Validation of Performance Measures for PMHPs
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Transcript of Validation of Performance Measures for PMHPs
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Validation of Performance Measures Validation of Performance Measures for PMHPsfor PMHPs
Presenter:
Peggy Ketterer, RN, BSN, CHCAExecutive Director, EQRO Services
Health Services Advisory Group
January 17, 2008
10:00 a.m.–12:00 p.m.
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Balanced Budget Act (BBA) of 1997
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Balanced Budget Act (BBA) of 1997
42CFR438.240
States must require each managed care organization (MCO) and pre-paid inpatient health plan (PIHP) to annually measure and report performance to the state using standardized measures.
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Balanced Budget Act (BBA) of 1997 (cont)
42CFR438.356
The BBA also requires that states contract with an EQRO for an annual independent review of each MCO and PIHP to evaluate the quality and timeliness of, and access to, health care services provided to Medicaid enrollees.
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Balanced Budget Act (BBA) of 1997
42CFR438.358
States must ensure that the performance measures are validated annually through the external quality review process.
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Performance Measures
Performance Measure Characteristics:
• Standardized
• Clearly defined
• Meaningful and timely
• Results in comparable data
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Performance Measures
Key Roles:
• States identify measures and data submission format
• MCOs and PIHPs collect, calculate, and submit performance measure data to the State using required submission format
• Performance measures are validated annually by the EQRO following required CMS protocols
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Calculation and Reporting of Performance Measures
Performance Measure Calculation:
A Brief Overview
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Step 1: Identify necessary data sources and data elements for reporting the selected measures
• Membership/enrollment data
• Claims/encounter data
• Other administrative data (if available), i.e., inpatient utilization reports, kept appointment database
Calculation and Reporting of Performance Measures
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Step 2: Prepare data set
• Extract data
• Clean data (valid variables, formats)
• Verify completeness and accuracy
• Establish data element to link data sources (unique member ID)
Calculation and Reporting of Performance Measures
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Step 3: Produce source code to calculate measures
• Calculate continuous enrollment and anchor date
• Determine member age• Include diagnosis and procedure codes needed
to identify service events• Exclusion logic
Calculation and Reporting of Performance Measures
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Step 4: Calculate measures administratively
• Run source code
• Examine output files
• Review preliminary administrative results
Calculation and Reporting of Performance Measures
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Step 5: Validate results
• Review calculated rates for reasonability
• Examine data output file and verify with source data (membership and encounter data)
Calculation and Reporting of Performance Measures
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Step 9: Submit Performance Measure reports to the state
• Utilize state-specified format
Calculation and Reporting of Performance Measures (cont)
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• Written Description
• Calculation (the percentage of X who had Y)
• Eligible Population Criteria
• Numerator Event Criteria
• Exclusion Criteria
• Reporting Format
Diagram of a Performance Measure
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The percent of enrollees who were hospitalized for a mental health diagnosis and were discharged to the community from an acute care facility and were seen on an outpatient basis by a mental health practitioner and/or case manager within seven days.
Written Description
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Three calculations will be generated:
•The percentage of enrollees who had a follow-up visit with a mental health practitioner
•The percentage of enrollees who had a follow-up visit with a mental health practitioner and/or case manager
•The percentage of enrollees who had a follow-up visit with a case manager
Calculation
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Specifies any age, continuous enrollment (CE), and event/diagnosis requirements•Age: no requirement – all enrollees•CE: Date of discharge through 7 days after discharge•Event/diagnosis: Discharged to the community from an acute care facility (inpatient or crisis stabilization unit) with specific diagnosis codes indicating a mental health disorder
Eligible Population Criteria
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Specifies any exclusions
•Enrollees who died
•Enrollees who were re-admitted within 7 days of discharge
•Enrollees whose discharges were followed by readmission or direct transfer
Exclusion Criteria
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Specifies any exclusions (cont’d)
•Enrollees who receive Florida Assertive Community Treatment services
•Enrollees who are admitted to hospice, nursing facilities, state mental health facilities, correctional institutions or hospice programs
Exclusion Criteria
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An outpatient follow-up encounter with a mental health practitioner up to seven days after hospital discharge
•Mental health practitioner definitions are specified
•Service codes for follow-up encounter are specified
Numerator Event Criteria
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•Identifies the data elements necessary for reporting (i.e. eligible population, numerator events, rate)
•Includes a grid for entering data elements
Reporting Format
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Three Main Phases:
•Pre-On-Site
•On-Site
•Post-On-Site
Validation Activities
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Validation Activities
Pre-On-Site Activities:
• Identify measures to be validated
• Prepare Information System Capabilities Assessment Tool (ISCAT) request
• Schedule site visits and prepare agendas
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Validation Activities
Pre-On-Site Activities (cont):
• Receive completed ISCATs from PMHPs
• Review ISCATs to assess information system integrity and capabilities
• Conduct pre-on-site conference call with each PMHP
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Validation Activities
On-Site Activities (for each PMHP):
• Duration – approximately 2 days
• Conduct opening meeting
• Complete on-site activities – including systems walkthroughs, demonstrations, and measure specific review
• Conduct exit conference
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Validation Activities
Post-On-Site Activities:
• Evaluate corrective actions and follow-up items
• Determine validation findings for each performance measure
• Prepare draft report – submit to AHCA and PMHPs for comments
• Prepare final report
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Validation ActivitiesProposed Timeline
Task Jan 2008
Feb 2008
Mar 2008
Apr 2008
May 2008
Jun 2008
Jul 2008
Aug 2008
Validation Performance
Measures
for PMHPs
05/19/08 – 05/30/08
Conduct Onsite Visits
04/11/08Receive PMHP documentation
03/10/08
Request ISCAT Documentation
06/09/08 – 07/11/08
Prepare Report
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Questions and Answers
Open Discussion