英文品质总结课件

1、Overview of 2009 Quality Assurance ActivitiesMaryland Department of Health and Mental HygieneNovember 19, 20091Overview of 2009 Quality AssuOverview2009 Quality review activities:Systems Performance ReviewEPSDT Record ReviewsHealthChoice Enrollee Satisfaction SurveysProvider Satisfaction SurveyHealt

2、hcare Effectiveness Data and Information Set (HEDIS) ReportValue-Based Purchasing Performance InitiativeConsumer Report CardPerformance Improvement Projects2Overview2009 Quality review acSystems Performance ReviewSince March 2003, CMS has required states to assess quality of care for Medicaid benefi

3、ciaries in managed care programs through review activities of the managed care organizations, including a review of organizational and structural performance, e.g. a Systems Performance Review (SPR). An External Quality Review Organization (EQRO) must carry out the tasks for the Medicaid program to

4、determine the degree of compliance with regulations, and provide quality assurance oversight. The Department contracts with Delmarva Foundation as our EQRO to conduct the SPR. The 2008 SPR consisted of 11 standards. The Department returned the Health Education standard as an active assessment area.3

5、Systems Performance ReviewSincSystem Performance Review (continued)The criteria applied to each standard is reviewed and updated annually to ensure compliance with any new regulations and to incorporate mutually agreed upon recommendations of the EQRO.Each MCO was rated separately on compliance with

6、 each standard.The minimum compliance rate was set for all standards at 100%, with the exception of the Fraud and Abuse standard, which again increased 10 points from the previous year, to 90%.For any standard, or components of a standard that did not meet the minimum compliance level, the MCO was r

7、equired to develop and implement an approved Corrective Action Plan (CAP).4System Performance Review (conSystems Performance ReviewStandardsMCO AggregateCY 2007MCO AggregateCY 2008ACCDIAMSFCJMSMPCPPMCOUHC1. Systematic Process100%100%100%100%100%100%100%100%100%2. Governing Body100%100%100%100%100%10

8、0%100%100%100%3. Oversight of Delegated Entities 98%*90%*86%*64%*100%100%100%79%*100%4. Credentialing96%*92%*97%*80%*100%87%*87%*95%*97%*5. Enrollee Rights99%*99%*100%100%100%100%100%100%96%*6. Availability and Access100%99%*100%95%*100%100%100%100%100%7. Utilization Review94%*95%*98%*88%*100%98%*98

9、%*90%*95%*8. Continuity of Care100%98%*100%88%*100%100%100%100%100%9. Health Education PlanExempt99%*100%96%*100%100%100%100%100%10. Outreach Plan95%*99%*100%96%*100%100%96%*100%100%11. Fraud and Abuse96%97%100%89%*100%100%97%95%97%5Systems Performance ReviewStanEPSDT Record ReviewsMedical record re

10、views of 2,618 children under the age of 21 were performed by Delmarva Foundation. Nurse reviewers went onsite to 416 provider offices.Adherence to Early and Periodic Screening, Diagnosis and Treatment standards in the following 5 components were the focus of the review:Health and Developmental Hist

11、oryComprehensive Physical ExamLaboratory TestsImmunizationsHealth Education and Anticipatory GuidanceMCOs must demonstrate at least a rate of 70% compliance by component; otherwise, a Corrective Action Plan (CAP) is required. Last year, 3 MCOs developed CAPS for lab testing; 2008 scores increased fo

12、r those MCOs by 8.8%-14.5%. No CAPs were indicated following this years review.6EPSDT Record ReviewsMedical reEPSDT Record Reviews (continued)ComponentAggregate Scores CY 2007Aggregate Scores CY 2008Health and Developmental History81%85%Comprehensive Physical Exam91%92%Laboratory Tests/At Risk Scree

13、nings(PKU, lead, anemia, risk assts. For TB, cholesterol, STD, etc.)78%79%Immunizations93%90%Health Education and Anticipatory Guidance89%89%7EPSDT Record Reviews (continueEnrollee Satisfaction Surveys DHMH conducts an enrollee satisfaction survey annually using the Consumer Assessment of Healthcare

14、 Providers and Systems (CAHPS) survey instruments to evaluate members satisfaction with their health plans. WB&A conducted the survey for DHMH with adults ages 18 or older, and children ages 17 or younger. All members surveyed were enrolled in HealthChoice for at least the last 5 of 6 months of 2008

15、. Surveys included question sets covering:Getting Needed CareGetting Care QuicklyShared Decision-makingHow Well Doctors CommunicateCoordination of Care8Enrollee Satisfaction Surveys Enrollee Satisfaction Surveys (continued)In 2009, CAHPS surveys were mailed to 11,952 Medicaid adults and 18,187 Medic

16、aid children. Completed surveys yielded 3,746 adult and 4,830 child questionnaires for analysis. This represents an adult response rate of 32%, a 1% increase from survey year 2008. Children responded at a rate of 39%, a 12% increase in participation from survey year 2008.On Adult responses, highest

17、satisfaction was found with Shared Decision-making, and Getting Needed Care. Of most importance to their satisfaction with a plan is Customer Service and Getting Needed Care. Specifically, adults want to receive information or help from Customer Service Reps., and to receive tests or treatment they

18、feel they need.On Child responses, highest satisfaction was found with How Well Doctors Communicate, and Shared Decision-making. Specifically, respondents feel doctors listened to them, explained things in a way that was understandable for them, and showed respect for caregivers opinions. 9Enrollee

19、Satisfaction Surveys Provider Satisfaction SurveysWB&A conducted the 2009 annual Provider Satisfaction Survey of the HealthChoice program for DHMH. A random sample of Primary Care Providers (PCPs) from each of the seven MCOs was chosen. From an aggregate of 4,155 mailed surveys, 769 responses were r

20、eceived, raising the response rate from last year to 19%, a 6% increase. 10Provider Satisfaction SurveysWProvider Satisfaction Surveys (continued)Satisfaction survey topics included:No-Show HealthChoice Appointments Overall SatisfactionFinance IssuesCustomer Service/Provider RelationsCoordination of

21、 Care and Case ManagementUtilization ManagementIn 2009, providers satisfaction overall was measured to be 71%. Seventy-five percent would recommend HealthChoice to their patients, and 72% said they would recommend the program to other physicians. Opportunities to increase satisfaction exist with Cus

22、tomer Service, Finance issues, Case Management, and Utilization Review processes. While lower scores were noted in these areas, all categories improved from 1-7%.11Provider Satisfaction Surveys HEDIS Performance Measures The Healthcare Effectiveness Data and Information Set (HEDIS) is a standardized

23、 set of performance measures developed by the National Committee for Quality Assurance (NCQA) to measure health plan performance for comparison among health systems. This standardized tool is used by more than 90% of health plans across the country. Health plans also use the information as a basis f

24、or strategic planning. Each element is evaluated at least every three years by NCQA on the basis of continued desirability, statistical analysis, audit review results, and user comments. Subsequently, NCQA releases yearly updates to the measurement set. HealthcareData Company, LLC, performs the audi

25、ts and reports to the Department on HealthChoice MCOs scores. MCOs use claims and encounter data to produce the results. For some measures, MCOs supplement incomplete data with medical record reviews. 12HEDIS Performance Measures TheHEDIS Performance MeasuresFor 2009, MCOs were required to report th

26、eir performance on 20 HEDIS measures.Effectiveness of Care-Childhood Immunization Status-Breast Cancer Screening-Cervical Cancer Screening-Comprehensive Diabetes Care-Use of Appropriate Medications for People with Asthma-Appropriate Treatment for Children with Upper Respiratory Infection -Appropriat

27、e Testing for Children with Pharyngitis -Chlamydia Screening in WomenAccess/Availability of Care-Children and Adolescents Access to Primary Care Practitioners-Adults Access to Preventive/Ambulatory Health Services-Prenatal and Postpartum Care-Call Answer Timeliness-Call Abandonment-Initiation and En

28、gagement of Alcohol and Other Drug Dependence TreatmentUse Of Services-Frequency of Ongoing Prenatal Care-Well-Child Visits in the First 15 Months of Life-Well-Child Visits in the Third, Fourth, Fifth and Sixth Year of Life-Adolescent Well-Care Visits-Ambulatory Care -Identification of Alcohol and O

29、ther Drug Services13HEDIS Performance MeasuresFor HEDIS Performance Measures (continued)HEDIS 2009 included the same measures as reported for the prior year, and the addition of two new measures, Initiation and Engagement of Alcohol and Other Drug Dependence Treatment, and Identification of Alcohol

30、and Other Drug Services. Because they are first year measures, they were test measures only for this report. Performance increases deserving special attention are: -*Appropriate Testing of Children with Pharyngitis (prior to dispensing antibiotic treatment) 5.4% *Eye Exams for Diabetics 2.9% *Use of

31、 Appropriate Medications for Asthma 2.8% *Timely Pre and Postnatal Visits 2.2% 14HEDIS Performance Measures (coDepartment of Health and Mental Hygiene15Department of Health and MentaDepartment of Health and Mental Hygiene16Department of Health and MentaDepartment of Health and Mental Hygiene17Depart

32、ment of Health and MentaValue-Based PurchasingValue Based Purchasing is a set of performance measures selected from current HealthChoice monitoring activities.The goal of our Value Based Purchasing strategy is to improve MCO performance by providing monetary incentives and disincentives.These nine m

33、easures cover important dimensions of MCO performance:Access to CareQuality of Care 5 of the 9 measures are taken from the HEDIS project, while 4 are selected by the Department from Maryland Medicaid HealthChoice Encounter Data.18Value-Based PurchasingValue BaValue-Based Purchasing (continued)Target

34、s for each measure have been established based on three levels of performance:Disincentive:For any measure that the MCO does not meet the minimum target, a disincentive of 1/9th of 1/2 percent of the total capitation paid to the MCO during the measurement year will be collected.NeutralIncentive:For

35、any measure that the MCO exceeds the minimum target, the MCO shall be paid an incentive payment of up to 1/9th of 1/2 percent of the total capitation amount paid to the MCO during the measurement year.19Value-Based Purchasing (contin2008 Preliminary Value Based Purchasing Scores-Department of Health

36、 and Mental HygienePerformanceMeasureCY 2008TargetACCDIAJMSMPCMSFCPPMCOUHCIncentive (I); Neutral (N); Disincentive (D)Well-Child Visits for Children Ages 36 Incentive: 87%Neutral: 73%87%Disincentive: 50%Neutral: 47%50% Disincentive: 86%Neutral: 80%86%Disincentive: 76%Neutral: 71%76%Disincentive: 97%

37、Neutral: 86%97%Disincentive: 73%Neutral: 66%73%Disincentive: 58%Neutral: 50%58%Disincentive: 79%Neutral: 65%79%Disincentive: 91%Neutral: 82%91%Disincentive: 82%82(N)73(D)87(N)75(D)89(N)82(N)85 (N)202008 Preliminary Value Based PConsumer Report CardThis is the ninth year of production for our HealthC

38、hoice Consumer Report Card.Since its inception, the Department has been contracting with the NCQA via the EQRO contract to develop the methodology and calculate the MCOs scores.The 6 performance areas rated in the Report Card are calculated compiling 40 measures from HEDIS, Encounter Data, and the S

39、atisfaction Survey. They cover performance in the following domains: Access to Care, Doctor Communication and Service, Keeping Kids Healthy, Care for Kids with Chronic Illness, Taking Care of Women, and Diabetes Care.A 1-3 star rating system (below average, average, above average) is used to represent how an MC