Quality of Care in Managed Care Eugenia Andrew, HHSC Julia Marsh Klepac, HHSC Jonica Fitzmorris, HHSC
May 30, 2012
Topics • Overview of Medicaid Managed Care in Texas • Managed Care Program History • Managed Care Programs • Managed Care Expansion • Texas Medicaid Managed Care Quality Strategy • MCO Compliance • Performance Measurement • Performance Improvement • Quality Report Results/Recommendations • Quality of Care Reports • CAHPS Survey Reports • EQRO Summary of Activities & Trends • Quality Initiatives 2
Overview of Medicaid Managed Care in Texas
Managed Care Program History 1993 • Texas implemented a managed care pilot project in Travis County for acute care services, known as LoneSTAR. The name later shortened to STAR. • Texas also implemented the Primary Care Case Management (PCCM) pilot for acute care services in Chambers, Jefferson, and Galveston Counties.
1995-2006 • STAR continued to expand to most urban areas. • September 2005 PCCM expanded to 197 counties outside of STAR Service Areas. • By December 2006, PCCM phased-out of the STAR service areas except Southeast Region (Jefferson, Chambers, Orange, Hardin, and Liberty) 4
Managed Care Program History 1998 • Texas implemented the STAR+PLUS pilot in the Harris Service Area. Nationally-recognized model integrated acute care and long-term services and supports (LTSS), and included capitated inpatient services.
1999 • Texas implemented the NorthSTAR behavioral health pilot in the Dallas Service Area.
2007 • STAR+PLUS expanded to the Bexar, Harris Expansion, Nueces, and Travis Service Areas, but carved out nonbehavioral health inpatient services. 5
Managed Care Program History 2008 • Texas implemented the statewide STAR Health model for children in State conservatorship.
2011 • Texas expanded the inpatient carve-out model of STAR+PLUS to the Dallas and Tarrant Service Areas. • Texas expanded STAR and STAR+PLUS to contiguous counties.
Managed Care Programs
Current Delivery Models STAR • Capitated Managed Care Organization (MCO) model for pregnant women, TANF recipients, SSI recipients, and low income children and families. • Provides acute care services. • Currently operates under a federal 1115 Waiver.
Primary Care Case Management (PCCM)* • Non-capitated service delivery model where primary care providers (PCPs) receive monthly case management fees for coordinating acute care services. • Provides acute care services. • Includes non-disabled pregnant women, children and disabled adults. • Currently operates under the State Plan and a 1915(b) Waiver for selective contracting. * PCCM is no longer in existence. 8
Current Delivery Models STAR+PLUS • Capitated MCO model for Medicaid recipients who are aged, disabled, and/or chronically ill • Provides integrated acute care services and LTSS through service coordination. • Includes Dual Eligibles (Medicaid and Medicare) • Dual Eligibles account for slightly more than half of STAR+PLUS membership • Service Coordinators help coordinate these members’ Medicare acute care and Medicaid services • Behavioral health inpatient services are capitated and, effective March 1, 2012, all other inpatient services are capitated. • Currently operates under a federal 1115 waiver. • MAO (217 group) Waiver includes an interest list, SSI 9 Waiver does not.
Current Delivery Models NorthSTAR • Capitated MCO model that provides mental health and substance abuse services to Medicaid clients. • Operates under a federal 1915(b) Waiver.
STAR Health • Capitated MCO model for children in or recently exiting State conservatorship (primarily foster children). • Provides acute care services. • Provides acute care services with emphasis on behavioral health and medication management. • Operates under the State Plan.
New Delivery Model Medicaid Dental Services • Capitated MCO model • Primary and preventative dental services for children
Managed Care Expansion
Managed Care Expansion September 1, 2011 Expanded existing STAR and STAR+PLUS Services Areas to contiguous counties: • STAR: • additional counties added to the Bexar, El Paso, Harris, Nueces, and Travis Service Areas, • combined Harris and Harris Expansion Service Areas in the Harris Service Area • Formed new Jefferson Service Area
• STAR+PLUS • Additional counties added to the Bexar, Harris, Nueces, and Travis Service Areas • Combined Harris and Harris Expansion Services Areas into the Harris Service Area • Formed new Jefferson Service Area 13
Managed Care Expansion March 1, 2012 Largest expansion of Medicaid Managed Care in the country had huge impact. • 3 million Medicaid recipients • Thousands of acute and long term services and support providers • Thousands of SSI adults taken off interest lists and provided Medicaid State Plan services. • Continuity of services maintained for majority of recipients. • Multi-agency effort and cooperation.
Managed Care Expansion March 1, 2012 STAR/Medicaid Rural Service Areas (MRSA) • Expanded STAR into two new regions: • Hidalgo Service Area • Medicaid Rural Service Areas (Medicaid RSAs) • Replaces PCCM • Carved-in prescription drugs • Added mandatory enrollment for SSI adults in MRSAs where STAR+PLUS is not an option.
STAR Expansion Dallam Sherman Hansford Ochiltree Lipscomb
Dallam Sherman Hansford Ochiltree Lipscomb Hartley Moore Hutchinson Roberts Hemphill Oldham Potter Carson GrayWheeler Deaf Randall Smith Armstrong Donley Collingsworth
Dallam Sherman Hansford Ochiltree Lipscomb
Hartley Hutchinson Moore Roberts Hemphill
Hartley Hutchinson Moore Roberts Hemphill
Oldham Potter Carson GrayWheeler
Oldham Potter Carson GrayWheeler
Deaf Randall Smith Armstrong Donley Collingsworth
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Medicaid Rural Service Areas
STAR+PLUS Expansion March 1, 2012 STAR+PLUS • Expanded STAR+PLUS: • El Paso, Lubbock, and Hidalgo Service Areas • Will not expand to the Medicaid MRSA – 1915(c) LTSS will be available to clients in these service areas through other waiver programs. • Carved-in inpatient hospital services (non-BH) • Carved-in prescription drugs • Added mandatory enrollment for SSI (age 21 and older) in new service areas.
STAR+PLUS Expansion Dallam Sherman Hansford Ochiltree Lipscomb
Dallam Sherman Hansford Ochiltree Lipscomb
Hartley Hutchinson Moore Roberts Hemphill
Hartley Hutchinson Moore Roberts Hemphill
Oldham Potter Carson GrayWheeler
Oldham Potter Carson GrayWheeler
Deaf Randall Smith Armstrong Donley Collingsworth
Deaf Smith Randall Armstrong Donley Collingsworth
Parmer Castro Swisher Briscoe HallChildress Parmer Castro Swisher Briscoe HallChildress Hardeman Hardeman Motley Cottle Wilbarger Bailey Lamb HaleFloyd Wichita Foard Motley Cottle Wilbarger Bailey Lamb HaleFloyd Wichita Foard Clay Lamar Cooke Grayson KingKnox Baylor Red River Hockley Lubbock Crosby Dickens Archer Montag Cochran ClayMontague Fannin Lamar Bowie Cooke KingKnox Baylor Grayson Red River Crosby Dickens Archer Hockley Lubbock Cochran Fannin Delta ue Titus Bowie JackWiseDenton Delta Collin KentStonewall Terry LynnGarza Haskell Throckmorton Young Yoakum Franklin HuntHopkins Morris Cass Jack Titus Collin Camp Terry LynnGarza KentStonewall Hask Throckmorton Young WiseDenton Franklin Yoakum HuntHopkins Morris Rains R Cass Palo Marion Wood Parker Tarrant Dallas Camp Dawson Borden Scurry Fisher Gaines Jones Shackelford Stephens Upshur ell Rains R Kaufman Palo Marion o Wood Parker Van Zandt Tarrant Harrison Dallas Pinto Borden Scurry Gaines Dawson Fisher Jones Shackelford Stephens Upshur Gregg Hood Johnson Smith Ellis oKaufman Eastland Erath Van Zandt Harrison Pinto Andrews Martin Howard Mitchell Nolan Taylor Callahan c Gregg Henderson Hood Somervell Navarro Panola Johnson Smith Ellis Rusk Eastland Erath Howard Mitchell Nolan Andrews Martin c Taylor Callahan Somervell Hill k Henderson Coma Bosque Panola El Paso CokeRunnels Ector Midland Glasscock Winkler Loving Rusk Cherokee Sterling Anderson Shelby Coleman Brown k Hill Navarro Hamilton w Freestone nche Bosque El Paso CokeRunnels Comanc Nacogdoches Ector Midland Glasscock Loving Winkler Cherokee Sterling McLennan Anderson Limestone Shelby Coleman Brown Mills Coryell San Augustine w Freestone Hudspeth Culberson WardCrane a Tom Green he Hamilton Upton Reagan Sabine Nacogdoches Concho Reeves Irion McLennan Falls LeonHouston Angelina Limestone McCulloch a Hudspeth Culberson WardCrane San Lampasas Saba l Green Mills Coryell San Augustine Trinity Upton Reagan Sabine Bell Reeves Robertson IrionTom Concho Angelina Fallsl LeonHouston Jasper M McCulloch Schleicher Menard San Lampasas Saba l Burnet Milam PolkTyler Newton Trinity Walker Crockett Bell Robertson Mason Jeff Davis Pecos Llano Madison Brazos Williamson Jasper a l Schleicher Menard San Jacinto Grimes SuttonKimble Burleson Burnet Milam PolkTyler Newton Walker Crockett Jeff Davis Pecos Mason Llano d Montgomery Brazos TravisLee Hardin Williamson Gillespie Blanco Terrell GrimesSan Jacinto Washington SuttonKimble Burleson Kerr iWaller Liberty Orange Hays BastropAustin PresidioBrewster TravisLee Hardin Edwards Gillespie Montgomery Kendall Blanco Jefferson Val Verde Terrell Washington Caldwell RealBandera F HarrisChambers Liberty Orange Comal s Kerr Bastrop Hays Waller Presidio Edwards Kendall Guadalupe Jefferson a Colorado Fort Bend Val Verde Austin HarrisChambers Fayette o Caldwell RealBanderaComal Gonzales Brewster Bexar Galveston Lavaca Uvalde Medina Kinney Wharton y GuadalupeColorado n Brazoria Wilson Fort Bend De Witt Bexar Gonzales Galveston Lavaca Uvalde Medina Kinney Jackson KarneseVictoria Wharton Frio Atascosa Zavala Matagorda Brazoria Wilson Maverick De Witt t Goliad Jackson KarnesVictoria Frio Atascosa Bee Zavala Matagorda Dimmit t Calhoun McMullen Live Oak La Salle Maverick Refugio Goliad eAransas Calhoun Bee San Patricio Dimmit McMullen Live Oak La Salle Refugio Webb Duval Jim Nueces Wells SanAransas Patricio K Webb Duval Jim Nueces Wells l Jim Brooks Hogg Zapata Kenedy K e l Jim Brooks Hogg Starr b Willacy Zapata Hidalgo eKenedy e Cameron Starr bWillacy r Hidalgo e Cameron g r g
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Children’s Medicaid Dental March 1, 2012 Medicaid Dental Services • Implemented a statewide managed care model for the delivery of primary and preventative dental care for children.
Benefits of Expansion • Better access to providers and provider information through member materials, such as member handbooks, provider directories, and educational materials. • Choice of a primary care provider and main dental home provider, or assignment to one if the member does not make a selection. • Enhanced Medicaid benefits 1915(b)(3) services: • Unlimited inpatient benefits (the current FFS program limits inpatient stays to 30 days, except for transplants) • Behavioral health services for adults that are not limited quantitatively as they are in FFS. • Value-added benefits offered by MCOs, which may include 24-hour nurse lines, additional transportation assistance, cell phones for high-risk clients, and weight loss programs. • Federal and State cost savings. 21
Managed Care Providers • Providers must contract and be credentialed with the MCO to provide STAR and/or STAR+PLUS services. • Rates are negotiated between the provider and the MCO.
• Authorization requirements may be different and must be obtained from the MCO. • Providers must follow MCO 95-day billing requirements.
Texas Medicaid Managed Care Quality Strategy Compliance – Measurement – Improvement
Managed Care Program Goals • HHSC contracts for measurable results that:
• Improve member access, satisfaction, and quality of care. • Maximize program efficiency, effectiveness, and responsiveness. • Limit operational costs. • How does the State measure results? • Value-Based Purchasing (VBP) • External Quality Review Organization (EQRO) 24
Value-Based Purchasing (VBP) • Refers to any purchasing practices aimed at improving the value of services provided by a contractor (e.g., MCOs) • Focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing contractors. • Examines the relationship between quality and cost, rather than the individual value alone.
Value-Based Purchasing (cont’d) HHSC’s objectives for VBP initiative and MCOs:
1. Specify what you want to buy 2. Prioritize aspects of MCO performance that are important 3. Identify opportunities for improvement 4. Set improvement goals 5. Recognize and reward excellence and improvement 6. Collect and evaluate 7. Apply incentives/disincentives 26
External Quality Review Organization (EQRO) • Balanced Budget Act of 1997 requires State Medicaid agencies to provide for an annual external independent review of the quality outcomes, timeliness of, and access to services provided by Medicaid managed care organizations. • HHSC contracts with Institute of Child Health Policy (ICHP) at the University of Florida
CMS EQRO Requirements CMS requires the EQRO to perform the following three functions: 1. Validation of performance improvement projects 2. Validation of performance measures 3. A review to determine MCO compliance with certain federal Medicaid managed care regulations.
Additional EQRO Functions In Texas, the EQRO also performs the following: 1. Focused quality of care studies 2. Encounter data validation
3. Assessment or validation of member satisfaction 4. Provides assistance with rate setting activities.
Administrator Interviews (AI) • Purpose: • To review and evaluate each MCO’s structure and processes to provide quality care and services to members. • The AI Survey Tools are web-based • Three separate AI tools: • Physical Health Tool (STAR/STAR+PLUS/CHIP/STAR Health/MRSA)
• Behavioral Health Tool (NorthSTAR) • Dental Health Tool (Children’s Medicaid Dental/CHIP Dental)
Quality Assessment and Performance Improvement Programs
• Purpose of the QAPI Program: • To ensure that the MCOs provide quality health care to Medicaid clients. • To provide a mechanism to ensure continuous improvement in the care and services provided. • To assess compliance to state and federal regulations required for managed care organizations.
CQI/TQM Principles 1. Evaluate performance using objective quality indicators. 2. Foster data-driven decision making. 3. Recognize that opportunities for improvement are unlimited. 4. Solicit member and provider input on performance and QAPI activities.
CQI/TQM Principles (cont’d) 5. Support continuous ongoing measurement of clinical and non-clinical effectiveness and member satisfaction. 6. Support programmatic improvements of clinical and non-clinical processes based on findings from ongoing measurements. 7. Support re-measurement of effectiveness and member satisfaction, and continued development and implementation of improvement interventions as appropriate.
QAPI Annual Evaluation • Performance Improvement Structure • This describes how to evaluate the MCO’s operational components. • MCO’s assessment of the effectiveness of its QAPI Program • State the MCO’s conclusions regarding the effectiveness of the QAPI Program during the measurement period. • Conclusions must be supported by subsequent reporting of the MCO’s ability to achieve established goal and objectives, as well as results and analyses. 35
EQRO Quality of Care Reports • ICHP produces an annual Quality of Care Report for each of Medicaid managed care programs in Texas. • Reports provide results of the quality of care for each MCO using: • Selected Healthcare Effectiveness Data and Information Set (HEDIS) measures • Rates of inpatient and emergency department services for ambulatory care sensitive conditions (ACSCs) • The Agency for Healthcare Research and Quality Pediatric Indicators (PDIs) and Prevention Quality Indicators (PQIs) 37
Quality of Care Reporting (cont’d) • Quality of care results allow comparison of findings across MCOs in each program. • Results are used in the development and review of performance improvement projects and benchmarks for the Dashboard indicators.
EQRO CAHPS Surveys The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey tool is: • Designed for adult members and parents of children under 21 to report on and evaluate their experiences with health care. • To address important domains of care such as: • Access of care. • Timeliness of care. • Doctor communication. • Health plan interactions.
EQRO Medical Chart Reviews • ICHP works with MCOs to annually assess selected HEDIS measures that require chart reviews. • CY 2012 measures for STAR and STAR+PLUS are: • Controlling High Blood Pressure • Comprehensive Diabetes Care – poor HbA1c control, LDL controlled • Adult BMI Assessment • Childhood Immunization Status – Combo 4 • Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
Performance Indicator Dashboard • Performance Indicator Dashboard is a series of measures that identify key aspects of performance to ensure the MCO’s accountability. • Assesses many of the most important dimensions of the MCO’s performance. • Includes measures that, when publicly shared, will serve to incentivize excellence.
• STAR and STAR+PLUS Performance Indicator Dashboard for Quality Measures for CY 2012 online: www.hhsc.state.tx.us/medicaid/umcm/Chp10/10_1_7.pdf
Dashboard BH Indicators • % of good access to BH treatment or counseling – adult and children • 7-day follow-up after hospital stay for mental health • 30-day follow-up after hospital stay for mental health • 30-day readmission rate after MH hospital stay – adult and children
• Antidepressant medication management – acute phase
Dashboard BH Indicators (cont’d) • Antidepressant medication management – Continuation phase • Follow-up care for children prescribed ADHD medication: Initiation (ADD)
• Follow-up care for children prescribed ADHD medication: Maintenance (ADD) • Initiation and engagement of alcohol and other drug dependence treatment (IET) • Identification of alcohol and other drug services (IAD) • Mental health utilization (MPT) 43
HHSC Overarching Goals • HHSC develops two overarching goals and negotiates a third goal suggested by the MCO each year for health care quality improvement. • SFY 2012 STAR Overarching Goals • Improve treatment for ACSC through reduction of emergency department visits. • Improve access to specialty care. • SFY 2012 STAR+PLUS Overarching Goals • Improve member understanding and utilization of service coordination. • Increase access to or utilization of preventive care 45
Performance Improvement Projects (PIPs) • MCO is required to provide three PIPs per MCO Program each year. • At least one PIP must be related to an overarching goal established by HHCS.
• Projects are highly specified and measurable and reflect areas that present significant opportunities for performance improvement. • The projects become part of each MCO’s annual plan for its Quality Assurance and Performance Improvement (QAPI) Program.
Capitation At-Risk • Capitation Rate At-Risk methodology is dependent on the outcome of pre-identified performance-based measures. • Uniform Managed Care Contract (UMCC) includes a provision which puts up to five percent of the MCO’s capitation at risk. • The objective is that all MCOs achieve performance levels that enable to receive the full at-risk amount. • HHSC identifies no more than 10 at-risk performance indicators for each MCO Program.
Performance-Based Measures Minimum percentage targets are based, in part, on:
• HHSC MCO Program objectives of ensuring access to care and quality of care. • Past performance of the HHSC MCOs. • Performance of Medicaid and CHIP MCOs nationally on HEDIS and CAHPS measures.
2012-2013 At-Risk Measures • CY 2012 5% At-Risk Measures • To assess network adequacy. • Clean claims adjudicated ≤ 30 days • Call timeliness • CY 2013 5% At-Risk Measures • Using 8 HEDIS measures and specifications to evaluate MCO performance in the STAR, CHIP, and STAR+PLUS Programs • Listed in Uniform Managed Care Manual, Chapter 6.2.1 www.hhsc.state.tx.us/medicaid/umcm/Chp6/6_2_1.pdf 49
Quality Challenge Award • HHSC reallocates any unearned funds from the performance-based, at-risk portion of a MCO’s capitation rate to the MCO Program’s Quality Challenge Award. • HHSC determines the number of MCOs that will receive Quality Challenge Award funds annually based on the amount of the funds to be reallocated. • Separate Quality Challenge Award payments are made for each of the MCO programs. • HHSC works with the EQRO and the MCOs to identify the performance indicators for which their capitation will be placed at risk. 50
Quality Report Results Quality of Care Reports CAHPS Survey Reports EQRO Summary of Activities & Trends
Quality Results • STAR and STAR+PLUS Medicaid Programs • Sampling of Results from Reports used in Quality Review • Positive Findings, Behavioral Health Findings, Areas Recommended for Improvement and Program Trends • Where to find Published Reports
Quality Results • Annual Quality of Care Reports (QOCs) • Consumer Assessment of Healthcare Providers and Systems Survey Reports (CAHPS) • Annual Summary of Activities and Trends in Healthcare Quality Report (SOA)
Measures Measures found in Reports and Survey Results • Demographic Characteristics • Member Health Status
• Access to Care • Utilization of Services
• Service Coordination • Effectiveness of Care • Behavioral Health Care 54
STAR Program Pregnant Women TANF Recipients SSI Recipients Low Income Children and Families
STAR Quality of Care Report Fiscal Year 2010
STAR Member Demographics
STAR Member Demographics – August 2010 Number of members:
Average member age:
Gender Female Male
Percent of STAR Members
Race/ethnicity Percent of STAR Members Hispanic 60% Black, non-Hispanic 18% White, non-Hispanic 15%
Pediatric Quality Indicators Pediatric Quality Indicators (PDIs) – rates lower for 4 out of 5 national averages. Inpatient admission rates for four of five PDIs were lower than the corresponding national averages, which is indicative of good pediatric outpatient care. Inpatient admission rates per 100,000 members: Pediatric Quality Indicators
Diabetes short-term complications
Urinary tract infection
ED Utilization Emergency department utilization lower than national HEDIS mean. • Overall, STAR members had 59 emergency department (ED) visits per 1,000 member months, which is lower than the national HEDIS mean of 67 per 1,000 member months. • Utilization of the ED was highest among members less than one year old and generally decreased with age.
Access to PCP High access rates to primary care practitioners for children and adolescents. Rates of access to primary care practitioners were very high for children and adolescents in STAR, with more than 95% reporting a visit with a PCP. – – – –
98% for members 12 to 24 months old 95% for members 25 months to 6 years old 96% for members 7 to 11 years old 95% for members 12 to 19 years old
BH Measure: ADHD Follow-up ADHD Follow-up Care for Children 6 to 12 years old. • 47% of children had an initial follow-up visit with a provider within 30 days of beginning an ADHD medication. • 58% of children remained on an ADHD medication for at least 7 months and had two or more follow-up visits with a provider within 9 months.
BH Measure: Follow-up Care Follow-up care after hospitalization for mental illness exceeds standards.
All STAR MCOs met or exceeded the HHSC Performance Dashboard standards for follow-up care after hospitalization for mental illness of 32% for 7-day follow-up after discharge and 52%
for 30-day follow-up after discharge.
BH Measure: MH Readmission Mental health readmission rates reduced. The percentage of STAR Program members readmitted within 30 days following an inpatient stay for a mental health disorder went from 22 percent in state fiscal year 2009 to 11 percent in 2010. Mental health readmissions are frequently used as a measure of an adverse outcome, which potentially results from efforts to contain behavioral health care costs, such as reducing the initial length of stay. Low rates of readmission indicate good performance.
Postpartum Care Access to postpartum care: Sixty percent of pregnant women in STAR had a postpartum visit three to eight weeks after giving birth.
HHSC’s Performance Indicator Dashboard Standard for this measure is 65 percent. Thirteen out of 14 MCOs did not meet the HHSC standard.
Postpartum Care Results by MCO Cook Children’s was the only STAR MCO to meet HHSC’s standard with 67% of women in the MCO receiving a timely postpartum visit. Five MCOs came close to meeting the 65% standard. Aetna 64% Amerigroup 61% Community First 63% El Paso First 64% UniCare 62%
Percentage of Female STAR Program Members Receiving Postpartum Care
Recommendation to Improve HHSC efforts to improve access to postpartum care: MCOs are required to offer obstetrics case management to those members identified with a high-risk pregnancy. HHSC continues to encourage MCOs to offer value-added services, which improve prenatal and postpartum care.
Recommendation to Improve Appropriate testing for children with pharyngitis: A little more than half (52 percent) of all children in the STAR Program diagnosed with pharyngitis and given an antibiotic also received a strep test from their provider, which is 10 percentage points below the national HEDIS Medicaid rate. A low percentage can be an indicator that providers are inappropriately prescribing antibiotics.
What is pharyngitis: Pharyngitis, an inflammation of the throat, remains one of the most common reasons for seeking medical care. It is usually caused by a bacterial or viral infection, with group A Streptococcus being the most likely cause. Pharyngitis is not normally serious, but cases related to strep throat can have severe complications.
Source: eHow.com http://www.ehow.com/how_4455118_diagnose-pharyngitis.html
Testing for Pharyngitis Appropriate Testing for Children with Pharyngitis
Only two STAR MCOs, Cook Children’s (69%) and Parkland (63%) met or exceeded the national Medicaid HEDIS rate of 62% for appropriate strep testing. El Paso First was the lowest performing MCO with 33% receiving appropriate testing. Four service areas met or exceeded the HEDIS rate (not on chart): Bexar – Superior 62% Dallas – Amerigroup 61% Dallas – Parkland 63% Tarrant – Cook 69% Travis – Amerigroup 65%
Recommendation to Improve HHSC’s efforts to improve appropriate testing for children with pharyngitis: HHSC encourages health plans to provide member and provider education on the use of antibiotics with proper testing to children presenting with a sore throat.
STAR CAHPS Report FY 2011 STAR Child Survey
Provider Ratings Child health services in STAR rated higher than national averages. The majority of caregivers in STAR rated their child’s health care, doctors, and health plan a 9 or 10 on a 10-point scale. These ratings were higher than nationally published Medicaid rates Percent of caregivers rating child's health services a "9" or "10" 100%
40% 20% 0% Chi l d's Heal th Care
Chi l d's Pers onal Doctor
Chi l d's Speci alis t
Chi l d's Heal th Pl an
Medi cai d nati onal average
Doctor Communication Majority of caregivers in STAR highly satisfied with how well doctors communicate. The majority of caregivers were highly satisfied with the quality of communication they had with their child’s personal doctor. Percentage of Caregivers Who Reported Their Child’s Doctor Usually or Always… Listened carefully
Explained things well to parent
Explained things well to child
Spent enough time w/child
Access to Care Measures • A majority of caregivers (79%) reported that they usually or always were able to make a routine appointment as soon as they thought their child needed. • Most caregivers (86%) whose child needed care right away for an illness, injury or other condition, reported they usually or always received care as soon as needed. • The majority of caregivers (69%) reported that they were usually or always able to get a referral for their child to see a specialist. • Most caregivers (84%) reported that they usually or always had positive interactions with customer service at their child’s health plan.
Developmental Care • A majority of caregivers in STAR whose child had a visit with their personal doctor in the past six months of the measurement period, reported their child’s doctor had a discussion with them about their child’s growth, moods and emotions, behavior, social functioning and learning ability. • National Medicaid comparative data is not available for these survey items, but the results are useful in evaluating the extent to which primary care providers take a “whole-person” approach to providing care. The Percentage of Caregivers Who Reported That Their Child’s Doctor Discussed… 76%
How child's body is growing
Child's moods and emotions
Behaviors that are normal for a child at this age 58%
How child gets along with others
Child's learning ability 0%
Recommendations to Improve Potentially preventable emergency department (ED) visits: Among caregivers who took their child to the ED, over half said they visited the ED because they could not get an appointment at a doctor’s office or clinic as soon as they thought their child needed care.
This type of potentially preventable ED visit was associated with lower personal doctor ratings and lower scores on doctors’ communication, independent of other demographic, health status and health plan factors.
Getting needed care: Seventy-two percent of STAR caregivers usually or always had positive experiences with getting needed care; however, this is lower compared to Medicaid plans nationally, in which 79 percent of caregivers report usually or always having positive experiences with getting needed care. 76
Recommendations to Improve HHSC’s efforts to reduce potentially preventable ED visits and improve access to routine care: HHSC established an overarching goal in fiscal year 2012, which targets potentially preventable emergency department visits. MCOs have implemented performance improvement projects that address the overarching goal relevant to the reduction of potentially preventable ED visits. The implementation of these performance improvement projects may also improve caregiver satisfaction in obtaining routine care. 77
Summary of Activities STAR Program Measurement Period September 2007 – August 2010
Well-Child Visits (0-15) STAR Well-Child Visits (0 – 15 Months) are Rising Well-Child visits for children 0-15 months increased by 1.3 times from 48% in 2008 to 63% in 2010. Rates exceeded the HHSC Dashboard standard of 35% all 3 years.
0% 2008 STAR
HHSC Dashboard Standard
Well-Child Visits (3-6 Yrs) STAR Well-Child Visits (3 – 6 Years) are Rising 100%
Well-Child visits for ages 3-6 years increased slightly from 71% in 2008 to 80% in 2010.
Rates exceeded the HHSC Dashboard standard of 56% in all 3 years.
2010 HHSC Dashboard Standard
Adolescent Well-Care STAR Adolescent Well-Care Visits are Rising 100%
Well-Care visits for adolescents increased by 1.2 times from 51% in 2008 to 63% in 2010.
Rates exceeded the HHSC Dashboard standard of 38% in all 3 years.
HHSC Dashboard Standard
PCP Access STAR Child/Adolescent PCP Access is Increasing 100%
Rates of good access to a PCP for children and adolescents were above the HHSC Dashboard Standard all three measurement years.
Children 12 to 24 months had the highest rates of good access to a PCP.
HHSC Dashboard Standard
STAR+PLUS Program Aged, Disabled, and/or Chronically Ill Integrated Acute Care + LTSS Includes Dual Eligibles
STAR+PLUS Quality of Care Report Fiscal Year 2010
STAR+PLUS Demographics STAR+PLUS Member Demographics – August 2010 Number of Medicaid-only members: 80,259 Average member age: Gender Female Male
Percent of STAR+PLUS Members 54% 46%
Race/ethnicity Percent of STAR+PLUS Members Hispanic 33% Black, non-Hispanic 31% White, non-Hispanic 26%
Preventive Care Adult Access to Preventive/Ambulatory Health Services meets national mean. Eighty-eight percent of members 45-64 years old and 87%of members 65 years and older had an outpatient or preventive care visit during the measurement period. For each of these age groups, the STAR+PLUS program had higher rates of preventive care visits than Medicaid Managed Care plans reporting nationally to the NCQA, both being 85%. Members 45 to 64 Years Old With 1+ Preventive Care Visits
0% STAR+PLUS Program
AMERIGROUP Evercare Molina Superior
Members 65+ Years Old With 1+ Preventive Care Visits
88.35% 86.02% 88.01%
HEDIS® mean 85%
89.14% 82.95% 88.89%
HEDIS® mean 85%
Well-Child Visits Well Child and Adolescent Well-Care Visits above HHSC Dashboard Standard. Sixty-nine percent of children three to six years old and 46% of adolescents in the STAR+PLUS program had a well-child visit. Exceeding HHSC Performance Indicator Dashboard standards of 56 and 38% respectively. Members 3 to 6 Years Old With One or More Well-Child Visits 0%
Adolescent Members With One or More Well-Child Visits 0%
42.54% 45.92% 51.82% HHSC Dashboard Standard - 38%
HHSC Dashboard Standard - 56%
Asthma Medication Use of Appropriate Medications for People with Asthma Exceeds Standards. Ninety-four percent of STAR+PLUS members 10 to 17 years old and 91 percent of members 18 to 56 years old were appropriately treated for asthma, exceeding HHSC Performance Indicator Dashboard standards of 57 and 62 percent respectively. Appropriate Asthma Rx for Members 10 to 17 Years Old. 0%
Appropriate Asthma Rx for Members 18 to 56 Years Old. 80%
93.02% HHSC Dashboard Standard - 57%
HHSC Dashboard Standard - 62%
Antidepressant Medication Antidepressant Medication Management The performance of the STAR+PLUS program in managing the antidepressant medication treatment of members with major depression was comparable to the national NCQA HEDIS mean. Half of the adults in STAR+PLUS remained on antidepressant medication for at least 12 weeks during the acute phase of treatment and 36% continued to take antidepressant medication for at least six months (continuation phase of treatment).
BH Follow-up Care Follow-Up Care After Hospitalization for Mental Illness Forty-six percent of STAR+PLUS members had follow-up care after hospitalization for mental illness with a provider within seven days of discharge from the hospital and 72% of members had a follow-up visit with a provider within 30 days of discharge, exceeding HHSC Performance Indicator Dashboard standards of 32 and 52 percent respectively. 0%
7-day follow-up 30-day follow-up
46.27% 72.23% 42.56% 69.66% 52.10% 72.06% 53.44%
75.40% 41.76% 74.89% HHSC Dashboard Standard, 7-day follow-up - 32%
HHSC Dashboard Standard, 30-day follow-up - 52%
Women’s Preventive Care Women’s Preventive Care and Screenings
Forty-two percent of adult women in STAR+PLUS had a Pap test to screen for cervical cancer and 43% had a mammogram screen for breast cancer. These rates are considerably lower than the national HEDIS means of 66 and 52 percent respectively and the HHSC cervical cancer screening Dashboard Standard of 66%.
Women’s Preventive Care by MCO Women’s Preventive Care and Screenings 0%
No STAR+PLUS MCOs met HHSC or national standards for Cervical Cancer Screenings.
46.24% HHSC Dashboard Standard - 60%
All STAR+PLUS MCOs performed below the HEDIS mean of 52% for Breast Cancer Screening.
HEDIS® mean 66%
41.40% 39.79% 35.45% 47.42%
HEDIS® mean 52%
Recommendations to Improve HHSC efforts to improve women’s preventive care and screenings:
National standards for these screenings changed in 2009. HHSC continues to review standards of care for breast and cervical cancer screening to determine if current baseline measurement reflects the industry standard. The HEDIS® measures Breast Cancer Screening and Cervical Cancer Screening were added to the 2011 Performance Indicator Dashboard to monitor MCO improvement. HHSC continues to encourage MCOs to educate providers on the importance of preventive screening for breast cancer and cervical cancer. 93
Avoidance of Antibiotics Avoidance of antibiotics treatment in adults with acute bronchitis: Eighteen percent of members who were diagnosed with acute bronchitis were appropriately treated for this condition and not dispensed an antibiotic prescription, compared to 26% among Medicaid Managed Care plans reporting nationally to the NCQA. Acute bronchitis is usually caused by a viral infection and thus symptom management is considered the appropriate treatment, rather than prescribing antibiotics.
Antibiotic Treatment by MCO Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis MCO performance on this measure was comparable across plans, with majority of members not receiving appropriate treatment. By service area, the percentage of members appropriately treated ranged from 13% in the Travis service area to 19 percent in Harris.
17.29% HEDIS® mean 26%
Recommendations to Improve HHSC efforts to improve avoidance of antibiotics treatment in adults with acute bronchitis: The HEDIS measure Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) was added to the 2011 Performance Indicator Dashboard in order to monitor MCO performance improvement. HHSC continues to encourage MCOs to educate providers and members on the appropriate use of prescribing antibiotics for the treatment of acute bronchitis.
STAR+PLUS CAHPS Report FY 2010 Adult Member Survey
CAHPS Composite Scores Among the four CAHPS composites, mean scores for the areas of How Well Doctors Communicate, Getting Care Quickly, and Customer Service were at or above 75, which indicates that members generally had positive experiences and were satisfied with their health care in these domains.
How Well Doctors Communicate
Getting Care Quickly
Getting Needed Care
Member Ratings Member Ratings A majority of members provided high ratings of their health care, personal doctor, specialist and health plan. The highest ratings were observed for members’ personal doctor and specialist. Member Ratings
Mental Health Care
HHSC STAR+PLUS Standards The STAR+PLUS program met the Dashboard standards for five of the seven performance indicators. The majority of members had good access to routine care, urgent care, specialist referral, and special therapies. In addition, a majority of smokers were advised to quit smoking by their provider within the last six months of the measurement period. FY 2010 STAR+PLUS
HHSC Performance Dashboard Standard
Good access to urgent care
Good access to specialist referral
Good access to routine care
No delays in health care while waiting for health plan approval
No exam room wait greater than 15 minutes
Good access to special therapies
Good access to Service Coordination
Smokers advised to quit smoking on a visit
BH: Mental Health Ratings Members’ Rating of Their Mental Health A large percentage of members (46%) rated their mental health as fair or poor. Twenty-seven percent rated their mental health as good and another 27% rated their mental health as very good or excellent. 35% 31% 30%
10% 5% 0% Good 101
Recommendation to Improve Specialized Services: The STAR+PLUS program overall had low member ratings for getting access to specialized services, which assesses access to specialist care, tests and treatment from the health plan. Special medical equipment
The Percentage of STAR+PLUS Members Reporting How Often They Were Able to Get Specialized Services
Home health care
Mental health treatment
Usually or Always
Recommendation to Improve
HHSC efforts to improve access to specialized services: HHSC will consider setting a program goal related to getting needed care to address members’ concerns regarding access to specialized services.
Service Coordination: A low percentage (23%) of STAR+PLUS members said they had a service coordinator; 77% said they did not have one, although many (41%) said they would like to have a service coordinator.
The Percentage of STAR+PLUS Members with a Service Coordinator
Had a service coordinator Did not have a service coordinator 77%
Recommendation to Improve
HHSC efforts to improve access to service coordination: For 2012, one of the program goals for STAR+PLUS is to “Improve member understanding and utilization of service coordination.” Performance improvement projects (PIPs) have been developed by the MCOs to address this goal.
Member Obesity: STAR+PLUS members had high rates of overweight and obesity, particularly among women and Hispanics.
Underweight Healthy Overweight
Recommendation to Improve
HHSC efforts to improve rates of member obesity: HHSC included the HEDIS Adult Body Mass Index (BMI) Assessment in the 2013 Quality Challenge Award, which is a financial incentive for health plans.
Summary of Activities STAR+PLUS Program Measurement Period September 2007 – August 2010
Access to Care Access to Care in STAR+PLUS is Improving Getting Needed Care combines responses regarding access to: appointments with specialists; and tests, or treatment through the health plan.
Getting Care Quickly combines responses regarding the timeliness of: urgent care; and appointments for health care at a doctor’s office or clinic.
Well-Child Visits STAR+PLUS Well-Child Visits (3 – 6 Years) are Increasing Well-Child Visits for STAR+PLUS members three to six years old increased from 62 % in 2008 to 69% in 2010.
Rates exceeded the HHSC Dashboard standard of 56 percent in all three years.
Adolescent Well-Child Visits STAR+PLUS Adolescent Well-Child Visits are Increasing The rate of Adolescent WellCare Visits in STAR+PLUS increased by 1.3 times, from 35% in 2008 to 46% in 2010.
The rate in SFY 2008 (35%) was slightly lower than the HHSC Dashboard standard of 38 percent, while rates in SFY 2009 and SFY 2010 exceeded the standard.
2011 Summary of Activities Report EQRO Findings
Access to Care Access to Primary & Specialist Care is Good • Across Programs, child and adolescent members had good access to PCPs.
• Generally, over 90% of members visited a PCP during the measurement period. • Survey results indicate that STAR+PLUS members generally received timely care and were able to get urgent care and doctor’s appointments when needed.
Asthma & Diabetes Management of Asthma & Diabetes is Very Good • Over the 3-year measurement period, rates of appropriate treatment for asthma were consistently high (above 90%) among children and adolescents. • In addition, the rate of appropriate asthma treatment among adults in STAR+PLUS was considerably higher (91%) than the HHSC Dashboard standard. • Rates of HbA1c testing, LDL-C screening, and medical attention for nephropathy were well above the corresponding HHSC Dashboard standards for all programs. 114
Follow-Care for MH Follow-up Care for Mental Illness is Above Dashboard Standards In all programs, rates of follow-up within seven and 30 days of discharge from hospitalization for mental illness were consistently above HHSC Dashboard standards.
Report References •
Quality of Care Reports • Texas Medicaid Managed Care STAR Program Quality of Care Report – FY 2010 • Texas Medicaid Managed Care STAR+PLUS Quality of Care Report – FY 2010 CAHPS Survey Reports • Texas Medicaid STAR Program Child Survey Report – FY 2011 • Texas Medicaid STAR+PLUS Program Adult Member Survey Report – FY 2010 2011 EQRO Summary of Activities and Trends in Healthcare Quality
HHSC Reports Online: www.hhsc.state.tx.us/about_hhsc/reports/search/Search_Reports.asp
Quality Initiatives • Potentially Preventable Events (PPEs) • Inpatient Stays • Hospital Readmissions • Emergency Department (ED) Visits
• High PPE rates may reflect inadequacies in the health care provided to the patient in multiple settings, including inpatient and outpatient facilities and clinics. • HHSC intends to include PPE measures in the CY 2014 5% At-Risk and Quality Challenge Award Measures 118
Quality Initiatives Rider 50 • The 2010-11 General Appropriations Act directed HHSC to develop a report on strategies to improve the transparency and accountability of behavioral health services in the STAR and STAR+PLUS Medicaid managed care programs.
• Results • Addition of five additional HEDIS measures related to behavioral health • • • • •
HEDIS Antidepressant Medication Management HEDIS Follow-up Care for Children Prescribed ADHD Medication HEDIS Initiation and Engagement of Alcohol and Other Drug Dependence Treatment HEDIS Identification of Alcohol and Other Drug Services HEDIS Mental Health Utilization 119
Quality Initiatives • Results (continued) •
Existing measures related to behavioral health: • Percent of members receiving follow-up within 7 days after an inpatient stay for mental health • Percent of members receiving follow-up within 30 days after an inpatient stay for mental health • Percent of members readmitted within 30 days after an inpatient stay for mental health Implementation of Performance Improvement Projects for MCOs Addition of biennial surveys to assess member satisfaction with behavioral health services delivered through STAR and STAR+PLUS 120
Quality Initiatives MIPCD Project • Medicaid Incentives for Prevention of Chronic Disease (MIPCD) Project is a five-year grant to fund interventions to help prevent chronic disease among STAR+PLUS Medicaidonly members with behavioral health conditions. • DSHS has oversight of project. • Employs a complement of person-centered incentives to empower participants to take charge of their health. • Goals include: • • • •
Improved health self-management Increased use of preventive services More appropriate use of health care services Greater satisfaction with health care and with personal progress toward wellness. 121
Quality Initiatives Dual Eligible STAR+PLUS Focus Study • To assess the unique needs of this population, the EQRO is conducting a two-year focus study to examine the following: • The physical and mental health status for STAR+PLUS beneficiaries using self-report measures. • • • •
Key aspects of health care quality to include: Aspirin use and discussion. Medical assistance with smoking and tobacco use cessation. Flu shots for older adults, using the CAHPS survey tool.
• The EQRO is working with CMS to obtain Medicare claims for the STAR+PLUS population and link these claims to the Medicaid claims/encounter data.