCO Incentive Payments Table 34: MCO Contract Point Summary Table 35: MCO HEDIS Performance to Goals by Program (PMAP & MinnesotaCare Only) FIGURES Figure 1: Rate of Grievances and Appeals by MCO, CY-2004 through CY Figure 2: Percentage of MCO Decision Overturned/Member Request Approved, CY-2004 through CY Figure 3: Percentage of MCO Decisions Upheld/Member Request Denied, CY-2004 through CY Figure 4: Total Withhold Points CY-2004 through CY

6 EXECUTIVE SUMMARY Patients, providers, and purchasers of health care share common goals in their desire to receive, provide, and purchase the highest possible quality health care at reasonable prices. As part of its commitment to this goal, the (DHS) purchases medical care coverage through contracts with managed care organizations (MCOs) who receive a fixed, prospective, monthly payment for each enrolled beneficiary. DHS is responsible for evaluating care to enrollees in Minnesota s publicly funded administered MCOs relative to health care quality, timeliness, and accessibility to services. To propel this common goal in the most positive direction, DHS in collaboration with Minnesota s publicly funded MCOs, and Michigan Peer Review Organization (MPRO), an External Quality Review Organization (EQRO) collaborating with DHS, are continuing to dedicate their efforts to maintaining and improving the timeliness of, quality of, and access to health care services for Minnesotans. Minnesota s publicly funded managed care programs include Prepaid Medical Assistance Program (PMAP), Prepaid General Assistance Medical Care (PGAMC), Minnesota Senior Care (MSC/MSC+), MinnesotaCare, and two voluntary managed care demonstrations: Minnesota Senior Health Options (MSHO) and Minnesota Disability Health Option (MnDHO). The DHS/MCO Contract specifies the relationships between purchaser and service providers, which explicitly states compliance requirements for financial, service delivery, and quality-of-care terms and conditions. In keeping with federal requirements, as set forth in the Balanced Budget Act of 1997 (BBA), MPRO conducted a comprehensive review of each of the nine MCOs listed below to assess each organization s performance relative to the quality of health care, timeliness of services, and accessibility to services for enrollees. Blue Plus FirstPlan of Minnesota (FirstPlan) HealthPartners (HP) Itasca Medical Care (IMCare) Medica Metropolitan Health Plan (MHP) PrimeWest Health System (PrimeWest) South Country Health Alliance (SCHA) UCare Minnesota (UCare) This 2006 Annual Technical Report (ATR) is MPRO s assessment of State and federally mandated activities related to the unifying framework: structure, process and outcomes. This framework serves as the foundation on which MPRO has made recommendations to help organizations maintain and improve the timeliness of, quality of, and access to health care services. The assessment consists of an inventory of activities and programs set forth in the DHS/MCO Contract and the BBA. QUALITY IMPROVEMENT PROGRAM CHANGES Minnesota Department of Health (MDH) will include DHS/MCO Contract requirements monitoring in its on-site triennial MDH QA Examination (QA Exam) beginning in Combining the QA Exam with the Triennial Structural and Operational Component (TSOC) Audit is consistent with the State s Quality Strategy to consolidate oversight activities while maintaining the appropriate fiduciary responsibilities needed to ensure compliance with State licensing and federal managed care requirements. In addition, integrating the Executive Summary Page i

7 on-site audit process will support MDH s continuing managed care licensing work witnessed changes in the public programs for seniors and disables enrollees. The Minnesota Senior Health Options (MSHO), a Joint Centers for Medicare and Medicaid Services (CMS) payment demonstration implemented in 1997, received CMS approval to expand the program. The expansion took the program statewide and now includes all nine MCOs. Starting January 1, 2008, the 1915(a) and (c) waiver will expire, and the program status of the MSHO project will end. This change will require all MCOs with contracts to serve the MSHO population and to enroll eligible disabled clients. The change will modify program administration, but it will not affect the MSHO program as it appears to the public. In addition to MSHO program changes, there are changes in the programs for managed care seniors. Minnesota Senior Care (MSC) is a program for enrollees who area eligible for Medicaid and who reside in non-county-based Purchasing (non-cbp) counties. Seniors will remain in the same health plans with the same basic health care services. Statewide expansion of the MSHO care coordination model, approval of MCOs as a Medicare Advantage Special Needs Plans (SNP), and the addition of the Medicare Prescription Drug Program are significant program changes for Minnesota public program seniors and disabled populations. Because of these program changes, the MSHO population increased to approximately 35,000 enrollees. Structural changes enacted in 2006 resulted in three managed care contracts: Families and Children, MSHO, Minnesota Disability Health Options (MnDHO). In support of the new QCare program, DHS incorporated new 2007 DHS/MCO Contract language, sustaining QCare s agenda for public program health care services. DHS made four changes to support QCare s agenda: Require MCOs to adopt, disseminate, and apply clinical practice guidelines consistent with QCare Preventive Care Standards on child and adolescent immunizations, well-child visits, chlamydia screening, and breast and cervical cancer screening. Replace previous performance improvement project (PIP) categories with the four QCare Preventive Care Standards. Future PIPs will be required to address diabetes care, cardiac care prevention, hospital care, or safety topics. Expand the requirement to make available a heart disease management program for public program enrollees. Add QCare financial performance incentives for chlamydia screening, child immunizations, and breast and cervical cancer screening. TSOC AUDITS MPRO performed 2006 TSOC audits for the following MCOs: Blue Plus TSOC Audit demonstrated 100% compliance with all standards. FirstPlan met all the standards with the exception of one utilization management (UM) standard, which received Partially Met for an overall compliance rating of 99.3%. PrimeWest met all the standards except one, Subcontractual Relationships and Delegation, which received a Partially Met for an overall compliance rating of 99.2%. MPRO also re-examined IMCare s compliance with DHS/MCO Contract standards evaluating IMCare s capacity to make its written policies and procedures operational. The 2006 TSOC follow-up results show IMCare at 95% compliance with all standards. Executive Summary Page ii

8 Although IMCare has increased its program structure MPRO advises DHS to continue monitoring until all new policies programs and procedures are fully implemented. IMCare should monitor the capacity of the programs to ensure adequate staffing of IMCare and an increase in enrollee participation. The results of the TSOC Audit results indicate that of the nine MCOs, eight now have overall compliance scores of 91% or higher. SCHA s overall compliance rating is the lowest at 70% 1. MDH QA EXAMINATION AUDITS The MDH QA Exam reviews MCO compliance with Minnesota Managed Care Licensing Statutes in the areas of Quality Program Administration, Internal Complaint and Appeal Program, Availability and Accessibility of health services to its enrollees, and Compliance with Minnesota s utilization review laws. During 2006, MDH conducted QA or Mid-cycle Exams for three MCOs (IMCare, HP, and Blue Plus). The results found IMCare had 11 deficiencies, including one repeat deficiency from the 2004 QA Exam; HP s 2006 QA Exam had 7 deficiencies; and Blue Plus s 2006 Mid-cycle Exam indicated that the organization completed the activities as stated in its corrective action plan (CAP) and is now in compliance with Minnesota rule and law. In addition, Blue Plus had a Targeted Exam in 2006 with a high number of enrollee complaints. This second review identified three grievance and appeal deficiencies. PERFORMANCE IMPROVEMENT PROJECTS (PIP) VALIDATION A PIP measures the impact of interventions or activities toward improving the quality of care and service delivery. DHS evaluates PIP proposals using activities specified in the CMS protocol for validating PIPs. The topics for the new PIPs are varied and cover both clinical and non-clinical subjects, including lipid management, pneumonia vaccines, blood lead testing, cardiovascular risk among diabetics, referral to tobacco cessation programs, breast cancer screening, chlamydia screening, and calcium/vitamin D supplementation. Generally, the MCOs provide status updates on in-progress PIPs in the body of the Quality Evaluation document. However, the level of detail included, and consistency of status references, varies significantly from MCO to MCO. GRIEVANCES AND APPEALS (G&A) ANALYSIS As in previous years, the majority of the G&As focused on professional and medical services and benefits. The MCO with the highest G&A rate was HP and the lowest was FirstPlan. The average rate (3.53%) shows a slight decrease from CY-2005, which was 3.85%. In isolation, it is difficult to make a determination whether each MCO s rate is too high or too low without details on the structure of each organization s utilization management (UM) program. Because of the G&A process, MCOs eventually overturn some decisions. Since CY-2005, the average rate of decisions overturned across all nine MCOs increased from 34% to 40%. As in years past, Blue Plus continues to have the highest decision overturned rate at 67% and a moderately high rate of G&As (5.96%). Given Blue Plus s rate of G&As, the process needs careful re-examination. Conversely, HP has the lowest decision overturned rate at 13% and the highest number of G&As at 8.13%, suggesting that HP s initial 1 Based on the results of the 2005 TSOC Audit. Executive Summary Page iii

9 decision process is functioning well. The average percentage of MCO decisions upheld has fluctuated slightly in the past three years. IMCare has the lowest percentage of MCO decisions upheld at 24%, which is an improvement from the previous year, but still quite low. QUALITY IMPROVEMENT (QI) WORK PLANS AND EVALUATIONS REVIEW An MCO s Quality Evaluation must include a review of the impact and effectiveness of the organization s quality assessment programs and PIPs. The Work Plan lays out a clear plan of QI activities for the upcoming calendar year. Overall, all MCOs realized improvement in the quality of their Quality Evaluations and Work Plans; however, opportunities exist to better connect the two documents and increase development in analysis and operational functionality. PRACTICE GUIDELINE REPORT REVIEW In accordance with DHS/MCO Contract, Section 7.1.5, MCOs must adopt practice guidelines based on clinical evidence, ensure the organization s dissemination to providers, ensure proper application of guidelines to an MCO decision-making process, and annually audit provider compliance with use of the guidelines Overall, all MCOs Practice Guideline Reports are compliant with the DHS/MCO Contract; however, all organizations should include more detail in their reports. HEDIS PERFORMANCE MEASURES CALCULATION (AND VALIDATION) DHS uses performance measures to quantify quality of care and service improvements by focusing on the measurement of process or outcome change. DHS bases these measures on Health Plan Employer Data and Information Set (HEDIS ) specifications, developed and maintained by the National Committee for Quality Assurance (NCQA). DHS contracts directly with MetaStar, an NCQA Certified HEDIS Auditor, to conduct an independent calculation and audit of each MCO s performance measures based on encounter data submitted to DHS. Overall, the results are higher than the 2006 Quality Compass National Medicaid HEDIS Mean for five measures across all programs, most notably the Adults Access to Preventive/Ambulatory Health Services for all ages. Conversely, the results are below the Medicaid HEDIS Mean for six measures across all programs with Childhood Immunizations (Combination 2) having the largest gap between aggregated rates by program and the HEDIS Mean. See Appendix D Managed Care Performance Measures: CONSUMER SATISFACTION SURVEY ADMINISTRATION Consumer satisfaction surveys provide an excellent source of information regarding enrollees perception of quality and provide a predictive means of assessing how enrollees will behave in the future. DataStat, Inc., an NCQA-certified Consumer Assessment of Health Plans Survey (CAHPS ) vendor, under contract with DHS conducted the Managed Care Public Programs Consumer Satisfaction Survey. The survey assesses and compares the satisfaction of enrollees in publicly managed care programs administered by DHS. Executive Summary Page iv

10 On average, respondents rated the composites for Courtesy, Respect, and Helpfulness of Office Staff and Getting the Care That Is Needed, the highest, both at 73%. The composite for Getting Care Without Long Waits received the lowest average rating at 39%. Executive Summary Page v

11 VOLUNTARY CHANGES IN MCO ENROLLMENT SURVEY Statewide voluntary change in MCO enrollment rates remain stable and below the state 5% threshold for both PMAP programs and MinnesotaCare with rates at 1.9% and 1.7%, respectively. These rates remain relatively unchanged from 2005 (PMAP at 0.9%; MinnesotaCare at 1.5%). It is important to review the findings with caution because of the small denominators for some MCOs. For both the PMAP and MinnesotaCare programs, the total number of enrollees who changed MCOs in 2006 was 4,222; however, only 1,562 of enrollees returned surveys for a response rate of 37%. Although the survey questions changed from 2005 to 2006, similar themes continue. Because of the diversity in populations served by each MCO, and that some MCOs have fewer than 50 enrollees who have changed from their organization, comparisons cannot be made between MCOs. In future years, MCOs may choose to use the new survey findings to make an evaluation of their organization s own performance over time. INCENTIVES AND WITHHOLDS To make recommendations on developing a sustainable, comprehensive managed care incentive program, incorporating both incentive (services expansion payments) and disincentive (withhold) strategies, DHS contracted with The Lewin Group, a national health care and human services consulting firm. Based on The Lewin Group s recommendations, DHS established approximately nine withhold performance target measures, including both administrative and clinical measures. DHS assigned points to the performance target measures ranging from 5 points to 20 points per measure for a total of 100 points. One key standard for establishing withholds performance target measures is the development of achievable performance targets that would stretch MCO improvement efforts each year ATR RECOMMENDATIONS FOLLOW-UP MPRO requested that each MCO describe how their organization addressed both general and MCO-specific recommendations in the 2004 ATR. All of the MCOs have addressed each recommendation and have indicated the action taken or plans for future action. These self-reported responses to the recommendations demonstrate that the MCOs have incorporated industry standards into their operations, such as NCQA standards for the utilization program and the CMS ten-step protocol for PIPs. All organizations have examined their CAHPS data for opportunities to improve customer satisfaction; run quality reports and analysis for opportunities to develop programs and interventions for people with various clinical conditions; and increased the rate of preventive service delivery to children and adolescents. MCO S STRENGTHS AND WEAKNESSES EVALUATION Overall, the quality of care for publicly funded programs is comparatively good and continues to improve in many important clinical and service areas. Key indicators of access, including the HEDIS measure Adults Access to Preventive and Ambulatory Health Services, allowed all nine of the MCOs to demonstrate high performance. Two of the MCOs, Medica and Blue Plus, ranked in the top 15 in the entire nation in the quality of their Medicaid services by a major external entity. In another positive effort, MCOs displayed collaborative work toward MSHO program improvement. Weaknesses exist for the upcoming year. Specifically, MCOs should focus on continuing to refine QI Work Plan and Quality Evaluation documents. Although most MCOs made gains improving both the format and content of these documents, important weaknesses remain. MPRO encourages each organization to continue finding ways to add to the document as a QI tool. In addition, the CAHPS results showed a wide variation of satisfaction levels from program to program. For MCOs whose scores ranked significantly lower Executive Summary Page vi

12 than program average, MPRO recommends examining the results closely and determining which key factors contributed to areas of dissatisfaction. The MCOs should be encouraged by MPRO s overall findings. Quality improvement is a continuous focused effort that will lead to positive changes in the health care of all enrollees in Minnesota s publicly funded programs. Through these efforts, by supporting processes and outcomes, and by conducting structured performance improvement projects and performance measures, the MCOs and DHS remain committed to ensuring and improving the quality of, timeliness of, and access to, health care services for Minnesotans. DISCUSSION AND ADVICE TO DHS DHS is in a good position: MCOs are performing at acceptable levels, with only a few areas where MCOs have demonstrated noncompliance. In fact, several MCOs are considered among the best in the country. Most areas identified as weaknesses are opportunities to improve the quality of services, such as enhancements to the Quality Evaluation and Work Plan documents. The goal is to continue to push for delivering effective, timely, patient-centered, and quality health care on behalf of vulnerable publicly funded program populations. To do so, DHS must expect more from its partnership with MCOs, and MCOs must recognize their interdependence on the health care community as a whole. DHS is in an important position to move MCO performance to the next level. MPRO advises DHS put forward efforts to continue refining processes, rewarding MCOs that exceed expectations; building positive, collaborative relationships with MCOs; and looking for new areas to focus improvement efforts to advance this goal. MPRO advises DHS to consider the following actions: Consider a plan to manage conflicting messages MCOs receive from other agencies or review entities, Increase transparency of quality reporting, Evaluate financial incentives and disincentives over time, Consider adopting performance measure goals, Monitor closely MCO progress, addressing 2005 ATR recommendations. Continuing to build the partnership between DHS and its MCOs that will accelerate and sustain progress toward a high-performance, quality health care system for the publicly funded program population will require bold, intentional, and far-reaching changes. This report can serve as the catalyst for such progress. Executive Summary Page vii

13 CHAPTER 1: INTRODUCTION The (DHS) touches the lives of one in four Minnesotans with a variety of services intended to help people live as independently as possible. DHS is the State s largest agency, with an annual budget of nearly $9 billion and approximately 7,200 employees located throughout Minnesota. DHS is responsible for evaluating care to enrollees in Minnesota s publicly funded managed care organizations (MCOs) relative to healthcare quality, timeliness, and accessibility to services. For this reason, DHS purchases medical care coverage through contracts with MCOs who receive a fixed, prospective, monthly payment for each enrolled beneficiary. Minnesota s publicly funded managed care programs include Prepaid Medical Assistance Program (PMAP), Prepaid General Assistance Medical Care (PGAMC), Minnesota Senior Care (MSC), MinnesotaCare, and two voluntary managed care demonstrations: Minnesota Senior Health Options (MSHO) and Minnesota Disability Health Option (MnDHO). The DHS/MCO Contract specifies the relationships between purchaser and service providers, which explicitly states compliance requirements for financial, service delivery, and quality-of-care terms and conditions. To ensure ongoing communication between the purchaser and service providers and to discuss contract issues, DHS and the MCOs meet throughout the year. DHS has contracted with Michigan Peer Review Organization (MPRO) to serve as its External Quality Review Organization (EQRO). As part of this contract, MPRO will assess MCO Quality Improvement (QI) activities and provide recommendations on how these activities can improve the timeliness of, quality of, and access to health care services for enrollees. This report is the result of MPRO s assessment and review activities during PURPOSE AND OBJECTIVES The purpose of the 2006 Annual Technical Report (ATR) is to Discuss the results of the quality assessments performed in accordance with the Balanced Budget Act (BBA) of 1997 [Subpart E, 42 Code of Federal Regulations (CFR), Section ]; Review the strengths and weaknesses of each contracted MCO; Provide recommendations for performance improvement; Establish a foundation upon which to enhance the State s quality-of-care services provided to publicly funded programs; and Provide technical assistance to MCOs as described in Article 7 of the DHS/MCO Contract. The objective of this report is to provide comprehensive insight into the performance of the State s nine managed care organizations on key indicators of health care quality for publicly funded program enrollees. Chapter 1, Introduction, provides general information about the DHS, ATR purpose and objectives, explanation of the DHS/MCO Contract requirements, details on the organization of the report, and explanations of the concepts and resources used to evaluate MCO activities. Chapter 2, Changes to Quality Improvement Programs, focuses on key changes to the Triennial Structural Operations Components (TSOC) Audit and MDH Quality Assurance (QA) Examination (QA Exam) review processes as these activities align with the State s Quality Strategy to consolidate oversight activities. The chapter examines program administration and structural changes to the Minnesota Senior Health Options (MSHO) as well as Contract changes in support of QCare program. Chapter 1: Introduction Page 1

14 Chapter 3, Key Findings Summary, considers the key concepts of Continuous Quality Improvement (CQI): structure, process, and outcomes, serving as the underpinning for Michigan Peer Review Organization s (MPRO s) entire report. Key findings examined for each MCO include TSOC Audits and Minnesota Department of Health (MDH) QA Examination audits (structure); PIP proposals, grievances and appeals, Quality Evaluations and QI Work Plans, and Practice Guideline Report (process); and Health Plan Employer Data and Information Set (HEDIS ) Performance Measures, Managed Care Public Programs Consumer Satisfaction Survey, and voluntary enrollment changes (outcomes). Chapter 4, 2004 ATR Recommendations, details 2004 follow-up recommendations regarding effectiveness to which each MCO addressed the recommendations for quality improvement made by the EQRO. Chapter 5, MCO Financial Incentives and Disincentives, provides a discussion of MCO financial incentives and disincentives to encourage MCOs to achieve the goals set for care delivery and outcomes. Chapter 6, MCO-specific Analysis, highlights each of the nine MCOs strengths and weaknesses, provides MPRO-recommended activities to help the MCOs focus their quality improvement efforts. These recommendations allow MCOs to align their organization s efforts with industry standards as well as benefit from the experience of other MCOs program and strategy efforts. The chapter discusses how integration of these recommendations contributes to improving the quality of health care services furnished by each MCO. Chapter 7, Discussion and Advice to DHS, provides commentary and advice regarding the structure of DHS programs and the requirements MCOs must meet based on each MCO s Contract agreement with DHS. This chapter examines those DHS efforts that are working well, offers considerations for future enhancement to programs, and outlines MCO progress made addressing MPRO s recommendations from the 2005 ATR. Chapter 8, MCO Comments, provides remarks from each responding MCO about the Annual Technical Report prior to its publication. DHS/MCO CONTRACT REQUIREMENTS DHS contracts with nine entities. The Minnesota Department of Health licensed six of the entities as MCOs (Blue Plus, FirstPlan of Minnesota, HealthPartners, Medica, Metropolitan Health Plan, and UCare Minnesota). The remaining three entities (Itasca Medical Care, PrimeWest Health System, and South Country Health Alliance) have licensure as County-based Purchasing (CBP) organizations. This report refers to all nine entities as MCOs. Through its Contract with each MCO, DHS requires the MCOs to provide a wide range of administrative management services and to develop and subcontract with health care providers to deliver services. The Contract also requires MCOs to work with their providers to improve quality of care to enrollees. DHS oversees and monitors compliance with these activities through the submission of various MCO reports on a broad range of Contract issues to ensure health care services are meeting enrollee needs. Additionally, MPRO uses the reports to review the impact and effectiveness of MCO contractual compliance as well as assess each organization s strengths and weaknesses. Each MCO must agree to comply with DHS/MCO Contract requirements and supply health benefits as specified in the Contract. The following table lists the MCOs included in this report and each organization s participation in publicly funded managed care programs. Chapter 1: Introduction Page 2

15 An asterisk (*) indicates the month and year that the MCO began registering enrollees in the designated program(s). See Appendix A Description of Minnesota Health Care Programs. MCO Abbreviation PMAP Minnesota Care Blue Plus Blue Plus (9/05) * FirstPlan of Minnesota FirstPlan (7/05)* HealthPartners HP (9/05) * MSHO PGAMC MnDHO MSC Itasca Medical Care IMCare Medica Medica Metropolitan Health Plan MHP PrimeWest Health System South Country Health Alliance PrimeWest (7/03) * (10/05) * (8/05) * SCHA (12/05) * UCare Minnesota UCare Table 1: MCO Participation in Publicly Funded Managed Care Programs EQR ACTIVITIES THAT ENSURE QUALITY, TIMELY HEALTH CARE In accordance with the BBA, MPRO conducts external quality review (EQR) activities for DHS to ensure enrollees receive quality and timely health care from MCOs. EQR is the analysis and evaluation of aggregated information on the timeliness of, quality of, and access to the healthcare services that a health plan provides to enrollees. As an EQRO, MPRO meets certain competency and independence requirements. Chapter 1: Introduction Page 3

16 Each year, DHS (or the EQRO) must perform three mandatory BBA (Section ) EQR-related activities for each contracted MCO. The following table describes these required activities. Mandatory EQR Activity Validate performance measures Validate performance improvement projects (PIPs) Conduct a review of the MCO s compliance with federal and State standards established by DHS Description DHS contracts with MetaStar, a certified HEDIS vendor, to fulfill the requirements of the Center for Medicare and Medicaid Services s (CMS s) EQRO Protocol, Validation of Performance Measures, including the Information Systems Capabilities Assessment Tool. The audit and validation assess the extent to which DHS s information system meets the requirements set forth in the BBA. The system s ability to collect, analyze, integrate, and report data is central to meeting this requirement and ensuring accurate performance measure reporting. The assessment includes extensive examinations of DHS s ability to monitor these data for accuracy and completeness. DHS validates that each MCO develops their proposed PIP in a manner consistent with CMS protocol, Conducting Performance Improvement Projects. MCOs must design their projects to achieve significant improvement sustainable over time. DHS uses TSOC Audits to determine whether MCOs meet access to care, structure and operations, and quality measurement and improvement requirements. 2 Table 2: Mandatory EQR-related Activities for Each Contracted MCO In addition to required EQR-related activities, the BBA also requires an EQRO to produce a detailed annual technical report each year that describes the method by which data from the mandatory and optional activities are aggregated, analyzed, and conclusions drawn. This 2006 ATR details MPRO, DHS, and MDH 2006 quality evaluation activities performed, including TSOC Audits; MDH QA Examination Audits; Performance Improvement Projects Validation; Grievances and Appeals Analysis; Quality Improvement Work Plans and Evaluations Review; Practice Guideline Report Review; HEDIS Performance Measures Calculation (and Validation); Consumer Satisfaction Survey Administration; and Voluntary Enrollment Changes Survey Administration CFR (g). Chapter 1: Introduction Page 4

17 MCO s Strengths and Weaknesses Evaluation MCOs must comply with federal and state requirements with the goal of ensuring that enrollees receive quality and timely health care. Understanding the strengths and weaknesses of each MCO helps to assess an organization s readiness to take on new tasks, identify initiatives that match an MCO s skills, and recognize areas where additional training or resources are necessary. Through development and implementation of clear and detailed plans specifically designed for change, an organization s weaknesses can evolve into strengths. MPRO s mission, in part, is to identify the strengths and weaknesses of each MCO, make recommendations for an organization s improvement, and supply the MCOs with the technical assistance necessary to achieve success. MPRO references both current and past performance, trends, benchmarks and comparisons, along with specific goals or targets of DHS to determine each MCO s strengths and weaknesses. Based on this evaluation, MPRO presents DHS with a high-level commentary on the direction of each of the MCO s quality improvement (QI) programs and advice on how to facilitate positive change and further improve the care and services provided to enrollees of DHS s publicly funded programs. STRENGTHS: An MCO s strengths are valuable resources and capabilities that it has developed or acquired over time and are seen as a distinguishing characteristic. MPRO identifies an organization s resource or capability as a strength when that organization consistently performs beyond requirements, exceeding both DHS and enrollees expectation of quality care and service (e.g., performance measure results above the 90 th percentile). Meeting one individual requirement is not considered a strength. Only when an MCO achieves consistent, high performance over several years or measurement periods, or across multiple indicators, is that organization s capability considered a strength. MPRO also bases its assessment of an organization s strengths on improvements over time. WEAKNESSES: An MCO s weaknesses are those resources or capabilities of an organization that are deficient and viewed as a shortcoming of its ability or performance. MPRO identifies an organization s resource or capability as a weakness when that organization is not compliant with the DHS/MCO Contract, federal regulations, or performs substantially below both DHS and enrollees expectations of quality care and service. Examples include MCO consumer satisfaction scores below the aggregate MCO average or deficiencies on MDH QA Examinations. MPRO uses information on the assessment of each of the MCO s strengths and weaknesses to make a statement of quality, access, and timeliness. Components of Care: Quality, Access, and Timeliness MPRO used 2006 EQR activities to formulate combined measures of the three components of care: Quality, Access, and Timeliness. To create a qualitative statement about the assessments contained within this report, MPRO defines quality, access, and timeliness components as follows: Quality is the extent to which an MCO increases the likelihood of desired health outcomes for enrollees through its structural and operational characteristics and through health care services provided, which are consistent with current professional knowledge. Access is the opportunity or right to receive health care. Access encompasses measures that address an enrollee s experience before care is delivered. Access to care affects an enrollee s experience and outcomes. Timeliness is the extent to which care and services are provided within the periods required in the DHS/MCO Contract and federal regulations. Timely Chapter 1: Introduction Page 5

18 interventions improve the quality of care and services provided as well as enrollee and practitioner satisfaction. Timeliness, a subset of access, refers to the time frame in which an enrollee obtains needed care. Timeliness of care is influenced by access to services, which can affect utilization of care, including appropriate care and over- or under-utilization of health care services. The following table represents how each EQR activity that MPRO, DHS, or MDH conducted in 2006 contributed to the analysis of each MCO s quality, access, and timeliness of care. MPRO used the results of these review activities to organize the discussion of MCO-specific strengths and weaknesses detailed in Chapter 6: MCO-specific Analysis. Review Activity Report Dimension Quality Access Timeliness TSOC Audit MDH QA Examination Audits Performance Improvement Projects Validation Grievances and Appeals Analysis Quality Improvement Work Plans and Evaluations Practice Guideline Report Review HEDIS Performance Measures Calculation (and Validation) 1. Adolescent Well-Care Visits 2. Adults Access to Preventive/ Ambulatory Health Services 3. Antidepressant Medication Management 4. Breast Cancer Screening 5. Cervical Cancer Screening 6. Childhood Immunizations 7. Children and Adolescents Access to Primary Care Practitioners 8. Chlamydia Screening in Women 9. Comprehensive Diabetes Care 10. Use of Appropriate Medications for People with Asthma 11. Well-Child Visits in the 1 st 15 Months of Life 12. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life Consumer Satisfaction Survey (CAHPS) Voluntary Enrollment Changes Survey Table 3: Assignment of EQR Activities into Quality, Access, and Timeliness Components Chapter 1: Introduction Page 6

19 CHAPTER 2: CHANGES TO QUALITY IMPROVEMENT PROGRAMS This chapter focuses on key changes to the Triennial Structural Operations Components (TSOC) Audit and MDH Quality Assurance Examination (QA Exam) review processes as these activities align with the State s Quality Strategy to consolidate oversight activities. The chapter also examines program administration and structural changes to the Minnesota Senior Health Options (MSHO) program as well as DHS/MCO Contract changes in support of the QCare program. DHS AND MDH COMBINE REVIEWS TO CONSOLIDATE OVERSIGHT ACTIVITIES The TSOC Audit is similar to an accreditation review: it is an in-depth process consisting of both a desk review of written materials and an on-site evaluation and interview of managed care organization (MCO) staff. MPRO reviews an MCO once every three years. By the end of 2006, MPRO completed the three-year rotation of TSOC audits for all nine MCOs. Recognizing the MCOs primary concern that the TSOC Audit process requires a significant number of additional staff resources and time to perform the audit, DHS collaborated with the Minnesota Department of Health (MDH) to combine the reviews of the two agencies. Beginning in 2007, MDH will include DHS supplemental compliance requirements monitoring in its on-site triennial MDH QA Examination. Combining the QA Exam with the TSOC Audit is consistent with the State s Quality Strategy to consolidate oversight activities while maintaining the appropriate fiduciary responsibilities needed to ensure compliance with State licensing and federal managed care requirements. In addition, integrating the on-site audit process will support MDH s continuing managed care licensing work. While on-site, beginning with the 2007 MDH QA Exam of South Country Health Alliance (SCHA), MDH will validate compliance with the following 13 DHS supplemental compliance requirements. MDH will produce a written report for DHS, summarizing its on-site audit findings. After DHS reviews the report findings, DHS will take corrective action if the MCO is deemed noncompliant. DHS Supplemental Compliance Requirements Listed below are the areas that MDH will gather compliance information and include in the DHS Triennial Compliance Assessment. Other areas may be added, or listed areas may be modified upon mutual agreement. See Appendix B Supplemental Compliance Requirements for full details of each of the supplemental compliance requirements listed below. 1. Coverage of Services Contract Sections Medical Necessity and Service Authorization and Utilization Review 3, 4 2. MCO Network Maintenance and Monitoring Contract Section 6.20 Geographic Accessibility of Providers 5, 6 3. QI Program Structure Contract Section Scope and Standards. 3 MSC contract section 6.5 and , MnDHO contract section and CFR (a and b) 5 MSC Contract section CFR (b)(1) Chapter 2: Changes to Quality Improvement Programs Page 7

20 4. Utilization Management Contract Section Utilization Management 5. Special Health Care Needs Contract Section (A-C) Special Health Care Needs. 7, 8 6. Practice Guidelines Contract Section Practice Guidelines 9 7. Credentialing/Recredentialing Contract Section Credentialing and Recredentialing Process. 8. Annual Evaluation Contract Sections Annual Quality Assessment and Performance Improvement Program Evaluation10, 11, 12, Performance Improvement Projects Contract Section Performance Improvement Project Interim Progress Assessment Disease Management Contract Section Disease Management Program Denial, Termination, or Reduction (DTR) Notice of Action to Enrollees Contract Section 8.2. Denial, Termination, or Reduction (DTR) Notice of Action to Enrollees. 12. Grievances and Appeals Contract Section 8.3. MCO Internal Grievance Process Requirements: 13. Advance Directives Contract Section 17. Advance Directives Compliance 16 PUBLIC PROGRAMS EXPANSIONS FOR SENIORS AND DISABLED The Minnesota Senior Health Options (MSHO) 17 is a health care program that combines separate programs and support systems into one package. MSHO offers all medically necessary Medicare Advantage (MA), State Plan and Medicare services including prescription drugs covered by the Medicare Prescription Drug Program (Part D), Elderly Waiver (EW) services, any alternative services the MCO may choose to offer, and the first 180 days of nursing facility care. Presently, DHS [and Center for Medicare and Medicaid Services (CMS)] considers MSHO MCOs as Medicare Advantage Plans. Medicare Advantage Plans are a continuation of the Medicare Plus Choice plan, 7 42 CFR (c)(1-4) 8 MSC contract section B - Care Transition Plan CFR CFR (e) 11 MSC Contract section also includes the requirement that the MCO must include the Quality Framework for the Elderly in its Annual Evaluation. 12 MnDHO Contract section Beginning July 2007, MDH will assess the MCO s annual Work Plan compliance with NCQA QI 1, element A, CFR (d)(2) 15 MSC Contract section is MSC contract only requires a diabetes disease management program C.F.R Pursuant to 42 U.S.C. 1396a(a)(57) and (58) and 42 C.F.R A joint Center for Medicare and Medicaid Services (CMS)/Minnesota payment demonstration implemented in Chapter 2: Changes to Quality Improvement Programs Page 8

21 created by the BBA, which gives Medicare enrollees the option to enroll in a managed care organization. In 2006, MSHO received CMS approval to expand the program. The program was originally located in seven metropolitan and three rural counties served by three MCOs. The expansion took the program statewide and now includes all nine MCOs. CMS also designates some Medicare Advantage Plans as Special Needs Plans (SNPs). SNP MCOs provide focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions. This designation allows MCOs to serve specific populations, such as MSHO clients eligible for both Medicare and Medicaid, referred to as dual eligibles. All nine MCOs serving MSHO enrollees also have SNP designation as of January Program Administration Changes Starting January 1, 2008, the 1915(a) and (c) waiver 19 will expire, and the program status of the MSHO project will end. This change will require all MCOs with contracts to serve the MSHO population to enroll eligible disabled clients. The change will modify program administration, but it will not affect the MSHO program as it appears to the public. MCOs will continue to contract with the State for the provision of Medicaid services; however, MCOs will contract directly with CMS for Medicare services. Managed Care Senior Program Changes In addition to MSHO program changes, there are changes in the programs for managed care seniors. The federal authority, under which Minnesota delivers basic State Plan managed care services for seniors, is no longer part of the State s Prepaid Medical Assistance Program (PMAP) waiver. Authority to provide services is now in a new 1915(b) waiver for basic care that includes only seniors. Minnesota Senior Care (MSC) is a program for enrollees who are eligible for Medicaid and who reside in non-county-based Purchasing (non-cbp) counties. Seniors will remain in the same health plans with the same basic health care services. New state legislation in 2003 required the addition of EW services and 180 days of nursing home care for non-msho seniors. The program, known as Minnesota Senior Care Plus (MSC+), began in June Currently, MSC+ is in 20 CBP counties served by Itasca Medical Care, PrimeWest Health Systems, and South Country Health Alliance. The development of MSHO/SNP and MSC+ programs resulted in important federal and state changes 20 in public programs for senior enrollees: statewide expansion of the MSHO care coordination model, approval of MCOs as a Medicare Advantage Special Needs Plans, and the addition of the Medicare Prescription Drug Program are significant program changes for Minnesota public program seniors and disabled populations. Because of these program changes, the MSHO population increased to approximately 35,000 enrollees. 18 In 1990, Minnesota began working with providers on a model that integrates Medicare and Medicaid funding, including acute and long-term care financing and services for elderly dual eligibles. CMS granted a final waiver extension in 2004 through 2007 to expand MSHO statewide with implementation starting January Until May 2000, CMS Section 1115 provided authority for Medicaid services. However, since MSHO enrollment is voluntary, CMS and the State agreed in 2000 to replace the Section 1115 waiver with a combination of Section 1915(a) waiver for State Plan services and Section 1915(c) waiver for home and community-based services. 20 As of January 2007 these program changes resulted in approximately 10,000 seniors enrolled in MSC/MSC+. Chapter 2: Changes to Quality Improvement Programs Page 9

22 New Managed Care Contracts Structural changes enacted in 2006 resulted in three managed care contracts Families and Children Contract, provides Prepaid Medical Assistance (PMAP), Prepaid General Assistance Medical Care (PGAMC), and MinnesotaCare services for children and adults under age 65; MSHO Contract, provides MSHO, MSC, and MSC+ services for adults over age 65 and, beginning in 2008, enrollees with disabilities; and Minnesota Disability Health Options (MnDHO) Contract, provides services to those enrollees with physical disabilities. CONTRACT CHANGES TO SUPPORT QCARE On July 31, 2006, the governor of Minnesota announced a new program designed to transform the State s health care system. The program, called Quality Care (QCare), aims to set a quality standard for care in four areas: diabetes, hospital stays, preventive care for adults and children, and cardiac care. QCare identifies quality measures, sets aggressive targets for health care providers, makes measures available online to the public, and changes the payment system to reward quality rather than quantity. In support of this program, DHS incorporated new 2007 DHS/MCO Contract language, sustaining QCare s agenda for public program health care services. 21 DHS made four changes to support QCare s agenda: Require MCOs to adopt, disseminate, and apply clinical practice guidelines consistent with QCare Preventive Care Standards on child and adolescent immunizations, well-child visits, chlamydia screening, and breast and cervical cancer screening. Replace previous performance improvement project (PIP) categories with the four QCare Preventive Care Standards. Future PIPs will be required to address diabetes care, cardiac care prevention, hospital care, or safety topics. Expand the requirement to make available a heart disease management program for public program enrollees. Add QCare financial performance incentives for chlamydia screening, child immunizations, and breast and cervical cancer screening. In addition, DHS, in collaboration with Minnesota Community Measurement and Smart Buy Alliance, is developing a diabetes pay-for-performance rewards program that recognizes outstanding quality health care. The QCare initiative will transform the way the State purchases health care by shifting the focus from cost to quality. The plan to report QCare outcomes publicly will be a powerful motivator to improve provider behavior and give enrollees information so that they can make more informed health care needs decisions. 21 Article 7, Quality Assessment and Performance Improvement. Chapter 2: Changes to Quality Improvement Programs Page 10

23 CHAPTER 3: KEY FINDINGS SUMMARY More and more, health care entities and their governance are required by payers to implement evidence-based health care programs and applications; for this reason, Michigan Peer Review Organization (MPRO) integrates quality concepts into the assessment of managed care organization (MCO) performance. Generally accepted concepts of Continuous Quality Improvement (CQI) in health care are based on a triad: structure, process, and outcomes. 22 The structure-process-outcome concept has long served as a unifying framework for examining health services and assessing patient outcomes. 23 The first element of this framework, structure, measures and assesses the capacity to provide care, rather than the actual delivery of care. This is based on an evaluation of resources, organizational arrangements, operations, and policies and procedures in place to safeguard the quality of care. Second, process, is the treatment or service being provided to the patient. Process of care measures address what is done to and for the patient most recognizably taking the form of performance improvement projects. The third important element, outcomes, is the result of the services rendered. Outcome measures assess how effectively a health care system maintains and improves the health and well-being both of individual patients and of overall populations. 24 The most common outcomes indicators are those that measure clinical quality performance and consumer satisfaction. Proper alignment of structure, process, and outcomes can clearly demonstrate how well the care and services rendered to the publicly funded managed care programs enrollees relate to improved quality, access, and timeliness. This chapter examines key findings for each MCO related to Structure: Triennial Structural and Operational Component (TSOC) Audits and MDH Quality Assurance Examinations (QA Exams) review; Process: Performance improvement project (PIP) validations, grievances and appeals, Quality Improvement (QI) Work Plans and Quality Evaluations, and Practice Guideline Reports; and Outcomes: Health Plan Employer Data and Information Set (HEDIS ) performance measures, the Managed Care Public Programs Consumer Satisfaction Survey, and voluntary enrollment changes. 22 Donabedian A. An Introduction to Quality Assurance in Health Care. New York: Oxford University Press, Baker DP, Gustafson S, Beaubien J, Salas E, Barach P. Medical teamwork and patient safety: the evidence-based relation. Literature Review. Rockville, MD: Agency for Healthcare Research and Quality; April AHRQ Publication No Centers for Medicare and Medicaid Services and National Committee for Quality Assurance. Health Care Quality Improvement Studies in Managed Care Settings: Design and Assessment A Guide for State Medicaid Agencies. Washington, DC: CMS and NCQA; Chapter 3: Key Findings Summary Page 11

24 STRUCTURAL FINDINGS Structure is the physical and organizational properties of settings in which an organization provides care. 25 Structure of care refers to the rules, regulations, policies, and goals an organization develops and carries out to govern how it provides the care or service. 26 The structures do not ensure appropriate care, but they do provide the necessary foundational elements to support processes and outcomes. TSOC Audits The BBA requires a review, conducted within a three-year period, to determine MCO compliance with standards established by the (DHS). To facilitate this monitoring process, MPRO developed the TSOC Audit procedures and guidelines. There are two main components to the TSOC Audit: a desk review of documents submitted by the MCO and DHS to MPRO and on-site MCO staff interviews. The desk review consists of an examination of existing policies, procedures, enrollee materials, Work Plans, reports, and other documents developed by the MCO to meet State and federal regulatory requirements. Additionally, MPRO reviews the findings from the most recent MDH QA Exam report, Centers for Medicare and Medicaid Services (CMS) Medicare Review report (if applicable), and available National Committee for Quality Assurance (NCQA) accreditation reports. Upon completion of each desk review, MPRO sends its findings to the MCO accompanied by a request that the organization provide select additional documents on-site because either the MCO did not include the document for the desk review or additional clarification or discussion is necessary. During the on-site visit, MPRO conducts interviews with key MCO staff. These interviews focus on clarifying information obtained during the desk review and gathering additional information to validate written materials compliance. Over the past three years, MPRO has conducted TSOC Audits of all nine MCOs, reviewing at least three organizations per year. MCOs submit corrective action plans (CAPs) to resolve any elements that do not meet or only partially meet the standards. During the 2006 review year, MPRO conducted TSOC Audits for Blue Plus, FirstPlan of Minnesota (FirstPlan), and PrimeWest Health System (PrimeWest), as well as a follow-up audit of Itasca Medical Care (IMCare). The following summarizes MPRO s TSOC Audit findings for these MCOs as well as providing 2005 followup and recommendations for IMCare. See 2006 Annual Technical Report Companion Report: 2006 Triennial Structural and Operational Component (TSOC) Audits for more detailed findings. 25 Donabedian A. Explorations in quality assessment and monitoring: the definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press; Medicare+Choice Quality Review Organizations for the Centers for Medicare & Medicaid Services (CMS). Quality Assessment and Performance Improvement (QAPI) Project Completion Report Instructional Guide. Revised: November Chapter 3: Key Findings Summary Page 12

25 BLUE PLUS Blue Plus demonstrates 100% compliance with all TSOC Audit standards. The following table summarizes Blue Plus s audit results. Review Category Met Partial Not Met N/A Utilization Review and Over- and Under-Utilization of Services Health Information Systems Quality Assessment and Performance Improvement Program Persons with Special Health Care Needs Clinical Practice Guidelines Disease Management Program Care Management and Care Coordination Access and Availability of Care and Services Emergency Room Services and Post-Stabilization Care Confidentiality Advanced Directives Subcontractual Relationships and Delegation Delta Dental Prime Therapeutics Public Health & Human Services Cultural Considerations Credentialing and Re-Credentialing Appendix A Care Management and Care Coordination MSHO Appendix B Persons with Special Health Care Needs MSHO FIRSTPLAN Total Compliance Percentage 100% Table 4: Blue Plus Demonstrates 100% Compliance with All TSOC Audit Standards FirstPlan demonstrates 99.3% compliance with TSOC Audit standards. FirstPlan s audit took place on November 30, FirstPlan meets all the standards with the exception of one utilization management (UM) standard, which received Partially Met. To be in full compliance, MPRO recommends that FirstPlan update the Non-formulary Request Guidelines policy to include time frames. The following table summarizes FirstPlan s audit results. Review Category Met Partial Not Met N/A Utilization Review and Over- and Under-Utilization of Services Health Information Systems Quality Assessment and Performance Improvement Program Chapter 3: Key Findings Summary Page 13

26 Review Category Met Partial Not Met N/A Persons with Special Health Care Needs Clinical Practice Guidelines Disease Management Program Care Management and Care Coordination Access and Availability of Care and Services Emergency Room Services and Post-Stabilization Care Confidentiality Advanced Directives Subcontractual Relationships and Delegation Delta Dental BCBS of Minnesota Prime Therapeutics Cultural Considerations Credentialing and Re-Credentialing Appendix A Care Management and Care Coordination MSHO Appendix B Persons with Special Health Care Needs MSHO PRIMEWEST Total Compliance Percentage 99.3% Table 5: FirstPlan Demonstrates 99.3% Compliance with All TSOC Audit Standards PrimeWest meets all the standards except one: Subcontractual Relationships and Delegation, which received a Partially Met for an overall compliance rating of 99.2%. The DHS/MCO Contract states that by January 15 of each year, an MCO must submit to the State an annual schedule identifying subcontractors, delegated functions and responsibilities, and the organization s performance review date. PrimeWest submitted this report to DHS on January 31. The following table summarizes PrimeWest s audit results. Review Category Met Partial Not Met N/A Utilization Review and Over- and Under-Utilization of Services Health Information Systems Quality Assessment and Performance Improvement Program Persons with Special Health Care Needs Clinical Practice Guidelines Disease Management Program Care Management and Care Coordination Access and Availability of Care and Services Emergency Room Services and Post-Stabilization Care Chapter 3: Key Findings Summary Page 14

27 Review Category Met Partial Not Met N/A Confidentiality Advanced Directives Subcontractual Relationships and Delegation Metropolitan Health Plan Cultural Considerations Credentialing and Re-Credentialing Appendix A Care Management and Care Coordination MSHO Appendix B Persons with Special Health Care Needs MSHO Total Compliance Percentage 99.2% Table 6: PrimeWest Demonstrates 99.2% Compliance with All TSOC Audit Standards ITASCA MEDICAL CARE (IMCARE) FOLLOW-UP During the 2005 audit, IMCare met only 45% of the DHS/MCO Contract standards. The organization did not meet 50% of the standards, and Partially Met the remaining 5%. IMCare submitted a CAP to DHS, and in November 2006, MPRO conducted a follow-up review of IMCare. For the 2006 review, MPRO re-examined IMCare s compliance with DHS/MCO Contract standards. MPRO evaluated IMCare s capacity to make its written policies and procedures operational. The 2006 re-audit shows IMCare at 95% compliance with all standards. The following table summarizes IMCare s current audit results. Review Category Met Partial Not Met N/A Utilization Review and Over- and Under-Utilization of Services Health Information Systems Quality Assessment and Performance Improvement Program Persons with Special Health Care Needs Clinical Practice Guidelines Disease Management Program Care Management and Care Coordination Access and Availability of Care and Services Emergency Room Services and Post-Stabilization Care Confidentiality Advanced Directives Subcontractual Relationships and Delegation Caremark DST Cultural Considerations Chapter 3: Key Findings Summary Page 15

28 Review Category Met Partial Not Met N/A Credentialing and Re-Credentialing Total Compliance Percentage 95% Table 7: IMCare s Current Audit Demonstrates 95% Compliance with All Standards Following the review of the TSOC standards, MPRO conducted an additional assessment of IMCare s QAPI program to evaluate if IMCare had the capacity to implement the new standards and determine if IMCare is able to put into operation what the organization indicates in its policies and procedures. MPRO assessed the capacity and functionality of each of the six key QAPI program components: utilization management, mental health services, quality management, disease management, and care management and care coordination. MPRO conducted the assessment using a question-and-answer format between MPRO and IMCare s key staff. RECOMMENDATIONS TO IMCARE IMCare has made significant improvement in compliance with the requirements of the TSOC Audits from 2005 to IMCare has developed structure in its programs; however, MPRO advises DHS to continue monitoring IMCare s capacity and functionality until IMCare fully implements all new policies programs and procedures. IMCare should also monitor staffing levels and increase enrollee participation in key programs TSOC Audit Results Each year, MPRO reviews three MCOs as part of the TSOC Audit cycle. The following table summarizes the results from the six MCOs [HealthPartners (HP), Metropolitan Health Plan (MHP), UCare Minnesota (UCare), Medica, Itasca Medical Care (IMCare), and South Country Health Alliance (SCHA)] reviewed during the 2004 and 2005 TSOC Audits. These audit results provide a comprehensive picture of the performance of all nine MCOs. An asterisk (*) indicates those review requirements Not Met or Partially Met. Chapter 3: Key Findings Summary Page 16

29 Review Category Utilization Review and Over- and Under- Utilization of Services Health Information Systems Quality Assessment and Performance Improvement Program Persons with Special Health Care Needs Clinical Practice Guidelines Disease Management Program Care Management and Care Coordination Access and Availability of Care and Services Emergency Room Services and Post- Stabilization Care Met HP MHP UCare IMCare Medica SCHA Not Met* Met Not Met* Met Not Met* Met Not Met* Met Not Met* Confidentiality Advanced Directives Subcontractual Relationships and Delegation (summary) Cultural Considerations Credentialing and Re- Credentialing Compliance Percentage Total % 94% 91% 45% 98% 70% Met Not Met* Table 8: TSOC Audit Results Summary Of the nine MCOs, eight now have overall compliance scores of 91% or higher. SCHA s overall compliance rating is the lowest at 70%. Although initially IMCare had the lowest score of 45% in 2005, the organization s 2006 follow-up audit resulted in a 95% compliance rating. Chapter 3: Key Findings Summary Page 17

30 The primary area of concern for five of the nine MCOs (MHP, SCHA, UCare, IMCare, and FirstPlan) is the Utilization Review and Over- and Under-Utilization of Services category. Of those five MCOs, there was no common requirement between the MCOs that was consistently noncompliant. The other four MCOs (Medica, HP, PrimeWest, and Blue Plus) had 100% compliance for this review category. MDH QA Examination The DHS/MCO Contract requires that MCOs remain in compliance with State MCO licensing regulations. To assess each MCO s compliance with Minnesota Managed Care Licensing Statutes, 27 MDH QA Exams include an evaluation of each MCO in the following areas: Quality Program Administration, including its quality assurance plan, work plan, quality studies and activities, organization and staffing, credentialing program, medical records management, delegated activities and quality of care complaints; Internal Complaint and Appeal Program, including checking systems and conducting quality of care examinations on a scheduled basis to assess the quality and processes, including its record keeping system for complaints and appeals; Availability and Accessibility of health services to enrollees, including the geographic location of providers, appointment scheduling, coordination of care activities, referrals, timely access to health services, access to emergency care, continuity of care, direct access to obstetrical and gynecological (OB/GYN) services, and equal access to chiropractic services; and Compliance with Minnesota's utilization review laws, including MCO standards, staffing, procedures, and qualifications of reviewers. If MDH reviewers discover regulatory deficiencies, the MCO must write a CAP, and a MDH Mid-cycle QA Examination must be conducted to ensure that the MCO corrects the identified deficiencies. 28 The DHS/MCO Contract, Section 4.5.1(E) Managed Care Withhold, requires MCOs to comply with the MDH licensing requirements and have no repeat deficiencies on the next QA Exam. If the MCO fails to correct previous deficiencies, DHS financial consequences could result, such as the loss of one percent of the organization s capitation payments Minnesota Statutes Chapter 62D, 62M, 62N, 62Q, Section 256B, and Minnesota Rules Parts through Mid-cycle Exams are generally scheduled 18 months following the original QA Examination. 29 The first repeat deficiency Withhold section was in the 2003 DHS/MCO Contract. DHS considers a repeat MDH QA Exam deficiency final once there is a report with a Final Issuance date. Chapter 3: Key Findings Summary Page 18

31 The following table describes the three MCOs (IMCare, HP, and Blue Plus) with a QA or Mid-cycle Exam conducted during The remaining five MCOs had no MDH review activity in MCO Itasca Medical Care (IMCare) HealthPartners (HP) Blue Plus QA Exam or Mid-cycle Exam Review Results Summary IMCare had 11 deficiencies, including 1 repeat deficiency from the 2004 QA Exam. This continued deficiency will result in 20 points being lost from the Withhold numeric scoring system and loss of a percentage of the organization s capitated payments for calendar year 2006, assessed in July The HP 2006 QA Exam found 7 deficiencies. The 2006 QA Exam found no repeat deficiencies and no impact on HP s 2006 Withhold. The results of the 2006 Mid-cycle Exam indicated that Blue Plus completed the activities as stated in its CAP and are now in compliance with Minnesota rule and law. MDH conducted an additional Targeted QA Examination in April 2006 based on an unusually high number of complaints received by MDH from public program enrollees. During this Targeted QA Examination, MDH identified 3 deficiencies of Blue Plus related to grievances and appeals. Deficiencies found during a Targeted Quality Examination do not affect the Withhold. MDH has tentatively planned Blue Plus s next full QA Examination for the second quarter in Table 9: QA Exam or Mid-cycle Exam Review Results Summary for IMCare, HP, and Blue Plus TWO COMMON DEFICIENCIES AMONG MCOS Although the MCOs undergo MDH QA Exams on different schedules, analysis of the results from the most recent full exams for all nine organizations reveals two common deficiencies: 1. Minnesota Rules Part : Program within the Quality Program Administration. All except three MCOs (Blue Plus, Medica, and FirstPlan) received at least one deficiency in this section. Subpart 6, related to delegated activities, was the most common deficiency for the MCOs. 2. Minnesota Statutes 62M.05: Procedures for Review Determination within the Utilization Review section. All except one MCO (FirstPlan) received at least one deficiency. While the specific subparts of deficiency varied among plans, both general categories proved to be problematic, suggesting that an opportunity exists for shared learning or additional clarification of expectations. PROCESS FINDINGS Process is the treatment or service provided to the enrollees. Process studies are most often used to measure and evaluate an MCO s quality of care. MPRO s review of process includes the assessment and/or discussion of findings from the following sources: Performance Improvement Projects; Grievance and Appeals (G&As); Chapter 3: Key Findings Summary Page 19

32 MCO Quality Evaluations and Work Plans; and Practice Guideline Reports. Performance Improvement Projects Validation Performance Improvement Projects (PIPs) assess and evaluate current health care processes for improving outcomes. In accordance with DHS/MCO Contract, Section 7.2.1, New Performance Improvement Project Proposals, each MCO must annually submit to DHS for review and approval, a written description of the PIP that the organization proposes to conduct beginning the first quarter of the next year. The project proposal must be consistent with CMS published protocol, Protocol for Use in Conducting Medicaid External Quality Review Activities: Conducting Performance Improvement Projects, as well as DHS requirements. PIP EVALUATION METHODOLOGY A PIP is a planned process of data gathering, evaluation, and analysis to determine interventions or activities that are projected to have a positive outcome. A PIP includes measuring the impact of the interventions or activities toward improving the quality of care and service delivery. PIPs are long-term, resource intensive processes with the objective to sustain improvement over a time. DHS assesses new PIP proposals for compliance with the first seven of the ten activities specified in the CMS protocol for validating PIPs: Review the selected study topic(s). 2. Review the study question(s). 3. Review the selected study indicator(s). 4. Review the identified study population. 5. Review the sampling method (if applicable). 6. Review the MCO s data collection procedures. 7. Assess the MCO s improvement strategies. DHS evaluated the MCOs current proposed PIPs for consistency with the protocol to determine the likelihood that, if implemented, they could result in sustained and meaningful improvement. These proposed PIPs lay the groundwork for future quality improvement and advancements in the quality of care for enrollees. The MCOs submitted PIP proposals, either as individuals or as part of a collaborative. See Appendix C 2005 through 2007 MCO Performance Improvement Projects Summary 30 CMS protocol: Validating Performance Improvement Project: A Protocol for Use in Conducting Medicaid External Quality Review Activities. Final Protocol Version 1.0, May 1, Chapter 3: Key Findings Summary Page 20

33 The following table lists the 2007 PIP project titles and goals for each MCO (or collaborative). MCO PIP Title Project Goal Blue Plus Lipid Management To achieve significant improvement, sustained over time, in the annual measurement of statin medication used to reduce low-density lipoprotein (LDL) cholesterol in patients with coronary heart disease (CHD), CHD equivalent conditions, and/or diabetes. The project will be considered successful when the percentage of statin prescriptions filled by enrollees increases six percentage points from the new baseline rate of 39.7% to 45.7% and is sustained for two consecutive measurement periods. FirstPlan HP Medica MHP Improve the Recommended Number of Pneumococcal Conjugate Vaccinations by Age Two in Encounter Data Increased Blood Lead Testing in Medicaid Children at 24 Months of Age Customer Service Referral to Tobacco Cessation Program Increasing the Rate of Annual Breast Cancer Screenings for PMAP Enrollees, yrs Inclusive To achieve a 5-percentage point increase over the baseline measurement rate of 9% through multiple interventions. To achieve significant improvement, sustained over time, in the annual measure of blood lead testing rates. HealthPartners expects to achieve a 10-percentage point increase over the baseline measurement rate of 41% by implementing birthday incentives, parent education, community outreach to silent enrollees, and provider incentives and education. To achieve significant improvement, sustained over time, in the annual measure of adult enrollees who discuss tobacco cessation services/benefits during the call with Customer Services and accept referral to Medica s cessation program/vendor. Medica expects to achieve a 20-percentage point increase over the baseline measurement rate of 6.7%. To achieve significant improvement, sustained over time, in the annual measure of breast cancer screenings for women ages years. MHP expects to achieve a 5-percentage point increase over the baseline measurement rate of 28.9% through multiple interventions, including enrollee mailing and incentive, advertising campaigns in local minority newspapers, and educational materials to Community Health Workers. UCare Chlamydia Screening To achieve significant improvement, sustained over time, in the semiannual measure of screening women ages years for Chlamydia. UCare expects to achieve a 5- percentage point increase over the baseline measurement rate of 50.35% by starting a clinic financial incentive program and sending providers Action Lists. Chapter 3: Key Findings Summary Page 21

34 MCO PIP Title Project Goal CBP Collaborative: IMCare PrimeWest SCHA MSHO/MSC Collaborative: Blue Plus FirstPlan HP Medica MHP UCare Reducing Cardiovascular Risk among Diabetics (PMAP and MinnesotaCare Population Ages yrs and MSHO and MSC Populations Ages yrs) Calcium/Vitamin D Supplementation To achieve significant improvement, sustained over time, in the number of enrollees who use statin medications consistent with 2005 ICSI Guideline, Management of Diabetes Mellitus, Type 2. The CBP Collaborative PIP will be considered successful when pharmacy claims for statin therapy achieve a five percentage point increase over the 2006 baseline measurements of those on statin therapy for the PMAP and MinnesotaCare population (ages years) and the MSHO and MSC populations (ages years) using CBP aggregated data measured every four months. To achieve significant improvement, sustained over time, in the annual measure of prescription claims for Calcium/Vitamin D for MSHO and MSC enrollees living in the community. The MCO Collaborative expects to achieve a 5- percentage point increase of the six MCO aggregated data over the baseline measurement of 5.25% by implementing pharmacy, provider, care coordinator, and enrollee-focused mailings/education interventions. Table 10: Project Titles and Goals for Each Proposed PIP by MCO (or Collaborative) The MCOs produce annual status updates on PIPs that are in progress in the body of the Quality Evaluation document. However, the level of detail included, and consistency of status references, varies significantly from MCO to MCO. Grievances and Appeals Analysis Grievances are expressions of dissatisfaction about any matter other than an action. Appeals are oral or written requests for reconsideration of an action (denial or limited authorization of a requested service) or grievance. MCOs log and report all grievances and appeals (G&As) to the State s ombudsman each quarter. The following table lists MCO grievances and appeals between CY-2003 and CY-2006 for all product lines and all ages. Year G&A Reported , , , ,233 Table 11: MCO Grievances and Appeals by Calendar Year (All Product Lines and All Ages) Chapter 3: Key Findings Summary Page 22

35 As in previous years, the majority of the G&As focused on professional and medical services and benefits. The following figure illustrates the grievances from enrollees or enrollee representatives received for CY- 2004, 2005, and 2006 as a rate per 10,000 enrollee (member) months. The average rate of G&As in CY-2006 was 3.53 per 10,000 enrollee (member) months with a range between 6.06 and This average rate shows a slight decrease from CY-2005, which was The number of grievances filed may be higher for organizations that actively promote the grievance process to enrollees. The MCO with the highest G&A rate in 2006 was HP; the lowest was FirstPlan. In isolation, it is difficult to make a determination whether each MCO s rate is too high or too low without details on the structure of each organization s UM program. Grievances & Appeals Per Year 12 Rate/10,000 Member Months BluePlus First Plan HP IMCare Medica MHP PrimeWest SCHA UCare MCO Figure 1: Rate of Grievances and Appeals by MCO, CY-2004 through CY-2006 MCO DECISIONS OVERTURNED OR ENROLLEE REQUESTS APPROVED MCOs deny services and overturn decisions for many reasons. Some MCOs deny health care services because other services exist that can better meet the health care needs of the enrollee, or the provider supplied insufficient evidence at the time of the initial decision. Other MCOs deny services because they have stricter standards about what the organization considers appropriate health care services. It is important to note that not all MCOs may report data in the same way. The following figure provides the percentage of MCO decisions overturned or enrollee (member) requests approved in CYs 2004, 2005, and This figure does not include FirstPlan and SCHA because each organization had denominators less than 30. Chapter 3: Key Findings Summary Page 23

36 MCO Decision Overturned / Member Request Approved 80% 70% 60% 60% 72% 67% 60% 55% 55% Percentage 50% 40% 30% 20% 10% 38% 14% 13% 11% 11% 29% 18% 23% 33% 3% 25% 39% 46% 36% 47% % BluePlus HP IMCare Medica MHP PrimeWest UCare MCO Figure 2: Percentage of MCO Decision Overturned/Member Request Approved, CY-2004 through CY-2006 Because of the G&A process, MCOs eventually overturn some decisions. Since CY-2005, the average rate of decisions overturned across all nine MCOs increased from 34% to 40%. As in years past, Blue Plus continues to have the highest decision overturned rate at 67%. A higher rate of decisions overturned may indicate one of two things: either an MCO s grievance process is responsive to the needs of its enrollees or there may be an issue with the process. Given Blue Plus and UCare s rate of G&As, combined with the rate of decisions overturned, both MCOs should examine carefully the G&A process used to detect any areas for process improvement. Conversely, HP has the lowest decision overturned rate at 13% and the highest number of G&As at 6.06 per 10,000 member months, suggesting that HP s initial decision process is accurate. Chapter 3: Key Findings Summary Page 24

37 MCO DECISIONS UPHELD OR ENROLLEE REQUESTS DENIED As a converse to the rate of decisions overturned, MCOs also reported the rate of decisions upheld. The following figure provides the percentage of MCO decisions upheld or enrollee (member) requests denied in CYs 2004, 2005, and This figure does not include FirstPlan and SCHA because each organization had denominators less than 30. MCO Decision Upheld / Member Request Denied 90% Percentage 80% 70% 60% 50% 40% 30% 34% 33% 31% 54% 77% 68% 33% 24% 53% 61% 52% 43% 46% 45% 38% 36% 31% 33% 36% 35% % 14% 10% 0% BluePlus HP IMCare Medica MHP PrimeWest UCare MCO Figure 3: Percentage of MCO Decisions Upheld/Member Request Denied, CY-2004 through CY-2006 The average percentage of MCO decisions upheld has fluctuated slightly in the past three years. In CY-2004 and CY-2006 the average was 41% and in CY-2005 it was 43%. Although not tested, the difference is not likely to be significant. HP continues to have the highest percentage of decisions upheld at 68%, which further confirms that the organization has an effective UM process. IMCare has the lowest percentage of MCO decisions upheld at 24%, which is an improvement from the previous year, but still quite low. Similar to the percentage of decisions overturned, a low percentage of decisions upheld may be an indication of a problem with the UM process, such as communication or timing. The IMCare rate for decisions upheld brings out another question of what is happening to those grievance cases that were neither overturned (29%) nor upheld (24%). IMCare reported the remaining 47% to DHS as grievances with outcomes of Grievance Acknowledged, Grievance Substantiated/Action Taken and Referred to Quality Review. The high rate of grievances versus appeals may be an indication that IMCare is logging and reporting its G&As incorrectly. QI Work Plans and Quality Evaluations Review A Quality Evaluation is a critical assessment of the activities covered in an MCO s previous Work Plan. The Quality Evaluation also provides a performance retrospective to assist an MCO with setting goals and objectives for next year s Work Plan Ideally, MCOs should write clear Work Plans and Quality Evaluations and show obvious connections and effective application between the two reports as working documents that MCO staff actively use. The 2006 DHS/MCO Contract, Section 7.1.7, Annual Quality Assurance Work Plan, requires each MCO to provide DHS an annual written Work Plan that describes the organization s proposed quality assurance Chapter 3: Key Findings Summary Page 25

38 programs and PIPs for the upcoming DHS/MCO Contract year. Although similar to the NCQA accreditation requirements for QI programs, the Work Plan also must follow Minnesota guidelines and specifications, requiring a detailed description of the proposed Quality Evaluation activities, a timetable for evaluation of activity completion, and specific clinical and organizational components. In addition, each MCO must conduct an annual quality assessment, performance improvement evaluation, and then submit the evaluation to DHS under the DHS/MCO Contract, Section 7.1.8, Annual Quality Assessment and Performance Improvement Evaluation. Evaluations must be consistent with State and federal regulations and current NCQA standards for MCO accreditation. The written evaluation must include a review of the impact and effectiveness of the organization s quality assessment programs and PIPs and include A description of completed and ongoing QI activities, addressing the quality and safety of clinical care and quality of service; Trending of measures to assess performance in the quality and safety of clinical care and quality of service; Statistically defensible analysis of the results of QI initiatives, including barrier analysis; and Evaluation of overall QI program effectiveness, including progress toward influencing network-wide safe clinical practices. In both the 2004 and 2005 ATRs, MPRO recommended that the MCOs work to create clear linkages between the Quality Evaluation and Work Plan documents. Overall, all MCOs have demonstrated improvement in the quality of the Quality Evaluations and Work Plans; however opportunities exist to better connect the two documents and increase development in analysis and operational functionality. The following table provides commentary on and recommendations for each MCO s Quality Evaluation and Work Plan reports. Blue Plus FirstPlan of Minnesota (FirstPlan) MCO Quality Evaluation Work Plan The Quality Evaluation is well organized and clearly describes the categories used to evaluate project outcomes. MPRO recommends adding a discussion of activities or outcomes resulting from the asthma disease management (DM) program. MPRO recommends including information on the results of FirstPlan s asthma DM program activities. To give more credibility to the discussion of outcomes, MPRO recommends using accepted statistical methods of analysis to determine real improvement, including measures of statistical significance and consideration of normal patterns of variation. The Work Plan provides detail, including timelines and descriptions of planned activities and references the MDH 2004 CAP on grievances and appeals. MPRO recommends including information from MDH s 2006 CAP on G&A, which will further promote continuity between the two documents. The Work Plan provides a more detailed description of planned activities than last year s Work Plan. MPRO recommends strengthening the organization s goals with targets to determine when it achieves goals. Chapter 3: Key Findings Summary Page 26

39 HealthPartners (HP) MCO Quality Evaluation Work Plan Itasca Medical Care (IMCare) Medica The Quality Evaluation, modified since last year, now includes more information and discussion about activities specific to public program enrollees. MPRO makes no recommendation at this time. The Quality Evaluation does not state how the organization determined its goal targets (e.g., NCQA, NCBD 31, and DMAA 32 ). Some aspects of the data analysis do not appear to consider the effect of normal variation in determining real improvement. MPRO recommends conducting data quality checks to ensure consistent key elements reporting from source to source. MPRO also recommends including consistent and clear references to next steps for each item. The Quality Evaluation is easy-to-follow and includes an effective statement about the relationship between the Quality Evaluation and the Work Plan. MPRO recommends adding a description of the organization s monitoring activities. The Work Plan does not provide a clear and detailed description of the 2007 projects the organization will work on as required by Minnesota Rule , Subpart 2.A. To demonstrate that the organization uses the Work Plan as a real working tool to support planned activities, MPRO recommends incorporating further detail about each project and related goals. The 2007 Work Plan shows definite improvement in quality compared with the 2006 Work Plan. The Work Plan is well structured, and it appears to be a working document. MPRO makes no recommendation at this time. The Work Plan and Quality Evaluation are well integrated; however, the Work Plan goals do not correlate with targets given in the Quality Evaluation. In addition, the Work Plan does not include all follow-up activities mentioned in the Quality Evaluation. MPRO recommends cross-referencing the Quality Evaluation to the Work Plan to ensure that all activities receive mention in both documents and that the targets correlate accurately. 31 National CAHPS Benchmarking Database 32 Disease Management Association of America Chapter 3: Key Findings Summary Page 27

40 MCO Quality Evaluation Work Plan Metropolitan Health Plan (MHP) PrimeWest Health System (PrimeWest) South Country Health Alliance (SCHA) UCare Minnesota (UCare) The Quality Evaluation shows no critical analysis of data results. In addition, no clear linkages exist between the previous Work Plan and the Quality Evaluation. To give more credibility to the outcomes discussion, MPRO recommends using accepted statistical methods of analysis to determine real improvement. MPRO also recommends using the previous year s Work Plan to develop the next Quality Evaluation and key identifiers and format the evaluation to demonstrate clearly the connection between the two documents. The Quality Evaluation indicates activities that the organization will complete in 2007; however, the activities do not appear in the Work Plan. The integration of the Quality Evaluation and the Work Plan is not apparent and lacks focus on key elements. MPRO recommends using the previous year s Work Plan to develop the next Quality Evaluation, key identifiers and format the evaluation to demonstrate clearly the connection between the two documents clearly. To give more credibility to the outcomes discussion, MPRO recommends using accepted statistical methods of analysis to determine real improvement, including a trends analysis for every activity. The Quality Evaluation includes a discussion of findings, barriers, next steps, and analysis of data over time. MPRO makes no recommendation at this time. The Quality Evaluation correctly and clearly describes the categories used to evaluate project outcomes and provides detailed descriptions of enrollee demographics. MPRO recommends including barrier analysis. Table 12: MCO Work Plan and Quality Evaluation Commentary MHP submitted a Work Plan Evaluation instead of an actual Work Plan. The Work Plan Evaluation document is duplicative of the Quality Evaluation and does not provide insight to the planned QI activities for the upcoming year. MPRO recommends developing the Work Plan in a format that allows clear identification of key items, following the requirements of Minnesota Rule , Subpart 2. The Work Plan tasks for some activities include multiple steps while others have minimal or no detail. MPRO recommends cross-referencing the Quality Evaluation to the Work Plan to ensure that all activities receive adequate mention in both documents. The Work Plan includes activities addressing TSOC findings and includes, as recommended by MPRO, activities to monitor the high rate of initial decisions overturned through closed appeals and State Fair Hearings. The Work Plan does not always include follow-up activities mentioned in the Quality Evaluation. MPRO recommends cross-referencing the Quality Evaluation to the Work Plan to ensure that all activities receive mention in both documents. UCare referenced some items in the Quality Evaluation that required action; however, the organization did not carry over these items into the Work Plan. MPRO recommends cross-referencing the Quality Evaluation to the Work Plan to ensure that all activities receive mention in both documents. Chapter 3: Key Findings Summary Page 28

41 Practice Guideline Report Review Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions regarding appropriate health care for specific clinical circumstances. The guidelines provide clear instructions regarding key decisions such as which diagnostic or screening tests to order, the length of time patients should stay in the hospital, and other details of clinical practice. The greatest benefit of the practitioner s use of these guidelines to enrollees is improved health outcomes. 33 Guidelines that encourage established, effective interventions and discourage practices proven ineffective or detrimental can reduce morbidity and mortality and improve quality of life for many persons suffering from clinical conditions. The use of guidelines also can improve the consistency of the care provided to the enrollee. 34 In accordance with DHS/MCO Contract, Section 7.1.5, MCOs must adopt practice guidelines based on clinical evidence, ensure the organization s dissemination to providers, ensure proper application of guidelines to an MCO decision-making process, and annually audit provider compliance with use of the guidelines. 35 The following table provides a brief discussion of the 2006 Practice Guideline Reports, which the MCOs submitted to DHS. Blue Plus MCO FirstPlan of Minnesota (FirstPlan) HealthPartners (HP) Itasca Medical Care (IMCare) Medica 2006 Practice Guideline Report Summary The Practice Guideline Report provides detailed information on all contractually required elements. Clinics that do not perform above the 25th percentile on any quality indicator for three consecutive years receive a letter, graphic presentation of the data, and educational materials. Whereas the concept is appropriate, the standard for quality is set too low. MPRO recommends setting the threshold for action at a higher level (e.g., 50 th percentile). The Practice Guideline Report does not provide information on how the organization disseminates guidelines to enrollees and potential enrollees. In addition, next steps analysis for improving provider guideline use is not fully developed. The Clinical Indicator Report includes information on practice guidelines that HP uses. The basic assumption of the report is that the performance on the key clinical indicators will allow the MCO to demonstrate compliance with practice guidelines. While the report is organized and contains a thorough selection of clinical indicators, the report does not contain a discussion of the findings presented, especially the less than favorable results, nor does the report contain information about actual practice guidelines. The Practice Guideline Report does not include a description of how the organization distributes practice guidelines to providers and enrollees upon request. The report does not include the last review date for the guidelines nor does the report address specific strategies to drive improvement. The Practice Guideline Report is very detailed and comprehensive. Medica documents the use of Institute for Clinical Systems Improvement (ICSI) and Medica-developed clinical guidelines. The report also provides detailed information on all other contractually required elements. Medica did not compare its guideline analysis findings to national benchmarks, and the organization did not give a rationale for this decision. 33 Woolf, SH, Grol, R, et al. Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999; 318: Ibid. 35 Practice guideline requirements per DHS/MCO Contract Section 7.1.5(D). Chapter 3: Key Findings Summary Page 29

42 MCO Metropolitan Health Plan (MHP) PrimeWest Health System (PrimeWest) South Country Health Alliance (SCHA) UCare Minnesota (UCare) 2006 Practice Guideline Report Summary The Practice Guideline Report does not include a date when MHP distributes the guidelines to providers. MHP documents the use ICSI guidelines. The report does not include improvement strategies or any corrective actions that the organization will take because of its audit. PrimeWest requires that contracted providers follow the adopted guidelines when assessing and treating PrimeWest enrollees. The organization posts all adopted guidelines on its Web site and, in July 2006, the organization published the guidelines in PrimePointers. The guidelines also are available to enrollees or providers upon request. PrimeWest conducted an audit of providers in August 2006 to measure adherence rates to the adopted guidelines. PrimeWest reports steady improvement for all practice guidelines; however, PrimeWest does not use benchmarks to evaluate improvement overtime. Improvement strategies and corrective actions based on audit results are general and are not action oriented. The Practice Guideline Report is missing improvement strategies and/or corrective actions. On an annual basis, SCHA uses HEDIS measures to evaluate compliance with all practice guidelines. The Practice Guideline Report states that ICSI guidelines, or nationally or communitybased recognized sources, are used when appropriate. UCare gives no further explanation indicating which guidelines the organization uses in specific situations. UCare monitors provider compliance with guidelines using relevant HEDIS measures. Although UCare indicates that the organization distributes the guidelines to providers, there is no information about how UCare disseminates the guidelines to providers and enrollees. The Practice Guideline Report indicates that the organization communicates and uses the guidelines in utilization and policy decisions and in enrollee communication and education. Table 13: 2006 Practice Guideline Report Summaries Overall, all MCOs Practice Guideline Reports are compliant with the DHS/MCO Contract; however, all organizations should include more detail in their reports, such as expansion on key indicator analysis and next steps. In the past year, DHS has increased its process flexibility on supplemental reports submission, including the Practice Guideline Report. To reduce overall reporting obligations to MCOs, organizations may now include supplemental reports in the body of the Quality Evaluation. Currently, MCOs decide on report format, which varies from MCO to MCO. It is important to note that all nine MCOs are using ICSI guidelines, which will help ease the burden on the providers. In the past, working with MCO-specific guidelines made compliance difficult to determine. More importantly, uniform adoption of one set of guidelines helps standardize the quality given to all enrollees in publicly funded programs. OUTCOMES FINDINGS An outcome is the result of enrollee health, functional status, or satisfaction following the receipt of care or services based on the diagnosis or problems presented and the health care team (including the enrollee). Changes in an enrollee s health status, knowledge, behavior, or satisfaction are all types of care outcomes. Measuring outcomes of care assesses the successfulness of structures and processes MCOs have in place to provide quality care to enrollees. Measuring outcomes is the tabulation, calculation, or recording of an activity or effort expressed in a quantitative manner. Outcomes discussed in this chapter include the following: Performance measures, Chapter 3: Key Findings Summary Page 30

43 Consumer satisfaction surveys, and Voluntary enrollment changes. HEDIS Performance Measures Calculation (and Validation) DHS uses performance measures to quantify quality of care and service improvements by focusing on the measurement of process or outcome change. DHS bases these measures on HEDIS specifications, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS is a set of measures nationally recognized as one of the premier sets of measures for managed care delivery systems. The BBA rules require a validation process to ensure that performance measures comply with federal protocols regarding methods of data collection and calculation. 36 DHS contracts directly with MetaStar, an NCQA Certified HEDIS Auditor, to conduct an independent calculation and audit of each MCO s performance measures based on encounter data submitted to DHS. The following table summarizes the validated 2006 HEDIS rates by program. Blank cells (--) indicate either the measure is not applicable to the program s enrolled population or the denominator was less than 50 for the measure. HEDIS Measure PMAP 2006 Rate Minnesota Care PGAMC MSC MSC+ MSHO ;Quality Compass Adolescent Well-Care Visits 31.9% 31.9% % Adults Access to Preventive/ Ambulatory Health Services years 90.8% 85.1% 86.0% % years 90.4% 87.2% 88.6% % 65+ years 96.2% 86.4% 100% 94.1% 76.5% 97.1% 79.5% Antidepressant Med Mgmt Optimal Contacts 17.5% 13.8% 21.6% 4.4% % 20.7% Acute Treatment 35.7% 50.6% 35.1% 33.8% % 46.0% Continuous Treatment 25.5% 37.8% 27.9% 22.1% % 30.3% Breast Cancer Screening 41.3% 59.7% % 72.7% 57.3% 53.9% Cervical Cancer Screening 76.7% 72.5% 56.7% % Childhood Immunizations (Combination 2) 55.3% 54.7% % 36 CMS protocols used in Conducting Medicaid External Quality Review Activities: Validating Performance Measures, Calculating Performance Measures, and Information Systems Capabilities Assessment for Managed Care Organizations and Prepaid Health Plans. Chapter 3: Key Findings Summary Page 31

44 HEDIS Measure Children and Adolescents Access to Primary Care Practitioners PMAP 2006 Rate Minnesota Care PGAMC MSC MSC+ MSHO ;Quality Compass months 98.5% 98.1% % 25 months 6 years 91.7% 91.7% % 7 11 years 77.6% 79.0% % years 77.5% 80.3% % Chlamydia Screening in Women (16 25 years) Comprehensive Diabetes Care 52.8% 40.7% 49.6% % HbA1c Testing 78.1% 88.9% 86.4% 74.1% % 76.2% LDL-C Screening 60.9% 79.4% 70.7% 62.0% % 80.5% Use of Appropriate Medications for People with Asthma (5 56 years) Well-Child Visits in the First Fifteen Months of Life (6 or more visits) Well-Child Visits in the 3 rd, 4 th, 5 th, and 6th Years of Life 87.6% 89.5% 81.2% % 45.0% 53.9% % 61.7% 61.2% % Table 14: 2006 HEDIS Performance Measures Accurate prevalence rates for some measures (i.e., Well-Child and Adolescent, Cervical Cancer Screening, Comprehensive Diabetes Care, and Childhood Immunizations) can be better achieved using the hybrid method, combining administrative data from claims and other databases with chart data abstracted from medical records. The actual rates for the MCOs may be higher than the rates calculated by encounter data only. The hybrid method requires development of medical record review tools, training and oversight processes, skilled medical record reviewers, identification of potential providers of the services, coordination with provider sites, and medical record review at provider sites. It is a time consuming, resource intensive, provider-burdensome process. Because of the resources involved, DHS elected to calculate its performance measures with administrative data only. This decision may impact the performance measures reported by DHS and the interpretation of some measurement results. Although the hybrid method would produce higher rates for some performance measures and rates collected using that method may better represent care, it is not necessary for comparing baseline measurements to subsequent changes. Thus, using administrative data is an appropriate mechanism for production of Chapter 3: Key Findings Summary Page 32

45 performance measurements for the purpose of comparisons over time. Exclusively using administrative data allows MCOs and programs to be equitably compared over time. 37 Chapter 7: Discussion and Advice to DHS provides follow up on MPRO s 2005 ATR recommendation to utilize a three-year rolling average to score selected MCO performance measure results. Consumer Satisfaction Survey Administration Together with health status, enrollee satisfaction is an ultimate outcome of the delivery of medical care service. Satisfaction ratings contain useful information about the structure, processes, and outcomes of care received from MCOs. Consumer satisfaction surveys provide an excellent source of information regarding enrollees perception of quality and provide a predictive means of assessing how enrollees will behave in the future. DataStat, Inc., an NCQA-certified Consumer Assessment of Health Plans Survey (CAHPS ) vendor, under contract with DHS conducted the 2007 Managed Care Public Programs Consumer Satisfaction Survey. The survey assesses and compares the satisfaction of enrollees in publicly managed care programs administered by DHS. DHS conducts a consumer satisfaction survey of managed care enrollees every year. TOPICS ASSESSED The standardized survey instrument chosen for this study was the CAHPS 3.0 Medicaid Core Module. The core instrument includes approximately 63 questions. The instrument assesses topics such as: How well doctors communicate; Getting care without long waits; Helpfulness of office staff; Getting care that is needed; Health plan customer service; and Overall satisfaction with health plans and health care. DHS added questions for some respondents to assess topics such as immunization, behavioral health, and care coordination. POPULATION GROUPS SURVEYED The survey included four core publicly funded managed care population groups: Prepaid Medical Assistance Program (PMAP); MinnesotaCare; Minnesota Senior Care (MSC); and Minnesota Senior Health Options (MSHO) DHS Performance Measure Validation Report MetaStar. Chapter 3: Key Findings Summary Page 33

46 RATING SYSTEM AND SURVEY RESULTS DataStat, Inc. combined the results from individual questions in the survey into nine different topic areas: four ratings of overall satisfaction and five composite scores. The following tables show the CAHPS Survey results by program. For each program, the number in the table shows the percentage of all people who responded most positively (e.g., 9-10, Always or No Problem ) to the questions. The most positive answers display after each topic. The CAHPS Survey asked enrollees to provide an overall rating of the health care received from their health plan and health plan providers by giving an overall rating from 0 10, where 0 = Worst Possible, to 10 = Best Possible. Rating Area How People Rated Their Doctor or Nurse How People Rated Their Specialist How People Rated Their Health Care How People Rated Their Health Plan Most Rate of Most Positive Response Positive Response PMAP MinnesotaCare MSC MSHO Avg % 57% 67% 70% 64% % 54% 62% 65% 59% % 57% 62% 71% 61% % 44% 62% 70% 57% Average 55% 53% 63% 69% Additional survey questions asked people to rate: How often their doctors communicated well; How often they got care without long waits; and Table 15: CAHPS Survey Rating Results by Program How often office staff was courteous, respectful, and helpful. The rating system was Never, Sometimes, Usually, or Always. For each program, the numbers in the following table shows the percentage of all people who responded most positively (or Always ) to these questions. Composite Area Most Positive Response Rate of Most Positive Response PMAP MinnesotaCare MSC MSHO Avg. How Well Doctors Communicate Always 59% 62% 65% 68% 64% Getting Care Without Long Waits Always 35% 38% 39% 42% 39% Courtesy, Respect, Helpfulness of Always 67% 71% 74% 78% 73% Office Staff Average 54% 57% 59% 63% Table 16: Composite Area Survey Communication, Waits, and Courteousness Chapter 3: Key Findings Summary Page 34

47 Survey questions also asked people to rate problems they had with Health plan customer service, and Getting care that is needed. The rating system was Big Problem, Small Problem, or No Problem. For each program, the numbers in the following table show the percentage of all people who responded most positively (or No Problem ) to these questions. Composite Area Most Positive Response Rate of Most Positive Response PMAP MinnesotaCare MSC MSHO Avg. Health Plan Customer Service No Problem 71% 62% 60% 68% 65% Getting the Care That Is Needed No Problem 73% 75% 67% 78% 73% Average 68% 66% 63% 71% Table 17: Composite Area Survey Health Plan Customer Service and Getting Needed Care Information obtained from consumer satisfaction surveys allows MCOs to measure how well the organization is meeting its enrollees expectations and needs. Surveys also can reveal areas of recent improvement and target areas to improve the quality of care provided. Average plan scores for satisfaction ratings and composites are compared using a difference-of-means statistical test. Key findings are those MCO scores that are significantly higher or lower than the program average for the program in which that MCO participates. KEY FINDING FOR PLANS WITHIN PROGRAMS Across all programs and MCOs, the composite area Getting Care without Long Waits received the lowest score, with an average satisfaction level of 39%. The highest ratings were for the composites, Courtesy, Respect, Helpfulness of Office Staff and Getting the Care That Is Needed, both with an average satisfaction level of 73%. Separate comparisons of the survey data from MCOs within PMAP, MinnesotaCare, MSC, and MSHO programs form the basis for the key findings for MCOs within these programs. The following table summarizes the key findings. Program Prepaid Medical Assistance Program (PMAP) Key Findings Four plans rated significantly lower than the PMAP average: PrimeWest for How People Rated Their Health Plan HealthPartners for How People Rated Their Specialist MHP for Getting Care without Long Waits SCHA for How Well Doctors Communicate Two plans rated significantly higher than the PMAP average: FirstPlan and IMCare for Courtesy, Respect, and Helpfulness of Office Staff PrimeWest for Getting Care without Long Waits Chapter 3: Key Findings Summary Page 35

48 Program Key Findings MinnesotaCare Four plans rated significantly lower than the MinnesotaCare average: IMCare and MHP for How People Rated Their Health Plan Medica for How People Rated Their Health Care UCare Minnesota for How People Rated Their Specialist IMCare and MHP for Health Plan Customer Service Minnesota Senior Care (MSC) Two plans rated significantly lower than the MSC average: Minnesota Senior Health Options (MSHO) HealthPartners for Health Plan Customer Service Medica for Getting Care That Is Needed One plan rated significantly higher than the MSC average: MSC Grouped Plans 38 for Getting Care Without Long Waits, Courtesy, Respect, and Helpfulness of Office Staff, Health Plan Customer Service, and Getting Care That Is Needed One plan rated significantly lower than the MSHO average in two areas: HealthPartners for How People Rated Their Health Plan and How People Rated Their Health Care HealthPartners for How Well Doctors Communicate, Getting Care without Long Waits, and Courtesy, Respect, and Helpfulness of Office Staff Four plans rated significantly higher than the MSHO average: MSHO Grouped Plans for How People Rated Their Health Plan and How People Rated Their Health Care Medica for How Well Doctors Communicate HealthPartners for Health Plan Customer Service MSHO Grouped Plans for Courtesy, Respect, and Helpfulness of Office Staff Table 18: Key Findings for Plans within Programs Voluntary Changes in MCO Enrollment Survey To track voluntary changes in MCO enrollment and to compare the reasons enrollees in PMAP and MinnesotaCare programs change from one MCO to another, DHS administers a monthly written survey. 39 Data on voluntary changes in enrollment exclude PMAP enrollees living in counties contracting with Countybased Purchasers (CBPs), because enrollees have limited enrollment in the CBP and can only change MCOs if they move to a non-cbp county. DHS provides these survey results to the MCOs to inform future initiatives related to organizational improvement of care and services. DHS provides the detailed results by question and category so that MCOs can determine specific areas of potential improvement. 38 MSHO Grouped Plans combine data from Blue Plus, FirstPlan, IMCare, MHP, PrimeWest, SCHA, and UCare. 39 DHS Voluntary Changes in MCO Enrollment Report is available on the DHS public Web site at: Chapter 3: Key Findings Summary Page 36

49 Change rates are likely to vary over time but remain below the DHS-established 5% threshold. The following table lists the voluntary enrollment change rates by MCO for MCO Number of Enrollees Changing MCO PMAP Average Number Enrolled Change Rate Number of Enrollees Changing MCO MinnesotaCare Average Number Enrolled Change Rate Blue Plus , % , % FirstPlan 15 3, % 63 3, % HP , % , % IMCare , % Medica , % , % MHP , % 155 1, % PrimeWest % SCHA % UCare , % , % Total , % , % Table 19: 2006 Voluntary Enrollment Change Rates by MCO Statewide change rates remain stable and below the State 5% threshold for both PMAP and MinnesotaCare with rates at 1.0%and 1.7%, respectively. These rates remain relatively unchanged from 2005 (PMAP at 0.9%; MinnesotaCare at 1.5%). It is important to review the findings with caution because of the small denominators for some MCOs. For both the PMAP and MinnesotaCare programs, the total number of enrollees who changed MCOs in 2006 was 4,222. The simplified 2006 Survey, Your Reasons for Changing Health Plans, consists of four composites: I changed my health plan because I was dissatisfied with my health plan because I was dissatisfied with my health plan s medical provider because I was dissatisfied with my health plan s dental provider because The following table summarizes results of each composite by program. Composite Responses I changed my health plan because PMAP n = 678 MinnesotaCare n = 884 The county or state put me in a health plan that I did not choose. 23% 47% I wanted everyone in my household on the same plan. 26% 6% I moved and the health plan was no longer available. 4% 17% I was dissatisfied with my health plan because Chapter 3: Key Findings Summary Page 37

50 Composite Responses The information I was given before I signed up for the plan was not correct. PMAP n = 678 MinnesotaCare n = 884 7% 5% The provider (doctor, clinic) I wanted was not in my health plan. 36% 29% The dentist I wanted was not in my health plan. 16% 13% When I called my health plan with a question or needed help, they did not help me. I was dissatisfied with my health plan s medical provider because I had trouble getting a referral to a specialist I needed to see or getting approval for a test or medicine I needed. I could not get an appointment I wanted (it took too long, it did not fit into my schedule, I could not see the same doctor). I spent too much time sitting in the waiting room (clinic, emergency room). The clinic was not sensitive to my cultural needs (staff not from my racial/ethnic group, interpreters were not available). The staff (office, doctor, nurse) was not respectful of my family or me. I was dissatisfied with my health plan s dental provider because 9% 5% 16% 7% 13% 6% 6% 2% 5% <1% 4% 2% The dentists on the health plan s list would not take new patients. 18% 12% I could not get an appointment I wanted (it took too long, it did not fit into my schedule, I could not see the same dentist). 17% 5% The dentist or office staff was not respectful to my family or me. 4% 2% Table 20: Composite Responses by Program Aggregate responses show the following top reasons for changing MCOs: The county or state put me in a health plan that I did not choose (PMAP 23%; MinnesotaCare 47%) I wanted everyone in my household on the same plan (PMAP 26%) I wanted to try a different health plan (MinnesotaCare 23%) The provider (doctor/clinic) I wanted was not in my health plan (PMAP 36%; MinnesotaCare 29%) I had trouble getting a referral to a specialist I needed to see or getting approval for a test or medicine I needed (PMAP 16%) The dentist on the health plan s list would not take new patients (PMAP 18%; MinnesotaCare 12%) I could not get an appointment (dental) I wanted (it took too long, it did not fit into my schedule, I could not see the same dentist (PMAP 17%) Although the survey questions changed from 2005 to 2006, similar themes continue. Because of the diversity in populations served by each MCO, and some MCOs have fewer than 50 enrollees who have changed from their organization, comparisons cannot be made between MCOs. In future years, MCOs may choose to use the new survey findings to make an evaluation of their organization s own performance over time. Additionally, MCOs also should track the findings of the Voluntary Enrollment survey in their annual Quality Evaluation. Chapter 3: Key Findings Summary Page 38

51 CHAPTER 4: 2004 ATR RECOMMENDATIONS FOLLOW-UP The BBA Section 42 CFR (a)(5) states that the EQRO (MPRO) must provide an assessment of the degree to which each MCO or Prepaid Inpatient Health Plan (PIHP) has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year s EQR. To meet this requirement, MPRO includes in this Annual Technical Report (ATR) MCO improvement recommendations and follow-up discussion on how effectively each MCO addressed the recommendations. Because of the 2004 ATR release timing, MPRO could not follow up directly with the MCOs regarding quality improvement recommendations before development of the 2005 ATR. Moving forward, MCOs will have an opportunity to respond to recommendations of the previous ATR in their MCO comments. See Appendix G Detailed 2004 ATR Responses from MCO for detailed responses from the MCOs. MPRO requested that each MCO describe how their organization addressed both general and MCO-specific recommendations from the 2004 ATR. MPRO made the following ten general recommendations and asked each MCO to provide commentary about how their organization addressed each one. Recommendation 1: Consider the development of and linkages to the QI Work Plan and Annual QI Evaluation as working tools for the Quality Improvement and Performance Improvement program. Creating a meaningful connection between the Work Plan and the Quality Evaluation documents has been one of MPRO s ongoing recommendations to MCOs. The purpose of MPRO s review of these two documents is to assist organizations in their efforts toward developing usable, valuable tools for both the MCO and DHS. As discussed previously, the MCOs have made notable progress in their efforts, with some, such as FirstPlan, adopting an improved format similar to that of Blue Plus. The MCOs self-reported progress toward addressing this recommendation also was informative. PrimeWest, SCHA, and FirstPlan all reported that efforts toward this recommendation remained in progress while the other plans (Blue Plus, HealthPartners [HP], IMCare, Medica, Metropolitan Health Plan [MHP], and UCare Minnesota [UCare]) all reported confidence in adequately met this recommendation. Some self-assessments, however, are not supported by MPRO s current evaluation of Quality Evaluations and Work Plans submitted to DHS. For example, MHP and HP still appear not to have a full understanding of the Work Plan; yet other MCOs (FirstPlan, MHP, and PrimeWest) need to improve the defensibility and depth of the statistical analysis in their Quality Evaluation. Recommendation 2: Use the MDH QA Examination Audit as part of the QI Evaluation and include specific documentation regarding activities, actions, time frames, and responsible parties in the QI Work Plan. The findings of the MDH QA Exam can have a significant effect on an MCO s future monetary incentives and withholds. In addition, the elements covered as part of the review are relevant quality improvement issues and activities. In 2007, the QA Exam audit will expand to include elements previously addressed in the TSOC Audit. Therefore, it is essential that MCOs act upon this recommendation. Recognizing the value of this recommendation, all except UCare incorporated efforts to address audit findings into their organization s Work Plan or is in the process of doing so. UCare, however, stated that the organization will only consider incorporating the audit findings at a future date. Recommendation 3: Use NCQA standards for the utilization management (UM) program. The self-reported responses to the recommendations demonstrate that the MCOs have worked to incorporate these commonly accepted industry standards into their UM operations. Further, the most recent round of TSOC Audits for the remaining three MCOs (BluePlus, FirstPlan, and PrimeWest) revealed high performance in UM program requirements. In general, meeting this recommendation was not a problem for Chapter 4: 2004 ATR Recommendations Follow-up Page 39

52 those accredited NCQA managed care organization (i.e., Blue Plus, HP and Medica). The larger concern is those MCOs (i.e., MHP, UCare, SCHA, and IMCare ) that account for a smaller number of enrollees and that have had challenges attaining full TSOC compliance in utilization management category. Specifically, the aforementioned MCOs report the following activities to address this recommendation: MHP developed its UM program to comply with NCQA standards. Specific MHP staff members within the UM area have training and expertise working with medical and mental/chemical health issues. MHP removed any programs or barriers to mental/chemical health and provided an open access system of delivery to ease its members ability to obtain these services. MHP uses an internal standardized reporting package to measure and monitor for over- and under-utilization of services. UCare updated its UM policy specifically to address behavioral health care utilization. UCare addresses behavioral health care utilization in its Utilization Management Plan, which details how the organization ensures appropriate utilization. Through the UCare Utilization Management Forum, an internal work group that ensures utilization management, issues are addressed based on NCQA standards, including the elements suggested in the 2004 ATR. SCHA reports that its organization has incorporated UM standards into its UM Plan Description. IMCare has a written a UM Program Description, has updated policies and procedures to be consistent with NCQA standards, and reviews over- and under-utilization. Because of TSOC Audit discontinuation, MPRO will continue to review the MDH QA Exam findings, monitoring this recommendation. Recommendation 4: Enhance documentation regarding delegation of UM and credentialing activities. In general, oversight and documentation regarding delegation has been a persistent challenge for MCOs as revealed by both the TSOC Audits and the MDH QA Exam. All MCOs report that their organizations are continuing to work to meet this recommendation. Those organizations with deficiencies or areas of noncompliance are required to submit CAPs. Recommendation 5: Develop Performance Improvement Projects (PIPs) consistent with the Centers for Medicare and Medicaid Services (CMS) protocol Conducting Performance Improvement Projects ten-step process. For many of the MCOs, the CMS protocol steps were new in However, time, experience, and understanding have helped all nine of the organizations to build their PIPs in a manner consistent with the protocol and with much less coaching and feedback from DHS. Recommendation 6: Add the review and update of policies and procedures to the QI Work Plan, and ensure compliance with grievance and appeal policies and procedures. Building the steps of review, update, and monitoring into the maintenance of an MCO s policies and procedures is essential to demonstrating full compliance. The easiest way for organizations to ensure that they do not miss these steps is to incorporate them into the QI Work Plan. Complete implementation of policies and procedures means communicating them to all involved individuals, for example, through staff training and manuals. Then, the MCO must implement the policy as written by monitoring compliance. The findings of the monitoring process help to inform the MCO s efforts to review and update policies regularly so that the organization keeps current with state, federal, contractual, and industry requirements. All of the MCOs, except UCare, report that they have fully met this recommendation. UCare has reported that they are currently working to meet this recommendation. Chapter 4: 2004 ATR Recommendations Follow-up Page 40

53 Recommendation 7: Implement strategies aimed at increasing preventive care services for child and adolescent enrollees; develop a PIP related to Child and Teen Check-Ups (C&TC). HealthPartners has a PIP in progress on lead screening, which is an element of childhood preventive care. Whereas most MCOs have not specifically added a C&TC PIP, all organizations report active efforts in place through existing Quality Improvement/Quality Improvement System for Managed Care (QI/QISMC) projects and programs. Although a formal program does not currently exist for C&TC, UCare has incorporated child preventive care to its QI Work Plan for Recommendation 8: Evaluate and analyze consumer satisfaction survey data from Consumer Assessment of Health Plans Survey (CAHPS ) to develop strategies for service improvement. All MCOs report careful consideration and analysis of CAHPS data. Some MCOs reported that their organization has developed new programs or initiatives because of this analysis. For example, MHP used member feedback to determine the need to remove a three-day advance notice for transportation services. PrimeWest included CAHPS-inspired improvement projects to its organization s 2006 Work Plan, including a new member welcome call process, monthly member advisory committee meetings, quarterly member informational meetings, staff educational meetings, and a quarterly member publication to build enrollee awareness of available programs. Recommendation 9: Adopt evidence-based preventive and chronic disease practice guidelines appropriate for child, adolescent, young adult, older adult, senior, and maternity populations. Almost all MCOs indicate that as members of the Institute for Clinical Systems Improvement (ICSI) their organizations have adopted the ICSI clinical practice guidelines, which are evidence-based and used by many healthcare organizations in Minnesota. Adopting these guidelines further reduces an MCO s burden to develop individual guidelines. Moreover, the new QCare initiative requires the adoption of guidelines consistent with QCare preventive care standards on child and adolescent immunizations, well-child visits, chlamydia screening, and breast and cervical cancer screening. Recommendation 10: Review ambulatory-sensitive conditions analysis and results for evaluation of case management, disease management, and PIPs on the following clinical conditions: asthma, bacterial pneumonia, heart failure, dehydration, diabetes, and gastroenteritis. All nine MCOs report using key administrative data related to many factors including ambulatory-sensitive conditions to make referrals to case and disease management programs. Medica provides detail on the actions the organization has taken because of the recommendations. One notable example is Medica s response to encounter data related to asthma. Specifically, the data revealed that among the PMAP population Medica s black enrollees five to nine years of age were less likely to receive appropriate asthma care compared with other racial groups. Through a Robert Wood Johnson Foundation grant-funded collaborative with the Center for Health Care Strategies and the American Lung Association, the MCO worked to address this disparity. Within one year, Medica s rates improved among this population, and Medica continues to monitor the issue. Discussion All of the MCOs have addressed adequately each recommendation and have indicated the action taken or plans for future action. These self-reported responses to the recommendations demonstrate that the MCOs Chapter 4: 2004 ATR Recommendations Follow-up Page 41

54 have incorporated industry standards into their operations, such as NCQA standards for the utilization program and the CMS ten-step protocol for PIPs. All organizations have Examined their CAHPS data for opportunities to improve customer satisfaction; Run quality reports and analysis for opportunities to develop programs and interventions for people with various clinical conditions; and Increased the rate of preventive service delivery to children and adolescents. If an MCO has not yet met the general recommendations, the organization s response describes the steps that it is or will be taking to meet compliance. MPRO encourages the MCOs to continue addressing all recommendations through activities both in progress and any future activities. See Appendix G Detailed 2004 ATR Responses from MCO for each MCO s detailed responses. MCO-SPECIFIC RECOMMENDATIONS In addition, MPRO provided MCO-specific recommendations in the 2004 ATR. As with the general recommendations, not all of the MCOs have implemented these recommendations; however, all have at least addressed them. The following table lists MCO-specific recommendations. Because of the limited time that PrimeWest had contracted with DHS, MPRO did not make any MCO-specific recommendations to PrimeWest. MCO Blue Plus FirstPlan HealthPartners IMCare Medica MHP SCHA UCare Recommendation Increase the number of clinics audited for practice guideline compliance. Identify and work with clinics with performance indicator rates below the 75 th percentile of Quality Compass. Give attention to CAP from MDH QA Exam. Give attention to CAP from MDH QA Exam. Increase number of clinics audited for practice guideline compliance. Stratify reporting results by program. Give attention to CAP from MDH QA Exam. Adopt, disseminate, apply and audit practice guidelines in accordance with the contract. Give attention to CAP from MDH QA Exam. Give attention to CAP from MDH QA Exam. Develop and conduct audit of provider compliance with practice guidelines. Analyze voluntary disenrollment rates. Give attention to CAP from MDH QA Exam. Give attention to TSOC CAP. Give attention to CAP from MDH QA Exam. Adopt a practice guideline applicable to persons with disabilities. Analyze MCO s Chlamydia screening rates/process and develop interventions. Give attention to CAP from MDH QA Exam. Table 21: MCO-specific Recommendations MPRO gave MCOs the opportunity to demonstrate how their organization addressed each requirement; nonetheless, there were some instances where MPRO did not see evidence to support an MCO s self- Chapter 4: 2004 ATR Recommendations Follow-up Page 42

55 reported status of a recommendation. For example, while MPRO agrees that IMCare has demonstrated significant efforts to address every MDH QA Exam recommendation or deficiency, the organization still has some room for improvement. The MDH QA Exam memo from April 2007 indicates that IMCare s 2006 QA Exam found a repeat deficiency from 2004, which means that the organization has not reached the quality goal of eliminating all repeat deficiencies. Discussion Overall, the quality of care for publicly funded programs is comparatively good and continues to improve in many important clinical and service areas. Key indicators of access, including the HEDIS measure Adults Access to Preventive and Ambulatory Health Services, allowed all nine of the MCOs to demonstrate high performance. Two of the MCOs, Medica and Blue Plus, ranked in the top 15 in the entire nation in the quality of their Medicaid services by NCQA. In another positive effort, MCOs displayed collaborative work toward MSHO program improvement. Weaknesses exist for the upcoming year. Specifically, MCOs should focus on continuing to refine QI Work Plans and Quality Evaluations documents. Although most MCOs made gains in improving both the format and content of these documents, important weaknesses remain. MPRO encourages each organization to continue finding ways use the document as a QI tool. In addition, the CAHPS results showed a wide variation of satisfaction levels from program to program. For MCOs whose scores ranked significantly lower than program average, MPRO recommends examining the results closely and determine which key factors contributed to areas of dissatisfaction. The MCOs should be encouraged by MPRO s overall findings. Quality improvement is a continuous focused effort that will lead to positive changes in the health care of all enrollees in Minnesota s publicly funded programs. Through these efforts, and by supporting processes and outcomes, and by conducting structured performance improvement projects and performance measures, the MCOs and DHS remain committed to ensuring and improving the quality of, timeliness of, and access to, health care services for Minnesotans Chapter 4: 2004 ATR Recommendations Follow-up Page 43

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57 CHAPTER 5: MCO FINANCIAL INCENTIVES AND DISINCENTIVES A financial incentive is an economic or other reward included in the Minnesota Department of Human Services/managed care organization (DHS/MCO) Contract to encourage MCOs to achieve the goals set for care delivery and outcomes. A financial disincentive (or withhold) is a form of reimbursement whereby DHS withholds or sets aside a percent of the capitation payment to an MCO until the end of a specified period, at which time DHS distributes withheld funds based on measures of an MCO s efficiency or performance. The measures reflect pre-established criteria for financial performance, productivity, utilization, and/or quality of care. INCENTIVES AND WITHHOLDS: CHALLENGES For the past six years, DHS has made available to contracted MCOs optional performance-based opportunities to obtain financial incentives for preventive services expansion. Beginning with the 2001 DHS/MCO Contract, MCOs could earn additional payments if dental, well child and lead screening access to services increased above the previous year s rate. Since calendar year (CY) 2001, the well child and lead screening incentives have continued with mixed results. In 2003, however, DHS discontinued the dental incentive primarily because of a shortage of dental providers, limiting the MCOs ability to expand access. 40 See Appendix E Managed Care Contract Incentive Rates and Payment Amounts. While DHS s ultimate goal is to maximize the value of preventive services, the immediate outcome is to determine if one of the traditional barriers to quality improvement financial issues can be minimized. Members of the health care industry have long recognized that capitation payment arrangements and quality improvement expansion of services may occur at a financial loss over the short term for an MCO. Capitation is a stipulated dollar amount established to cover the cost of health care services delivered to a given population. DHS bases its capitation rates on a historical utilization and risk-based methodology, so MCO services expansion beyond the organization s capitation rate could result in financial losses until DHS adjusts the rates to reflect current utilization. In CY-2003, DHS began to withhold 5% of each MCO s capitation payment. DHS would return the MCO s capitation payment in July of the following year if the MCO achieved specified performance targets. 41 The purpose of the financial withhold is to motivate MCOs to perform at a high level through negative incentives, complementing the established incentives for services expansion. The ongoing challenge for DHS is the structure of the performance measures targets. Performance targets must be clear, meaningful and achievable, but nonetheless require the MCOs to perform at a high level to secure their withhold dollars. However, the degree to which the MCO will feel motivated to push themselves to reach any established target will also be strongly influenced by the size of their withhold. 42 To make recommendations on developing a sustainable, comprehensive managed care incentive program, incorporating both incentive (services expansion payments) and disincentive (withhold) strategies, DHS contracted with The Lewin Group, a national health care and human services consulting firm. Based on The 40 Appendix E Managed Care Contract Incentive Rates and Payment Amounts 41 Minnesota legislation authorizing public programs MCO withhold: Minnesota Statute 2000, Sections: 256B.69, Subd. 5C, and 256L. 12, Subd. 9B. 42 The Lewin Group, Performance-based Payments to Minnesota Health Plan: Program Design Features. Minnesota Department of Human Services, November 20, Chapter 5: MCO Financial Incentives and Disincentives Page 45

58 Lewin Group s recommendations, DHS established approximately nine withhold performance target measures, including both administrative and clinical measures. 43 DHS assigned points to the performance target measures ranging from 5 points to 20 points per measure for a total of 100 points. WITHHOLD STRATEGY AND PERFORMANCE TARGET MEASURE CONCERNS Since the establishment of performance targets in 2003, DHS has modified the measures. DHS added, deleted, or suspended clinical measures and adjusted the point value of several other measures. In June of each year, DHS calculates the number of points earned for each measure and computes the amount of withheld funds DHS will return to an MCO. For example, an MCO earning 80 points out of a possible 100 points will have 4% of their withheld capitation payment returned and only 1% retained by the State. Since CY-2003, the following withhold strategy as well as performance target measure results have emerged: In 2003 and 2004, almost all MCOs achieved performance target measures goals, and DHS returned 100% of withheld funds. DHS suspended the Lead Screening measure because eligibility changes affected the measure for both years. In 2005, five MCOs (FirstPlan, Medica, MHP, PrimeWest, and SCHA) failed to reach the Lead Screening performance target measure. In addition, one MCO had a repeat deficiency in the Minnesota Department of Health (MDH) Quality Assurance Examination (QA Exam) resulting in a loss of 20 additional points. Withhold points lost ranged from 5 points to 30 points. In 2006, four MCOs (Blue Plus, FirstPlan, IMCare, and SCHA) failed to achieve the Lead Screening performance target measure, while three MCOs failed to meet the Treating Provider Number performance target measure, and one MCO had a repeat MDH QA Exam deficiency. The following figure illustrates the total withhold points for each MCO from CY-2004 through CY Because of measures suspension in most years, many MCOs achieved less than 100 points. For a few MCOs [Itasca Medical Care (IMCare), South Country Health Alliance (SCHA), and PrimeWest Health System (PrimeWest)], DHS suspended other additional measures or points. See Appendix F Withhold Point Summary (F&C Contracts Only). 43 Performance targets: Denial, termination or reduction of service notice (20 points), Grievance and appeal Reporting (15 points), Claims payment timeliness (10 points), Identifying treating provider (20 points), MDH QA Examination (10 points) Member service phone responsiveness (10 points), Psychiatrist UR/QA advisor (5 points), Lead Screening in Families and Children Contract only (10 points), Care Plan Audit and Screening Documentation Audit in MSHO MSC Contract only (10 points each). Chapter 5: MCO Financial Incentives and Disincentives Page 46

59 Figure 4: Total Withhold Points CY-2004 through CY-2006 CLINICAL AND ADMINISTRATIVE MEASURES OF PERFORMANCE One key standard for establishing withhold performance target measures is the development of achievable performance targets that would stretch MCO improvement efforts each year. Contractual expectations form the basis for target administrative measures near 100% performance; however, contractual expectations do not form the basis for clinical performance target measures. Historically, process or outcome measures usually do not meet optimum established goals based on clinical guidelines (expectations), but it is expected that overtime performance will improve to reach local and national goals. It was expected that MCOs may have difficulties achieving the clinical performance measure targets, but surprisingly, MCOs had difficulty meeting targets established for two administrative measures: Identifying Treating Providers and repeat MDH QA Exam Deficiencies. The following summarizes MCO administrative measures performance: Identifying Treating Providers The Treating Providers measure monitors the percentage of encounter claims with the correct provider number at the line level on the claim form. MCOs are expected to include the treating provider number on 90% of submitted claim forms. In 2003, 2004, and 2005, almost all MCOs met this target and received the allotted 20 points. In 2006, however, three MCOs failed to meet the 90% target and received less than 20 points. The reasons reported to DHS for failing to meet the performance target was staff turnover, new computer billing systems, and changing third-party administrators. MDH QA Examination Deficiencies While DHS is only beginning to realize the full impact of repeat deficiencies, DHS did not expect the MCOs to have a problem achieving the administrative target of no repeat deficiencies after three years. MCOs, however, have a history of multiple triennial MDH QA Examination deficiencies and, on a number of occasions, have had repeat deficiencies after completing a MDH-required corrective action plan (CAP) and Mid-cycle re-examination by MDH. See Chapter 3: Key Findings Summary. Chapter 5: MCO Financial Incentives and Disincentives Page 47

60 Lead Screening For many years, DHS expected MCOs to provide lead screening to at least 80% of one- and two-year olds enrolled in public programs. MCOs were slow to meet this target. To stimulate improvement strategies in this area, DHS added the Lead Screening Incentive to the DHS/MCO Contracts in 2001 and the Withhold Lead Screening measure in Although progress is slow, MCOs are continuing to make improvement. Using the new proposed HEDIS Lead Screening Measure for Children as an independent measure of improvement, MCOs have made significant progress toward achieving the 80% performance target. In CY- 2001, the performance rate was 40.4%; in CY-2003, the rate was 54%; and in CY-2006, the rate was 76.6%. The MCOs that lost withhold funds in the past two years have had difficulty developing improvement efforts focused enough to meet the annual 10% of the gap withhold requirement. To date, Lead Screening Incentive and Treating Provider measures have reportedly been the most challenging for MCOs; however, DHS believes it is only beginning to realize the impact of the MDH QA Examination repeat deficiencies. At present, it is not clear if significant financial disincentives alone achieve real and sustained managed care delivery system improvement. Using Incentives to Improve Enrollee Health Care Services Although a comprehensive financial evaluation of DHS s preventive incentives and the impact on MCO revenues is outside the scope of MPRO s contract services as the EQRO, it is important to ask whether the financial-based incentives have resulted in improved quality of services for enrollees. Financial and utilization perspectives, in part, provide some insight to this question. Financial Perspective From a financial perspective, individual MCO efforts to expand well child and lead screening services appear inconsistent. Although DHS has disbursed approximately $8.5 million dollars, or on average, $1.4 million dollars annually among the nine contracted MCOs, the annual incentive amounts vary significantly. For example, Medica s annual well-child incentive payments varied from $65,000 to more than $2,300,000. In contrast, most MCOs lead incentive payments remain steady. This steady improvement may be because DHS includes lead screening in the withhold. With more data, it may become evident that DHS must match a financial incentive with a financial disincentive for MCOs to achieve sustained improvement. A million dollar incentive out of a three billion dollar overall annual budget may seem like a small financial motivator for MCOs; however, from a quality improvement perspective, the purpose of financial incentives is not to reward but to reduce a capitation payment barrier limiting the appropriate use of preventive services. Utilization Perspective The utilization perspective of services reflects how enrollees actually use services as well as enrollees perceived need for care. The following table shows Prepaid Medical Assistance Program (PMAP) and MinnesotaCare Well-Child performance measures (15 months, 3 6 years, and years), over the past four years, indicating a steady increase for both populations. PMAP Program 15 Mos > 6 visits 3 6 Yrs Yrs % 54.3% 30.9% % 57.9% 32.3% % 59.4% 31.5% Chapter 5: MCO Financial Incentives and Disincentives Page 48

61 Program 15 Mos > 6 visits 3 6 Yrs Yrs % 61.7% 31.9% MinnesotaCare % 53.6% 29.9% % 57.7% 30.2% % 59.1% 30.4% % 61.2% 31.9% Table 22: Well-Child Performance Measures Whereas the results of these three well-child performance measures do not indicate a direct cause-and-effect relationship between incentives and increased use of well-child services, incentives may have contributed to an increase in performance measures. The lead screening incentive calculation also indicates an increase similar to well-child incentives. Using the new proposed HEDIS Lead Screening Measure for Children, confirms lead screening rates for all public programs continuously enrolled two-year olds have increased significantly since CY Public program managed care two-year olds who had a lead test any time before their second birthday increased from 40.4% in CY-2001 to 77.1% in CY Individual MCO rates followed the same steadily increasing pattern of 30-percentage points seen in the overall managed care rates from CY-2001 through CY Rates for all managed care enrollees: 2001 = 40.4%, 2002 = 46.9%, 2003 = 54.0%, 2004 = 64.6%, 2005 = 69.2%, 2006 = 76.6%. Chapter 5: MCO Financial Incentives and Disincentives Page 49

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63 CHAPTER 6: MCO-SPECIFIC ANALYSIS Improvement is the result of focused effort. This chapter highlights each of the nine MCO s strengths and weaknesses, and provides MPRO-recommendations to help the organizations focus on their weaknesses. BLUE PLUS Blue Plus, a wholly owned subsidiary of Blue Cross and Blue Shield of Minnesota, received licensure in 1974 as a non-profit MCO to deliver services to all populations. Blue Plus operates statewide. In the Prepaid Medical Assistance Program (PMAP), Prepaid General Assistance Medical Care (PGAMC), Minnesota Senior Care (MSC), MinnesotaCare programs, Blue Plus s average monthly enrollment is 110,201 for 2006, which accounts for 26.7% of the entire enrolled managed care population in publicly funded programs. The following table highlights Blue Plus s strengths and weaknesses as the organization s capabilities relate to quality, access, and timeliness of care. Strengths Weaknesses Quality NCQA Accreditation Quality Evaluation 100% TSOC Audit compliance Practice Guideline Report Comprehensive Diabetes Care (HEDIS measure) Access CAHPS results G&A process Children and Adolescent Access to PCPs (HEDIS measure) Adults Access to Preventive and Ambulatory Health Services (HEDIS measure) Cervical Cancer Screening (HEDIS measure) Timeliness No timeliness strengths noted No timeliness weaknesses noted Table 23: Blue Plus s Strengths and Weaknesses Strengths Earned and maintains an Excellent accreditation status from NCQA for both its commercial and publicly funded products. Ranked 13 th in the nation in the U.S. News & World Report list of Best Medicaid Health Plans. Expanded its smoking cessation initiatives statewide to primary health care providers and dentists. Demonstrated 100% compliance with all TSOC Audit requirements: Provides a well-organized Quality Evaluation and clearly describes the categories used to evaluate project outcomes. Blue Plus ranked in the 90 th percentile of Medicaid Quality Compass for the following Health Plan Employer Data and Information Set (HEDIS ) performance measures: Adults Access to Preventive and Ambulatory Health Services for ages years and years (PMAP) and 65 years and older (MinnesotaCare and MSHO); Cervical Cancer Screening (PMAP); Chapter 6: MCO-specific Analysis Page 51

64 Comprehensive Diabetes Care HbA1c testing (MSHO and MinnesotaCare); and Children and Adolescent Access to Primary Care Physicians (PCPs) measure for ages 12 to 24 months (PMAP). As part of Minnesota Senior Health Options (MSHO) Grouped Plans, Blue Plus rated significantly higher than the MSHO average for the Courtesy, Respect, and Helpfulness of Office Staff, How People Rated Their Health Plan, and How People Rated Their Health Care composites in the Consumer Assessment of Health Plans Survey (CAHPS ). Weaknesses Overall, Grievances and Appeals (G&As) are Blue Plus s greatest area for improvement. During the Targeted QA Examination (QA Exam), MDH identified three deficiencies related to grievances and appeals. Blue Plus also has the highest rate of decisions overturned at 67%. Blue Plus also has minor weaknesses with the level of detail in its Quality Evaluation and Practice Guideline Report ATR Recommendations MPRO recommends Blue Plus consider the following actions: Add a discussion in the Quality Evaluation of activities or outcomes resulting from the asthma disease management (DM) program; Include information in the Work Plan from the Minnesota Department of Health (MDH) QA Exam 2006 corrective action plan (CAP) on G&As; and Add further detail in the Practice Guideline Report to track the success of the performance requirements listed over time. Blue Plus should note the number of clinics that fall below the established quality threshold from year to year. Set the threshold for action at a higher level for selected quality indicators as noted in the Practice Guideline Report. FIRSTPLAN OF MINNESOTA (FIRSTPLAN) FirstPlan is a regional MCO founded in FirstPlan became a MCO under applicable state statutes in FirstPlan carries the distinction of being the first MCO in Minnesota and the third in the United States. For 2006, FirstPlan provided services to an average of 8,373 enrollees per month in the PMAP, PGAMC, MSHO, MSC, and MinnesotaCare programs, accounting for 2% of the entire enrolled managed care population in publicly funded programs. Chapter 6: MCO-specific Analysis Page 52

65 The following table summarizes FirstPlan s strengths and weaknesses as the organization s capabilities relate to quality, access, and timeliness of care. Strengths Weaknesses Quality 99.3% TSOC Audit compliance Quality Evaluation Practice Guideline Report UM Policy: Non-formulary Request Guidelines Access Adults Access to Preventive and Ambulatory No access weaknesses noted Health Services (HEDIS measure) CAHPS results Timeliness No timeliness strengths noted No timeliness weaknesses noted Table 24: FirstPlan s Strengths and Weaknesses Strengths Demonstrated 99.3% compliance with all TSOC Audit requirements. As part of MSHO Grouped Plans, rated significantly higher than the MSHO average for the Courtesy, Respect, and Helpfulness of Office Staff, How People Rated Their Health Plan, and How People Rated Their Health Care composites in the CAHPS. Ranked in the 90 th percentile of Medicaid Quality Compass for the HEDIS performance measure Adults Access to Preventive and Ambulatory Health Services for ages years (PMAP) and age 65 years and older (MSHO). Weaknesses FirstPlan s Quality Evaluation and Practice Guideline Report documents need more detail. In addition, FirstPlan s UM policy for non-formulary requests does not properly detail timeframe expectations ATR Recommendations MPRO recommends that FirstPlan consider the following actions: Update the Non-formulary Request UM Guidelines policy to include time frames; Include information in the Quality Evaluation on the results of its asthma DM program activities; Strengthen the organization s goals with targets in the Practice Guideline Report to determine when it achieves goals. To give more credibility to the discussion of outcomes, MPRO also recommends using accepted statistical methods of analysis to determine real improvement, including measures of statistical significance and consideration of normal patterns of variation; and Document how the organization disseminates guidelines to enrollees and potential enrollees in the Practice Guideline Report and consider other mechanisms to ensure practitioner guideline use. Chapter 6: MCO-specific Analysis Page 53

66 HEALTHPARTNERS (HP) HP became a managed care entity with the 1992 affiliation of two MCOs: Group Health, Inc. and MedCenters Managed Care Organization. HP provides services to enrollees in PMAP, MinnesotaCare, MSHO, MSC, and PGAMC programs. HP serves an average of nearly 46,806 publicly funded managed care enrollees per month, accounting for 11.4% of the entire enrolled managed care population in publicly funded programs. The following table summarizes Health Partners s strengths and weaknesses as the organization s capabilities relate to quality, access, and timeliness of care. Strengths Weaknesses Quality Comprehensive Diabetes Care (HEDIS measure) Practice Guideline Report NCQA Accreditation Work Plan 100% TSOC Audit compliance MDH QA Exam Access Chlamydia Screening (HEDIS measure) CAHPS results UM Process Adults Access to Preventive and Ambulatory Health Services (HEDIS measure) Breast Cancer Screening Children and Adolescent Access to PCPs (HEDIS measure) Timeliness No timeliness strengths noted No timeliness weaknesses noted Table 25: HealthPartners s Strengths and Weaknesses Strengths Earned and maintains an Excellent accreditation status from NCQA for its commercial and Medicare Advantage products. Demonstrated 100% compliance with all 2004 TSOC Audit requirements. Has the lowest rate of decisions overturned at 13% and the highest number of grievances and appeals, suggesting that HP is quite effective at sharing its G&A process as an enrollee benefit to its members. Furthermore, HP continues to have the highest percentage of decisions upheld at 68%, confirming that HP has an effective UM process. Ranked in the 90 th percentile of Medicaid Quality Compass for the following HEDIS performance measures: Chlamydia Screening (PMAP); Comprehensive Diabetes Care HbA1c testing (MSHO); Adults Access to Preventive and Ambulatory Health Services for ages years and age 65 years and older (MSHO and MSC); Chapter 6: MCO-specific Analysis Page 54

67 Breast Cancer Screening (MinnesotaCare); and Children and Adolescent Access to PCPs measure for age 12 to 24 months (PMAP and MinnesotaCare) and 25 months to 6 years (MinnesotaCare). In the CAHPS, HP rated significantly higher than the MSHO average for Health Plan Customer Service composites. Weaknesses In the CAHPS, Health Partners rated significantly lower than the PMAP average for How People Rated Their Specialist ratings; MSC average for Health Plan Customer Service composites; MSHO average in two areas: How People Rated Their Health Plan and How People Rated Their Health Care ratings; and The Work Plan does not provide a clear and detailed description of the projects the organization will be working on during the upcoming year. HP received seven deficiencies in the 2006 MDH QA Exam. No mention of practice guidelines or improvement activities in Quality Indicator Report (submitted to fulfill Practice Guideline Report requirement) ATR Recommendations Consider identifying and addressing factors that may contribute to lower CAHPS scores in certain rating and composite areas. Incorporate further detail about each project and related goals into Work Plan. Incorporate the CAP from the seven MDH QA Exam into Work Plan. Elaborate on findings and related actions in Quality Indicator Report. ITASCA MEDICAL CARE (IMCARE) Itasca County Health and Human Services administers Itasca Medical Care (IMCare), a CBP organization. Itasca County contracts with DHS to provide PMAP, PGAMC, MSC, and MinnesotaCare medical benefits through the IMCare program. In addition to residents of Itasca County, individuals in southern Koochiching, eastern Cass, and northern Aitkin counties can choose to enroll in IMCare. IMCare serves a public program population of approximately 4,941 enrollees per month, accounting for 1.2% of the entire enrolled managed care population in publicly funded programs. Chapter 6: MCO-specific Analysis Page 55

68 The following table summarizes IMCare s strengths and weaknesses as the organization s capabilities relate to quality, access, and timeliness of care. Strengths Weaknesses Quality Use of Appropriate Medications for People with Asthma (HEDIS measure) Access Children and Adolescent Access to PCPs (HEDIS measure) Cervical Cancer Screening (HEDIS measure) Adults Access to Preventive and Ambulatory Health Services (HEDIS measure) Breast Cancer Screening (HEDIS measure) CAHPS results Timeliness No timeliness strengths noted MDH QA Exam Quality Evaluation Practice Guideline report UM Percentage Decisions Upheld No timeliness weaknesses noted Table 26: IMCare s Strengths and Weaknesses Strengths Ranked in the 90 th percentile of Medicaid Quality Compass for the following HEDIS performance measures: Adults Access to Preventive and Ambulatory Health Services for ages years (PMAP and PGAMC) and 65 years and older (MSHO); Breast Cancer Screening (MinnesotaCare); Cervical Cancer Screening (PMAP); and Children and Adolescent Access to PCPs ages 12 to 24 months and 25 months to 6 years (PMAP). In the CAHPS, IMCare rated significantly higher than the PMAP average for Courtesy, Respect, and Helpfulness of Office Staff; MSC average as part of MSC Grouped Plans for Getting Care Without Long Waits, Courtesy, Respect, and Helpfulness of Office Staff, Health Plan Customer Service, and Getting Care That Is Needed; and MSHO average as part of the MSHO Grouped Plans for How People Rated Their Health Plan, How People Rated Their Health Care ratings, and Courtesy, Respect, and Helpfulness of Office Staff composites. Weaknesses Received 11 deficiencies including 1 repeat deficiency in the 2006 MDH QA Exam. Has the lowest percentage of MCO decisions upheld at 24%. A low percent of decisions upheld may be an indication of a flaw in the UM process, such as communication or timing. Chapter 6: MCO-specific Analysis Page 56

69 Rated significantly lower than the MinnesotaCare average for How People Rated Their Health Plan ratings and for Health Plan Customer Service composites in the CAHPS ATR Recommendations MPRO recommends IMCare consider the following actions: Monitor the capacity of the programs to ensure adequate staffing and functionality of IMCare; Conduct data quality checks to ensure consistent reporting of quality information in various documents; Include consistent and clear references to next steps for each item in the Quality Evaluation; and Include a description in the Practice Guideline Report of how the organization distributes its practice guidelines to providers and enrollees upon request. MEDICA Medica is one of Minnesota s largest MCOs and Preferred Provider Organizations, serving an average of 122,978 public program enrollees per month in 2006, accounting for 29.8% of the entire enrolled managed care population in the publicly funded programs. Medica provides services to enrollees in PMAP, PGAMC, MSHO, MSC, and MinnesotaCare programs. The following table summarizes Medica s strengths and weaknesses as the organization s capabilities relate to quality, access, and timeliness of care. Quality NCQA Accreditation Strengths Access Adults Access to Preventive and Ambulatory Health Services (HEDIS measure) Children and Adolescent Access to PCPs (HEDIS measure) Weaknesses Quality Evaluation & Work Plan Practice Guideline Report CAHPS results Timeliness No timeliness strengths noted No timeliness weaknesses noted Table 27: Medica s Strengths and Weaknesses Strengths Earned and maintains an Excellent accreditation status from NCQA for both its commercial and publicly funded products. Ranked 15 th in the nation in the U.S. News & World Report list of Best Medicaid Health Plans. Ranked in the 90 th percentile of Medicaid Quality Compass for the following HEDIS performance measures: Adults Access to Preventive and Ambulatory Health Services for ages years and 65 years and older, and Children and Adolescent Access to PCPs ages 12 to 24 months and 25 months to 6 years. Chapter 6: MCO-specific Analysis Page 57

70 Medica rated significantly higher than the MSHO average for How Well Doctors Communicate composites in the CAHPS. Weaknesses In the CAHPS, Medica rated significantly lower than the MinnesotaCare average for How People Rated Their Health Care ratings, and MSC average for Getting Care That Is Needed composites ATR Recommendations MPRO recommends Medica consider the following actions: Add a description in the Quality Evaluation of the organization s monitoring activities; Cross-reference the Quality Evaluation to the Work Plan to ensure that all activities receive mention in both documents and that the targets correlate accurately; and Compare the organization s findings in the Practice Guideline Report to national benchmarks, or give a rationale for this decision not to compare findings. METROPOLITAN HEALTH PLAN (MHP) MHP has been a licensed Health Maintenance Organization (HMO) since 1983 and has provided medical assistance benefits to public program enrollees since MHP operates under the sponsorship of Hennepin County and is one of only a few government-operated MCOs in the nation. MHP serves an average of 14,587 enrollees per month in PMAP, PGAMC, MSHO, MSC, and MinnesotaCare programs, accounting for 3.5% of the entire enrolled managed care population in publicly funded programs. The following table summarizes MHP s strengths and weaknesses as the organization s capabilities relate to quality, access, and timeliness of care. Strengths Weaknesses Quality No quality strengths noted Access Adults Access to Preventive and Ambulatory Health Services (HEDIS measure) Chlamydia Screening (HEDIS measure CAHPS results Breast Cancer Screening (HEDIS measure) Timeliness No timeliness strengths noted Quality Evaluation & Work Plan Practice Guideline Report No access weaknesses noted No timeliness weaknesses noted Table 28: MHP s Strengths and Weaknesses Chapter 6: MCO-specific Analysis Page 58

71 Strengths MHP ranked in the 90 th percentile of Medicaid Quality Compass for the following HEDIS performance measures: Breast Cancer Screening (MSHO); Adults Access to Preventive and Ambulatory Health Services for ages 24 to 44 years (PMAP), 65 years and older (MSHO and MSC); Chlamydia Screening in Women ages 16 to 25 years (PMAP); and Children and Adolescent Access to PCP ages 25 months to 6 years (MinnesotaCare). In the CAHPS, MHP rated significantly higher than the MSC average as part of MSC Grouped Plans for Getting Care Without Long Waits, Courtesy, Respect, and Helpfulness of Office Staff, Health Plan Customer Service, and Getting Care That Is Needed, and MSHO average as part of MSHO Grouped Plans for How People Rated Their Health Plan, How People Rated Their Health Care ratings, and Courtesy, Respect, and Helpfulness of Office Staff composites. Weaknesses In the CAHPS, MHP rated significantly lower than the PMAP average MHP for Getting Care without Long Waits composites, and MinnesotaCare average for How People Rated Their Health Plan ratings ATR Recommendations MPRO recommends MHP consider the following actions: Use accepted statistical methods of analysis to determine real improvement in the Quality Evaluation; Develop the Work Plan in a format that allows clear identification of key items that MHP will address in upcoming years; Complete and document a more thorough data analysis, and use comparable rates in the Practice Guideline Report; and Document how the organization is ensuring practice guidelines application to decisions for UM, enrollee education, services coverage, and other areas to which there is application and consistency with the guidelines in the Practice Guideline Report. Chapter 6: MCO-specific Analysis Page 59

72 PRIMEWEST HEALTH SYSTEM (PRIMEWEST) Organized through a Joint Powers Board of ten local county governments as a CBP, PrimeWest is a publicly funded MCO serving rural counties of western Minnesota. PrimeWest commenced enrollment in July 2003 and now provides services to approximately 9,461 enrollees in the PMAP, PGAMC, MSHO, MSC, and MinnesotaCare programs in Big Stone, Douglas, Grant, McLeod, Meeker, Pipestone, Pope Renville, Stevenson, and Traverse counties, accounting for 2.3% of the entire enrolled managed care population in publicly funded programs. The following table summarizes PrimeWest s strengths and weaknesses as the organization s capabilities relate to quality, access, and timeliness of care. Strengths Weaknesses Quality 99.2 % TSOC Audit compliance Quality Evaluation and Work Plan Comprehensive Diabetes Care (HEDIS measure) Use of Appropriate Medications for People with Asthma (HEDIS measure) Access Adults Access to Preventive and Ambulatory No access weaknesses noted Health Services (HEDIS measure) Cervical Cancer Screening (HEDIS measure) Children and Adolescent Access to PCPs (HEDIS measure) CAHPS results Timeliness No timeliness strengths noted No timeliness weaknesses noted Table 29: PrimeWest s Strengths and Weaknesses Strengths Demonstrated 99.2 % compliance with all TSOC standards. Ranked in the 90 th percentile of Medicaid Quality Compass for the following HEDIS measures: Adults Access to Preventive and Ambulatory Health Services for all years (PMAP, PGAMC, and MinnesotaCare), years (PMAP), and ages 65 years and older (MSHO); Cervical Cancer Screening (PMAP); Children and Adolescent Access to PCPs ages 12 to 24 months and 25 months to 6 years (PMAP); Comprehensive Diabetes Care HbA1c Screening (PGAMC and MSHO); and Use of Appropriate Medications for People with Asthma ages 5 to 56 years (PMAP). Chapter 6: MCO-specific Analysis Page 60

73 In the CAHPS, PrimeWest rated significantly higher than the PMAP average for Getting Care without Long Waits MSC average as part of MSC Grouped Plans for Getting Care Without Long Waits, Courtesy, Respect, and Helpfulness of Office Staff, Health Plan Customer Service, and Getting Care That Is Needed, and MSHO average as part of MSHO Grouped Plans for How People Rated Their Health Plan, and How People Rated Their Health Care ratings, and Courtesy, Respect, and Helpfulness of Office Staff composites. Weaknesses In the CAHPS, PrimeWest rated significantly lower than the PMAP average for How People Rated Their Health Plan ratings ATR Recommendations MPRO recommends PrimeWest consider the following actions: Use the previous year s Work Plan to develop the next Quality Evaluation and key identifiers, and format the evaluation to demonstrate clearly the connection between the two documents. Use accepted statistical methods of analysis to determine real improvement, including an analysis of trends for every activity in the Quality Evaluation. Cross-reference the Quality Evaluation to the Work Plan to ensure that all activities receive mention in both documents. SOUTH COUNTRY HEALTH ALLIANCE (SCHA) SCHA is a partnership of nine Minnesota counties formed as a CBP in For 2006, SCHA serves 12,903 enrollees in the PMAP, PGAMC, MSC, and MSHO programs in Brown, Dodge, Freeborn, Goodhue, Kanabec, Sibley, Steele, Wabasha, and Waseca counties in southeast Minnesota, accounting for 3.1% of the entire enrolled managed care population in publicly funded programs. Chapter 6: MCO-specific Analysis Page 61

74 The following table summarizes SCHA s strengths and weaknesses as the organization s capabilities relate to quality, access, and timeliness of care. Strengths Weaknesses Quality Comprehensive Diabetes Care (HEDIS measure) Access Adults Access to Preventive and Ambulatory Health Services (HEDIS measure) CAHPS results Timeliness No timeliness strengths noted 70% TSOC Audit compliance Quality Evaluation and Work Plan Practice Guideline Report No access weaknesses noted No timeliness weaknesses noted Table 30: SCHA s Strengths and Weaknesses Strengths SCHA ranked in the 90 th percentile of Medicaid Quality Compass for the HEDIS performance measure: Adults Access to Preventive and Ambulatory Health Services for ages 20 to 44 years (PMAP, PGAMC, and MinnesotaCare) and 65 years and older (MSHO); and Comprehensive Diabetes Care HbA1c testing (MSHO). In the CAHPS, SCHA rated significantly higher than the MSC average as part of MSC Grouped Plans for Getting Care Without Long Waits, Courtesy, Respect, and Helpfulness of Office Staff, Health Plan Customer Service, and Getting Care That Is Needed, and MSHO average as part of MSHO Grouped Plans for How People Rated Their Health Plan, and How People Rated Their Health Care ratings, and Courtesy, Respect, and Helpfulness of Office Staff composites. Weaknesses SCHA s overall TSOC compliance rating is the lowest of the nine MCOs at 70% 45. In the CAHPS, SCHA rated significantly lower than the PMAP average for How Well Doctors Communicate composites. 45 Based on the findings of the 2005 TSOC Audit. Chapter 6: MCO-specific Analysis Page 62

75 2006 ATR Recommendations MPRO recommends SCHA consider the following actions: Cross-reference the Quality Evaluation to the Work Plan to ensure that all activities receive mention in both documents. Provide detailed improvement strategies or corrective actions with dates of implementation in the Practice Guideline Report. UCARE MINNESOTA (UCARE) UCare is a non-profit MCO founded in 1984 by the Department of Family Practice at the University of Minnesota Medical School. UCare is now an independent MCO and is the fourth largest MCO in the state. In 2006, UCare served an average of 81,755 enrollees per month, accounting for 19.8% of the entire enrolled managed care population in publicly funded programs. UCare serves enrollees in the PMAP, PGAMC, Minnesota Disability Health Option (MnDHO), MSHO, MSC, and MinnesotaCare programs. The following table summarizes UCare s strengths and weaknesses as the organization s capabilities relate to quality, access, and timeliness of care. Strengths Weaknesses Quality Comprehensive Diabetes Care (HEDIS measure) Access Adults Access to Preventive and Ambulatory Health Services (HEDIS measure) Children and Adolescent Access to PCPs (HEDIS measure) CAHPS results Timeliness No timeliness strengths noted Quality Evaluation and Work Plan Practice Guideline Report G&A process No timeliness weaknesses noted Table 31: UCare s Strengths and Weaknesses Strengths Ranked in the 90 th percentile of Medicaid Quality Compass for the following HEDIS performance measures: Comprehensive Diabetes Care HbA1c testing (PGAMC); Adults Access to Preventive and Ambulatory Health Services for ages years (PMAP), years (PMAP and PGAMC), and 65 years and older (MSHO and MSC); and Children and Adolescent Access to PCPs ages 12 months to 24 months (PMAP) and 25 months to 6 years (PMAP and MinnesotaCare). In the CAHPS, UCare rated significantly higher than the MSC average as part of MSC Grouped Plans for Getting Care Without Long Waits, Courtesy, Respect, and Helpfulness of Office Staff, Health Plan Customer Service, and Getting Care That Is Needed. Chapter 6: MCO-specific Analysis Page 63

76 Weaknesses In the CAHPS, UCare rated significantly lower than the MinnesotaCare average for How People Rated Their Specialist ratings. UCare s relatively high rate of G&As combined with a high percentage of decisions overturned indicates a flaw in the process ATR Recommendations MPRO recommends UCare consider the following actions: Include barrier analysis to the Quality Evaluation; Cross-reference the Quality Evaluation to the Work Plan to ensure that all activities receive mention in both documents; Provide detail in the Practice Guideline Report about which type of guidelines the organization uses (by topic) and how UCare made the decision to adopt each one; Document complete HEDIS rates with numerators and denominators when describing changes in rates in the Practice Guideline Report; and Include how the organization disseminates practice guidelines to providers and enrollees in the Practice Guideline Report. Evaluate the UM process to determine the contributing factors to the high G&A rate and high percentage of decisions overturned. Chapter 6: MCO-specific Analysis Page 64

77 CHAPTER 7: DISCUSSION AND ADVICE TO DHS Over the years, the Department of Human Services (DHS) has sought out and acted on various weaknesses, both in the structure of its programs and the requirements of the managed care organizations (MCOs) to meet the requirements of the DHS/MCO Contract. Whereas the programs are working well, Michigan Peer Review Organization (MPRO) presents the following considerations to DHS for supporting the development and maintenance of quality improvement initiatives. This chapter also discusses each MCO s progress with MPRO 2005 ATR recommendations. WHAT IS WORKING WELL DHS s efforts toward reducing the MCOs burden and minimizing duplication are a positive change and merit mention. Examples of this reduction are evident in numerous activities, including reporting requirements and compliance reviews. For example, DHS allows the MCOs to report only the results of their PIPs to the State with the expectation that the MCOs will incorporate annual monitoring into their organization s QA Evaluation. In addition, DHS has eliminated separate reporting requirements for the Practice Guideline Report and the Special Health Care Needs Report. Doing so reduces the number of duplicative reports each MCO must generate. Perhaps the most notable change is in the expansion of the Minnesota Department of Health (MDH) Quality Assurance Examination (QA Exam) process to include Triennial Structural Operations Components (TSOC) Audit requirements. MPRO recognizes that preparation for any type of review or audit is both stressful and taxing on resources. Combining the requirements of the two reviews is likely to allow the MCOs more time to prepare and fully address the findings between reviews without receiving conflicting messages from various agencies within the State. WHAT TO CONSIDER As the MCOs continue to grow and mature in the quality and depth of their reporting and the structure of their operations, DHS may choose to consider addressing several recurring issues across MCOs or as part of the emerging direction of health care services. Performance Measurement Goals Following MPRO s advice from the 2004 ATR, DHS began development of a methodology to establish performance measurement expectations MPRO provided additional goal setting input in the 2005 ATR 46. The advice suggested setting the current year goal based on a three-year rolling average to account for normal variation in the measures. If the average is Greater than or equal to 90%, the goal is set at 90%; Between 75% and 89%, the goal is set at 10% of the gap between the three-year average and 90% (for example: three year average = 80%; = 10; 10 x 10% = one; one + 80% = goal of 81%); and Less than 75%, the goal is set at the three-year average plus five percentage points (for example: three year average = 70% + five percentage points = goal of 75%) Annual Technical Report, February 2007, Chapter 6, p 59. Chapter 7: Discussion and Advice to DHS Page 65

78 This strategy provides three different goal-setting techniques based on where the measure begins and recognizing the difficulties of achieving incremental increases as measures approach 90%. Because DHS has not adopted a specific goal-setting technique this goal measurement process remains an MPRO suggestion. Using the methodology presented in the 2005 ATR, MPRO has re-calculated the results by MCO and program against 17 select performance measure goals. Appendix H MCO HEDIS Performance to Goals provides a summary of the MCO HEDIS performance to goals by PMAP and MinnesotaCare program. PrimeWest performed the best among the MCOs in this hypothetical calculation attaining 82% of its PMAP goals. Conversely, MHP attained the lowest percentage of its PMAP goals at 25%. MHP reached the highest percentage of MinnesotaCare goals at 71% and IMCare was the lowest for MinnesotaCare goals at 31%. Based on the above methodology, all nine of the plans reached their performance goals for the two HEDIS measures Children and Adolescents Access to Primary Care Practitioners for the month age group and Comprehensive Diabetes Care HbA1c Testing. Viewing hypothetical results by MCO, only three MCOs would meet their 2005 goal for HbA1c screening for diabetics: BluePlus, SCHA, and UCare. HP would be the only MCO to meet its goal for Chlamydia screening and its goals for all three age ranges for Adult Ambulatory/Preventive Visits. FirstPlan would be the only MCO that would not meet any of the 2005 goals for Adult Ambulatory/Preventive Visits for the three age ranges. Quality Evaluations and QI Work Plans One area where the MCOs have demonstrated variable quality is the QI Work Plans and Quality Evaluations submitted to DHS each year. MCOs have shown an overall improvement in the quality of these documents. However, some areas remain as weaknesses for many of the MCOs, including the quality of the statistical analysis and results reporting in the Quality Evaluation. Another issue is the lack of consistent linkages between the Quality Evaluation and the Work Plan by some MCOs. The most common linkage issue is that activities presented in the Work Plan for a specified year are not evaluated or discussed in detail in the Quality Evaluation for the same year s activities. It is clear that reviewing the Minnesota Statutes and DHS/MCO Contract is insufficient to provide the needed clarification. As in years past, MPRO is available to provide technical assistance to the MCOs on this issue. Further, DHS may choose to consider a plan for managing conflicting messages from other agencies or outside entities, such as Minnesota Department of Health (MDH) and National Committee for Quality Assurance (NCQA) regarding the quality and acceptability of these QI documents. For example, Metropolitan HealthPartners (MHP) reports that it received instructions from MDH to submit a Work Plan Evaluation instead of an actual Work Plan. Not only is this evaluation duplicative of the Quality Evaluation that MHP also submitted, it appears to be in direct conflict with the requirements of the DHS/MCO Contract section 7.1.7, Annual Quality Assurance Work Plan, which requires each MCO to provide DHS an annual written Work Plan. The Work Plan describes the organization s proposed QA programs and PIPs for the upcoming DHS/MCO Contract year. What most likely occurred is that MHP misunderstood the advice provided by MDH. It is unlikely that MDH would advise the MCO to develop two duplicative documents. As another example, although MPRO has consistently found HealthPartners s Work Plan to be unclear and unusable as an actual working document, according to HP, the Centers for Medicare and Medicaid Services (CMS), MDH, and NCQA have consistently accepted the document. While it is not MPRO s intention to oppose the findings of other entities, it is unclear how the other entities would find the document to be acceptable given the quality of the documents that DHS provided to MPRO for evaluation in the context of this Annual Technical Report (ATR). Chapter 7: Discussion and Advice to DHS Page 66

79 Transparency in Reporting The information that exits within our health care system is complex. How well providers perform in the delivery of health care is an aspect of data that until recently, thanks in large part to the increase in access to and use of the Internet, has been previously unseen by the public. As noted in the Committee on Quality of Health Care in America, Institute of Medicine s influential book, Crossing the Quality Chasm: A New Health Care System for the 21st Century, an increase in transparency is essential to the changes needed to improve health care. The author comments, The system should make available to patients and their families information that enables them to make informed decisions [T]his should include information describing the system s performance on safety, evidence-based practice, and patient satisfaction. 47 The findings of the TSOC Audits, MDH QA Exams, and the ATR are essential tools that major stakeholders, including advocacy groups, MCOs, and enrollees, can use to gain a comprehensive picture of the quality of health care services to enrollees of publicly funded programs. Publicizing information on health system performance can help to make MCOs and DHS more accountable to enrollees for the overall quality of care provided to enrollees. For the reports to serve this purpose there must be added transparency of the results to the public. One way to achieve this is to post the reports (or at least executive summaries) on the DHS Web site. Another is to take key elements of information from the findings and make supplemental reports that highlight select areas of interest for key stakeholders. Financial Incentives and Disincentives The financial incentives in the DHS/MCO Contract have had a positive impact on the expansion of child preventive services. What is not clear, however, is whether there is a direct relationship between the implementation of incentives that reduce the financial barrier and the expansion of services. Once MCOs meet their quality goals, based on incentives, it remains unclear from the findings whether continuing the incentives helps to maintain the current level of preventive services and improvements already achieved. After accumulating additional data, DHS should consider engaging in a comprehensive financial evaluation of its incentive and disincentive efforts. MPRO S ASSESSMENT OF 2005 ATR RECOMMENDATIONS The following is a brief, subjective assessment of each MCO s progress toward addressing the recommendations of the 2005 ATR. Because improvements take time, and MPRO has not asked the MCOs to respond formally to these recommendations, this assessment should be used to gauge each organization s current level of effort and may highlight topics that DHS may wish to follow up on in upcoming months. BLUE PLUS Blue Plus s progress with MPRO s 2005 ATR recommendations is as follows: Look at the causes for the high number of MDH QA Exam deficiencies and institute steps to ensure that the correction and monitoring of deficiencies in the future to avoid repeated deficiencies. Although Blue Plus currently has no repeat deficiencies, the identified issues related to Grievances and Appeals identified during the 2006 Targeted MDH QA Exam will be re-evaluated during the next QA Exam scheduled for the second quarter of Michael A. Barger. Crossing the Quality Chasm: A New Healthcare System for the 21st Century. Healthcare Financial Management. March 2003: 9 Chapter 7: Discussion and Advice to DHS Page 67

80 Modify written documentation to reference the specific regulation supporting its actions when sending DTR notices. Blue Plus has not indicated how it has addressed this recommendation in any of the documents used to formulate the 2006 ATR, including the MCO responses in the 2005 ATR, the Quality Evaluation and Work Plan and other documents. Review process for initial decisions for G&As and address any identified causes of the high G&A reversal rate. This issue has persisted for Blue Plus. MPRO continues its recommendation for Blue Plus to examine its G&A process to determine and act on weaknesses. The current Work Plan specifies actions related to the appeals, utilization and utilization management (UM) decision-making processes, including quarterly internal monitoring of select quality indicators. MPRO will continue to monitor Blue Plus s progress for this recommendation in the future. FIRSTPLAN OF MINNESOTA (FIRSTPLAN) FirstPlan s progress with MPRO s 2005 ATR recommendations is as follows: Improve the Quality Evaluation and Work Plan to include sufficient detail, clear narratives, and critical evaluations. FirstPlan has improved notably by completely revising the format of its Quality Evaluation and Work Plan. The new documents are much more effective at conveying clear and detailed information that is both meaningful and actionable. HEALTHPARTNERS (HP) HP s progress with MPRO s 2005 ATR recommendations is as follows: Improve the Work Plan to meet requirements better by including sufficient detail to direct the MCO s quality improvement initiatives. HealthPartners has not adjusted the format of its Work Plan, citing in its MCO comments from the 2005 ATR, [O]ur work plans and quality evaluations comply with MDH, NCQA, and CMS requirements and expectations. Whereas MPRO suggests noncompliance with Minnesota (MN) Rule , MDH accepts a 100% score on the corresponding NCQA standard as equivalent to the MN Rule. MPRO does not agree with HP s position of maintaining a document that clearly lacks the necessary elements to be a working document and will discontinue our recommendation for HP to improve its Work Plan. ITASCA MEDICAL CARE (IMCARE) IMCare s progress with MPRO s 2005 ATR recommendations is as follows: Address all areas of non-compliance with the DHS/MCO Contract. Following MPRO s re-evaluation of IMCare in 2006 for compliance with TSOC requirements, IMCare has moved from 45% compliance with contractual requirements to 95% compliance. This marked improvement is telling of IMCare s effort over the past year to address areas of noncompliance. In the future, it will be imperative that IMCare continue to monitor its own progress and ability to maintain and make its newly developed policies and procedures operational. Improve the Work Plan and Quality Evaluation. MPRO has noted significant improvement in the level of detail and clarity of IMCare s current Work Plan and Quality Evaluation. IMCare will need to implement quality checks to ensure that data reported in the Quality Evaluation matches information provided in other contexts and that there are next steps identified for each activity included in the evaluation; Institute a disease management program for diabetic and asthmatic enrollees. According to the Disease Management Report contained in the 2007 Program Evaluation, IMCare has contracted with Caremark to provide the CarePatterns DM Program to its enrollees for eight targeted clinical conditions. Although relatively new, the program already has targeted 215 enrollees to the adult asthma program, 245 to the pediatric asthma program, and 176 enrollees to the Diabetes program. It is not clear from the report how many of these people actually have enrolled. Chapter 7: Discussion and Advice to DHS Page 68

81 Modify the DTR processes to be certain it is able to provide exact copies/duplicates of Denials, Terminations and Reductions (DTR) with accurate dates for quality oversight purposes. IMCare currently generates DTR statistics in the context of its Quality Evaluation; however, this quality-monitoring tool does not track IMCare s ability to meet the prescribed timeliness requirements for DTRs. MPRO recommends IMCare consider adding this indicator to the reporting elements of the Quality Evaluation. Modify written documentation to reference the specific regulation supporting its actions when sending DTR notices. In the documents presented for evaluation in the 2006 ATR, IMCare has not indicated how it has addressed this recommendation. MEDICA Medica s progress with MPRO s 2005 ATR recommendations is as follows: Develop policies to address care coordination of American Indians, individualized educational and family care plans, and children s mental health and family services collaborative. In the MCO comments of the 2005 ATR, Medica noted, Our aim has always been to treat all our members the same when it comes to care coordination, so we had established a global care coordination policy. However, when the auditors requested that we single out the above three populations by name in our policy, we immediately revised it. Modify the DTR processes to provide exact copies or duplicates of DTRs with accurate dates for quality oversight purposes. Modify written documentation to reference the specific regulation supporting its actions when sending DTR notices. However, Medica did note in its MCO comments to the 2005 ATR that they have taken immediate action to address the two other Medica-specific ATR recommendations. Monitor processes to ensure that Medica develops a care plan for every MSHO enrollee at the beginning of program enrollment. However, Medica did note in its Quality Evaluation that it has been conducting detailed reviews of its MSHO care coordination process at the care-system level to identify weaknesses. The annual quality site visits review quality improvement activities and regulatory requirements, rate cell changes and care plan documentation. The report in the Quality Evaluation noted some continued weaknesses and strengths in care coordination, but the organization fully meets the intent of MPRO s previous recommendation. Ensure clear linkages between the Quality Evaluation and the Work Plan. Although the current Work Plan and Quality Evaluation are well integrated, the goals in the Work Plan must directly correlate with the targets in the Quality Evaluation. MPRO will continue to monitor Medica s progress for this recommendation. METROPOLITAN HEALTH PLAN (MHP) MHP s progress with MPRO s 2005 ATR recommendations is as follows: Address the QA Exam deficiencies and recommendations. Monitor progress by addressing CAP-identified deficiencies. In the organization s MCO comments from the 2005 ATR, MHP noted, MHP has taken action on every deficiency and recommendation made by MDH and is preparing for a Mid-cycle audit in Monitor processes to ensure that MHP develops a care plan for every enrollee at the beginning of program enrollment and works toward adopting electronic documentation systems to ensure improved accountability and continuity for MSHO enrollees. In its MCO comments from the 2005 ATR, MHP noted, Although no official form is required, we are in the process of developing an electronic standardized format for care plan documentation for internal use by MHP case managers to assure accountability and continuity for our enrollees. Improve Quality Evaluation and Work Plans documents so that the Quality Evaluation includes findings and trend data. The Quality Evaluation also must include sufficient detail, clear narratives, and critical evaluations so the Work Plan is an accurate, usable document that assists the MCO in directing quality improvement efforts. In its MCO comments from the 2005 ATR, MHP noted, [D]uring the 2005 MDH audit, MHP was required to make some Chapter 7: Discussion and Advice to DHS Page 69

82 changes to the Quality Program. MDH recommended that MHP migrate information from the Work Plan into the Quality Program and begin to do an annual evaluation of the Quality Program instead of the Work Plan. MHP was not asked and therefore did not provide the Quality Program to MPRO or the DHS. MPRO did not receive the full array of materials. Calling the documents not well prepared may be inaccurate since MHP was transitioning these documents at the suggestion of MDH. Based on the duplicative documentation that MHP submitted, it is clear MHP misunderstood the advice of MDH. In general, the Quality Evaluation is an evaluation and detailed analysis of the previous year s Work Plan. To submit both a Quality Evaluation and a Work Plan Evaluation would not meet the intent of the DHS/MCO Contract. Investigate and address causes of the 8% voluntary enrollment change rate. In its MCO comments from the 2005 ATR, MHP noted, MHP is carefully analyzing the disenrollment survey results to identify weaknesses. Expand the number of practice guidelines it reports to DHS. MHP has doubled the number of guidelines included in the report from two to four. PRIMEWEST HEALTH SYSTEM (PRIMEWEST) PrimeWest s progress with MPRO s 2005 ATR recommendations is as follows: Develop linkages between the Quality Evaluation and Work Plan, which are evident to the reader and ensure the Work Plan is a stand-alone document. PrimeWest has improved the format of its Work Plan; however, key details for every activity noted are inconsistent. MPRO encourages PrimeWest to continue to address this recommendation since it has become a recurring opportunity for improvement. SOUTH COUNTRY HEALTH ALLIANCE (SCHA) SCHA s progress with MPRO s 2005 ATR recommendations is as follows: Develop policies and procedures for utilization management over- and under-utilization and pharmaceutical management. Update the various policies identified as incomplete during the TSOC Audit. Review all policies and procedures to include SCHA s name on the documentation, and receive appropriate committee(s) approval for all documentation. In the organization s Quality Evaluation, SCHA noted that, SCHA recognized the need for a formal process for development and approval of SCHA policies and procedures. Therefore, SCHA developed a formal process for development of policies and procedures including a policy and procedure template and review and approvals by SCHA s Compliance Committee and Joint Powers Board. Compliance 360, a compliance tracking and documentation system, was purchased to track the development, approval, and annual review processes. This Internet-based system is also used to house policies, procedures, and other critical documents. In 2006, sixty new policies were approved by the Joint Powers Board. Modify the DTR processes to provide exact copies or duplicates of DTRs with accurate dates for quality oversight purposes. Modify written documentation to reference the specific regulation supporting the organization s actions when sending DTR notices. SCHA did make the following general comment in its Quality Evaluation, In 2007, SCHA plans to complete an internal audit of SCHA s compliance with Minnesota statutes and rules, federal regulations, applicable NCQA standards, and the DHS contract. This process will assist SCHA with assuring compliance with state and federal requirements for managed care organizations. Investigate causes for high rates of overturned initial decisions through closed appeals and State Fair Hearings, and address resultant issues in its Work Plan. In the organization s Quality Evaluation, SCHA noted that, SCHA was pleased that the 2006 rate declined significantly from 2005 since the high rate of overturned appeals in 2005 was found to be largely the result from a drug formulary change that led to several negative coverage decisions being reversed on appeals. SCHA will continue to monitor the volume of overturned appeals in Chapter 7: Discussion and Advice to DHS Page 70

83 UCARE MINNESOTA (UCARE) UCare s progress with MPRO s 2005 ATR recommendations is as follows: Monitor processes to ensure the development of a care plan for every MSHO enrollee at the beginning of program enrollment. MPRO will conduct the next MSHO review in Although UCare s Quality Evaluation does include a description of the MSHO care plan, there is no related evaluation on how UCare has sought to monitor the organization s progress for ensuring that a developed plan exists for every MSHO enrollee. Modify the DTR processes to provide exact copies or duplicates of DTRs with accurate dates for quality oversight purposes. In the organization s 2005 ATR comments, UCare provided the following update, We are aware that the DTR notices submitted for the audit showed the same date (the date they were generated). It is UCare s intent to solve this situation. In the meantime, accurate DTR timelines can be generated, although the need is infrequent. Conclusion MCOs are performing at acceptable levels, with only a few areas where MCOs have demonstrated noncompliance. In fact, several MCOs are considered among the best in the country. Most areas identified as weaknesses are opportunities to improve the quality of services, such as enhancements to the Quality Evaluation and Work Plan documents. The goal is to continue delivering effective, timely, patient-centered, and quality health care on behalf of vulnerable publicly funded program population, including children, seniors, disabled, and the poor. To do so, DHS must expect more from its vendors, and MCOs must recognize their interdependence on the health care community as a whole. MPRO advises DHS put forward efforts to continue refining processes, rewarding MCOs that exceed expectations; building positive, collaborative relationships with MCOs; and looking for new areas to focus improvement efforts to advance this goal. MPRO advises DHS to consider the following actions: Consider a plan to manage conflicting messages MCOs receive from other agencies or review entities, Increase transparency of quality reporting, Evaluate financial incentives and disincentives over time, Consider adopting performance measure goals, Monitor closely MCO progress, addressing 2005 ATR recommendations. Continuing to build the partnership between DHS and its MCOs that will accelerate and sustain progress toward a high-performance quality health care system for the publicly funded program population will require bold, intentional, and far-reaching changes. This report can serve as the catalyst for such progress. Chapter 7: Discussion and Advice to DHS Page 71

84 CHAPTER 8: MCO COMMENTS The 2007 DHS/MCO Contract Section provides each MCO the opportunity to review the final draft of the Annual EQR Technical Report prior to the report s publication and provide DHS with written comments. The STATE shall allow the MCO to review a final draft copy of the Annual EQR Technical Report prior to the date of publication. The MCO shall provide the STATE written comments about the study report, including comments on its scientific soundness or statistical validity, within 30 days of receipt of the final draft study report. The STATE shall include a summary of the MCO s written comments in the final publication of the study report, and may limit the MCO s comments to the study report s scientific soundness and/or statistical validity. MPRO considers the comments from the MCOs valuable feedback to inform future ATRs and correct errors in the ATR. The final draft of the 2006 ATR was sent to the MCOs for their comments on December 12, 2007 and DHS received comments from four MCOs; First Plan, HealthPartners, SCHA and UCare. In accordance with this contract provision, MPRO has included a summary of each responding MCO s written comments below. FIRSTPLAN OF MINNESOTA (FIRSTPLAN) We have one comment directed towards the partial finding on the TSOC audit. The timeframes were clearly in our PBM s policies and procedures and MPRO recommended that as a matter of courtesy we should include the non-formulary exception request timelines in our internal policy and procedures. Thank you for allowing us the opportunity to respond. Alyssa Meller Public Programs Manager First Plan of Minnesota/First Plan Blue HEALTHPARTNERS (HP) We are writing with regard to the final draft of the 2006 Annual Technical Report (ATR) as produced by the Michigan Peer Review Organization (MPRO) and the (DHS). As specified in the 2007 DHS/MCO Contract Section 7.5.4, we have the opportunity to review the final draft prior to publication and submit written comments about the report. We have the following comments regarding the HealthPartners-specific results in the following categories: CAHPS Results HealthPartners has a multi-disciplinary work group that analyzes the CAHPS results and determines follow-up actions as needed. CAHPS results are shared with leadership at the Government Programs Quality and Utilization Improvement Committee, the HPCare Quality Utilization Improvement Work Group and the Government Programs Operations Committee. Feedback from these committees is included in our CAHPS analysis and action plans. The results of HealthPartners analysis identified the following factors as impacts on the CAHPS results specified in the ATR report as below the PMAP, MSC or MSHO average: PMAP average for How People Rated Their Specialist rating: Chapter 8: MCO Comments Page 72

85 o Analysis found that specialty access is an issue that needs to be addressed on a broad level. There is a nationwide shortage of specialists, most notably, Dermatologists, Geriatricians, and Psychiatrists. The following examples illustrate this shortage. Wait times for both routine and urgent dermatology appointments typically exceed 3 to 4 weeks (Journal of the American Academy of Dermatology, 2007 Dec) Minnesota has 710 licensed psychiatrists, only 512 of whom provide direct patient care, according to the MPS (33 percent fewer per capita than the national average). Today, 70 of 87 Minnesota counties meet federal criteria for mental health professional shortages. By 2010, the state will need an estimated 907 psychiatrists, assuming the national average remains at 16.5 for every 100,000 people (Minnesota Medicine, January 2007). Approximately 85% of both deans and medical society respondents perceived shortages of physicians, usually in multiple specialties (JAMA Dec 10) seems to be a pivotal year in acknowledging the shortage of physicians especially by the AMA. Newer reports and cites continue to use this article as a benchmark. If current trends continue, the full time equivalent (FTE) physician supply is projected to grow to 866,400 by 2020, while the demand for physicians will increase to 921,500 due to the growth and aging of the U.S. population. The report projects shortages will be greatest in non-primary care specialties. (Health Resources and Services Administration (HRSA) Physician Supply and Demand: Projections to October 2006). o HealthPartners has formed a work group to do a root cause analysis of this issue with the goal of determining an action plan. MSC average for Health Plan Customer Service composite rating: o In our analysis of this rating, we did not find a significant HealthPartners issue that contributed to a lower MSC score. When we evaluate our CAHPS scores, we also look for how the scores trend over the years. Since we did not find a trend with a low composite rating, we will continue to monitor this area in our 2008 CAHPS results to determine if the trend continues. o There were several changes that may have contributed to the 2007 rating. MSC members with Part D coverage were enrolled into Stand-Alone PDPs in This change may have contributed to the lower rating for these members. It changed drug coverage and lead to member confusion since the drug benefit was fragmented from their medical coverage. The health plan was not able to resolve all issues with their drug coverage. We anticipate this benefit fragmentation may continue to be a dissatisfier in future CAHPS results. MSC member reaction to some PCA network and management changes may have contributed to dissatisfaction in this composite rating. Now that members are familiar with HealthPartners PCA network and process, we do not expect this will continue to be a dissatisfaction trend in future years. MSHO average for How People Rated their Health Plan, How People Rated Their Health Care, How Well Doctors Communicate, Getting Care Without Long Waits, and Courtesy, Respect, and Helpfulness of Office Staff ratings: o Analysis found that while there are opportunities for improvement in the areas identified, many of the issues that may have impacted the results have been resolved Chapter 8: MCO Comments Page 73

86 and/or, there already were current initiatives in place to address the areas that received low results. o HealthPartners Case Management continues to take a proactive approach in communicating our PCA network and eligibility requirements. o HealthPartners has an initiative in place to enhance the patient s clinic experience. For example, an enterprise-wide training was conducted regarding ways to create a welcoming clinic environment. o HealthPartners started a pilot program to identify long wait times at clinics; members are given the option to reschedule appointments. The 2006 ATR report states This report is the result of MPRO s assessment and review activities during However, it is noted that the CAHPS results in the 2006 ATR report are for the 2007 Managed Care Public Programs Consumer Satisfaction Survey. The 2005 ATR report contained information on the 2005 CAHPS survey results. Therefore, the 2006 CAHPS results have not been addressed in an ATR. Work Plan HealthPartners has consistently achieved 100% compliance with NCQA, MDH and CMS requirements related to the Annual Work Plan. The format is a reflection of the corporate strategic planning process in which health improvement focuses on all of our members and patients, regardless of product. Going forward, HealthPartners will create a State Public Programs Annual Work Plan that will incorporate the recommendations included in the ATR Minnesota Department of Health (MDH) Quality Assurance (QA)Exam HealthPartners finds that citing the number of deficiencies found in a QA exam as a weakness is oversimplistic and misleading for a few reasons: First, MDH finds a deficiency in situations where there is non-compliance with a statute or rule, regardless of whether the non-compliance significantly affects the plan s members or is merely a technical deficiency that had no adverse affect on anyone. Accordingly, a single deficiency with a big impact on members might be more important than a dozen technical deficiencies but it is less likely that a QA exam with a single deficiency would be cited as a weakness, though the lesssignificant Exam with a dozen would surely be listed as a weakness. Second, MDH issues no more than a single deficiency for each provision of law. For example, if a plan failed to comply with a provision twice or three hundred times, it would be listed as a single deficiency. Third, four of HealthPartners seven deficiencies coming out of the 2006 Quality Exam were situations where a single instance of non-compliance was found or HealthPartners had selfcorrected the problem long before the exam. MDH has indicated that, going forward, they will no longer list these types of findings as deficiencies. Fourth, because the areas of focus, interpretations, and approaches to QA exams taken by MDH evolve over the years, and because the health plans are reviewed on a staggered basis, comparing or attributing significance to numbers of deficiencies as a means of indicating relative strength of plans is highly unreliable. For all these reasons, although it seems proper to list the results of quality exams completed in the past year as a factual part of the ATR, drawing conclusions or characterizing the strength or weakness of a plan based simply on the number of deficiencies found is misleading. Chapter 8: MCO Comments Page 74

87 Quality Indicator Report HealthPartners Practice Guideline Report is consistent with the format (Appendix K) that was provided as a reporting template with the 2004 ATR findings. It is unclear what report is being referred to as the Quality Indicator Report. The Clinical Indicators report is provided as an attachment to the guideline report and includes our audit results of provider compliance with the practice guidelines. The report reflects comparative provider performance on over 30 measures, which are based on evidence-based practice guidelines. If the guideline reporting template provided by MPRO does not comply with reporting requirements, it would be helpful to receive additional guidance from DHS. Practice Guidelines The recommendation to incorporate discussion of practice guidelines into County-based Purchasing Report does not pertain to HealthPartners, since HealthPartners is not a county-based plan. This recommendation should be removed from the report. 48 HEDIS Performance Measures Calculation HealthPartners understands the compliance requirement for DHS to produce some administrative performance measures for reporting purposes to CMS. These same measures, however, do not serve as the basis for quality improvement monitoring and initiatives. These measures do not have the benefit of full HEDIS methodology (i.e., hybrid) and full HEDIS auditing (source data are not audited) and conflict with other community measures. For quality improvement purposes, the community is best served when the nationally accepted methodology and rates are shared and used for providers, beneficiaries, plans, and purchasers. Other Comments On page 54, the report lists HealthPartners earning and maintaining an Excellent NCQA accreditation status on our commercial products as a strength. The report does not mention that HealthPartners also has earned and maintained an Excellent accreditation status on the Medicare Advantage Product 49. Overall Process For the ATR report development process, we strongly encourage that components of the report are shared during the year (or at least the results and summaries of every compliance review) prior to the issuance of the final draft. The reasons for this are three-fold: Feedback provided during the year may strengthen the health plan compliance process and outcome; The ability to provide comprehensive feedback is improved when more time is allowed for review of such a comprehensive report; Health plan ability to incorporate the results of the review into operations will be more timely. Thank you for considering our response to this report. We anticipate that the HealthPartners information and comments we provide in this letter will be included and attached to the final version of the ATR. Please do not hesitate to contact us if you have questions. 48 MPRO has removed this recommendation from the text of the report. 49 MPRO has added the mention of the Medicare Advantage accreditation to the list of strengths. Chapter 8: MCO Comments Page 75

88 Terry Crowson, M.D. Medical Director Medical Management and Government Programs HealthPartners Health Plan Jennifer J. Clelland Senior Director Government Programs SOUTH COUNTRY HEALTH ALLIANCE (SCHA) 1. The 2006 ATR identifies in a few places that two of the MCOs, Medica and Blue Plus, ranked in the top 15 of the entire nation in the quality of their Medicaid services in US World and News Report. While Medica and Blue Plus should be commended for this achievement, the readers of this report would not be aware that only NCQA Medicaid Accredited Health Plans or MCOs in the nation are ranked and rated in the US World and News Report. US World and News Report does not review and rank non-ncqa Accredited Medicaid Health Plans (the other 7 MCOs identified in this report) when doing this report. As an example, HealthPartners, although NCQA Accredited for their Medicare and Commercial products and ranked in US World and News Report for their excellence in quality of Commercial and Medicare services, are not eligible to be included in this group. As it is stated in the ATR, readers would be misled to believe that all MCOS identified in the ATR would be eligible for this ranking by US News and World Report. Readers could draw the conclusion that only Medica and Blue Plus provide quality Medicaid Services to their members and the other 7 MCOs identified in this report do not. SCHA strongly recommends that a statement and footnote be included on all pages that contain the above information as to identify that methodology that is used by US World and News Report in determining the ranking of MCOs and that this does not mean that the other MCOs do not provide quality Medicaid services. This would ensure that information contained in this report is accurately interpreted. 2. When identifying MCOs weaknesses, the ATR does not contain the frequency or specific information/ examples as to what led to this conclusion. An example is on page 28, under SCHA, when it states The Work Plan does not always include follow-up activities mention in the Quality Evaluation. SCHA is unsure what was missed and the frequency of the occurrence. SCHA will follow up on this finding, but without specific additional information, SCHA may not be addressing the right issue at the right time, leading to potentially the same conclusion in subsequent years. SCHA recommends that this information be shared either in the report or in a separate specific report to the individual MCOs. MCOs would then have a better understanding how the ATR drew the conclusion(s) and what/ how needs to be corrected or followed up on. 3. The ATR identifies in the Executive Summary the year that each MCO had their TSOC audit. However, in the remaining portion of the report, when the TSOC findings are cited, there is no mention of the year the specific finding was identified or the time period evaluated. The time period evaluated for SCHA, IMCare and Medica was 2004 and 2005 while the time period evaluated for Blue Plus, First Plan and Prime West was 2004, 2005 and The time period evaluated is especially important to know since MCO s level of sophistication varies greatly with their level of maturity. Since the ATR offers a comparison of MCOs, the reader should be made aware of these differences. If the reader does not read the entire 166+-page report, they could be led to the inaccurate conclusion that all of these findings were identified during the calendar year 2006, as the report title indicates. As an example, on pages iii of the Executive Summary and 62, one of SCHA s Chapter 8: MCO Comments Page 76

89 weaknesses is cited as 70% TSOC Audit compliance. Only on page 17 of the ATR report does it indicate the calendar year of each MCO s TSOC audit. SCHA recommends that this information type be cross-referenced throughout the report. 50 Annette Baumann Grievance, Appeal and Audit Manager South Country Health Alliance UCARE MINNESOTA (UCARE) We are responding to the final draft 2006 Annual Technical Report presented by MPRO to the Department of Human Services in October 2007 and sent to the plans on December 4, Thank you for the opportunity to comment on the draft ATR Recommendation Addressed In chapter 4, in discussing one of its 2004 recommendations (Recommendation 2 Use the MDH QA Examination Audit as part of the QI Evaluation and include specific documentation regarding activities, actions, time frames, and responsible parties in the QI Work Plan), MPRO notes that The findings of the MDH QA Exam can have a significant effect on an MCO s future monetary incentives and withholds. In addition, the elements covered as part of the review are relevant quality improvement issues and activities. In 2007, the QA Exam audit will expand to include elements previously addressed in the TSOC Audit. Therefore, it is essential that MCOs act upon this recommendation. Recognizing the value of this recommendation, all except UCare incorporated efforts to address audit findings into their organization s Work Plan or is in the process of doing so. UCare, however, stated that the organization will only consider incorporating the audit findings at a future date. UCare is committed to incorporating efforts to address audit findings in future work plans. We will review 2008 audit findings, evaluate the recommendations against our current 2008 Work Plan, and identify changes needed to improve the plan. We request that this be acknowledged in the final 2006 report ATR Recommendations Specific to UCare 1. MPRO recommended that UCare monitor its processes to ensure the development of a care plan for every MSHO enrollee at the beginning of program enrollment. MPRO noted that even though UCare s Quality Evaluation does include a description of the MSHO care plan, there is no related evaluation on how UCare has sought to monitor the organization s progress for ensuring that a developed plan exists for every MSHO enrollee. 50 MPRO has added the date of the SCHA TSOC Audit to the Executive Summary and the weaknesses. Chapter 8: MCO Comments Page 77

90 As part of delegation oversight, our audits include monitoring the establishment of care plans for MSHO members. Delegation agreements include a requirement that counties establish written plans of care for MSHO members. UCare audit tools for delegates include identifying whether delegates have a policy or procedure for developing a plan of care for each member. Specific member charts (UCare and delegates) are also audited to determine whether a plan of care was developed. We request that this be acknowledged in the final 2006 report. 2. MPRO also recommended that UCare modify the DTR processes to provide exact copies or duplicates of DTRs with accurate dates for quality oversight purposes. In our 2005 ATR comments, we noted our intent to solve this situation, but that in the meantime, accurate DTR timelines can be generated, although the need is infrequent. Since we responded, we have modified the process of issuing service DTRs. For service DTRs, we now save an exact copy of each letter sent to members and providers. We anticipate that by the end of 2008 exact copies of all DTRs will be retrievable. We request that this be acknowledged in the final 2006 report ATR Recommendations for all Plans MPRO recommends that plans whose CAHPS scores ranked significantly lower than program examine the results closely and determine which key factors contributed to areas of dissatisfaction. UCare and three other plans had ratings below the average of 54% for How People Rated Their Specialist. UCare notes that overall our CAHPS performance was satisfactory. Singling out this one area for action without a concomitant issue regarding complaints against specialists places this at a lower priority for action than other activities. In addition, initial evaluation of our most recent CAHPS survey indicates improvement from the previous survey ATR Recommendations Specific to UCare In the 2004 and 2005 ATR reports, MPRO recommended the plans work to create clear linkages between the quality evaluation and work plan documents. In the 2006 final draft ATR, chapter 3, MPRO notes that all MCOs have demonstrated improvement in the quality of the Quality Evaluations and Work Plans; however opportunities exist to better connect the two documents and increase development in analysis and operational functionality. Specific to UCare, MPRO noted that UCare s Quality Evaluation correctly and clearly describes the categories used to evaluate project outcomes and provides detailed descriptions of enrollee demographics. MPRO makes the following UCare-specific recommendations: 1. Include barrier analysis to the Quality Evaluation. UCare s 2007 Quality Program Evaluation includes a barrier analysis as part of the project evaluation. 2. Cross-reference the Quality Evaluation to the Work Plan to ensure that all activities receive mention in both documents. UCare s 2008 Work Plan Executive Summary cross references all items that are mentioned in the Quality Program Evaluation document for which there will be activities in Chapter 8: MCO Comments Page 78

91 3. Provide detail in the Practice Guideline Report about which type of guidelines the organization uses (by topic) and how UCare made the decision to adopt each one. This has been addressed in our latest report. We used the DHS recommended form to write our report. 4. Document complete HEDIS rates with numerators and denominators when describing changes in rates in the Practice Guideline Report. Numerators and denominators are included in the report. 5. Include how the organization disseminates practice guidelines to providers and enrollees in the Practice Guideline Report. Our Practice Guideline Report notes how UCare disseminates guidelines to providers: Through hard copies to providers upon request. Through our Provider Manual ( (see chapter 24), also available hard copy upon request. Providers are notified of manual updates via our listserv. Members are sent newsletters with references to the guidelines. The guidelines are also disseminated upon request to members. We request that these five responses be acknowledged in the final 2006 report. Grievances & Appeals On page 24 of the draft final report, MPRO notes that given UCare s rate of grievances and appeals, combined with the rate of decisions overturned, UCare should examine carefully the G&A process used to detect any areas for process improvement. In chapter 6, MPRO also suggests that UCare evaluate the utilization management process to determine the contributing factors to the high grievance and appeal rate and high percentage of decisions overturned. In 2006, UCare began utilizing Community Standards Guidelines for personal care assistant (PCA) hours determinations. The result was a significant increase in appeals, along with an increase in overturns. In 2007, we changed our process so that we now rely upon the completed Medicaid Health Status Assessment (MAHSA) for our PCA hours determinations. The result was a significant decrease in the number of appealed decisions that have been overturned. We request that this be acknowledged in the final 2006 report. We should also point out that as a result of compliance with Department of Human Services determination timelines, we have seen an increase in denials related to lack of information. When these determinations are appealed, information that was previously requested is submitted and this new and more complete information may result in overturning our original decision. HEDIS Performance Measures Calculation (and Validation) In chapter 3, page 32 of the 2006 final draft report, MPRO notes that [A]ccurate prevalence rates for some measures (i.e., Well-Child and Adolescent, Cervical Cancer Screening, Comprehensive Diabetes Care, and Childhood Immunizations) can be better achieved using the hybrid method, combining administrative data from claims and other databases with chart data abstracted from medical records. The actual rates for the MCOs may be higher than the rates calculated by encounter data only.... Because of the resources involved, DHS elected to calculate its performance measures with administrative Chapter 8: MCO Comments Page 79

92 data only. This decision may impact the performance measures reported by DHS and the interpretation of some measurement results. Although the hybrid method would product higher rates for some performance measures and rates collected using that method may better represent care, it is not necessary for comparing baseline measurements to subsequent changes. Thus, using administrative data is an appropriate mechanism for production of performance measurements for the purpose of comparisons over time. Exclusively using administrative data allows MCOs and programs to be equitably compared over time. In UCare s comments to the final 2005 ATR, we noted that In Chapter 4, MPRO provides information on the 2005 results of health plans eighteen performance measures for Prepaid Medical Assistance Program enrollees using submitted encounter data. MPRO notes that continued data collection will assist with building clear linkages between outcomes measures and the structure and process measures, as well as guide projections related to outcomes. As is always the case, accuracy in measuring performance must be paramount. UCare Minnesota suggests that any data collection and analysis include not only encounter data, but also the more accurate chart data. We add here that using encounter data only for measures that are nationally reported using chart data results in an inaccurate and distorted view of actual performance. Numbers based solely on encounter data billing may be unreliable due to claims payment-related factors that have nothing to do with quality. Relying solely on encounter data for some measures undermines the credibility of the conclusions of performance comparisons. Stephanie Schwartz Director Government Programs Chapter 8: MCO Comments Page 80

93 APPENDICES Appendix A Description of Minnesota Health Care Programs Appendix B Supplemental Compliance Requirements Appendix C 2005 through 2007 MCO Performance Improvement Projects Summary Appendix D Managed Care Performance Measures: Appendix E Managed Care Contract Incentive Rates and Payment Amounts Appendix F Withhold Point Summary (F&C Contracts Only) Appendix G Detailed 2004 ATR Responses from MCOs Appendix H MCO HEDIS Performance to Goals Appendices Page 81

94

95 APPENDIX A DESCRIPTION OF MINNESOTA HEALTH CARE PROGRAMS DHS provides health care to more than 600,000 low-income eligible people through its Minnesota Health Care Programs, costing 3 billion dollars annually. Human services spending alone account for approximately 25% of the state s budget. Minnesota s Medicaid programs include Medical Assistance (MA), General Assistance Medical Care and MinnesotaCare. Most children, adults under 65 who do not have a disability, and eligible seniors receive their services through managed care arrangements. All MinnesotaCare enrollees receive their care through managed care arrangements. The Minnesota Health Care Programs operating under managed care arrangements are: Prepaid Medical Assistance Program (PMAP). PMAP is a state-run plan that purchases health care (hospital care, clinical care, preventative care, prescription drugs and medical equipment) from licensed health maintenance organizations. PMAP was launched as a demonstration project in 1985 with Hennepin County as one of the pilot sites. With continued concerns about mounting health costs, the state moved to offer PMAP to all counties. Monthly enrollment as of December 2005 was 283,807 enrollees. Prepaid General Assistance Medical Care (PGAMC). PGAMC is a state-funded program that pays health care services for Minnesota residents whose income, resources are insufficient to cover their expenses, and who are not eligible for other health care programs. The legislature established PGAMC in 1975 and it was implemented on January 1, State law gives DHS authority to fund and administer the program. DHS administrative policy sets requirements related to eligibility, the provision of heath care services, state and county duties, and provider payments. County human services agencies determine eligibility for PGAMC. The counties are responsible for the costs of administering the PGAMC program at the local level. Monthly enrollment as of December 2005 was 27,119 enrollees. MinnesotaCare. The MinnesotaCare is a state funded program that provides subsidized health coverage for eligible Minnesotans. To be eligible for MinnesotaCare, individuals must meet income limits and satisfy other requirements related to residency and lack of access to health insurance. MinnesotaCare eligibility must be renewed every six months. Monthly enrollment as of December 2005 was 134,391 enrollees. Minnesota Senior Health Options (MSHO). Minnesota Senior Health Options (MSHO) is a voluntary health care program for seniors age 65 and over who are eligible for both Medical Assistance (MA) and Medicare. MSHO combines the health care and support services that are normally offered by separate programs into one seamless package making it simpler for people to get these services. Seniors can choose to join MSHO or stay in their current PMAP MCO. There is no additional cost to join MSHO. MSHO is administered by DHS with three participating MCOs: Medica, Metropolitan Health Plan, and UCare Minnesota. Monthly enrollment as of December 2005 was 7,178 enrollees. Appendix A: Description of Minnesota Health Care Programs Page 83

96 Minnesota Disability Health Options (MnDHO). MnDHO is a voluntary program composed of enrollees who are between ages 18 through 64 or over 64 if the enrollees are enrolled prior to reaching their 65th birthday. They must be eligible for Medical Assistance, reside within the MnDHO service area and they must have a certified disability. MnDHO also covers enrollees in nursing facilities and acute care facilities, and enrollees living in the community. Enrollees may also be identified by CMS as having endstage renal disease or age 65 after enrollment in the MCO s MnDHO product and may remain enrolled in the MCO s MnDHO product, after reaching age 65. These enrollees may also choose to enroll in the MCO s MSHO or PMAP products. UCare Minnesota is currently the only participating MCO. Monthly enrollment as of December 2005 was 460 enrollees. Minnesota Senior Care (MSC). MSC is the mandatory PMAP program for enrollees age 65 years and over. MSC is the benefit set that includes only the State Plan services, including 90 days of Nursing Facility care. Enrollees in MSC continue to receive Home and Community-Based Services through the Local Agency on a fee-for-service basis. Minnesota Senior Care Plus (MSC+) is the health care program that includes all services covered under MSC plus the Elderly Waiver Home Community-Based services and an additional 90 days of Nursing Facility care. MSC+ was initially implemented in CBP counties June 2005 and will transition statewide no earlier than January 1, Appendix A: Description of Minnesota Health Care Programs Page 84

97 APPENDIX B SUPPLEMENTAL COMPLIANCE REQUIREMENTS As part of the QA Examination, MDH will collect MCO compliance information for DHS publicly funded managed care programs. 51 The compliance information will be gathered and reported for each publicly funded program (PMAP, MinnesotaCare, MSHO, MSC and MnDHO) as appropriate. MDH will produce a written report containing a summary of the information gathered during each QA Examination. Listed below are the areas that MDH will gather compliance information and include in the DHS Triennial Compliance Assessment. Other areas may be added or listed areas modified upon mutual agreement. 1. Coverage of Services Contract Sections Medical Necessity and Service Authorization and Utilization Review52, 53 a. Unless otherwise provided in this agreement, or otherwise mandated by state or federal law, the MCO shall be responsible for the provision and cost of health care services as described in Article 6 only when such services are deemed to be Medically Necessary by the MCO. b. The MCO, and if applicable its subcontractor, must have in place and follow written policies and procedures for utilization review that reflect current standards of medical practice in processing requests for initial or continued Service Authorization of services as specified in Minnesota Statutes, sections 62M.05 and 62M.09. The MCO s policies and procedures shall ensure the following: i. Consultation with the requesting provider when appropriate; ii. Decisions to deny an authorization request or authorize it in an amount, duration, or scope that is less than requested be made by a health care professional who has appropriate clinical expertise in treating the enrollee s health condition; and iii. Notification to the requesting Provider and written notice to the enrollee of the MCO s decision to deny or limit the request for services. 2. MCO Network Maintenance and Monitoring Contract Section 6.20 Geographic Accessibility of Providers54, 55 a. In accordance with Minnesota Statutes, Section 62D.124, the MCO must demonstrate that its Provider network is geographically accessible to enrollees in its Service Area. In determining the MCO s compliance with the access standards, DHS may consider an exception granted to the MCO by MDH for areas where the MCO cannot meet these standards DHS/MCO Contracts and current NCQA Standards and Guidelines. 52 MSC contract section 6.5 and , MnDHO contract section and CFR (a and b) 54 MSC Contract section CFR (b)(1) Appendix B: Supplemental Compliance Requirements Page 85

98 3. QI Program Structure Contract Section Scope and Standards. a. The MCO must incorporate into its quality assessment and improvement program the standards as described in 42 CFR 438, Subpart D (access, structure and operations, and measurement and improvement). 4. Utilization Management Contract Section Utilization Management a. The MCO shall adopt a utilization management structure consistent with state regulations and current NCQA Standards for Accreditation of Managed Care Organizations. The MCO shall facilitate the delivery of appropriate care and monitor the impact of its utilization management program to detect and correct potential under and over utilization. The MCO shall: i. Choose the appropriate number of relevant types of utilization data, including one type related to behavioral health to monitor. ii. Set thresholds for the selected types of utilization data and annually quantitatively analyze the data against the established thresholds to detect under and over-utilization. iii. Conduct qualitative analysis to determine the cause and effect of all data not within thresholds. iv. Analyze data not within threshold by medical group or practice. v. Take action to address identified problems of under or over-utilization and measure the effectiveness of its interventions. 56 b. The following are the 2007 NCQA Standards and Guidelines for the Accreditation of MCOs UM 1-4 and NCQA Standard UM 1: Utilization Management Structure The organization clearly defines the structures and processes within its utilization management (UM) program and assigns responsibility to appropriate individuals. Element A: Written Program Description Element B: Physician Involvement Element C: Behavioral Health Involvement Element D: Annual Evaluation NCQA Standard UM 2: Clinical Criteria for UM Decision To make utilization decisions, the organization uses written criteria based on sound clinical evidence and specifies procedures for appropriately applying the criteria. Element A: UM Criteria Element B: Availability of Criteria Element C: Consistency in Applying Criteria CFR (b)(3) Appendix B: Supplemental Compliance Requirements Page 86

99 NCQA Standard UM 3: Communication Services The organization provides access to staff for members and practitioners seeking information about the UM process and the authorization of care. Element A: Access to Staff NCQA Standard UM 4: Appropriate Professionals Qualified licensed health professionals assess the clinical information used to support UM decisions. Element D: Practitioner Review of BH Denials Element F: Affirmative Statement About Incentives NCQA Standard UM 10: Evaluation of New Technology The organization evaluates the inclusion of new technologies and the new application of existing technologies in the benefits plan. This includes medical and behavioral health procedures, pharmaceuticals, and devices. Element A: Written Process Element B: Description of the Evaluation Process Element C: Implementation of New Technology NCQA Standard UM 11: Satisfaction with the UM Process The organization evaluates member and practitioner satisfaction with the UM process. Element A: Assessing Satisfaction with UM Process. NCQA Standard UM 12: Emergency Services The organization provides, arranges for or otherwise facilitates all needed emergency services, including appropriate coverage of costs. Element A: Policies and Procedures NCQA Standard UM 13: Procedures for Pharmaceutical Management The organization ensures that its procedures for pharmaceutical management, if any, promote the clinically appropriate use of pharmaceuticals Element A: Policies and Procedures Element B: Pharmaceutical Restrictions/Preferences Element C: Pharmaceutical Patient Safety Issues Element D: Reviewing and Updating Procedures Element F: Availability of Procedures Element G: Considering Exceptions NCQA Standard UM 14: Triage and Referral for Behavior Health Care The organization has written standards to ensure that any centralized triage and referral functions for behavioral health services are appropriately implemented, monitored and professionally managed. Appendix B: Supplemental Compliance Requirements Page 87

100 This standard applies only to organizations with a centralized triage and referral process for behavioral health, both delegated and non delegated. Element A: Triage and Referral Protocols 5. Special Health Care Needs Contract Section (A-C) Special Health Care Needs.57, 58 a. The MCO must have effective mechanisms to assess the quality and appropriateness of care furnished to Enrollees with special health care needs. i. Mechanisms to identify persons with special health care needs, ii. Assessment of enrollees identified, and iii. Access to specialists 6. Practice Guidelines Contract Section Practice Guidelines59 a. The MCO shall adopt preventive and chronic disease practice guidelines appropriate for children, adolescents, prenatal care, young adults, adults, and seniors age 65 and older populations. i. Adoption of practice guidelines. The MCO shall: adopt guidelines based on valid and reliable clinical evidence or a consensus of Health Care Professionals in the particular field; consider the needs of the MCO enrollees; adopt in consultation with contracting Health Care Professionals; review and update them periodically as appropriate. ii. Dissemination of guidelines. The MCO shall ensure that guidelines are disseminated to all affected Providers and, upon request, to enrollees and potential enrollees. iii. Application of guidelines. The MCO shall ensure that these guidelines are applied to decisions for utilization management, enrollee education, coverage of services, and other areas to which there is application and consistency with the guidelines. 7. Credentialing/Recredentialing Contract Section Credentialing and Recredentialing Process. a. Discrimination Against Providers Serving High Risk Populations. The MCO is prohibited from discriminating against particular providers that serve high-risk populations or specialize in conditions that require costly treatment. b. Provider Discrimination. The MCO shall not discriminate with respect to participation, reimbursement, or indemnification as to any provider who is acting within the scope of the provider s license or certification under applicable State law, solely on the basis of such license or certification. This section shall not be construed to prohibit the MCO from including providers only to the extent necessary to meet the needs of the MCO s enrollees or from establishing any measure designated to maintain quality and control costs consistent with the responsibilities of the MCO. If the MCO declines to include individuals or groups of providers in tits network, it must give the affected providers written notice of the reason for its decision CFR (c)(1-4) 58 MSC contract section B - Care Transition Plan CFR Appendix B: Supplemental Compliance Requirements Page 88

101 c. Affiliated Provider Access Standards. The MCO shall require all affiliated providers to meet the access standards required by Section 6.15 of the Contract, and applicable state and federal laws. The MCO shall monitor, on a periodic or continuous basis, but no less than every 12 months, the providers adherence to these standards. 8. Annual Evaluation Contract Sections Annual Quality Assessment and Performance Improvement Program Evaluation60, 61, 62, 63 a. The MCO must conduct an annual quality assessment and performance improvement program evaluation consistent with state and federal regulations and current NCQA Standards for Accreditation of Managed Care Organization. This evaluation must review the impact and effectiveness of the MCO s quality assessment and performance improvement program including performance on standardized measures (example: HEDIS ) and MCO s performance improvement projects. NCQA QI 1, element B: There is an annual written evaluation of the QI program that includes: 1. a description of completed and ongoing QI activities that address quality and safety of clinical care and quality of service 2. a trending of measures to assess performance in the quality and safety of clinical care and quality of service 3. analysis of the results of QI initiatives, including barrier analysis 4. evaluation of the overall effectiveness of the QI program, including progress toward influencing network-wide safe clinical practices. 9. Performance Improvement Projects Contract Section Performance Improvement Project Interim Progress Assessment. 64 a. By December 1 st of each calendar year, the MCO must produce an interim performance improvement project report for each current project. The interim project report must include any changes to the project(s) protocol steps one through seven and steps eight and ten as appropriate. 10. Disease Management Contract Section Disease Management Program 65 a. The MCO s Disease Management Program shall be consistent with the components as defined by the Disease Management Association of America and/or current NCQA Standards and Guidelines for disease management programs CFR (e) 61 MSC Contract section also includes the requirement that the MCO must include the Quality Framework for the Elderly in its Annual Evaluation. 62 MnDHO Contract section Beginning July 2007, MDH will assess the MCO s annual Work Plan compliance with NCQA QI 1, element A, CFR (d)(2) 65 MSC Contract section is MSC contract only requires a diabetes disease management program. Appendix B: Supplemental Compliance Requirements Page 89

102 11. Denial, Termination, or Reduction (DTR) Notice of Action to Enrollees Contract Section 8.2. Denial, Termination, or Reduction (DTR) Notice of Action to Enrollees. a. Section General Requirements. i. Written Notice. The DTR must be a written Notice, which meets the language requirements of 42 C.F.R (c). It must also meet the following requirements: Be understandable to a person who reads at the 7 th grade reading level; Be available in alternative formats as required by Section B. Be approved in writing by the State, pursuant to Section B. Maintain confidentiality for Family Planning Services, that is, ensure that all information related to Family Planning is provided only to the enrollee, in a confidential manner. The MCO must send the DTR form to the enrollee. The MCO may have its subcontractor send the DTR to the enrollee only if MCO has received prior written approval by the DHS. The MCO must submit in advance for DHS approval any DTR notification form that will be used by subcontractor and a sample written explanation of the MCO and State Grievance System. DHS approval will only be granted for major MCO subcontractors, as determined by the DHS, who provide a single type of health service. ii. Content of DTR. The DTR must include: A clear detailed description in plain language of the reason for the denial, termination, or reduction (DTR); and of the enrollee s rights; The Action that the MCO has taken or intends to take; The type of service or claim that is being denied, terminated, or reduced; The reasons for the Action; The specific federal or state regulations or MCO policies that support or require the Action, whichever applies; The enrollee s right (or Provider on behalf of enrollee with the enrollee s written consent) to file an Appeal with the MCO; The enrollee s right to file a request for a State Fair Hearing without first exhausting MCO s Grievance or Appeal procedures, or up to 30 days after the MCO s final determination of the Grievance or Appeal; The process the enrollee must follow in order to exercise these rights; The circumstances under which expedited resolution is available and how to request it for an Appeal or State Fair Hearing; The enrollee s right to continuation of benefits, how to request that benefits be continued, and under what circumstances the enrollee may have to pay for these services if the enrollee files an Appeal at the MCO or requests a State Fair Hearing; The Notice of Member Rights; The requirements and timelines for filing an MCO Appeal pursuant to 42 CFR ; The right to seek an expert medical opinion from an external organization in cases of Medical Necessity at the DHS expense, for consideration at State Fair Hearings; A language block in the languages specified by Minnesota Statutes, Section 256B.69, subd. 27, in a format determined by the DHS; and A phone number at the MCO where enrollees may call to obtain information about the DTR, including how to receive a translation of the notice into Spanish, Hmong, Laotian, Russian, Somali, Vietnamese, or Cambodian. iii. Notice to Provider. The MCO must also notify the Provider, but this may be in the form of an Explanation of Benefits (EOB), Explanation of Payments, or Remittance Advice. The MCO Appendix B: Supplemental Compliance Requirements Page 90

103 must also notify the Provider of the enrollee s right, and provider s right on behalf of the enrollee and with enrollee s written permission, to Appeal a DTR, and an explanation of the Appeal process. This notification may be through Provider contracts, Provider manuals, or through other forms of direct communication such as Provider newsletters. b. Section Timing of the DTR Notice. i. Previously Authorized Services. For previously authorized services the MCO must mail the Notice to the enrollee at least ten (10) days before the date of the proposed Action in accordance with 42 CFR (c)(1). The ongoing medical service must have been ordered by a Participating or treating physician, osteopath, dentist, mental health professional, or chiropractor. The service must be eligible for payment according to Minnesota Statutes, Section 256B.0625 and Minnesota Rules, Part to All procedural requirements must have been met. Advance notice and continuation of benefits are not required if the provider who orders the service is not an MCO Participating Provider or authorized non-participating Provider. ii. Denials of Payment. For denial of payment, the MCO must mail the DTR notice to the Enrollee at the time of any Action affecting the claim. iii. Standard Authorizations. For standard authorization decisions that deny or limit services, notice must be provided as expeditiously as the Enrollee s health condition requires, not to exceed ten (10) business days following receipt of the request for the service, with a possible extension, pursuant to Section D. iv. Extensions of Time. The MCO may extend the timeframe by an additional fourteen (14) days for resolution of a standard authorization if the enrollee or the provider requests the extension, or if the MCO justifies a need for additional information and how the extension is in the enrollee s interest. The MCO must provide written notice to the enrollee of the reason for the decision to extend the timeframe, and the enrollee s right to file a Grievance if he or she disagrees with the MCO s decision. The MCO must issue a determination no later than the date the extension expires. DHS may review the MCO s justification upon request. v. Delay in Authorizations. For Service Authorizations not reached within the timeframe specified in 42 CFR (d)(1), the MCO must provide a notice of denial on the date the timeframe expires. vi. Expedited Authorizations. For expedited Service Authorizations, as expeditiously as the enrollee s health condition requires, but within 72 hours of receipt of the request for the service. Expedited Service Authorizations are for cases where the provider indicates or the MCO determines that following the standard timeframe could seriously jeopardize the Enrollee s life or health. c. Contract Section Continuation of Benefits Pending Decision. If an enrollee files an Appeal with the MCO before the date of the Action proposed on a DTR, the MCO in accordance with 42 CFR (b) may not reduce or terminate the service until 10 days after a written decision is issued in response to that Appeal, unless the enrollee withdraws the Appeal 12. Grievances and Appeals Contract Section 8.3. MCO Internal Grievance Process Requirements: a. Contract Section Filing Requirements. The enrollee, or the provider acting on behalf of the enrollee with the enrollee s written consent, may file a Grievance within 90 days of a matter involving an enrollee s dissatisfaction with the health care received. A Grievance may be filed orally or in writing. The enrollee may also request a State Fair Hearing. b. Contract Section Timeframe for Resolution of Grievances. i. Oral Grievances must be resolved within 10 days of receipt. ii. Written Grievances must be resolved within 30 days of receipt. Appendix B: Supplemental Compliance Requirements Page 91

104 iii. Oral Grievances may be resolved through oral communication, but the MCO must send the enrollee a written decision for written Grievances. c. Contract Section Timeframe for Extension of Resolution of Grievances. The MCO may extend the timeframe by an additional fourteen (14) days for resolution of the Grievance if the enrollee or the provider requests the extension, or if the MCO justifies a need for additional information and how the extension is in the enrollee s interest. The MCO must provide written notice to the enrollee of the reason for the decision to extend the timeframe if the MCO determines that an extension is necessary. The MCO must issue a determination no later than the date the extension expires. DHS may review the MCO s justification upon request. d. Contract Section Handling of Grievances. i. The MCO must mail a written acknowledgment to the Enrollee within 10 days of receiving a written Grievance, and may combine it with the MCO s notice of resolution if a decision is made within the 10 days. ii. The MCO must maintain a log of all Grievances, oral and written. iii. The MCO must not require submission of a written Grievance as a condition of the MCO taking action on the Grievance. iv. The MCO must give enrollees any reasonable assistance in completing forms and taking other procedural steps, including but not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability. v. The individual making a decision on a Grievance shall not have been involved in any previous level of review or decision-making. vi. If the MCO is deciding a Grievance regarding the denial of an expedited resolution of an Appeal or one that involves clinical issues, the individual making the decision must be a Health Care Professional with appropriate clinical expertise in treating the Enrollee s condition or disease. 66 The MCO shall make a determination in accordance with the timeframe for an expedited Appeal Contract Section 8.4. MCO Internal Appeals Process Requirements a. Contract Section Filing Requirements. The enrollee or the provider acting on behalf of the enrollee with the enrollee s written consent, may file an Appeal within 90 days of the DTR Notice of Action or for any other Action taken by the MCO as it is defined in 42 CFR (b). An Appeal may be filed orally or in writing. If the Appeal is filed orally the MCO must offer to assist the enrollee, or provider filing on behalf of the enrollee, in completing a written Appeal. The enrollee may also request a State Fair Hearing. b. Contract Section Timeframe for Resolution of Standard Appeals. The MCO must resolve each Appeal as expeditiously as enrollee s health requires, and no later than 30 days, including resolution of those oral appeals which were not reduced to writing by the Enrollee, or the provider acting on behalf of the enrollee. c. Contract Section Timeframe for Resolution of Expedited Appeals. i. The MCO must resolve and provide written notice of resolution for both oral and written Appeals as expeditiously as the enrollee s health condition requires, but no later than 72 hours after receipt of the Appeal. The MCO shall make reasonable efforts to provide an oral notice prior to sending the written notice of resolution. 66 A licensed practitioner, who within his/her scope of practice, has the training knowledge and experience to treat the enrollee s health condition. Appendix B: Supplemental Compliance Requirements Page 92

105 ii. The MCO must not take punitive action against a provider who requests an expedited resolution or supports an enrollee s Appeal. iii. If the MCO denies a request for expedited Appeal, the MCO shall transfer the denied request to the standard Appeal process, preserving the first filing date of the expedited Appeal. The MCO must notify the enrollee of that decision orally within 24 hours and follow up with a written notice within 2 days. d. Contract Section Timeframe for Extension of Resolution of Appeals. An extension of the timeframes of resolution of Appeals of fourteen (14) days is available for standard Appeals if the enrollee requests the extension, or the MCO justifies both the need for more information and that an extension is in enrollee s interest. The MCO must provide written notice to the enrollee of the reason for the decision to extend the timeframe if the MCO determines that an extension is necessary. The MCO must issue a determination no later than the date the extension expires. DHS may review the MCO s justification upon request. e. Contract Section Handling of Appeals i. All oral inquiries challenging or disputing a DTR Notice of Action or any Action as defined in 42 CFR (b) shall be treated as an oral Appeal and shall follow the requirements of Section 8.4. ii. The MCO must send a written acknowledgment within 10 days of receiving the request for an Appeal and may combine it with the MCO s notice of resolution if a decision is made within the 10 days. iii. The MCO must give enrollees any reasonable assistance required in completing forms and taking other procedural steps, including but not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TDD and interpreter capability. iv. The MCO must ensure that the individual making the decision was not involved in any previous level of review or decision-making. v. If the MCO is deciding an Appeal regarding denial of a service based on lack of Medical Necessity or one that involves clinical issues, the MCO must ensure that the individual making the decision is a health care professional with appropriate clinical expertise in treating the enrollee s condition or disease. vi. The MCO must provide the enrollee with a reasonable opportunity to present evidence and allegations of fact or law, in person, by telephone, as well as in writing. For expedited Appeals, the MCO must inform the Enrollee of limited time available for this to happen. vii. The MCO must provide the enrollee, and his or her representative, an opportunity, before and during the Appeals process, to examine the enrollee s case file, including medical records, and any other documents and records considered during the Appeal process. viii.the MCO must include as parties to the Appeal, the enrollee, his or her representative, or the legal representative of a deceased enrollee s estate. f. Contract Section Subsequent Appeals. If an enrollee Appeals a decision from a previous Appeal on the same issue, and the MCO decides to hear it, for purposes of the timeframes for resolution, this will be considered a new Appeal. g. Section Notice of Resolution of Appeal. The written notice of resolution of Appeal must include the results of the resolution process and date it was completed; the enrollee s right to request a State Fair Hearing and how to do so; the enrollee s right to receive benefits during the State Fair Hearing process; the fact that the MCO may hold the enrollee liable for the cost of benefits provided if the MCO s decision is upheld; and the DHS Notice of Rights. h. Contract Section Reversed Appeal Resolutions. If a decision by an MCO is reversed by the State Fair Hearing process, the MCO: i. Must comply with the hearing decision promptly and as expeditiously as Enrollee s health condition requires; Appendix B: Supplemental Compliance Requirements Page 93

106 ii. Must pay for any services the Enrollee already received that are the subject of the State Fair Hearing. i. Contract Section Upheld Appeal Resolutions. The MCO may bill the enrollee if the MCO s denial is upheld and the Enrollee already received the service. 13. Advance Directives Contract Section 17. Advance Directives Compliance 67 a. The MCO agrees to provide all Enrollees at the time of enrollment a written description of applicable State law on advance directives and the following: i. Information regarding the enrollee s right to accept or refuse medical or surgical treatment; and to execute a living will, durable power of attorney for health care decisions, or other advance directive. ii. Written policies of the MCO respecting the implementation of the right; and iii. Updated or revised changes in State law as soon as possible, but no later than 90 days after the effective date of the change. b. To require MCO s providers to ensure that it has been documented in the enrollee s medical records whether or not an individual has executed an advance directive. c. To not condition treatment or otherwise discriminate on the basis of whether an individual has executed an advance directive. d. To provide, individually or with others, education for MCO staff, providers and the community on advance directives C.F.R Pursuant to 42 U.S.C. 1396a(a)(57) and (58) and 42 C.F.R Appendix B: Supplemental Compliance Requirements Page 94

107 APPENDIX C 2005 THROUGH 2007 MCO PERFORMANCE IMPROVEMENT PROJECTS SUMMARY The DHS/MCO 2004 Contract was the first year that MCOs were required to submit proposals for performance improvement projects to begin within the first quarter of the next year (2005). MCOs were instructed to follow a ten-step protocol outlined by CMS in the document entitled Conducting Performance Improvement Projects. Annually, the MCOs submit a Performance Improvement Project (PIP) proposal for review and approval. A PIP may take several years to achieve improvement goals with a final report due to DHS. Therefore, it is important for the MCOs to have sound organizational structures and definitive processes to be able to provide the quality, timeliness, and access of health care for enrollees as required by the BBA. The following is a summary of the 2005, 2006 and 2007 Performance Improvement Projects for the Family and Children, and Minnesota Senior Care Contracts, validated as being compliant with the protocol and expected to result in real and sustained improvement over time. Since 2005, Minnesota Senior Health Options (MSHO) health plans have collaborated on the PIPs and beginning in 2007, the County Based Purchasing health plans also have begun to collaborate on their own project. The Collaborative PIPs are found at the end of the report. FAMILY AND CHILDREN CONTRACT Blue Plus 2005 Project: PMAP and MinnesotaCare Population with a New Diagnosis of Depression and Antidepressant Medication Initiated. This project theorizes that provider reminder/education and disease management interventions will result in an increase in the use of antidepressant medications in the members with newly diagnosed depression Project Measure of Success: The project will be judged successful when the annual combined Blue Plus PMAP and MinnesotaCare antidepressant medication management HEDIS measurement rate increases by 10 percentage points from 28.99% to 38.99% and is sustained for two consecutive measurement periods Project Revisions Approved December 14, Blue Plus requested, and DHS reviewed and approved the following: Recalculating baseline data based on revised specifications to determine feasibility of project continuation due to population same size; Using additional CPT cods to identify population; Using GPI list for antidepressants to identify pharmacy claims Identifying the initial fill date as within 14 days of depression diagnosis and ensuring clean claims through 180 days prior to date of diagnosis; and Changing the measurement of prescription refills based on length of enrollment Revised Project Measure of Success: The project will be considered successful when the annual combined Blue Plus PMAP and MinnesotaCare antidepressant medication management measurement rate increases by percentage points from 23.16% to 33.79% and is sustained for two consecutive measurement periods Project: Interventions to Improve Adherence to Anti-hypertension Medications in the Public Programs Population. This project theorizes that providing non-compliant hypertensive enrollees age 18 and older with a Appendix C: MCO Performance Improvement Projects Summary Page 95

108 medication reminder system and promotion of self-management regarding medication compliance will improve enrollee adherence to the filling of prescriptions Project Measure of Success: The project will be judged to be successful when the ratio of months of anti-hypertensive medication adherence to enrolled member months increases by five percentage points over the three year average rate from April 2002 through March Project: Lipid Management. This project is designed to achieve significant improvement, sustained over time, in the annual measurement of statin medication use to reduce low density lipoprotein (LDL) cholesterol in patients with coronary heart disease (CHD), CHD equivalent conditions, and/or diabetes Project Measure of Success: The project will be considered successful when the percentage of statin prescriptions filled by enrollees increases six percentage points from the new baseline rate of 39.7% to 45.7% and is sustained for two consecutive measurement periods. FirstPlan of Minnesota 2005 Project: Interventions to Improve Geriatric Depression Management in Primary Care Clinics. This project theorizes that providing screening tools and reimbursement to the primary care providers for completing a geriatric depression screening tool will result in more completed screening and improved quality of care for geriatric enrollees Project Measure of Success: The project will be judged to be successful when the annual geriatric screening rate increases by 10 % of the difference between the 80% target rate and the 2004 depression screening baseline rate and is sustained for two consecutive measurement periods Project: Interventions to Improve Blood Lead Screening at 24 Months. The project theorizes when parents and/or guardians of children approaching 24 months of age are sent a personalized outreach letter that addresses the importance of blood lead testing and incenting them with a $30.00 gift card will increase the number of blood lead tests performed Project Measure of Success: The project will be judged to be successful if the lead testing rate has a 5 percentage point increase over the three year average rate for calendar years Project: To Improve the Recommended Number of Pneumococcal Conjugate Vaccinations by Age Two in Encounter Data. This project is expected to achieve a five percentage point increase over the baseline measurement rate of 9% through multiple interventions including: Personalized calendar mailing to parents and/or guardians of newborns showing pneumococcal immunization due dates, lead screening reminders, and child and teen check up reminders mapped out by stickers on the calendar based on the child s month of birth. Parents will also receive postcard reminders and articles about the pneumococcal vaccine in member newsletters. FirstPlan also plans to implement physician/clinic supportive interventions with reminder lists of children due for pneumococcal immunizations, provider newsletters, provider feedback sessions, and yearly medical record audits Project Measure of Success: The project will be considered successful when the annual pneumococcal vaccination rate for children age 2 years old has increased from 9% to 14% and is sustained for two consecutive measurement periods. Appendix C: MCO Performance Improvement Projects Summary Page 96

109 HealthPartners 2005 Project: Improving Asthma Management and Treatment in HealthPartners PMAP Population. This project theorizes that an Asthma Disease Management program (telephonic screening and counseling) will increase the number of PMAP and MinnesotaCare members with persistent asthma on appropriate medications 2005 Project Measure of Success: This project will be judged to be successful when the combined PMAP and MinnesotaCare population HEDIS measures (four measures) are each five to six percentage points greater than the 2004 baseline measures and are sustained for two consecutive measurement periods Project: Improving Behavioral Health Care of HealthPartners Medicaid Patients (HPCare) with a Dual Diagnosis of Mental Health and Chemical Dependence. The project theorizes that the use of a Behavioral Health Focused Case Management Program for HPCare dually diagnosed (MH/CD) enrollees will increase outpatient visits, decrease inpatient utilization, will have a minimal impact if any on Emergency Department Behavioral Health Crisis use, and improve enrollees perceived functional status Project Measure of Success: The project will be judged to be successful when Outpatient Treatment Visits increase by 5 percentage points and Inpatient Days decrease by 10 percentage points Project: Increased Blood Lead Testing in Medicaid Children at 24 Months of Age. The project is designed to achieve significant improvement, sustained over time, in the annual measure of blood lead testing rates. HealthPartners expects to achieve a 10 percentage point increase over the baseline measurement rate of 41% by implementing birthday incentives, parent education, community outreach to silent members, and provider incentives and education Project Measure of Success: The project will be considered successful when the annual blood lead screening rate for children 24 months old increases 10 percentage points from 41% to 51% and is sustained for two consecutive measurement periods. Itasca Medical Care 2005 Project: Obesity Diagnosis and Management. This project theorizes that by: 1. Increasing provider medical record documentation of height, weight, and BMI, and 2. Providing advice and counseling for those enrollees with a BMI >25 will lead to more successful weight loss management Project Measure of Success: This project will be judged to be successful when: 1. There is a 10 percentage point increase over the baseline rate of adults seen at Grand Itasca Clinic for a preventive visit with a height, weight, and BMI documented in the medical record -AND 2. There is a 10 percentage point increase over the baseline rate of adults at the Grand Itasca Clinic with a BMI >25 that have weight management elements and appropriate strategies documented in the medical record. 3. Both of these rates must be sustained for two consecutive measurement periods Project: Hypertension Management: Remembering Hypertension. The project theorizes that the intervention strategies increase the proportion of enrollees with a hypertension diagnosis that attains a blood pressure at or below 140/90 mm Hg within 18 months following diagnosis. Appendix C: MCO Performance Improvement Projects Summary Page 97

110 2006 Project Measure of Success: The project will be considered successful with a five percentage point improvement in the proportion of members with a hypertension diagnosis attaining their goal blood pressure at or below 140/90 mm Hg within eighteen months of their initial diagnosis Project: Reducing Cardiovascular Risk among Diabetics (PMAP and MinnesotaCare population ages and the MSHO and MSC populations ages 65-75years). See Collaborative section. Medica 2005 Project: State Public Programs Depression Project. This project theorizes that enrollees diagnosed with depression that are unreachable by telephone will benefit from a face-to-face program that provides education, support, coordination of benefits and community services, and help to improve compliance with medications and appointment attendance Project Measure of Success: This project will be judged to be successful when: 1. The percentage of medication compliance is 75% or greater- AND- 2. The visit completion rate is 60% or greater- AND- 3. Documentation of the case plan in the UBH record within 30 days of program enrollment is 85% or greater- AND- 4. Member satisfaction with the face-to-face project is 85% or greater. 5. Rates must be sustained for two consecutive measurement periods Project: Chlamydia Screening. This project theorizes that providing financial incentives combined with resource support to primary care clinics will increase the overall rate of Chlamydia screening for female enrollees ages enrolled in MHCP that present for preventive care visits. This will promote consistency in Chlamydia screening recommendations and improve screening rates of enrollees that are defined as high risk under the Institute for Clinical Systems Improvement (ICSI) clinical guidelines for preventive service Project Measure of Success: The project will be judged to be successful when the rate of Chlamydia screening will increase by 4 percentage points over the three year average rate for calendar years 2002 through Project: Customer Service Referral to Tobacco Cessation Program. This project is designed to achieve significant improvement, sustained over time, in the annual measure of adult members who discuss tobacco cessation services/benefits during the call with Customer Services and accept referral to Medica s cessation program/vendor. Medica expects to achieve a 20 percentage point increase over the baseline measurement rate of 6.7%. Medica did a thorough investigation tracking how members heard about the organization s smoking cessation program. Medica believes Customer Services telephone support is a key factor to increase access to health care services for the Medicaid population. The PIP intervention strategies focus on information provided by Customer Service staff and the referral/direct transfer to a vendor operated stop smoking counseling program Project Measure of Success: The project will be considered successful when the annual measurement of adult members discussing smoking with Customer Services and accepting referral to Medica s cessation program increases from 6.7% to 26.7% and must be sustained for two consecutive measurement periods. Appendix C: MCO Performance Improvement Projects Summary Page 98

111 Metropolitan Health Plan 2005 Project: Increasing the Rate of Preventive Colorectal Cancer Screenings for MHP s Year Old Population. This project theorizes that multifaceted interventions (provider and member education and awareness, member telephonic outreach, mailing of fecal occult blood testing [FOBT] kits with incentive for completion, and advertising and media campaigns) will increase the rate of annual fecal occult blood testing for colon cancer Project Measure of Success: This project will be judged to be successful when the MHP member rate of colorectal cancer screening increased by 5 percentage points from 22.2% to 27.2% and is sustained over two consecutive measurement periods Project: Guideline Use In Primary Care Treatment of Depression with Anti-depressants. The project theorizes that when providers who prescribe antidepressant medications for enrollees are provided the Institute for Clinical Systems Improvement (ICSI) health care guideline, Major Depression in Adults in Primary Care and a set of specific interventions are preformed, an increase in the documentation of guideline based care for primary care treatment of depression with antidepressants will occur. Interventions for the project include Plan representatives making academic detailing visits to provider sites and informing providers of their individual and clinic-level progress toward the goal of the project Project Measure of Success: The project will be judged to be successful when a 10 percentage point increase in documentation according to the established guideline is found in the latest episode that the enrollee was treated Project: Increasing the Rate of Annual Breast Cancer Screenings for PMAP members, inclusive. The project is designed to achieve significant improvement, sustained over time, in the annual measure of breast cancer screenings for women ages MHP expects to achieve a five percentage point increase over the baseline measurement rate of 28.9% through multiple interventions including: member mailing and incentive, advertising campaigns in local minority newspapers, and educational materials to Community Health Workers Project Measure of Success: The project will be considered successful when the annual breast cancer screening rate for women years old increases five percentage points from 28.9% to 33.9% must be sustained for two consecutive measurement periods. PrimeWest Health System 2005 Project: Improving Self-Management of Asthma in Child Members. This project theorizes that the quality of care for children ages 3-21 years old will be improved if each child with persistent asthma has an annual Asthma Action Plan, a completed EPA Home Environmental Checklist (completed by the county public health nurse), and an annual mediation review by a pharmacist as part of Prime West s Asthma Disease Management Program Project Measure of Success: This project will be successful when six percent or more of the enrollees have: 1. An Asthma Action Plan recorded in the member s medical record at the primary care provider s office-or- 2. A Home Environmental Checklist recorded in the child s public health record and/or primary care clinic medical record- OR- Appendix C: MCO Performance Improvement Projects Summary Page 99

112 3. An annual medication management review conducted by the Prime West pharmacist. 4. Rates must be sustained for two consecutive measurement periods Project: Hypertension Management: Remembering Hypertension. The project theorizes that the intervention strategies increase the proportion of enrollees with a hypertension diagnosis that attain a blood pressure at or below 140/90 mm Hg within 18 months following diagnosis Project Measure of Success: The project will be considered successful with a five percentage point improvement in the proportion of members with a hypertension diagnosis attaining their goal blood pressure at or below 140/90 mm Hg within eighteen months of their initial diagnosis Project: Reducing Cardiovascular Risk among Diabetics (PMAP and MinnesotaCare population ages and the MSHO and MSC populations ages years). See Collaborative section. South Country Health Alliance 2005 Project: Depression Management. This project theorizes that depression is under-diagnosed among adult enrollees recently hospitalized and that by implementing telephonic screening, management, and support and providing educational interventions, the care and quality of life of community enrollees with major depression will be improved Project Measure of Success: This project will be judged to be successful when: 1. Fourteen percent (14%) or more of SCHA enrollees are identified with major depression symptoms that were unrecognized prior to or during hospitalization by telephonic screening and there is a HEDIS medication compliance rate of at least 65% or a HEDIS physician visit rate of at least 60%- OR- 2. Fourteen percent (14%) or more of SCHA enrollees are diagnosed based on claims data with major depression that were unrecognized prior to or during hospitalization AND- a HEDIS medication compliance rate of at least 65%- OR- a HEDIS physician visit rate of at least 60 %. 3. Rates must be sustained for two consecutive measurement periods Project: Hypertension Management: Remembering Hypertension. The project theorizes that the intervention strategies increase the proportion of enrollees with a hypertension diagnosis that attains a blood pressure at or below 140/90 mm Hg within 18 months following diagnosis Project Measure of Success: The project will be considered successful with a 5-percentage point improvement in the proportion of members with a hypertension diagnosis attaining their goal blood pressure at or below 140/90 mm Hg within eighteen months of their initial diagnosis Project: Reducing Cardiovascular Risk among Diabetics (PMAP and MinnesotaCare population ages and the MSHO and MSC populations ages years). See Collaborative section. UCare Minnesota 2005 Project: Postpartum Depression. This project theorizes that telephonic or home visit depression screening of women in the postnatal period will improve the health outcomes for both the mother and newborn child Project Measure of Success: This project will be judged to be successful when the percentage of screenings is 10-percentage points greater than the 2004 baseline screening rate and is sustained for two consecutive measurement periods. Appendix C: MCO Performance Improvement Projects Summary Page 100

113 2006 Project: Colorectal Cancer Screening Project. The project theorizes that when home Fecal Occult Blood Testing (FOBT) screening kits are provided directly to the enrollee (age 50 to 65) by the health plan an increase in the FOBT screening rate and an increase in the rate of colorectal cancer screening by any procedure will occur Project Measure of Success: The project will be judged to be successful when a five-percentage points improvement in the FOBT screening rate will occur based on claims for FOBT within 365 days prior to the date of the measure and a three percentage points improvement in the number of claims for a screening procedure satisfying colorectal cancer screening for the date of the measure over the three year average rate for calendar years 2003 through Project: Chlamydia Screening. The project is designed to achieve significant improvement, sustained over time, in the semiannual measure of screening women ages years for Chlamydia. UCare expects to achieve a five-percentage point increase over the baseline measurement rate of 50.35% by starting a clinic financial incentive program and sending providers Action Lists Project Measure of Success: The project will be considered successful when the semiannual Chlamydia screening rate for women years old increases five percentage points from 50.35% to 55.35% and must be sustained for two consecutive measurement periods. COLLABORATIVE PERFORMANCE IMPROVEMENT PROJECTS Medica, Metropolitan Health Plan and UCare Minnesota Collaborative 2005 Project: MSHO Depression Collaborative Project. The project theorizes that depression screening and assessment will increase for new MSHO members living in nursing homes after performing the following MCO-sponsored interventions by MSHO Care Coordinators and Nurse Practitioners: 1. Requiring use of specific tools for depression screening and clinic assessment, AND 2. Requiring attendance at two educational sessions, AND 3. Implementing compliance feedback tools for MSHO Care Coordinators and Nurse Practitioners 2005 Project Measure of Success: The project will be judged to be successful when the rate of MSHO members receiving depression screening increases by at least 10 percentage points over baseline AND the rate of MSHO members receiving a clinical assessment increases by at least 10 percentage points over baseline Project: Pneumococcal Project. The project theorizes when care coordinators working with enrollees initiate referrals to the Minnesota Visiting Nurse Agency (MVNA), primary care, or community clinics for vaccine administration, the number of pneumococcal vaccines given to eligible Minnesota Senior Health Options (MSHO) populations age 65 or older will increase Project Measure of Success: The project will be judged to be successful when the number of claims and enrollee self-reported vaccinations for pneumococcal increases by 5 percentage points for eligible MSHO community enrollees over the three year average rate for calendar years BLUE PLUS, FIRSTPLAN OF MINNESOTA, HEALTHPARTNERS, MEDICA, METROPOLITAN HEALTH PLAN, UCARE MINNESOTA COLLABORATIVE 2007 Project: MSHO/MSC Calcium/Vitamin D Supplementation. The project is designed to achieve significant improvement, sustained over time, in the annual measure of prescription claims for Calcium/Vitamin D for MSHO and MSC enrollees living in the community. The MCO Collaborative expects to achieve a five percentage point increase of the six MCO aggregated data over the baseline Appendix C: MCO Performance Improvement Projects Summary Page 101

114 measurement of 5.25% by implementing pharmacy, provider, care coordinator, and member focused mailings/education interventions Project Measure of Success: The project will be considered successful when the annual Calcium/Vitamin D prescription claims rate for MSHO/MSC enrollees in the collaborative increases by five percentage points from 5.25% to 10.25% and must be sustained for two consecutive measurement periods. Itasca Medical Care, PrimeWest Health System and South Country Health Alliance (CBP) Collaborative 2007 Project: Reducing Cardiovascular Risk among Diabetics (PMAP and MinnesotaCare population ages and the MSHO and MSC populations ages years). The project is designed to achieve significant improvement, sustained over time, in the number of enrollees that use statin medications consistent with 2005 Institute for Clinical Systems Improvement (ICSI), Management of Diabetes Mellitus, Type 2 Guideline. The PIP s primary strategy is to identify a closed cohort of diabetic enrollees not on statin therapy, mail enrollee and provider letters explaining the value of using statin medication to reduce CVD risk, and determine if the interventions increase the use of statins. Information for providers will also include lists of enrollees in the cohort who are not on statins and the recommended use of the 2005 ICSI Diabetes guideline Project Measure of Success: The CBP Collaborative PIP will be considered successful when pharmacy claims for statin therapy achieve a five percentage point increase over the 2006 baseline measurements of those on statin therapy for the PMAP and MinnesotaCare population (ages 40-64) and the MSHO and MSC populations (ages years) using CBP aggregated data measured every four months. Appendix C: MCO Performance Improvement Projects Summary Page 102

115 APPENDIX D MANAGED CARE PERFORMANCE MEASURES: Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adolescents With a Well Care Visit Program: PMAP MCO Meas Year Num Den Rate BluePlus ,693 6, % ,771 6, % ,767 6, % ,865 6, % First Plan Blue % % % % HealthPartners ,329 3, % ,403 3, % ,486 4, % ,526 3, % Itasca Med % % % % Medica ,445 10, % ,624 11, % ,931 11, % ,597 10, % MHP , % , % , % , % PrimeWest % % % SCHA , % , % , % , % UCare ,092 7, % ,749 8, % ,540 8, % ,572 8, % All Plans ,639 31, % ,917 33, % ,066 35, % ,818 33, % Percentage of enrolled members who were years of age who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during the measurement year. Appendix D: Managed Care Performance Measures: Page 103

116 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adolescents With a Well Care Visit Program: MinnesotaCare MCO Meas Year Num Den Rate BluePlus ,516 12, % ,302 11, % ,977 10, % ,509 8, % First Plan Blue % % % % HealthPartners , % , % , % , % Itasca Med % % % % Medica ,487 4, % ,468 4, % ,524 4, % ,251 3, % MHP % % % % PrimeWest % % SCHA % UCare ,229 4, % ,211 3, % , % , % All Plans ,540 25, % ,185 23, % ,680 22, % ,523 17, % Percentage of enrolled members, who were years of age, and who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during the measurement year. Appendix D: Managed Care Performance Measures: Page 104

117 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adult Enrollees With Ambulatory or Preventive Visit Program: PMAP MCO Meas Year Num Den Rate Num Den Rate Num Den Rate BluePlus ,217 5, % % 7,512 8, % ,175 5, % % 6,751 7, % ,655 6, % % 5,502 5, % ,602 6, % % % First Plan Blue % % % % % % % % % % % % HealthPartners ,988 3, % % 2,625 2, % ,090 3, % % 2,804 3, % ,282 3, % % 2,696 2, % ,078 3, % % % Itasca Med % % % % % % % % % % % - - Medica ,492 9, % 1,113 1, % 7,512 7, % ,916 9, % 1,267 1, % 7,836 8, % ,353 10, % 1,409 1, % 7,416 7, % ,721 9, % 1,298 1, % % MHP , % % % , % % % % % % % % - - PrimeWest % % 1,441 1, % % % % % % - - SCHA , % % 1,675 1, % , % % 1,622 1, % ,038 1, % % 1,592 1, % ,081 1, % % - - UCare ,278 4, % % 3,345 3, % ,156 5, % 933 1, % 3,967 4, % ,758 6, % 1,107 1, % 3,041 3, % ,748 6, % 1,214 1, % % All Plans ,576 26, % 3,248 3, % 24,255 25, % ,643 28, % 3,953 4, % 25,988 27, % ,421 30, % 4,479 4, % 22,183 23, % ,781 29, % 4,357 4, % % Percentage of enrollees 20 and over who had an ambulatory or preventive care visit during the measurement year. Appendix D: Managed Care Performance Measures: Page 105

118 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adult Enrollees With Ambulatory or Preventive Visit Program: PGAMC Meas MCO Year Num Den Rate Num Den Rate Num Den Rate BluePlus % % - - na % % - - na % % % % % % First Plan Blue % % - - na % % - - na % % - - na % % - - na HealthPartners % % - - na % % % % % % % % % Itasca Med % % - - na % % - - na % % - - na % % - - na Medica , % 1,035 1, % % ,120 1, % 1,247 1, % % ,207 1, % 1,465 1, % % ,071 1, % 1,521 1, % - - na MHP % % - - na % % % % % % % % - - na PrimeWest % % - - na % % - - na % % - - na SCHA % % - - na % % % % % - - na % % % UCare % % % % % % % % - - na % % % All Plans ,917 3, % 3,194 3, % % ,274 3, % 3,748 4, % % ,662 4, % 4,389 5, % % ,180 3, % 4,257 4, % % Percentage of enrollees 20 and over who had an ambulatory or preventive care visit during the measurement year. Appendix D: Managed Care Performance Measures: Page 106

119 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adult Enrollees With Ambulatory or Preventive Visit Program: MSHO 65 + MCO Meas Year Num Den Rate BluePlus ,252 1, % ,677 7, % First Plan Blue % % HealthPartners % ,912 1, % Itasca Med % Medica ,905 1, % ,073 2, % ,555 2, % ,735 7, % MHP % % % % PrimeWest ,065 1, % ,714 1, % SCHA % ,575 1, % UCare ,896 1, % ,073 2, % ,357 3, % ,307 6, % All Plans ,166 4, % ,510 4, % ,083 9, % ,767 29, % Percentage of enrollees 65 and over who had an ambulatory or preventive care visit during the measurement year. Appendix D: Managed Care Performance Measures: Page 107

120 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adult Enrollees With Ambulatory or Preventive Visit Program: MSC MCO Meas Year Num Den Rate Itasca Med % PrimeWest % SCHA % All Plans % Percentage of enrollees 65 and over who had an ambulatory or preventive care visit during the measurement year. Appendix D: Managed Care Performance Measures: Page 108

121 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adult Enrollees With Ambulatory or Preventive Visit Program: MSC 65 + MCO Meas Year Num Den Rate BluePlus % First Plan Blue % HealthPartners ,261 1, % Itasca Med % Medica ,537 2, % MHP % UCare % All Plans ,369 5, % Percentage of enrollees 65 and over who had an ambulatory or preventive care visit during the measurement year. Appendix D: Managed Care Performance Measures: Page 109

122 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adult Enrollees With Ambulatory or Preventive Visit Program: MinnesotaCare MCO Meas Year Num Den Rate Num Den Rate Num Den Rate BluePlus ,363 16, % 8,647 9, % % ,289 15, % 8,105 9, % % ,306 14, % 7,782 8, % % ,419 11, % 6,764 7, % % First Plan Blue ,071 1, % % % ,004 1, % % % , % % % % % % HealthPartners ,499 4, % 1,683 1, % % ,284 3, % 1,585 1, % % ,227 3, % 1,577 1, % % ,527 2, % 1,443 1, % % Itasca Med % % % % % % % % - - na % % - - na Medica ,526 7, % 3,291 3, % % ,659 7, % 3,413 3, % % ,749 7, % 3,659 4, % % ,623 6, % 3,344 3, % % MHP % % % % % % % % % % % % PrimeWest % - - na - - na % % - - na SCHA % % - - na UCare ,957 5, % 3,044 3, % % ,482 5, % 2,864 3, % % ,183 4, % 2,822 3, % % ,393 3, % 2,697 3, % % All Plans ,258 36, % 17,983 20, % % ,471 34, % 17,198 19, % % ,049 32, % 17,042 19, % % ,306 26, % 15,361 17, % % Percentage of enrollees 20 and over who had an ambulatory or preventive care visit during the measurement year. Appendix D: Managed Care Performance Measures: Page 110

123 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults Receiving Antidepressant Medication Management Program: PMAP Optimal Contacts Acute Treatment Continuous Treatment MCO Meas Year Den Num Rate Num Rate Num Rate BluePlus % % % % % % % % % % % % First Plan Blue % % % % % % % % % % % % HealthPartners % % % % % % % % % % % % Itasca Med % % % % % % % 0 0.0% 0 0.0% % % % Medica % % % % % % % % % % % % MHP % % % % % % % % % % % % PrimeWest % % % % % % % % % SCHA % % % % % % % % % % % % UCare % % % % % % % % % % % % All Plans , % % % , % % % , % % % % % % Percentage of enrollees 18 and over as of April 30 of the measurement year, who were diagnosed with a new episode of depression and treated with antidepressant medication, and who a) had three mental health follow-up contacts, b) remained on an antidepressant drug for 12 weeks, c) remained on an antidepressant drug for 6 months. Appendix D: Managed Care Performance Measures: Page 111

124 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults Receiving Antidepressant Medication Management Program: PGAMC Optimal Contacts Acute Treatment Continuous Treatment MCO Meas Year Den Num Rate Num Rate Num Rate BluePlus % % % % % % % % % % % % First Plan Blue % % % % % % % % % % % % HealthPartners % % % % % % % % % % % % Itasca Med % % % % 0 0.0% 0 0.0% % 0 0.0% 0 0.0% % % 0 0.0% Medica % % % % % % % % % % % % MHP % % % % % % % % % % % % PrimeWest % % % % % % % 0 0.0% 0 0.0% SCHA % % % % % % % % % % % % UCare % % % % % % % % % % % % All Plans Percentage of enrollees 18 and over as of April 30 of the measurement year, who were diagnosed with a new episode of depression and treated with antidepressant medication, and who a) had three mental health follow-up contacts, b) remained on an antidepressant drug for 12 weeks, c) remained on an antidepressant drug for 6 months. Appendix D: Managed Care Performance Measures: Page 112

125 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults Receiving Antidepressant Medication Management Program: MSHO Optimal Contacts Acute Treatment Continuous Treatment MCO Meas Year Den Num Rate Num Rate Num Rate BluePlus % % % % % % First Plan Blue % % % HealthPartners % % % % % % Itasca Med % % % Medica % % % % % % % % % % % % MHP % % % % % % % % % % % % PrimeWest % % % % % % SCHA % % % UCare % % % % % % % % % % % % All Plans % % % % Percentage of enrollees 65 and over as of April 30 of the measurement year, who were diagnosed with a new episode of depression and treated with antidepressant medication, and who a) had three mental health follow-up contacts, b) remained on an antidepressant drug for 12 weeks, c) remained on an antidepressant drug for 6 months. Appendix D: Managed Care Performance Measures: Page 113

126 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults Receiving Antidepressant Medication Management Program: MSC+ Optimal Contacts Acute Treatment Continuous Treatment MCO Meas Year Den Num Rate Num Rate Num Rate PrimeWest % % % All Plans % % % Percentage of enrollees 65 and over as of April 30 of the measurement year, who were diagnosed with a new episode of depression and treated with antidepressant medication, and who a) had three mental health follow-up contacts, b) remained on an antidepressant drug for 12 weeks, c) remained on an antidepressant drug for 6 months. Appendix D: Managed Care Performance Measures: Page 114

127 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults Receiving Antidepressant Medication Management Program: MSC Optimal Contacts Acute Treatment Continuous Treatment MCO Meas Year Den Num Rate Num Rate Num Rate BluePlus % % % HealthPartners % % % Medica % % % MHP % % % UCare % % % All Plans % % % Percentage of enrollees 65 and over as of April 30 of the measurement year, who were diagnosed with a new episode of depression and treated with antidepressant medication, and who a) had three mental health followup contacts, b) remained on an antidepressant drug for 12 weeks, c) remained on an antidepressant drug for 6 months. Appendix D: Managed Care Performance Measures: Page 115

128 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults Receiving Antidepressant Medication Management Program: MinnesotaCare Optimal Contacts Acute Treatment Continuous Treatment MCO Meas Year Den Num Rate Num Num Rate Num BluePlus % % % % % % % % % % % % First Plan Blue % % % % % % % % % % % % HealthPartners % % % % % % % % % % % % Itasca Med % % % % % % % % % % % % Medica % % % % % % % % % % % % MHP % % % % % % % % % % % % PrimeWest % 0 0.0% 0 0.0% SCHA % % % UCare % % % % % % % % % % % % All Plans , % % % % % % % % % % % % Percentage of enrollees 18 and over as of April 30 of the measurement year, who were diagnosed with a new episode of depression and treated with antidepressant medication, and who a) had three mental health follow-up contacts, b) remained on an antidepressant drug for 12 weeks, c) remained on an antidepressant drug for 6 months. Appendix D: Managed Care Performance Measures: Page 116

129 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Women Screened for Breast Cancer Program: PMAP MCO Meas Year Num Den Rate BluePlus , % , % , % % First Plan Blue % % % % HealthPartners % % % % Itasca Med % % % % Medica , % , % , % , % MHP % % % % PrimeWest % % SCHA % % % % UCare % , % , % % All Plans ,999 5, % ,108 5, % ,311 5, % ,519 3, % Percentage of women years of age who had a mammogram to screen for breast cancer. Appendix D: Managed Care Performance Measures: Page 117

130 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Women Screened for Breast Cancer Program: MSHO MCO Meas Year Num Den Rate BluePlus % % First Plan Blue % % HealthPartners % % Itasca Med % Medica % % % % MHP % % % % PrimeWest % % SCHA % % UCare % % % % All Plans % % % , % Percentage of women years of age who had a mammogram to screen for breast cancer. Appendix D: Managed Care Performance Measures: Page 118

131 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Women Screened for Breast Cancer Program: MSC+ MCO Meas Year Num Den Rate Itasca Med % PrimeWest % SCHA % All Plans % Percentage of women years of age who had a mammogram to screen for breast cancer. These health plans had MSC+ enrollees in 2006 as County Based Purchaser Appendix D: Managed Care Performance Measures: Page 119

132 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Women Screened for Breast Cancer Program: MSC MCO Meas Year Num Den Rate BluePlus % First Plan Blue % HealthPartners % Itasca Med % Medica % MHP % UCare % All Plans % Percentage of women years of age who had a mammogram to screen for breast cancer. Appendix D: Managed Care Performance Measures: Page 120

133 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Women Screened for Breast Cancer Program: MinnesotaCare MCO Meas Year Num Den Rate BluePlus ,045 7, % ,849 6, % ,654 6, % ,970 4, % First Plan Blue % % % % HealthPartners , % , % , % % Itasca Med % % % % Medica ,237 2, % ,423 2, % ,534 2, % ,345 2, % MHP % % % % PrimeWest % SCHA % UCare ,341 2, % ,265 2, % ,165 2, % ,039 1, % All Plans ,959 14, % ,798 14, % ,610 13, % ,408 10, % Percentage of women years of age who had a mammogram to screen for breast cancer. Appendix D: Managed Care Performance Measures: Page 121

134 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Women Screened for Cervical Cancer Program: PMAP MCO Meas Year Num Den Rate BluePlus ,040 4, % ,191 4, % ,598 4, % ,685 4, % First Plan Blue % % % % HealthPartners ,831 2, % ,025 2, % ,172 2, % ,091 2, % Itasca Med % % % % Medica ,333 7, % ,830 7, % ,239 8, % ,985 7, % MHP % % % % PrimeWest % % % SCHA % % % % UCare ,486 3, % ,107 4, % ,401 4, % ,479 4, % All Plans ,247 19, % ,207 21, % ,499 23, % ,345 22, % Percentage of women who received one or more Pap tests during the measurement year or the two years prior to the measurement year. Appendix D: Managed Care Performance Measures: Page 122

135 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Women Screened for Cervical Cancer Program: PGAMC MCO Meas Year Num Den Rate BluePlus % % % % First Plan Blue % % % % HealthPartners % % % % Itasca Med % % % % Medica % , % , % , % MHP % % % % PrimeWest % % % SCHA % % % % UCare % % % % All Plans ,717 2, % ,971 3, % ,140 3, % ,959 3, % Percentage of women who received one or more Pap tests during the measurement year or the two years prior to the measurement year. Appendix D: Managed Care Performance Measures: Page 123

136 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Women Screened for Cervical Cancer Program: MinnesotaCare MCO Meas Year Num Den Rate BluePlus ,253 14, % ,718 13, % ,870 12, % ,268 10, % First Plan Blue , % , % % % HealthPartners ,242 3, % ,190 2, % ,145 2, % ,769 2, % Itasca Med % % % % Medica ,640 6, % ,918 6, % ,950 6, % ,235 5, % MHP % % % % PrimeWest % % SCHA % UCare ,493 4, % ,290 4, % ,118 4, % ,673 3, % All Plans ,136 30, % ,540 29, % ,374 27, % ,033 23, % Percentage of women who received one or more Pap tests during the measurement year or the two years prior to the measurement year. Appendix D: Managed Care Performance Measures: Page 124

137 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Children Age Two Receiving Immunizations Program PMAP Combo #2 Combo #3 MCO Meas Year Den Num Rate Num Rate BluePlus % % % % % % % % First Plan Blue % % % % % % % % HealthPartners % % % % % % % % Itasca Med % % % % % % % % Medica % % % % % % % % MHP % % % % % % % % PrimeWest % % % % % % SCHA % % % % % % % % UCare % % % % % % % % All Plans % % % % % % % % Percentage of child enrollees two years old who had the recommended series of vaccines by their second birthday. Combination #2 = Children who received four DTaP/DT vaccinations; three IPV vaccinations; one MMR vaccination; three HiB vaccinations; three hepatitis B vaccinations; and one VZV vaccination on or before the child s second birthday. Combination #3 = Children who received all antigens listed in combination 2 and four pneumococcal conjugate vaccinations on or before the child s second birthday. Appendix D: Managed Care Performance Measures: Page 125

138 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Children Age Two Receiving Immunizations Program MinnesotaCare Combo #2 Combo #3 MCO Meas Year Den Num Rate Num Rate BluePlus % % % % % % % % First Plan Blue % % % % % % % % HealthPartners % % % % % % % % Itasca Med % 1 4.3% % % % 1 7.7% % % Medica % % % % % % % % MHP % % % % % % % % UCare % % % % % % % % All Plans % % % % % % % % Percentage of child enrollees two years old who had the recommended series of vaccines by their second birthday. Combination #2 = Children who received four DTaP/DT vaccinations; three IPV vaccinations; one MMR vaccination; three HiB vaccinations; three hepatitis B vaccinations; and one VZV vaccination on or before the child s second birthday. Combination #3 = Children who received all antigens listed in combination 2 and four pneumococcal conjugate vaccinations on or before the child s second birthday. Appendix D: Managed Care Performance Measures: Page 126

139 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Children With a Visit to a Primary Care Practitioner Program: PMAP Months 25 Months 6 Years 7 11 Years Years MCO Meas Year Num Den Rate Num Den Rate Num Den Rate Num Den Rate BluePlus ,198 3, % 5,497 6, % 2,023 2, % 2,536 3, % ,133 2, % 4,974 5, % 2,144 2, % 2,671 3, % ,194 2, % 5,182 5, % 2,427 3, % 3,127 4, % ,378 2, % 5,228 5, % 2,449 3, % 3,191 4, % First Plan Blue % % % % % % % % % % % % % % % % HealthPartners ,618 1, % 2,939 3, % 1,143 1, % 1,592 2, % ,155 1, % 2,781 3, % 1,141 1, % 1,671 2, % ,168 1, % 2,876 3, % 1,234 1, % 1,761 2, % ,159 1, % 2,679 2, % 1,269 1, % 1,812 2, % Itasca Med % % % % % % % % % % % % % % % % Medica ,712 4, % 8,803 9, % 3,748 4, % 4,915 6, % ,673 3, % 8,774 9, % 3,610 4, % 5,123 6, % ,935 3, % 8,675 9, % 3,900 4, % 5,383 6, % ,938 3, % 8,492 9, % 4,046 5, % 5,313 6, % MHP % 1,567 1, % % 847 1, % % 1,345 1, % % 785 1, % % 1,133 1, % % % % 1,020 1, % % % PrimeWest % % - - na - - na % % % % % % % % SCHA % 1,046 1, % % % % 1,052 1, % % % % 1,094 1, % % % % 1,075 1, % % % UCare ,424 2, % 4,864 5, % 2,328 3, % 3,351 4, % ,042 2, % 5,434 6, % 2,519 3, % 3,854 5, % ,095 2, % 5,673 6, % 2,736 3, % 4,008 5, % ,311 2, % 5,753 6, % 2,942 3, % 4,216 5, % All Plans ,784 14, % 25,357 28, % 10,487 14, % 14,107 18, % ,594 10, % 25,760 28, % 10,591 14, % 15,066 19, % ,955 11, % 26,067 28, % 11,830 15, % 16,379 21, % ,307 11, % 25,712 28, % 12,276 15, % 16,596 21, % Percentage of child enrollees in four age groups who had a visit with a primary care practitioner during the measurement year (for mo and for 25 mos 6 yr) or during the measurement year or the year prior to the measurement year (7 11 yrs and yrs). Appendix D: Managed Care Performance Measures: Page 127

140 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Children With a Visit to a Primary Care Practitioner Program: MinnesotaCare MCO Meas Months 25 Months 6 Years 7 11 Years Years Year Num Den Rate Num Den Rate Num Den Rate Num Den Rate BluePlus % 4,088 4, % 3,793 4, % 7,073 8, % % 3,930 4, % 3,541 4, % 6,973 8, % % 3,781 4, % 3,331 4, % 6,461 8, % % 3,086 3, % 2,595 3, % 5,170 6, % First Plan Blue % % % % % % % % % % % % % % % % Health Partners % 1,085 1, % % 1,225 1, % % 1,057 1, % % 1,176 1, % % 977 1, % % 1,162 1, % % % % 979 1, % Itasca Med % % % % % % % % % % % % % % % % Medica % 2,198 2, % 1,343 1, % 1,975 2, % % 2,335 2, % 1,482 1, % 2,278 2, % % 2,300 2, % 1,625 1, % 2,402 2, % % 1,866 1, % 1,366 1, % 2,076 2, % MHP % % % % % % % % % % % % % % % % PrimeWest na % - - na - - na % % % % SCHA % % % % UCare % 1,486 1, % 1,265 1, % 2,236 2, % % 1,333 1, % 1,118 1, % 2,162 2, % % 1,301 1, % 996 1, % 2,001 2, % % 1,024 1, % 792 1, % 1,582 1, % All Plans ,986 2, % 9,316 10, % 7,558 9, % 13,304 16, % ,014 2, % 9,127 10, % 7,237 9, % 13,364 16, % ,006 2, % 8,780 9, % 7,014 8, % 12,708 15, % ,683 1, % 7,111 7, % 5,584 7, % 10,389 12, % Percentage of child enrollees in four age groups who had a visit with a primary care practitioner during the measurement year (for mos and for 25 mos 6 yrs) or during the measurement year or the year prior to the measurement year (7 11 yrs and yrs). Appendix D: Managed Care Performance Measures: Page 128

141 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Young Women Screened for Chlamydia Program: PMAP MCO Meas Year Num Den Rate BluePlus , % , % , % , % First Plan Blue % % % % HealthPartners , % , % , % , % Itasca Med % % % % Medica ,809 3, % ,849 3, % ,900 3, % ,883 3, % MHP % % % % PrimeWest % % % SCHA % % % % UCare , % , % ,041 2, % ,114 2, % All Plans ,951 10, % ,220 10, % ,415 10, % ,477 10, % Percentage of women who were identified as sexually active, who had at least one test for Chlamydia during the measurement year. Appendix D: Managed Care Performance Measures: Page 129

142 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Young Women Screened for Chlamydia Program: PGAMC MCO Meas Year Num Den Rate BluePlus % % % % First Plan Blue % % % % HealthPartners % % % % Itasca Med % % % % Medica % % % % MHP % % % % PrimeWest % % % SCHA % % % % UCare % % % % All Plans % % % % Percentage of women who were identified as sexually active, who had at least one test for Chlamydia during the measurement year. Appendix D: Managed Care Performance Measures: Page 130

143 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Young Women Screened for Chlamydia Program: MinnesotaCare MCO Meas Year Num Den Rate BluePlus , % , % , % , % First Plan Blue % % % % HealthPartners % % % % Itasca Med % % % % Medica , % , % , % , % MHP % % % % PrimeWest % % SCHA % UCare , % , % , % % All Plans ,300 7, % ,311 6, % ,468 6, % ,039 5, % Percentage of women who were identified as sexually active, who had at least one test for Chlamydia during the measurement year. Appendix D: Managed Care Performance Measures: Page 131

144 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults with Diabetes Screened for HbA1c and LDL-C Program: PMAP HbA1c Testing LDL-C Screening MCO Meas Year Den Num Rate Num Rate BluePlus % % % % % % % % First Plan Blue % % % % % % % % HealthPartners % % % % % % % % Itasca Med % % % % % % % % Medica % % % % % % % % MHP % % % % % % % % PrimeWest % % % % % % SCHA % % % % % % % % UCare % % % % % % % % All Plans ,212 2, % 1, % ,737 3, % 2, % ,675 3, % 2, % ,991 1, % 1, % Percentage of enrollees with diabetes who had HbA1c testing/ldl-c screening during the measurement year. Appendix D: Managed Care Performance Measures: Page 132

145 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults with Diabetes Screened for HbA1c and LDL-C Program: PGAMC HbA1c Testing LDL-C Screening MCO Meas Year Den Num Rate Num Rate BluePlus % % % % % % % % First Plan Blue % % % % % % % % HealthPartners % % % % % % % % Itasca Med % % % % % % % % Medica % % % % % % % % MHP % % % % % % % % PrimeWest % % % % % % SCHA % % % % % % % % UCare % % % % % % % % All Plans % % % % , % % , % % Percentage of enrollees with diabetes who had HbA1c testing/ldl-c screening during the measurement year. Appendix D: Managed Care Performance Measures: Page 133

146 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults with Diabetes Screened for HbA1c and LDL-C Program: MSHO HbA1c Testing LDL-C Screening MCO Meas Year Den Num Rate Num Rate BluePlus % % % % First Plan Blue % % % % HealthPartners % % % % Itasca Med % % Medica % % % % % % % % MHP % % % % % % % % PrimeWest % % % % SCHA % % % % UCare % % % % % % % % All Plans % % % % , % % ,317 2, % 2, % Percentage of enrollees with diabetes who had HbA1c testing/ldl-c screening during the measurement year. Appendix D: Managed Care Performance Measures: Page 134

147 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults with Diabetes Screened for HbA1c and LDL-C Program: MSC+ HbA1c Testing LDL-C Screening MCO Meas Year Den Num Rate Num Rate Itasca Med % % PrimeWest % % SCHA % % All Plans % % Percentage of enrollees with diabetes who had HbA1c testing/ldl-c screening during the measurement year. These health plans had MCS+ enrollees in 2006 as County Based purchasers. Appendix D: Managed Care Performance Measures: Page 135

148 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults with Diabetes Screened for HbA1c and LDL-C Program: MSC HbA1c Testing LDL-C Screening MCO Meas Year Den Num Rate Num Den BluePlus % % First Plan Blue % % HealthPartners % % Medica % % MHP % % UCare % % All Plans % % Percentage of enrollees with diabetes who had HbA1c testing/ldl-c screening during the measurement year. Appendix D: Managed Care Performance Measures: Page 136

149 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Adults with Diabetes Screened for HbA1c and LDL-C Program: MinnesotaCare HbA1c Testing LDL-C Screening MCO Meas Year Den Num Rate Num Rate BluePlus ,315 1, % % ,324 1, % % ,249 1, % % ,161 1, % % First Plan Blue % % % % % % % % HealthPartners % % % % % % % % Itasca Med % % % % % % % % Medica % % % % % % % % MHP % % % % % % % % PrimeWest % % % % SCHA % % UCare % % % % % % % % All Plans ,027 2, % 2, % ,060 2, % 2, % ,019 2, % 2, % ,932 2, % 2, % Percentage of enrollees with diabetes who had HbA1c testing/ldl-c screening during the measurement year. Appendix D: Managed Care Performance Measures: Page 137

150 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Program: PMAP Percent of Enrollees With Persistent Asthma Receiving Appropriate Medications MCO Meas Year Num Den Rate Num Den Rate Num Den Rate Num Den Rate BluePlus % % % % % % % % % % % % % % % % First Plan Blue % % % % % % % % % % % % % % % % Health- Partners % % % % % % % % % % % % % % % % Itasca Med % % % % % % % % % % % % % % % % Medica % % % % % % % % % % % % % % % % MHP % % % % % % % % % % % % % % % % PrimeWest % % % % % % % % SCHA % % % % % % % % % % % % % % % % UCare % % % % % % % % % % % % % % % % All Plans % % % 1,307 1, % % % % 1,427 1, % % % % 1,823 2, % % % % 1,993 2, % Percentage of enrollees 5-56 who were identified as having persistent asthma during the measurement year and the year preceding the measurement year, and who were appropriately prescribed medication. Appendix D: Managed Care Performance Measures: Page 138

151 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Enrollees With Persistent Asthma Receiving Appropriate Medications Program: PGAMC MCO Meas Year Num Den Rate BluePlus % % % % First Plan Blue % % % % HealthPartners % % % % Itasca Med % % % % Medica % % % % MHP % % % % PrimeWest % % SCHA % % % % UCare % % % % All Plans % % % % Percentage of enrollees who were identified as having persistent asthma during the measurement year and the year preceding the measurement year, and who were appropriately prescribed medication. Appendix D: Managed Care Performance Measures: Page 139

152 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of Enrollees With Persistent Asthma Receiving Appropriate Medications Program: MinnesotaCare MCO Meas Ye Num Den Rate Num Den Rate Num Den Rate Num Den Rate BluePlus % % % % % % % % % % % % % % % % First Plan Blue % % % % % % % % % % % % % % % % HealthPartners % % % % % % % % % % % % % % % % Itasca Med % % % % % % % % % % % % % % % % Medica % % % % % % % % % % % % % % % % MHP % % % % % % % % % % % % na % % % PrimeWest na - - na % % SCHA na - - na % % UCare % % % % % % % % % % % % % % % % All Plans % % ,382 1, % % % 928 1, ,583 1, % % % 979 1, ,656 1, % % % 951 1, ,532 1, % Percentage of enrollees 5-56 who were identified as having persistent asthma during the measurement year and the year preceding the measurement year, and who were appropriately prescribed medication. Appendix D: Managed Care Performance Measures: Page 140

153 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of 15-Month Olds Who Received Four Through Six or More Primary Care Visits Program PMAP Four Visits Five Visits Six or More Visits MCO Meas Year Den Num Rate Num Rate Num Rate BluePlus , % % % , % % % , % % % , % % % First Plan Blue % % % % % % % % % % % % HealthPartners , % % % , % % % % % % % % % Itasca Med % % % % % % % % % % % % Medica , % % 1, % , % % 1, % , % % % , % % 1, % MHP % % % % % % % % % % % % PrimeWest % % % % % % % % % SCHA % % % % % % % % % % % % UCare , % % % , % % % , % % % , % % % All Plans ,282 1, % 2, % 4, % ,787 1, % 2, % 3, % , % 1, % 2, % ,573 1, % 2, % 4, % Percentage of enrollees who turned 15 months old during the measurement year, who received four, five, or six or more well child visits with a primary care practitioner during the measurement year. Appendix D: Managed Care Performance Measures: Page 141

154 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of 15-Month Olds Who Received Four Through Six or More Primary Care Visits Program MinnesotaCare Four Visits Five Visits Six or More Visits MCO Meas Year Den Num Rate Num Rate Num Rate BluePlus % % % % % % % % % % % % First Plan Blue % % % % % % % % % % 4 9.3% % HealthPartners % % % % % % % % % % % % Itasca Med % % % % % % % 0 0.0% % % % % Medica % % % % % % % % % % % % MHP % % % % % % % % % % % % UCare % % % % % % % % % % % % All Plans , % % % , % % % , % % % , % % % Percentage of enrollees who turned 15 months old during the measurement year, who received four, five, or six or more well child visits with a primary care practitioner during the measurement year. Appendix D: Managed Care Performance Measures: Page 142

155 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of 3-6 Year Olds Who Received a Primary Care Visit Program: PMAP MCO Meas Year Numerator Denominator Rate BluePlus ,250 4, % ,336 4, % ,423 4, % ,633 4, % First Plan Blue % % % % HealthPartners ,408 2, % ,427 2, % ,625 2, % ,558 2, % Itasca Med % % % % Medica ,245 7, % ,391 7, % ,650 7, % ,681 7, % MHP , % , % , % % PrimeWest % % % SCHA % % % % UCare ,031 4, % ,770 4, % ,799 4, % ,950 4, % All Plans ,363 20, % ,700 21, % ,326 22, % ,635 22, % Percentage of enrollees who were 3-6 years old during the measurement year, who received one or more well-child visits with a primary care practitioner during the measurement year. Appendix D: Managed Care Performance Measures: Page 143

156 Managed Care Performance Measurement System Performance Measurement and Quality Improvement Percent of 3-6 Year Olds Who Received a Primary Care Visit Program: MinnesotaCare MCO Meas Year Numerator Denominator Rate BluePlus ,869 3, % ,996 3, % ,842 3, % ,613 2, % First Plan Blue % % % % HealthPartners % % % % Itasca Med % % % % Medica ,182 1, % ,284 2, % ,329 2, % ,108 1, % MHP % % % % PrimeWest % SCHA % UCare , % , % , % % All Plans ,628 8, % ,847 8, % ,699 7, % ,968 6, % Percentage of enrollees who were 3-6 years old during the measurement year, who received one or more well-child visits with a primary care practitioner during the measurement year. Appendix D: Managed Care Performance Measures: Page 144

157 APPENDIX E MANAGED CARE CONTRACT INCENTIVE RATES AND PAYMENT AMOUNTS MCO INCENTIVE RATES Well Child Incentive Svc / 1000 Member Per Month 1999 Base Rate Blue Plus FirstPlan Blue HealthPartners Itasca Medical Care Medica Metropolitan Health Plan PrimeWest South Country Health Alliance UCare Newly Enrolled Incentive 69 ( % visits x number of enrollees) Blue Plus FirstPlan Blue HealthPartners Itasca Medical Care Medica Metropolitan Health Plan PrimeWest South Country Health Alliance UCare Lead Screening Incentive (% visits x number of enrollees) Blue Plus FirstPlan Blue HealthPartners Itasca Medical Care Medica PrimeWest enrollment began in July Newly Enrolled Incentive will be calculated in November PrimeWest enrollment began in July South Country Health Alliance: enrollment began in November Appendix E: Managed Care Contract Incentive Rates and Payment Amounts Page 145

158 Metropolitan Health Plan PrimeWest South Country Health Alliance UCare MCO INCENTIVE PAYMENTS Blue Plus Table 32: MCO Incentive Rates MCO Well Child $ 55, $218, $ 577, $ 65, $190, Newly Enrolled $ 2, $ 12, $ 36, $ 14, Lead $ 26, $ 47, $ 67, $ 32, $ 55, $ 26, Total $ 84, $277, $ 829, $111, $ 55, $216, FirstPlan Dental Incentives Well Child -- $ 3, $ 39, $ 8, $ 8, $ 17, Newly Enrolled -- $ $ 1, $ Lead $ $ 2, $ 9, $ 3, $ 2, $ 2, Total $ $ 6, $ 50, $ 12, $ 10, $ 19, HP Dental Incentives $ 84, $ 92, $ 60, Well Child $ 35, $ 82, $ 234, $119, $ 29, Newly Enrolled $ 2, $ 2, $ 10, $ 12, Lead $ 38, $ 53, $ 44, $ 12, $ 42, $ 30, Total $160, $230, $ 349, $ 25, $161, $ 59, IMCare Dental Incentives $ 16, $ 9, $ 27, Well Child $ 3, $ 5, $ 14, $ 5, Newly Enrolled $ $ $ Lead $ $ $ 3, $ 7, Total $ 20, $ 15, $ 46, $ 6, $ 7, PrimeWest enrollment began in July Appendix E: Managed Care Contract Incentive Rates and Payment Amounts Page 146

159 MCO Dental Incentives $ $ $1,656, Well Child $114, $259, $ 450, $ 78, $397, Newly Enrolled $ 6, $ 4, $ 13, $ 22, Lead $ 32, $ 54, $ 253, $ 46, $ 65, $ 89, Total $154, $319, $2,374, $147, $ 65, $486, MHP Dental Incentives $ 156, Well Child $ 51, $ 70, $ 38, $ 64, Newly Enrolled $ 4, Lead $ 20, $ 13, $ 4, $ $ 8, $ 17, Total $ 72, $ 84, $ 198, $ 4, $ 8, $ 81, PrimeWest 73 Dental Incentives $ 22, Well Child $ 43, $ 11, $ 45, Newly Enrolled $ 1, $ 1, Lead $ 12, $ 5, $ 7, Total $ 67, $ 12, $ 17, $ 53, SCHA 74 Dental Incentives Well Child -- $12, $ 29, $ 41, $ 8, Newly Enrolled $ 4, Lead -- $ 1, $ 9, $ 5, $ 6, Total -- $13, $ 39, $ 4, $ 46, $ 14, UCare Dental Incentives $ 469, Well Child -- $44, $ 97, $202, $ 159, $159, Newly Enrolled $ 2, $ 1, $ 3, $ 35, Lead $ 21, $33, $ 73, $ 17, $ 49, $ 52, Total $24, $79, $643, $255, $208, $211, Table 33: MCO Incentive Payments PrimeWest enrollment began in July South Country Health Alliance: enrollment began in November Appendix E: Managed Care Contract Incentive Rates and Payment Amounts Page 147

160 APPENDIX F WITHHOLD POINT SUMMARY (F&C CONTRACTS ONLY) 75 Blue Pus CY-2003 Total Points = 90 First Plan Health Partners Itasca Medical Care Medica Metropolitan Health Plan Prime West South Country Health Alliance UCare Minnesota DTR G&A CP TP ** QA MS PSY Total CY-2004 Total Points = 100 DTR G&A CP TP ** QA MS PSY Total CY-2005 Total Points = 95 * DTR G&A CP TP** QA MS PSY Pb Total CY-2006 Total Points = 90 DTR Performance targets: Denial, termination or reduction of service (DTR) notice (20 points), Grievance and appeal (G&A) Reporting (15 points), Claims payment (CP) timeliness (10 points), Identifying treating provider (TP) (20 points), MDH QA Examination (QA) (10 points) Member service phone responsiveness (MS) (10 points), Psychiatrist UR/QA advisor (PSY) (5 points), Lead Screening in Families and Children Contract only (10 points), Care Plan Audit and Screening Documentation Audit in MSHO MSC Contract only (10 points each). Appendix F: Withhold Point Summary (PMAP/F&C Contracts Only) Page 148

161 Blue Pus First Plan Health Partners Itasca Medical Care Medica Metropolitan Health Plan Prime West South Country Health Alliance UCare Minnesota G&A CP TP ** QA MS PSY Pb Total Table 34: MCO Contract Point Summary = Failed to meet measure performance target * CY-2005 Points for IMC, PW & SCHA totaled 90 as Member Services and Psychiatrist advisor was assigned 5 points instead of 10 ** Treating provider measure is the only measure where partial points are available. Appendix F: Withhold Point Summary (PMAP/F&C Contracts Only) Page 149

162

163 APPENDIX G DETAILED 2004 ATR RESPONSES FROM MCOS This section provides 2004 follow-up recommendations regarding the degree to which each MCO has effectively addressed the recommendations for quality improvement made by the External Quality Review Organization (EQRO) during the previous year s external quality review (EQR). This feedback allows MCOs to align their organization s efforts with state and federal requirements and industry standards as well as benefit from the experience of other MCOs program and strategic efforts. Chapter 4 highlights how integration of these recommendations contributes to improving the quality of health care services furnished by each MCO. MPRO requested that each MCO describe how their organization addressed both general and MCO-specific recommendations from the 2004 ATR. MPRO made ten general recommendations and asked each MCO to provide commentary about how their organization addressed each one. The following are the exact responses from each MCO. Recommendation 1: Consider the development of and linkages to the QI Work Plan and Annual QI Evaluation as working tools for the Quality Improvement and Performance Improvement program. Blue Plus Response: Blue Plus is in compliance with these recommendations as evidenced by our 2006 NCQA accreditation and also by audits conducted by MPRO. First Plan Response: First Plan s annual QI work plan already encompasses the recommendations addressed in this section. In 2005, First Plan added an additional staff member to support quality improvement efforts. Extensive revisions to the QI work plan evaluation are currently underway to be more reflective of the 2005 ATR recommendations. HealthPartners Response: HealthPartners has consistently received 100% compliance on the NCQA standards and MDH requirements related to the annual QI work plan and QI evaluation. IMCare Response: IMCare s 2007 Work Plan is more comprehensive, addressing the prescribed elements, which include quality and service related activities for the year, as per the recommendation of MPRO and MDH. Our November 29, 2006 MPRO audit (reported February 23, 2007), indicates the 2005 Annual Program Evaluation (April 2006) meets the requirements. Medica Response: Medica took to heart the recommendations listed in the 2004 ATR regarding the QI Work Plan and QI Annual Evaluation recommendations. This was made evident by MPRO s comments in the 2005 ATR report where they stated under our strengths that Medica s Quality Evaluation and QI Work Plan are well done with many inclusions of strengths and challenges addressed regarding the effectiveness of quality programs. MPRO goes on to state that our QI Work Plan is well integrated with our QI Program Evaluation and that our evaluation report includes complete data tables and graphs to enhance the document. MHP Response: MHP has two distinct quality plans. One is the larger over-arching Quality Program. This document describes relationships, roles, responsibilities, structures, reporting goals and objectives along with other elements required by the National Committee for Quality Assurance (NCQA). The second document is the annual Work Plan. The Work Plan is the outline of programs and activities along with detailed descriptions of timeframes, data, methodology, responsibilities. PrimeWest Response: PrimeWest s 2006 QI Work Plan was revised to include the recommended elements. PrimeWest included all staff participation in the development, monthly updating and completion of the Plan. The Plan is now standard operating procedure for the organization as a whole and we have found the Plan to Appendix G: Detailed 2004 ATR Responses from MCOs Page 151

164 be a very useful working document. PrimeWest QI Evaluation did include the adequacy of the resources devoted to the program, committee structure, practitioner participation, and leadership involvement. Because of the disconnect and lack of focus between the submitted documents identified by DHS, organizational structure and personnel changes have occurred at PrimeWest that have dramatically improved the communication and integration of data gathering, utilization management processes, quality improvement initiatives and overall analysis. FTEs have been allocated and job descriptions developed specifically for the purpose of improving quality initiatives and outcomes. Current policies were amended and others developed in order to support quality within the organization. PrimeWest s evaluation process did not include comparative analysis since there were only two data points of reference when the 2005 Evaluation was completed. With three years experience data, PrimeWest assures DHS that the 2006 evaluation will include trended data, comparative analysis and critical assessments of barriers to achieving program goals. SCHA Response: Effective in 2006, SCHA s QI Work Plan does include all quality and service related activities for the year and does provide specific details regarding objectives and activities, scope of the QI Program, timeframe for each activity and responsible party, monitoring of previously identified issues, and evaluation of the effectiveness of both the QI and PI program. SCHA s 2005 annual QI evaluation did contain all required elements identified above, except for the critical assessment of barriers to achieving program goals. This aspect will be incorporated in the 2006 annual QI evaluation. SCHA does refer to the most current Standards and Guidelines for the Accreditation of MCO s, NCQA on a regular basis to ensure that we incorporate the appropriate requirements into the annual QI evaluation process. UCare Response: As of 2007, UCare s Quality Improvement Work Plan includes all of the elements suggested on page 47 of the 2004 Annual Technical Report. On page 56 of the 2005 Annual Technical Report, MPRO cited UCare s Quality Evaluation as one of UCare s strengths. MPRO noted that UCare s Quality Evaluation is prepared well, with detailed description of member demographics, use of other MCO rates for comparisons, and good integration of graphs and data. Recommendation 2: Use the MDH QA Examination Audit as part of the QI Evaluation and include specific documentation regarding activities, actions, time frames, and responsible parties in the QI Work Plan. Blue Plus Response: We have included the MDH QA audits as part of our 2007 Quality Improvement Workplan Evaluation. First Plan Response: The recommendations in this section were already and currently a part of First Plan s QI work plan and evaluation process. HealthPartners Response: HealthPartners annual work plan has an overall compliance section. We do not include specific CAP information in our work plan, since this is addressed separately. HealthPartners had a successful 2006 MDH QA Examination with no repeat findings. IMCare Response: MDH conducted an audit in August of The deficiencies resulted in a corrective action plan. The CAP has been incorporated in to the 2007 Work Plan subject to approval by the Itasca County Board of Commissioners. The board will approve the Work Plan April, Medica Response: Medica s QI Program Evaluation was adapted to include a section discussing regulatory and accreditation obligations that include those related to the Minnesota Department of Health, who performs the MDH QA Exam Audits. This QI Program Evaluation section goes on to describe how Medica s QI department monitors compliance with regulatory requirements including MDH requirements on an ongoing basis. Medica s MDH QA Exam results were released in February of The report showed that Medica was in compliance with all quality program requirements. Within Medica s QI Program Evaluation there is a section on regulatory and accreditation compliance. Included within that section is a reference to Medica s Appendix G: Detailed 2004 ATR Responses from MCOs Page 152

165 MDH QA Examination preparation activity work plan, which lists all such activities and includes timelines and responsible parties for each activity listed. MHP Response: This issue is described under the Specific Recommendations section of this response. PrimeWest Response: MDH accepted PrimeWest s 2004, 05 and 06 Quality Plan submissions without required revisions. After meeting with DHS Quality June 05, PrimeWest revised the 2006 QI Work Plan to include all quality and service related activities for the year which included the aspects identified in Chapter 5, p 48. As stated previously, PrimeWest now utilizes the Plan as a standard operating procedure document that is updated monthly to reflect progress on QI activities throughout the year. SCHA Response: SCHA s QI Annual Work Plan and Annual Evaluation did include documentation regarding the MDH QA Examination Audits activities that need to be completed for compliance. SCHA s 2006 QA Program Description does not address MDH QA Examination Audit. This requirement will be added to the 2007 QA Program Description. UCare Response: Going forward, UCare will consider adding the QA Evaluation Audit information into UCare s Quality Improvement and Performance Improvement Program, as well as the Quality Improvement Work Plan and Quality Improvement Evaluation. UCare has established internal processes for preparing for and monitoring MDH audit requirements. The Quality Management Department has an important role in these processes, but other departments, such as the Government Programs and Compliance Departments, have significant roles. Recommendation 3: Use NCQA standards for utilization management (UM) program. Blue Plus Response: Blue Plus is in compliance with these recommendations as evidenced by our 2006 NCQA accreditation and also by audits conducted by MPRO. First Plan Response: First Plan s UM Program description and evaluation includes all of the recommendations described in this section. In 2006, First Plan worked collaboratively with BlueCross and BlueShield of Minnesota on the Appropriate Utilization Sterling Committee on identifying services and interventions to address over and under utilization. HealthPartners Response: This general recommendation is not applicable to HealthPartners as demonstrated by MPRO s Triennial Structural and Operational Component (TSOC) Audit results showing HealthPartners was 100% compliant. Also, HealthPartners was 100% compliant with NCQA requirements. IMCare Response: IMCare has a written UM Program Description, has updated policies and procedures to be consistent with the NCQA standards, and reviews over and underutilization. This is reflected in the November 29, 2006 TSOC Audit (as reported February 23, 2007). Medica Response: Prior to the TSOC audit we had received the results from our 2004 NCQA accreditation audit (relevant to our State Public Programs products) where they had audited these same standards. We ended up with an Excellent ranking, and that included scoring 100% on all Utilization Management related NCQA standards. Medica was able to demonstrate in it s January 2006 TSOC audit conducted by MPRO that our UM program complied with NCQA standards QA1-QA4 and QA 10-QA 15. We met all 37 UM TSOC requirements audited by MPRO at that time. All of this means that we have had and continue to have all aspect of a Utilization Management Program in place as called for by MPRO in the 2004 ATR All MCO General Recommendations. MHP Response: MHP s UM Program has been developed with every effort to fully comply with NCQA standards. Specific staff members within the UM area at MHP have training and expertise in working with Appendix G: Detailed 2004 ATR Responses from MCOs Page 153

166 medical and mental/chemical health issues. MHP, after conducting analysis on this issue, removed any programs or barriers to mental/chemical health and provides an open access system of delivery to ease the ability of members to obtain mental/chemical health services. MHP utilizes an internal standardized reporting package to measure and monitor for over and under utilization of services. A full description of MHP s UM Program, which has been approved by the governing body and Quality Management Committee, is available upon request. PrimeWest Response: PrimeWest s UM Plan (UM 01 P&P) is compliant with NCQA requirements. UM01 was updated in 2006 to reflect behavioral health care aspects of the program, and the requirements for ensuring appropriate utilization. Both under and over utilization are addressed in the UM yearly evaluation summary analysis. Areas of identified improvement are included in the Quality Work Plan. SCHA Response: SCHA incorporated NCQA s current MCO UM Standards 1-4 and into our 2006 UM Plan Description. UCare Response: UCare updated its utilization management policy specifically to address behavioral health care utilization. In addition, this is addressed in the UCare Utilization Management Plan, which details how the organization ensures appropriate utilization, and through the UCare Utilization Management Forum, an internal work group that ensures utilization management issues are addressed based on NCQA standards, including the elements suggested in the 2004 Annual Technical Report. Recommendation 4: Enhance documentation regarding delegation of UM and credentialing activities. Blue Plus Response: Blue Plus is in compliance with these recommendations as evidenced by our 2006 NCQA accreditation and also by audits conducted by MPRO. First Plan Response: First Plan meets the recommendations and expectations outlined in this section. First Plan s UM delegation agreements already met the expectations outlined in this section. First Plan s credentialing delegation agreement with Blue Cross was updated in 2005 to meet the recommendations outlined in this section. HealthPartners Response: This general recommendation is not applicable to HealthPartners as demonstrated by MPRO s Triennial Structural and Operational Component (TSOC) Audit results showing HealthPartners was 100% compliant. Also, HealthPartners was 100% compliant with all NCQA delegation requirements. IMCare Response: IMCare does not delegate credentialing activities. IMCare s delegation contracts include the Pharmacy Benefit Manager and Disease Management Program. The delegation agreement clearly defines the roles and responsibilities for both parties, as well as oversight functions and termination language. All other UM activities are performed and monitored by IMCare. Medica Response: In Medica s 2004 NCQA accreditation audit for our State Public Programs Products Medica scored 100% on all Utilization Management and on all Credentialing standards, including related delegation-related requirements. When MPRO conducted our TSCO audit in early 2006 they also reviewed for compliance with these NCQA standards as this is what DHS contract requirements for these same areas were based on at the time. MPRO determined that Medica continued to be in compliance with all 29 TSOC Credentialing requirements as well as all 37 Utilization TSOC standards. This means Medica has met and continues to meet all the requirements for Utilization Management and Credentialing and related delegation as called for by MPRO in the 2004 ATR All MCO General Recommendations. MHP Response: The only entity for whom MHP has delegated UM is Delta Dental Plan of Minnesota (Delta). Delta is audited annually to assure compliance with MHP and NCQA standards for UM activities. A report outlining the findings of this audit is available upon request. At the time of the UM audit, MHP Appendix G: Detailed 2004 ATR Responses from MCOs Page 154

167 also audited Delta for compliance with credentialing and appeal & grievances. The findings are in the previously noted report. MHP s UM delegation to Delta is outlined in the contract between the entities. Both MHP and Delta are aware of the various NCQA requirements for timelines and notices and have incorporated these requirements into policy, procedures and practices. MHP receives quarterly reports from Delta regarding UM cases and appeals and grievances. In addition, MHP is a member of a credentialing collaborative chaired by the Minnesota Council of Health Plans (Council). The members of this collaborative share the findings of their NCQA delegation audits thus decreasing the number of redundant audits. MHP has credentialing delegation agreements with Hennepin County Medical Center (HCMC), Fairview Health Services, Dakota Clinics, and Blue Cross Blue Shield. MHP conducts its own NCQA level review of HCMC and Delta. We accept NCQA accreditation or the Council supplied audit findings for Fairview, Dakota and Blue Cross. MHP maintains files with all audits which are available for review. MHP and its delegates closely follow and audit for the NCQA required data elements for credentialing as this has been deemed the community standard for Minnesota. Every contract between MHP and a business associate requires HIPAA compliant language related to protected health information (PHI). MHP s Privacy Notice gives members and others an opportunity to file a complaint related to privacy. Further, MHP provides annual training to all employees on HIPAA and requires the successful completion of a test as a condition of employment. MHP has an active Compliance Committee who oversees privacy and security complaints. PrimeWest Response: PrimeWest s UM Plan, Credentialing Plan and Delegation Agreements with Medical TPA and Credentialing Entities are compliant with stated requirements. MDH audit required a Process Improvement resulting in a CAP regarding TPA compliance with delegated functions and specific State Statute requirements. CAP submitted/approved by MDH then submitted to DHS. CAP continues with MDH re-visit May 07. Yearly UM Summary is compliant with requirements. In 2005, PrimeWest revised the Credentialing Plan and all associated policies to meet NCQA requirements as recommended. PrimeWest s Credentialing Plan and P&P are NCQA compliant. SCHA Response: SCHA s Utilization Management Program Description, delegation contracts and UM and Credentialing Delegation Policies and Procedures contain the written description of all delegated UM and credentialing activities, roles and responsibilities for each party, how SCHA monitors and evaluates each delegate s performance and how PHI is protected by each of the delegates. SCHA s delegation contract for each of the delegates, who are responsible for delegated UM activities, identifies which entity is responsible for and who conducts which of the activities as identified above. Annually, SCHA evaluates network access and availability to ensure our members receive equitable access to care and service. SCHA s Delegation Policy and Procedures stated what standards and contractual requirements are audited on an annual basis, at a minimum. SCHA also reviews our delegates policies and procedures addressing the topics above and provides appropriate feedback to the delegates to ensure compliance with federal and state requirements. SCHA s delegation audit tools reflect federal and state requirements as well as DHS contract requirements. SCHA receives UM delegates reports which identify number of UM cases by type and by service, number of denials and number of cases appeals, as appropriate for delegated activities. SCHA s delegation contract for each of the delegates, who are responsible for delegated credentialing activities, identifies which entity is responsible for and who conducts which of the activities as identified above as well as any additional requirements identified in the current NCQA Standards and Guidelines for the Accreditation of MCOs. UCare Response: MPRO had no findings or recommendations regarding UCare s credentialing activities, which were found to be compliant. Because there were no deficiencies in the MDH QA Examination report dated August 13, 2003, MPRO did not conduct an on-site review of credentialing activities. UCare s Delegation Agreement, based on NCQA standards, contains a written description of delegated utilization management activities and the elements noted on pages of the 2004 Annual Technical Report. All delegates are audited on an annual basis, which includes review of the utilization review metrics. Appendix G: Detailed 2004 ATR Responses from MCOs Page 155

168 Recommendation 5: Develop Performance Improvement Projects (PIPs) consistent with the Centers for Medicare and Medicaid Services (CMS) protocol Conducting Performance Improvement Projects ten-step process. Blue Plus Response: Blue Plus is in compliance with these recommendations as evidenced by our 2006 NCQA accreditation and also by audits conducted by MPRO. First Plan Response: Due to program and contract changes that were made when the 2004 PIP was validated, the PIP reviewed for this ATR was exempt from continuing. With that being said, First Plan closely followed CMS protocol Conducting Performance Improvement Projects ten set process for PIPs validated in 2005 and In turn, each PIP includes the recommendations outlined in this section. First Plan continues to follow the guidance outlined in this document. HealthPartners Response: HealthPartners utilizes the CMS Conducting Performance Improvement Projects ten-step process. IMCare Response: IMCare participates in a County Based Purchasing PIP Collaborative. The PIPs are developed consistent with CMS protocol. All PIPs are reviewed and approved by DHS QMPI Medica Response: Each year Medica has to develop and submit a separate report to DHS for each State Public Programs and MSHO performance improvement project by a DHS-established deadline. DHS or their vendor then evaluates these reports to determine if each PIP has been developed adhering to CMS PIP protocols. Depending on whether the report pertains to a New PIP Proposal, an Interim PIP or a Final PIP, we have to address a certain number of CMS protocol steps for each type of PIP report per DHS contract requirements. The 2004 ATR report was released in late All of our PIP reports submitted in both 2005 and 2005 were reviewed and approved as meeting all DHS contract requirements and thus all PIP protocol requirements as outlined in MPRO s 2004 ATR All MCO General Recommendations by either DHS or their vendor. MHP Response: MPRO has been the review entity for MHP s solo and collaborative PIPs. MHP uses the CMS protocol Conducting Performance Improvement Projects and MHP has a checklist to assure completion of each of the ten steps. Current PIPs include colorectal cancer screening, depression management in primary care, nursing home depression, pneumococcal pneumonia vaccine, calcium vitamin D, and mammography. MHP maintains a detailed record for each PIP that is available for audit. Further, MHP employs an epidemiologist to evaluate and calculate statistical significance. Staff conducting the PIPs is qualified based on education and training. PrimeWest Response: PrimeWest s PIPs are in compliance with stated requirements and have been approved by DHS. SCHA Response: SCHA s PIPs are developed consistent with the CMS protocol Conducting Performance Improvement Projects ten-step process. SCHA s PIPs do include the information as outlined above. Additionally, all PIP proposals are approved by DHS on an annual basis. UCare Response: UCare strives to submit PIP reports that are clear, concise, consistent with CMS protocol. UCare s PIPs include the information listed on page 52 of the 2004 Annual Technical Report. As evidence of this, UCare s 2006 PIP proposals were approved by the Department of Human Services without changes. Recommendation 6: Add the review and update of policies and procedures to the QI Work Plan, and ensure compliance with grievance and appeal policies and procedures. Appendix G: Detailed 2004 ATR Responses from MCOs Page 156

169 Blue Plus Response: Blue Plus annually reviews all its policies and procedures against current state, federal and contractual obligations. Our completion of required delegation oversight functions has been found fully compliant by NCQA and MDH. First Plan Response: First Plan met all the recommendations described in this section. HealthPartners Response: HealthPartners has consistently achieved 100% compliance on NCQA standards and MDH requirements related to the annual QI work plan. HealthPartners has a policy on Development of Policies and Procedures which defines annual review requirements and refers to supporting compliance with state and federal laws, rules and regulations. IMCare Response: IMCare performs an annual review of all policies and procedures. This is identified in the 2007 Work Plan. Grievance and Appeals P&P s are currently in review with DHS (updated version submitted February 23, 2007). Note: DHS approval of the Grievance and Appeals P&P was received March 20, Medica Response: Medica received the 2004 ATR in late At that time MPRO had concluded that none of the MCOs Grievance and Appeals policies or Notice of Action polices and procedures were in compliance with BBA requirements or the existing DHS contract requirements. MPRO then did a re-assessment following DHS implementing an MCO corrective action and determined that all MCOs were in compliance with BBA and contract requirements by that time. In January of 2006 MPRO conducted Medica s TSOC audit, which included a desk top review of specified policies/procedures, (including a review of Medica s Grievance and Appeals System and Notice of Action policies). MPRO determined at that time that Medica continued to remain in compliance with all BBA and DHS contract requirements for these key policies and procedures. Although Medica does not reference an annual review of these policies within their QI Work Plan as MPRO suggested in the 2004 ATR, Medica does make note in their QI Program Description that Medica s established policy is that each individual department is responsible for taking ownership of their policies. This includes reviewing these policies to ensure that they remain in compliance with regulatory and/or accreditation requirements at all times. MHP Response: MHP conducts an annual review of policies and procedures through several venues within MHP. MHP has initiated a Policy and Procedure Committee whose membership includes a broad spectrum of MHP employees. Further review is then conducted by the MHP managers as the staff who are considered the owners and who are closest to the actual practices covered by the policy. Once completed, policies/procedures are reviewed for consistency and compliance by the MHP directors. This includes the grievance and appeals policies. As pertinent, policy changes will be reflected in the Quality Work Plan or Program. MHP provides all employees with online access to policies and procedures. A copy of any MHP policy is available upon request for your review. PrimeWest Response: PrimeWest P&P are in compliance with contract requirements. P&P are reviewed, reported and committee approved on a yearly basis or more frequently based on State and/or Federal changes. PrimeWest s MDH audit revealed compliance with G & A according to contractual requirements. SCHA Response: SCHA annually reviews and revises our policies and procedures to ensure that our policies and procedures meet DHS contract requirements as well as federal and state requirements. SCHA has updated our Grievance and Appeals P&P s annually to ensure compliance with not only the 2004 DHS/MCO contract but also with the current year DHS/MCO contract. All policies and procedures are reviewed and approved by SCHA s Compliance Committee as well as SCHA s Joint Powers Board. SCHA will add reviewing the activities of and updating program documents and policies and procedures to our 2007 QI Work Plan. Appendix G: Detailed 2004 ATR Responses from MCOs Page 157

170 UCare Response: All quality improvement, and grievance and appeals, policies and procedures were updated to reflect current Department of Human Services contract language. Currently, UCare reviews its quality improvement program documents and, starting in 2008, will add to the Quality Improvement Work Plan an annual review of policies and procedures. Recommendation 7: Implement strategies aimed at increasing preventive care services for child and adolescent enrollees; develop a PIP related to Child and Teen Check-Ups (C&TC). Blue Plus Response: Blue Plus has a long standing quality improvement project focused on improving Child and Teen Check Up rates, it is not a formal PIP but serves the same function. Its goals and objectives are reviewed and revised annually. First Plan Response: In 2004 and ongoing, one of First Plan s QI initiatives is to increase not only participation rates in the Child & Teen Check Up (C&TC) program, Minnesota s EPSDT program, but to improve compliance of all elements of the C&TC exam. Components of this initiative are: Provide age specific C&TC documentation and billing forms to each primary care clinic Conduct yearly audits of each primary care clinics C&TC exams Provide customized training as needed and requested based on First Plan s feed back of the results of the audits to primary care clinics Provide monthly reports to clinics that identify primary care clinic First Plan Blue members that have an upcoming birthday to assist in outreach Provide monthly reports to clinics that state their C&TC billed participation rate Provide quarterly reporting that lists primary care clinics missed opportunities Write articles for both provider and member newsletters on the importance of C&TC exams. HealthPartners Response: Multiple interventions are in place to improve C&TC rates including an adolescent incentive program, patient registries and public reporting of comparative provider performance. HealthPartners 2006 Performance Improvement Project (PIP) focuses on Blood Lead in 24 Month Olds. Blood Lead is one of the Child and Teen Check-Ups Interventions. IMCare Response: IMCare has considered a C&TC PIP in the past. Due to our small population, the PIP was insignificant. However, IMCare has implemented improvement strategies to increase preventive care services. Medica Response: Following the receipt of the 2004 ATR Medica increased its efforts at improving C&TC screening rates and continues to implement multiple interventions to positively impact these rates to this date. Shortly after the 2004 was released, (in September 2005), a 2005 C&TC CAP Report was submitted to DHS on November 14, This report described for DHS all activities that Medica had in place in 2005 to address our C&TC screening rates. These activities continue today. Medica completed a barrier analysis to determine why children were not accessing well child checkups. The barrier analysis included focus groups of members and providers and a survey of members. The following topics were identified as barriers by members: finding transportation to a clinic; not having a personal value related to taking a child to the doctor when the child was well; the perception that clinic personnel are rushed, impersonal, unpleasant, inconvenient and slow; and the desire to have providers respect them as individuals, and talk to them using words and descriptions that they can understand. Providers identified the following barriers for members: lateness of members for visits due to having to rely on others for a ride and members having competing needs such as fulfilling the basics of daily-living that take priority over well child checkups. Based on these findings and other work Medica had done, Medica s has continued its multifaceted approach to the improvement of member participation in well child checkups and provider documentation of actual screenings. Some of these strategies are listed below. Appendix G: Detailed 2004 ATR Responses from MCOs Page 158

171 The Way To Better Health : The State Public Programs department at Medica continues to promote the Well Child Checkups / Immunization program through The Way to Better Health (TWTBH) program. This program has encouraged complete C&TCs by offering a store gift card for each "complete" Child and Teen Checkups visit. Since its implementation Medica has frequently sent targeted mailings to families with children promoting well child checkups which included a voucher that could be redeemed for a gift card if the child received a complete C&TC. In 2005 State Public Programs completed three targeted mailings, totaling 21,000, directed toward parents/guardians of children who had not received a C&TC in the previous 12 months; 8000 letters targeted children 3 through 20 years, 13,000 letters targeted children birth to 24 months. The latter also included a blood lead voucher that could be redeemed for an additional gift card if the member had a blood lead test. Many clinics have now developed their own C&TC outreach program and are using TWTBH vouchers and brochures to mail to their Medica SPP patients or are making them available at the clinic site. It's Your Health is Medica's quarterly newsletter for SPP members. The primary focus of this newsletter is to offer information about prevention and accessing appropriate health care. In 2005 It s Your Health offered information about Child and Teen Checkups and/or blood lead testing in three editions. Mothers Advocating Their Children s Health (MATCH): MATCH started as a unique partnership between Medica and Metropolitan Health Plan in April of 2001 and continued into MATCH s goal is to increase well child checkups/c&tcs for all children.. MATCH is associated with mothers who are taking their own children in for well child checkups; these mothers are also helping to spread the word to other mothers and caregivers about the importance of well child care. The Greater Minneapolis Council of Churches (GMCC) has operated the day-to-day operations under the name of CATCH (Congregations advocating their Communities' Health) since August of In 2005, CATCH has worked with 16 Christian and Non-Christian communities of faith inclusive of Baptists, Catholics, Lutherans and Muslims. MATCH and CATCH sponsored a conference "In Good Health II: The Human Face of Blood Lead Poisoning" attended by 49 professional and lay persons on October 12, The focus was to present the effects of blood lead poisoning and advocating preventative healthcare for children and adolescents. THEATER Corps presented Jimmy s Getting Better, a play describing the impact of blood lead poisoning. Additional presenters discussed the following topics: Blood Lead Prevention and Resources Filter Paper Testing-as option for collection Child & Teen Checkups Program and Services (Hennepin County) Well Child QISMC/PIP Project: Implemented in 2002, Medica partnered with the Minnesota Visiting Nurse Agency (MVNA) on this PIP which focused on providing in-home C&TCs. The target population was identified as English-speaking Medica State Public Programs member households living in Hennepin County, with two or more children ages 0-9 who had not had a well child checkup for over a year. The members were also continuously enrolled for at least one year and had a telephone number listed in Medica s records. Siblings over 9 years of age were also included on the list to receive checkups if they had no preventive visits in the last year. The 2002 pilot focused primarily on English-speaking families for implementation ease. In 2003, Spanish and Hmong speaking families were added to the implementation group. The geographic range was expanded to include the western side of Ramsey County (as the number of children in Hennepin County who met the parameters began to dwindle). The short-term intent of this intervention was to get these children quickly caught up on necessary preventive care services, get them established with a primary care clinic, and educate them about the importance of regular well child checkups. Long-term, the Appendix G: Detailed 2004 ATR Responses from MCOs Page 159

172 intent was to have these members access future well child checkups at their clinic. Medica staff members worked closely with MVNA on this project to ensure that there was complete documentation of the well child visits. The project showed short-term success in that 206 members without documented C&TC's in the previous 12 months received in-home C&TCs in 2002, 634 in 2003 and 408 between January and November 1, Medica still is continuing the program beyond the QISMC/PIP project and has transitioned the responsibility for this partnership with MVNA to the regional coordinators on its Community Health team. Central MN C&TC collaborative: The Central MN C&TC collaborative partnership includes Benton, Cass, Chisago, Crow Wing, Douglas, Grant, Pope, Stevens, Traverse, Isanti, Kanabec, Mille Lacs, Morrison, Pine, Sherburne, Stearns, Todd, Wadena, Wilkin and Wright counties. This collaborative meets quarterly and includes Medica, Blue Plus, Health Partners, PrimeWest and UCare Minnesota health plans. The purpose of the partnership is to share information, coordinate clinic trainings, and strategize outreach initiatives. The partnership also assures that clinics are up-to-date with C&TC information and produced a regional clinic newsletter focusing on C&TC issues. C&TC Metro Action Group (MAG): The Child & Teen Checkups Metro Action Group is a collaborative partnership between the seven county metro C&TC programs and the five health plans serving those on Minnesota Health Care Programs recipients in the metro area. The mission is to improve the health of children and teens that are eligible for the Minnesota Child & Teen Checkups (C&TC) program and reside in the seven county metropolitan area accomplishments include: Strategy planning implementation by multi-cultural workgroups which focused on Russian, Spanish, Somali and Hmong populations. The workgroups were responsible for: Conducting a 2005 blood lead screening training with informational flyers printed in Somali, Russian and English. Exploration of opportunities for working with Spanish speaking populations. MAG representation at the Cinco de Mayo celebration in St. Paul Continued focus on getting Hmong refugees in for health screenings and encouraging clinics to perform C&TCs for the refugee health screenings. Updating the charge ticket to reflect 2005 MDH Periodicity Schedule. Developing and distributing Prescription for C&TC slips for provider clinics. Provider and Community Outreach (PACO): This Hennepin County Provider Outreach Group is a collaborative partnership between the county s C&TC program and the four health plans serving those on Minnesota Health Care Programs. Achievements in 2005 included: Continuation of the prioritization of clinic key to the provision of health care to public Minnesota Health Care Programs recipients. Conducting meetings with clinics on the subject on Child and Teen Checkups. Provision of five clinic trainings by and November of Northeast Regional C&TC Partnership: This partnership includes eight Northeast counties, Fond du Lac Reservation, and health plans that participate in MHCP in the region. Medica State Public Programs' staff play an integral role in planning and participating in activities to assure all eligible children receive a C&TC. In 2005 the partnership produced two newsletters focusing on C&TC components, including blood lead testing. The newsletters were sent to all providers in the NE Region that administer Child and Teen Checkups to children enrolled in MHCP. Also, the partnership secured grant funding for a series of MHCP recipient C&TC input forums that Appendix G: Detailed 2004 ATR Responses from MCOs Page 160

173 will take place in each of the eight counties and the Fond du Lac Reservation. The purpose of these forums is to collect information about the barriers families experience, the level of information they have about C&TCs, and the value placed on preventive care. Three of the forums will occur in December Northwest C&TC: The Northwest C&TC is a collaborative partnership which includes Becker, Beltrami, Clay, Clearwater, Hubbard, Lake of the Woods, Mahnomen, Marshall, Norman, Otter Tail, Polk, White Earth Home Health and Wilken counties. This collaborative meets on a quarterly basis and includes Blue Plus, Metropolitan Health Plan, and UCare Minnesota health plans in addition to Medica health plan. Some of the accomplishments of this collaborative in 2005 have included: Distribution of C&TC Connections-Newsletter for the northwest region began in C&TC clinic trainings (Barneo, Clay County Public Health Nurses, Family Healthcare Center-Moorhead, Family Healthcare Center-Fargo, Independent Family Doctors, Dakota Clinic-Fargo, Dakota Clinic-Moorhead, Dakota Clinic-Fosston, First Care Hospital and Clinic, Altru Clinic-Crookston and Altru Clinic-Grand Forks). The development of C&TC educational materials (other than what's provided by the state) to educate providers and families about the importance of C&TCs. Clinical Review Programs: In 2005, Medica s Clinical Review department supported the C&TC effort by assessing medical record documentation of C&TC visits at high volume (Medicaid and MinnesotaCare members) clinic systems through the Choice Care Quality Improvement Program as well as other clinic groups visited as part of our Commercial Quality Improvement program. Results and opportunities for improvement related to C&TC documentation will be shared with clinic managers and clinic system quality contacts in November and December of 2005 following distribution of Choice Care Quality Improvement Program (CCQIP) results. For those clinics that fall below the established C&TC threshold, an improvement plan will be requested. (The C&TC threshold is based on one standard deviation from the plan aggregate mean for complete C&TC of the previous review year) Follow up will occur at the time of their next review. In addition, during the course of the review year, clinical nurse reviewers advised clinic managers of missing elements when a significant trend was observed while completing the review. Clinical review nursing staff also distributed C&TC chart documentation tools to interested clinics. Also, complete C&TC and blood lead rate results from the 2004 CCQIP were published on the Medica Web site in August of These results identify participating clinic groups by name and compare their results to the health plan aggregate score. Choice Care Quality Improvement Program: The Choice Care Quality Improvement Program (CCQIP) is a product-specific, incentive-based program representing 72% of members enrolled in Medica s Medicaid or MinnesotaCare plans. This program focuses on multiple quality improvement goals which include assessment of complete C&TC documentation as well as blood lead rates via claims data for 9 to 30 month old children. These two measures carry a weight of 20% each for the total CCQIP incentive payout to each clinic system. Through this program providers are encouraged to improve by a proportional 10% over their baseline score or maintain their score if they were in the 90 th percentile. If a provider is unable to meet this requirement for a measure, they do not receive the incentive payment for the measure. Clinic Trainings: Medica's state public program's community health staff continue to work with public health agencies and other health plans on educational efforts for providers/clinics. Provider Bulletins: Connections is a monthly publication for Medica and Select Care SM network providers and includes at least one article each year related to C&TCs. Appendix G: Detailed 2004 ATR Responses from MCOs Page 161

174 Toddler Tuesdays at the Mall of America: Medica s State Public Program s Community Health Staff worked with the Mall of America (MOA) to participate in their Toddler Tuesday program. Toddler Tuesdays is a program that provides entertainment especially for toddlers. Events include special character appearances, arts and crafts, and story time. Events are held every Tuesday from 10am until 12pm and are free and open to the public. Medica staff has attended five Toddler Tuesday events since July 2005 to promote the importance of Child and Teen Checkups and blood lead testing. Parents receive information about Child and Teen Checkups as well as a home lead test kit with instructions and phone numbers to the local and state health departments in the event that there is lead present in their home. Community Health Fairs, Conferences and Minnesota State Fair: State Public Programs staff attended various health fairs and conferences throughout the year to promote Child and Teen Checkups. In 2005, Medica was present at the Minnesota State Fair, where State Public Programs promoted Child and Teen Checkups and distributed home lead test kits to all families with children. MHP Response: While not a PIP topic, Child and Teen Checkups (C&TC) is an active program within MHP. MHP employs a C&TC Coordinator to arrange outreach events and to monitor the children who are MHP members. New in 2006 was a gift card incentive offered to MHP members who had not yet obtained a preventive examination. C&TC utilization is carefully monitored through standardized reporting and is a key indicator for MHP as under-utilization. Additional reports or C&TC activities are available upon request. PrimeWest Response: While PrimeWest has not yet conducted a formal PIP aimed at improving EPSDT (C&TC in Minnesota) rates, there are several programs that have been implemented during the past 3 years with this same goal. The first program started in 2003, and continues to date, involving an additional reimbursement amount to providers for a complete C&TC. In 2005, a member incentive program for lead screening at the one and two year C&TC exams was instituted. In 2006, two C&TC incentive programs were introduced for four year olds who have a complete C&TC, PrimeWest offers a booster car seat as an incentive. For eight year olds who have a complete C&TC, PrimeWest offers a bike helmet. PrimeWest agrees with the suggestion to use C&TC as a PIP study topic, particularly since recent PIPS have been a combined effort with other CBP PMAPs. Sharing ideas about what other measures could be taken to improve C&TC rates could help all of us improve in this endeavor. SCHA Response: SCHA recently completed our QISMC project which addressed improving EPSDT Rates and increasing preventive care services for child and teen enrollees. SCHA continues to encourage enrollees to seek preventive care services for child and teen enrollees through our Health Promotion Programs. SCHA recently developed and hired a Health Promotion Specialist who will over see these activities. UCare Response: UCare has added quality performance improvement projects and interventions in its 2007 Quality Work plan aimed at increasing well child visits for children and teens and increasing two year old and adolescent immunizations. Our interventions include new member and provider focused communications and incentives, a new internal cross-developmental workgroup to monitor progress throughout the year, and input from members and providers to our intervention strategies. Appendix G: Detailed 2004 ATR Responses from MCOs Page 162

175 Recommendation 8: Evaluate and analyze consumer satisfaction survey data from Consumer Assessment of Health Plans Survey (CAHPS ) to develop strategies for service improvement. Blue Plus Response: Blue Plus obtains its own CAHPS results on the Medicaid population annually, we then analyze this data and identify priorities for action. During this analysis we also review data from any other surveys or focus groups as well as complaints and appeals to identify what is important and/or of concern to the member. First Plan Response: First Plan uses CAHPS results, termination survey results and analysis of our grievance and appeals to determine opportunities to improve service to our members. HealthPartners Response: DHS conducts the CAHPS surveys for State Public Programs members. HealthPartners reviews and analyzes the CAHPS results at the Government Programs Quality and Utilization Improvement Committee and the Health Service Quality Council. IMCare Response: IMCare performs an analysis of the CAHPS survey data. The analysis is included in our annual program evaluation and includes interventions, barriers, opportunities, and recommendations to increase customer service. In addition, IMCare formed a Service Advisory Committee to include representation from a myriad of avenues, a major goal of the committee being the improvement to customer care and satisfaction. Medica Response: Medica ensures that the CAHPS survey is used annually for its consumer satisfaction survey related to their SPP and MSHO members. The CAHPS survey tool is recognized by DHS as a reputable and is a tool that presents an accurate picture of an MCO s consumer satisfaction levels. However, Medica reviews the CAHPS survey tool questions annually to see if there are clarifications we need to pursue or if there are additional survey questions that we would like added within the limitations of plan-specific survey questions. We also evaluate through an interdepartmental review whether plan-specific questions added to the prior year s CAHPS survey should be continued or be switched for new questions. The results from the CAHPS survey are analyzed by Medica s Regulatory Quality area within their Government Programs division, and then are distributed to areas relevant to the CAHPS survey questions, and the individual areas who have opportunities for improvement identified through the CAHPS survey determine actions to be taken to address the issues identified through the CAHPS survey. MHP Response: MHP receives the results of the DHS CAHPS surveys conducted by DataStat. These results are included in MHP s Quality Program (see #1 above). Further, MHP contract, member services and outreach areas use the CAHPS results to tailor programs to the members. One area of practice at MHP that was changed as a result of CAHPS findings relates to prior notice for transportation services. MHP formerly required a three-day notice of a medical appointment and transportation. Based on member feedback and analysis, this advance notice requirement was dropped. Another area of change is in primary care clinic designation. While it is still advised to establish a healthcare home, it is not required. Thus member can obtain specialty care without referral from any specialist in the MHP service area including chiropractic, family planning, mental health or chemical health services. PrimeWest Response: CAHPS survey tool is included as a required component of analysis in the PrimeWest QA Plan. CAHPS identified areas of improvement were included in the 2006 Work Plan with implementation of improvement strategies. Some of the strategies are: New Member Welcome Call process Monthly Member Advisory Committee meetings Quarterly Member Informational meetings Quarterly member publication awareness of PrimeWest programs and services Staff Educational meetings Appendix G: Detailed 2004 ATR Responses from MCOs Page 163

176 An analysis according to recommendations of those strategies will be included in the 2006 evaluation. This was not previously completed or a part of the Quality Assessment. SCHA Response: SCHA reviews and evaluates customer satisfaction results from our TPAs on an annual basis. SCHA also monitors and analyzes grievances and appeals and customer service activities data which can impact customer satisfaction. Additionally, SCHA reviews and analyzes our CAHPS survey results on an annual basis. All CAHPS scores were higher than the PMAP average and State average scores. Communication improvements seen over the past two years were likely influenced by SCHA CRMT activities and primary care providers. UCare Response: UCare uses the time-tested CAHPS survey to measure consumer satisfaction. UCare s CAHPS results did not reflect needed improvements. Nevertheless, UCare conducted a customer satisfaction survey for the third quarters of 2005 and In both years, our customer satisfaction ratings were greater than 90%. UCare members are encouraged to provide feedback to our Customer and Member Services areas. The information collected includes feedback regarding: 1) marketing and sales; and 2) complaints, appeals and grievances. This information is tracked via a database and used to heighten UCare s awareness of member trends. This allows UCare the opportunity to resolve a variety of member concerns and increase satisfaction. Recommendation 9: Adopt evidence-based preventive and chronic disease practice guidelines appropriate for child, adolescent, young adult, older adult, senior, and maternity populations. Blue Plus Response: Blue Plus is in compliance with these recommendations as evidenced by our 2006 NCQA accreditation and also by audits conducted by MPRO. First Plan Response: First Plan supports and encourages that all our network providers use the Institute for Clinical Systems Improvement (ICSI) evidence based guidelines. ICSI guidelines represent all the age groups outlined in this section. First Plan s audit program of provider compliance of adopting evidence based guidelines was updated for the 2006 report based on a letter received from DHS requesting clarifications and/or updates after reviewing our 2005 report. For instance, we did not audit a guideline that represented the member population of 16 months to six years. Therefore, we extended the audit of well child compliance through 15 months to include through 6 years. In addition, in previous reports we did not specifically report that we audit all of our providers. First Plan now meets the requirements of this section. HealthPartners Response: This general recommendation is inapplicable to HealthPartners as demonstrated by MPRO s Triennial Structural and Operational Component (TSOC) Audit results showing HealthPartners was 100% compliant. HealthPartners has consistently achieved 100% compliance with NCQA requirements related to clinical practice guidelines. HealthPartners is a founder and principal sponsor of the Institute for Clinical System Improvement (ICSI) and a state and national leader in comparative provider performance data and reporting. IMCare Response: IMCare adopts preventive and chronic disease practice guidelines as indicated in the MPRO TSOC audit conducted November 29, 2006 (reported February 23, 2007). Medica Response: At the time of the 2004 ATR and also since that time Medica has demonstrated that the practice guidelines we monitor are based on valid and reliable clinical evidence, as all are based on ICSI Guidelines. Medica adopted all Institute for Clinical Systems Improvement (ICSI) guidelines effective September 1, ICSI guidelines are reviewed and updated every 12 to 18 months or sooner if the scientific validity and/or community standard of care warrant, by physicians and other health care providers throughout Minnesota. Medica also has a Health Promotion and Disease Prevention Visit Schedule Guideline for High-Risk Children, Adolescents and Adults (Infant to 21) years which is based on the Minnesota Child and Teen Checkups Periodic Screening Schedule. Medica has been monitoring provider Appendix G: Detailed 2004 ATR Responses from MCOs Page 164

177 compliance with practice guidelines that are appropriate for children, adolescents, young adults, adults and seniors aged 65 and older as you can see from the following topics described in the most recent contractrequired Practice Guidelines report submitted to DHS. The topics included Pediatric Asthma, Depression- Major (Adult including seniors), Child and Teen Checkup, Diabetes Mellitus-Type I & II (Adult including seniors), Chlamydia Screening, (Teen and young adult women), Colorectal Cancer Screening (Adult including seniors), and Hypertension-Chronic (Adult including seniors) guidelines. By 2005, MPRO stated in Medica s 2005 ATR that Medica was one of only two plans that sampled a reasonable number of our providers. They went on to state that our Medica s data sources were appropriate for monitoring provider compliance with practice guidelines. MHP Response: In 2005 and 2006, MHP s Medical Administration area was responsible to develop, adopt, disseminate, audit and analyze compliance with MHP s guidelines. In 2007, this responsibility has moved to Quality Management so that MHP could continue its quality strategy more broadly internally and externally. MHP has adopted the Institute for Clinical Systems Integration (ICSI) guidelines. These guidelines have been reviewed and adopted by the Quality Management Committee. Whenever possible, MHP utilizes HEDIS measures as a standard for compliance. MHP is also a member of the Minnesota Community Measurement Project which conducts measurement and public reporting of compliance with HEDIS measures. The process has been very successful in encouraging clinic competition to improve their rates as compared to peers and to improve Minnesota s overall HEDIS rates. PrimeWest Response: PrimeWest s Practice Guidelines Reports (2003, 04 & 05) is documented evidence that PrimeWest has been and is in compliance with this recommendation. Additional Clinical Guidelines are added based on identified need and through the Quality and Care Coordination Committee. SCHA Response: SCHA reviews and adopts, on an annual basis, ICSI s preventive and chronic disease practice guidelines which are based on valid and reliable clinical evidence that are appropriate for children, adolescents, prenatal care, young adults, adults, and seniors aged 65 and older. ICSI is a community organization, who involves local community practitioners and providers, as well as utilizing valid and reliable national and local clinical evidence, in the development of preventive and chronic disease practice guidelines. UCare Response: UCare s has practice guidelines that are appropriate for children, adolescents, prenatal care, young adults, adults, and seniors aged 65 and older (see page 53 of the 2004 Annual Technical Report). In addition, UCare has made several revisions to our guideline program. We: 1) utilize the DHS-recommended format for the guideline report; 2) measure in a manner that allows for increased provider-specific analysis; 3) adopted and measure a guideline specific to the physically disabled MnDHO population; and 4) are finalizing a guideline and measurement plan for the developmentally disabled MnDHO population. Recommendation 10: Review ambulatory-sensitive conditions analysis and results for evaluation of case management, disease management, and PIPs on the following clinical conditions: asthma, bacterial pneumonia, heart failure, dehydration, diabetes, and gastroenteritis. Blue Plus Response: Blue Plus uses its own claims data to identify candidates for case, disease and utilization management screening and action. First Plan Response: Enrollees identified with ambulatory sensitive conditions are assessed for case and disease management. HealthPartners Response: HealthPartners has a comprehensive process to review multiple data sources to identify opportunities for improvement initiatives. HealthPartners offers asthma and diabetes disease management programs, as required by the DHS contract. HealthPartners also has additional disease management programs for Congestive Heart Failure. Appendix G: Detailed 2004 ATR Responses from MCOs Page 165

178 IMCare Response: IMCare currently has a Performance Improvement Project in place for Diabetes. IMCare s Disease Management Program currently has programs for asthma, diabetes, depression, heart failure, COPD, CAD, and ulcer. Members with any of these conditions are evaluated for case management. Ambulatory sensitive conditions are analyzed. Medica Response: After reviewing the 2004 ATR companion report Minnesota Healthcare Program Encounter Data Analysis Medica took the following actions: Asthma: PMAP was shown in the report as having the highest rate of members with Asthma, and after Medica evaluated our plan-specific Asthma data we discovered that within the PMAP population Black children aged 5-9 were less likely to receive appropriate Asthma care as compared to Caucasian children in the same age range. Once we identified this healthcare disparity we then implemented a two year project aimed at decreasing the disparity by focusing on optimizing the care provide to our Black members with asthma that were aged 5-9. This was a RWJ grant-based project overseen by the Center for Health Care Strategies. Medica partnered with the Minnesota branch of the American Lung Association to address the disparity. We identified members that fell into our target population, matched them with a provider and then ultimately with a clinic. The multiple interventions, (which ALAMN implemented in the clinics Medica identified that saw the highest number of our at risk population), were aimed at introducing a systematic approach for the care of patients with Asthma to the selected clinics. Although the grant ended in 2006, Medica saw improved HEDIS rate in the Black, 5-9 year old PMAP members with persistent asthma following the implementation of the interventions in the clinics seeing a high volume of these members. Medica continues to this day to partner with ALAMN in introducing this Asthma Clinic System Change Program to additional clinics. In addition Media continues to offer a disease management program focused on Pediatric Asthma and is in the process of exploring an initiative to reduce inpatient hospitalizations and/or ER visits related to Asthma. CHF: Medica s data reflected what the MPRO report had shown that CHF is more prevalent among older adults, especially the 85+ population, (the majority of which are MSHO enrollees). Medica along with two other MSHO MCO s, (UCare and MHP) implemented a collaborative CHF QISMC project in 2002 targeting both community and institutionalized MSHO members. DHS accepted and approved the final CHF QISMC report in 2005, and the project ended with the submission of this final report. However, Medica continues to monitor CHF encounter data to this day and also continues to offer a CHF disease management program. Dehydration: The MPRO report showed that only.9% of MHCP members experienced an episode of dehydration during CY It also stated that dehydration does not appear to be a large problem in the MHCP population Medica s own encounter data also reflected this low prevalence. Thus Medica did not prioritize dehydration as an identified opportunity for improvement in their PMAP or MSHO populations and thus did not implement a quality improvement effort focused on this topic. Diabetes: Medica along with UCare and MHP, (two other MSHO plans), had already identified that there were opportunities for improvement related to Diabetes care in their MSHO populations and thus implemented a Diabetes QISMC project that ended with DHS accepting and approving the project s final report in This very successful project aimed at improving the community MSHO members annual comprehensive diabetes care and at improving the rate at which institutionalized MSHO members received eye examinations. Medica transitioned the efforts that the quality improvement staff were leading during the QISMC project to their MSHO staff once the project ended in order to make these efforts permanent MSHO processes. Appendix G: Detailed 2004 ATR Responses from MCOs Page 166

179 Gastroenteritis: The MPRO report showed that in 2001, the rate for related admissions reflected only.13% of the MCHP population. It did show that the prevalence among the infant population was on the increase between 2001 and 2004 and that this was relevant to the PMAP population. However, the report also went on to state that gastroenteritis does not appear to be a large problem in the MHCP population As Medica s own gastroenteritis data, (collected as part of a data report showing PMAP ER visits broken down by diagnosis/frequency), also showed that this was not a high clinical priority for their PMAP member population, there has not been a disease management program or a performance improvement project implemented to specifically address gastroenteritis to date. Bacterial Pneumonia: After reviewing our own data in this area, Medica also recognized the importance of prevention in this clinical area, as studies showed us that 20% of people 80 years of age or older will die from pneumococcal bacteremia. We also identified low rates of pneumococcal vaccinations in our community MSHO population. We thus identified the need to target the community-based senior population that were enrolled in our MSHO product with a quality improvement activity of some sort. This lead to Medica joining with two other MSHO plans, (UCare and MHP), to implement a collaborative MSHO performance improvement project focusing on increasing the rates of pneumococcal vaccinations in the MSHO community population. The PIP was implemented in 2006 and is still underway. The expectation is that the final report on this PIP will be submitted to DHS in MHP Response: MHP has thoroughly reviewed the 2004 ATR Companion Report. To address Ambulatory sensitive conditions for our members with disease such as Asthma, Diabetes and COPD, MHP calls all members with these diseases and offers the member the opportunity to participate in our Disease Management programs. MHP also does follow up hospitalization phone calls for all discharged members to assure that their health needs in the home are being addressed after discharge. If problems are found then arrangements are made to put in place services that are needed to help prevent an unnecessary rehospitalization. MHP will be implementing a Heart Failure program in PrimeWest Response: PrimeWest retains documented evidence of compliance with this recommendation through monthly UM meetings, policies and procedures, disease management programs, monthly/quarterly/yearly reports, committee meetings, PIPs, Focus Studies, and with case management/care management programs. SCHA Response: All enrollees with the conditions of asthma, bacterial pneumonia, congestive heart failure, dehydration, and diabetes are screened and evaluated on a monthly basis through the Special Health Care Needs report. Gastroenteritis will be added to the screening diagnoses. These enrollees are assessed for potential case management. Additionally, SCHA has a disease management program of asthma and diabetes conditions for enrollees who have these conditions. UCare Response: UCare addresses this concern through the quarterly review of Special Health Care Needs data. Care managers review the data, provide screening for cases that meet clinical criteria, and refer members to county case management as appropriate. An annual report is submitted to the State addressing this standard. Also, a new PIP aimed at improving diabetes care in the physically disabled MnDHO population is being developed as a coordinated project involving both the Disease Management and Performance Improvement areas. These two areas have successfully worked together over the past several years to effect a significant improvement in the percentage of members with asthma who have appropriate long- term controller medication. Appendix G: Detailed 2004 ATR Responses from MCOs Page 167

180 MCO-specific Recommendations Blue Plus FirstPlan MCO Recommendation MCO Response HealthPartners Increase the number of clinics audited for practice guideline compliance. Identify and work with clinics with performance indicator rates below the 75 th percentile of Quality Compass. Give attention to CAP from MDH QA Exam. Give attention to CAP from the MDH QA Exam. Increase number of clinics audited for practice guideline compliance. Stratify reporting results by program. The annual Blue Plus audit of clinics included every contracted medical group, it audits 100% of network performance. As Blue Plus Medicaid enrollment is often low within a given group, small denominators prevent our reporting on many of the medical groups. To overcome this problem, we do additional work and combine commercial data with the public programs data so that we have sufficient numbers to provide feedback. We send results of this analysis out to our medical groups annually. Per our contract, we report on only the Medicaid population results to DHS. Blue Plus uses its Quality Council, which is composed of actively practicing physicians and selected Plan staff, to set thresholds for action on quality indicators. Our guideline policies and procedures have been reviewed. The 75 th percentile is higher than the percentage the Quality Council has selected for action. The Blue Plus mid-cycle MDH QA review in 2006 found the Plan fully compliant with our CAP and that we had implemented our corrective action plans for the identified deficiencies. Audits of cases found we are complying with our CAP. In 2004, (based on the 2003 MDH QA Exam Report) there were no deficiencies identified. HealthPartners reviewed this recommendation. The need for this recommendation is contraindicated by MPRO s Triennial Structural and Operational Component (TSOC) Audit results showing 100% compliance with Clinical Practice Guidelines. Also, HealthPartners was 100% compliant with NCQA requirements. HealthPartners is a founder and principal sponsor of the Institute for Clinical System Improvement (ICSI) and a state and national leader in comparative provider performance data and reporting. Our Guideline report for 2006 (2005 dates of service) utilized the Appendix K Managed Care Public Program Practice Guideline Report Template recommended by the 2004 ATR report. HealthPartners subsequently reported HEDIS Medicaid specific data for four (cervical cancer screening, breast cancer screening, coronary artery disease and blood lead testing rates) guidelines. In addition, HealthPartners publicly reported comparative performance data for C&TC and lead screening in the 2006 Clinical Indicators report. HealthPartners reviewed this recommendation. HealthPartners annually produces and monitors over 285 reports specific to State Public Programs. HealthPartners combines an overall population health focus with a product-specific set of report and monitoring specific to Appendix G: Detailed 2004 ATR Responses from MCOs Page 168

181 IMCare Medica MCO Recommendation MCO Response Give attention to CAP from MDH QA Exam. Adopt, disseminate, apply and audit practice guidelines in accordance with the contract. Give attention to CAP from MDH QA Exam. Give attention to CAP from MDH QA Exam. State Public Programs. In addition, HealthPartners provides member-level, product-specific data to providers as part of a web-based registry. On a biannual basis HealthPartners performs a comprehensive review and analysis of quality and utilization data and initiatives specific to State Public Programs including trend and benchmark analysis. The results are utilized to identify course correction or new initiatives HealthPartners has been and continues to be attentive to the MDH QA Examination CAP. HealthPartners had a successful 2006 MDH QA Examination with no repeat findings. MDH has recently acknowledged it will be making changes to the quality assurance examination process to improve the consistency, transparency and credibility of its oversight of health plans. They have agreed to develop a monitoring guide to standardize and improve the objectivity of the review process IMCare adopts preventive and chronic disease practice guidelines as indicated in the MPRO TSOC audit conducted November 29, 2006 (reported February 23, 2007). IMCare complied with this recommendation per the requirements of MDH. Medica worked hard on the MDH QA Examination corrective action plan deficiencies identified in the MDH QA exam that was the closest to (and conducted prior to) the 2004 ATR release. In March of 2005 after an MDH mid-cycle review, Medica received word from MDH that they felt Medica had met their corrective action plan requirements related to two of the three deficiencies they had received in the earlier QA Examination Final Report. The third deficiency had called for a revision of Medica s policies related to Clinical Appeals, the education of customer service staff regarding this revised policy and a successful chart audit to prove that the new policy was indeed being implemented consistently. Unfortunately, although the Clinical Appeals policies had been revised and the education had been done, Medica did not pass a chart audit done in this area during the next MDH QA Examination, (per the final report released in 2006), as it was not a 100% score, and the chart audit was pass or failif Medica did not have 100% chart audit results they failed. Medica expressed their concern to MDH about this chart audit failure as it was directly tied to a single employee whom Medica had identified and worked with. As this was now considered an MDH repeat deficiency Medica took this chart audit failure seriously and ended up expressing their concern about the MDH chart review sampling methodology not being a recognized standard sampling methodology directly to MDH. They also pointed out that Appendix G: Detailed 2004 ATR Responses from MCOs Page 169

182 MHP MCO Recommendation MCO Response Develop and conduct audit of provider compliance with practice guidelines. Analyze voluntary disenrollment rates. Give attention to CAP from MDH QA Exam. it was unrealistic to hinge a deficiency on a case where one employee did not follow procedure and where Medica had corrected the problem as soon as it was recognized. As a result of this discussion between Medica and MDH the repeat deficiency was dropped by MDH. Practice guidelines are selected, reviewed and adopted at the Quality Management Committee based on the recommendation of Medical Administration (UM). MHP adopted the ICSI guidelines and has mailed and hand carried copies of the ICSI guidelines to contracted clinics. Measurement of the guidelines selected for focus was through HEDIS data collected annually. MHP continuously initiates internal process improvements related to guidelines. Quality Management assumed responsibility for the implementation and reporting of this activity. Eleven ICSI measures will be collected, reported by clinic and compared to the Minnesota Community Measurement rate. Clinics that do not meet the MHP rate or the Minnesota Community Measurement rate will be asked for a plan of correct if there are a significant number of MHP members at the clinic. As a small health plan, we do have clinics with only one or two members utilizing the site. MHP has conducted analysis and developed an action plan to address MHP s high rate of voluntary disenrollment. Interventions include more assistance for member who feels that they cannot locate a dentist or physician. MHP and/or Delta Dental will find a willing provider for every interested member. In addition, MHP continues to conduct in-depth analysis on the demographics of the people who switch plan for commonalities. Appeals and Grievances are a potential key source of data for root cause analysis. MHP is determining if focus groups and open house opportunities for members or providers to come to MHP for information and problem solving would be beneficial. Since the MDH audit in August of 2005, MHP has worked carefully to isolate each issue, to evaluate the root cause of the issue, to assign ownership and to establish a time frame for correction. MHP s compliance area has tracked these activities in a series of issue logs and updates. As the mid-cycle MDH audit has approach, MHP engaged independent consultants to review MHP s CAP and to assess our compliance with the CAP prior to the MDH mid-cycle audit. MHP has been working diligently to address each concern noted as an MDH deficiency or recommendation. The consultants working with MHP have replicated an audit to help MHP identify strengths and opportunities to do something better. MHP continuously strives to meet all regulatory requirements of MDH and included the findings of the MDH audit in the evaluation of the 2005 Work Plan. Complete Appendix G: Detailed 2004 ATR Responses from MCOs Page 170

183 SCHA UCare MCO Recommendation MCO Response Give attention to TSOC CAP. Give attention to CAP from MDH QA Exam. Adopt a practice guideline applicable to persons with disabilities. Analyze MCO s Chlamydia screening rates/process and develop interventions. Give attention to CAP from MDH QA Exam. documentation is available at MHP upon request. The two major areas highlighted by the TSOC audit were in over/under utilization and subcontractual relationships/delegation. MHP has established methods to measure and address over/under utilization as part of the UM Program. A standardized reporting package has been developed and the analysis is presented to the Quality Management Committee on a regular basis. MHP has greatly strengthened and clarified its subcontractual relationships along with regular auditing for oversight of delegated functions. This is also described in the general comments section of this response. SCHA completed all CAP activities which were developed in response to the regulatory deficiencies identified during our 2004 MDH QA Examination. SCHA also worked closely with all of our delegates to ensure compliance with the CAP activities. MDH has just completed their site visit for SCHA s 2007 MDH QA Exam and we are awaiting this report. Please see the answer to Question #9, above. New in 2007, UCare has a PIP aimed at improving the rate of Chlamydia screening in women meeting the HEDIS eligibility criteria. UCare implemented the CAP addressing the findings and completed the following actions in response: hired a psychiatrist on a consultant basis to be the designated behavioral health care practitioner involved in utilization management programs. revised the delegation agreement to include the specificity recommended. updated the policy and procedures to include state notification, clarification of the utilization management process, annual approval of the Utilization Management Plan, and documentation on how oversight reports are received and reviewed for utilization management purposes. Appendix G: Detailed 2004 ATR Responses from MCOs Page 171

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185 APPENDIX H MCO HEDIS PERFORMANCE TO GOALS This following tables detail MCO HEDIS Performance to Goals by Program (PMAP & MinnesotaCare Only) and MCO HEDIS Performance Rates by Program (PMAP and MinnesotaCare Only). Appendix H: MCO HEDIS Performance to Goals Page 173

186 MCO HEDIS Performance to Goals by Program (PMAP & MinnesotaCare Only) Table 35: MCO HEDIS Performance to Goals by Program (PMAP & MinnesotaCare Only) Appendix H: MCO HEDIS Performance to Goals Page 174