Medicaid Managed Care EQRO and MLTSS Quality. April 3, 2014 IPRO State of Nebraska EQRO

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1 Medicaid Managed Care EQRO and MLTSS Quality April 3, 2014 IPRO State of Nebraska EQRO

2 IPRO provides a full spectrum of healthcare assessment and improvement services that foster the efficient use of resources and enhance healthcare quality to achieve better patient outcomes.

3 IPRO About Us Over 25 years in business as an independent, not-for-profit 501(c)(3) working to improve the quality and value of healthcare services 400 full-time staff and 300 physician consultants Headquartered in Lake Success, NY Offices in Albany, NY; Raleigh, NC; Mercerville, NJ; and Harrisburg, PA Affiliates: Lumetra Healthcare Solutions (California) Currently supporting over 50 government healthcare programs Clients in more than 33 states Federal, State and local government as well as private clients 3

4 Definition of an EQRO EQRO stands for External Quality Review Organization An EQRO is a company operating as a quality of care oversight organization, providing oversight of Medicaid Managed Care Organizations (MCOs), in an effort to maximize the quality of care that these organizations provide to their enrollees. In this capacity, EQROs are contracted at the state level, and are involved in a number of activities, some required by the Federal government (CMS), some voluntary (requested by the state) 4

5 EQRO Activities (Required) Compliance Review Every 3 years, the states are required to perform a compliance review of each MCO. The EQRO normally conducts this review. The compliance review considers how well the MCO is performing, according to some specific Federal requirements. These requirements include : Availability of information about benefits, doctors, how to file a complaint, how to choose a new doctor if one leaves the plan, etc. Availability of information in foreign languages for members not fluent in English. Is information available easily to blind or hearing impaired members? The availability of doctors in all areas served by the MCO, for all of the services provided by the MCO. Are there enough doctors to service the members? 5

6 EQRO Activities (Required) Compliance Review (continued) Is there a system in place to monitor the quality of care members are receiving? Are services available to members with special needs? Is there a system in place to handle complaints, grievances? Is there sufficient technology to pay claims, handle calls from members, calls from doctors, report data showing how well the plan is servicing its members? How does the EQRO conduct this review? The EQRO goes to the MCO, for 2-3 days, and reviews policies, procedures, member and provider manuals, reports, and samples of files containing member information If problems are discovered in any of the above areas, the EQRO will report these problems to the state and make recommendations for improvement. The following year, the EQRO will follow up to see if the problems are resolved. 6

7 EQRO Activities (Required) Performance Measure Validation A performance measure is a determination of the level of success or failure of a health care practice or procedure. Performance measures are developed in accordance with clinical guidelines, and /or recommended services. Performance measure results are reported to the state (at least annually) by the MCO. Measures are usually defined by a numerator and a denominator, and a rate (numerator divided by the denominator). Example: Flu Immunization Performance Measure Denominator: The number of members in the health plan (MCO) Numerator: The number of members in the health plan who received a flu shot in the past 12 months Denominator=50, Numerator=25 Rate=50% Example: HbA1C Control for Diabetic Members Measure Denominator: The number of diabetic members in the health plan (MCO) Numerator: The number of diabetic members with an HbA1C test in the past 12 months Denominator=50, Numerator=25, Rate=50% 7

8 EQRO Activities (Required) Performance Measure Validation Annually, the EQRO is required to validate performance measures, in other words, determine if the reported measure results are correct and accurate. In the flu measure example, the EQRO could validate the measure by reviewing the medical records of the 25 people to find evidence of the flu shot in the record, and the date the flu shot was given. In the diabetic member measure, the EQRO could validate the measure by reviewing the medical records of the 25 people in the numerator, to confirm the diagnosis of diabetes and the evidence of the HbA1C test. 8

9 EQRO Activities (Required) Performance Improvement Project Validation Annually, EQROs must validate Performance Improvement Projects (PIPs) A PIP is a project which addresses a problem or concern that the MCO or the state has identified which needs to be addressed, with the goal of improving care quality. MCOs are required to conduct PIPs annually. Examples: Increasing the number of female members getting a mammogram at least every 2 years Increasing the number of members with an advance directive in place 9

10 EQRO Activities (Required) PIP Validation The EQRO will hold calls/ collect data from the MCO during the course of the project period, to determine if : There was reasonable justification for the project (does the baseline, or historical, data show low measure rates, member dis-satisfaction, etc) The data for the project was collected from a good source (claims, member surveys, medical records) The interventions (the steps / processes taken to bring about change) are meaningful and achievable and are reviewed regularly during the course of the project period The project results were significant (improvement was seen at the end of the project period). If improvement was minimal, or, there was no improvement, the EQRO can work with the MCO in determining how to modify the project going forward. 10

11 EQRO Activities (Required) Detailed Technical Report EQROs are required, annually, to submit a technical report for each MCO to the state. The report describes and discusses the results of the activities previously discussed (compliance review, performance measure validation, PIP validation) as well as any other optional activities conducted by the EQRO during the year 11

12 EQRO Activities-Optional Validation and Implementation of Surveys Surveys are a common method of measuring healthcare quality satisfaction. MCOs often conduct surveys to their members at least annually. The surveys will give the MCOs feedback on care quality and other factors contributing to care quality ( e.g. timeliness of services, access to doctors for routine and urgent appointments). EQROs can, at the request of the state, review the MCO s survey tool, and the survey policies and procedures, to determine if: The survey questions are appropriate for the population(s) being surveyed. The survey questions are understandable (is the survey presented at a reading level appropriate for the members). Are technical terms and medical jargon explained sufficiently? If applicable, is the survey administered in languages other than English only? The survey is being conducted in an effective manner. If a mail only survey, is there a second, or follow up mailing to attempt to reach members who didn t respond the first time? If a telephone survey, the EQRO may review the interview scripts and training tools to determine if these are appropriate. The EQRO may review the survey results, and compare the results to prior survey results, to assist the MCO in identifying trends, quality of care problems, etc. EQRO s can develop surveys for MCO members, based upon specifications from the state. 12

13 EQRO Activities-Optional Encounter Data Validation Encounters are data about a distinct service provided to an MCO member. The MCO obtains encounter data from the doctors and other staff providing services to the members, and generally report these data to the state periodically. Encounter data includes the date(s) that services were rendered. States may request EQROs to validate the integrity of the encounter data that is reported. Example: The state sends a file consisting of encounter data for regular doctor visits, cardiology specialist visits, and home health care visits to the EQRO. The EQRO contacts the MCO and requests the medical records for the members included in the file. The MCO requests the records from these doctors and home health agency, and sends them to the EQRO. The EQRO reviews the records to validate, or confirm that the information in the encounter is accurate, and that the service was performed. The EQRO issues a report of findings to the state. 13

14 MLTSS and Quality (Examples) Projects which IPRO has worked on with the Managed Long Term Care Plans in NY relating to quality of care Satisfaction Surveys IPRO has developed and administered surveys for MLTC membership. One survey was conducted in 2011 and another similar survey in The surveys addressed member feedback on: Handling of complaints and grievances Care quality of providers Provider timeliness (e.g. home health aides, transportation, visiting nurses) Access to providers (e.g. regular doctor, dentist, eye care, foot care) Overall assessment of the MCO 14

15 MLTSS and Quality Satisfaction Surveys (Continued) Survey results for 2011 and 2013 were compared. Major findings: Overall results were favorable. In the 2013 survey, nearly 85% of respondents rated the MCO as good or excellent, and 90% said that they d recommend their plan to others. Member rating of the quality of certain services (e.g. physical therapists, meals on wheels, dentists) declined between 2011 and In 2013, a higher percentage of members indicated that they contacted the plan with questions, or for help. A higher percentage also indicated that they called the MCO with complaints and grievances in A lower percentage indicated that complaints and grievances were responded to in a timely manner. IPRO presented the survey findings in a report to the state and to the MCOs. 15

16 MLTSS and Quality Performance Improvement Projects (PIPS) IPRO monitors the MLTC MCO PIPs by reviewing and approving the topic selections, holding calls with the MCOs during the year for project status, and reviewing the final project reports. Common project topics (a number of the MLTC plans have conducted these PIPs over the years) Emergency Room Visit Reduction Emergency Preparedness Flu Vaccinations Advance Directives (Health Care Proxies) Poly pharmacy Reduction Falls Mitigation Transportation Grievances Diabetic Care (e.g. HbA1C testing, Annual Podiatry, Annual Eye Exam) 16

17 MLTSS and Quality Performance Measures The following performance measures are required to be submitted annually to CMS by the Medicare SNP (Special Needs Plans) MCOs. Colorectal Cancer Screening Glaucoma Screening in Older Adults Care for Older Adults Advance Directive Discussion Medication Review Functional Status Assessment Pain Assessment Use of Spirometry Testing in Assessment and Diagnosis of COPD Antidepressant Medication Management Follow Up After Hospitalization for Mental Illness Annual Monitoring for Patients on Persistent Medications Medication Reconciliation Post Discharge Potentially Harmful Drug Disease Interactions in the Elderly Use of High Risk Medications in the Elderly Plan All Cause Readmissions Board Certification Pharmacotherapy Management of COPD Controlling High Blood Pressure Persistence of Beta Blocker Treatment After a Heart Attack Osteoporosis Management in Women Who Had a Fracture 17

18 MLTSS and Quality Special Projects Clinical assessment validation The NYSDOH requires MLTC enrollees to be clinically assessed every six (6) months. The assessment addresses a number of areas; including members ability to perform activities of daily living (e.g. grooming, ability to dress upper body, lower body, feeding/eating, bathing), behavioral status ( cognitive functioning, confusion, anxiety, depressive feelings), sensory status (hearing, speech, vision, pain frequency). The assessment results are submitted to the state twice annually. IPRO pulled a sample of members assessed during a specific six month period and requested the medical records and care management documentation for these members to validate, or support, the assessment findings that had been reported to the state. IPRO s findings were that the majority of the assessment findings were supported by documentation in the records. Only in a small number of instances was a less serious condition found in the record warranting a lower level of care. 18

19 MLTSS and Quality Quality Conferences Periodically, IPRO and the state conduct quality conferences for the MLTC MCOs. These are one day events consisting of general quality presentations and examples of successful performance improvement projects. At these conferences the MLTC plans are encouraged to present their own performance improvement project findings. 19

20 Questions? 20

21 For more information Virginia Hill, RN, MPA Vice President (516) ext. 567 Thomas LoGalbo, MBA, CHCA Director (516) ext 349 Jeremy Anderson, PhD Assistant Director (516) ext. 636 Jeanne Alicandro, MD, MPH Medical Director (516) ext. 352 CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY