Patricia MacTaggart, GWU

ACAP July 15 at 11:15 a.m.

Plugging the Gaps in Quality Reporting

Quality & Financial Costs Due to Gaps In Insurance

Coverage• Interruptions in Medicaid

Coverage: increases in hospitalizations for ambulatory sensitive conditions

• Women with continuous Medicaid enrollment: more likely to be screened for breast cancer

• Those with continuous coverage: less likely to be hospitalized in an inpatient psychiatric facility and have lower overall psychiatric care costs

Current Medicaid Quality Federal Requirements

Managed Care Organizations:

• Pre-contract: MCOs have sufficient provider capacity to serve the expected enrollment

• Ongoing: – Quality monitoring & improvement

processes mandated– Development and Implementation

of Quality Assessment and Improvement Strategy (QAPI) that addresses timely access, quality of care and quality of care delivery,

– Annual external independent review of the quality outcomes and timeliness of, and access to, services

Primary Care Case Management (PCCM) & fee-for-service arrangements:

• No comparable quality monitoring or improvement requirements

Current Approaches to Quality Monitoring in

Medicaid MCOs

• CAHPS: experience survey for past 6 months

• HEDIS: performance measures

• HEDIS-Like: same numerator and denominator specifications as a HEDIS measure but exclude the continuous enrollment requirement Reproduced from NCQA, State Recognition of NCQA,

http://www.ncqa.org/tabid/135/Default.aspx

Quality MonitoringPCCMs & FFS

• CMS: reinitiated a Medicaid modernization and quality measurement analysis project, which is being undertaken by NCQA

• Oklahoma and North Carolina: developed quality measurement approaches for their PCCM programs, including the use of HEDIS measures.

MCO vs FFS Feasibility: The New York State

Experience

Reproduced from Roohan, et al. 2006.

Measure MCO Rate FFS Rate

Well-child and preventive health visits age 15 months

55% 62%

Well-child and preventive health visits age 3-6 years

77% 71%

Adolescent well care and preventive care visit 64% 47%

Prenatal care in the first trimester 63% 59%

Use of appropriate medications for persons with asthma (Total)

60% 55%

Ages 5-17 53% 51%

Ages 18-56 62% 60%

Comparison Between Medicaid Managed Care and Medicaid Fee-for-Service Administrative Measures

Medicaid Continuous Quality Act Proposal: HHS Within 2 Years

• Develop System and Process to be used by States to Report on Quality of Care: Managed Care Organizations, PCCM or Fee-For-Service Providers

• Comparisons of Quality Measurements:– Across Systems Nationally or by State– Head-to-head Comparison: Across MCOs, PCCM, and

FFS • Feasible with Comparable Measures

• Consult Advisory Group in Developing System:

– State Agency Officials, – Health Care Providers and Consumers, – National Organizations with Expertise in Health Care

Quality and Performance Measurement and Public Reporting,

– Voluntary Consensus Standard-Setting Organizations and Other Organizations involved in the Advancement of Evidence-Based Measures of Health Care.

Medicaid Continuous Quality Act Proposal: Within 2 Years HHS

• Measures: Reviewed & Approved by National Quality Forum

• Timeline: Initial reporting within Two Years of Enactment

• Measures include:– Duration of Health Insurance Coverage over 12-Month

Time Period,– Preventive Services Availability and Effectiveness – Acute Conditions Treatments and Follow-up Care – Chronic Physical & Behavioral Health Treatment and

Management– Availability of Care in Ambulatory and Inpatient – Other Measures Relevant to Measuring Quality of Health

Care for Medicaid Enrollees to allow for Comparability across Health Care Delivery Approaches.

Future Case Rate Payments Dependent on Addressing

Quality• Acute-Care Global Case Rate: admitting

hospital would get payment for initial stay and any additional hospital admissions that occur within 30 days

• Acute-Care Global Case Rate, including Post-Acute Care: hospital care plus post-acute care

• Acute-Care Global Case Rate, including Post-Acute, Physician-Treated Inpatient and ER Care:

Opportunities through Children’s Health Insurance Program

Reauthorization Act of 2009 (CHIPRA), H.R. 2

• Expanding Eligibility: Streamline enrollment/retention: Express Lane Eligibility and Outreach

• Expanding Coverage: wrap around dental coverage• Payment: study on provider payments• Improving Quality:

– Develop and implement evidence-based quality measures for children: Core set of measures through AHRQ/CMS effort

– Encourage development and dissemination of model children’s e-health record

– Demonstrated program to reduce child obesity

Opportunities Through ARRA Incentives for Medicaid Providers

• Providers:– Non-hospital based professionals:

• At least 30 percent patient volume Medicaid patients• Physicians, dentists, certified nurse mid-wives, nurse practitioners

& certain physician assistants – Non-hospital based pediatricians: at least 20 percent patient volume

Medicaid– Children’s Hospitals– Acute-care hospital: at least 10 percent patient volume Medicaid

patients– Federally Qualified Health Center or Rural Health Clinic : at least 30

percent of patient volume needy individuals

• Payments:– “Meaningful Use”:

• Established by State & Acceptable to the Secretary• Aligned with Medicare & including Support Services • Exchanges information across different health care

providers• Reporting quality measures

ARRA for Medicaid State Responsibilities

• States must use the funds for purposes of administering the incentive payments, including tracking of meaningful use by Medicaid providers; – Based on Medicaid Management Information System (MMIS) and

MITA framework capable to pay the incentive payments. (APD)

• States must conduct adequate oversight, including routine tracking of meaningful use attestations and reporting mechanisms; which will require look behinds– Human and IT resources for look behind capability

• States must “pursue initiatives to encourage the adoption of certified EHR technology to promote health care quality and the exchange of health care information under this title, subject to applicable laws and regulations governing such exchange”– Need to address information exchanges with other state agencies

within their state, with other public and private entities within their states, with other states and entities in other states and with ONC .

– Following the MITA framework, states need to establish a baseline (“as is”), a vision of where they are going (“to be”), and roadmap to go from the “as is” to the “to be” vision.

Questions/Comments