DISliNGUISHED FACULTY

Teri Barthels Chief, Managed Care Initiatives Section California Department of Health Services Lynn Dierker Senior Health Analyst Colorado Department of Healthcare Policy and Financing Jose Fernandez Vice President American Family Care (Former Medi-Cal Director) Sandra Franck-Welby Fmancial Solvency Reporting Coordinator Oregon Office of Medical Assistance T. Hershel Gardin, Ph.D. Director, Corporate Development and Quality The Wellness Plan Gloria Gonzalez Director, Product Management Resource Information Management Systems Catherine Graeff Vice President Information Network Corporation Embry M. Howell, Ph.D: Vice President Mathematica Policy Research Jodi Korb Health Policy Analyst Laguna Research Associates Dixon Larkin, MD, JD Deputy Commissioner State of Utah Insurance Department Richard Ueberman President Health Data Systems Nelda McCall President Laguna Research Associates Darendia McCauley, Ph.D. Quality Assurance Manager Oklahoma Healthcare Authority J. Mario Molina, MD Vice President, Medical Operations Molina Medical Centers Faye Newsome Vice President, Operations Managed Care Solutions John O'Brien Senior Program Manager Technical Assistance Collaborative Winifred Odo Healthcare Administrator Hawaii Department of Social Services and Housing Suzanne Pollack Driver Research Analyst Laguna Rel>earch Associates Stephen Schneider Executive Director Libe•ly Health Plan Barry Volin Senior Manager, Managed Care Consulting Ernst & Young Jerry Witherspoon Chief Information Officer Managed Care Solutions

PLUS: optional TECHNICAL ASSISTANCE WORKSHOP conducted by the Oregon Office of Medical Assistance showing new applicants how to prepare a Request for Application

Data Collection and Reporting Requirements for Medicaid

Managed Care Prepare now. •• dlscover how

Medicaid HEDIS Is setting new data collectlota ami ....,. standards aad

hear how it Is alreadr being used In selected states

BENEFITS OF ATTENDING ./ Discover how & where health plans can obtain required financial, quality,

utilization, membership, access & corporate qualifications data ./ Find out what types of data are currently being required by HCFA ... and discover

exactly how they are being used

./ Maximize your Medicaid information systems to market your services, track enrollment, manage quality/utilization, develop capitation vs. fee-for-service data

./ Hear new state/federal reporting requirements discussed and debated ... and hear first hand from state evaluators in CA, CO, HI, OK, OR, UT how they will impact your operations

./ Hear two leading states-California and Arizona-describe how they report and track data ... and what's ahead

./ Find out how the move toward collecting encounter vs. aggregate data will impact your information systems requirements

./ Hear about McData: HCFA's effort to develop a core Medicare/Medicaid data set

./ Determine whether your system is compatible with your state's information system ... and learn what you can do if it is not

./ Develop a system for documenting quality improvements and capturing appropriate outcome and performance data

A must fot health pian~, pz.rtic1pating in the explosive Medicaid rna~ •~~, ~ i Please review the

conference <·,hjective::s inside .

January 24-25, 1996 - U.S. Grant Hotel - San Diego, CA

GLOBAL BUSINESS RESEARCH L T D

Medicaid HEDIS is Here - Sooner or Later States will Require you to Report HEDIS Data ... You Must Remain on Top of the Critical Issues of Collecting

and Evaluating Healthcare Information By attending this intensive two day event, you will learn: 1) how to develop information systems to collect

Medicaid managed care data ... and how/where to find the data

2) how to accurately and effectively comply with changing- and more stringent-state/federal quality, utilization, membership, access, financial solvency and general management reporting requirements

Here, specifically, is how you will benefit: Data Collection (Day One) ... High utilizing Medicaid enrollees are prime candidates for the development of sophisticated medical management systems. Medicaid information systems requirements must incorporate detailed subscriber data, allow for volatile enrollment and eligibility situations,

- -support preventive care in conjunction with clinical modules and tie in with claims, marketing, and quality of care information. Unfortunately, management information systems for Medicaid HMOs ... and for State agencies ... are often the weakest link.

This hands-on conference will teach you how & where to find data, how to choose a Medicaid managed care information system .•. and/or develop your own ... plus how to use information systems to capture primary care encounter data, market your services, track enrollment, manage quality/utilization in conjunction with Medicaid providers and develop valid/reliable capitation vs. fee­for-service data.

Given its twin emphasis on data collection and reporting requirements, this seminar will also consider data elements needed to successfully interface with state information systems.

Reportin& Requirements (Day Two) ... With the number of states enrolling entire Medicaid populations into a managed care plan, state evaluators must review increasingly large amounts of data to guarantee that Medicaid MCOs which offer managed care have the necessary financial backing and management skills to provide adequate levels of service to Medicaid clients.

In December 1995, the NCQA distributes its final draft

of the Medicaid version of the Health Plan Employer Data and Information Set (HEDIS)-before it turns its attention to Medicare HEDIS and finally a HEDIS version 3.0 for commercial populations. This marks the firs e 'e mea By December, the NCQA expects over 1,000 individuals and organizations to have reviewed the new HEDIS document.

Also, HCFA has recently pl.lblished guide · a common Medicare/Medicaid core data set which requires collection of person level, encounter data in addition to the qualitative and evaluative reporting in HEDIS.

State evaluators we spoke with ... many of whom will be speaking at/attending this conference ... agree that data reporting requirements are moving in the direction of HEDIS and toward required collection of encounter data. "Were I a health plan representative," one State representative said to us, "I would be very concerned with what data I will be required to collect, how I should collect it, what I should do with the data, and why state regulators are suddenly so interested in all this new information."

Plan today to attend this, your best opportunity to hear state Medicaid officials discuss, debate and inform health plans of their overall approach to requiring and evaluating financial, quality, membership, utilization, access, general plan management, and encounter data.

Plus, as if all this weren't reason enough to attend, we will integrate the two topics-Data Collection and Reporting Reguirements-in a comprehensive, te hm al . t 1 ' on the optional third day (Friday, January 26). During this workshop, Sandra Franck-Weiby from the Oregon Office of Medical Assistance will guide you step by step through each of the data elements a health plan must have in place while u demon rate ... orp 11 ial solvenc This will be of invaluable assistance to both managed care plans and state regulators.:.and should generate a meaningful level of discussion between the two. For a full description of this workshop, please see page 6.

• C II 1 81\/\ '"68-7188 1i R 1 t Data Collection and Reporting

~-----------------------------a-----~----~· ____ o __ e~g_s_e_r __________ ~R~e~qu~lr~em~e~nt~sf~or~M~ed~i~~~~d~Ma~n~aE~~C~a~m

Here are

14 Additional Reasons you

Should Attend 1. Discover how state reporting requirements can

double-or even triple-data storage requirements

2. Examine data elements required for successful information exchange, reporting and clinical accountability

3. Hear detailed, practical advice on choosing a Medicaid managed care information system

4. Improve the validity/reliability of analytical data

5. Evaluate new techniques for risk adjusting your data

6. Compare different ways of producing research and evaluation data ... and, hear first-hand-and maybe for the first time-how Federal/State regulators actually use the information you give them

7. Come to grips with changes in state quality assurance/utilization management reporting requirements

8. Discover how to collect and report EPSDT information

9. Find out how to use claims data to estimate future Medicaid costs

10. Plan ahead for Medicaid managed care implementation ... review each and every data element which a health plan must have in place while putting together a business plan to demonstrate corporate qualifications

11. Discuss new requirements for public mental health and substance abuse programs

12. See new systems with the ability to map expected patient populations against physician office locations

13. Gain access to most currently available data regarding managed care financial, utilization and membership indicators

14. Decide for yourself exactly how close you think Medicaid HEDIS is to becoming a workable performance indicator

Data Collection and Reporting Requirements for Medicaid Managed Care

Wednesday. lanuaty 24. I996

8:30 Registration, Coffee and Danish

8:45 Chairperson's Introductory Remarks

Jose Fernandez Vice President American Family Care (formerly, Medi-Cal Director)

Data Collection

9:00 MEDICAID MANAGED CARE INFORMATION BENEFITS/REQUIREMENTS This session will prl3vide you with revealing insights for using Medicaid information systems to:

• Market your plan's services. • Track your plan's enrollment • Manage your plan's quality/utilization • Develop capitation vs. fee-for-service data

Faye Newsome Vice President, Operations Managed Care Solutions

Jerry Witherspoon Chief Information Officer Managed Care Solutions

10:15 Refreshment and Discussion Break

10:30 WHAT TYPE OF MEDICAID MANAGED CARE INFORMATION SYSTEM WILL MEET NEW MEDICAID DATA REPORTING REQUIREMENTS?

The decision to implement a new system is one of the most important operational decisions the plan can make. It is critical to understand the unique issues of entitlement programs, member and provider needs as well as state reporting requirements.

This presentation will teach you how to follow a proven process for choosing the best system for you.

• Identifying internal system needs • Conducting an external system needs analysis • How to determine what special functionality is needed • Understanding the systems ramifications of state

requirements • Is outsourcing for you?

Catherine C. Graeff Vice President Information Network Corporation

11:30 Luncheon for Speakers and Delegates

1:00 HOW/WHERE HEALTH PLANS CAN OBTAIN REQUIRED DATA

This session will begin with information for all health plans in general and will then move to a case study allowing you to learn from the experience of one health plan in particular.

• Claims data

Data Collection and Reporting C 11 1 800 868 71881i R • t • ~R~e~u~ir~e~me~n~ts~fu~r~M~ed~ic=a=id~~=a~na~ed~C~a~re~----------a ___ -___ • ___ -______ o __ e~g~•s __ e_r ________________________________ ~

• Demographic, eligibility data • Current and historical utilization and expenditures • Data on quality, service delivery • Systems for capturing primary care encounter data • Data elements required for successful information

exchange, reporting and clinical accountability

Barry Volin Senior Manager, Managed Care Consulting Ernst & Young (former Director, Health Care Plus & Assistant Vice President, Lutheran Medical Center)

Stephen Schneider Executive Director Liberty Health Plan

2:30 Refreshment and Discussion Break

2:45 ESTIMATING COSTS OF CARE FOR MEDICAID MANAGED CARE

Estimating costs of a managed care arrangement is complicated by data anomalies and the inherent risks of predicting utilization based upon a population with potentially different characteristics. This talk will provide insight into some of the problems a data analyst must consider when working with claims data.

• Building risk-adjusted rate cells • Computing the denominator-instability ofeligible

population • Statistical considerations-impact of outliers, year-to­

year persistence, etc. • What to do when source data is derived from

capitated services

Richard N. Lieberman President Health Data Systems, Inc.

3:30 DATA ELEMENTS FOR COLLECTING AND REPORTING EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) INFORMATION

• What information components do you need to capture to comply with state and federal government mandated reporting requirements?

• From what sources and through what methodologies can this data be captured?

• How can data from multiple sources be combined into a single data set for reporting purposes?

• How can reports be assembled and submitted (i.e. electronically, via tape, etc.) to ensure compliance with governmental requirements?

Gloria Gonzalez Director, Product Management Resource Information Management Systems, Inc.

4:15 HEALTH PLAN/PROVIDER PERSPECTIVE ON EPSDT DATA COLLECTION AND REPORTING

EPSDT services form an important core for pediatric preventive care in managed care organizations. Government and outside agencies are increasingly scrutinizing health plans' performance in delivering EPSDT services. This session will address EPSDT requirements, data collection, quality improvement and utilization management. Learn about the new HEDIS guidelines for

5:00

Medicaid

• Collecting encounter data • QIIUM for EPSDT services • Medicaid HEDIS guidelines • Reporting encounter data

]. Mario Molina, MD Vice President, Medical Operations Molina Medical Centers

DATA REQUIREMENTS FOR PUBLIC MENTAL HEALTH AND SUBSTANCE ABUSE SYSTEMS

The significant variance in State's mental and substance abuse authorities data sets makes client, utilization and expenditure tracking difficult. This session will address what minimum data set will be needed by States and managed care organizations implementing behavioral health managed care programs

• Client tracking data • Outcome and performance data • Expenditure data • Data reliability and validity

John O'Brien Senior Program Manager Technical Assistance Collaborative

5:45 Day One Concludes

Thursday. Tanuaa 25. 1996

8:00 Coffee and Danish

Reporting Requirements

8:30 STATE ROUNDTABLE-WHAT TYPE OF DATA DO STATES REQUIRE, WHY DO THEY REQUIRE THIS DATA, AND WHAT DO THEY DO WITH IT ONCE IT HAS BEEN SUBMITTED?

This session will provide a forum for State Medicaid officials to discuss, debate and inform health plans of their overall approach to requiring and reviewing the following types of data/data oriented topics.

• Financial Reporting/Financial Solvency • Quality Assurance Data • Utilization Review • Marketing, Enrollment Data • Access • Encounter vs. Aggregate Data • Provider Network Data • Patient Satisfaction • Demonstration of Corporate Qualifications • Reporting Formats • Interfacing with State Management Information Systems • Withholds for Data Errors • Sanctions for non-compliance

The panelists will also examine how the "hot off the presses" release of NCQA Medicaid HEDIS guidelines and HCFA's Medicare/Medicaid core data set (McData) will impact state requests for research and evaluation data

Panel Moderator Winifred Odo Healthcare Administrator Hawaii Department of Social Services and Housing

• Data Collection and Reporting

• L_ __________________________________ c~a~ll_1_-_a~ ____ s_~_7_1_88 __ ~_o __ R_e~g~l-s_te_r ______________ ~R~~~ui~re~me~nt~s~ro~r_M_oo_i_~_~_M_a_n_a~goo __ c_a_re~

10:45

11:00

12:00

1:30

2:30

State Representatives

Lynn Dierker Senior Health Analyst State of Colorado Department of Healthcare Policy & Financing

Dixon Larkin, MD, JD Deputy Commissioner State of Utah Insurance Department

Darendia McCauley, Ph.D. Quality Assurance Manager Oklahoma Healthcare Authority

Refreshment and Discussion Break

QUALITY ASSURANCE/UTILIZATION MANAGEMENT DATA REPORTING REQUIREMENTS

• Development of Perfonnance Indicators • Appropriate QA/UR Data Elements • Documenting Quality Improvements • Action and Follow-Up • Relationship to Quality Assurance Refonn

Initiative (QARI)

Dixon Larkin, MD, JD Deputy Commissioner State of Utah Insurance Department

Luncheon for Speakers and Attendees

TECHNIQUES AND PITFALLS OF PRODUCING RESEARCH AND EVALUATION DATA

Most current Medicaid managed care programs are conducted under federal waivers which require evaluation. All broad 1115 waivers require complete encounter data. The speaker will discuss tire types of data currently being collected at HCFA and how they are being used ... as well as some of the pitfalls plans face in producing data

• States need to examine the impact of managed care on cost and use of services

• States will increasingly require detailed, person level reporting

• Why do States need this? • What are the pitfalls in producing these data? • How do Federal and State evaluators use the data?

Embry M. Howel~ Ph.D. Vwe President Mathematica Policy Research

MEDICAID HEDIS ... WHERE DOES IT FIT? CAN IT WORK? ASIS?

The draft Medicaid HEDIS was developed to provide a standardized perfonnance measuring tool for both State Medicaid agencies and the Managed Care entities with which they contract. The final version of Medicaid HEDIS .LQ is intended to relate well with the current HEDIS 2.5 and be a harbinger of a considerable portion of HEDIS 3.0. Although developed by a collaborative effort on the part of some managed care entities, State Medicaid agencies, HCFA, NCQA and others, it is not yet ready for implementation by States.

• Composition of the group that created Medicaid HEDIS • Consensus strategy for creating the draft-did it work?

• How close is the draft to becoming a useable perfonnance indicator?

• What are the current limitations in the document? • How should Medicaid HEDIS be implemented? • What next?

T. Hershel Gardin, Ph.D. Director, Corporate Development and Quality The Wellness Plan

CASE STUDIES OF LEADING STATES/PLANS AND HOW THEY REPORT AND TRACK DATA

3:30

4:15

5:00

HISTORY OF ARIZONA'S DATA COLLECTION/ REPORTING SYSTEM

The Arizona Health Care Cost Containment System (AHCCCS) is now in its 13th year of operation as a Medicaid 1115 Research and Demonstration project.

This presentation will highlight the findings of the independent evaluators contracted by HCFA to assess the AHCCCS program. They will cover the following areas:

• Qlli-ln the first II years of the program AHCCCS produced cost savings of approximately seven percent compared to the cost of a traditional Medicaid program in Arizona.

• Utilization Hospital utilization under AHCCCS was lower than under traditional Medicaid

• Quality of Care-AHCCCS probably does more than any other state Medicaid program in the area of quality assurance ·

• Access and Satisfaction Access to routine care was better under AHCCCS and absolute satisfaction levels were high

JodiKorb Health Policy Analyst Laguna Research Associates

Nelda McCall President Laguna Research Associates

Suzanne Pollack Driver Research Analyst Laguna Research Associates

MEDI-CAL MANAGED CARE UTILIZATION REQUIREMENTS

California is in the process of a major expansion of its Medi-Cal managed care programs. Beneficiary participation is expected to grow from about 90,000 in July, I995 to 3 million by mid-I996. One of the new elements in this expansion is the requirement that managed care plans report encounter level data. This session will describe key issues/ decisions behind this requirement, focusing on the following areas:

• Medi-Cal managed care program history • The decision to require encounter level reporting • Initial implementation issues • Plans for the future

Teri Barthels Chief, Managed Care Initiatives Section California Department of Health Services

Main Conference Concludes

~~~~ • ~R~e~ui~ffi~m~en~ts~f~o~rM~e~d~i~~i~d~M~Ian~a~oo~C~a~ffi~-------------C_a~II_1_·~8~~~~6~~~7~1~8~8~TI~o~R=e~g=ls=te:r~--------------------------------J

Friday, January 26, 1996

I~tan~e Work~hop

8:00 Registration, Coffee and Danith 8:~0-12:'20 Workshop Hours

DEVELOPING DATA TO SUPPORT A REQUEST FOR APPLICATION

State Medicaid agencies are increasingly funding new managed care organizations who are not HMOs in order to provide health services to the Medicaid population. Because thes.e organizations are usually not regulated by the state's insurance division and are start-up organizations, the state needs to assure these funded organizations will have the necessary financial backing and management skills to provide services to Medicaid clients.

The state must develop standards in reviewing Requests for Application which ensure the proposed health plan has:

1) Incorporated specific provisions against insolvency commensurate with Medicaid enrollment and level of assumed risk

2) Demonstrated financial management ability

3) Generated periodic financial reports and made them available to the state

This part of the workshop will cover each of the following elements which a health plan must have in place while putting together a business plan to demonstrate corporate qualification

Standards

Reinsurance Estimation of fee-for-service liability for capitated services Restricted reserves Sub-contractor relationships - Hold harmless provision - Professional liability insurance

Creatin& projected capitalization requirements

Development of proposed monthly budget prior to start-up and for two years after start-up showing - Projected enrollment - Projected expenses - Projected medical expenses by type of service (hospital,

physician, drugs, etc.) - Projected revenue Development of proposed monthly budget in per member per month form Development of monthly staffing plan prior to start-up and for two years after start-up

Developin& financial information that shows key financial indicators

Developing audited financial statements Developing project quarterly and annual financial information Developing key financial indicators - Whether application has experienced consistently positive

earnings - The medical loss ratio - Administrative expenses -Net worth -Liquidity Developing sources of additional capital and financial guarantees

Deyelopin~: projected future costs

Developing business assumptions (or where do you want your business to go financially?) Estimating enrollment Estimating revenue

• Estimating current assets and liabilities Estimating claims payable (or how to use the ffiNR) - Estimating reserves

- Restricted reserves - Internal reserves

Estimating membership utilization

Demonstratin& that the start-up prepaid health plan has the wherewithal to evaluate the aforementioned jnfoonation

The importance of management reports -Financial - Utilization - Membership enrollment The importance of desk procedures The importance of documenting this information

'0- J . ONS .o

OLVENCY

This part of the workshop will examine state requirements to assure that Medicaid managed care organizations are solvent and financially well managed

Relationship to HMO Re~:ulations

• Why develop and use Medicaid Managed Care organizations rather than traditional HMOs? Use of National Association of Insurance Commissioners' (NAIC) standards, principles and annual statements Statutory accounting principles Actuarial principles

Developin& a feedback loop to the State Insurance Division

How Ore~:on's financial solvency reportin& requirements assess solvency

1) Assessing degree of risk - Identification of corporate identity - Identification of financial arrangements - Risk-sharing arrangements - Financial guarantees

2) Assessing restricted reserves 3) Assessing financial status

- The general framework -Examination of the managed health plan's structure - The layers of the onion: corporate vs. particular plan - Services provided - Geographic areas covered

Examination of the trends in managed health plan's financial indicators

Net income - Liquidity - Cash flow - Net worth Medical loss ratio-adjusted and unadjusted - ffiNR/Claims Jag analysis - Other

Examination of the trends in managed health plan's utilization/ membership indicators

Number of members not served - Thrnover - Use rates

Sandra Franck-Weiby Financial Solvency Reporting CoordiiUltor State of Oregon Office of Medical Assistance Program

• C II 1 800 868 71 88 ., R · Data Collection and Reporting

• ~------------------------------------a ___ -___ -____ -_____ ,o ___ e_g~•-s_te_r ______________ ~R~e~q~u~ire~m~e~n~ts~fo~r~M~e~di~~~id~M~a=n~a~goo~C~a~re~

[[ ON SCREEN BEFORE START]]

MEDICAID HEDIS ...

[[ put on screen and read to audience ]]

AT ONE TIME THE BELIEF WAS

YESTERYEAR:

WE HAVE NOT LOST FAITH, BUT WE HAVE TRANSFERRED IT

FROM GOD TO THE MEDICAL PROFESSION

GEORGE BERNARD SHAW

TODAY:

WE HAVE NOT LOST FAITH, BUT WE HAVE TRANSFERRED IT

FROM THE MEDICAL PROFESSION TO NCQA AND HEDIS

You all are welcome to guess who anonymous might be

1

ANONYMOUS

May appear a bit awkward at first because I have been wearing two hats, one as work group member and one as HMO representative. However, my position on the work group was as HMO representative and that will be the hat I wear today, more or less.

I was asked to offer my personal reflections and observations of the entire project and process of developing the draft XIX HEDIS document. Thus, as you have already seen, you may find my presen­tation sprinkled with such extemporaneous opinions.

I may have to alter my intended presentation a bit as we go along because the change in schedule late last week required that my presentation be reduced from about an hour to about 45 minutes.

Some topics may get short changed. I hope this does not inconven­ience you.

NCQA's original intention was to get XIX HEDIS Version 1.0 out by the end of 1995. However, on the last day of the year all I received was a pre press copy. The final copy was due out by the 2nd week of January, but as you are all aware, the weather was atrocious and so perhaps that has delayed printing and distribu­tion. As of today the most recent draft I have seen is the pre press draft which presumably none of you have and so any specific references will be back to the July 95 draft which was nationally distributed. I'll speak more about this at the end of my presen­tation.

Before we get to the heart of the matter, and since it may help guide some of my comments, could some of you call out the states you are from?

Do any of you know your State's current plans if any for imple­menting XIX HEDIS? This too would be helpful to know and discuss during any Q and A time that might be available.

[[ looking especially for MN, WI, MA, MI ]]

2

The next slide exhibits the discussion points I hope to cover this afternoon.

• WHO CREATED MEDICAID HEDIS?

• DID THE CONSENSUS STRATEGY WORK?

• IS THE CURRENT DRAFT USABLE?

• WHAT ARE SOME OF THE DRAFT'S STRENGTHS AND LIMITATIONS?

• HOW SHOULD MEDICAID HEDIS BE IMPLEMENTED?

• WHAT NEXT?

3

[[ next slide ]]

1. The Draft Medicaid HEDIS document was created by an NCQA invited heterogeneous group consisting of representatives from such institutions as:

U.S. government:

HCFA U.S. PUBLIC HEALTH SERVICE

Single State Agencies:

CA, MN, MA, NY, OR

HMOs:

THE WELLNESS PLAN, KAISER PERMANENTE, DC CHARTER HEALTH PLAN, BRONX HEALTH PLAN,

PRUDENTIAL HEALTH CARE, HIP OF NY, ARIZONA PHYSICIANS IPA, U.S. HEALTHCARE

advocacy groups:

CENTER FOR HEALTH POLICY AT GEORGE WASH UNIV, McMANUS HEALTH POLICY,

AMERICAN PUBLIC WELFARE ASSOCIATION

physician groups:

AMERICAN ACADEMY OF PEDIATRICS

of course, the grantee:

NATIONAL COMMITTEE FOR QUALITY ASSURANCE

and, mostly observed by the funding agency:

PACKARD FAMILY FOUNDATION

4

This array of independent participants was perhaps one of the strongest features of the project's development. We all came together because we wanted to develop a standardized performance measuring device. One that would reduce the ever growing number of RFis we get from state and federal governments.

This next slide may be the best way to describe what happened?

[[ Fly Cartoon ]]

[[ next slide ]]

• DID THE CONSENSUS STRATEGY WORK?

The stated ground rules for preparing the first draft were that it would be written as a consensus document (see page ix of the July 95 draft) and not one "yet" based on scientifically estab­lished measuring principles and objectively collected data. In fact, the draft discusses at length these limitations and many more in its own introduction section.

Consensus is kind of a funny word. it does not really mean com­promise. It does not mean majority rule. And, most importantly, it does not mean that a particular consensual decision is based on the best objective data and knowledge available. For the XIX HEDIS work group it sometimes meant that the most vocal or ener­getic champion of an issue carried the day. Sometimes political expediency ruled, e.g., women of an age requiring mammography in a XIX population are small in number and yet it was deemed not politically wise to exclude this measure --- Even though other measures with few if any sound benchmarks, were included only because they occurred most frequently.

[[ slide ]]

• IS THE CURRENT DRAFT USABLE?

[[ slide ]]

• FIRST DRAFT • NEEDS PILOT TESTING

• STATE READINESS TO USE THE DATA • READINESS FOR IMMEDIATE STATEWIDE IMPLEMENTATION

5

The July 6, 1995 cover letter that was included with the publica­tion of the draft document clearly states that the work group looks " ••• forward to the continuous improvement and refinement of this document."

The letter ends with the statement that "We hope it will become (stress added) a useful tool for performance measurement in Medicaid managed care."

Both the sponsors and the work group recognize that the tool is not yet ready for statewide use. even though some states have jumped the gun, including MI

2. The current publicly distributed July 95 Medicaid HEDIS docu­ment is only a first draft. It has been reviewed and obviously continues to be reviewed nationwide by representatives of all parties interested in the Medicaid program. The initial comments and requested changes resulting from this ongoing review were first assessed ~n October 1995 by the Work Group. This review did lead to some changes that had to be implemented by the NCQA staff. Since the work group did not see the pre publication December 28, 1995 draft before it went to the printers, it is difficult to discuss improvements that may or may not have made it into the final version.

What is certain is that

The final version 1. 0 should be somewhat different than the currently available July 95 draft. Attempts by states to use the July 95 draft as a working measuring tool are too premature and will likely lead to the expensive and time consuming necessity to redo much effort once the final tool is available.

3. Many of the document's own authors (obviously myself included) strongly feel that a scientifically rigorous pilot testing period is absolutely necessary before XIX HEDIS can be universally accepted as an appropriate means by which states can, in a reli­able and valid manner, measure the performance of the HMOs with which they contract.

4. Considering all the above, Michigan and some other states are moving much faster than is justified (or intended by the work group itself) in adopting the present and untested document.

Moreover,

ignoring all the above, one could argue ( AND MANY RESPONDENTS TO THE JULY VERSION DID) that the Work Group simply did not provide enough time to adequately review the document. (before the Octob­er 95 meeting)

6

HMOs have not been able to engage in a considered analysis and evaluation of the measures' impact on our protocols and practices nor is enough time granted to set up the data systems necessary to be responsive to it. Finally, and very importantly, neither the state nor we yet know what implementation of the document will ultimately cost. As will be discussed later in the hour, the cost of modifying our data systems and engaging in the extraordi­narily large numbers of chart reviews could be prohibitive.

(Remember, dollars spent on these activities are dollars not available for the provision of preventative, direct health and medical services to our patients.)

5. Even though The Wellness Plan, (whose current XIX membership is in excess of 136,000 ) amongst a number of similar HMOs across the nation, already assess performance of health delivery to Medicaid on many levels, we are simply not able to immediately comply with all the specifications in the draft document.

The process of implementing a final and scien-tifically proven Medicaid HEDIS measuring tool should be phased in.

Only the most meaningful measures for Medicaid should be initial­ly pilot tested and implemented over time. Then, as each meas­ure's usefulness is proven, others can be phased in. The current number, depth and breadth of measures is too complex to properly engage in at once.

It is interesting to note, noted it,

and some of you may have already

The report card pilot study of HEDIS 2.0 selected only a subset of HEDIS 2.0 measures to pilot. Not all the measures at once.

The report card study also strongly recommended that future measures I.E. XIX HEDIS be subjected to longer developmental periods with extensive testing prior to implementation.

6. Finally, states are not off the hook themselves.

States need to consider the demands the document places on them.

States will be required to provide HMOs with some of the neces­sary data to complete some of the measures. For example, is the state prepared to collect and provide HMOs with the "cultural diversity of the Medicaid Membership"? Its race composition, Hispanic origin and primary language diversity? (See pages 35-

7

37.) Will the state be able to appropriately aggregate data coming from smaller BMOs whose data cell sizes are too small to be independently statistically significant? (See pages 5 1 7-8 1

Appendices II and III). Will the state guarantee enough recipi­ents who are eligible for the required duration of many of the measures to make them meaningful?

[[ slide ]]

• WHAT ARE SOME OF THE DRAFT'S STRENGTHS AND LIMITATIONS?

[[ slide ]]

STRENGTHS:

• MANY RELEVANT PARTIES AT THE TABLE

we have already discussed this

• ATTEMPTS TO ADDRESS WIDE VARIETY OF FOCUSED CONCERNS

pretty much a function of those entities represented and the initial public comment

• ATTEMPTS AT CONSISTENCY WITH HEDIS 2.5/3.0

as you review the draft and/ or Version 1. 0 you should discover many similarities and indeed this was part of the work group's strategy

• MUCH COGNITIVE REFLECTION AND DELIBERATION ON EACH MEASURE

the process took more than 1 1/2 years and the work group met several times by phone conference and 9 times face to face

• NATIONWIDE INVITATION FOR ADDITIONAL COMMENT

self-explanatory

[[ Slide ]]

8

WEAKNESSES:

As a 382 page document (my pre publication copy), there are nu­merous specific areas that could be commented on. The following is a brief sampling of the more dominant issues.

This slide a bit out of order. We will look first at

• SOME MEASURES SELECTED BECAUSE OF FREQUENCY

Some of the performance measures appear to be included only because they are high frequency (occur many times) or high volume (occur across many patients) events amongst the Medicaid popula­tion. Their ability to evaluate the quali~y of services delivered remains unexplained and untested. These include tonsillectomies (with or without adenoidectomies), Myringotomies, and D and Cs, to mention a few.

• NOT ALL MEASURES ARE SCIENTIFICALLY ESTABLISHED • NOT BASED ON OBJECTIVELY COLLECTED DATA

The document cites the 3 state study on T and A and D and C which revealed that there was variation, but what the variation means is not really understood yet. Thus, at this point in time, this hardly constitutes measures of performance.

The literature is equivocal on the appropriate population rates (utilization) of many of the measures, especially for Medicaid specific populations. These include those already described and most importantly, number of prenatal care visits (see pages 172-17 5 of the July draft) • The numbers produced by the current document ' s measures cannot indicate whether there is over or under utilization of specific services. For example, how many D and Cs represent appropriate utilization? How many are too many? How many are too few? Both the literature and the current docu­ment are silent on this issue. This again speaks to the lack of "science" in the document as indicated in the general comments above.

(It is interesting to note that for prenatal care, the U.S. based literature appears to stress what activities take place during the prenatal care visit rather than the absolute number of vis­its.

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TWP • s own research on prenatal care, including the Bentley Demonstration Grant Project, indicates that it is the comprehen­siveness of services provided that impact on birth outcome rather than simply the raw number of visits to the Doctor.)

• RISK ADJUSTMENT MISSING

As with HEDIS 2.0/2.5 there is no risk adjustment for different population mixes

• OUTCOMES MEASURES MISSING

There are nor real outcomes measures, as with HEDIS 2.5. Hopeful­ly HEDIS 3.0 will begin to address this issue

• LIMITED ANALYSIS OF PRACTICALITY AND COST TO MEDICAID

In the attempt to be consistent with HEDIS 2.0/2.5, this document attempts to include some of the very same and understandably critical core measures. Unfortunately,

the Medicaid population is very different than the conunercial sector in terms of continuity of enrollment.

A case in point is childhood immunization. HEDIS 2.0/2.5 right­fully measures this activity. However, it specifies patients with continuous enrollment between 45 days and two years of age. Because of the instability of Medicaid enrollment, the July draft document specifies a continuous enrollment period of 10 months prior to the second birthday (page 144.)

According to Karen White, the Center for Disease Control liaison with GBAA, the minimum requirement for full immunization catch-up is at least 12 months. (Again, an example of the little science that was introduced into the July draft.

JUMPING AHEAD TO SOME LATE BREAKING NEWS

(The work group finally reached a different consensus in October and now thinks a 12 months period is better. This should be the specification in the PUBLICLY released Version 1.0)

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This imposes two herculean tasks on HMOs. There will be a target population of young children for whom the HMO has only had ten/12 months of membership contact. During this brief time period, the HMO is held responsible for 1. determining the immunization status of the child

MORE A PUBLIC HEALTH ISSUE (I.E. BEING RESPONSIBLE FOR HEALTH STATUS RATHER THAN CARE DELIVERY)

and 2. "catching up" on any immunization deficits. It is under­stood that the narrow window of opportunity provided was an attempt to recognize the instability in Medicaid eligibility. However, it makes it extraordinarily difficult for HMOs to comply with the specifications within the allotted time period. Truly a "catch 22" situation, given the present state of immunization records.

• MANY MEASURES CURRENTLY REQUIRE EXTENSIVE CHART REVIEWS

There are at least a dozen measures unavailable in current admin­istrative data sets. These therefore require extensive chart reviews to complete. The draft document indicates a sample size of at least 384 charts per measure (see pages 273-275.) Using the conservative estimate of one dozen samples, this results in at least 4,608 chart reviews per year. Using a very liberal estimate of 1 FTE per 2,000 chart reviews, a minimum of 2.25 FTEs will have to be added to an HMO's staff in order to fully complete the Medicaid report (this estimate assumes that one person can reli­ably review close to ten charts per day. ) When added to HEDIS 2. 0/2.5, a staff of approximately 5 people could be necessary just to complete HEDIS related chart reviews.

Since some administrative data sets are incomplete, the hybrid approach will have to be used on those measures as well, adding to the overall chart review burden.

Furthermore, both HEDIS documents (commercial and Medicaid) recommend the addition of a statistician to insure appropriate sampling and data collection (see page 275 of the Medicaid docu­ment.) Will the state alter capitation rates to fund these new positions? Or, otherwise, will the state assist in the develop­ment of sophisticated data systems that will permit administra­tive data set analyses?

MORE

Some measures are not directly related to Medicaid populations,

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others are not covered benefits and still others are potential candidates for unbundling in at least Michigan. Examples include:

Mammography

(the Medicaid population by and large is too young for this to be a meaningful screening measure - again an example of a consensus and politically correct based inclusion of a measure rather than of scientifically based relevance, its optional status not with­standing);

Dentistry (not covered in all states, Michigan included); and

Mental Health (current legislative proposals in Michigan intend to unbundle or carve out this HMO benefit).

The document requires such confidential information as provider specific compensation (see pages 244-245). Payments to intermedi­ary organizations (such as hospitals, PHOs and other networks) are not sufficient. I am not sure that HMOs will be willing to reveal such information when it is available. Mor~over, because of the complex relationships HMOs have with health systems, it will not likely be possible to whittle down the compensation data to all specific providers. (E.g., what is the compensation pro­vided to DMC radiologists for reading TWP Medicaid x-rays?)

As a relief from all this documentation activity, you may enjoy reviewing the following.

[[ Cartoon slide here ]]

[[ one slide back ]]

Out of plan providers, such as health fairs, mall screenings, health depts ect. are not required to report their services to HMOs. E.g., Some health depts do not provide their immunization records to us.

• SMALL USER FRIENDLY

Many of the measures were developed in consideration of the fact that about half the HMOs with Medicaid contracts have fewer than 6,000 Medicaid members and only eight plans (3%) have more than 100,000 members (see page 8 of the document.) Clearly, and as stated throughout the document, many of the measures were de­signed to accommodate this distribution. Little attention was

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paid to the degree of effort and cost that would be required of the larger HMOs. This is doubly worrisome as most expert predic­tions indicate that over the next few years, financing and states' own predilections will lead to large populations of recipients in fewer HMOs. The document and its intended audience would have been better served had the Work Group focused its measures development on HMOs with large numbers of Medicaid members rather than on those who temporarily have smaller numbers.

Finally, the document was funded by a private initiative of the Packard Foundation and developed under the auspices of the pri­vately held NCQA. Thus, the entire project was not accountable to any relevant regulatory body (such as HCFA) or nationally rec­ognized institute of health care or medical research (such as NIH or university based Medical Centers).

[[ Slide ]]

I think we have covered most of what is on this slide

• HOW SHOULD MEDICAID HEDIS BE IMPLEMENTED?

DRAFT FAIRLY SILENT ON THIS ISSUE but a work group meeting this past Monday was to discuss this issue. Perhaps some reasonable strategies will emerge that will slow some states down a bit

• SCIENTIFICALLY RIGOROUS PILOT TESTING

• TESTING OF MEASURES' USEFULNESS

• PHASED IMPLEMENTATION

[[ slide ]]

• WHAT NEXT?

• ADDITIONAL FUNDING NEEDED FOR PILOTS

• MEDICAID HEDIS USERS GROUP SHOULD BE FORMED

• VERSION 2 TEAM SHOULD BE FORMED

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[[ Slide ]]

LATE BREAKING NEWS •••

As already indicated, on Monday 22nd, the work group did meet once more in DC to receive pre public release copies. I was not there because I was in route here. Apparently, there was some discussion on

implementation strategies

support for XIX HEDIS through the current HEDIS 2.5 users group rather than a specific XIX HEDIS USERS GROUP

NCQA to provide TA to states

individual NCQA/State projects (MI participates, as does specifi­cally The Wellness Plan) were discussed

and general discussion of developing the next version of XIX HEDIS.

Moreover, I am advised that Version 1. 0 will not be publicly released until after NCQA and HCFA have been able to schedule a press conference. Current thinking is that this will occur in very early February.

[[ ONLY IF TIME ]]

Some folks have been asking me

WHAT CAN YOU DO?

Lobby to slow process down

give HMOs additional time to react

Add science and piloting

allow for phased in approach so that efficient response systems can be put into place

let states know that they have responsibilities also

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