SFY EXTERNAL QUALITY REVIEW TECHNICAL REPORT

Transcription

1 Florida Agency for Health Care Administration SFY EXTERNAL QUALITY REVIEW TECHNICAL REPORT January East Camelback Road, Suite 300 Phoenix, AZ Phone Fax

2 CONTENTS 1. Executive Summary Background Scope of Review Summary of Findings Overall Conclusions and Recommendations Introduction Background Purpose Description of External Quality Review Activities Validation of Performance Improvement Projects HMO/PSN Collaborative PIP PMHP Collaborative PIP NHDP Health Plan Collaborative PIP SIPP Collaborative PIP Validation of Performance Measures Review of Compliance With Access, Structure, and Operations Standards HMO Compliance Review PSN Compliance Review PMHP and CWPMHP Compliance Review Overall Conclusions and Recommendations Technical Assistance Information Dissemination and Education Follow-Up on Prior Recommendations Validation of Performance Improvement Projects Validation of Performance Measures Review of Compliance With Access, Structure, and Operations Standards Appendix A. Assessment of MCO/PIHP Strengths and Weaknesses... A-1 Methodology... A-1 HMO Findings... A-3 PSN Findings... A-19 PMHP Findings... A-24 NHDP Health Plan Findings... A-26 SIPP Findings... A-28 Appendix B. Listing of MCO PIP Validation Results for SFY B-1 Appendix C. Other Quality Activities... C-1 Child Health Check-Up Participation Rates... C-1 Maternal and Infant Health Status Indicators... C-1 FARS/CFARS... C-1 Accreditation Outcomes... C-2 Medicaid Encounter Data System (MEDS) Project... C-2 Technical Assistance for AHCA... C-2 Technical Assistance for MCOs... C-3 SFY External Quality Review Technical Report Page i

3 ACKNOWLEDGMENTS AND COPYRIGHTS HEDIS refers to the Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA). NCQA HEDIS Compliance Audit is a trademark of the NCQA. SFY External Quality Review Technical Report Page ii

4 1. Executive Summary Background The Balanced Budget Act of 1997 (BBA), Public Law , requires states to prepare an annual report that describes the manner in which data from activities conducted in accordance with the Code of Federal Regulations (CFR), at 42 CFR , were aggregated and analyzed. The report must also describe how conclusions were drawn as to the quality and timeliness of, and access to, care furnished by their managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs). The Florida Agency for Health Care Administration (AHCA) chose to meet this requirement by contracting with an external quality review organization (EQRO), Health Services Advisory Group, Inc. (HSAG), beginning in state fiscal year (SFY) , following a brief development phase. This is the sixth full year of the external quality review (EQR) contract. By producing and delivering this SFY External Quality Review Technical Report, AHCA has complied with 42 CFR This report provides: A description of the Florida Medicaid managed care program. A description of the scope of SFY EQR activities. MCO- and PIHP-specific findings, including an assessment of each plan s strengths and weaknesses regarding the quality and timeliness of, and access to, care and services. Recommendations to AHCA to improve MCO and PIHP compliance with BBA requirements and, subsequently, to improve the quality and timeliness of, and access to, services provided to Florida Medicaid managed care enrollees. The BBA states that each contract with a Medicaid managed care organization must provide for an annual external independent review conducted by a qualified independent entity of the quality outcomes and timeliness of, and access to, the items and services for which the organization is responsible. 1-1 The Centers for Medicare & Medicaid Services (CMS) has chosen the domains of quality, access, and timeliness as keys to evaluating the performance of MCOs and PIHPs. HSAG used the following definitions to evaluate and draw conclusions about the performance of the MCOs in each of these domains. 1-1 Department of Health and Human Services Centers for Medicare & Medicaid Services. Legislative Summary: Balanced Budget Act of 1997 Medicare and Medicaid Provisions. SFY External Quality Review Technical Report Page 1-1

5 EXECUTIVE SUMMARY Quality CMS defines quality in the final rule at 42 CFR as follows: Quality, as it pertains to external quality review, means the degree to which an MCO or PIHP increases the likelihood of desired health outcomes of its recipients through its structural and operational characteristics and through provision of health services that are consistent with current professional knowledge. 1-2 Timeliness The National Committee for Quality Assurance (NCQA) defines timeliness relative to utilization decisions as follows: The organization makes utilization decisions in a timely manner to accommodate the clinical urgency of a situation. 1-3 NCQA further discusses the intent of this standard to minimize any disruption in the provision of health care. HSAG extends this definition of timeliness to include other managed care provisions that impact services to enrollees and that require timely response by the MCO or PIHP e.g., processing expedited appeals and providing timely follow-up care. Access In the preamble to the BBA Rules and Regulations, 1-4 CMS discusses access to and the availability of services to Medicaid enrollees as the degree to which MCOs and PIHPs implement the standards set forth by the state to ensure that all covered services are available to enrollees. Access includes the availability of an adequate and qualified provider network that reflects the needs and characteristics of the enrollees served by the MCO or PIHP. 1-2 Department of Health and Human Services Centers for Medicare & Medicaid Services. Federal Register. Code of Federal Regulations. Title 42, Vol 3, October 1, National Committee for Quality Assurance Standards and Guidelines for MBHOs and MCOs. 1-4 Department of Health and Human Services Centers for Medicare & Medicaid Services. Federal Register, Vol. 67, No. 115, June 14, SFY External Quality Review Technical Report Page 1-2

6 EXECUTIVE SUMMARY Scope of Review Mandatory Activities The scope of this sixth-year contract for EQR services consisted of the following key categories of mandatory activities to be conducted on an annual basis: Validation of performance improvement projects (PIPs). HSAG reviewed the MCOs and PIHPs PIPs to ensure that the health plans designed, conducted, and reported on the projects in a methodologically sound manner, allowing real improvements in care and services and giving confidence in the reported improvements. Validation of performance measures. HSAG validated the performance measures required by AHCA to evaluate the accuracy of performance measure results reported by the MCOs and PIHPs. The validation also determined the extent to which Medicaid-specific performance measures calculated by the MCOs and PIHPs followed specifications established by AHCA. Review of compliance with access, structure, and operations standards. HSAG evaluated AHCA s compliance monitoring process and recommended additions or revisions to the process to align the review with federal standards and guidelines. Technical report. HSAG compiled all data from the sixth-year EQR activities and drew conclusions related to the quality and timeliness of, and access to, care furnished by the State s MCOs and PIHPs. Optional Activities Some of the EQR activities were optional activities and may not have been intended to produce MCO- or PIHP-specific results; rather, the activities involved an evaluation of a key component of the overall managed care program with respect to BBA requirements. These activities were: (1) strategic analysis of Healthcare Effectiveness Data and Information Set (HEDIS ) data, (2) technical assistance, and (3) information dissemination and education. The following describes key categories of optional activities to be conducted on an annual basis: Strategic HEDIS analysis reports. HSAG performed a strategic analysis of the available HEDIS 2011 data. Technical assistance. HSAG provided technical assistance as requested by AHCA related to validation of PIPs, development of performance measures, and compliance-related activities. In addition, AHCA requested HSAG s assistance in facilitating an Emergency Department (ED) Collaborative to reduce avoidable emergency department visits. Information dissemination and education. HSAG continued to provide information to keep all appropriate AHCA staff members, key stakeholders, MCOs, PIHPs, and other interested parties informed of all EQR projects and activities. SFY External Quality Review Technical Report Page 1-3

7 EXECUTIVE SUMMARY Organizations Included in External Quality Review During SFY , AHCA included certain MCO and PIHP model types within the scope of the EQR, as listed in the following table. The table also indicates the type of entity (MCO or PIHP) as defined by the BBA. Table 1-1 MCO and PIHP Model Types Under External Quality Review Model Type MCO/PIHP Description of Services Health maintenance organizations (HMOs) Reform and Non-Reform Provider service networks (PSNs) Reform and Non-Reform Prepaid mental health plans (PMHPs) Child welfare prepaid mental health plan (CWPMHP) Nursing home diversion program health plans (NHDP health plans) Statewide inpatient psychiatric program health plans (SIPPs) MCO PIHP or MCO PIHP PIHP PIHP PIHP Prepaid, comprehensive physical and mental health services provided to enrolled members Prepaid or Fee for Service, comprehensive physical and mental health services provided to enrolled members Mental health services provided to Medicaid recipients who are not enrolled in an HMO or PSN Prepaid mental health services provided to children and adolescents with open cases in Florida s Safe Families Network Prepaid home and community-based services for Medicaid enrollees who qualify for nursing home placement Medicaid recipients under the age of 18 years receiving mental health services in an intensive residential setting. AHCA is responsible for the administration of the Medicaid managed care program in Florida. The Florida Legislature delegated operational responsibility for Florida s nursing home diversion program health plans (NHDP health plans) to the Department of Elder Affairs (DOEA). Florida s Medicaid Reform Pilot Program is a comprehensive demonstration that seeks to improve the Medicaid delivery system. AHCA implemented the Medicaid Reform Pilot Program in July 2006, operating under an 1115 Research and Demonstration Waiver approved by CMS. Reform plans in the pilot program began providing services to Medicaid beneficiaries in two counties in September 2006, with expansion to three additional counties in September Reform plans operate as either HMOs or PSNs, but with different benefits and requirements for their separate Reform enrollment. HSAG began PIP validation activities for the contracted Reform HMOs and PSNs during SFY Reform plans collected and submitted performance measure data to AHCA in July This report includes the findings and results from the EQR validation of the PIPs and performance measure validation. Nineteen HMOs, 6 PSNs (one with two separate Reform areas), 5 PMHPs, 1 CWPMHP, 16 NHDP health plans and 14 SIPPs had active contracts during SFY and were included under the scope of the EQR. For ease of reference, this report refers to the HMOs, PSNs, PMHPs, CWPMHP, NHDP health plans, and SIPPs as MCOs. For circumstances in which the activities or findings apply to one or more model types, but not to all, the report identifies the individual model types. SFY External Quality Review Technical Report Page 1-4

8 EXECUTIVE SUMMARY Summary of Findings During SFY , HSAG validated two PIPs for each MCO. In addition, HSAG validated selected performance measures reported by the MCOs. The following is a summary of MCO findings for PIPs and performance measures, and compliance with standards. HMOs and PSNs The HMOs performance showed improvement in SFY for PIP validity. Of the 24 PIPs assessed, 79 percent received a Met validation status. In SFY , 19 PIPs were assessed and 68 percent received a Met validation status. Overall, the PSNs demonstrated substantial improvement in implementing and documenting valid PIPs, with 88 percent receiving a Met validation status in SFY compared to 83 percent in SFY AHCA required all HMOs and PSNs to report a selected set of HEDIS performance measures as well as Agency-defined measures. HSAG reviewed and validated the audit findings from each health plan s final audit report produced by the auditing licensed organization (LO). Findings for the HMOs and PSNs were broken down into IS standards as outlined in the NCQA HEDIS specifications. Overall, HMOs and PSNs had sufficient processes and information systems capabilities that supported the accurate collection and reporting of performance measure data. While some plans were not fully compliant with all IS standards, the issues did not result in a significant bias to any reported rate. Across all HEDIS measures required this year, both Reform and Non-Reform plans had a few measures for which the statewide performance exceeded AHCA s performance targets. AHCA established the State s performance targets based on HEDIS benchmarks for each measure. For the Reform plans, statewide performance exceeded their respective performance targets for nine measures (i.e., Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life; two Follow-Up Care for Children Prescribed ADHD Medication measures [Pediatric Care]; Breast Cancer Screening [Women s Care]; two Antidepressant Medication Management measures; two Comprehensive Diabetes Care measures; and Adult BMI Assessment [Living With Illness]). For the Non-Reform plans, the statewide average of the Diabetes Care LDL-C Screening, Antidepressant Medication Management Continuation Phase Treatment, and Adult BMI Assessment (Living With Illness) measure reached its performance target. In general, opportunities for improvement existed where the statewide averages were below their performance targets in each domain of HEDIS measures. For Reform plans, statewide performance was weakest in Lead Screening in Children (Pediatric Care), Timeliness of Prenatal Care (Women s Care), Diabetes Care Eye Exam, Controlling High Blood Pressure (Living With Illness), and Adults Access Years (Access to Care). For Non-Reform plans, opportunities were greatest in Annual Dental Visits, Lead Screening in Children (Pediatric Care), Cervical Cancer Screening, Timeliness of Prenatal Care (Women s Care), Diabetes Care Eye Exam (Living With Illness), and Adults Access Years and 65+ Years (Access to Care). SFY External Quality Review Technical Report Page 1-5

9 EXECUTIVE SUMMARY Among the seven Agency-defined measures required for HMOs and PSNs reporting, all except two (HIV-Related Outpatient Medical Visits and Frequency of HIV Disease Monitoring Lab Tests) can be compared with previous year results for both Reform and Non-Reform plans. The statewide performance from Non-Reform plans showed improvement on all five measures from last year, but none reported an increase or decrease for more than 10 percentage points. For Reform plans, the statewide average improved by 12.2 percentage points for Highly Active Anti-Retroviral Treatment. PMHPs/CWPMHP Overall, the PMHPs and CWPMHP showed strong improvement in PIP validity in SFY Of the 12 PIPs assessed, 100 percent received a Met validation status in SFY compared to 75 percent in SFY For performance measure validation, HSAG conducted the validation audits for the PMHPs and the CWPMHP. HSAG validated a set of performance measures that AHCA identified and selected for validation. The PMHPs and CWPMHP all received Fully Compliant audit designations for the three required performance measures. For those three Agency-defined measures, the plans calculated the measures according to AHCA specifications. PMHP statewide performance demonstrated a slight improvement on both the Follow-up After Acute Care Discharge for a Mental Health Diagnosis 7-Day and 30-Day submeasures. The PMHP plans also reported a statewide decline on the Thirty- Day Readmission Rate measure. NHDP Health Plans SIPPs The NHDP health plans demonstrated improvement in the area of PIP validation. Of the 15 PIPs that were submitted and validated, 33 percent received a Met finding in SFY compared to 27 percent in SFY For performance measure validation, all except one NHDP health plan received a Fully Compliant audit designation for all reported measures. One NHDP health plan received a Substantially Compliant audit designation for all four measures because Medicaid-pending enrollees were excluded from all of the quarterly rates, which deviated from the measure specifications. The issue was corrected by the time the annual rate was submitted. The NHDP health plans performance measure data were determined to be complete and accurate. Enrollment and disenrollment data were captured and managed by the NHDP health plans for accuracy in reporting rates. HSAG determined that NHDP health plans calculated the performance measure rates according to DOEA specifications. In SFY , the SIPPs began the Restraint & Seclusion collaborative PIP. The purpose of this PIP was to reduce the use of restraints and seclusion during the members inpatient stay. Of the 14 PIPs that were submitted and validated, 43 percent received a Met finding in SFY compared to 14 percent in SFY SFY External Quality Review Technical Report Page 1-6

10 EXECUTIVE SUMMARY Review of Compliance for All MCO Types AHCA has significantly enhanced its compliance review activities to align with CMS protocols for monitoring MCOs and PIHPs. AHCA HMO, PSN, and PMHP staff have developed and refined comprehensive compliance monitoring tools, file review tools, checklists and tracking logs to assess MCO compliance with State and federal standards. DOEA identified and addressed specific standards within the BBA to be added to DOEA s compliance monitoring of NHDP MCOs. The review of standards enabled reviewers to determine if the MCOs developed, maintained, and operationalized policies, procedures, and protocols to ensure appropriate and timely access to quality services by the Medicaid population. Because the AHCA staff members in the PMHP, HMO, and PSN programs reviewed all standards in SFY , HSAG recommended that beginning in SFY , these AHCA programs consider choosing one-third of the standards to review to initiate the three-year schedule. SFY was the third year of a three-year cycle of compliance reviews completed for HMOs and PSNs. AHCA HMO and PSN staff members chose three standards to review in SFY For the PMHPs, AHCA staff completed the third year of a three-year review cycle, reviewing all standards. SFY External Quality Review Technical Report Page 1-7

11 EXECUTIVE SUMMARY Overall Conclusions and Recommendations Overall, the Florida Medicaid managed care program has demonstrated some improvements in performance for the sixth year of EQR activities as well as some areas that need continued focus. AHCA has established performance targets for most of the performance measures within all dimensions of care. While there was improvement from the previous year for some measures, many of them remain short of the performance goals set by AHCA. HSAG recommends the following related to performance measure reporting: HMOs/PSNs should continue to focus efforts on improving performance for all low-performing measures, specifically in the areas of Access to Care and Women s Care. Though improvements were observed across several measures, those in the Access to Care dimension performed the lowest among the five dimensions, with none of the measures for either Reform or Non-Reform plans meeting the performance targets. HMOs/PSNs should educate providers on accurately capturing prenatal and postpartum care visits through the use of CPT and CPT Category II codes. The use of these codes will help to facilitate the administrative capture of prenatal and postpartum visits and subsequently increase rates. Working with providers to ensure that accurate and complete data are captured may help to increase rates. HSAG recommends the following related to the collaborative PIP and the PIP requirements of the individual HMOs/PSNs: AHCA/DOEA AHCA should identify a statewide goal or standardized level of improvement for any collaborative PIP without a goal. AHCA should have plans that achieved statistically significant improvement in remeasurement periods discuss lessons learned and identify successes. AHCA should select a future HMO/PSN collaborative PIP topic to be implemented when the current PIP is retired, allowing participating MCOs to begin planning improvement strategies. AHCA/DOEA should extend the overall NHDP health plans PIP timeline to ensure that participating plans have sufficient time to evaluate the effects of the collaborative intervention on outcomes. HMOs/PSNs The HMOs/PSNs should ensure that audited HEDIS data reported to AHCA are the same data reported in the PIP submissions. The HMOs/PSNs should report hybrid HEDIS rates unless administrative rates are equivalent. The HMOs/PSNs should document in the PIP Summary Form only the targeted interventions implemented to address the specific barriers identified. HSAG recommends the following related to the collaborative PIP and the PIP requirements of the individual PMHPs: SFY External Quality Review Technical Report Page 1-8

12 EXECUTIVE SUMMARY PMHPs The PMHPs should continue to ensure that performance measure results validated by HSAG and reported to AHCA are consistent with the results reported in the PIP submissions. The PMHPs should clearly define the time frame associated with the implementation of each intervention. This definition will support HSAG s further analysis of intervention effectiveness. The PMHPs should document in the PIP Summary Form only the targeted interventions implemented to address the specific barriers identified. NHDP Health Plans HSAG recommends the following related to the collaborative PIP and the PIP requirements of the individual NHDP health plans: The NHDP health plans should document Activity I through Activity X on their individual PIP Summary Forms. The NHDP health plans should document in the PIP Summary Form only the targeted interventions implemented to address the specific barriers identified. The NHDP health plans should review the collaborative methodology to completely understand the measurement period difference between the a and b study indicators. SIPPs HSAG recommends the following related to the collaborative PIP for the SIPPs: The SIPPs should document Activity I through Activity X on their individual PIP Summary Forms. The SIPPs should document in the PIP Summary Form only the targeted interventions implemented to address the specific barriers identified. The SIPPs should document in the PIP Summary Form any subgroup analysis performed and the intervention evaluation results. Through its evaluation of best practices in PIPs, HSAG recommends the following: MCOs should use data mining/analysis techniques and knowledge of their structure, member characteristics, utilization statistics, and provider practice patterns to implement interventions that target a specific barrier or disparate subgroup within the study population. Both the barrier analyses and corresponding targeted interventions should be thoroughly documented. Barrier analyses should be conducted annually or more frequently if interim measurements are performed by the MCO. The MCOs should implement interventions that include system or process changes. Focus groups, surveys, and other methods should be used to evaluate an intervention s effectiveness. SFY External Quality Review Technical Report Page 1-9

13 EXECUTIVE SUMMARY All interventions should have an evaluation plan, and the results should be documented in the PIP Summary Form. The MCOs should refer to the PIP Validation Tool and address all Points of Clarification and all Partially Met and Not Met scores in future submissions. For further enhancement of AHCA s compliance with access, structure, and operations activity, HSAG recommends that AHCA staff consider the following: Continue to define necessary revisions to the database, checklists, and file review tools based on State and federal policy changes or changes in requirements. Create policies and procedures to document the process used to perform compliance reviews. Review and update the policies annually to ensure that they adequately capture the compliance review process. Carefully review the standards/elements to be included in the SFY compliance audit to ensure that monitoring tools align with the most current contract requirements prior to starting the on-site reviews. HSAG evaluated the degree to which the MCOs, AHCA, and DOEA, as applicable, addressed the recommendations made by the EQRO from the prior year s activities. HSAG found that while many recommendations were implemented across the three mandatory activities evaluated (PIPs; performance measures; and review of compliance with access, structure, and operations standards), additional opportunities existed to fully implement the recommended improvements. A summary of the prior-year recommendations for PIPs, performance measures, and review of compliance with access, structure, and operations standards made by the EQRO and an evaluation of recommendations that were implemented are in Section 4. SFY External Quality Review Technical Report Page 1-10

14 2. Introduction Background The Balanced Budget Act of 1997 (BBA), Public Law , requires that states ensure that a qualified external quality review organization (EQRO) performs an annual review of each contracted managed care organization (MCO) and prepaid inpatient health plan (PIHP), as specified in the Code of Federal Regulations (CFR), at 42 CFR The BBA further specifies that the external quality review (EQR) activities be conducted in a manner consistent with the protocols established under by the Centers for Medicare & Medicaid Services (CMS). The BBA identifies the scope of the EQR, including mandatory and optional activities. History of Florida Medicaid Managed Care and Demographics Florida s Medicaid program began January 1, Approximately 1.2 million Medicaid recipients are currently enrolled in the health maintenance organization (HMO) program, and approximately 255,000 are enrolled in the provider service network (PSN) program statewide. During SFY , AHCA contracted with, and HSAG evaluated activities for, 19 HMOs; 6 PSNs (one with two separate Reform areas); 5 prepaid mental health plans (PMHPs); 1 child welfare prepaid mental health plan (CWPMHP); 14 statewide inpatient psychiatric program health plans (SIPPs); and, through DOEA, 16 nursing home diversion program health plans (NHDP health plans). Florida State Quality Strategy In 2005, the Florida Legislature authorized the implementation of the Florida CMS-approved 1115 Medicaid Reform Waiver. With the implementation of the waiver, the State established an internal Quality and Performance Standards (QPS) Team to review and revise Florida Medicaid s standards, policies, and procedures related to quality in managed care. 2-1 The QPS Team s goal was to ensure the state s quality strategies reflect a deliberate and systematic approach to planning, designing, assessing, measuring, monitoring and continuously improving the quality of the consumer health care delivery system in Florida Medicaid managed care programs. 2-2 The current goals and objectives of Florida s Medicaid managed care programs are: To promote quality standards of health care within managed care programs by monitoring internal/external processes for improvement opportunities and to assist the managed care plans with the implementation of strategies for improvement. To ensure access to quality health care through contract compliance within all managed care programs in the most cost-effective manner. To promote the appropriate utilization of services within acceptable standards of medical practice. 2-1 Florida Medicaid Managed Care Quality Assessment and Improvement Strategies 2008/2009 Update. Available at: Accessed on: December 7, Ibid. SFY External Quality Review Technical Report Page 2-1

15 INTRODUCTION To coordinate quality management activities within the State as well as with external customers. To comply with State and federal regulatory requirements through the development and monitoring of quality improvement policies and procedures. To meet CMS requirements and State goals, the Florida Agency for Health Care Administration (AHCA) contracted with Health Services Advisory Group, Inc. (HSAG), to conduct the EQR activities beginning in SFY , with a two-month development phase in SFY The sixth year of the contract (SFY ) consisted of the following seven key categories of annual activities: Validation of performance improvement projects (PIPs) Validation of performance measures Review of compliance with access, structure, and operations standards Strategic HEDIS analysis reports Technical assistance (upon request) Information dissemination and education Technical report AHCA is responsible for administration of the Medicaid managed care program in Florida. During SFY , the following MCO and PIHP model types were included under the scope of the EQR. The table also indicates the type of entity (MCO or PIHP) as defined by the BBA. Table 2-1 MCO and PIHP Model Types Under External Quality Review Model Type MCO/PIHP Description of Services Health maintenance organizations (HMOs) Reform and Non-Reform MCO Prepaid, comprehensive physical and mental health services provided to enrolled members Provider service networks (PSNs) Reform and Non-Reform PIHP or MCO Prepaid or Fee for Service, comprehensive physical and mental health services provided to enrolled members Prepaid mental health plans (PMHPs) PIHP Mental health services provided to Medicaid recipients who are not enrolled in an HMO or PSN Child welfare prepaid mental health plan (CWPMHP) Nursing home diversion program health plans (NHDP health plans) Statewide inpatient psychiatric program health plans (SIPPs) PIHP PIHP PIHP Prepaid mental health services provided to children and adolescents with open cases in Florida s Safe Families Network Prepaid home and community-based services for Medicaid enrollees who qualify for nursing home placement Medicaid recipients under the age of 18 years receiving mental health services in an intensive residential setting SFY External Quality Review Technical Report Page 2-2

16 INTRODUCTION In addition, the EQR contract included technical assistance on an as-needed basis to the Medicaid Provider Access System (MediPass), the State s primary care case management (PCCM) model for delivering coordinated primary care to Florida Medicaid beneficiaries. Oversight of the MCOs, PIHPs, and PCCM was conducted by three AHCA bureaus and the Florida Department of Elder Affairs (DOEA). Table 2-2 displays the names of the oversight entities and the model types for which they are responsible: Table 2-2 Florida Oversight Structure Bureau/Department Bureau of Managed Health Care Bureau of Health Systems Development Bureau of Medicaid Services Department of Elder Affairs Bureau/Department Bureau of Health Systems Development HMO, PSN HMO, PSN MCO/PIHP PMHP, CWPMHP, NHDP health plan, SIPP NHDP PCCM MediPass Note: Throughout this report, for ease of reference, the HMOs, PMHPs, CWPMHP, PSNs, NHDP health plans, and SIPPs are collectively referred to as MCOs. For circumstances in which the activities or findings apply to only one or more model types, but not all, the individual model types are identified. To improve the health outcomes of Medicaid beneficiaries and achieve budget predictability, the 2005 Florida Legislature authorized AHCA to reform the State Medicaid program with a pilot initiative. 2-3 One of the goals of the Medicaid Reform Pilot Program was to provide beneficiaries with additional managed care options and managed care plans from which to choose. Also under Medicaid Reform, health plans could develop customized benefit packages for different beneficiary groups, while Non-Reform plans were required to offer the same levels of services to all beneficiaries as prescribed by Florida s Medicaid State Plan. The pilot program began providing services to Medicaid beneficiaries in Broward and Duval counties in September 2006, with expansion to Baker, Clay, and Nassau counties in September During SFY , managed care plans with a Reform contract began participating in EQR activities. The Reform plans submitted PIPs for validation. The Reform plans collected performance measure data and submitted the data to AHCA in July Table 2-3 displays the list of Florida MCOs that HSAG evaluated in the EQR, along with the corresponding acronyms used in this report. 2-3 Chapter , Laws of Florida. 2-4 AHCA received approval to implement an 1115 Research and Demonstration Waiver application from CMS in October The Florida Legislature approved implementation of the waiver in December 2005 (Chapter , Laws of Florida). SFY External Quality Review Technical Report Page 2-3

17 INTRODUCTION Table 2-3 List of Florida MCOs Included in the External Quality Review MCO Type MCO Name Shortened Name Acronym HMO AHF MCO of Florida, Inc. dba Positive Healthcare Florida (Reform) Positive POS Amerigroup Community Care (Non-Reform) Amerigroup AMG Coventry Health Care of Florida, Inc. Buena Vista (Non-Reform) Buena Vista VIS Coventry Health Care of Florida, Inc. Vista (Non-Reform) VISTA VSF Freedom Health, Inc. (Reform and Non-Reform) Freedom FRE Healthy Palm Beaches (Non-Reform) Healthy PB HPB Humana Family c/o Humana Medical Plan, Inc. (Reform and Non-Reform) Humana HUM Jackson Memorial Health Plan (Non-Reform) JMH JMH Medica Health Plans of Florida (Reform and Non-Reform) Medica MHP Molina Healthcare of Florida (Non-Reform and Reform) Molina MOL Preferred Care Partners dba CareFlorida (Reform and Non- Reform) CareFlorida CFL Preferred Medical Plan, Inc. (Non-Reform) Preferred PRE Simply Healthcare Plans (Non-Reform) Simply Healthcare SHP Sunshine State Health Plan (Reform and Non-Reform) Sunshine SUN UnitedHealthcare Community Plan (Reform and Non-Reform) United URA United Healthcare of Florida, Inc. Evercare at Home (Non-Reform) Evercare at Home URE Universal Health Care, Inc. (Reform and Non-Reform) Universal UNI Wellcare Health Plans, Inc. HealthEase of Florida, Inc. (Non-Reform) HealthEase HEA Wellcare Health Plans, Inc. Staywell of Florida, Inc. (Non-Reform) Staywell STW PSN PMHP Better Health (Reform) Better Health BET Children s Medical Services Broward (Reform) CMS Broward CMB Children s Medical Services Duval (Reform) CMS Duval CMD First Coast Advantage (Reform) First Coast FCA Integral Quality Care (Non-Reform) Integral IQC Prestige Health Choice (Non-Reform) Prestige PHC South Florida Community Care Network (Reform and Non- Reform) SFCCN SFC Lakeview Center dba Access Behavioral Health (Area 1) Access (A1) ABH Florida Health Partners (Areas 5, 6, 7, and 8) FHP (A5, A6, A7, and A8) FHP Jackson Health System/Public Health Trust of Dade County Public Health Trust (Area 11) (A11) PHT Magellan Behavioral Health of Florida, Inc. (Areas 2, 4, 9, Magellan (A2, A4, and 11) A9, and A11) MAG North Florida Behavioral Health Partners (Area 3) North Florida (A3) NFHP SFY External Quality Review Technical Report Page 2-4

18 INTRODUCTION Table 2-3 List of Florida MCOs Included in the External Quality Review MCO Type MCO Name Shortened Name Acronym CWPMHP Community Based Care Partnership CBC Partnership CBC NHDP SIPP American Eldercare, Inc. Eldercare AEC Amerigroup Community Care Amerigroup DP AMG Brevard Alzheimer s Foundation, dba YourCare Brevard YourCare Brevard BRE Coventry Health Care of Florida, Inc. Vista VISTA DP VHP Evercare Health and Home Connection Evercare HHC EHH Florida Comfort Choice c/o Humana Medical Plan, Inc. Comfort Choice FCC Hope of Southwest Florida, Inc. Hope HOP Humana Senior s Choice Senior s Choice HSC Little Havana Activities and Nutrition Centers, Inc. Little Havana LHA Miami Jewish Home and Hospital Project Independence Project Independence MJH Neighborly Care Network Neighborly NCN Sunshine State Health Plan, Tango Sunshine DP SST United Home Care Services United Home Care UHS Universal Health Care, Inc. Universal UHC Urban Jacksonville, Inc., Senior Connections Senior Connections UJV WorldNet Services Corporation WorldNet WNI Alternate Family Care Alternate Family Care AFC BayCare Behavioral Health, Inc. BayCare BAY Citrus Health Network, Inc. CATS Citrus-C CHN-C Citrus Health Network, Inc. RITS Citrus-R CHN-R Daniel Memorial, Inc. Daniel Memorial DMI Devereux Orlando Devereux-O DXO Jackson Memorial Hospital Jackson JXM La Amistad dba Central Florida Behavioral Hospital La Amistad CFB Lakeview Center, Inc. Lakeview LCI Manatee Palms Youth Services Manatee Palms MPY River Point River Point RPT Sandy Pines Sandy Pines SPS The Vines The Vines TVS University Behavioral Center University Behavioral UBC Although all of the entities had an active contract during SFY , due to different contract start dates and other issues, not all the MCOs were reviewed for all activities. SFY External Quality Review Technical Report Page 2-5

19 INTRODUCTION Purpose The BBA requires states to prepare an annual technical report that describes the manner in which data from activities conducted in accordance with 42 CFR were aggregated and analyzed. The report must describe how conclusions were drawn as to the quality and timeliness of, and access to, care furnished by the contracted MCOs and PIHPs. The report must also contain an assessment of the strengths and weaknesses of the plans regarding health care quality, timeliness, and access, and must make recommendations for improvement. Finally, the report must assess the degree to which the MCOs and PIHPs addressed any previous recommendations. By producing and delivering this SFY External Quality Review Technical Report, AHCA has complied with 42 CFR SFY External Quality Review Technical Report Page 2-6

20 3. Description of External Quality Review Activities Validation of Performance Improvement Projects During the sixth state fiscal year of the EQR contract HSAG validated selected MCO PIPs under way during the 12 months preceding SFY This section describes the processes used by HSAG to complete the validation activities and the overall findings across all contracted MCOs. For specific details related to the approach, methodologies, and findings from the PIP validation activities, refer to the Performance Improvement Project Validation Annual Summary Report, SFY , prepared for AHCA. Objectives and Background Information As part of its quality assessment and performance improvement program, AHCA required the MCOs to conduct PIPs in accordance with 42 CFR The purpose of the PIPs was to achieve, through ongoing measurements and interventions, significant improvement sustained over time in both clinical and nonclinical areas. For the projects to achieve real improvements in care and for interested parties to have confidence in the reported improvements, the PIPs must be designed, conducted, and reported using sound methodology and must be completed in a reasonable time. This structured method of assessing and improving MCO processes is expected to have a favorable effect on health outcomes and member satisfaction. Additionally, as one of the mandatory EQR activities under the BBA, the State is required to have PIPs conducted by the MCOs validated. AHCA contracted with HSAG to meet this validation requirement. The primary objective of PIP validation was to determine each MCO s compliance with requirements set forth in 42 CFR (b)(1), including: Measurement of performance using objective quality indicators. Implementation of systematic interventions to achieve improvement in quality. Evaluation of the effectiveness of the interventions. Planning and initiation of activities for increasing or sustaining improvement. HSAG based its review on the CMS protocol steps outlined in Validating Performance Improvement Projects: A Protocol for Use in Validating Medicaid External Quality Review Activities, final protocol, Version 1.0, May 1, HSAG s review focused on the following areas: Assessing the MCO s methodology for conducting PIPs. Evaluating the overall validity and reliability of study results. Each MCO contract required PIPs, although the number of required PIPs varied. For most HMOs and PSNs, four PIPs were contractually required, with one focused on culturally and linguistically appropriate services, one focused on behavioral health services, one being a clinical PIP, and one being a collaborative PIP. Two additional PIPs were required of the one HMO with a frail and SFY External Quality Review Technical Report Page 3-1

21 elderly program. The PMHPs and the CWPMHP were required to conduct two PIPs each, one of which was the collaborative PIP. The NHDP health plans were required to conduct two quality-ofcare studies, which contained the same components of a PIP. Participation in the NHDP health plan collaborative PIP satisfied one of the required quality-of-care studies for the NHDP health plans. The SIPPs were required to conduct two PIPs each, one of which was the collaborative PIP. HSAG s validation process results in a final status for each PIP of Met, Partially Met, or Not Met. To be consistent with the CMS protocol for validating PIPs, HSAG must determine the overall validity and reliability of the PIP and report whether interested parties can have confidence in the PIP results. HSAG translates the final validation status as follows: According to HSAG s scoring methodology, for an MCO to have received a Met validation status, HSAG would have scored all critical evaluation elements as Met and 80 percent to 100 percent of all evaluation elements as Met across all activities. For a Partially Met validation status, HSAG would have scored all critical evaluation elements as Met and 60 percent to 79 percent of all evaluation elements as Met across all activities. Alternately, a Partially Met validation status could result from HSAG scoring one or more critical elements as Partially Met and 60 percent or more of all evaluation elements across all activities scored as Met. For a Not Met validation status, HSAG would have scored all critical elements as Met and fewer than 60 percent of all evaluation elements as Met across all activities, or one or more critical elements as Not Met. As indicated above, AHCA expected each MCO to participate in a collaborative PIP, which could be used to meet contractual requirements. HSAG facilitated the implementation of three statewide collaborative PIPs during SFY (one for the HMOs/PSNs, one for the PMHPs/ CWPMHP, and one for the NHDP health plans), focusing quality improvement efforts on specific aspects of care and services. Since June 2007, the MCOs, on a rotating basis, have been responsible for leading monthly meetings, including the development of agendas, facilitation of conference call meetings, and preparation of meeting minutes for distribution. The SIPPs began their collaborative PIP during SFY SFY External Quality Review Technical Report Page 3-2

22 Summary of the SFY 2012 PIP Validation Status Table 3-1 summarizes the overall Met validation results for each group of health plans for the SFY through SFY 2012 validation years. The detailed validation scoring for each MCO is provided in Appendix A. The MCOs submitted a total of 56 collaborative PIPs for review and evaluation for the SFY validation cycle, 59 PIPs for the SFY validation cycle, 55 PIPs for the SFY validation cycle, 66 for the SFY validation cycle, and 73 for the SFY validation cycle. During SFY , the number of HMOs increased by four health plans; and the number of PSNs, PMHPs, NHDP health plans, and the SIPP health plans remained constant. Based on the validation of the collaborative PIP studies, HSAG s assessment determined the level of confidence in the results. Table 3-1 Collaborative PIP Overall Validation Status SFY SFY SFY SFY SFY Plan Type PIPs PIPs Met* Met* Assessed Assessed Met* PIPs Assessed Met* PIPs PIPs Met* Assessed Assessed HMOs 87% 23 54% 24 50% 22 68% 19 79% 24 PSNs 100% 8 50% 8 33% 6 83% 6 88% 8 NHDP health plans 100% 13 40% 15 13% 15 27% 15 33% 15 PMHPs 50% 12 83% 12 25% 12 75% % 12 SIPPs NA NA NA NA NA NA 14% 14 43% 14 Overall Total 84% 56 56% 59 33% 55 50% 66 66% 73 * Met status denotes confidence in reported PIP results. NA Not applicable since SFY was the first year that the SIPPs submitted PIPs. State fiscal year (SFY) covers the period of July 1 through June 30 of each year. For SFY , 66 percent of the MCOs attained a Met validation status. This represented a 16-percentage-point increase from the previous year. All MCO types that had submitted PIPs in SFY demonstrated an increase in PIP validation scores in SFY All PIPs advanced to more challenging activities such as data analysis, causal/barrier analysis, and interpretation of findings. The greatest improvements in validation scores were seen in the PMHPs and SIPPs and corresponded to high compliance rates with the prior year s recommendations. SFY External Quality Review Technical Report Page 3-3

23 HMO/PSN Collaborative PIP Baseline to Remeasurement 2 Results Results for the Well-Child Visits in the First 15 Months of Life Six or More Visits collaborative PIP were reported separately for the Reform and Non-Reform health plans as required by AHCA. Fifteen Non-Reform HMOs/PSNs and 12 Reform HMOs/PSNs participated in the collaborative PIP. The baseline measurement period was January 1, 2006, through December 31, 2006, for the Non-Reform plans, and January 1, 2007, through December 31, 2007, for the Reform plans. The study indicator for the collaborative PIP was a HEDIS measure. When applicable, HSAG cross-validated the reported rates within the PIP submissions against audited HEDIS results provided by AHCA to resolve any discrepancies. HSAG accepted the audited data as valid since HSAG does not duplicate an NCQA HEDIS Compliance Audit already conducted. The methodology for evaluating and reporting PIP results differs from the typical performance measure reporting in that all plans performance measure rates, regardless of study population size, are validated, reported, and subsequently included in the overall totals. While the individual rates reported for small populations (i.e., < 30 members) potentially have greater variability and should be interpreted with caution, these rates are evaluated for real and sustained improvement and contribute to the analysis of the collaborative PIP s overall success. Additionally, the overall totals are not population-based weighted averages, but are instead calculated by dividing the sum of all numerators by the sum of all denominators; therefore, plans with small study populations have minimal effect on the reported overall total rates. Table 3-2 reports the results for the Non-Reform HMOs and PSNs. For the current validation year, plans were required to report Remeasurement 2 results. Ten plans reported Remeasurement 2 results; of those plans, three elected to report Remeasurement 3 results and three reported Remeasurement 4 results. One plan reported Remeasurement 1 data, three plans reported only baseline data, and two plans had not progressed to reporting data during this validation cycle. SFY External Quality Review Technical Report Page 3-4

24 Table 3-2 Non-Reform HMO/PSN Results for Well-Child Visits in the First 15 Months of Life Six or More Visits Plan Name Preferred Medical Plan, Inc. UnitedHealthcare Community Plan Universal Health Care, Inc. Healthy Palm Beaches, Inc. Coventry Health Care of Florida, Inc. VISTA Coventry Health Care of Florida, Inc. Buena Vista Amerigroup Community Care Wellcare Health Plans, Inc. Staywell of Florida, Inc. Wellcare Health Plans, Inc. HealthEase of Florida, Inc. Humana Family c/o Humana Medical Plan, Inc. South Florida Community Care Network Prestige Health Choice Sunshine State Health Plan Freedom Health, Inc. Baseline Remeasurement 1 Remeasurement 2 Remeasurement 3 Remeasurement 4 N Rate N Rate N Rate N Rate N Rate % % % % %* % %* %* % % % % % % %* % % % % % %* % % % %* % % % % %* % %* % % %* % % % %* % % % % % SFY External Quality Review Technical Report Page 3-5