Clinical Affairs. Quality Management and Improvement and Utilization Management Program Evaluation July 1 December 31 Calendar Year 2011

Transcription

1 Clinical Affairs July 1, 2011 December 31, 2011 Annual Evaluation of the Quality Management and Improvement Program. This evaluation is organized into sections which include Clinical Practice Guidelines, Patient Safety, Utilization Review Management (for Behavioral Health, Medical Management and Pharmacy), Care Management, Disease Management, HEDIS, EQRO, Delegated Entities and Multicultural Health Care. This Evaluation is reviewed and approved by the Network Health Quality Improvement Committee, a subcommittee of the Network Health Quality Management Committee. Quality Management and Improvement and Utilization Management Program Evaluation July 1 December 31 Calendar Year

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3 Table of Contents Executive Summary A. Introduction...11 I. Oversight of the Quality Management and Improvement Program (QMIP) II. Quality Program Highlights for CY III. Quality Program Overview i. Improve enrollee clinical outcomes...14 ii. Meet/exceed expected service levels for enrollees 18 iii. Maintain compliance with regulatory and NCQA requirements for all processes, policies, and procedures.. 18 iv. Evaluate existing UM processes and workflows to identify improvement opportunities..19 v. Improve quality of multicultural health care data to support efforts to address health care disparities vi. HEDIS and CAHPS.. 21 vii. Delegation..21 B. Program Findings...23 I. Improve Enrollee Clinical Outcomes Maternal Child Health Disease Management a. Effectiveness and Satisfaction with Asthma Disease Management b. Effectiveness and Satisfaction with Diabetes Disease Management Increase Enrollee Engagement Fully Integrate Care Management Disciplines (medical, behavioral health, social) under One Director Clinical Practice Guidelines Patient Safety.. 37 a. Serious Reportable Events...37 b. Adverse Events.. 38 c. Adequacy of Medical Record Documentation Continuity and Coordination of Care Decrease Avoidable Emergency Department (ED) Utilization Early Identification of Health Issues.. 43 II. Meet/Exceed Expected Service Levels for Enrollees Telephone Access to Behavioral Health Care

4 2. Appointment Access and Availability Member Satisfaction with Services III. IV. Maintain Compliance with Regulatory and NCQA Requirements for All Processes, Policies, and Procedures..50 Evaluate Existing UM Processes and Workflows To Identify Improvement Opportunities Utilization Management Policies and Procedures Evidence based Criteria/Guidelines for Making UM Decisions Improve Quality of UM Processes Monitored and Tracked Opportunities for UM Process Improvements UM Decisions Appealed Technology Reviews Triage and Referral for Behavioral Healthcare Satisfaction with UM Process 60 V. Improve Quality of Multicultural Health Care Data to Support Efforts to Address Health Care Disparities. 61 VII. HEDIS and CAHPS VIII. Delegation C. Development Opportunities/Next Steps..75 I. Improve Enrollee Clinical Outcomes Maternal Child Health Disease Management a. Effectiveness and Satisfaction with Asthma Disease Management 77 b. Effectiveness and Satisfaction with Diabetes Disease Management Increase Enrollee Engagement Fully Integrate Care Management Disciplines (medical, behavioral health, social) under One Director Clinical Practice Guidelines Patient Safety...78 a. Serious Reportable Events...78 b. Adverse Events

5 c. Adequacy of Medical Record Documentation Continuity and Coordination of Care Decrease Avoidable Emergency Department (ED) Utilization Early Identification of Health Issues II. Meet/Exceed Expected Service Levels for Enrollees Telephone Access to Behavioral Health Care Appointment Access and Availability Member Satisfaction with Services III. IV. Maintain Compliance with Regulatory and NCQA Requirements for All Processes, Policies, and Procedures..81 Evaluate Existing UM Processes and Workflows To Identify Improvement Opportunities Utilization Management Policies and Procedures Evidence based Criteria/Guidelines for Making UM Decisions Improve Quality of UM Processes Monitored and Tracked Opportunities for UM Process Improvements UM Decisions Appealed Technology Reviews Triage and Referral for Behavioral Healthcare Satisfaction with UM Process 84 V. Improve Quality of Multicultural Health Care Data to Support Efforts to Address Health Care Disparities.. 85 VI. HEDIS and CAHPS VII. Delegation D. References.87 5

6 Executive Summary To date, Network Health s annual quality management and improvement program evaluation (QMIPE) has been conducted at the close of the organization s fiscal year, which ran from July 1 to June 30 of the following year. Network Health was acquired by The Tufts Health Plan in November of As part of the efforts to align business processes, Network Health has adopted the Tufts Health Plan reporting calendar which is based on the calendar year. In order to synchronize reporting schedules, this QMIPE is intended to incorporate the assessment of quality activities that took place during the period from July 1, 2011 to December 31, Subsequent reports will be based on the calendar year with the next report assessing activities taking place in CY2012. The reporting period covered in this document will vary among the various areas discussed based on the nature of the activities being assessed. For example, HEDIS and CAHPS results are produced once per year. The measures that are reported in this document will be the same as those produced in the previous QMIPE because no new measurements have become available in the additional six months covered by this report. However, there are modifications to initiatives such as improvement activities, which are noted. Other areas such as Customer Service opted to amend their previous FY2011 reports and produced 18 month extended reports covering the period from July 1, 2010 to December 31, This permitted analysis for seasonality as the plan transitions to the new reporting schedule. And, finally some areas such as Disease Management chose this opportunity to move to a calendar year report for CY2011 to establish baseline data for their work in CY2012. The QMIPE is reviewed and approved by the quality improvement committee (QIC) and the quality management committee (QMC) prior to being submitted to the board of directors. This document reflects the evaluation of the Network Health QMIP for the period July 1, 2010 through June 30, 2011 (FY2011). It comprises material from a variety of trend reports and program evaluations that were reviewed and approved by appropriate quality committees including the Utilization Management Committee (UMC), QIC and QMC. In CY2011, Network Health retained its top ten NCQA ranking among Medicaid plans, with a national ranking of 7 th of 99 plans submitting complete results for review. The plan had a total score of 87.4 ranking points out of a possible 100 points. Slight increases were seen in performance scores for both HEDIS and CAHPS for CY2011 as compared to CY2010, despite the elimination of points by NCQA for sampling variation from their calculation (2011: 38.98, 2010: 38.71). Accreditation points remain fixed for ranking calculations between accreditation surveys. Improve enrollee clinical outcomes 6

7 Network Health saw improvements in seven of fourteen HEDIS measures associated with Maternal Child Health, with four measures remaining steady from FY2010 to FY2011. Ten of these measures surpassed the 75 th national percentile and nine surpassed the 90 th national percentile. Network Health s asthma and disease management programs had notable successes in CY2011. Asthma specific inpatient stays showed a 4.6% decrease in CY2011 (15.1 per 1,000 in CY2010 versus 14.4 per 1,000). However, the PMPM cost for asthma specific inpatient stays increased 14.7% in CY2011 ($7.20 PMPM in CY2010 versus $8.26 PMPM), suggesting that enrollees with less severe asthma are avoiding hospitalization. The rate of asthma specific ED visits decreased 2.8% in CY2011 (106 per 1,000 in CY10 versus 103 per 1,000 in CY2011). The rate of diabetes specific inpatient stays was about the same in CY10 and CY11 (48.5 per 1,000 in CY11 versus 49.2 in CY10). However, the PMPM cost for such stays decreased 11% in CY11. The rate of diabetes specific ED visits decreased 26% in CY11 (47 per 1,000 in CY11, down from 63 in CY10). In addition, the PMPM cost for such ED visits decreased 33% in CY11. The plan exceeded targets to improve enrollee engagement; increasing engagement for the top 5% high risk/high cost enrollees from 22% to 49%, and for the top 10% of high risk/high cost enrollees from 18% to 37%. 99% of enrollees referred to care management had outreach attempts within the timeframe guidelines of 10 days, with 44% of these cases engaged. 100% of assessments were completed for enrollees referred to care management, with 92% of these completed within the required 10 day timeframe. Outcomes included a 35% decrease in readmissions, with a 157% increase in ED utilization for this group (excluding high risk obstetrics). ED follow up decreased ED utilization rates per thousand by 7.3% and reduced Low Acuity None Emergent (LANE) visits by 8.4%. Network Health reviewed and adopted two clinical practice guidelines in FY2011. Regarding patient safety, the quality concerns committee met three times in CY2011, investigating nine potential Serious Reportable Events (SREs), with eight cases found to be SREs and reported to the state and six determined to be quality of care concerns with appropriate follow up actions taken. Adverse events remained about the same with nine in CY2010 and ten in FY2011. During the second half of CY2011, more than 140 medical records and 140 treatment records were reviewed using Network Health s standard review tools with added measures including determination of whether advanced directives were discussed with the enrollee. For continuity and coordination of care, Network Health reviewed multiple standards of medical and behavioral health charts to determine whether follow up care occurred as planned, whether providers obtained permission to share information with other providers and assessed what information was shared. Further, the plan assessed how 7

8 effectively clinical information was shared within the reorganized care management team, especially between medical and behavioral health/social care management (BH/SCM) staff. There was an 8% increase in referrals from medical to BH/SCM staff in FY2011. i. Meet/exceed expected service levels for enrollees Telephone access to behavioral healthcare exceeded both the answer time requirements (90% of all calls answered within 30 seconds), and call abandonment requirement (rate below 5%) for all four quarters of CY2011. For appointment access and availability, network adequacy exceeded requirements as did provider reported appointment access for all types of medical appointments and for emergency services and urgent care for behavioral health practitioners. Urgent care for adolescents/children, post hospital intake for adults, adolescents/children and post hospital psychopharmacology for adults, adolescents/children all failed to meet standards. While Network Health did well on ratings of the Health Plan and Health Care provided to its enrollees, reports on the CAHPS survey yielded lower results than comparative plans in the region for Getting Needed Care and Getting Care Quickly for PCPs. ii. Maintain compliance with regulatory and NCQA requirements for all processes, policies, and procedures Network Health conducted four quarterly quality management committee (QMC) meetings and eleven quality improvement committee (QIC) meetings in CY2011. These committees provide oversight for the quality improvement efforts for the health plan. The plan created the position of manager, NCQA and compliance to manage all NCQA accreditation efforts for the organization. Network Health began working to bring the HEDIS medical record review process in house during CY2011. The quality improvement program (QIP) midterm report was submitted early to MassHealth, assessing 72 interventions. iii. Evaluate existing UM processes and workflows to identify improvement opportunities Utilization management increased the number of actively managed complex cases by 33% in FY2011 as compared to FY2010. The plan developed the substance management UM aftercare program in FY2011. All medical, behavioral health, general utilization management and pharmacy policies and procedures due for review in FY2011 were reviewed, updated as needed and approved by appropriate quality committees. Through appropriate committees, InterQual criteria, current Network Health clinical guidelines and medication request guidelines were approved. 8

9 Completion of medical authorization requests was compliant with required timelines for Mass Health enrollees 94.6% of the time and for Commonwealth Care enrollees 70.27% of the time. For behavioral health, the plan was compliant for both lines of business 100% of the time. Network Health s pharmacy team continues to meet average turnaround time requirements 100% of the time. Overall denial rate for medical services across lines of business was 5.5%. For behavioral health services, inpatient/outpatient rates for MassHealth were 0.3%/7.0% and for Commonwealth Care were 0.2% /7.4%. For pharmacy, 23% of requests were denied. The technical review committee reviewed 17 medical technologies in CY2011. Technology assessments for each of these reviews were provided to the appropriate department directors. For satisfaction with the UM process, the plan received a score of / 13 points on the CAHPS survey, but was negatively affected by a drop in ratings of customer service and access to PCP services. For the case management satisfaction survey, enrollee satisfaction exceeded the target of 90% of members being satisfied with services. On the provider satisfaction survey, there was a slight decrease from the previous year of providers who were very satisfied (drop from 39% to 36%) and a similar increase in providers who were not at all satisfied (increase from 4% to 9%). iv. Improve quality of multicultural health care data to support efforts to address health care disparities During CY2011, Network Health worked to improve the quality of its data regarding enrollee race, ethnicity and language (REL) to better evaluate and address disparities in health care. The plan revised data standards for all (REL) data being collected to reflect current, accepted standards, built a data warehouse to house REL data for all Network Health enrollees, revised and augmented workflows to collect REL data from multiple sources and produced preliminary reports using the new standards and data warehouse. The Plan also began collecting improved quality REL data from providers along with data about the linguistic supports available at their offices. Network Health will apply for NCQA s Multicultural Health Care Distinction in CY2012. Work was basically completed for meeting standards I III for the distinction by the close of CY2011 and work was either completed or underway to meet the remaining two standards. Network Health expects to complete the NCQA survey process before midyear v. HEDIS and CAHPS: Improve quality of care as measured by HEDIS and CAHPS performance In CY2011, Network Health generated HEDIS reports for both the MassHealth and Commonwealth Care lines of business. Scores improved for 11 of the 18 targeted measures for HEDIS 2011 over the previous year s results, 3 remained the same and 4 decreased. Seven of the 18 targeted measures/sub measures were above the 75 th percentile for national scores. Another 7 of the 18 targeted measures/sub measures 9

10 were above the 90 th percentile for national scores. Overall HEDIS points for NCQA health plan ranking improved slightly from last year despite the elimination of one point for sample variation with of 30 possible ranking points scored in 2011 vs of 30 possible ranking points scored in Overall CAHPS points for NCQA health plan ranking improved slightly from last year with of 13 possible ranking points scored in 2011 vs of 13 possible ranking points scored in As noted above, there was a notable decrease in CAHPS performance for satisfaction with customer service, with overall ranking on customer service at the 50 th national percentile. Access to PCP services for care also is an area of concern, with ranking at the 75 th national percentile, but well below that of regional competitors who outranked us in the NCQA annual ranking of Medicaid health plans. vi. Delegation: Provide oversight for delegated functions Network Health retains the accountability for delegated utilization management activities and ensures that UM processes meet contractual, regulatory and accreditation standards. Network health oversees the activities of five vendors: MedSolutions (an NCQA fully accredited Utilization Management provider performing medical necessity review of imaging services) MedImpact Healthcare Systems, Inc. (a pharmacy benefit management services which includes utilization management responsibilities) Caremark LLC (a managed specialty pharmacy services which includes utilization management responsibilities) MBHP (provides Behavioral Health utilization management services, through telephone service coverage by qualified mental health professionals during overnight, weekend, and holiday hours) Health Integrated (health coaching) Delegation oversight reports were produced for each vendor summarizing performance in CY2011 with results compiled in this document. These reports are available on request. No significant issues were noted. 10

11 Submitted by: James Merola, Director of Quality Date: Reviewed and Approved by: Date: _ Pano Yeracaris, MD, MPH, Chief Medical Officer Date: _ Christina Severin, President 11