validation of performance measures for pmhps

Validation of Performance Measures Validation of Performance Measures for PMHPsfor PMHPs

Presenter:

Peggy Ketterer, RN, BSN, CHCAExecutive Director, EQRO Services

Health Services Advisory Group

January 17, 2008

10:00 a.m.–12:00 p.m.

Balanced Budget Act (BBA) of 1997

Balanced Budget Act (BBA) of 1997

42CFR438.240

States must require each managed care organization (MCO) and pre-paid inpatient health plan (PIHP) to annually measure and report performance to the state using standardized measures.

Balanced Budget Act (BBA) of 1997 (cont)

42CFR438.356

The BBA also requires that states contract with an EQRO for an annual independent review of each MCO and PIHP to evaluate the quality and timeliness of, and access to, health care services provided to Medicaid enrollees.

Balanced Budget Act (BBA) of 1997

42CFR438.358

States must ensure that the performance measures are validated annually through the external quality review process.

Performance Measures

Performance Measure Characteristics:

• Standardized

• Clearly defined

• Meaningful and timely

• Results in comparable data

Performance Measures

Key Roles:

• States identify measures and data submission format

• MCOs and PIHPs collect, calculate, and submit performance measure data to the State using required submission format

• Performance measures are validated annually by the EQRO following required CMS protocols

Calculation and Reporting of Performance Measures

Performance Measure Calculation:

A Brief Overview

Step 1: Identify necessary data sources and data elements for reporting the selected measures

• Membership/enrollment data

• Claims/encounter data

• Other administrative data (if available), i.e., inpatient utilization reports, kept appointment database

Calculation and Reporting of Performance Measures

Step 2: Prepare data set

• Extract data

• Clean data (valid variables, formats)

• Verify completeness and accuracy

• Establish data element to link data sources (unique member ID)

Calculation and Reporting of Performance Measures

Step 3: Produce source code to calculate measures

• Calculate continuous enrollment and anchor date

• Determine member age• Include diagnosis and procedure codes needed

to identify service events• Exclusion logic

Calculation and Reporting of Performance Measures

Step 4: Calculate measures administratively

• Run source code

• Examine output files

• Review preliminary administrative results

Calculation and Reporting of Performance Measures

Step 5: Validate results

• Review calculated rates for reasonability

• Examine data output file and verify with source data (membership and encounter data)

Calculation and Reporting of Performance Measures

Step 9: Submit Performance Measure reports to the state

• Utilize state-specified format

Calculation and Reporting of Performance Measures (cont)

• Written Description

• Calculation (the percentage of X who had Y)

• Eligible Population Criteria

• Numerator Event Criteria

• Exclusion Criteria

• Reporting Format

Diagram of a Performance Measure

The percent of enrollees who were hospitalized for a mental health diagnosis and were discharged to the community from an acute care facility and were seen on an outpatient basis by a mental health practitioner and/or case manager within seven days.

Written Description

Three calculations will be generated:

•The percentage of enrollees who had a follow-up visit with a mental health practitioner

•The percentage of enrollees who had a follow-up visit with a mental health practitioner and/or case manager

•The percentage of enrollees who had a follow-up visit with a case manager

Calculation

Specifies any age, continuous enrollment (CE), and event/diagnosis requirements•Age: no requirement – all enrollees•CE: Date of discharge through 7 days after discharge•Event/diagnosis: Discharged to the community from an acute care facility (inpatient or crisis stabilization unit) with specific diagnosis codes indicating a mental health disorder

Eligible Population Criteria

Specifies any exclusions

•Enrollees who died

•Enrollees who were re-admitted within 7 days of discharge

•Enrollees whose discharges were followed by readmission or direct transfer

Exclusion Criteria

Specifies any exclusions (cont’d)

•Enrollees who receive Florida Assertive Community Treatment services

•Enrollees who are admitted to hospice, nursing facilities, state mental health facilities, correctional institutions or hospice programs

Exclusion Criteria

An outpatient follow-up encounter with a mental health practitioner up to seven days after hospital discharge

•Mental health practitioner definitions are specified

•Service codes for follow-up encounter are specified

Numerator Event Criteria

•Identifies the data elements necessary for reporting (i.e. eligible population, numerator events, rate)

•Includes a grid for entering data elements

Reporting Format

Three Main Phases:

•Pre-On-Site

•On-Site

•Post-On-Site

Validation Activities

Validation Activities

Pre-On-Site Activities:

• Identify measures to be validated

• Prepare Information System Capabilities Assessment Tool (ISCAT) request

• Schedule site visits and prepare agendas

Validation Activities

Pre-On-Site Activities (cont):

• Receive completed ISCATs from PMHPs

• Review ISCATs to assess information system integrity and capabilities

• Conduct pre-on-site conference call with each PMHP

Validation Activities

On-Site Activities (for each PMHP):

• Duration – approximately 2 days

• Conduct opening meeting

• Complete on-site activities – including systems walkthroughs, demonstrations, and measure specific review

• Conduct exit conference

Validation Activities

Post-On-Site Activities:

• Evaluate corrective actions and follow-up items

• Determine validation findings for each performance measure

• Prepare draft report – submit to AHCA and PMHPs for comments

• Prepare final report

Validation ActivitiesProposed Timeline

Task Jan 2008

Feb 2008

Mar 2008

Apr 2008

May 2008

Jun 2008

Jul 2008

Aug 2008

Validation Performance

Measures

for PMHPs

05/19/08 – 05/30/08

Conduct Onsite Visits

04/11/08Receive PMHP documentation

03/10/08

Request ISCAT Documentation

06/09/08 – 07/11/08

Prepare Report

Questions and Answers

Open Discussion