Transcript Title

Plugging the Gaps in
Quality Reporting
Patricia MacTaggart, GWU
ACAP July 15 at 11:15 a.m.
Quality & Financial Costs Due
to Gaps In Insurance Coverage
• Interruptions in Medicaid Coverage:
increases in hospitalizations for
ambulatory sensitive conditions
• Women with continuous Medicaid
enrollment: more likely to be
screened for breast cancer
• Those with continuous coverage:
less likely to be hospitalized in an
inpatient psychiatric facility and
have lower overall psychiatric care
costs
Current Medicaid Quality Federal
Requirements
Managed Care Organizations:
• Pre-contract: MCOs have sufficient
provider capacity to serve the
expected enrollment
• Ongoing:
– Quality monitoring & improvement
processes mandated
– Development and Implementation of
Quality Assessment and Improvement
Strategy (QAPI) that addresses
timely access, quality of care and
quality of care delivery,
– Annual external independent
review of the quality outcomes and
timeliness of, and access to, services
Primary Care Case
Management (PCCM) &
fee-for-service
arrangements:
• No comparable quality
monitoring or improvement
requirements
• CAHPS:
experience
survey for past
6 months
Current Approaches to
Quality Monitoring in
Medicaid MCOs
• HEDIS:
performance
measures
• HEDIS-Like:
same
numerator and
denominator
specifications
as a HEDIS
measure but
exclude the
continuous
enrollment
requirement
Reproduced from NCQA, State Recognition of NCQA,
http://www.ncqa.org/tabid/135/Default.aspx
Quality Monitoring
PCCMs & FFS
• CMS: reinitiated a Medicaid modernization
and quality measurement analysis project,
which is being undertaken by NCQA
• Oklahoma and North Carolina: developed
quality measurement approaches for their
PCCM programs, including the use of
HEDIS measures.
MCO vs FFS Feasibility: The
New York State Experience
Comparison Between Medicaid Managed Care and Medicaid Feefor-Service Administrative Measures
Measure
MCO Rate
FFS Rate
Well-child and preventive health visits age 15
months
55%
62%
Well-child and preventive health visits age 3-6 years
77%
71%
Adolescent well care and preventive care visit
64%
47%
Prenatal care in the first trimester
63%
59%
Use of appropriate medications for persons with
asthma (Total)
60%
55%
Ages 5-17
53%
51%
Ages 18-56
62%
60%
Reproduced from Roohan, et al. 2006.
Medicaid Continuous Quality Act Proposal:
HHS Within 2 Years
• Develop System and Process to be used by States to Report
on Quality of Care: Managed Care Organizations, PCCM or
Fee-For-Service Providers
• Comparisons of Quality Measurements:
– Across Systems Nationally or by State
– Head-to-head Comparison: Across MCOs, PCCM, and FFS
• Feasible with Comparable Measures
• Consult Advisory Group in Developing System:
– State Agency Officials,
– Health Care Providers and Consumers,
– National Organizations with Expertise in Health Care Quality
and Performance Measurement and Public Reporting,
– Voluntary Consensus Standard-Setting Organizations and Other
Organizations involved in the Advancement of Evidence-Based
Measures of Health Care.
Medicaid Continuous Quality Act
Proposal: Within 2 Years HHS
• Measures: Reviewed & Approved by National Quality Forum
• Timeline: Initial reporting within Two Years of Enactment
• Measures include:
– Duration of Health Insurance Coverage over 12-Month Time
Period,
– Preventive Services Availability and Effectiveness
– Acute Conditions Treatments and Follow-up Care
– Chronic Physical & Behavioral Health Treatment and
Management
– Availability of Care in Ambulatory and Inpatient
– Other Measures Relevant to Measuring Quality of Health Care
for Medicaid Enrollees to allow for Comparability across Health
Care Delivery Approaches.
Future Case Rate Payments
Dependent on Addressing Quality
• Acute-Care Global Case Rate: admitting
hospital would get payment for initial stay and
any additional hospital admissions that occur
within 30 days
• Acute-Care Global Case Rate, including
Post-Acute Care: hospital care plus post-acute
care
• Acute-Care Global Case Rate, including
Post-Acute, Physician-Treated Inpatient
and ER Care:
Opportunities through Children’s Health
Insurance Program Reauthorization Act of
2009 (CHIPRA), H.R. 2
• Expanding Eligibility: Streamline enrollment/retention:
Express Lane Eligibility and Outreach
• Expanding Coverage: wrap around dental coverage
• Payment: study on provider payments
• Improving Quality:
– Develop and implement evidence-based quality measures for
children: Core set of measures through AHRQ/CMS effort
– Encourage development and dissemination of model children’s ehealth record
– Demonstrated program to reduce child obesity
Opportunities Through ARRA
Incentives for Medicaid Providers
• Providers:
– Non-hospital based professionals:
• At least 30 percent patient volume Medicaid patients
• Physicians, dentists, certified nurse mid-wives, nurse practitioners & certain
physician assistants
– Non-hospital based pediatricians: at least 20 percent patient volume Medicaid
– Children’s Hospitals
– Acute-care hospital: at least 10 percent patient volume Medicaid patients
– Federally Qualified Health Center or Rural Health Clinic : at least 30 percent of
patient volume needy individuals
• Payments:
– “Meaningful Use”:
• Established by State & Acceptable to the Secretary
• Aligned with Medicare & including Support Services
• Exchanges information across different health care providers
• Reporting quality measures
ARRA for Medicaid State Responsibilities
• States must use the funds for purposes of administering the incentive
payments, including tracking of meaningful use by Medicaid providers;
– Based on Medicaid Management Information System (MMIS) and MITA
framework capable to pay the incentive payments. (APD)
• States must conduct adequate oversight, including routine tracking of
meaningful use attestations and reporting mechanisms; which will
require look behinds
– Human and IT resources for look behind capability
• States must “pursue initiatives to encourage the adoption of certified
EHR technology to promote health care quality and the exchange of
health care information under this title, subject to applicable laws and
regulations governing such exchange”
– Need to address information exchanges with other state agencies within
their state, with other public and private entities within their states, with
other states and entities in other states and with ONC .
– Following the MITA framework, states need to establish a baseline (“as
is”), a vision of where they are going (“to be”), and roadmap to go from
the “as is” to the “to be” vision.
Questions/Comments