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Physical Health

PERFORMANCE MEASUREMENT PROGRAM AND PERFORMANCE

IMPROVEMENT PROJECTS AUDIT

July 1, 2011 – June 30, 2012

Final Report July 19, 2013

Prepared for the New Mexico Human Services Department under PSC 12-630-8000-0017

By HealthInsight New Mexico External Quality Review (EQR) staff:

Debi Peterman, RN, MSN, Project Manager Allen Buice, MA, PMP, CPHQ, Project Manager

Greg Lujan, LISW, Project Manager Denise Anderson, MAOM, CQPA, Analyst

Margaret White, RN, BSN, MSHA, EQR Director Herb Koffler, MD, EQR Medical Director

Eric Martinez, Senior Communications Specialist Boyd Kleefisch, Executive Director

5801 Osuna NE, Suite 200 Albuquerque, NM 87109

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Physical Health Performance Measurement and Performance Improvement Projects July 19, 2013

Table of Contents Executive Summary .................................................................................................................... 2

Background ................................................................................................................................. 3

Audit Tool/Audit Tool Guide ........................................................................................................ 5

Audit Overview ............................................................................................................................ 5

Scoring Method ........................................................................................................................... 6

Salud! PMP Audit Results ........................................................................................................... 9

SCI PMP Audit Results ............................................................................................................... 9

Salud! PIP Audit Results ........................................................................................................... 10

SCI PIP Audit Results ............................................................................................................... 12

Process and Outcome Measures .............................................................................................. 13

ISCA Audit Results ................................................................................................................... 14

Conclusion and Recommendations ........................................................................................... 15

Rebuttal and Reconsideration ................................................................................................... 16

Section A: Blue Cross and Blue Shield of New Mexico (BCBS) ................................................ 17

Section B: Lovelace Community Health Plan (Lovelace) ........................................................... 23

Section C: Molina Healthcare of New Mexico (Molina) .............................................................. 34

Section D: Presbyterian Health Plan (Presbyterian) .................................................................. 43

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Executive Summary This report details the findings of the external quality review of the New Mexico Medicaid Salud! (Salud!) and the State Coverage Insurance (SCI) managed care organizations’ (MCOs’) compliance with state regulations and standards and contractual obligations for the State Fiscal Year (SFY) 2012 (July 1, 2011 through June 30, 2012).

HealthInsight New Mexico planned and implemented an audit to evaluate the MCOs’ performance in accordance with New Mexico Human Services Department/Medical Assistance Division (HSD/MAD) Letter of Direction (LOD) 13-06. The audit addressed Performance Measures (PMs) and Performance Improvement Projects (PIPs) for Blue Cross and Blue Shield of New Mexico’s (BCBS) Salud! program. Lovelace Community Health Plan (Lovelace), Molina Healthcare of New Mexico (Molina) and Presbyterian Health Plan (Presbyterian) had PMs and PIPs examined for both their Salud! and their SCI programs.

The audit included a comprehensive desk review of the MCO reports, interventions, internal quality review materials and other documentation. An Information Systems Capability Assessment (ISCA) was also performed as a part of this audit. Table 1 shows the overall scores and compliance designations for SFY 2012. Complete findings and detailed scores are included in the section prepared for each MCO following this report. Table 1. PMP1 Audit Results Summary

Medicaid Salud! Demonstrated Compliance Levels

PMP Compliance

PIP #1 Compliance

PIP #2 Compliance

Blue Cross and Blue Shield of New Mexico (BCBS) Full Full Full

Lovelace Health Plan (Lovelace) Full Full Moderate

Molina Healthcare of New Mexico (Molina) Full Full Full

Presbyterian Health Plan (Presbyterian) Full Full Full

State Coverage Insurance Demonstrated Compliance Levels

PMP Compliance

PIP #1 Compliance

PIP #2 Compliance

Lovelace Full Full Moderate

Molina Full Full Full

Presbyterian Full Moderate Full

Summary of Findings

BCBS Salud! achieved Full Compliance for the PMP and for both of the PIPs.

Lovelace Salud! achieved Full Compliance for the PMP. One of the PIPs achieved Full Compliance and the other achieved Moderate Compliance.

Lovelace SCI achieved Full Compliance for the PMP. One of the PIPs achieved Full Compliance and the other achieved Moderate Compliance.

Molina Salud! achieved Full Compliance for the PMP and for both of the PIPs.

Molina SCI achieved Full Compliance for the PMP and for both of the PIPs.

Presbyterian Salud! achieved Full Compliance for the PMP and for both of the PIPs.

Presbyterian SCI achieved Full Compliance for the PMP. One of the PIPs achieved Full Compliance and the other achieved Moderate Compliance.

1 In this report, PMP refers to the overall performance measurement program, while PM refers only to

individual performance measures within the PMP.

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Background The Centers for Medicare & Medicaid Services (CMS) and the Balanced Budget Act (BBA) requires each state to promote quality services for its enrollees and to subject all MCOs rendering services to Medicaid consumers to an external quality review. HealthInsight New Mexico is contracted with HSD/MAD to serve as its External Quality Review Organization (EQRO) to audit contracted MCOs for adherence to federal and state regulations and contractual obligations based on CMS-published protocols. HSD/MAD published the State of New Mexico Quality Assessment and Performance Improvement Strategy for Medicaid Services in May 2009. In the report HSD/MAD outlines the strategy for Medicaid MCOs in New Mexico to exceed standards for access to care, clinical quality of care and quality of service. The MCO must perform continuous quality improvement (CQI) functions that recognize opportunities for improvement, and CQI projects must include the following elements, based on CMS protocols:

Be performed using objective quality indicators

Be data driven

Employ continuous measurement

Implement programmatic improvements with remeasurement of effectiveness As required in 42 CFR 438.240, PIPs must include the following components:

Measurement of performance using objective quality indicators

Implementation of system interventions to achieve improvement

Evaluation of the effectiveness of the interventions

Planning and initiation of activities for increasing or sustaining improvement

Purpose The purpose of this audit was to evaluate the four contracted MCOs’ adherence to applicable Salud! and SCI New Mexico Administrative Code (NMAC) regulations. The objectives of the audit were to:

Measure and score the MCOs’ performance against state-mandated quality standards

Review the MCOs’ structures and processes

Evaluate whether or not each MCO is following its own established policies and procedures

Compare and analyze audit findings

Identify opportunities for improvement in both systems and processes

Make recommendations

Audit Approach The audit approach and methodology were designed to align the audit process with the MCO’s specifications in the contractual requirements and LOD # 13-06 from HSD/MAD to HealthInsight New Mexico. Appropriate data collection and data analysis procedures, consistent with industry standards, were utilized to provide audit assurance and to identify areas requiring further investigation. The methodologies were developed using NMAC and CMS protocols for assessing performance. The final methodology consisted of the following sections:

Rationale (understanding of the regulations and LOD specifications)

Evidence required (documentation)

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Interpretive guidelines

Data collection tools

Scoring criteria The first deliverable included the review of MCO policies, procedures and operations related to their comprehensive PMP. Nine PMs were selected by HSD/MAD for review in this audit. Some of the PMs have sub-measures, which brought the total numbers of measures and sub-measures reviewed to 18:

PM #1 Annual Dental Visit (combined rate) o Number of people age 2-21 years with dental visits

PM #2 Well Child Visits o Number of babies from birth through 15 months with at least six well child visits

with a primary care provider (PCP) o Number of children age 3-6 years with at least one well child visit with PCP

PM #3 Children and Adolescent Access to Primary Care Providers o Number of babies age 12-24 months who had a visit with a PCP o Number of children age 25 months through 6 years who had a visit with a PCP o Number of children age 7-11 years who had a visit with a PCP during

measurement year or the year prior o Number of adolescents age 12-19 years who had a visit with a PCP during

measurement year or the year prior

PM #4 Childhood Immunizations (Combo 2) o Number of children age 2 years who have received Combo 2 immunizations

PM #5 Use of Appropriate Medications for People with Asthma o Number of children age 5-11 years identified with chronic asthma and placed on

appropriate medications

PM #6 Breast Cancer Screening o Number of women ages 40-69 years who had a mammogram to screen for

breast cancer

PM #7 Comprehensive Diabetes Care (ages 18-75) o Number of members who received a Hemoglobin A1c (HbA1c) test o Number of members with HbA1c in poor control (>9%) o Number of members who received a retinal eye exam o Number of members who received a LDL-C screening o Numbers of members who received medical attention for nephropathy

PM #8 Timeliness of Prenatal and Postpartum Care o Number of members who received a prenatal care visit in first trimester or within

42 days of enrollment o Number of members who received a postpartum visit on or between 21-56 days

after delivery

PM #9 Frequency of Ongoing Prenatal Care o Number of members who received greater than 81 percent of expected prenatal

visits The process assessment included a review of targeted quality-related interventions for each individual measure. All of the PMs selected were HEDIS®2 defined.

2HEDIS is the abbreviation for the Healthcare Effectiveness Data and Information Set and is a registered trademark

of the National Committee for Quality Assurance (NCQA).

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The second deliverable was the review of the quality improvement processes associated with two internal, clinically related PIPs. The PIPs were selected by the individual MCO to demonstrate the effectiveness of the performance improvement processes established within the MCO. The objective of the audit was to evaluate all processes related to the CQI system of tracking, intervention and reevaluation and to assign scores accordingly.

Audit Tool/Audit Tool Guide The audit tools were developed based upon LOD #13-06 and the September 2012 edition of the CMS EQR Protocols 2 and 3. The audit tools were developed to address the regulatory requirements specific to each PM and PIP. The tools were tested prior to implementation to increase accuracy, ease of use and consistency. HealthInsight New Mexico auditors reviewed the tools in advance to facilitate familiarity with the tools prior to application and scoring. The tools were revised in response to the recommendations made during testing. HSD/MAD approved the audit tools prior to HealthInsight New Mexico requesting documentation from the MCOs for the audit. The PM program tool was developed from CMS EQR Protocol 2. The tool was divided into two sections. The first section assessed the MCO’s data tracking process, such as how the numerator and denominator are determined, how the data are collected, and how the reports are analyzed. The second section addressed the MCO’s CQI program requirements, such as how interventions are formulated, how barriers are identified, and how success is measured. The PIP tool was developed based on the CMS EQR Protocol 3. This tool assesses each project by completing the following 10 steps:

1. Review the selected study topic 2. Review the selected study question 3. Review the study indicators 4. Review the identified study population 5. Review sampling methods 6. Review data collection procedures 7. Assess improvement strategies 8. Review data analysis and interpretation of study results 9. Assess whether improvement is “real” improvement

10. Assess sustained improvement

Audit Overview An overview meeting was held on March 8, 2013, at the HealthInsight New Mexico offices. Representatives from HSD/MAD and each MCO were present. The audit timeline and data requests were sent to each MCO prior to the meeting so that they could be reviewed in advance. During this meeting time was allowed for questions and answers. The MCOs were given the following documents:

Audit timeline

Scoring criteria for both PMs and PIPs

Document request for desk review items

Data submission roadmaps

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Scoring Method This section describes the PM and PIP numerical system used for scoring the standards within each category and for calculating an overall score for performance.

PM Scoring Method In assessing performance, the following indicators related to CQI functions were reviewed:

Assessment of methods for conducting the PMP for:

o Identification of systematic processes to extrapolate claims data o Establishment of accurate calculation methods including definition of numerators

and denominators o Review and analysis of required reports

Evaluation of quality documents that demonstrate the CQI process for:

o Identification of strengths, weaknesses and potential barriers to improvement o Development and implementation of interventions o Periodic reassessment to determine level of success for interventions

PIP Scoring Method In assessing PIP performance, the following areas were reviewed:

Assessment of methods for conducting their PIPs

Verification of the data processes to confirm that the reported results are based on accurate source information

Assessment of consistent application of the CQI functions when developing targeted interventions designed to improve performance rates

Evaluation of quality documents that demonstrate the CQI process in relation to identifying opportunities for improvement; targeting appropriate populations; reviewing measurement methods, data analysis, and demonstrated implementation; and assessing reevaluation outcomes

PIPs must:

Use objective quality indicators

Implement system intervention to achieve results

Evaluate the effectiveness of interventions in creating sustained improvement

Be repeatedly measured over time

ISCA Method This portion of the evaluation included a complete review of the ISCA tool completed by each MCO as well as supporting documentation submitted. The ISCA was developed using CMS EQR Protocol Appendix V: Information System Capabilities Assessment, Sept. 2012.

Information Systems Each MCO’s systems development cycle and supporting environments were assessed using a detailed review of data processing policies and procedures, evidence of database management systems (DBMS), programming languages, and training for programmers.

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Staff Access Designation Physical access by staff to information technology (IT) equipment as well as electronic records was evaluated by reviewing the IT organizational chart and responses provided in the ISCA questionnaire. Specific training requirements for programmers and new staff were reviewed using the ISCA tool.

Integrity of Security System integrity to prevent data loss and corruption was evaluated by reviewing each MCO’s disaster policies and procedures.

Data Acquisition Capabilities This portion of the evaluation included a detailed review of accurate submission of information, process for description discrepancies when verifying accuracy of submitted claims, and data assessment and retention. Additionally, claims processing and encounter data processes were reviewed.

Enrollment Systems The Medicaid enrollment systems for enrollment/disenrollment processes, tracking claims and encounter data, Medicaid enrollment data updates, Medicaid enrollment code, and data verification were reviewed. The response was evaluated in accordance with the ISCA scoring tool.

Ancillary Systems This section pertains to recording information on stand-alone systems, or benefits provided through subcontracts, such as pharmacy. Each MCO’s ancillary systems were reviewed for vendor data and information.

Integration and Control of Data Procedures for consolidating claims, encounters and consumer and provider data were reviewed. A flowchart outlining the structure of the management information systems and data integration was assessed. This review included accuracy of Medicaid claims reports.

Vendor Data Integration This portion of the review examined the number of contracted vendors. A review of how each MCO integrates vendor data with administrative data was assessed for completeness and quality of data.

Performance Measure Repository The structure of the performance measure repository was assessed to determine system characteristics and processes used to collect and analyze performance measure data.

MCO Report Production The MCO’s ability to generate accurate and reliable reports that conform to HSD/MAD requirements was assessed. This included Medicaid report generation, program revisions, claim encounters, and provider data.

Provider Database A review of mechanisms the MCO incorporates to maintain its provider directory was examined as well as a review of the fee schedules and contractual payments updates.

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Requested IS/IT Documents IS/IT documents were inventoried for accuracy and completeness. The following documents were requested and reviewed:

Data integration flow chart

Program query language for performance measures

Continuous enrollment source code

Medicaid member months source code

Medicaid claims edits

Statistics on Medicaid claims and encounters

Notice of privacy practices

Disaster recovery plan Calculation of Final Overall Score Each measure was assigned a number of points. The number of points earned by the MCO was divided by the number of available points to arrive at a percentage score. This score translated into one of the demonstrated compliance levels identified in Table 2 below. MCO-specific and maximum available scores can be found on Table 3 on page 10. The ISCA, as directed by HSD/MAD, was not given a separate score in this audit. Table 2. Demonstrated Compliance Level Scale

Demonstrated Compliance Level

Score Description

Full Compliance 90-100% Met or exceeded standard

Moderate Compliance 80-89% Met most requirements of the standard but has deficiencies in certain areas

Minimal Compliance 50-79% Met some requirements of the standard but has significant deficiencies requiring corrective action

Noncompliance <50% Did not meet standard and requires corrective action

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Salud! PMP Audit Results Each MCO was evaluated for its ability to collect accurate data, evidence of CQI process implementation, and demonstration of improvement in processes and outcomes for the Salud! program. All four MCOs earned Full Compliance levels. Table 3 reflects scores and demonstrated compliance levels of each MCO’s Salud! PMP. Table 3. Salud! PMP Audit Results

Salud! PMP Audit BCBS Lovelace Molina Presbyterian

Data Tracking Process

HEDIS Interactive Data Submission System 4 4 4 4

HEDIS Compliance Audit 5 5 5 5

CQI Program

Annual Preventive Dental Visits (ages 2-21 years) 13 13 13 13

Well Child Visits (first 15 months; 3-6 years) 13 13 13 13

Children and Adolescents' Access to PCPs 13 13 13 13

Childhood Immunizations (Combo 2) 13 13 13 10

Use of Appropriate Medications for People with Asthma (ages 5-11)

13 13 13 13

Breast Cancer Screening 13 13 13 13

Diabetes Disease Management (HbA1c Testing) 13 13 13 12

Timeliness of Prenatal and Postpartum Care 13 13 13 13

Frequency of Ongoing Prenatal Care 13 13 13 13

Total Points Available 126 126 126 126

Total Points Scored 126 126 126 122

Final Percentage Score 100% 100% 100% 97%

Demonstrated Compliance Level Full Full Full Full

SCI PMP Audit Results As with the Salud! program, each MCO was evaluated for its ability to collect accurate data, evidence of CQI process implementation, and demonstration of improvement in processes and outcomes for the SCI program. As discussed earlier, BCBS did not administrate the SCI program.

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Two MCOs earned Full Compliance levels and one MCO earned a Moderate Compliance level. Table 4 below reflects scores and demonstrated compliance levels of each MCO’s SCI PMP. Table 4. SCI PMP Audit Scores

SCI PMP Audit Lovelace Molina Presbyterian

CQI Program

Breast Cancer Screening 10 13 13

Diabetes Disease Management (HbA1c Testing) 10 13 13

Timeliness of Prenatal and Postpartum Care 13 13 13

Frequency of Ongoing Prenatal Care 10 13 13

Total Points Available 52 52 52

Total Points Scored 43 52 52

Final Percentage Score 83% 100% 100%

Demonstrated Compliance Level Moderate Full Full

Salud! PIP Audit Results Each MCO submitted 2 PIPs for this audit as follows: Blue Cross and Blue Shield PIPs

1. Childhood Immunization Status 2. Breast Cancer Screening

Lovelace PIPs 1. Use of Appropriate Medications for People with Asthma 2. Utilizing Synagis in Improving Health and Reducing Hospitalizations in RSV3 Vulnerable

Infants and Children

Molina PIPs 1. Annual Dental Visits 2. Breast Cancer Screening

Presbyterian PIPs 1. Breast Cancer Screening 2. Comprehensive Diabetes Care (HbA1c Testing)

Each PIP was evaluated and scored for CQI processes, performance rates, and demonstrated improvement. For PIP #1, all four MCOs earned Full Compliance levels. For PIP #2, three MCOs earned Full Compliance levels and one MCO earned a Moderate Compliance level. The resulting scores for each PIP are given in Tables 5 and 6 that follow.

3 Respiratory syncytial virus is a major cause of lower respiratory tract infections in small children.

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Salud! PIP #1 Table 5. Salud! PIP Scores and Compliance Levels

Salud! PIP #1 BCBS Lovelace Molina Presbyterian

1. Review the Selected Study Topic 5 5 5 5

2. Review the Selected Study Question 5 5 5 5

3. Review the Study Indicators 10 10 10 10

4. Review the Identified Study Population 5 5 5 5

5. Review Sampling Methods 5 5 5 5

6. Review Data Collection Procedures 20 20 20 20

7. Assess Improvement Strategies 20 20 20 20

8. Review Data Analysis and Interpretation of Study Results

5 5 5 5

9. Assess Whether Improvement Is “Real” Improvement

10 8 10 10

10. Assess Sustained Improvement NA4 15 15 15




Demonstrated Compliance Level Full Full Full Full

Salud! PIP #2 Table 6. Salud! PIP Scores and Compliance Levels

Salud! PIP #2 BCBS Lovelace Molina Presbyterian

1. Review the Selected Study Topic 5 5 5 5

2. Review the Selected Study Question 5 5 5 5

3. Review the Study Indicators 10 10 10 10

4. Review the Identified Study Population 5 5 5 5

5. Review Sampling Methods 5 5 5 5

6. Review Data Collection Procedures 20 20 20 20

7. Assess Improvement Strategies 20 20 20 20

8. Review Data Analysis and Interpretation of Study Results

5 5 5 5

9. Assess Whether Improvement Is “Real” Improvement

10 5 10 10

10. Assess Sustained Improvement NA5 0 15 15




Demonstrated Compliance Level Full Moderate Full Full

4 This score is not applicable because not enough time has passed to assess sustained improvement.


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SCI PIP Audit Results BCBS did not administrate an SCI program. Each of the other three MCOs submitted two PIPs for this audit as follows: Lovelace PIPs

1. Use of Appropriate Medications for People with Asthma 2. Improving the Frequency of Prenatal Care

Molina PIPs

1. Comprehensive Diabetes Care (HbA1c Testing) 2. Improving Postpartum Care

Presbyterian PIPs

1. Breast Cancer Screening 2. Comprehensive Diabetes Care (HbA1c Testing)

Each PIP was evaluated and scored for CQI processes, performance rates, and demonstrated improvement. For PIP #1, two of the three MCOs earned Full Compliance levels and one MCO earned Moderate Compliance level. For PIP #2, two of the three MCOs earned Full Compliance levels and one MCO earned a Moderate Compliance level. The resulting scores for each PIP are given in Tables 7 and 8 that follow.

SCI PIP #1 Table 7. SCI PIP Scores and Compliance Levels

SCI PIP #1 Lovelace Molina Presbyterian

1. Review the Selected Study Topic 5 5 5

2. Review the Selected Study Question 5 5 5

3. Review the Study Indicators 10 10 10

4. Review the Identified Study Population 5 5 5

5. Review Sampling Methods 5 5 5

6. Review Data Collection Procedures 20 20 20

7. Assess Improvement Strategies 20 20 20

8. Review Data Analysis and Interpretation of Study Results 5 5 5

9. Assess Whether Improvement Is “Real” Improvement 8 10 5

10. Assess Sustained Improvement NA6 15 0




Demonstrated Compliance Level Full Full Moderate


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SCI PIP #2 Table 8. SCI PIP Scores and Compliance Levels

SCI PIP #2 Lovelace Molina Presbyterian

1. Review the Selected Study Topic 5 5 5

2. Review the Selected Study Question 5 5 5

3. Review the Study Indicators 10 10 10

4. Review the Identified Study Population 5 5 5

5. Review Sampling Methods 5 5 5

6. Review Data Collection Procedures 20 20 20

7. Assess Improvement Strategies 20 20 20

8. Review Data Analysis and Interpretation of Study Results 5 5 4

9. Assess Whether Improvement Is “Real” Improvement 8 10 10

10. Assess Sustained Improvement 0 15 15




Demonstrated Compliance Level Moderate Full Full

Process and Outcome Measures The measurement and reporting of process measures is an important part of the quality improvement section of the HSD/MAD contracts with the MCOs. Three years prior to this audit, HSD/MAD began discussions with the MCOs about adding health outcome measures. Each MCO was instructed to identify measure and report health care outcomes as well as performance rates. Since this is not yet a contractual requirement for the MCOs, HSD/MAD did not make reporting of health care outcomes a mandatory portion of the audit. Process measures assess the incidence of a specific health care service provided to an individual. Process measures are often used to assess adherence to recommendations for clinical practice based on evidence or consensus and can identify specific areas of care that may require improvement. A performance rate is an example of a process measure. Performance rates represent the percentage of eligible members who received a specific treatment or service. A health care outcome is a result of treatment or services provided. It measures health change as a result of specific health care interventions. For example, if 50 percent of eligible women receive a screening mammogram, what percentage of those women goes on to receive additional services such as a biopsy, lumpectomy, mastectomy or chemotherapy as a result of receiving the mammogram? Then of those women who received additional services, what was the health care outcome? The goal of mammography is prevention or early detection and treatment of breast cancer. The outcome measure would lead directly to reduced morbidity and mortality rates resulting from breast cancer. Another example is to review what percentage of women who received more than 81 percent of expected prenatal visits went on to give birth to a low-birth-weight baby (<2500 grams) and

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compare that to the rate of low-birth-weight babies born to women who received fewer than 20 percent of expected prenatal visits. Nationwide, there is a trend toward measuring health care outcomes in addition to process measures. According to the Agency for Healthcare Research and Quality (AHRQ), “By linking the care people get to the outcomes they experience, outcomes research has become the key to developing better ways to monitor and improve the quality of care.”7 For this audit, BCBS, Molina and Presbyterian reported health care outcome measures. These three MCOs developed and reported health care outcome measures for all PMs. Health care outcome measures are discussed in more detail in the individual MCO sections.

ISCA Audit Results In association with the PM/PIPs audit, HealthInsight New Mexico conducted an ISCA for 2013. This review examined the 2012/2013 status of the MCOs’ information systems and data processing and reporting procedures, identifying strengths, challenges and recommendations. The goal of the ISCA is to determine the extent to which each MCO’s information technology systems supported the production of valid and reliable state performance measures, the completeness and accuracy of the data collected and submitted to the State, and the capacity to manage the health care of its members.

BCBS ISCA Findings and Recommendations Discussion of Findings Overall, BCBS is fully compliant with the requirements of the ISCA. Despite the designation of full compliance, it is recommended that BCBS address the following:

Acquisition Capabilities: Administrative Data (Claims and Encounter Data) BCBS provided recent actual performance results for the performance monitoring standards on the claims adjudication system. The contract requires that 90 percent of claims/encounter data be submitted within 120 days and 90 percent of adjustments be submitted within 30 days. Currently, the percentage is 89.3 and 23.1 percent, respectively. BCBS indicated that it is aware of this issue and has a plan to bring the percentage up to meet contract requirements.

Recommendations The following is recommended:

The State work with the MCO on its plan to increase the amount of claims/encounter

data submitted to the State to meet contract requirements

Lovelace ISCA Findings and Recommendations Discussion of Findings Overall, Lovelace is fully compliant with the requirements of the ISCA. Despite the designation of full compliance, it is recommended that Lovelace address the following:

7 http://www.ahrq.gov/clinic/outfact.htm (accessed June 3, 2012)

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Policies and Procedures Lovelace did not provide a signed policy and procedure that showed the process Lovelace has implemented for resolution of pended claims.

Data Processing Procedure and Personnel Lovelace did not provide the financial and time resources devoted to training programmers or other evidence of training for programmers.

Process for Programmer Performance Lovelace indicated it does not have a process for measuring programmer performance.

Recommendations The following is recommended for Lovelace:

Create a policy and procedure that shows the process Lovelace has implemented for

resolution of pended claims

Document the financial and time resources it devotes to training programmers

Develop a process for measuring programmer performance

Molina ISCA Findings and Recommendations Discussion of Findings Overall, Molina is fully compliant with the requirements of the ISCA. Despite the designation of full compliance, it is recommended that Molina address the following:

Data Processing Procedure and Personnel Molina does not calculate program defect rates.


Molina start calculating program defect rates and implement a process to evaluate the

number of defects in order to improve the program

Presbyterian ISCA Findings and Recommendations Discussion of Findings Overall, Presbyterian is fully compliant with the requirements of the ISCA. Recommendations There are no recommendations at this time.

Conclusion and Recommendations Based on HealthInsight New Mexico’s review of CMS requirements, evidence acquired during this audit, interpretive guidelines, and the scoring methodology approved by HSD/MAD, HealthInsight New Mexico finds that overall the MCOs continue to maintain high quality standards for the provision of clinical care to Medicaid members in New Mexico. Each MCO has processes in place designed to improve rates for each PM.

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Recommendations to HSD HealthInsight New Mexico recommends that HSD/MAD implement a corrective action plan to assist Lovelace to come into Full Compliance with the SCI PMP and the PIP entitled “Improving the frequency of prenatal visits/improving birth outcomes.” HealthInsight New Mexico recommends that HSD/MAD implement a corrective action plan to assist Presbyterian to come into Full Compliance with the PIP entitled “Breast Cancer Screening” in both the Salud! and the SCI programs. However, there are opportunities for further improvement. Please see the MCO-specific sections (sections A-D) for further details.

Rebuttal and Reconsideration Each MCO was allotted time to offer rebuttals and requests for reconsideration of any findings or scores in this report. Please see the MCO-specific section for further detail.

of 52 Final Report Section A: BCBS

Performance Measurement and Performance Improvement Projects Audit July 19, 2013

Section A: Blue Cross and Blue Shield of New Mexico (BCBS) This section describes the scoring and demonstrated compliance levels for the Performance Measures Program (PMP) and Performance Improvement Projects (PIPs) submitted by BCBS. BCBS administrated only the Salud! program during the audit time period. As described in the scoring method section of this report, the actual total points are calculated as a percentage and result in the following demonstrated compliance levels shown in Table 1. Unless otherwise stated, all numeric scores in the following tables are rounded to the nearest whole number.

Salud! PMP Audit Results BCBS achieved Full Compliance for the PMP audit. Table 1 reflects the scores for BCBS for the selected PMP standards. The performance rates for the quality indicators were supplied by the MCO and are found in Table 2. Table 1. Salud! PMP Audit Scores, Compliance Level and Historical Comparison

BCBS Salud! PMP Audit

2011 Actual Score

2012 Actual Score


HEDIS Interactive Data Submission System 4 4

HEDIS Compliance Audit 5 5

CQI Program

Annual Preventive Dental Visits (ages 2-21 years) 13 13

Well Child Visits (first 15 months; 3-6 years) 13 13

Children and Adolescents' Access to Primary Care Physicians (PCPs) 13 13

Childhood Immunization Status (Combo 2) 13 13

Use of Appropriate Medications for People with Asthma (ages 5-11 years)

13 13

Breast Cancer Screening 13 13

Comprehensive Diabetes Care 13 13

Timeliness of Prenatal and Postpartum Care 13 13

Frequency of Ongoing Prenatal Care 13 13

Total Points Available 126 126

Total Points Scored 126 126

Final Percentage Score 100% 100%

Demonstrated Compliance Level Full Full

As shown in Table 1, BCBS demonstrated Full Compliance (100%) in all areas of the Salud! PMP. Table 2 shows that while BCBS fell below the HSD/MAD thresholds in some of the categories, the rates improved over the previous year in 13 of 18 categories. Use of Appropriate Medications for People with Asthma was reportable for the first time this year for BCBS. The largest improvement was in Breast Cancer Screening, up 13 percentage points from the previous year. There were statistically insignificant declines in four categories. Statistical significance in this report is based on the HEDIS Baseline Rate/Minimal Effect Size Table.



Performance rates are the percentage of eligible members who received a specific treatment or service. Performance rates are helpful in assessing the effectiveness of MCO interventions and for comparing trends with state and national levels. Table 2 compares Salud! performance rates with minimum thresholds set by HSD/MAD. The rates in red indicate rates that did not meet HSD/MAD thresholds for the given years. HSD/MAD reviews its thresholds yearly and revises periodically. Only the 2012 thresholds are displayed in the table below. Table 2. Salud! PM Performance Rates and Historical Comparison

BCBS Salud! PM Performance Rates 2011 2012 2012 HSD/MAD

Threshold

Annual Preventive Dental Visits:

Combined 2-21 years 56% 62% 70%

Well Child Visits by Ages:

First 15 months of life 52% 63% 62%

3-6 years 60% 56% 70%

PCP Access by Ages:

12-24 months 96% 97% 97%

25 months-6 years 82% 85% 90%

7-11 years 86% 84% 90%

12-19 years 84% 85% 90%

Childhood Immunization Status (Combo 2) 70% 75% 78%

Use of Appropriate Medications for People with Asthma ages 5-11 years

NA 97% 91%

Breast Cancer Screening 38% 51% 55%

Comprehensive Diabetes Care

HbA1c Testing 84% 82% 85%

HbA1c Test (Poor Control 9.0%)8 47% 40%

48%

Retinal Eye Exam 49% 54% 56%

LDL-C Screening 65% 72% 74%

Medical Attention for Nephropathy 69% 76% 75%

Timeliness of Prenatal Care 87% 88% 85%

Timeliness of Postpartum Care 59%9 68% 60%

Frequency of Ongoing Prenatal Care (>81% of expected visits)

67% 66% 60%

Salud! PIP Audit Results BCBS submitted two PIPs for the Salud! Program:

1. Childhood Immunization 2. Breast Cancer Screening

8 HbA1c Test is the only rate in which a decrease is the desired outcome. A decreased rate means that

fewer members have poor control of their blood glucose levels. 9 The HSD/MAD threshold for 2011 was 59 percent.



Each PIP was evaluated and scored for CQI processes, performance rates, and demonstrated improvement.

Salud! PIP 1: Childhood Immunization Status BCBS demonstrated Full Compliance (100%) for the Childhood Immunization Status PIP. BCBS has all the structures and processes in place to accurately track this project. This was the third year for reporting on this PIP. The rate for the current year has increased 5 percentage points to 75 percent. The measure of “Sustained Improvement” has been scored “NA” this year. BCBS’s quality teams have completed barrier analysis and defined new interventions to improve member immunization rates. For members who have not had up-to-date immunizations and are 13 months of age will receive targeted mailings. A member incentive was being developed to target members turning 2 years of age during 2012. Table 3 provides a breakdown of how this PIP was scored. Criteria 10 on Table 3 “Sustained Improvement” is currently scored as “NA” because it is undetermined until the next audit whether or not this PIP is successful in sustaining performance, since this is only in its second reportable year since HEDIS revised the data collection procedure. Table 3. Salud! PIP #1 Audit Scores, Compliance Level and Historical Comparison

BCBS Salud! PIP # 1 Childhood Immunization Status

2011 Actual Score

2012 Actual Score

1. Review the Selected Study Topic 5 5

2. Review the Selected Study Question 5 5

3. Review the Study Indicators 10 10

4. Review the Identified Study Population 5 5

5. Review Sampling Methods 5 5

6. Review Data Collection Procedures 20 20

7. Assess Improvement Strategies 20 20

8. Review Data Analysis and Interpretation of Study Results 5 5

9. Assess Whether Improvement Is “Real” Improvement NA 10

10. Assess Sustained Improvement NA

NA





Salud! PIP 2: Breast Cancer Screening NCQA requires a two-year continuous enrollment for a woman to qualify for this measure. This is the second reportable measurement year for this PIP. Although BCBS’s Breast Cancer Screening program has shown improvement, the rate of 51 percent falls short of the state performance measure threshold of 55 percent. Thus, there remains opportunity for improvement to reach the state performance measure threshold.



Table 4 provides a breakdown of how this PIP was scored. Criteria 10 on Table 4 “Sustained Improvement” is currently scored as “NA” because it is undetermined until the next audit whether or not this PIP is successful in sustaining performance, since this is only in its second reportable year since HEDIS revised the data collection procedure. Table 4. Salud! PIP #2 Audit Scores, Compliance Level and Historical Comparison

BCBS Salud! PIP # 2 Breast Cancer Screening

2011 Actual Score

2012 Actual Score










10. Assess Sustained Improvement NA NA


Total Points 75 85



Outcome Measures Quality of health care is improved by striving to decrease the incidence of disease and/or reduce complications related to a disease process. Improvements are accomplished through a variety of activities designed to promote wellness and prevent disease. There is growing interest at the national and state levels for reporting health care outcome measures. In addition to process measures, HSD/MAD urged the MCOs to identify health care outcomes that will be addressed in future audits. On behalf of HSD/MAD, HealthInsight New Mexico requested clinical outcome measures for review, but those measures did not constitute a scored section of this audit. The information submitted is above and beyond what was required for the audit. BCBS submitted samples of their initial efforts to improve the quality of care received by members. HealthInsight New Mexico acknowledges and welcomes the additional information that BCBS provided in the spirit of cooperation to better understand the work BCBS is doing to improve health care quality. BCBS identified and reported the following as measures for monitoring Salud! PM clinical outcomes.



Annual Dental Visits The frequency of dental exams and the impact on the number of revisits for dental cavity restoration. Well Child Visits The number of members who had a well-child visit who were diagnosed with a developmental delay or symptoms concerning nutrition and metabolism and who had a follow-up visit with a specialist. Children and Adolescents’ Access to Primary Care Physicians The number of members who had an occurrence of follow-up care in children ages 13-17 years after an initial diagnosis of obesity was identified. Childhood Immunization Status (Combo 2) The number of members who were diagnosed with pertussis.

Use of Appropriate Medications for People with Asthma The number of members with asthma (ages 5-11 years) who had an inpatient admission or an emergency room visit during the measurement year. Breast Cancer Screening The number of members who received a screening mammogram, had additional diagnostic testing, and were diagnosed with breast cancer. Comprehensive Diabetes Care The rates for the sub-measures. This is a process measure that tracks the effectiveness of the intervention rather than the health care outcome. Timeliness of Prenatal Care/Frequency of Ongoing Prenatal Care The number of members who had a low-birth-weight10 or stillborn baby. This is the same measure used for the Frequency of Ongoing Prenatal Care PM.

Information Systems Capabilities Assessment (ISCA) In association with the PM/PIPs audit, HealthInsight New Mexico conducted an ISCA for 2013. This review examined the 2012/2013 status of the MCOs’ information systems and data processing and reporting procedures, identifying strengths, challenges and recommendations.

The goal of the ISCA is to determine the extent to which each MCO’s information technology systems supported the production of valid and reliable state performance measures, the completeness and accuracy of the data collected and submitted to the State, and the capacity to manage the health care of its members. Discussion of Findings Overall, BCBS is fully compliant with the requirements of the ISCA. Despite the designation of full compliance, it is recommended that BCBS address the following:

Acquisition Capabilities: Administrative Data (Claims and Encounter Data) BCBS provided recent actual performance results for the performance monitoring standards on the claims adjudication system. The contract requires that 90 percent of

10

Low-birth-weight is defined as greater than 24 weeks gestational age and 500-2,500 grams.



claims/encounter data be submitted within 120 days and 90 percent of adjustments be submitted within 30 days. Currently, the percentage is 89.3 and 23.1 percent, respectively. BCBS indicated that it is aware of this issue and has a plan to bring the percentage up to meet contract requirements.


The State work with the MCO on its plan to increase the amount of claims/encounter

data submitted to the State to meet contract requirements

Salud! Recommendations

Continue efforts to develop and implement innovative targeted interventions to continue improvement of performance rates for all measures.

Rebuttals and Reconsideration Requests BCBS advised that it has enacted an internal Corrective Action Plan in regard to BCBS compliance with Encounters submission. It is actively working with HSD/MAD to provide a status update on its mitigation plan and interventions. This work will continue until satisfactory performance is achieved. BCBS also submitted a correction for the outcome measures section which was incorporated into this report.

of 52 Final Report Section B: Lovelace


Section B: Lovelace Community Health Plan (Lovelace) This section describes the scoring and demonstrated compliance levels for the Performance Measures Program (PMP) and Performance Improvement Projects (PIPs) submitted by Lovelace. The Salud! program is presented first, in its entirety, followed by the SCI program. As described in the scoring method section of this report, the actual total points are calculated as a percentage and result in the following demonstrated compliance levels shown in Table 1. Unless otherwise stated, all numeric scores in the following tables are rounded to the nearest whole number.

Salud! PMP Audit Results Lovelace achieved Full Compliance for the PMP audit. Table 1 reflects the scores for Lovelace for the selected PMP standards. The performance rates for the quality indicators were supplied by the MCO and are found in Table 2. Table 1. Salud! PMP Audit Scores, Compliance Level and Historical Comparison

Lovelace Salud! PMP Audit

2011 Actual Score

2012 Actual Score


HEDIS Interactive Data Submission System 4 4


CQI Program






13 13









As shown in Table 1, Lovelace demonstrated Full Compliance (100%) in all areas of the Salud! PMP. Table 2 shows Lovelace improved the rates for Annual Dental Visits from 64 to 69 percent. This is a 5-percentage point increase in the rate, which is statistically significant but did not meet the HSD/MAD threshold of 70 percent.



The rates for Well Child Visits are shown in Table 2 and were split by age group. The rate for the first 15 months of life increased from 62 to 67 percent and surpasses the HSD/MAD threshold of 62 percent. For the 3-6 year-old group, the rate fell from 70 to 65 percent, which puts it below the HSD/MAD threshold of 70 percent. Lovelace met the HSD/MAD threshold for all age groups in the Children and Adolescents' Access to Primary Care Physicians (PCPs) measure except the 25 months to 6 years age group. This age group rate increased by one percentage point but did not meet the HSD/MAD threshold of 90 percent. Shown in Table 2, every sub measure was stable or improved by 1 or 2 percentage points. Childhood Immunizations (Combo 2) saw a rate decline from 80 to 76 percent and did not meet the HSD/MAD threshold of 78 percent. For Use of Appropriate Medications in People with Asthma measure, shown in Table 2, Lovelace had a one percentage point drop to 92 percent but remains above the HSD/MAD threshold of 91 percent. The Breast Cancer screening rate, shown in Table 2, continues to remain stable and at 41 percent, is less than the HSD/MAD threshold of 55 percent. There have been no statistically significant changes in the rate over the last several measurement periods. There are many barriers to overcome including member apathy toward the importance of screening, fear of a cancer diagnosis, cultural/language barriers, and economic barriers. Lovelace has implemented interventions to address this measure. Lovelace rates for Comprehensive Diabetes Care all declined from last year. Four of the five sub measures did not meet the HSD/MAD thresholds. One sub measure, HbA1c with Poor Control (>9%), rose 9 percentage points from 34 to 43 percent but remains below the HSD/MAD threshold of 48 percent. Retinal Eye Exams fell 4 percentage points from 54 to 49 percent, which is below the HSD threshold of 56 percent. The LDL-C screening rate fell three percentage points to 68 percent and is below the HSD/MAD threshold of 74 percent. The rate for Timeliness of Prenatal Care improved from 83 to 87 percent, which exceeded the HSD/MAD threshold of 85 percent. The rate for Postpartum Care increased from 64 to 67 percent and exceeded the HSD/MAD threshold of 60 percent. The Frequency of Ongoing Prenatal Care fell from 74 to 71 percent, but remains well above the HSD/MAD threshold of 60 percent. Performance rates are the percentage of eligible members who received a specific treatment or service. Performance rates are helpful in assessing the effectiveness of MCO interventions and for comparing trends with state and national levels. Table 2 compares Salud! performance rates with minimum thresholds set by HSD/MAD. Lovelace scored above the HSD/MAD threshold for 10 of 18 measures and sub measures for which HSD/MAD thresholds were established. The rates in red indicate rates that did not meet HSD/MAD thresholds for the given years. HSD/MAD reviews its thresholds yearly and revises periodically. Only the 2012 thresholds are displayed in the table below.



Table 2. Salud! PM Performance Rates and Historical Comparison

Lovelace Salud! PM Performance Rates

2011 2012 2012

HSD/MAD Threshold


Combined Rate (2-21 years) 64% 69% 70%



3-6 years 70% 65% 70%

PCP Access by Ages:

12-24 months 98% 98% 97%

25 months-6 years 88% 90% 90%

7-11 years 91% 92% 90%

12-19 years 90% 91% 90%

Childhood Immunizations (Combo 2) 80% 76% 78%

Use of Appropriate Medications for People with Asthma ages 5-11 years 94% 92% 91%




HbA1c Test (Poor Control >9.0%)11

34% 43% 48%





Timeliness of Postpartum Care 64% 67% 60%

Frequency of Ongoing Prenatal Care (>81% of expected visits) 74% 71% 60%

Salud! PIP Audit Results Lovelace submitted two PIPs for the Salud! program:

1. Use of Appropriate Medications for People with Asthma (ages 5-11 and 12-50) 2. Utilizing Synagis in Improving Health and Reducing Hospitalizations in RSV12

Vulnerable Infants and Children Each PIP was evaluated and scored for CQI processes, performance rates and demonstrated improvement.

Salud! PIP 1: Use of Appropriate Medications for People with Asthma Lovelace demonstrated full compliance (98%) for the Use of Appropriate Medications for Asthma PIP. Points were removed for “effective interventions” because of rate declines from 93 to 92 percent in the 5-11 age group and from 85 to 83 percent in the 12-50 age group. This is

11

HbA1c Test is the only rate in which a decrease is the desired outcome. A decreased rate means that fewer members have poor control of their blood glucose levels. 12

Respiratory syncytial virus is a major cause of lower respiratory tract infections in small children. Although this is not a HEDIS measure, the MCO has the latitude to choose a PIP for auditing that improves processes but is not necessarily directly related to a published HEDIS measure.



the second re-measurement year since baseline rates of 93 and 85 percent, respectively, were set in 2010. The rate has not changed a statistically significant amount either up or down during the three measurement periods. Next year, this PIP will be scored for “sustained improvement.” Lovelace has identified a variety of potential barriers and has developed interventions to overcome them. Some of the barriers include member unawareness of recommended treatments, member socio-economic hardship, maintaining accurate member contact information, and physician unawareness of guidelines. Interventions include, but are not limited to, health fairs targeted at current and potential members, outreach by disease management staff to members, and making educational resources available to physicians. Table 3 provides a breakdown of how this PIP was scored. Table 3. Salud! PIP #1 Audit Scores, Compliance Level and Historical Comparison

Lovelace Salud! PIP #1 Use of Appropriate Medications for People with Asthma

(ages 5-50)

2011 Actual Score

2012 Actual Score









9. Assess Whether Improvement Is “Real” Improvement 9 8






Salud! PIP 2: Utilizing Synagis in Improving Health and Reducing Hospitalizations in RSV Vulnerable Infants and Children Shown on table 4, the score for this PIP declined due to a decline in rates. Of the 78 infants referred for Synagis, 59 received the recommended dosage (76 percent compared to 100 percent last year). Two of these infants were subsequently hospitalized. For the 19 infants who received a partial course of therapy four were hospitalized. Lovelace has identified a variety of potential barriers and has developed interventions to overcome them. Many provider offices do not want to administer Synagis treatment at the office as they believe bringing at-risk children to an environment where there are both well and very sick children places the at-risk children at further risk of infection. These providers instead want home care to provide the treatment. Parents/guardians may have difficulties transporting the member to a provider office as the member may have various clinical needs such as oxygen, GI- tubes, or may be ventilator dependent. Parents continue to need education on signs and



symptoms of respiratory infection and prevention of respiratory infection and parents continue to need education on the gravity or the necessity of having their infant receive all required doses. Table 4 provides a breakdown of how this PIP was scored. Table 4. Salud! PIP #2 Audit Scores, Compliance Level and Historical Comparison

Lovelace Salud! PIP #2 Utilizing Synagis in Improving Health and Reducing Hospitalizations in

RSV Vulnerable Infants and Children

2011 Actual Score

2012 Actual Score










10. Assess Sustained Improvement 10 0




Demonstrated Compliance Level Full Moderate

SCI PMP Audit Results Lovelace achieved Full Compliance for the SCI PMP Audit. Table 5 reflects the scores for Lovelace for the selected PMP standards. The performance rates for the quality indicators were supplied by the MCO and are found in Table 6. Table 5. SCI PMP Audit Scores, Compliance Level and Historical Comparison

Lovelace SCI PMP Audit

2011 Actual Score

2012 Actual Score

CQI Program











As shown in Table 5, Lovelace demonstrated Full Compliance (90%) for the SCI PMP. Breast Cancer Screening data is shown on Table 6. Since the 2009 baseline data, this rate has dropped a statistically significant amount. The baseline year was 71 percent followed by 66 percent in 2010, 60 percent last year and is now at 57 percent. Points were removed for “effective interventions” due to the rate declines. Lovelace continues to exceed the HSD/MAD threshold of 55 percent. Lovelace implemented interventions including member education, mobile mammography units, and a targeted outreach campaign. Barriers include transportation issues, cultural taboos, and fear of a cancer diagnosis. Shown in Table 6, although there was a rate decline in four of the five sub measures for Comprehensive Diabetes Care, Lovelace continued to meet or exceed the HSD/MAD threshold in most measures. Partial points were removed from the Comprehensive Diabetes Care measure for “effective interventions” due to the rate declines. The rate for Retinal Eye Exam declined from 54 to 49 percent and did not meet HSD/MAD threshold of 56 percent. The rates for HbA1c Testing, HbA1c Poor Control (>9%), and LDL-C were either stagnant or experienced a negative trend but continued to meet or exceed the HSD/MAD thresholds. The rate of Medical Attention for Nephropathy rose from 78 to 82 percent, well above the HSD/MAD threshold of 75 percent. Lovelace continues to implement interventions including attending health fairs, member calls to encourage testing, member education and a provider pay-for-performance program. Barriers include outdated telephone numbers and addresses, low health literacy issues, and chronic disease management. Reflected in Table 6, there was a rate increase for Timeliness of Prenatal Care from 89 to 91 percent and Timeliness of Postpartum Care rose from 72 to 75 percent. Both rates exceed the HSD threshold of 85 percent and 60 percent, respectively. The rate of Frequency of Ongoing Prenatal Care declined a statistically significant amount from 81 to 74 percent, shown in Table 6. Although the HSD threshold for this measure was 85 percent, points were removed for “effective interventions” due to the rate decrease. Lovelace continues to implement interventions including the Baby Love Program, member incentives such as free infant car seats, member education and case management. Barriers include difficulty identifying pregnant women early in the pregnancy, out-of-date addresses and phone numbers, mobility of the population, and ongoing economic uncertainty. Table 6 compares SCI performance rates with minimum thresholds set by HSD/MAD. The rates in red indicate rates that did not meet HSD/MAD thresholds for the given years. HSD/MAD reviews its thresholds yearly and revises periodically. Only the 2012 thresholds are displayed in the table below.



Table 6. SCI PM Performance Rates and Historical Comparison

Lovelace SCI PMP Rates

2011 Rate

2012 Rate

2012 HSD/MAD Threshold





38% 42% 48%

Retinal Eye Exam; 54% 49% 56%





Frequency of Ongoing Prenatal Care 81% 74% 60%

SCI PIP Audit Results Lovelace submitted two PIPs for the SCI Program:

1. Use of Appropriate Medications for People with Asthma (ages 5-11 years) 2. Improving the Frequency of Prenatal Visits/Improving Birth Outcomes

Each PIP was evaluated and scored for CQI processes, performance rates and demonstrated improvement.

SCI PIP 1: Use of Appropriate Medications for People with Asthma As shown in Table 7, Lovelace achieved Full Compliance (98%) for this PIP. This is the second re-measurement year since the baseline rate of 86% was set in 2010. Points were removed for step nine for “statistical evidence that observed improvement is true improvement” due to the rate decline from 87 to 82 percent from last year to this. The number of members in this study has gone from 44 in HEDIS year 2009 to 238 in HEDIS year 2011. Lovelace developed interventions with disease management staff for outreach to members who are identified as having asthma or who called the nurse advice line with asthma-related concerns. Lovelace also developed targeted educational materials to increase member awareness of appropriate treatments and management techniques for asthma. These interventions were designed to overcome identified potential barriers.

Table 7 provides a breakdown of how this PIP was scored. Criteria 10 on Table 7 “Sustained Improvement” is currently scored as “NA” because it is undetermined until the next audit whether or not this PIP is successful in sustaining performance, since this is only in its second reportable year.

13

HbA1c Test is the only rate in which a decrease is the desired outcome. A decreased rate means that fewer members have poor control of their blood glucose levels.



Table 7. SCI PIP #1 Audit Scores, Compliance Level and Historical Comparison

Lovelace SCI PIP #1 Use of Appropriate Medications for People with Asthma (ages 5-50)

2011 Actual Score

2012 Actual Score















SCI PIP 2: Improving the Frequency of Prenatal Care/Improving Birth Outcomes Lovelace demonstrated Moderate Compliance (83%) for this PIP. This is the third re-measurement year since the baseline rate of 33 percent was set in 2009. This performance rate declined from 81 to 74 percent of eligible members who attended more than 80 percent of expected prenatal visits. Lovelace identified numerous barriers for this measure that include, but are not limited to, identification of pregnant women early in their pregnancies, lack of access in rural areas, members’ financial problems, cultural and linguistic issues, and pregnant teens that are hesitant to seek treatment or are unaware of treatment availability. Lovelace has implemented a variety of interventions designed to overcome the identified barriers. These interventions include locating and identifying pregnant women through the Baby Love Program, offering free car seats, providing a nurse advice line, streamlining the referral process, and implementation of the Community Health Worker Program to outreach to pregnant members.

Table 8 gives a breakdown of how this PIP was scored.




Lovelace SCI PIP #2 Improving the Frequency of Prenatal

Visits/Improving Birth Outcomes

2011 Actual Score

2012 Actual Score















Outcome Measures HealthInsight New Mexico requested health care outcome measures for review, but those measures did not constitute a scored section of this audit. Lovelace submitted the following information: “HEDIS measure results are the outcomes Lovelace utilizes to measure performance and compare results to national and regionally developed benchmarks as well as local competitors.”


The goal of the ISCA is to determine the extent to which each MCO’s information technology systems supported the production of valid and reliable state performance measures, the completeness and accuracy of the data collected and submitted to the State, and the capacity to manage the health care of its members. Discussion of Findings Overall, Lovelace is fully compliant with the requirements of the ISCA. Despite the designation of full compliance, it is recommended that Lovelace address the following:

Policies and Procedures Lovelace did not provide a signed policy and procedure that showed the process Lovelace has implemented for resolution of pended claims.



Data Processing Procedure and Personnel Lovelace did not provide the financial and time resources devoted to training programmers or other evidence of training for programmers.

Process for Programmer Performance Lovelace indicated it does not have a process for measuring programmer performance.

Recommendations The following is recommended for Lovelace:

Create a policy and procedure that shows the process Lovelace has implemented for

resolution of pended claims

Document the financial and time resources it devotes to training programmers

Develop a process for measuring programmer performance

Salud! and SCI Recommendations

Continue efforts to develop and implement innovative targeted interventions to increase rates of the following measures: o Annual Preventive Dental Visits ages 2-21 in the Salud! population o Well Child Visits ages 3-6 years in the Salud! population o Childhood Immunizations in the Salud! population o Breast Cancer Screenings for the Salud! and SCI population o Comprehensive Diabetes Care in the Salud! and SCI population living with diabetes:

HbA1c Testing Retinal Eye Exam LDL-C Screening Medical Attention for Nephropathy

o Synagis in Improving Health and Reducing Hospitalizations in RSV Vulnerable Infants and Children in the Salud! population

Consider generating health care outcome measures for each PM

Rebuttals and Reconsideration Requests Lovelace submitted reconsideration requests for several individual measures in the PMP program and both SCI PIPs. SCI BCS PM:

Credit was added for SCI Breast Cancer Screening process improvement due to new interventions.

SCI CDC PM:

The Comprehensive Diabetes Care has five sub measures. Partial credit was given for two of the five.

The rate for Medical Attention for Nephropathy increased from 78 to 82 percent. The HSD/MAD threshold for this sub measure was 75 percent.

The HbA1c Testing sub measure has had a flat rate since the baseline of 87 percent was set in 2009 but continues to exceed the HSD/MAD threshold of 85 percent.



SCI Prenatal PM: Frequency of Ongoing Prenatal Care experienced a rate decrease from 81 to 74 percent but continues to exceed the HSD/MAD threshold of 60 percent.

After re-consideration of the above, the score changed from 75 percent Minimal Compliance to 90 percent Full Compliance for the SCI PMP. SCI PIP Asthma:

Lovelace also requested a reconsideration of the SCI PIP “Use of Appropriate Medications in People with Asthma.” An error in reporting was discovered and corrected. The score for this PIP was erroneously figured as 83 points out of 100 possible. Since one of the scoring criteria was not applicable, the score should have read 83 points out of a possible 85 with equals 98 percent with a Full Compliance Level. This has been corrected in the report.

SCI PIP Prenatal:

The final reconsideration request was for the SCI PIP Improving the Frequency of Prenatal Visits/Improving Birth Outcomes. Originally scored at 78 percent Minimal Compliance, upon further inspection, credit was given for process improvement for new interventions during the year. The revised score is 83 percent with Moderate Compliance.

of 52 Final Report Section C: Molina


Section C: Molina Healthcare of New Mexico (Molina) This section provides information on the scoring and demonstrated compliance levels for the Performance Measures Program (PMP) and Performance Improvement Projects (PIPs) submitted by Molina. The Salud! program is presented first, in its entirety, followed by the SCI program. As described in the scoring method section of this report, the actual total points are calculated as a percentage and result in the following demonstrated compliance levels shown in Table 1. Unless otherwise stated, all numeric scores in the following tables are rounded to the nearest whole number.

Salud! PMP Audit Results Molina achieved Full Compliance for the PMP audit Table 1 reflects the scores for Molina for the selected PMP standards. The performance rates for the quality indicators were supplied by the MCO and are found in Table 2. Table 1. Salud! PMP Audit Scores, Compliance Level and Historical Comparison

Molina Salud! PMP Audit

2011 Actual Score

2012 Actual Score


HEDIS Interactive Data Submission System (IDSS) 4 4


CQI Program






13 13









Molina demonstrated full compliance (100%) in all areas of the Salud! PMP. Molina scored above the HSD/MAD threshold for 16 of 18 measures and sub measures for which HSD/MAD thresholds were established.



HSD/MAD thresholds were not met for one the sub measures for PCP Access by Ages, specifically ages 25 months to 6 years old. Although improved by 1 percentage point from last year to this year, Molina’s rate of 89 percent was below the HSD/MAD threshold of 90 percent. HSD/MAD thresholds were not met for one of the Comprehensive Diabetes Care sub measures: LDL-C Screening. Molina’s rate was 73 percent and the HSD/MAD threshold is 74 percent. There were no statistically significant rate declines from the previous report year. Performance rates are the percentage of eligible members who received a specific treatment or service. Performance rates are helpful in assessing the effectiveness of MCO interventions and for comparing trends with state and national levels. Table 2 compares Salud! performance rates with minimum thresholds set by HSD/MAD. The rates in red indicate rates that did not meet HSD/MAD thresholds for the given years. HSD/MAD reviews its thresholds yearly and revises periodically. Only the 2012 thresholds are displayed in the table below. Table 2. Salud! PM Performance Rates and Historical Comparison

Molina Salud! PM Performance Rates

2011 2012 2012

HSD/MAD Threshold





3-6 years 66% 70% 70%

PCP Access by Ages:

12-24 months 98% 98% 97%

25 months-6 years 88% 89% 90%

7-11 years 92% 91% 90%

12-19 years 92% 91% 90%


Use of Appropriate Medications for People with Asthma Ages 5-11 years

91% 92% 91%





50% 48% 48%



Medical Care for Nephropathy 75% 76% 75%



Frequency of Ongoing Prenatal Care (>81% of expected visits) 69% 69% 60%

14




Salud! PIP Audit Results Molina submitted two PIPs for the Salud! Program:

1. Annual Preventive Dental Visits 2. Breast Cancer Screening


Salud! PIP 1: Annual Preventive Dental Visits Molina’s Annual Preventive Dental Visit rate increased from 66 percent in 2011 to 70 percent in 2012. Molina reported that this increase was due to correction of the encounter data issue and being loaded correctly for HEDIS abstraction. Molina surpassed the NCQA Medicaid 90th percentile for the combined measure. No significant data issues were identified this year. Table 3 presents the scoring for this PIP. This is the first year for this PIP to be reviewed so the score for 2011 is NA in Table 3 below. Table 3. Salud! PIP #1 Audit Scores, Compliance Levels and Historical Comparisons

Molina Salud! PIP #1 Annual Preventive Dental Visits

2011 Actual Score

2012 Actual Score

1. Review the Selected Study Topic NA 5

2. Review the Selected Study Question NA 5

3. Review the Study Indicators NA 10

4. Review the Identified Study Population NA 5

5. Review Sampling Methods NA 5

6. Review Data Collection Procedures NA 20

7. Assess Improvement Strategies NA 20

8. Review Data Analysis and Interpretation of Study Results NA 5


10. Assess Sustained Improvement NA 15

Total Points Available NA 100

Total Points Scored NA 100

Final Percentage Score NA 100%

Demonstrated Compliance Level NA Full

Salud! PIP 2: Breast Cancer Screening Molina achieved Full Compliance (100%) for this PIP. The rate increased 2 percentage points over its 2011 numbers to 55 percent and has met the HSD/MAD threshold of 55 percent for the measure. Molina continues to assess barriers and develop interventions. Some of the barriers are common to other measures including lack of member awareness, transportation issues, and inaccurate member contact information. Other barriers are unique to breast cancer screening such as cultural or religious issues with the procedure. Table 4 gives a breakdown of how this PIP was scored.



Table 4. Salud! PIP #2 Audit Scores, Compliance Level and Historical Comparison

Molina Salud! PIP #2 Breast Cancer Screening

2011 Actual Score

2012 Actual Score















SCI PMP Audit Results Molina achieved Full Compliance for the SCI PMP Audit. Table 5 reflects the scores for Molina for the selected PMP standards. The performance rates for the quality indicators were supplied by the MCO and are found in Table 6. Table 5. SCI PMP Audit Scores, Compliance Level and Historical Comparison

Molina SCI PMP Audit

2011 Actual Score

2012 Actual Score

CQI Program









As shown in Table 5, Molina demonstrated full compliance (100%) in all areas of the SCI PMP. Molina had small declines in some areas but Table 6 showed statistically significant improvements in three areas: the rates for HbA1c Testing, Timeliness of Prenatal Care and Timeliness of Postpartum Care improved by 3, 3 and 8 percentage points, respectively. For the increase in the Timeliness of Prenatal Care, Molina identified several barriers including, but not limited to, the 30-45 day processing time for the state’s Income Support Division to



approve Medicaid eligibility, frequent member relocations, and inaccurate claims from global billing practices. Molina continues to implement a variety of initiatives including the Motherhood Matters Program, incentivizing programs like Rewards for Healthy Choices Program, and providing physicians with standardized forms to assist with accurate coding. Table 6 compares SCI performance rates with minimum thresholds set by HSD/MAD. The rates in red indicate rates that did not meet HSD/MAD thresholds. Table 6. SCI Performance Rates and Historical Comparison

Molina SCI PM Performance Rates

2011 2012 2012

HSD/MAD Threshold




HbA1c Test (Poor Control >9.0%) 46% 48% 48%






Frequency of Ongoing Prenatal Care 75% 70% 60%

Note: No rates are reported in red ink in this table. All SCI Performance Measure rates met HSD/MAD thresholds for 2011 and 2012.

SCI PIP Audit Results Molina submitted two PIPs for the SCI Program:

1. Improving the Timeliness of Postpartum Care 2. Comprehensive Diabetes Care (HbA1c Testing)


SCI PIP 1: Improving the Timeliness of Postpartum Care Molina received a compliance designation of Full Compliance (100%) for this PIP. The 2012 rate was stable at 60 percent which meets the HSD/MAD threshold of 60 percent. Molina continues to encourage Utilization Management (UM) initiative (17P and High Risk program) for early pregnancy enrollment, identification for prenatal care, with provider incentive program for timely prenatal care visits.




Molina SCI PIP #1 Improving the Timeliness of Postpartum Care

2011 Actual Score

2012 Actual Score















SCI PIP 2: Comprehensive Diabetes Care (HbA1c Testing) As shown in Table 8, Molina received Full Compliance for this PIP. The performance rate increased from 87 to 90 percent. The HSD/MAD threshold is 85 percent. Molina emphasizes to its members the importance of chronic disease management, promotes increased access to the resources for self-management, and offers a variety of customer services options including care coordination and disease management. Table 8. SCI PIP #2 Audit Scores, Compliance Level and Historical Comparison

Molina SCI PIP #2 Comprehensive Diabetes Care (HbA1c Testing)

2011 Actual Score

2012 Actual Score

















Outcome Measures Quality of health care is improved by striving to decrease the incidence of disease and/or reduce the occurrence of complications related to a disease process. Improvements are accomplished through a variety of activities designed to promote wellness and prevent disease. There is growing interest at the national and state levels for reporting health care outcome measures. In addition to process measures, HSD/MAD urged the MCOs to identify health care outcomes that will be addressed in future audits. On behalf of HSD/MAD, HealthInsight New Mexico requested clinical outcome measures for review, but those measures did not constitute a scored section of this audit. The information submitted is above and beyond what was required for the audit. Molina submitted samples of their initial efforts to improve the quality of care received by members. HealthInsight New Mexico acknowledges and welcomes the additional information that Molina provided in the spirit of cooperation to better understand the work Molina is doing to improve quality. Molina identified and reported the following measures for monitoring Salud! PM clinical outcomes.

Annual Preventive Dental Visit The number of eligible members who received a diagnosis of dental caries or restorative dentistry. Molina will monitor the occurrence of the diagnosis of dental caries and incidence of restorative care in order to determine if current interventions are having an impact on the identified population. Molina hopes to see the occurrence of dental caries and restorative dentistry decrease. Well Child Visits The number of eligible members who are diagnosed with asthma during their well child visits who then had an emergency department encounter during the measurement year. As one of the purposes of well care visits in children is to identify and effectively treat chronic conditions early, the health plan goal is to decrease the incidence of emergency room visits for one major chronic condition (asthma) and increase the number of well care visits. Children and Adolescents’ Access to Primary Care Physicians The number of eligible members who had an emergency department encounter during the measurement year with any diagnosis. As access to PCPs improves for this population, the health plan hopes to see emergency room utilization decrease. Childhood Immunizations (Combo 2) The number of eligible members who turned 2 years old during the measurement year and who were later diagnosed with measles, mumps or rubella. Use of Appropriate Medications for People with Asthma The number of members with asthma who had emergency room visits with any diagnosis code during the measurement year. Molina hopes to see the number of members with asthma having ER visits decrease as more members with asthma are placed on effective medication regimens.



Breast Cancer Screening The number of eligible members who had a lumpectomy, partial mastectomy or mastectomy during the measurement year. Molina hopes to see the ratio of lumpectomies and partial mastectomies to total mastectomies increase over time as breast cancer is detected earlier and less invasive surgeries are utilized with earlier detection. Comprehensive Diabetes Care The number of eligible members who had an HbA1c test who were later diagnosed with diabetic retinopathy. The health plan hopes to see the incidence of diabetic retinopathy decrease over time in this population as HbA1c screening increases. Timeliness of Prenatal Care The number of eligible members who received timely care who gave birth to a low-birth-weight15 baby. As access to PCPs and OB/gyns improves for this population, the health plan hopes to see percentages of low-birth-weight babies stabilize or decrease. Frequency of Ongoing Prenatal Care The number of eligible members who had an emergency department encounter with any diagnosis during the measurement year. As access to PCPs and Ob/gyns improves for this population, the health plan hopes to see emergency room utilization decrease.


The goal of the ISCA is to determine the extent to which each MCO’s information technology systems supported the production of valid and reliable state performance measures, the completeness and accuracy of the data collected and submitted to the State, and the capacity to manage the health care of its members. Discussion of Findings Overall, Molina is fully compliant with the requirements of the ISCA. Despite the designation of full compliance, it is recommended that Molina address the following:

Data Processing Procedure and Personnel Molina does not calculate program defect rates.


Molina start calculating program defect rates and implement a process to evaluate the

number of defects in order to improve the program


Continue efforts to develop and implement innovative targeted interventions to increase rates of the following measures: o Childhood Immunizations and LDL-C Screening for the Salud! population

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Rebuttals and Reconsideration Requests Molina submitted no rebuttal or reconsideration requests.

of 52 Final Report Section D: Presbyterian


Section D: Presbyterian Health Plan (Presbyterian) This section describes the scoring and demonstrated compliance levels for the Performance Measure Program (PMPs) and Performance Improvement Projects (PIPs) submitted by Presbyterian. The Salud! program is presented first, in its entirety, followed by the SCI program. As described in the scoring method section of this report, the actual total points are calculated as a percentage and result in the following demonstrated compliance levels shown in Table 1. Unless otherwise stated, all numeric scores in the tables to follow are rounded to the nearest whole number.

Salud! PMP Audit Results Presbyterian received Full Compliance for the PMP audit. Table 1 reflects the scores for the selected PMP standards. The performance rates for the quality indicators were supplied by the MCO and are found in Table 2. Table 1. Salud! PMP Audit Scores, Compliance Level and Historical Comparison

Presbyterian Salud! PMP Audit

2011 Actual Score

2012 Actual Score


HEDIS Interactive Data Submission System (IDSS) 4 4


CQI Program






13 13








Demonstrated Compliance Level Moderate Full

As shown in Table 1, Presbyterian demonstrated Full Compliance (97%) for the Salud! PMP. As shown in Table 2, rates increased or remained the same for 14 of the 18 measures and sub-measures. Four measures had reduced rates: Childhood Immunizations (Combo 2) fell from 75 to 70 percent, Use of Appropriate Medications for People with Asthma declined from 91 to 90 percent. LDL-C Screening fell one percentage point to 72 percent and Medical Care for Nephropathy fell from 76 to 73 percent.



Rates for Annual Dental Visits increased from 64 to 72 percent and exceeded the HSD/MAD threshold of 70 percent. Well Child Visits for 3-6 year-olds showed a statistically significant increase of 6 percentage points from 55 to 61 percent; however, it does not yet meet the HSD threshold of 70 percent. Children and Adolescents’ Access to PCP rates improved for three of the four age groups; the other remained stable at 98 percent. The age group of 25 months-6 years improved 7 percentage points to 89 percent but remains just below the 90 percent HSD threshold. Ages 7-11 years rose from 86 to 91 percent and12-19 years rose from 86 to 90 percent. At 46 percent, Breast Cancer Screening remains less than HSD/MAD threshold of 55 percent. The rate for HbA1c Test (poor control >9.0%) declined 8 percentage points from 49 to 41 percent16 and remains well under the HSD/MAD threshold of <48 percent. LDL-C screening rates fell a percentage point to 72 percent and does not meet the HSD/MAD threshold of 74 percent. Timeliness of Postpartum Care rates went from 54 to 56 percent but did not meet the HSD/MAD threshold of 60 percent. The Frequency of Ongoing Prenatal Care (>81% of expected visits) increased 6 percentage points from 56 to 62 percent. Presbyterian continues to review its processes to find weaknesses and opportunities for improvement. Performance rates are the percentage of eligible members who received a specific treatment or service. Performance rates are helpful in assessing the effectiveness of MCO interventions and for comparing trends with state and national levels. Table 2 compares Salud! performance rates with minimum thresholds set by HSD/MAD. Presbyterian fell below the HSD threshold for 10 of 18 measures and sub measures. The rates in red indicate rates that did not meet HSD/MAD thresholds for the given years. HSD/MAD reviews its thresholds yearly and revises periodically. Only the 2012 thresholds are displayed in the table below.

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Table 2. Salud! PM Performance Rates and Historical Comparison

Presbyterian Salud! PM Performance Rates

2011 2012 2012

HSD/MAD Threshold





3-6 years 55% 61% 70%

PCP Access by Ages:

12-24 months 98% 98% 97%

25 months-6 years 82% 89% 90%

7-11 years 86% 91% 90%

12-19 years 86% 90% 90%


Use of Appropriate Medications for People with Asthma Ages 5-11 years

91% 90% 91%





49% 41% 48%






Frequency of Ongoing Prenatal Care (>81% of expected visits)

56% 62% 60%

Salud! PIP Audit Results Presbyterian submitted two PIPs for the Salud! Program:



Salud! PIP 1: Breast Cancer Screening As shown in Table 3, Presbyterian demonstrated Full Compliance (100%) for the Breast Cancer Screening PIP. The rate of members 42-69 years of age receiving breast cancer screenings increased six percentage points over the baseline rate of 39.47 percent. The HSD/MAD threshold for this measure is 55 percent.

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Rate of screening mammograms for women ages 40-69 increased .73% from HEDIS 2011 to HEDIS®18 2012, while the denominator increased by 83.66% for this population. Presbyterian worked diligently to educate members and providers across the state on the importance of breast cancer screening, participating in more than 5 member health fairs/events in 2012. Increases in mobile mammography services and member incentives appear to have improved the rate. Presbyterian continues to pursue the use of member incentives for the SCI population, as they have seen a positive response from members in conjunction with Mobile Mammography services. Table 3 provides a breakdown of how this PIP was scored. Table 3. Salud! PIP #1 Audit Scores, Compliance Level and Historical Comparison

Presbyterian Salud! PIP #1 Breast Cancer Screening

2011 Actual Score

2012 Actual Score















Salud! PIP 2: Comprehensive Diabetes Care (HbA1c Testing) As shown in Table 4, Presbyterian demonstrated full compliance (100%) for the HbA1c PIP. Presbyterian continues to complete annual Strengths Weaknesses and Opportunities and Threats (SWOT) analyses. Strengths include collaboration among individuals and organizations to improve care, having a project manager dedicated to resolving data issues, and increased engagement with employer groups. Weaknesses included data capture issues that in some cases consumed a disproportionate amount of resources and the Health Solutions Coaching Program, which did not demonstrate consistent improvement. Interventions that Presbyterian implemented to overcome issues identified through their review include outreach efforts, gift card mailings, member education efforts, call campaigns, coordination with electronic health records and provider education.

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HEDIS is a registered trademark of the National Committee for Quality Assurance



Table 4. Salud! PIP #2 Audit Scores, Compliance Level and Historical Comparison

Presbyterian Salud! PIP #2 Comprehensive Diabetes Care (HbA1c Testing)

2011 Actual Score

2012 Actual Score















SCI PMP Audit Results Presbyterian achieved Full Compliance for the SCI PMP Audit. Table 5 reflects the scores for Molina for the selected PMP standards. The performance rates for the quality indicators were supplied by the MCO and are found in Table 6. Table 5. SCI PMP Audit Scores, Compliance Level and Historical Comparison

Presbyterian SCI PMP Audit

2011 Actual Score

2012 Actual Score

CQI Program









Presbyterian demonstrated full compliance (100%) in all areas of the SCI PMP. For the SCI Program, Presbyterian maintained rates for all measurements except HbA1c Testing, which declined by one percentage point. Their Breast Cancer Screening rate continues to be above the HSD/MAD threshold for this population. Presbyterian met all HSD/MAD thresholds except two: Retinal Eye Exams and Frequency of Ongoing Prenatal Care, which missed the threshold by 18 and 2 percent, respectively.



For Diabetes Disease Management, Presbyterian conducted a “Healthy Solutions Coaching Intervention” in which members were coached on lifestyle choices and how those impact HbA1c and LDL-C test results. The average HbA1c test result before the intervention was 9.16 and afterwards decreased to 8.17. The average LDL-C test result was 101.9 before the intervention and 107.6 after the intervention. Presbyterian also worked to increase the rates for timeliness of prenatal and post-partum care. Interventions undertaken were providing education materials through the PRESious Beginnings case management system, fundraising for Newborns in Need, call campaigns, and health promotion as part of the Presbyterian Rust Medical Center grand opening. Performance rates are the percentage of eligible members who received a specific treatment or service. Performance rates are helpful in assessing the effectiveness of MCO interventions and for comparing trends with state and national levels. Table 6 compares SCI performance rates with minimum thresholds set by HSD/MAD. The 2012 rates in red indicate rates that did not meet HSD/MAD thresholds. Table 6. SCI PM Performance Rates and Historical Comparison

Presbyterian SCI PM Performance Rates

2011 Rate

2012 Rate

2012 HSD/MAD Threshold





46% 46% 48%






Frequency of Ongoing Prenatal Care (>81%) 58% 58% 60%

SCI PIP Audit Results Presbyterian submitted two PIPs for the SCI Program:



SCI PIP 1: Breast Cancer Screening As shown in Table 7, Presbyterian achieved moderate compliance (80%) for this PIP. This PIP has not shown an increase in the rate of Breast Cancer Screening since its baseline year in

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2009. However, the 2009 denominator was fewer than 30 members; therefore, the 2010 rate became the baseline from which improvement and sustainability is assessed. Presbyterian continues to analyze the issue and find weaknesses to address. Currently, weaknesses include issues with scheduling mobile mammography events, lack of a call to action in the member newsletters, electronic medical record rollout with limited data sharing capacity, and a lack of proactivity by physicians. Table 7. SCI PIP #1 Audit Scores, Compliance Level and Historical Comparison

Presbyterian SCI PIP #1 Breast Cancer Screening

2011 Actual Score

2012 Actual Score















SCI PIP 2: Comprehensive Diabetes Care (HbA1c Testing) As shown in Table 8, Presbyterian demonstrated Full Compliance (100%) for this PIP. The baseline rate 76.47 percent was set in 2004. Performance rates is the ensuing years went up and have remained fairly stable vacillating from a low of 82 to a high 88 percent performance rates. As with the other PIPs, Presbyterian completed a Strengths Weaknesses, Opportunities and Threats (SWOT) analysis to find areas for improvement and intervention development. Presbyterian focused on member engagement for this PIP by implementing the Healthy Solutions Lifestyle Coaching, promoting use of family supports, working with community efforts including American Diabetes Association events, and television spots. Presbyterian also supported member involvement in the Take Care of Your Diabetes Conference and provided additional educational resources to providers. The interventions developed for this PIP proved effective at raising the rates of members with diabetes who received the HbA1C test and maintaining those rates above the HSD threshold.




Presbyterian SCI PIP #2 Comprehensive Diabetes Care (HbA1c Testing)

2011 Actual Score

2012 Actual Score















Outcome Measures Quality of health care is improved by striving to decrease the incidence of disease and/or reduce the occurrence of complications related to a disease process. Improvements are accomplished through a variety of activities designed to promote wellness and prevent disease. There is growing interest at the national and state levels for reporting health care outcome measures. In addition to process measures, HSD/MAD urged the MCOs to identify health care outcomes that will be addressed in future audits. On behalf of HSD/MAD, HealthInsight New Mexico requested clinical outcome measures for review, but those measures did not constitute a scored section of this audit. The information submitted is above and beyond what was required for the audit. Presbyterian submitted samples of their initial efforts to improve the quality of care received by members. HealthInsight New Mexico acknowledges and welcomes the additional information that Presbyterian provided in the spirit of cooperation to better understand the work they are doing to improve quality.



Presbyterian identified and reported the following measures for monitoring Salud! PM clinical outcomes.

Annual Preventive Dental Visits The number of members who had a dental exam during the measurement year who went on to have one crown installed within six months. Well Child Visits The number of members with a “Failure to Thrive” diagnosis who had at least one follow-up visit. Children and Adolescents’ Access to Primary Care The number of members aged 12 months to 19 years who had a PCP visit and a visit to the ER or urgent care office. Childhood Immunization Status (Combo 2) The number of members who had a Combo 2 vaccination who then had a claim for an illness against which they were vaccinated. Use of Appropriate Medications for People with Asthma The number of members who were compliant with their medication regimens and those that were not compliant. Presbyterian then measured how many in each category had an emergency department encounter from January through December of the measurement year. Breast Cancer Screening The number of eligible members who had mammograms who then had any of the following within three months: follow-up, biopsies, magnetic resonance imaging (MRI) or ultrasounds. Comprehensive Diabetes Care Presbyterian outcomes measures include: length of inpatient stay for members with diabetes, the number of admits per 1,000 members with diabetes and the number of ER visits per 1,000 members with diabetes. The reason for trending inpatient utilization is to determine if case management results in fewer ER visits, inpatient stays or less severe stays. Timeliness of Prenatal Care The number of members who received a prenatal visit in the first trimester or within 42 days of enrollment who then went on to give birth to a low-birth-weight20 baby. Frequency of Ongoing Prenatal Care The number of members who received more than 81 percent of expected visits that went on to give birth to a low-birth-weight baby.

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Information Systems Capabilities Assessment (ISCA) In association with the PM/PIPs audit, HealthInsight New Mexico conducted an ISCA for 2013. This review examined the 2012/2013 status of the MCOs’sinformation systems and data processing and reporting procedures, identifying strengths, challenges and recommendations.

The goal of the ISCA is to determine the extent to which each MCO’s information technology systems supported the production of valid and reliable state performance measures, the completeness and accuracy of the data collected and submitted to the State, and the capacity to manage the health care of its members. Discussion of Findings Overall, Presbyterian is fully compliant with the requirements of the ISCA. Recommendations There are no recommendations at this time.


Continue efforts to develop and implement innovative targeted interventions to improve rates for the Salud! population of: o Annual Preventive Dental Visits o Well Child Visits o Children and Adolescents Access to PCP Providers o Childhood Immunization o Breast Cancer Screening o HbA1c Testing o HbA1c Poor Control o Retinal Eye Exams o Timeliness of Prenatal Care o Timeliness of Post-Partum Care o Frequency of Ongoing Prenatal Care

Develop effective interventions to improve the rates of both Salud! PIPs.

For the SCI Population, develop effective interventions to improve the rates of Breast Cancer Screening to prevent further declines in both the PM and the related PIP.

Rebuttals and Reconsideration Requests Presbyterian requested reconsideration of the Salud! and the SCI PIPs entitled Breast Cancer Screening (BCS). The audit team held a conference call with Presbyterian representatives on June 27, 2013 to clarify and address the concerns set forth in the rebuttal materials. Salud! BCS PIP:

The Salud! BCS PIP was reconsidered and full points were awarded for question 8, “Identifies factors that affect ability to compare initial measurement with repeat measurement and/or threaten internal or external validity of finding” because the performance rate remains 6.19 percentage points over the baseline set in 2008. This information was originally overlooked in the submission. This PIP is now scored at 100 percent with full compliance.



Salud! HbA1c Testing PIP:

Reconsideration was also requested for the Salud! PIP HbA1c Testing. An original baseline was submitted and the current performance rate is 8.20 percentage points above the original baseline. Originally this PIP was reviewed with what was thought to be the baseline and determined to not have improved. With the original baseline, the score was revised to 100 percent with full compliance.

SCI BCS PIP:

The SCI BCS PIP was reconsidered and one point was awarded for identifying factors that affect ability to compare initial measurement with repeat measurements and for identifying factors that threaten the internal or external validity of findings. This PIP is now scored at 80 percent with a moderate compliance level.

A second rebuttal was received from Presbyterian with another request for reconsideration for the SCI BCS PIP. The score for question 9 remained unchanged. Credit was not awarded for “Improvement that appears to be the result of interventions” nor for “There is statistical evidence that observed improvement is true improvement.” For 2008, thought to be the baseline year, the performance rate was 75 percent. In that first year, the denominator was not sufficient to be reportable to NCQA (24 members in the universe) and therefore, could not be considered a true baseline rate. The next measurement rate was 62.41 percent and it being used as the baseline. The rate this year was 59.36 percent. The change is statistically insignificant but there is no rate improvement. There are documented changes in processes that could represent improvement and 50% credit was given for these efforts in the original audit determination.

The score for question 10, Assess Sustained Improvement, remains unchanged as repeated measurements over time (2009-2011) did not show an improvement. Last year only the 2009 and 2010 rates were considered for this PIP and question 10 was considered not applicable. This year there are three data points and sustained rate improvement was not documented. Therefore, the points for this question were not awarded.

SCI HbA1c Testing PIP:

The SCI HbA1c PIP remains unchanged for question 8, “Identifies factors that affect ability to compare initial measurement with repeat measurement and/or threaten internal or external validity of finding” because the performance rate remains stagnant at less than 1 percentage point above the baseline rate of 87.34 percent. Therefore, the points for this question were not awarded.