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Medicaid/CHIP Managed Care Rules: Assuring Quality Kelly Whitener Tricia Brooks David Machledt September 8, 2016
Medicaid/CHIP Managed Care Rules: Assuring Quality
Kelly Whitener Tricia Brooks
David Machledt September 8, 2016
Children in Managed Care
• CMSfinalizedsweepingchangestoMedicaidandCHIPmanagedcareregula;onsinMay2016
• Regula;onssetminimumstandards;stateshaveflexibilitytodomore
• Manyopportuni;esforlegalandhealthadvocatestotakeac;on
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Flagpoten+alac+onsforlegalandhealthadvocates
Why are these rules so important?
66% of children in Medicaid/CHIP are enrolled in MCOs
22% of children in Medicaid/ CHIP are enrolled in
PCCMs
11% of children in Medicaid/ CHIP are enrolled in
FFS
Source:CMSMedicaidManagedCareEnrollmentReport2013
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Managed Care Project
• Seriesofsixexplainerbriefsandwebinars① LookingattheRulethroughaChildren’sLens(6/9)② ImprovingConsumerInforma;on(6/23)③ EnhancingtheBeneficiaryExperience(7/19)④ AssuringNetworkAdequacyandAccesstoServices(8/5)⑤ AdvancingQuality(9/8)⑥ EnsuringAccountabilityandTransparency(9/29)
• Fallmee;nginD.C.withchildhealthandlegaladvocatestostrategizeoverimplementa;on
• ThankstoRobertWoodJohnsonFounda;on• Linkstopastreportsandwebinarslides:
hfp://ccf.georgetown.edu/2016/06/22/medicaidchip-managed-care-series/
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Our Topic Today: Assuring Quality
• HealthInforma;onSystemsandEncounterData
• ManagedCarePlanQualityAssessmentandPerformanceImprovementProgram(QAPI)
• Accredita;onStatus
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Flagpoten+alac+onsforlegalandhealthadvocates
• ManagedCareQualityRa;ngSystem
• StateQualityStrategy• ExternalQualityReview
Background – Why these Rules?
• Significantimprovementsinscienceofqualitymeasurementandimprovement
• Intendedtoadvancequalityassuranceeffortsbystrengtheningdataandexpandingexternalqualityreview
• Focusedafen;ononLTSS• Providesconsumerswithinforma;ontoassessqualityin
choosingaplan• Improvesdatatransparencyand
;meliness• Providesopportunityfor
stakeholderengagement
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Applicability
• AllMCO’s,PIHPs,andPAHPs• AlimitedsetofprovisionsapplytoPCCMen;;eswithcontractsthatallowforsharedsavings,financialreward,orperformanceincen;ves
• Statequalitystrategydoesnotencompassfee-for-serviceasini;allyproposed
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Timeline
• Implementa;on;melinesvaryfordifferentprovisionsfromimmediatetocontractra;ngperiodsthatstartJuly1,2017to3yearsfromreleaseofCMSguidanceonthequalityra;ngsystem(expectedin2018).
• Provisionsthatmodifycurrentrulesareeffec;vesoonerthannewprovisions,suchasthequalityra;ngsystem
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Health Information Systems
• Statecontractsmustrequireeachplantomaintainahealthinforma;onsystem
• Systemmustcollect,analyze,integrateandreportspecialdata
• Datamustminimallyincludeu;liza;on,claims,grievancesandappeals,anddisenrollmentsforreasonsotherthanlossofeligibility
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Appliesto,MCOs,PIHPs,PAHPs
Contractra+ngperiods≥July1,2017
Basic Elements of Health Information Systems
① Meetspecificstandardsforclaimsprocessing② Collectdataonenrolleeandprovidercharacteris;cs
asspecifiedbythestate③ Collectencounterleveldataonservicesfurnished
toenrollees④ Ensurethatdatareceivedfromprovidersis
accurateandcomplete⑤ Makeallcollecteddataavailabletothestateand
uponrequesttoCMS
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EncounterData
QualityMeasurement
Rate-selng
Value-basedpurchasing
Policydevelopment
Riskadjustment
Programintegrity
Encounter Level Data
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Encounter Level Data
• CMSmayspecifythelevelofdetailandfrequencyrequiredinstatecontractswithplans
• Statesmustreviewandvalidatethedataandhaveprotocolstoensurethatitisaccurateandcomplete
• MonthlysubmissiontoCMSisrequired
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Appliesto,MCOs,PIHPs,PAHPs
Contractra+ngperiods≥July1,2018
Encounter Level Data Financial Implications
• StatesmayuseanEQROtovalidateencounterdatabutmatchvaries:– 75%fundingforMCOsonly– 50%matchforPIHPsandPAHPs
• IfCMSassessesthatastate’ssubmissionisnotaccurateandcomplete,itwillno;fythestate
• CMSmaywithholdordisallowmatchingfundstoenforcecompliance
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New or Updated Definitions
• Access,Quality,HealthCareServices,Outcomes• Ar;culatesabroaderviewofhealthbeyondclinicalcareandmedicaloutcomes
• Definesservicesasthoseprovidedinanyselngbutnotlimitedtomedicalcare,behavioralhealthcare,andLTSS
• Outcomesincludepa;enthealth,func;onalstatus,sa;sfac;on,orgoalachievement
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Quality Assessment & Performance Improvement Program (QAPI)
• Notthestatequalitystrategy• StatecontractsmustrequireplanstoestablishanongoingcomprehensiveQAPI
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Appliesto,MCOs,PIHPs,PAHPsandcertainPCCMen++es
Contractra+ngperiods≥July1,2017
Basic Elements of QAPI
• PerformanceImprovementProjects(detailnextslide)• Collec;onandsubmissionofperformancedata*• Mechanismsto:- Detectbothunderu;liza;onandoveru;liza;on*- Assessquality/appropriatenessofcareforindividualswithspecialhealthcareneeds
- AssessqualityofcareforindividualsreceivingLTSSandinhome/community-basedwaivers
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*OnlytheseprovisionsapplytoPCCMen++eswithcontractstheprovideforsharedsavings,financialreward,orperformanceincen+ves.
Performance Improvement Projects (PIPs)
• Useobjec;vequalityindicators• Implementinterven;onstoachieveimprovementinaccesstoservicesandqualityofcare
• Evaluatetheeffec;venessofinterven;onsbasedonthequalityindicators
• Includeac;vi;estoincrease/sustainimprovementsinhealthoutcomesandenrolleesa;sfac;on
• Focusonclinicalandnon-clinicalareas• Atleastannualrepor;ng
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CMSretainsauthoritytospecifyfederalPIPsarerformalpublicno;ceand
commentprocess
Performance Measures
• Statemustiden;fythestandardperformancemeasurestobereportedannually
• CMShasauthoritytorequirespecificmeasures
• MLTSSmustaddressqualityoflife,rebalancing,andcommunityintegra;on
Op$onsforRepor$ng
• Plancalculatesandreportsbasedonstandardmeasures
• Plansubmitsdataforstatetocalculatethemeasures
• Combina;onofthese
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QAPI Program Review
• Statemustreviewtheimpactandeffec;venessofeachplan’sQAPIprogramatleastannually
• Reviewmustincludetheplan’sperformanceonrequiredmeasures,outcomesandtrendedresultsofPIPs,andcommunityintegra;onforLTSS
• Statesmayrequireaplantoevaluatetheimpactandeffec;venessofitsownQAPI
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Accreditation Accredita+onisacomprehensiveevalua+on
processinwhichaplan’ssystems,processesandperformanceareexaminedbyanindependent
accredi+ngen+ty(e.g.NCQA).
• Notrequiredinfinalrule,althoughini;allyproposed
• Stateshaveflexibilitytorequireaccredita;on
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Encourageyourstatetorequireaccredita3ontoensurethatmanagedcareplansmeetna3onalstandards
If a Plan Has Undergone the Accreditation Process
• Regardlessofwhetherastaterequiresaccredita;on- Theplanmustdisclosethestatusandauthorizetheaccredi;ngen;tytoprovidespecificinforma;ontothestate.
- Thestatemustpostandupdateaccredita;onstatusannually,alongwithnameofaccredi;ngen;ty,program,andlevel.
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Appliesto,MCOs,PIHPs,PAHPs
Contractra+ngperiods≥July1,2018
Quality Rating System (QRS)
• CMSwilldevelopamodelMMCQRSfocusingon:- clinicalqualitymanagement;- memberexperience;and- planefficiency,affordabilityandmanagement
• AlignedwiththeMarketplaceQRSbuttailoredforMedicaidenrollees
• Stakeholderconsulta;on&publiccommentrequired• StatesmayadoptmodelMMCQRSordevelopanalterna;ve
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Appliesstatestocontrac+ngwithMCOs,PIHPs,PAHPs
Nolaterthan3years>CMSpublishesguidance
State QRS Alternative • Mustyieldsubstan;allycomparableinforma;on• CMSapprovalbeforeimplementa;onorchanges• ObtaininputfromMCACandprovideopportunityforpubliccomment
• Documentissuesraisedandstate’sresponse
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Federallevel:ProvideinputtoCMSonthedevelopmentofthemodelMMCQRS,andtheneedforarobustandtransparentpublicprocessandhowtodefine“substan+allycomparable”forastatealterna+ve.Statelevel:EncourageyourstatetoinvolvearobustgroupofstakeholdersindeterminingwhethertoadoptthemodelQRS,andindevelopingastatealterna+veifdeemedbest.
State Managed Care Quality Strategy
• Awrifenqualitystrategyforassessingandimprovingthequalityofmanagedcare
• Providescomprehensivedetailsaboutthestate’sMCprogramsanditsoversightandqualityassurance
• Mustbereviewedandupdatedarersignificantchanges(andnolessthanevery3years)
• ReviewprocessincludespubliccommentsandfeedbackfromCMS- StateresponsivenesstoEQRrecommenda;ons- Evalua;onofeffec;venessofpriorqualitystrategy
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Minimal Elements of State Quality Strategy • Strategymustreflectstate’sgoalsand
objec;vesandhowthestatewill:– Measureandimprovequality– Definenetworkadequacy– ArrangeforindependentEQRreview– Addresshealthdispari$es– Ensurequalitythroughtransi;ons– Iden;fyindividualswithspecialhealthcare
needsorwhoneedLTSS– Imposesanc;onsonMCOsthatviolate
federallaw– Definesignificantchangethatrequiresthat
thestrategybeupdated– More(seepage7ofthebrief)
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Writecommentstorecommendperformance
measures,PIPs,EQRreviewac+vi+es,and
be[erdispari+estrackingtoberequiredinallstatemanagedcarecontracts.
External Quality Review = A Key Tool
• Arequiredac;vityformorethanadecade• Hasnotalwaysliveduptopoten;al;butnowstronger
• Improvedatatransparencyand;meliness• HoldMCplansaccountabletoperformanceexpecta;ons
• Providestateswithfinancialincen;vestoinnovatequalityac;vi;es
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External Quality Review Protocols
• Methodologyforconduc;ngEQRlaidoutindetailedprotocolsforeachac;vity
• Revisionswillbenecessarytocurrentac;vi;es• Newprotocolsfornewac;vi;es:valida;ngnetworkadequacyandassis;ngwiththeQRS
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Federallevel:Takeadvantageofthecommentperiodtoweighinonthenewprotocols.Statelevel:Engageinopportuni+estoprovideinputtoyourstate’squalitystrategydevelopmentasitdeterminesitsownEQRarrangements.
Qualifications of an EQR Organization
• Establishescompetence,financialsecurity,andindependenceofEQRO
• Specialrulesforagovernmenten;ty• Newrulestrengthensseveralelementsrela;ngtoindependence- thedisallowanceofallowinganEQROtoreviewamanagedcareen;ty
itownsorcontrolshasbeenextendedtoreviewofcompe;tormanagedcareplansinthestate.
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State Contract Options for EQR
• StatesmustcontractwithoneormoreEQROstocompileandreviewallcollecteddataandpreparetheannualtechnicalreport
• Contractmustallowopen,compe;;veprocurementprocess
• EQROsmaysubcontractwithen;;esthatmeettheindependencerequirementsbutEQROremainsaccountable
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EQR Activities
MandatoryAc$vi$es
• Valida;onofPIPs• Valida;onofrequired
performancemeasures• Reviewofcompliancewith
managedcareandQAPIstandardsevery3years
• Valida;onofnetworkadequacyevery12months
Op$onalAc$vi$es
• Valida;onofencounterdata• Administra;onorvalida;on
ofconsumer/providersurveys
• Calcula;onofaddi;onalperformancemeasures
• Conductaddi;onalPIPs• Conductspecialstudies• AssistwithQRS
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Encourageyourstatetoadoptop+onalac+vi+estoensurethatqualityreviewiscomprehensiveandconductedindependently.
Direct Testing of Network Adequacy
Directtes+ngiscenteredonac+veevalua+onofplancompliance,suchasconduc+ngasecretshoppersurveyasopposedtoadeskreviewofaplan’s
policiesandproviderdirectories.• Valida;ngnetworkadequacyisasignificantchange• OIGfoundthatthreestates(outof33surveyed)found77%ofallthenetworkadequacyviola;onsfrom2008-2013.Allthreecalledprovidersdirectly.*
*HHSOIG,StateStandardsforAccesstoCareinMedicaidManagedCare,15-16(Sept.2014). 31
UrgeCMStodevelopguidancemanda+ngrobustandindependentdirecttes+ngtovalidatenetworkadequacy.
Non-Duplication
• Avoidsunnecessaryduplica;onofwork• Allowssubs;tu;onofinforma;onfromprivateaccredita;on(orMedicareAdvantage)
• Newlyallowssubs;tuteforvalida;onofPIPsandperformancemeasuresifstatesprovideadetaileddescrip;onandra;onaleofsubs;tu;onsintheirqualitystrategy
• Explicitlydoesnotallowsubs;tu;onoftherequiredvalida;onofnetworkadequacy
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EQR Results
• EQRreportscanprovidevaluabledataaboutplanperformance- includingimplementa;onofpriorrecommenda;ons
• StatesmustcontractwithanEQROtoproducetheannualreport
• Statescannotsubstan;velyrevisethecontentwithoutevidenceoferrororomission
• Reportsmustbe:- FiledbyApril30ofeachyear- Postedonthestatewebsite- Providedinpaperoralterna;veformatsuponrequest
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Federal Financial Participation (FMAP)
• Previously,anenhancedfederalmatchof75%wasallowedforEQRac;vi;esconductedbyEQROs
• ThenewrulereinterpretsthelawandonlypermitstheenhancedmatchasitappliestoEQRac;vi;esassociatedwithMCOs
• Evenifrequired,EQRac;vi;esassociatedwithPIHPs,PAHPs,orPCCMen;;eswillreceive50%match
• Couldhavechillingeffectonstatewillingnesstoadoptmorethanthemandatoryac;vi;es
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Creative Ways to Use EQR Financial Incentives
• Testanewmeasureoraconsumersurvey- Ex.Na;onalCoreIndicators–AdultsandPeoplewithDisabili;es
• Directtes;ngofencounterdata• Stra;fica;onofqualitydatatoexaminehealthdispari;es
• Howdoyouinterpret:“Conductofstudiesonqualitythatfocusonapar;cularaspectofclinicalornonclinicalservicesatapointin;me.”
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Applicability to PCCM Entities
• AppliesonlytoPCCMen;;eswithcontractsthatprovideforsharedsavings,financialreward,orperformanceincen;vesforoutcomes
• LimitedrequiredQAPIforPCCMen;;es- Collectandreportstate-iden;fiedperformancemeasures- Havemechanismstodetectbothunderu;liza;onandoveru;liza;on
• LimitedrequiredEQRforPCCMen;;es- Valida;onofperformancemeasures- Compliancereview- AnnualreportproducedbyEQRO
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CHIP Applicability
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QualityMeasurementandImprovement
• Healthinforma;onsystems
• Encounterdatasubmissionandvalida;on
• QAPI• Statereviewofplan
accredita;on
ExternalQualityReview
• EQRprovisionsgenerallyapplyacrosstheboard
• Non-duplica;ononlyappliestoprivateaccredita;on;Medicarecannotsubs;tute
• EQRismatchedatCHIPrate
Additional Resources • Foraprimeronthebasics,backgroundandstatusofquality
measurementandimprovementinMedicaidandCHIP,seeMeasuringandImprovingHealthCareQualityforChildreninMedicaidandCHIP:APrimerforChildHealthStakeholders.
• Toaccesseachofthebriefsinthisseries,includingrecordingsofwebinarsandpresenta;onsoneachofthetopics,seeCCF’sMedicaidandCHIPManagedCareSerieswebpage.
• Foraddi;onalinforma;ononvariousotheraspectsofthenewmanagedcareregula;ons,seeNHeLP’sManagedCarewebpage.
• Formoreinforma;ononMedicaidMCEQR,seeNHeLP’sExternalQualityReview:AnOverview.
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For More Information
• KellyWhitener- [email protected]
• TriciaBrooks- [email protected]
• DavidMachledt- [email protected]
