Plugging the Gaps in Quality Reporting

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Plugging the Gaps in Quality Reporting
Patricia MacTaggart, GWU
ACAP July 15 at 1115 a.m.
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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

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Current Medicaid Quality Federal Requirements

• Primary Care Case Management (PCCM)
  fee-for-service arrangements
• No comparable quality monitoring or improvement
  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

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Current Approaches to Quality Monitoring in
Medicaid MCOs

• CAHPS experience survey for past 6 months
• 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
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Quality MonitoringPCCMs 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.

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MCO vs FFS Feasibility The New York State
Experience
Comparison Between Medicaid Managed Care and
Medicaid Fee-for-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.
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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.

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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.

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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

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Opportunities through Childrens 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
  childrens e-health record
• Demonstrated program to reduce child obesity

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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
• Childrens 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

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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.

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Questions/Comments