Texas Medicaid and Children’s Health Insurance Program · 2017. 10. 27. · List of Tables Table 1. Texas Medicaid/CHIP Managed Care Organizations and Programs in 2016 8 Table 2

Texas Medicaid and Children’sHealth Insurance Program

Summary of Activities and Trends in Healthcare Quality

Addendum: Performance Improvement Projects and Encounter Data Validation: Medical Record Review

Contract Year: 2016

Measurement Period: 2015-2016

The Institute for Child Health PolicyUniversity of Florida

The External Quality Review Organizationfor Texas Medicaid Managed Care and CHIP

Table of Contents

1.

Executive Summary

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.................................................................................................................................. 11.1. Introduction ......................................................................................................................................................................................2

1.2. Methodology 2

1.3. Findings & Recommendations 3

2. Introduction 52.1. Managed Care Programs and Participating Managed Care Organizations 6

3. Encounter Data Validation: Medical Record Review 93.1. Methodology 10

3.1.1. Sampling 10

3.1.2. Health Records and Confidentiality 11

3.1.3. Analysis 12

3.2. Results 13

3.3. Recommendations...........................................................................................................................................................................18

4. Performance Improvement Project Evaluation 194.1. Methodology 20

4.2. Results 21

4.2.1. Asthma 21

4.2.2. Diabetes 25

4.2.3. COPD 27

4.2.4. Well-Child Visits in the Third through Sixth Years of Life 29

4.2.5. Adolescent Well-Care Visits 30

4.3. Recommendations...........................................................................................................................................................................34

5. Endnotes 36

List of Acronyms

AMR Asthma Medication Ratio

AWC Adolescent Well-Care Visits

CDC Comprehensive Diabetes Care

CHIP Children’s Health Insurance Program

CMS Centers for Medicare and Medicaid Services

COPD Chronic Obstructive Pulmonary Disorder

DOS Date of Service

EDVMRR Encounter Data Validation: Medical Record Review

EQRO External Quality Review Organization

HEDIS® Healthcare Effectiveness Data and Information Set

HHS Texas Health and Human Services (A Multi-Agency Enterprise Which Includes the State Medicaid Agency)

ICHP Institute for Child Health Policy

MCO Managed Care Organization

MMA Medication Management for People with Asthma

PIP Performance Improvement Project

POS Point of Service

PPA Potentially Preventable Admissions

STAR State of Texas Access Reform

W34 Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life

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List of Tables

Table 1. Texas Medicaid/CHIP Managed Care Organizations and Programs in 2016 8

Table 2. Date of Service Match Rates by MCO and Program 14

Table 3. Place of Service Match Rates by MCO and Program 15

Table 4. Primary Diagnosis Match Rates by MCO and Program 16

Table 5. Procedure Match Rates by MCO and Program ....... 17

Table 6. STAR MCOs, with Asthma PIPs, Performance on Select Measures 23

Table 7. STAR+PLUS MCOs, with Asthma PIPs, Performance on Select Measures ..... 24

Table 8. CHIP MCOs, with Asthma PIPs, Performance on Select Measures 24

Table 9. STAR MCOs, with Diabetes PIPs, Performance on Select Measures 26

Table 10. STAR+PLUS MCOs, with Diabetes PIPs, Performance on Select Measures 26

Table 11. STAR+PLUS MCOs, with COPD PIPs, Performance on Select Measures 28

Table 12. CHIP Health Plan, with W34 PIPs, Performance on Select Measures 30

Table 13. STAR MCOs, with AWC PIPs, Performance on Select Measures 32

Table 14. CHIP MCOs, with AWC PIPs, Performance on Select Measures 33

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List of Figures

Figure 1. Asthma PIP Plan and Final PIP Revised Scores by Program and Health Plan 21

Figure 2. Diabetes PIP Plan and Final PIP Revised Scores by Program and Health Plan 25

Figure 3. COPD PIP Plan and Final PIP Revised Scores by Program and Health Plan 27

Figure 4. W34 PIP Plan and Final PIP Revised Scores by Program and Health Plan 29

Figure 5. AWC PIP Plan and Final PIP Revised Scores by Program and Health Plan 31

1. EXECUTIVE SUMMARY

2 Addendum: Performance Improvement Projects and Encounter Data Validation: Medical Record Review

1.1. Introduction

This report addendum summarizes evaluation activities conducted by the Institute for Child Health Policy (ICHP) at the University of Florida to meet federal requirements for external quality review of Texas Medicaid managed care and the Children's Health Insurance Program (CHIP). The ICHP has served as the external quality review organization (EQRO) for the Texas Health and Human Services (HHS) since 2002. The findings discussed in this report are based on performance improvement project (PIP) review and encounter data validation: medical record review (EDVMRR) activities conducted during fiscal year 2016, and supplement the primary annual report document titled Texas Medicaid Managed Care and Children’s Health Insurance Program: Summary of Activities and Trends in Health Care Quality, Contract Year 2016.

The review is structured to comply with the Centers for Medicare and Medicaid Services (CMS) federal guidelines and protocols, and addresses care provided by health plans participating in Texas Medicaid and CHIP. 1

1.2. Methodology

Encounter Data Validation: Medical Record Review

The EQRO annually validates encounter data for accu-racy and completeness by comparing submitted claims against a representative sample of dental or medical re-cords. In 2016, medical records were reviewed. Using medical records received directly from Texas Medicaid and CHIP providers, the EQRO examined the claims data for the corresponding members to validate whether each data element could be matched in both sources. The EQRO calculated match rates for: date of service (DOS), place of service (POS), primary diagnosis, and procedures.

Please note that the methodology used in this study changed from the one used in the 2013 Physical Health EDVMRR study. Therefore, the results cannot be com-pared to results from previous years’ EDVMRR studies.

Performance Improvement Project

Following guidance by CMS, the EQRO systematizes evaluation of each PIP according to several activities,

1. Executive Summary


each of which comprises one or more components. Activities for the planning phase, progress reports, and final evaluation differ for each phase. Scoring for each component of each activity for each PIP is based on a three-point scale: component met (100 percent), component partially met (50 percent), or component not met (0 percent). The score for each activity is the average of component scores. The score for each performance improvement project at each phase is the average of all activity scores.

1.3. Findings & Recommendations

Encounter Data Validation: Medical Record Review

Finding 1: Match Rates Vary by Health Plan and Program - Across all data elements, the match rates for STAR+PLUS were the lowest, while the highest match rates were for CHIP. For STAR+PLUS, across the four review data elements, Molina consistently had the lowest match rates amongst STAR+PLUS MCOs.

Recommendation 1: The EQRO recommends that HHS investigate the reasons for low match rates for some MCOs, such as type of diagnosis or whether the POS occurred at community or clinic setting.

Performance Improvement Project

Finding 1: Asthma – All STAR MCOs addressed Medication Management for People with Asthma (MMA) as part of their asthma PIPs. UnitedHealthcare was the only MCO to see a decline in their MMA rate from 2013 through 2015, despite having one of the higher overall PIP scores for asthma. Community Health Choice and Texas Children’s partnered with Walgreens Pharmacy to provider asthma education at the point of sale for asthma medication. FirstCare had a targeted outreach program for members who were non-compliant with their medication. UnitedHealthcare only provided asthma literature to members on the disease process and the asthma education plan, but did not clearly state how it would address medication management.

Recommendation 1: The EQRO recommends that HHS encourage the health plans to have targeted, detailed interventions that address the specific quality of care measure(s) that are part of their PIP.

Finding 2: Well-Child Visits – Among CHIP MCOs that had a Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34) PIP, Molina had the lowest PIP plan and final scores, the lowest overall PIP score, and




the lowest 2015 W34 rate. Amerigroup and Superior targeted primary care providers by offering a pay-for-performance program and encouraging providers to be a part of a preferred provider network respectively. El Paso offered a $15 gift card to members due for a well-child visit in their birthday month. However, Molina just contacted members that were not in compliance.

Recommendation 1: The EQRO recommends that HHS encourage the health plans conducting a W34 PIP use either member- or provider-based incentives.

Finding 3: PIP Interventions – Health plans who conducted PIPs in multiple programs used the same interventions across programs despite the diverse member and provider populations across programs. For example, Molina and FirstCare conducted the same asthma PIP intervention for their STAR, STAR+PLUS, and CHIP populations; while Superior conducted the same Comprehensive Diabetes Care PIP intervention for their STAR and STAR+PLUS provider populations. FirstCare and Molina had different overall PIP scores based on program, while Molina had the same overall PIP score for each program.

Recommendation 1: Despite some observed positive outcomes from the PIPs overall, the EQRO recommends that HHS encourage MCOs, who address the same PIP topic across multiple programs, tailor their intervention plans so that they are specific to the provider/member make-up of each program.

2. INTRODUCTION

2. Introduction


This report addendum summarizes evaluation activities conducted by the Institute for Child Health Policy (ICHP) at the University of Florida to meet federal requirements for external quality review of Texas Medicaid managed care and the Children's Health Insurance Program (CHIP). The ICHP has served as the external quality review organization (EQRO) for the Texas Health and Human Services (HHS) since 2002. The findings discussed in this report are based on performance improvement project (PIP) review and encounter data validation: medical record review (EDVMRR) activities conducted during fiscal year 2016, and supplement the primary annual report document titled Texas Medicaid Managed Care and Children’s Health Insurance Program: Summary of Activities and Trends in Health Care Quality, Contract Year 2016. This report provides the EQRO’s evaluation of EDVMRR and PIPs.

Validation of Medicaid and CHIP managed care PIPs is one of the key federally mandated activities of an EQRO.2 All health plans that participate in state Medicaid programs must design and implement PIPs that cover specific problems and populations, with the aim of improving quality of care and health outcomes for Medicaid and CHIP beneficiaries.

This report also shows findings of EDVMRR study conducted by the EQRO to assess the quality of administrative claims and encounter data generated by the managed care organizations (MCO). Conducting medical record review to validate encounter data—the EDVMRR study—is considered by Centers for Medicare and Medicaid Services (CMS) to be an optional activity for EQRO.

2.1. Managed Care Programs and Participating Managed Care Organizations

In 2016, Texas Medicaid and CHIP medical benefits were administered through the following programs:

•

•

•

STAR – The State of Texas Access Reform (STAR) program provides managed care in coordination with 18 MCOs to the majority of Texas Medicaid beneficiaries.

STAR+PLUS – The STAR+PLUS program integrates acute health services with long-term services and supports in coordination with five MCOs.

STAR Health – This managed care program covers children and adolescents in state conservatorship and young adults previously in foster care and


receiving Medicaid. In 2016, the sole MCO for STAR Health was Superior HealthPlan.

• CHIP – CHIP provides managed care through 17MCOs to children in families whose income is toohigh to qualify for Medicaid but too low to affordprivate insurance for their children.

Table 1 lists the programs served by each MCO.

Introduction2.


Table 1. Texas Medicaid/CHIP Managed Care Organizations and Programs in 2016

MCO Name STAR STAR+PLUS STAR Health CHIP

Aetna Better Health

Amerigroup

Blue Cross and Blue Shield of Texas

CHRISTUS Health Plan

Community First Health Plans

Community Health Choice

Cook Children’s Health Plan

Cigna-HealthSpring

Dell Children’s Health Plan (formerly Seton)

Driscoll Health Plan

El Paso First Health Plans, Inc.

FirstCare

Molina Healthcare of Texas, Inc.

Parkland Community Health Plan

RightCare from Scott & White Health Plan

Sendero Health Plans

Superior HealthPlan

Texas Children’s Health Plan

UnitedHealthcare Community Plan

2. Introduction

3. ENCOUNTER DATA VALIDATION:MEDICAL RECORD REVIEW

3. Encounter Data Validation: Medical Record Review

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This section presents assessments of the processes for collecting and submitting accurate and complete encounter data and of the quality of the data themselves. This procedure follows guidance by CMS on optional EQRO activities: review of medical records.3

The EQRO annually validates encounter data for accuracy and completeness by comparing claims against a representative sample of dental or medical records. The 2016 EDVMRR study examined physical health encounters and records from 2015 for members in STAR, STAR+PLUS, STAR Health, and CHIP. The EDVMRR study validated: date of service (DOS); place of service (POS); primary diagnoses; and procedures.

3.1. Methodology

The EQRO requested 239 records from each health plan for each program, sufficient to obtain 155 records per quota with a 65 percent record return rate. This approach follows National Center for Quality Assurance guidelines for sample size and estimated record return rate when data from previous studies are available. The sample size was calculated based on the lowest match rate obtained in the previous physical health EDVMRR

study conducted in 2014. The record return rate of 65 percent was based on the return rate achieved with prior medical record requests.

The study timeframe was from January 1, 2015 through December 31, 2015, with at least a three-month lag for processing purposes and data quality verification. This was the time-period for which 2015 claims data is available via the Texas data warehouse.

3.1.1. Sampling

A random sample was drawn from MCO encounters that occurred during calendar year 2015 for each program (STAR, STAR+PLUS, STAR Health, and CHIP). A random sample was drawn from outpatient office or clinic visit (as defined by POS codes) encounters with DOS during the specified time frame. POS codes that were used are: 11 – Office, 17 – Walk-in retail health clinic, 49 – Independent clinic, 50 – Federal qualified health center, and 53 – Community mental health center.

Each claim in the random sample was associated with one member-provider pair – this claim is considered the ‘qualifying claim’ for each member in the sample. Once the sample of members was identified, the



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EQRO requested a full year’s worth of records from the provider associated with the qualifying claim. Therefore, for the purposes of this study, one year’s worth of records was counted as one record, which may include documentation of multiple encounters for one enrollee. All claims associated with that provider for the measurement year were pulled and validated against the medical record for the measurement year. A full year’s worth of records was requested and reviewed in order to provide a global view of events rather than what occurs on a single date of service.

Providers associated with the qualifying claims were asked via hard copy mailing for one year’s worth of records for the specific member. Additionally, EQRO staff called high volume providers to ask for the records if the records were not received after the first record request.1 A second mailing, three weeks after the initial mailing, was sent to those providers who did not respond to the first mailed request or telephone calls.

i High volume providers are those from whom we are requesting records for six or more members.

Caveat

Please note that the methodology used in this study changed from the one used in the 2013 Physical Health EDVMRR study. In the earlier study, the EQRO looked at one DOS per member, while in the 2015 Physical Health EDVMRR study, the EQRO looked at a full year of DOS for each member. Therefore, the results cannot be compared to results from previous years’ EDVMRR studies.

3.1.2. Health Records and Confidentiality

The EQRO designed record request, submission, log-in, and abstraction procedures to protect confidentiality in accordance with federal and state regulations. To ensure confidentiality, the following steps were taken:

• All personnel involved in record processing andreviewing records were trained in the handling ofpatient identifiable data, as required by the Universityof Florida Health Science Center Privacy Office.

• Patient- and provider-specific data were maintainedin a password-protected database. All health recordsreceived were logged into this password-protecteddatabase.



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• Hard copies received were placed in file folders witha provider code and filed in locked filing cabinets.Faxed health records were received by a secure faxline and saved to a password- protected networkdrive used by the medical record review team.

3.1.3. Analysis

A team of certified medical record reviewers conducted the validation study, meeting daily to discuss any questions or interpretations related to the validation process. The EQRO used a standardized protocol and assessed inter-rater reliability to ensure accuracy. At the onset of the project, cross-review charts per reviewer showed accuracy of 98 to 100 percent. For the subsequent weeks, reviewers exchanged ten percent of the records validated during the previous week to assess inter-rater reliability. The reviewers had a 99.7 percent agreement rate.

The review team conducted the Physical Health EDVMRR study by reviewing one year’s worth of medical records for each member in the sample to validate whether the information in the claims matched the documentation in the medical record. In addition, the medical records

were reviewed to ensure that all documented visits in the medical records had a corresponding claim. The EQRO calculated final match rates for:

1. DOS - The denominator for this match rate isthe total number of DOS in the claims and in themedical records. A DOS was numerator compliantwhen the DOS in the medical record matched theDOS in the administrative data.

2. POS - The denominator for this match rate isthe total number of POS in the claims and in themedical records. A POS was numerator compliantwhen the POS in the medical record matched thePOS in the administrative data.

3. Primary diagnosis - The denominator for thismatch rate is the total number of primary diagnosesin the claims and in the medical records. A primarydiagnosis was numerator compliant when theprimary diagnosis in the medical record matchedthe primary diagnosis in the administrative data.

4. Procedure - The denominator for this match rate isthe total number of procedures in the claims and inthe medical records. A procedure was numeratorcompliant when the procedures in the medical



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record matched the procedure in the administrative data.

Multiple members may have been seen by the same provider. Therefore, all match rates account for clustering around a single provider. In addition, some members may have more encounters during the study timeframe than other members. Consequently, all match rates account for clustering within one medical record. Further, to account for variability in length of enrollment between members, the match rates are weighted by length of enrollment.

The record review team cross-checked the date of service in the medical record against all claims submitted by all providers during the study timeframe in order to ensure visits where the beneficiary was seen by a different provider than the provider associated with the qualifying claim were not included in the denominator for the match rates. In addition, because the sample was pulled by health plan and program, all claims and documentation of a visit in the medical record were not validated if it occurred during a time when the member was not enrolled in the health plan and/or program he/ she was in when randomly selected in the sample.

3.2. Results

Table 2 through Table 5 provide the match rates for the four review categories by MCO and program. Across all review categories, the match rates for STAR+PLUS were the lowest, while the highest match rates were for CHIP. For STAR+PLUS, across the four review categories, Molina consistently had the lowest match rates amongst STAR+PLUS MCOs.



Table 2. Date of Service Match Rates by MCO and Program


Total Across MCOs 88.2% 77.1% 80.7% 88.8%

Aetna Better Health 91.2% 89.8%

Amerigroup 84.6% 73.9% 90.2%

Blue Cross and Blue Shield of Texas 92.3% 92.3%

CHRISTUS Health Plan 83.5% 86.4%

Community First Health Plans 87.4% 90.7%

Community Health Choice 91.1% 84.4%

Cook Children’s Health Plan 86.7% 93.1%

Cigna-HealthSpring 78.3%

Dell Children’s Health Plan (formerly Seton) 84.7% 91.4%

Driscoll Health Plan 88.3% 85.9%

El Paso First Health Plans, Inc. 91.1% 87.0%

FirstCare 81.3% 84.4%

Molina Healthcare of Texas, Inc. 84.8% 66.1% 88.4%

Parkland Community Health Plan 88.0% 91.8%

RightCare from Scott & White Health Plan 89.3%

Sendero Health Plans 92.8% 94.2%

Superior HealthPlan 92.5% 84.1% 80.7% 89.5%

Texas Children’s Health Plan 88.9% 88.3%

UnitedHealthcare Community Plan 89.7% 84.3% 82.0%



Table 3. Place of Service Match Rates by MCO and Program




Amerigroup 84.6% 74.7% 90.2%




















Table 4. Primary Diagnosis Match Rates by MCO and Program




Amerigroup 80.5% 69.3% 89.7%




















Table 5. Procedure Match Rates by MCO and Program




Amerigroup 80.4% 69.3% 88.8%




















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3.3. Recommendation

This section provides the EQRO’s recommendations for the EDVMRR study.

Finding 1: Match Rates Vary by Health Plan and Program -Across all data elements, the match rates for STAR+PLUS were the lowest, while the highest match rates were for CHIP. For STAR+PLUS, across the four data elements, Molina consistently had the lowest match rates amongst STAR+PLUS MCOs.

Recommendation 1: The EQRO recommends that HHS investigate the reasons for low match rates for some MCOs, such as type of diagnosis or whether the POS occurred at community or clinic setting.


4. PERFORMANCE IMPROVEMENT PROJECT EVALUATION

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PIP validation is a mandatory EQRO activity per 42 CFR §438.358(b)(1). The EQRO annually reviews the TexasMedicaid and CHIP health plans’ PIPs to evaluate aspects of structure and process that contribute to the success of these programs. This section presents assessments of study methodologies and evaluations of overall validity and reliability of PIP results following guidance by CMS on required EQRO activities. 4

Health plans participating in Medicaid or CHIP in Texas now are required to conduct PIPs on a two-year cycle. Previously, PIPs were conducted on a one-year cycle. HHS is transitioning to a staggered two-year cycle to allow more time for each project to develop improvements, to alleviate planning burden, and to facilitate use of feedback from completed PIPs in the design of new projects. This section describes the two-year 2014 PIPs.

4.1. Methodology

The EQRO assesses the study methodology, evaluates the overall validity and reliability of study results, and makes recommendations for each PIP by each health plan participating in Medicaid or CHIP in Texas. In 2014 and 2015, these health plans included 19 MCOs, two dental maintenance organizations, and one behavioral

health organization. Each health plan implemented two PIPs for each program of participation; over the course of the study period, some aspects of various projects and interventions were replaced or retired in response to feedback from the EQRO or internal monitoring. The EQRO evaluated and provided feedback and recommendations for each PIP at the planning phase, at two mid-year reviews, and at the conclusion of the two-year cycle.

Following guidance by CMS, the EQRO systematizes evaluation of each PIP according to several activities, each of which comprises one or more components. Activities for the planning phase, progress reports, and final evaluation differ for each phase. Scoring for each component of each activity for each PIP is based on a three-point scale: component met (100 percent), component partially met (50 percent), or component not met (0 percent). The score for each activity is the average of component scores.

The PIP Plan score is the average of score for activities one through seven. The final PIP score includes average of scores for activities eight through 11. The overall PIP score is the average of all activities one through 11.

4. Performance Improvement Project Evaluation


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4.2. Results

This section provides an overview of the PIPs that addressed: asthma, diabetes, chronic obstructive pulmonary disorder (COPD), well-child visits, and adolescent well-care.

4.2.1. Asthma

Figure 1 illustrates the asthma PIP plan and final PIP scores by program and health plan. Only STAR Community Health Choice and UnitedHealthcare saw an increase in scores. The overall PIP scores for health plans can be found in Table 6 through Table 8.

Figure 1. Asthma PIP Plan and Final PIP Revised Scores by Program and Health Plan



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Table 6 through Table 8 describe how the health plans with asthma PIPs performed on select HEDIS®

asthma measures and the 3M® potentially preventable admissions (PPA) for asthma.2 In STAR, all health plans with an asthma PIP saw a decrease in their asthma PPAs rates from 2013 to 2015. The rate for Asthma Medication Ratio (AMR), which assesses the ratio of controller medications (which prevent asthma attacks) to total asthma medications for people age 5-85 with persistent asthma, decreased for these health plans. In contrast, the rate for Medication Management for People with Asthma (MMA), which assesses the percentage of members age 5-85 who had persistent asthma and were dispensed appropriate medications that they remained on for specified time periods, increased for all health plans except UnitedHealthcare. The rate for asthma disease management programs decreased for CommunityHealth Choice and Texas Children’s. In STAR+PLUS, the rates for asthma PPA and MMA decreased for Molina. There was slight increase (0.7 percent) in the AMR rate. In CHIP, FirstCare had an increase in its rates for asthma PPA and MMA. The AMR rate decreased by 5.8 percent.

2 A reduction in PPA rate demonstrates an improvement.



Table 6. STAR MCOs, with Asthma PIPs, Performance on Select Measures 3

Community Health Choice

FirstCare Molina Texas Children’s UnitedHealthcare

2015 percentage

Change in percentage

points (2013 to

2015) 2015

percentage


points (2013 to

2015) 2015

percentage


points (2013 to

2015) 2015

percentage


points (2013 to

2015) 2015

percentage


points (2013 to

2015)

Overall PIP score

77.1% 91.9% 75.8% 69.4% 87.4%

Asthma Disease Management Program Participation

1.5% -1.3% * 100% 79.2% 2.2% -22.2% *

AMR 5 to 64, Ratio > 50%

68.9% -9.9% 65.8% -8.8% 68.9% -14.4% 71.1% -12.1% 73.6% -3.7%

MMA 5 to 64, Ratio > 50%

41.6% 3.9% 45.7% 5.0% 37.4% 1.3% 42.8% 3.7% 39.8% -1.2%

PPA - Asthma 0.075 -0.033 0.173 -0.034 0.045 -0.017 0.070 -0.020 0.063 -0.045

3 The health plan submitted inaccurate data submission for the asthma management program.



Table 7. STAR+PLUS MCOs, with Asthma PIPs, Performance on Select Measures3

Molina

2015 percentage

Change in percentage points (2013

to 2015)

Overall PIP score 75.8%


100.0% 40.6%


58.4% 0.7%


33.3% -24.9%

PPA - Asthma 0.045 -0.017

Table 8. CHIP MCOs, with Asthma PIPs, Performance on Select Measures3

FirstCare

2015 percentage


to 2015)



* *


74.2% -5.8%


50.0% 5.9%

PPA - Asthma 0.270 0.133

3 The health plan submitted inaccurate data submission for the asthma management program.

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4.2.2. Diabetes

Superior was the only health plan to conduct PIPs to address Comprehensive Diabetes Control (CDC) in STAR and STAR+PLUS. Figure 2 illustrates the diabetes PIP plan and final PIP revised scores by program and health plan. Superior saw a decrease in scores in both STAR and STAR+PLUS. Overall PIP scores can be found in Table 9 and Table 10.

Table 9 and Table 10 describe how Superior performed on its PIPs performed on the HEDIS® CDC measures. Superior had an increase in these select CDC measures.

Figure 2. Diabetes PIP Plan and Final PIP Revised Scores by Program and Health Plan


Table 9. STAR MCOs, with Diabetes PIPs, Performance on Select Measures 4,5

Superior

2015 percentage


to 2015)


Diabetes Disease Management Program Participation*

66.4% *

CDC, HbA1c Testing 85.9% 4.1%

CDC, HbA1c Control (<8%)

38.2% 2.2%

CDC, Eye Exam 48.1% 7.6%

CDC, Monitoring for Nephropathy

89.2% 13.6%

Table 10. STAR+PLUS MCOs, with Diabetes PIPs, Performance on Select Measures 4,5

Superior

2015 percentage


to 2015)


Diabetes Disease Management Program Participation*

65.7% *

CDC, HbA1c Testing 88.6% 4.2%

CDC, HbA1c Control (<8%)

46.7% 8.3%

CDC, Eye Exam 46.7% 1.2%

CDC, Monitoring for Nephropathy

91.7% 7.7%

4 The health plan submitted inaccurate data submission for the asthma management program. 5 CDC, Eye Exam and CDC, Monitoring for Nephtopathy were not measures addressed in the PIP.

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4.2.3. COPD

Two health plans, Cigna-HealthSpring and UnitedHealthcare, had PIPs in place for STAR+PLUS. Figure 3 illustrates the COPD PIP plan and final PIP scores by program and health plan. There was a decrease in PIP scores for UnitedHealthcare, while there was almost no change in scores for Cigna-HealthSpring. Overall PIP scores can be found in Table 11.

Table 11 describes how the STAR+PLUS health plans performed on its PIPs on COPD measures. There was an increase in the COPD PPA for Cigna-HealthSpring. While UnitedHealthcare had an increase in their COPD management program, the EQRO is going to investigate how UnitedHealthcare defines active members.

Figure 3. COPD PIP Plan and Final PIP Revised Scores by Program and Health Plan

Table 11. STAR+PLUS MCOs, with COPD PIPs, Performance on Select Measures 6,7,8

Cigna-HS UnitedHealthcare

2015 percentage


to 2015) 2015

percentage


to 2015)

Overall PIP score 71.2% 87.4%

COPD Disease Management Program Participation * * 100.0% 14.0%

Use of Spirometry 16 34.1% ** 21.9% **

Pharm Mgmt COPD 16, Systemic Corticosteroids 69.6% ** 69.1% **

Pharm Mgmt COPD 16, Bronchodilators 84.8% ** 85.2% **

PPA - COPD 0.818 0.391 *** ***

6 The health plan submitted inaccurate data submission for the COPD management program. 7 HEDIS measure not calculated in 2013. HEDIS measures were not used in the health plans’ PIPs. 8 PPA not part of health plan’s PIP

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4.2.4. Well-Child Visits in the Third through Sixth Years of Life

Four CHIP health plans had PIPs in place to address well-child visits in the third through sixth years of life (W34). Figure 4 illustrates the W34 PIP plan and final PIP scores by program and health plan. While all health plans saw a decrease in PIP scores, El Paso First’s decrease was only 0.3 percent. Overall PIP score can be found in Table 12.

Table 12 describes how the CHIP health plans performed on its PIPs for the W34 measure. All four CHIP health plans had an increase in W34 rates, ranging from 0.5 percent for Amerigroup to 8.2 percent for Superior.

Figure 4. W34 PIP Plan and Final PIP Revised Scores by Program and Health Plan



Table 12. CHIP Health Plan, with W34 PIPs, Performance on Select Measures

Amerigroup El Paso First Molina Superior

2015 percentage


points (2013 to

2015) 2015

percentage


points (2013 to

2015) 2015

percentage


points (2013 to

2015) 2015

percentage


points (2013 to

2015)

Overall PIP score 93.2% 90.2% 72.0% 93.9%

Well Child Visits in Years 3-6

79.2% 0.5% 85.9% 5.4% 74.6% 3.4% 80.5% 8.2%

4.2.5. Adolescent Well-Care Visits

Three STAR health plans and 10 CHIP health plans had PIPs that addressed Adolescent Well-Care Visits (AWC). Figure 5 illustrates the AWC PIP plan and final PIP scores by program and health plan. In STAR, two health plans had their scores decreased while Cook Children’s scores increased. In CHIP, five health plans saw their scores increase. Overall PIP scores can be found in Table 13 and Table 14.

Table 13 and Table 14 describes how the STAR and CHIP health plans performed on its PIPs for the AWC measure. All three STAR health plans had an increase in AWC rates, ranging from 5.1 percent for Cook Children’s to 6.8 percent for Sendero. There was greater variation for CHIP health plans, with changes ranging from -2.7 percent for BCBSTX to 17 percent for Sendero.

30



Figure 5. AWC PIP Plan and Final PIP Revised Scores by Program and Health Plan

PIP Plan Score Final PIP Score

STAR CHIP

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31




32

Table 13. STAR MCOs, with AWC PIPs, Performance on Select Measures

Aetna Cook Children's Sendero

2015 percentage


to 2015)2015

percentage


to 2015)2015

percentage


to 2015)

Overall PIP score 81.3% 86.6% 92.4%

AWC 57.2% 6.6% 60.3% 5.1% 59.1% 6.8%



33

Table 14. CHIP MCOs, with AWC PIPs, Performance on Select Measures

Aetna BCBSTX Community First CHC Dell Children’s

2015 percentage


points (2013 to

2015)2015

percentage


points (2013 to

2015)2015

percentage


points (2013 to

2015)2015

percentage


points (2013 to

2015)2015

percentage


points (2013 to

2015)

Overall PIP score

75.3% 79.9% 70.8% 82.6% 97.2%

AWC 53.2% 3.2% 44.7% -2.7% 57.2% 6.0% 76.3% 12.1% 60.2% 13.2%

Cook Children’s Parkland Sendero Texas Children’s United Healthcare

2015 percentage


points (2013 to

2015)2015

percentage


points (2013 to

2015)2015

percentage


points (2013 to

2015)2015

percentage


points (2013 to

2015)2015

percentage


points (2013 to

2015)

Overall PIP score

97.2% 93.2% 93.2% 93.2% 93.2%

AWC 60.2% 13.2% 70.1% 5.3% 67.7% 17.0% 72.0% 6.5% 62.0% 6.9%



34

4.3. Recommendations

This section provides the EQRO’s findings and recommendations for the PIP evaluation study.

Finding 1: Asthma – All STAR MCOs addressed MMA as part of their asthma PIPs. UnitedHealthcare was the only MCO to see a decline in their MMA rate from 2013 through 2015, despite having one of the higher overall PIP scores for asthma. Community Health Choice and Texas Children’s partnered with Walgreens Pharmacy to provider asthma education at the point of sales for asthma medication. FirstCare had a targeted outreach program for members who were non-compliant with their medication. UnitedHealthcare only provided asthma literature to members on the disease process and the asthma education plan, but did not clearly state how it would address medication management.

Recommendation 1: The EQRO recommends that HHS encourage the health plans to have targeted, detailed interventions that address the specificquality of care measure(s) that are part of their PIP.

Finding 2: Well-Child Visits – Among CHIP MCOs that

had a W34 PIP, Molina had the lowest PIP plan and final scores, the lowest overall PIP score, and the lowest 2015 W34 rate. Amerigroup and Superior targeted primary care providers by offering a pay-for-performance program and encouraging providers to be a part of a preferred provider network respectively. El Paso offered a $15 gift card to members due for a well-child visit in their birthday month. However, Molina just contacted members that were not in compliance.

Recommendation 1: The EQRO recommendsthat HHS encourage the health plans conducting a W34 PIP use either member- or provider-based incentives.

Finding 3: PIP Interventions – Health plans who conducted PIPs in multiple programs used the same interventions across programs despite the diverse member and provider populations across programs. For example, Molina and FirstCare conducted the same asthma PIP intervention for their STAR, STAR+PLUS, and CHIP populations; while Superior conducted the same CDC PIP intervention for their STAR and STAR+PLUS provider populations. FirstCare and Molina had different overall PIP scores based on program, while Molina had



35

the same overall PIP score for each program.

Recommendation 1: Despite some observedpositive outcomes from the PIPs overall, the EQRO recommends that HHS encourage MCOs, who address the same PIP topic across multiple programs, tailor their intervention plans so that they are specific to the provider/member make-up of each program.


5. ENDNOTES

5. Endnotes

37

1. Texas Health and Human Services. 2015. TexasMedicaid and CHIP in Perspective – 10th Edition.Available at: http://www.hhsc.state.tx.us/medicaid/about/PB/PinkBook.pdf.

2. CMS. 2012a. Quality of Care External Quality Review(EQR). Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Quality-of-Care-External-Quality-Review.html.

3. CMS. 2012d. EQR Protocol 4: Validation ofEncounter Data Reported by the MCO. Availableat: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/eqr-protocol-4.pdf

4. CMS. 2012c. EQR Protocol 3: ValidatingPerformance Improvement Projects (PIPs). Availableat: http://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/eqr-protocol-3.pdf.


http://www.hhsc.state.tx.us/medicaid/about/PB/PinkBook.pdf

http://www.hhsc.state.tx.us/medicaid/about/PB/PinkBook.pdf

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Quality-of-Care-External-Quality-Review.html




https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/eqr-protocol-4.pdf






Documents

Texas Medicaid and Children’s Health Insurance Program · 2017. 10. 27. · List of Tables Table 1. Texas Medicaid/CHIP Managed Care Organizations and Programs in 2016 8 Table 2