Texas Medicaid Managed Care and · Texas Medicaid Managed Care and Children’s Health Insurance Program. Summary of Activities and Trends in Health Care Quality. Contract Year 2016

Texas Medicaid Managed Care and

Children’s Health Insurance Program

Summary of Activities and Trends in Health Care

Quality

Contract Year 2016

Measurement Period:

2011 through 2016

The Institute for Child Health Policy

University of Florida

The External Quality Review Organization

for Texas Medicaid and CHIP

Table of Contents

1. Executive Summary .......................................................................................................... 1

1.1. Introduction .................................................................................................................. 1

1.2. Methods ....................................................................................................................... 1

1.3. Summary of Key Findings ............................................................................................ 2

1.3.1. Access to and Utilization of Care Findings ............................................................ 2

1.3.2. Effectiveness of Care ............................................................................................ 3

1.3.3. Satisfaction with Care ........................................................................................... 3

1.4. Summary of Recommendations ................................................................................... 4

1.4.1. Access to and Utilization of Care .......................................................................... 4

1.4.2. Effectiveness of Care Recommendations ............................................................. 5

1.4.3. Satisfaction with Care ........................................................................................... 5

2. Introduction ....................................................................................................................... 6

2.1. Managed Care Programs and Participating Plans ........................................................ 6

2.2. External Quality Review in Texas Medicaid and CHIP ................................................. 7

2.3. External Quality Review Organization Activities ........................................................... 8

3. Characterizing Texas Medicaid and CHIP Populations .................................................11

3.1. STAR Program ...........................................................................................................11

3.2. CHIP Program ............................................................................................................13

3.3. STAR+PLUS Program ................................................................................................14

3.4. STAR Health ...............................................................................................................17

4. Managed Care Organization and Dental Maintenance Organization Structure and

Process 19

4.1. Data Certification ........................................................................................................19

4.2. Administrative Interviews ............................................................................................21

4.2.1. MCO Compliance with State and Federal Regulations .........................................22

4.2.2. Disease Management Programs ..........................................................................26

4.3. Quality Improvement ...................................................................................................29

4.3.1. Quality Assessment and Performance Improvement Program Evaluations ..........29

5. Quality-of-care Evaluation by Program ..........................................................................35

5.1. Quality-of-care Evaluation Methods ............................................................................35

5.1.1. Administrative and Hybrid Measures ....................................................................35

5.1.2. Survey Measures .................................................................................................35

5.2. STAR Program ...........................................................................................................38

5.2.1. Access to and Utilization of Care in STAR ...........................................................38

5.2.2. Effectiveness of Care in STAR .............................................................................48

5.2.3. Satisfaction with Care in STAR ............................................................................55

5.3. CHIP Program ............................................................................................................58

5.3.1. Access to and Utilization of Care in CHIP ............................................................58

5.3.2. Effectiveness of Care in CHIP ..............................................................................66

5.4. STAR+PLUS Program ................................................................................................73

5.4.1. Access to and Utilization of Care in STAR+PLUS ................................................73

5.4.2. Effectiveness of Care in STAR+PLUS .................................................................81

5.4.3. Satisfaction with Care in STAR+PLUS .................................................................85

5.5. STAR Health Program ................................................................................................91

5.5.1. Access to and Utilization of Care in STAR Health ................................................91

5.5.2. Effectiveness of Care in STAR Health .................................................................98

5.5.3. Satisfaction with Care in STAR Health ............................................................... 102

5.6. Medicaid and CHIP Dental Programs........................................................................ 105

5.6.1. Access to and Utilization of Care in Medicaid and CHIP Dental Programs ......... 105

5.6.2. Satisfaction with Care in Medicaid and CHIP Dental Programs .......................... 108

6. Focus Studies and Special Projects ............................................................................. 110

6.1. HCBS Settings Assessment Survey .......................................................................... 110

6.2. STAR Kids Pre-Implementation Study ...................................................................... 111

6.3. National Core Indicators – Aging and Disabilities Study ............................................ 112

6.4. House Bill 3823 Patient Experience Analysis in STAR+PLUS versus PACE ............. 113

6.5. STAR+PLUS HCBS Waiver – Service Validation Study ............................................ 115

6.6. Senate Bill 760 Background Report .......................................................................... 116

6.7. Appointment Availability ............................................................................................ 117

6.8. MCO Report Cards ................................................................................................... 120

6.8.1. MCO Report Card Evaluation Survey ................................................................ 123

6.9. Primary Care Provider Referral Pilot Study ............................................................... 124

7. Fiscal Year 2016 Findings and Recommendations...................................................... 129

7.1. Access to and Utilization of Care Recommendations ................................................ 129

7.2. Effectiveness of Care Recommendations ................................................................. 131

7.3. Satisfaction with Care Recommendations ................................................................. 133

8. Appendices .................................................................................................................... 134

8.1. Managed Care Expansion Since SB 7 ...................................................................... 134

8.2. HHS Performance Indicator Dashboard Standards ................................................... 135

8.3. Quality-of-care Administrative and Hybrid Measures ................................................. 136

8.3.1. HEDIS® 2016 ..................................................................................................... 136

8.3.2. AHRQ Pediatric Quality Indicators and Prevention Quality Indicators ................ 137

8.3.3. 3M™ Health Information Systems measures ..................................................... 138

8.4. MCO Report Card Item Definitions ............................................................................ 141

List of Tables

Table 1. Texas Medicaid/CHIP Health Plans and Programs in 2016 .......................................... 7

Table 2. 2016 Administrative Interview Evaluation Scores and Percent Change from 2015 ......24

Table 3. STAR – Member Participation in Disease Management Programs, 2015 ....................28

Table 4. CHIP – Member Participation in Disease Management Programs, 2015 .....................28

Table 5. STAR+PLUS – Member Participation in Disease Management Programs, 2015 .........28

Table 6. Quality Assessment and Performance Improvement Scores by Health Plan,

Measurement Year 2016 ...........................................................................................................32

Table 7. Quality Assessment and Performance Improvement Scores by Activity, Measurement

Year 2016 .................................................................................................................................33

Table 8. Examples of Recommendations Made for Quality Assessment and Performance

Improvement Programs in STAR, CHIP, STAR+PLUS, and STAR Health, 2016 ......................34

Table 9. Member and Caregiver Survey Enrollment and Fielding Periods, 2015-2016 ..............36

Table 10. STAR – HEDIS® Access and Utilization Measures, 2015 ...........................................39

Table 11. STAR – HEDIS® Utilization of Care Measures, 2015 .................................................42

Table 12. STAR – AHRQ Pediatric Quality Indicators, 2015 ......................................................43

Table 13. STAR – 3M™ Potentially Preventable Hospital Admissions, Most Common Reasons,

for 2015.....................................................................................................................................44

Table 14. STAR – 3M™ Most Common Admission Reasons Associated with Potentially

Preventable Readmission, for 2015 ..........................................................................................45

Table 15. STAR – 3M™ Most Common Potentially Preventable Emergency Department Visits

Reasons, for 2015 .....................................................................................................................46

Table 16. STAR –3M™ Most Common Potentially Preventable Complications, for 2015 ..........47

Table 17. STAR – HEDIS® Effectiveness of Care Measures for Children and Adolescents, 2015

.................................................................................................................................................49

Table 18. STAR – HEDIS® Effectiveness of Care Measures, 2015 ...........................................52

Table 19. STAR – CAHPS® Adult Member Satisfaction with Care, 2016 ...................................55

Table 20. CHIP – HEDIS® Access and Utilization Measures, 2015 ...........................................58

Table 21. CHIP – HEDIS® Utilization of Care Measures, 2015 ..................................................60

Table 22. CHIP – AHRQ Pediatric Quality Indicators, 2015 ......................................................61

Table 23. CHIP – 3M™ Potentially Preventable Hospital Admissions, Most Common Reasons,

for 2015.....................................................................................................................................62

Table 24. CHIP – 3M™ Most Common Admission Reasons Associated with Potentially


Table 25. CHIP – 3M™ Most Common Potentially Preventable Emergency Department Visits

Reasons, for 2015 .....................................................................................................................64

Table 26. CHIP – 3M™ Most Common Potentially Preventable Complications, for 2015 ..........65

Table 27. CHIP – HEDIS® Effectiveness of Care Measures, 2015 ............................................69

Table 28. STAR+PLUS – HEDIS® Access and Preventive Care Measures, 2015 .....................73

Table 29. STAR+PLUS – HEDIS® Utilization of Care Measures, 2015 ......................................75

Table 30. STAR+PLUS – AHRQ Prevention Quality Indicators, 2015 .......................................76

Table 31. STAR+PLUS – 3M™ Potentially Preventable Hospital Admissions, Most Common

Reasons, for 2015 .....................................................................................................................77

Table 32. STAR+PLUS – 3M™ Most Common Admission Reasons Associated with Potentially


Table 33. STAR+PLUS – 3M™ Most Common Potentially Preventable Emergency Department

Visits Reasons, for 2015 ...........................................................................................................79

Table 34. STAR+PLUS – 3M™ Most Common Potentially Preventable Complications, for 2015

.................................................................................................................................................80

Table 35. STAR+PLUS – HEDIS® Effectiveness of Care Measures, 2015 ................................82

Table 36. STAR+PLUS – HEDIS® Effectiveness of Behavioral Health Care Measures, 2015....84

Table 37. STAR+PLUS – CAHPS® Medicaid-only Member Satisfaction with Care, 2016 ..........88

Table 38. STAR Health – HEDIS® Access to Care, 2015 ..........................................................91

Table 39. STAR Health – HEDIS® Utilization of Care Measures, 2016 ......................................93

Table 40. STAR Health – AHRQ Pediatric Quality Indicators, 2015 ..........................................93

Table 41. STAR Health – 3M™ Potentially Preventable Hospital Admissions, Most Common

Reasons, for 2015 .....................................................................................................................94

Table 42. STAR Health – 3M™ Most Common Admission Reasons Associated with Potentially


Table 43. STAR Health – 3M™ Most Common Potentially Preventable Emergency Department

Visits Reasons, for 2015 ...........................................................................................................96

Table 44. STAR Health – 3M™ Most Common Potentially Preventable Complications, for 2015

.................................................................................................................................................97

Table 45. STAR Health – HEDIS® Effectiveness of Care Measures, 2015 ................................99

Table 46. STAR Health – CAHPS® Caregiver Satisfaction with Care, 2016 ............................ 102

Table 47. Medicaid Dental and CHIP Dental – Access and Utilization Measures, 2015 .......... 107

Table 48. Medicaid Dental and CHIP Dental – Caregiver Satisfaction with Care, 2015 ........... 109

Table 49. Comparison of Select Access to Care Measures for PACE and STAR+PLUS

Members ................................................................................................................................. 114

Table 50. Appointment Standards Defined in the Texas Medicaid

Uniform Managed Care Contract............................................................................................. 117

Table 51. Percentage of Providers (Type) who Met the UMCC Appointment Standard Overall

(Weighted Percentages) by Program ...................................................................................... 120

Table 52. MCO Report Cards by Program, 2016 ..................................................................... 122

Table 53. Member and Caregiver Annual MCO Report Card Survey ...................................... 123

Table 54. Sampling Description, Primary Care Provider Referral Pilot Study .......................... 125

Table 55. Provider Process Satisfaction Ratings of “4 or 5” (Weighted Percentages) ............. 127

Table 56. Top Four Specialty Referral Barriers Reported by PCPs with Pediatric and Adult

Patients (Weighted Percentages) ............................................................................................ 127

Table 57. Pediatric Attention Deficit Hyperactivity Disorder Specialist Referrals by PCP Density

(Weighted Percentages) ......................................................................................................... 128

Table 58. HEDIS® Hybrid Measures, 2015 .............................................................................. 137

Table 59. AHRQ Pediatric Quality Indicators and Prevention Quality Indicators ...................... 138

List of Figures

Figure 1. STAR – Program Enrollment, 2011-2015 ...................................................................11

Figure 2. STAR – Member-reported Health Status, 2016 ..........................................................12

Figure 3. Body Mass Index Classification Based on Member (STAR Adult) Report of Height and

Weight, 2016 .............................................................................................................................12

Figure 4. CHIP – Program Enrollment, 2011-2015 ....................................................................13

Figure 5. STAR+PLUS – Program Enrollment, 2011-2015 ........................................................14

Figure 6. STAR+PLUS – Member-reported Health Status, 2016 ...............................................15

Figure 7. STAR+PLUS Body Mass Index Classification Based on Member Reported Height and

Weight, Medicaid-only (left) and Dual-eligible (right), 2016 .......................................................15

Figure 8. Member reported Limitations with Activities of Daily Living, Quality of Life, and

Personal Care, 2012-2016 ........................................................................................................16

Figure 9. STAR Health – Program Enrollment, 2011-2015 ........................................................17

Figure 10. STAR Health – Caregiver-Reported Health Status ...................................................17

Figure 11. STAR Health – Caregiver-Reported Special Health Care Needs, 2016 ....................18

Figure 12. STAR Health - Body Mass Index Classification Based on Member Reported Height

and Weight, 2016 ......................................................................................................................18

Figure 13. STAR – HEDIS® Access to and Utilization of Primary Care, 2011-2015 ...................40

Figure 14. STAR – HEDIS® Initiation & Engagement of Alcohol & Other Drug

Dependence Treatment, 2011-2015 ..........................................................................................41

Figure 15. STAR – HEDIS® Prenatal and Postpartum Care, 2011-2015 ...................................41

Figure 16. STAR – Weighted 3M™ Potentially Preventable Hospital Admissions, per 1,000

Member-months, 2011-2015 .....................................................................................................44

Figure 17. STAR – Weighted 3M™ Potentially Preventable Readmission Chains per 1,000

Candidate Admissions, 2011-2015 ............................................................................................45

Figure 18. STAR – Weighted 3M™ Potentially Preventable Emergency Department Visits per

1,000 Member-months, 2011-2015 ...........................................................................................46

Figure 19. STAR – Weighted 3M™ Potentially Preventable Complications per At-Risk

Admissions, 2013-2015 .............................................................................................................47

Figure 20. STAR – HEDIS® Effectiveness of Care: Prevention and Screening ..........................50

Figure 21. STAR – HEDIS® Effectiveness of Care for Respiratory Conditions, 2011-2015 ........51

Figure 22. STAR – HEDIS® Follow-up Care for Children Prescribed ADHD Medication, 2011-

2015 ..........................................................................................................................................51

Figure 23. STAR – HEDIS® Effectiveness of Care Measures, 2011-2015 .................................53

Figure 24. STAR – HEDIS® Comprehensive Diabetes Care, 2011-2015 ...................................54

Figure 25. STAR – CAHPS® Member Satisfaction with Care Composites and Question

Summary Rates, 2012-2016 .....................................................................................................56

Figure 26. STAR – CAHPS® Member Satisfaction with Care Ratings, 2012-2016 .....................57

Figure 27. CHIP – HEDIS® Access to and Utilization of Primary Care, 2011-2015 ....................59

Figure 28. CHIP – Weighted 3M™ Potentially Preventable Hospital Admissions, per 1,000

Member-months, 2011-2015 .....................................................................................................62

Figure 29. CHIP – Weighted 3M™ Potentially Preventable Readmission Chains per 1,000

Candidate Admissions, 2011-2015 ............................................................................................63

Figure 30. CHIP – Weighted 3M™ Potentially Preventable Emergency Department Visits per

1,000 Member-months, 2011-2015 ...........................................................................................64

Figure 31. CHIP – HEDIS® Effectiveness of Care: Prevention and Screening, 2011-2015 ........70

Figure 32. CHIP – HEDIS® Effectiveness of Care for Respiratory Conditions, 2011-2015 .........71

Figure 33. CHIP – HEDIS® Effectiveness of Care for Behavioral Health Conditions, 2011-2015

.................................................................................................................................................72

Figure 34. STAR+PLUS – HEDIS® Access and Preventive Care Measures, 2011-2015 ...........74

Figure 35. STAR+PLUS – Weighted 3M™ Potentially Preventable Hospital Admissions, per

1,000 Member-months, 2011-2015 ...........................................................................................77

Figure 36. STAR+PLUS – Weighted 3M™ Potentially Preventable Readmission Chains per

1,000 Candidate Admissions, 2011-2015 ..................................................................................78

Figure 37. STAR+PLUS – Weighted 3M™ Potentially Preventable Emergency Department

Visits per 1,000 Member-months, 2011-2015 ............................................................................79

Figure 38. STAR+PLUS – Weighted 3M™ Potentially Preventable Complications per At-Risk

Admissions, 2013-2015 .............................................................................................................80

Figure 39. STAR+PLUS – HEDIS® Effectiveness of Care Measures, 2011-2015 ......................83

Figure 40. STAR+PLUS – HEDIS® Effectiveness of Behavioral Health Care Measures, 2011-

2015 ..........................................................................................................................................85

Figure 41. STAR+PLUS – CAHPS® Member Satisfaction with Care Composites and Question

Summary Rates, 2012-2016 .....................................................................................................89

Figure 42. STAR+PLUS – CAHPS® Member Satisfaction with Care Ratings, 2012-2016 ..........90

Figure 43. STAR+PLUS – CAHPS® Satisfaction with Care Coordination and

Access to Care, 2012-2016 .......................................................................................................90

Figure 44. STAR Health – HEDIS® Access to and Utilization of Primary Care, 2011-2015 ........92

Figure 45. STAR Health – Weighted 3M™ Potentially Preventable Hospital Admissions, per

1,000 Member-months, 2011-2015 ...........................................................................................94

Figure 46. STAR Health – Weighted 3M™ Potentially Preventable Readmission Chains per

1,000 Candidate Admissions, 2011-2015 ..................................................................................95

Figure 47. STAR Health – Weighted 3M™ Potentially Preventable Emergency Department

Visits per 1,000 Member-months, 2011-2015 ............................................................................96

Figure 48. STAR Health – HEDIS® Effectiveness of Care for Respiratory Conditions, 2011-2015

............................................................................................................................................... 100

Figure 49. STAR Health – HEDIS® Effectiveness of Care for Behavioral Health Conditions,

2011-2015 ............................................................................................................................... 101

Figure 50. STAR Health – CAHPS® Member Satisfaction with Care, Composites and Question

Summary Rates, 2012-2016 ................................................................................................... 103

Figure 51. STAR Health – CAHPS® Member Satisfaction with Care, Ratings, 2012-2016 ....... 104

Figure 52. HCBS Settings Survey – Satisfaction and Decision-Making between ALF Urban and

ALF Rural Residents ............................................................................................................... 111

List of Acronyms

ADD Follow-Up Care for Children Prescribed ADHD Medication

ADV Annual Dental Visit

AFC Adult Foster Care

AHRQ Agency for Healthcare Research and Quality

AI Administrative Interview

ALF Assisted Living Facility

AMB Ambulatory Care

AMR Asthma Medication Ratio

APP Use of First-Line Psychosocial Care for Children and Adolescents

on Antipsychotics

APR-DRG All Patient Refined Diagnosis-Related Groups

AWC Adolescent Well-Care Visits

BH behavioral health

CAHPS® Consumer Assessment of Healthcare Providers and Systems

CATI computer-assisted telephone interviewing

CDC Comprehensive Diabetes Care

CFR Code of Federal Regulations

CHIP Dental CHIP Dental Services

CHIP Children’s Health Insurance Program

CMS U.S. Centers for Medicare & Medicaid Services

CPT Current Procedural Terminology

CRG Clinical Risk Groups

CWP Appropriate Testing for Children with Pharyngitis

DMO Dental Maintenance Organization

EDV Encounter Data Validation

EQRO External Quality Review Organization

FFS Fee-for-Service

FUH Follow-Up After Hospitalization for Mental Illness

HB House Bill

HCBS Home and Community Based Services

HEDIS® Healthcare Effectiveness Data and Information Set

Texas Contract Year 2016 External Quality Review Organization: Summary of Activities and Trends in Health Care Quality

HHS dashboard standards HHS Performance Indicator Dashboard for Quality Measures

HHS Texas Health and Human Services (a multi-agency enterprise

which includes the state Medicaid agency)

HSRI Human Services Research Institute

ICD-10-CM International Classification of Diseases, 10th Revision

ICHP Institute for Child Health Policy

IET Initiation and Engagement of Alcohol and Other Drug Dependence

Treatment

IPU Inpatient Utilization – General Hospital/Acute Care

ISP individual service plans

LTSS long-term services and supports

MCO managed care organization

Medicaid Dental Children’s Medicaid Dental Services

MMA Medication Management for People with Asthma

MMP Medicare-Medicaid Plan

MPT Mental Health Utilization

NASUAD National Association of States United for Aging and Disabilities

NCI-AD National Core Indicators–Aging and Disability

NCQA National Committee for Quality Assurance

NORC National Opinion Research Center at the University of Chicago

NPI National Provider Identifier

OAA Older Americans Act

OIG Federal Office of the Inspector General

P4Q Pay-for-Quality

PACE Program of All-Inclusive Care for the Elderly

PCP Primary Care Provider

PDI Pediatric Quality Indicators

PIP Performance Improvement Projects

PPA Potentially Preventable Hospital Admissions

PPC Potentially Preventable Complications

PPE Potentially Preventable Events

PPR Potentially Preventable Readmissions

Texas Contract Year 2016 External Quality Review Organization: Summary of Activities and Trends in Health Care Quality

PPV Potentially Preventable Emergency Department Visits

PQI Prevention Quality Indicators

QAPI Quality Assessment and Performance Improvement Programs

QI Quality Improvement

SB Senate Bill

SSI Supplemental Security Income

STAR State of Texas Access Reform Program

STAR+PLUS State of Texas Access Reform Plus Program

UFSRC University of Florida Survey Research Center

UMCC Uniform Managed Care Contract

UMCM Uniform Managed Care Manual

W15 Well-Child Visits in the First 15 Months of Life

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

WCC Weight Assessment and Counseling for Nutrition and Physical

Activity for Children/Adolescents

Texas Contract Year 2016 External Quality Review Organization: Summary of Activities and Trends in Health Care Quality Version: 7.0 HHS Approval Date Page 1

1. Executive Summary

1.1. Introduction

This Summary of Activities and Trends in Health Care Quality for Texas Medicaid Managed

Care and the Children’s Health Insurance Program (CHIP) is prepared by the University of

Florida’s Institute for Child Health Policy (ICHP) and presented to the Texas Health and Human

Services Commission (HHS) to comply with the Code of Federal Regulations (CFR). According

to 42 CFR Part 438, subpart E, an external quality review by an outside agency is mandated to

evaluate the aggregated information on quality, timeliness, and access to health care services

by a health plan for its Medicaid enrollees.1

ICHP has been the External Quality Review Organization (EQRO) for HHS since 2002. This

fiscal year 2016 review includes administrative quality-of-care measures for calendar year 2015

claims and encounter data, quality improvement activities conducted by managed care

organizations (MCO) calendar year 2015, and member satisfaction surveys in 2016.i

This review also tracks performance trends for key quality-of-care measures between 2011 and

2015 where data are available, with a focus on the state’s Pay-for-Quality program. A

companion document profiles health care quality for each of the MCOs participating in Texas

Medicaid and CHIP with measures that include the HHS Performance Indicator Dashboard for

Quality Measures (hereafter, HHS dashboard standards) designed to incentivize excellence.

1.2. Methods

The EQRO uses a comprehensive set of health care quality measures to evaluate performance

in Texas Medicaid and CHIP. These include:

Measures from the Healthcare Effectiveness Data and Information Set (HEDIS®).

Measures of potentially avoidable hospitalizations from the Agency for Healthcare Research

and Quality (AHRQ), including the Pediatric Quality Indicators (PDIs) for children and

adolescents and Prevention Quality Indicators (PQIs) for adults.

Measures of potentially preventable events (PPE) developed by 3M™,

o potentially preventable hospital admissions (PPA),

o potentially preventable readmissions within 30 days (PPR),

o potentially preventable emergency department visits (PPV), and

o potentially preventable complications (PPC).

Measures from member and caregiver surveys, including the Consumer Assessment of

Healthcare Providers and Systems (CAHPS®) survey.

i Throughout the report, references to “calendar year” correspond with the period January 1 through December 31,

and are used in regard to data periods (e.g., claims and encounter data from calendar year 2015). References to “fiscal year” correspond with the period September 1 through August 31. In reference to EQRO reports, the term “fiscal year” may also refer to the EQRO contract year for which the report was written.


For many administrative HEDIS® measures, the 2016 HEDIS® national percentiles for Medicaid

programs were available as benchmarks for performance in the State of Texas Access Reform

Program (STAR). The EQRO also compared other programs in this report with the national

HEDIS® percentiles. However, these comparisons are for reference only, as CHIP, State of

Texas Access Reform Plus Program (STAR+PLUS), and STAR Health serve populations that

are not directly comparable with the national means and percentiles. The HHS dashboard

standards are an annually updated list of measures by program, which HHS has defined as

being of highest priority to the agency. This list can be found in the Texas Medicaid and CHIP

Uniform Managed Care Manual Chapters 10.1.7 to 10.1.12.2 For measures where HHS

dashboard standards are available, these standards are the preferred benchmarks for

assessing performance as they more closely reflect the Texas Medicaid and CHIP populations.

1.3. Summary of Key Findings

This section provides the EQRO’s findings by: (1) Access to and Utilization of Care, (2)

Effectiveness of Care, and (3) Satisfaction with Care.

1.3.1. Access to and Utilization of Care Findings

Finding 1: Well-Child Visits: Across programs, the rate of Well-Child Visits in the 3rd, 4th, 5th,

and 6th Years of Life (W34) was at least 80 percent. In STAR Health, Texas is in the 90th

percentile or higher for W34 and in the 66th to 89th percentiles for STAR and CHIP. There was

variability in the W34 rates across health plans. In STAR, the W34 rate ranged from 66.4

percent for Scott & White Health Plan to 86.2 percent for UnitedHealthcare. In CHIP, the W34

rate ranged from 66 percent for Blue Cross Blue Shield of Texas to 85.9 percent for El Paso

First Health Plan. Alternatively, the rates for Well-Child Visits in the First 15 Months of Life

(W15) were considerably lower across programs: 54.7 percent for STAR and 60.2 percent for

STAR Health. In STAR, the rates ranged from 45.6 percent for Blue Cross Blue Shield of Texas

to 68.2 percent for Driscoll Health Plan.

Finding 2: Prenatal and Postpartum Care: Within the STAR program, Texas overall has a

Prenatal and Postpartum Care rate of 87.8 percent for timeliness of prenatal care, which is

around 76th percentile nationally (Table 10). While the rate for STAR prenatal care was 87.8

percent, the rates for STAR+PLUS and STAR Health were considerably lower (64.3 percent

and 63.6 percent, respectively). The Prenatal and Postpartum Care rate demonstrates variability

across programs. Additionally, less than a quarter of STAR members (23.6 percent) participated

in in high-risk obstetric programs, and even fewer CHIP members (6.8 percent) participated.

Finding 3: Substance Use and Behavioral Health-Related Access to Care: For Texas

overall, access to substance use and behavioral health (BH) related access to specialty care

has varied by program. The rates for Initiation and Engagement of Alcohol & Other Drug

Dependence Treatment (IET) and Use of First Psychosocial Care for Children and Adolescents

on Antipsychotics (APP) varied by program and MCO. The rates for IET ranged from 36.5

percent for STAR+PLUS to 57.2 percent for STAR Health. The rates for APP ranged from 32.9

percent for STAR+PLUS to 91.5 percent for STAR Health. While the IET rates were lowest for


STAR+PLUS members, the participation rates for mental and BH programs was highest in

STAR+PLUS (41.6 percent) and lower for STAR and CHIP members (9.4 percent and 2.1

percent respectively).

Finding 4: Occurrence of Potentially Preventable Events: The trends for the rates of PPEs

varied by program. The majority of PPE reasons have remained constant since 2014. The

health plans have had Performance Improvement Projects (PIPs) addressing the PPEs since

2014.

1.3.2. Effectiveness of Care

Finding 1: Asthma: Since 2012, the rates for HEDIS measures Medication Management for

People with Asthma (MMA) and the Asthma Medication Ratio (AMR) has remained relatively

stable or decreased despite the fact that health plans listed asthma as the second most

common topic among PIPs in 2014. Moreover, asthma remains a leading reason for PPAs

within STAR and CHIP, warranting further exploration about ways to improve asthma care.

Compounding the high rates of asthma PPAs is that member participation in asthma programs

ranged from 52.6 percent in STAR+PLUS to 14.9 percent in CHIP.

Finding 2a: Mental Health Follow-Up After Hospitalization: The rates for mental health

follow-up vary by program. For at-risk populations in the STAR+PLUS and STAR Health

programs, the rates of HEDIS measure Follow-up After Hospitalization for Mental Illness (FUH)

are lower than in 2011. Additionally, the rate for FUH varied by program and MCO. For

example, the STAR overall FUH rate within 30 days was 56.0 percent and for STAR+PLUS was

48.9 percent. Within program rates also varied. In STAR, the rates for FUH ranged from 32.4

percent for CHRISTUS to 71.2 percent for Blue Cross Blue Shield of Texas. Of note, three

MCOs have a PIP for STAR to address follow-up, and Superior has a PIP in place for STAR

Health.

Finding 2b: Mental Health-Related Potentially Preventable Admissions and

Readmissions: Bipolar disorders and major depressive disorders accounted for at least 12

percent of the PPAs in 2015. Additionally, readmission for mental health or substance abuse

following an initial admission for mental health or substance abuse accounted for nearly one-

third of PPR reasons in 2015 (Table 14). As noted above, participation in behavioral disease

management programs was below 50 percent across all programs.

1.3.3. Satisfaction with Care

Finding 1: Coordination of Care: The rate for member satisfaction with care coordination has

varied by program. In STAR+PLUS there was a steady increase for Medicaid-only (from 51.6

percent to 60.9 percent) and dual-eligible members (58.6 percent to 72.6 percent) from 2012 till

2016. In STAR there was an increase in the rate of satisfaction with care coordination then a

slight decrease from 2014 to 2016. In STAR Health from 2012 to 2016 there was relatively no

change in the rate of care coordination satisfaction.


1.4. Summary of Recommendations

This section provides the EQRO’s recommendations by: (1) Access to and Utilization of Care,

(2) Effectiveness of Care, and (3) Satisfaction with Care.

1.4.1. Access to and Utilization of Care

Finding 1: Well-Child Visits:

Recommendation 1: Despite Texas performing well in the W34 measure, efforts should

be made to implement PIPs focused on this measure. Specifically, the lower performing

MCOs in STAR and CHIP, which showed a greater range of scores when compared to

STAR Health and relative to Medicaid managed care plans nationally, should implement

PIPs on this measure and report to NCQA. Strategies that the better-performing MCOs

are using should be shared with the lower performing MCOs. Strategies that the better-

performing MCOs are using should be shared with the lower performing MCOs.

Recommendation 2: In 2014, UnitedHealthcare was the only MCO to have a PIP to

address W15 rates. In 2017, eight MCOs have PIPs to address W15 rates for CHIP and

STAR. Efforts should be made to monitor the W15 rates once these PIPs are

implemented.

Recommendation 3: HHS and the MCOs should explore methods to increase the

validity of their member-facing directories. Increasing the accuracy of the directories will

assist members in identifying providers and explore if they improve the W34 and W15

rates.

Finding 2: Prenatal and Post-Partum Care:

Recommendation 1: HHS and the MCOs should explore methods to address barriers

to prenatal care across the programs. HHS could identify the best practices used in

STAR MCOs and share these with lesser-performing MCOs.

Recommendation 2: HHS and the MCOs could explore the barriers to participating

high-risk obstetrics management. Increased participation in the programs could improve

the quality of care and medication management.

Finding 3: Substance Use and Behavioral Health-Related Access to Care:

Recommendation 1: HHS and the MCOs should explore ways to increase access to

behavioral and specialty health care for IET overall and for APP in STAR+PLUS. A

positive step includes the development of PIPs addressing BH that will be implemented

in 2017.

Recommendation 2: HHS and the MCOs could explore the barriers to participating in

the BH management programs. Increased participation in the programs could improve



Finding 4: Occurrence of Potentially Preventable Events:

Recommendation 1: HHS and the MCOs should explore why the PPE rates have

leveled off and explore the implications of having the PPEs level off.

Recommendation 2: HHS and the MCOs should explore and monitor possible reasons

for different PPE rates by race and age.

1.4.2. Effectiveness of Care Recommendations

Finding 1: Asthma:

Recommendation 1: In STAR, despite the fact that Texas is rated within the 66th and

89th percentile nationally for AMR, efforts should be made to increase the rates for MMA

as asthma represents one of the leading causes of Potentially Preventable Admissions

(PPAs) to hospitals in this population.

Recommendation 2: In addition, efforts should be made to determine barriers to

members enrolling in the asthma disease management programs. It is possible that

enrollment in these programs might improve medication management.

Finding 2: Mental Health Follow-Up After Hospitalization and Related Potentially

Preventable Admissions and Readmissions:

Recommendation 1: HHS and MCOs should explore how to expand the current

programs/practices for community-based mental health treatment and counseling to

reduce the number of members with PPAs and PPRs and to improve follow-up after an

inpatient mental health stay. In addition, MCOs should explore barriers to participation in

the BH management disease programs.

1.4.3. Satisfaction with Care

Finding 1: Coordination of Care:

Recommendation 1: Because of the overall increase in satisfaction with care

coordination, HHS and the MCOs should explore evidenced-based best practices that

can be implemented in lower performing MCOs.

Recommendation 2: HHS should continue gathering data and report on the findings for

the culturally competency items, from the CAHPS measures in the member surveys as a

means to improve care coordination.


2. Introduction

Approximately 73 million Americans had health coverage through Medicaid or the Children’s

Health Insurance Program (CHIP) in 2016.3 Enrollment in Medicaid grew 3.9 percent that year.4

To ensure quality health care that is effective and efficient, equitable and safe, timely and

patient-centered, states have adopted managed care as their predominant delivery model. 5 As

of 2014, 39 states had contracts with managed care organizations (MCO). More than half of

Medicaid enrollees nationally receive their care through a risk-based health plan such as an

MCO.6

Texas enrolled approximately 4.7 million individuals in either Medicaid or CHIP in 2016.7 The

state launched its Medicaid managed care pilot programs in 1991,8 and in 2012, expanded

Medicaid managed care statewide.9 The programs have undergone expansion since then, as

described in Section 8.1. In 2015, approximately 88 percent of all Medicaid beneficiaries in

Texas were enrolled in an MCO.10

Section 2.1 describes the programs and health plans that comprise Texas Medicaid and CHIP.

2.1. Managed Care Programs and Participating Plans

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

STAR provides managed care in coordination with 18 MCOs for the majority of Texas

Medicaid beneficiaries (low-income families, children, pregnant women, and some former

foster care youth).

STAR+PLUS integrates acute health services with long-term services and support (LTSS)

for people who are age 65 or older or adults who have a disability in coordination with five

MCOs.

STAR Health is a managed care program for children and adolescents in state

conservatorship and young adults previously in foster care and receiving Medicaid, up to

age 20. Members may elect to enroll in a STAR plan upon their 18th birthday, and may

continue to receive Medicaid benefits through the STAR plan of their choice up to age 26. In

2014, the sole MCO for STAR Health was Superior HealthPlan.

NorthSTAR was a carve-out program for behavioral health (BH) services for STAR and

STAR+PLUS members who live in the Dallas service area: it was in place through

December 2016.

CHIP provides managed care through 17 health plans to children and families whose

income is too high to qualify for Medicaid but too low afford private insurance for their

children.

Children’s Medicaid Dental Services (hereafter, Medicaid Dental) provides dental services

for children and young adults up to age 20 enrolled in Texas Medicaid through two dental

maintenance organizations (DMOs), DentaQuest and MCNA.

CHIP Dental Services (hereafter, CHIP Dental) provides dental services for children and

adolescents ages 18 and younger in CHIP, through DentaQuest and MCNA.


CHIP Perinate expands CHIP services to unborn children and neonates, with a smooth

transition of coverage to Medicaid or CHIP at birth or before a child's first birthday.

As of August 31, 2016, 21 health plans served the Texas Medicaid and CHIP populations,

including two dental maintenance organizations (DMOs) and 19 MCOs.

Table 1 lists the programs served by each plan.

Table 1. Texas Medicaid/CHIP Health Plans and Programs in 2016ii

Health Plansiii STAR CHIP STAR+ PLUS

STAR Health

CHIP Dental

Medicaid Dental

Aetna Better Health

Amerigroup

Blue Cross and Blue Shield of Texas

CHRISTUS Health Plan

Cigna-HealthSpring

Community First Health Plans

Community Health Choice

Cook Children's Health Plan

Dell Children’s Health Plan (Formerly Seton Health Plan)

DentaQuest

Driscoll Health Plan

El Paso First Health Plans, Inc.

FirstCare

MCNA

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

2.2. External Quality Review in Texas Medicaid and CHIP

Federal regulations require external quality review of Medicaid managed care programs to

ensure that state programs and their contracted MCOs and DMOs are compliant with

ii The NorthSTAR behavioral health carve-out operating in the Dallas service area was served by ValueOptions through the end of calendar year 2016.

iii MCO names have been abbreviated or acronyms used in some tables and charts.


established standards. States are required to validate MCOs’/DMOs’ performance-improvement

measures and projects, and assess their compliance with access-to-care and quality-of-care

standards. In addition, states also may validate member-level encounter data, conduct surveys

and focus studies, and independently calculate performance measures. The U.S. Centers for

Medicare & Medicaid Services (CMS) provides guidance for these mandatory and optional

activities through protocols for evaluating the state’s quality assessment and improvement

strategy.11

The Texas Health and Human Services Commission (HHS) has contracted the Institute for

Child Health Policy at the University of Florida (ICHP) to serve as the Texas external quality

review organization (EQRO) since 2002. This report summarizes the activities conducted during

state fiscal year 2016 (September 1, 2015, to August 31, 2016). Findings include administrative

quality-of-care calculations from calendar year 2015 claims and encounter data; studies of MCO

quality improvement (QI) activities MCOs in calendar year 2015; and member-satisfaction

surveys spanning all or part of calendar year 2016.iv

To further assist Texas HHS and the state’s MCOs in developing and implementing quality-

improvement strategies, this report shows performance trends for selected quality-of-care

measures from 2011 through 2015 (where data are available), with a focus on the state’s Pay-

for-Quality (P4Q) program. Most of the trends presented are at the program level (e.g., STAR,

CHIP).

2.3. External Quality Review Organization Activities

Mandatory activities:

1. Validation of MCO Performance Improvement Projects (PIP).

a. Evaluation of MCO PIPs assess the methodology used, verify the findings, and evaluate

the overall reliability and validity of the results.

2. Validation of performance measures.

a. Quality-of-care studies: description of data collection, aggregation, and analysis and

outcomes for each measure.

3. Review of MCO compliance with state and federal regulations for access to care, structure

and operations, and quality measurement and improvement.

a. Claims and encounter data quality certification: assess key data elements, including

those that are critical for proper care coordination and quality-of-care measurement.

b. MCO administrative interviews (AI): structured and targeted interviews to assess health

plan organizational structure, strengths, and opportunities for improvement with respect

iv Throughout the report, references to “calendar year” correspond with the period January 1 through December 31,

and are used in regard to data periods (e.g., claims and encounter data from calendar year 2015). References to

“fiscal year” correspond with the period September 1 through August 31. In reference to EQRO reports, the term “fiscal year” may also refer to the EQRO contract year for which the report was written.


to quality, timeliness, and access to health care services. In addition, responses on the

AIs are reviewed and evaluated to assess health plan compliance with state and federal

regulations.

c. Evaluation of MCO Quality Assessment and Performance Improvement Programs

(QAPI): evaluate the structure and process of the health plans’ QI programs, which

includes the evaluation of clinical and nonclinical aspects of quality and performance

improvement, availability of human and material resources, indicator monitoring efforts,

and the implementation of evidence-based clinical practice guidelines.

Optional activities:

1. Validation of encounter data reported by MCOs.

d. Encounter data validation (EDV) studies (biennial): determine the accuracy and

completeness of claims and encounter data by comparing paid and denied claims to

documentation in a representative sample of medical or dental records.

2. Administration or validation of consumer or provider surveys of quality-of-care.

a. Member and caregiver satisfaction surveys (biennial): collect member and caregiver

perspectives on satisfaction with and experience of care and communicate to

stakeholders and the MCOs.

3. Calculation of performance measures in addition to those reported by a MCO and validated

by the EQRO.

a. Quality-of-care studies: The EQRO independently calculates a number of additional

measures, and each year chooses several to analyze in depth.

4. Conduct quality assessment studies that focus on a particular aspect of clinical or non-

clinical services at a point in time.

a. Focus studies: ad hoc reports on topics selected annually.

b. Health-based risk analysis: in-depth reports of factors associated with health outcomes.

The EQRO also calculates results of administrative and hybrid measures from National

Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set

(HEDIS®), the AHRQ Pediatric Quality Indicators (PDI) and Prevention Quality Indicators (PQI),

and 3M™ Health Information Systems measures of Potentially Preventable Events (PPE).

Results for these measures were reported using calendar year 2015 data for STAR, CHIP,

STAR+PLUS, STAR Health, and Medicaid/CHIP Dental. The set of measures for each program

varies, with measures selected according to state health care quality priorities as well as the

demographic and health profile of each program’s members. A number of measures specific to

adults (e.g., HEDIS® Comprehensive Diabetes Care, HEDIS® Adults’ Access to

Preventive/Ambulatory Health Services) were not calculated for CHIP or STAR Health because

the vast majority of members in these programs do not meet the age criteria. In addition, the

measure set for STAR Health was more limited than the measure sets for STAR and CHIP.12


The EQRO annually produces results on administrative measures at the MCO and service

delivery area levels. These include in-depth analyses of selected performance measures, which

are reported to HHS and made available to the Medicaid and CHIP MCOs through the Texas

Health Care Learning Collaborative web portal.13

In addition, the EQRO conducts certain optional activities on a biennial basis: member

satisfaction surveys and EDV studies. EQRO member survey projects are specific to particular

populations, and their content can vary from year to year.

The EQRO conducted a number of special studies and projects in calendar year 2016 to assist

HHS in quality-of-care evaluation activities and policy decisions, including:

A Home and Community Based Services (HCBS) Settings Assessment Study.

A pre-implementation study that examined administrative quality measures and survey

results for members identified as being potentially eligible for the new STAR Kids program.

An analysis of National Core Indicators–Aging and Disability (NCI-AD) Study

implementation.

Appointment availability studies to assess provider compliance with contractual

requirements for timeliness of appointments.

MCO Report Card evaluation study.

Primary Care Provider (PCP) Referral pilot study.

To promote continued improvements in health care quality for Texas Medicaid and CHIP

members, the EQRO also provides resources and guidance for MCOs and patients. These

include training and continuing education sessions as well as new tools to share quality-of-care

results with MCOs and members. In state fiscal year 2016, the EQRO continued two initiatives

to advance tools for sharing health care quality information. The Texas Health Care Learning

Collaborative web portal allows MCOs to access and analyze their results on important quality-

of-care measures. MCO report cards make quality-of-care information easily accessible to

Medicaid members and help new Medicaid and CHIP enrollees make informed decisions when

selecting their MCO. The MCO report cards are mailed to new members with their enrollment

packet and posted to the HHS website.14


3. Characterizing Texas Medicaid and CHIP Populations

This section provides a snapshot of Medicaid and CHIP populations, including overall program

numbers; demographics for gender, race, and age, and some key health indicators. The EQRO

surveys members on a biennial basis.

In calendar year 2016, the EQRO surveyed adult members (STAR adult and STAR+PLUS) and

adult caregivers of STAR Health members under 18. The surveys gathered self-reported health

and mental health status; height and weight; quality of life impressions; needing help with daily

living and personal care for STAR+PLUS members; and special health care needs for children

with chronic conditions for STAR Health members.

3.1. STAR Program

Enrollment for STAR was approximately 2.9 million (Figure 1) in 2015.

Figure 1. STAR – Program Enrollment, 2011-2015

Among members in December 2015:

53.1 percent were female.

57.4 percent were Hispanic, 15.6 percent white non-Hispanic, and 14.1 percent Black

non-Hispanic.

The mean age was 9.5 years old (standard deviation 8.2 years).

1,746,595

2,541,901 2,504,606

3,002,643 2,971,298

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

2011 2012 2013 2014 2015


Figure 2 shows the member-reported overall health and mental health status in 2016. Less than

half (44.7 percent) of adult STAR members reported their overall health as either “Excellent” or

“Very Good,” while over half (55.2 percent) reported their mental health as either “Excellent” or

“Very Good.”

Figure 2. STAR – Member-reported Health Status, 2016

More than two-thirds of adults in STAR were obese (44.1 percent) or overweight (23.1 percent)

(Figure 3).

Figure 3. Body Mass Index Classification Based on Member (STAR Adult) Report of Height and Weight, 2016

19.3%25.4%

31.6%

18.7%

5.0%

30.6%24.6%

27.8%

13.7%

3.3%

0%

10%

20%

30%

40%

50%

Excellent Very Good Good Fair Poor

Overall Health Mental Health

Underweight, 2.1%

Healthy, 30.7%

Overweight, 23.1%

Obese, 44.1%


3.2. CHIP Program

CHIP enrollment decreased sharply from 2013 to 2014, by more than 200,000 members. This

drop may be explained in part by changes under the Patient Protection and Affordable Care Act

to the minimum income for Medicaid eligibility. Under this change, some children who had

previously been eligible for CHIP became eligible for Medicaid instead. Changes to income

calculations also may have played a role. The enrollment for CHIP began to increase once more

between 2014 and 2015, increased by approximately 17,000 members (Figure 4).

Figure 4. CHIP – Program Enrollment, 2011-2015



45 percent were Hispanic, 14.4 percent were white non-Hispanic, and 8.5 percent were

Black non-Hispanic.


562,647588,160 567,286

335,009 352,432

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

2011 2012 2013 2014 2015


3.3. STAR+PLUS Program

The enrollment for STAR+PLUS was approximately 250,000 Medicaid-only- enrollees and

286,000 dual-eligible enrollees (Figure 5).

Figure 5. STAR+PLUS – Program Enrollment, 2011-2015

Among Medicaid-only members in December 2015:


26.8 percent were Hispanic, 25.1 percent were white non-Hispanic, and 21.3 percent

were Black non-Hispanic.


Among dual-eligible members in December 2015:



The EQRO collected the health status of STAR+PLUS members through a survey in 2016

(Figure 6). Less than one-fifth of Medicaid-only enrollees and dual-eligible enrollees reported

their overall health status as either “Excellent” or “Very Good” (18.2 percent and 8.8 percent

respectively).

137,372

182,061 183,339

242,360249,398

144,092

221,992 226,322

280,167 286,222

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

2011 2012 2013 2014 2015

STAR+PLUS Medicaid-only STAR+PLUS Dual Eligible


Figure 6. STAR+PLUS – Member-reported Health Status, 2016

More than three-quarters of Medicaid-only and dual-eligible STAR+PLUS members were obese

or overweight (

Figure 7).

Figure 7. STAR+PLUS Body Mass Index Classification Based on Member Reported Height and Weight, Medicaid-only (left) and Dual-eligible (right), 2016

Underweight, 2.3%

Healthy, 18.9%

Overweight, 24.8%

Obese, 54.0%

Underweight, 2.9%

Healthy, 16.9%

Overweight, 21.9%

Obese, 58.3%

8.0% 10.2%

23.8%

37.5%

20.5%

12.6% 12.3%

32.6% 30.5%

12.1%

0%

10%

20%

30%

40%

50%


STAR+PLUS (Medicaid-only) – Member-reported Health Status, 2016


2.8%6.0%

24.8%

40.8%

25.6%

10.7%7.5%

29.4%

41.7%

10.7%

0%

10%

20%

30%

40%

50%


STAR+PLUS (Dual-eligible) – Member-reported Health Status, 2016



The EQRO surveyed STAR+PLUS members (Figure 8) to find out:

(1) If they required help with daily living, such as everyday household chores, doing

necessary business, shopping, or getting around for other purposes;

(2) Their quality of life, such as whether a physical or medical condition seriously

interferes with the member’s their independence, participation in the community, or

quality of life; and

(3) If they required help with personal care, such as eating, dressing, or getting around

the house.

Approximately half (51.5 percent) of Medicaid-only members reported requiring help with daily

living tasks. Nearly two-thirds (62.7 percent) of dual-eligible STAR+PLUS members reported

requiring help with personal care.

Figure 8. Member reported Limitations with Activities of Daily Living, Quality of Life, and Personal Care, 2012-2016

51.5%

57.1%

51.5%

43.0%

43.3%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Help with Daily Living

65.2% 66.3% 65.1%

67.5% 67.2%

2012 2014 2016

Quality of Life

Medicaid-only Dual-eligible

32.7%

37.8%

32.6%

62.9%

62.7%

2012 2014 2016

Personal Care


3.4. STAR Health

The enrollment for STAR Health was approximately 31,700 enrollees (Figure 9).

Figure 9. STAR Health – Program Enrollment, 2011-2015



41.5 percent were Hispanic, 30.5 percent white non-Hispanic, and 24.5 percent Black

non-Hispanic.


The EQRO surveyed caregivers to collect the health status of STAR Health members in 2016

(Figure 10). Over three-quarters of caregivers reported the child or adolescent STAR Health

member as having either “Excellent” or “Very Good” health. More than half (57.7 percent) of

caregivers reported the child or adolescent member as having either “Excellent” or “Very Good”

mental health.

Figure 10. STAR Health – Caregiver-Reported Health Status

32,24230,462

31,719 32,305 31,703

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

2011 2012 2013 2014 2015

36.7%40.0%

19.3%

2.7% 1.3%

28.7% 29.0%

22.7%

16.7%

3.0%

0%

10%

20%

30%

40%

50%




More than half (51.9 percent) of the caregivers reported the child or adolescent STAR Health

member required a special need (Figure 11). The most common special need was “Problems

that require counseling.”

Figure 11. STAR Health – Caregiver-Reported Special Health Care Needs, 2016

Approximately a third of caregivers reported the child or adolescent STAR Health member was

either obese (22.6 percent) or overweight (17.9 percent) (Figure 12).

Figure 12. STAR Health - Body Mass Index Classification Based on Member Reported Height and Weight, 2016

33.3% 30.1% 27.7%19.2% 17.1%

51.9%

0%

20%

40%

60%

80%

100%

Problems thatrequire

counseling

Dependence onmedication

Use or needmore care or

services

Functional/abilitylimitations

Need for specialtherapy

Any specialneeds

Underweight, 13.7%

Healthy, 45.8%

Overweight, 17.9%

Obese, 22.6%


4. Managed Care Organization and Dental Maintenance Organization

Structure and Process

The EQRO for Texas annually conducts:

Data certification to assess the completeness and validity of claims and encounter data

maintained by Texas Medicaid and CHIP MCOs.

AIs to assess MCO compliance with state and federal regulations in addition to different

components of MCO structure and process, including data systems capabilities and

processes and disease management programs.

Evaluations of MCO QI programs.

Evaluations of MCO PIPs.15

This section presents data certification findings on key elements in claims and encounter data,

select findings from AIs with each health plan, disease management programs, and QAPI

evaluations.

The EQRO conducts EDV studies every year. Each year the EDV studies alternate being for

MCOs and DMOs.16

An addendum is provided to the report that highlights PIP topics. A PIP topic reflects the health

plan’s enrollee characteristics including the demographics, disease prevalence, and disease

consequence. The topic addresses the patterns of over or underutilization that lowers an

enrollee’s health or functional status.17The addendum covers the three-year 2014 PIPs.

4.1. Data Certification

The EQRO annually certifies key data elements in claims and encounter data maintained by

Texas Medicaid and CHIP MCOs. Annual data certification includes four types of analyses: (1)

volume analysis based on service category, (2) data validity and completeness analysis, (3)

consistency analysis between encounter data and financial summary reports, and (4) validity

and completeness analysis of provider information.

Key data elements assessed during data certification include those that are critical for proper

care coordination and quality-of-care measurement. These include place of service code,

admission date, discharge status, discharge date, primary diagnosis code, National Provider

Identifier (NPI), provider taxonomy code, procedure code, and present-on-admission code.

The EQRO developed procedures for certifying the Texas Medicaid and CHIP encounter data

using two documents: (1) Texas Government Code §533.0131, Use of Encounter Data in

Determining Premium Payment Rates; and (2) U.S. Department of Health and Human Services,

CMS – Validation of Encounter Data Reported by the MCO.18,19 Data certification is conducted

separately for STAR, STAR+PLUS, STAR Health, CHIP, CHIP Dental, Medicaid Dental, CHIP

Perinate, and NorthSTAR. For managed care programs served by multiple MCOs (e.g., STAR,


CHIP, and STAR+PLUS), analyses are conducted at the plan code level (MCO and service

area combined).

Volume analysis based on service category

For each month of state fiscal year 2015 in each program and plan code, the analysis assessed

the number of records for facility, physician, dental (where present), and total services. The

EQRO examined monthly totals to determine the extent to which the number of records for each

of the service categories and the total number of records varied from month to month. The

EQRO found the results to be consistent for all plan codes based on overall volumes.

Data validity and completeness analysis

The EQRO examined the presence and validity of critical data elements in the claims extracts

submitted by the MCOs for state fiscal year 2015. The EQRO derived data validity standards

from accepted lists from a variety of sources, including data dictionaries supplied by HHS,

Current Procedural Terminology (CPT) manuals, and International Classification of Diseases,

10th Revision (ICD-10-CM) manuals.20,21 The EQRO analyzed the final image of all state fiscal

year 2015 claims received from Texas Medicaid and Health Care Partnership through

December 2015. All critical fields were present in the data as specified in the CMS Data

Validation Protocol.

Consistency analysis between encounter data and financial summary reports provided by the

MCOs

The EQRO compared payment dollars documented in the state fiscal year 2015 claims data to

payment dollars in the MCOs’ self-reported financial summaries provided by HHS. The analysis

found that consistency between encounter data and financial summary reports met the HHS

standard that claims data and the financial summary report must agree within three percent for

the data to be certifiable.

Validity and completeness analysis of provider information

Adequate provider identification is critical to the EQRO’s efforts to calculate HEDIS® and other

administrative measures and obtain medical records to validate encounter data and calculate

hybrid HEDIS® measures. For state fiscal year 2015, a valid NPI was found in almost all

encounters. When locating records, and particularly for attributing services to providers with

identified specialties (e.g., for HEDIS® measure calculation), the individual service provider must

be identified on the encounter, with the taxonomy (specialty) code included. The EQRO

assessed the quality of provider identification in the encounter data in two ways: (1) presence of

a primary NPI identified as an individual (not an organization) in the provider table; and (2)

taxonomy for the primary NPI on professional encounter records. Primary NPI was the first filled

NPI field among rendering, pay to, and billing NPI fields. Professional encounters had

transaction type ‘P’ and included a CPT code for evaluation and management services,

excluding non-office and non-hospital facilities, and non-face-to-face services.


Overall, the primary NPI on over 90 percent of these encounters was an individual. However,

within STAR+PLUS, all five MCOs had at least one service area where less than 80 percent of

encounters had an individual NPI as the primary NPI. When the primary provider identification

number is for a group and not the individual providing the service, the taxonomy reported or

associated with the identification number may not reflect the qualifications required for

calculating quality measure defined with provider constraints.

Certain quality of care measures rely on provider specialization information, and the accuracy of

these measures suffers when MCOs and DMOs do not submit complete information about

provider specialization in their encounter data. Examples of these problems are when

professional claims are submitted in which no individual person is named as the rendering

provider or when encounter data has missing provider identification numbers or taxonomy

codes. . If valid taxonomy information was absent on more than 5 percent of the encounters, the

EQRO considered this an area of concern. Overall, the EQRO identified 72 percent of

professional encounters in STAR, 78 percent in CHIP, and 69 percent in STAR+PLUS with an

individual NPI and included the taxonomy. For STAR Health, the rate was only 54 percent.

Because the valid taxonomy was absent more than five percent of the time, the EQRO

considered this an area of concern.

4.2. Administrative Interviews

CMS protocols for external quality review of Medicaid and CHIP managed care include AIs to

assess health plan compliance with relevant state and federal regulations. The AIs entails the

completion of a web-based tool by the health plan on an annual basis. The web-based tool

includes questions that address the state and federal regulations with which the health plans

must comply. The EQRO evaluates the health plans’ web-based tool, including reviewing

health plan policy and procedures, to assess health plan compliance with the state and federal

regulations. Each health plan receives a final score and a set of recommendations informing

them what regulations have not been fully met. This happens on an annual basis. Every year,

The EQRO either calls or visits the health plan to address outstanding issues with compliance

and collect supplemental information related to other CMS-required activities, such as the QAPI

and PIPs. The site visit rotation is set up to ensure that the EQRO visits each health plan at

least once every three years, as per CMS requirements in Protocol 1.

The EQRO conducted MCO AIs in 2016 that addressed the following areas:

Organizational structure

Member enrollment and disenrollment

Children’s programs and preventive care

Care coordination and disease management programs

Member services

Member complaints and appeals

Provider network and reimbursement


Authorizations and utilization management

Information systems

Data acquisition

In addition, the NorthSTAR questionnaire included items specific to BH, while the Medicaid

Dental and CHIP Dental questionnaires included items specific to dental health.

After MCO completion of the web-based AI tool, the EQRO conducted follow-up

teleconferences and site visits to further address quality and compliance. The EQRO conducted

AI teleconferences with 17 of the health plans and site visits with the remaining five. The EQRO,

working with HHS, selected to visit the health plans participating in the Dual Demonstration,

which included all of the health plans providing coverage for the STAR+PLUS population. The

teleconferences focused on health plan care coordination efforts and strategies. The site visits

focused on care coordination efforts and strategies in addition to LTSS and the Dual

Demonstration program.

4.2.1. MCO Compliance with State and Federal Regulations

The EQRO reviewed MCO responses on the web-based AI tool to assess compliance with state

and federal regulations. These regulations fall in the following categories.

General Provisions:

o Information about enrollment, benefits and access to care the MCOs are required

to provide to members

o Type and timeframe for communication of the required information to the

members

State Responsibilities:

o Timeframe requirements for disenrollment from a MCO by the State

Member Rights and Protections:

o Members’ rights to access to care and to participate in treatment

o Required coverage and payment of emergency and post-stabilization services

QAPIs:

o Provider network requirements and member access to out-of-network providers

o Requirements for identification and assessment of members with special health

care needs and the development of treatment plans for these members

o Process and timeframes for standard and expedited authorization of services

o Provider selection and credentialing

o Requirement that the MCO ensure that accurate and complete data reported by

providers is verified for accuracy and timeliness


Grievance System:

o Establishment of a grievance system which includes the processes by which a

provider or member may file a complaint or appeal, at the MCO or State level, in

accordance with federal and/or state regulations

o Timeframes for the MCO’s response to a complaint or appeal and the information

that must be included in the MCO’s response

The MCOs were in compliance with state and federal requirements overall, although no health

plans were compliant with 100 percent of the regulations. Table 2 shows the 2016 AI Evaluation

Scores and Percent Change from 2015.


Table 2. 2016 Administrative Interview Evaluation Scores and Percent Change from 2015

2016 Administrative

Interview Evaluation Scores

Administrative Interview

Evaluations Percent Change in Scores from 2015

to 2016v

(0-100) %

Health Plan Average 93.2 7.5

Aetna Better Health 95.4 22.6

Amerigroup 95.9 -2.0

Blue Cross and Blue Shield of Texas 94.3 0.6

CHRISTUS Health Plan 86.0 4.4

Community First Health Plans 97.8 0.4

Community Health Choice 86.3 16.3

Cook Children’s Health Plan 97.3 6.0

Dell Children’s Health Plan (formerly Seton) 96.2 29.4

Driscoll Health Plan 94.7 -0.4

El Paso First Health Plans, Inc. 95.6 1.8

FirstCare 97.8 13.5

Cigna-HealthSpring 93.9 5.1

Molina Healthcare of Texas, Inc. 96.3 19.7

Parkland Community Health Plan 79.7 -0.4

RightCare from Scott & White Health Plan 95.6 6.8

Sendero Health Plans 91.0 4.5

Superior HealthPlan 93.7 -2.6

Texas Children’s Health Plan 86.6 12.6

UnitedHealthcare Community Plan 95.6 3.4

v Changes in health plan scores could be attributed to improved documentation that they submitted during the AI process and modified policies to meet state and federal requirements.



4.2.2. Disease Management Programs

HHS requires all MCOs participating in STAR, STAR+PLUS, CHIP, and STAR Health to provide

disease management services covering asthma and diabetes.22 In addition to asthma and

diabetes, HHS requires MCOs participating in STAR+PLUS to offer disease management for

chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease.

Finally, all MCOs are required by HHS to provide disease management programs for other

chronic diseases based on disease prevalence within each MCO's membership.23 In calendar

year 2015, these included programs for depression, attention deficit hyperactivity disorder, other

mental and BH, high-risk perinatal, human immunodeficiency virus / acquired immunodeficiency

syndrome, hypertension, oncology, obesity, and general disease management.

This section presents findings from calendar year 2015 MCO AIs on the structure and practice

of disease management and health promotion programs operating in Texas Medicaid and CHIP

MCOs, focusing on programs that are required by the state.


Table 3, Table 4, and Table 5 show rates of member participation in select disease-

management programs in STAR, CHIP, and STAR+PLUS, respectively, in calendar year 2015.

Active members are defined as members (or their representatives) with one or more telephonic

or face-to-face encounter with disease-management staff.

Fewer than one in five eligible members participated in asthma disease management in STAR

(18.6 percent) or CHIP (14.9 percent). Disease management participation rates were higher in

STAR+PLUS for both asthma (52.6 percent) and diabetes (48.2 percent).


Table 3. STAR – Member Participation in Disease Management Programs, 2015

Active

Members Members

Eligible Participation Rate

Depression 2,889 4,542 63.6%

General Disease Management 5,704 9,656 59.1%

High-Risk Obstetrics 6,535 27,738 23.6%

Asthma 56,054 301,063 18.6%

Attention Deficit Hyperactivity Disorder 1,510 16,124 9.4%

Mental and Behavioral Health 4,403 46,652 9.4%

Diabetes 7,955 190,613 4.2%

Table 4. CHIP – Member Participation in Disease Management Programs, 2015

Active

Members Members


Depression 225 323 69.7%

General Disease Management 236 420 56.2%

Asthma 5,358 35,891 14.9%

High-Risk Obstetrics 537 7,850 6.8%

Attention Deficit Hyperactivity Disorder 93 2,915 3.2%

Diabetes 538 23,379 2.3%

Mental and Behavioral Health 715 33,723 2.1%

Table 5. STAR+PLUS – Member Participation in Disease Management Programs, 2015

Active

Members Members


Obesity in Adults 453 453 100.0%

Chronic Obstructive Pulmonary Disease 2,903 4,934 58.8%

Congestive Heart Failure 2,264 4,153 54.5%

Coronary Artery Disease 2,266 4,156 54.5%

Asthma 3,873 7,368 52.6%

Diabetes 15,383 31,918 48.2%

Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome

774 1,719 45.0%

Mental and Behavioral Health 3,447 8,287 41.6%

Depression 1,148 3,149 36.5%

General Disease Management 4,214 12,626 33.4%


4.3. Quality Improvement

The EQRO annually reviews the Texas Medicaid MCO QI programs to evaluate aspects of

structure and process that contribute to their success, and to assess compliance specified in the

CFR. This section discusses the EQRO’s evaluation of calendar year 2016 MCO QAPI

programs as they pertain to 42 CFR §438.358 Activities Related to External Quality Review and

42 CFR §438.364 External Quality Review Results.

4.3.1. Quality Assessment and Performance Improvement Program Evaluations

Evaluations

The QAPI Program Evaluations follow CMS guidelines to evaluate both quality assurance and

QI practices of the Texas Medicaid MCOs. CMS specifies five essential elements of a quality

assessment and performance-improvement program: (1) design and scope; (2) governance and

leadership; (3) feedback, data systems, and monitoring; (4) performance-improvement projects;

and (5) systematic analysis.24 This review covers the first three elements and part of the fifth.

Using documentation submitted by the MCOs, the QAPI program evaluations review the MCOs’

performance-improvement structures and program assessments. This evaluation captures the

structure and process of the QI program through review and scoring of the following sections:

Documentation of the MCO’s work plan, QI organizational chart, performance-improvement

projects and completed quality assessment and evaluation of those projects (maximum 3.75

points).

Role of the Governing Body, covering the level and type of governance and leadership

within the organization (maximum 10 points).

Structure of QI Committee(s), including the role, structure, and function of QI committee(s),

and level of provider and member representative involvement (maximum 3.75 points).

Identification of Adequate Resources, including human and material resources available for

the QAPI program (maximum 10 points).

Identification of Improvement Opportunities, including actions taken to improve at the

system, process, and outcome levels (maximum 10 points).

Program Description, including the MCO’s statement of purpose, scope, goals and

objectives, organization-wide communication of results, methodology, and monitoring and

evaluation of progress toward accomplishing goals and objectives (maximum 10 points).

Assessment of Overall QAPI Program Effectiveness, including the method by which the

MCO addresses barriers to implementation, factors of success, and program effectiveness

(maximum 3.75 points).

Clinical Practice Guidelines, including a review of current clinical practice guidelines to

ensure they are evidence-based, relevant to member needs, and support care of members

and services for members (maximum 3.75 points).

Availability and Accessibility Indicators, including results of MCO monitoring of member

access-to-care indicators, goals for all indicators, the MCO’s actions to improve rates of


accessibility and availability of care for members, and the effectiveness of actions taken

(maximum 10 points).

Clinical Quality Indicators, including results of MCO monitoring of clinical indicators, goals

for all indicators, the MCO’s actions to improve rates of clinical indicators, and the

effectiveness of actions taken (maximum 10 points).

Service Quality Indicators, including results of MCO monitoring of service indicators, goals

for all indicators, the MCO’s actions to improve rates of service indicators, and the

effectiveness of actions taken (maximum 10 points).

Credentialing/Re-credentialing, summarizing the number of providers and facilities

credentialed or re-credentialed, the number who requested or were denied credentialing,

reasons for denials, the number who were reduced, suspended, or had privileges terminated

during calendar year 2015, and the reasons for these reductions, suspensions, or

terminations (maximum 3.75 points).

Delegation of QAPI Program Activities, including procedures for monitoring and evaluating

delegated functions, results of evaluation of delegated activities, and deployment of the

results to improve quality (maximum 3.75 points).

Corrective Action Plans, including any corrective actions required and taken following a

Texas Department of Insurance audit (maximum 3.75 points).

Previous Year’s Recommendations, including a review of whether and how the MCO

addressed the recommendations (maximum of 3.75 points).

Each section includes different components that target key elements of QI, as described above.

The overall evaluation of health plan responses focuses on whether the MCO satisfied the

requirements of a strong, comprehensive QI program and complied with specific CFR

policies.25,26


Scoring Methodology

The scoring system rates each MCO on a scale of 0-100 based on its QAPI summary report.

The QAPI program evaluation includes 15 activities. The EQRO calculated the scores for each,

then weighted them to assign more importance to those activities representing the five essential

components of a successful QI program as described above. Excluding Element 4 PIPs,

evaluated separately, the EQRO applied more weight to the following activities, together

representing 70 percent of the score. Each of these activities contributed 10 percent of the final

score:

A1: Role of Governing Body (CMS Element 2)

A3: Adequate Resources (CMS Element 2)

A4: Improvement Opportunities (CMS Elements 3 and 5)

B1: Program Description (CMS Elements 1 and 3)

B4: Availability and Access to Care Monitoring and Results (CMS Elements 3 and 5)

B5a: Clinical Indicator Monitoring (CMS Elements 3 and 5)

B5b: Service Indicator Monitoring (CMS Elements 3 and 5)

The remaining eight activities accounting for 30 percent of the final score are also important

components of the QI program. These eight capture the health plan's compliance with CFR

policies or support the above activities:

Required Documentation

A2: Structure of QI Committee(s)

B2: Overall Effectiveness

B3: Clinical Practice Guidelines

B6: Credentialing and Re-credentialing

B7: Delegation of QAPI Activities

B8: Corrective Action Plans

B9: Previous Year’s Recommendations

The EQRO divided the 30 points allotted to these activities evenly among all those applicable.

For any activity that did not apply to a plan, the EQRO scored the activity as N/A and

redistributed the points to all remaining activities. Overall, the final weighted scores allow for a

more accurate analysis of the MCOs’ QI programs. The results presented below are based on

the QAPI program evaluations reporting on data elements and occurrences during calendar

year 2016.

Table 6 shows the overall score for each health plan. The average score of all health plans was

95.6 percent. Fourteen of 22 MCOs or dental plans scored above that. All plans, with the

exception of Cook Children’s Health Plan, scored above 90 percent.


Table 6. Quality Assessment and Performance Improvement Scores by Health Plan, Measurement Year 2016

Health Plan Score

Average 95.6%

Aetna Better Health 99.4%

Parkland Community Health Plan 98.4%

UnitedHealthcare Community Plan 98.4%

Superior HealthPlan 98.1%

Driscoll Health Plan 97.6%

Dell Children’s Health Plan (formerly Seton) 97.5%

Texas Children’s Health Plan 97.5%

Blue Cross and Blue Shield of Texas 97.4%

RightCare from Scott & White Health Plan 96.9%

El Paso First Health Plans, Inc. 96.8%

FirstCare 96.8%

Amerigroup 96.7%

Community Health Choice 96.3%

DentaQuest 96.3%

Sendero Health Plans 94.6%

MCNA Dental 93.8%

ValueOptions 93.5%

Community First Health Plans 93.1%

Cigna-HealthSpring 92.8%

CHRISTUS Health Plan 91.4%

Molina Healthcare of Texas, Inc. 91.1%

Cook Children’s Health Plan 89.8%

The EQRO also evaluated the plans’ QAPI program summary reports by section to identify

areas of high performance and opportunities for both systematic and individual improvement.

Table 7 presents the average QAPI program summary report activity score, calculated as the

average weighted score across all MCOs for each activity. Overall, the MCOs scored highest in

activities related to: A1: Role of governing body; B7: Delegation of QAPI Activities; and B8:

Corrective Action Plans, with scores of 100 percent. The score for B9: Previous Year’s

Recommendations is low because one health plan received a zero, 11 health plans received a

50, and only nine received a 100.


Table 7. Quality Assessment and Performance Improvement Scores by Activity, Measurement Year 2016

Activity Score

Average 95.3%

A1: Role of Governing Body 100.0%

B7: Delegation of QAPI Program Activities 100.0%

B8: Corrective Action Plans 100.0%

A2: Structure of Quality Improvement Committee(s)

99.7%

B6: Credentialing and Re-credentialing 99.4%

B5a: Clinical Indicator Monitoring 98.9%

Required Documentation 98.9%

B5b: Service Indicator Monitoring 98.5%

B3: Clinical Practice Guidelines 97.7%

A4: Improvement Opportunities 97.3%

B4: Availability and Access to Care Monitoring and Results

96.2%

B1: Program Description 92.6%

B2: Overall Effectiveness 92.4%

A3: Adequate Resources 92.0%

B9: Previous Year’s Recommendations 65.9%

Quality Assessment and Performance Improvement Recommendations

In the 2016 QAPI program evaluations, the EQRO made a number of recommendations to each

MCO to strengthen QI practices based on activities in 2015. Table 8 provides examples of

recommendations made for each activity. Importantly the EQRO recommended that health

plans: develop long-term goals for their QI programs; evaluate and report on the effectiveness

of access to care, clinical indicator, and service indicator monitoring; and evaluate and report on

the effectiveness of the overall program.


Table 8. Examples of Recommendations Made for Quality Assessment and Performance Improvement Programs in STAR, CHIP, STAR+PLUS, and STAR Health, 2016

Activity Example Recommendation

Required Documentation Complete all sections of the Quality Assessment and Performance Improvement evaluation tool.

Role of Governing Body Describe actions taken by the governing body to modify the quality improvement program. Indicate if no actions taken.

Structure of Quality Improvement Committee(s)

Specify which committee members have clinical and non-clinical voting rights.

Adequate Resources Provide greater detail about human resources available to operate and oversee the quality improvement program.

Opportunities for Improvement

Describe the process of how non-clinical improvements were identified.

Program Description Develop long-term goals for overall and measure-specific quality improvement.

Overall Effectiveness Include an evaluation of the overall effectiveness of the quality assessment and performance-improvement program.

Clinical Practice Guidelines Detail how guidelines are relevant to member needs.

Access to Care Monitoring and Results

Evaluate and report the effectiveness of actions and provide future actions for all indicators.

Clinical Indicator Monitoring and Results

Include an analysis of the effectiveness of actions such as the percentage change in measurement from the previous year.

Service Indicator Monitoring Report change in rates from the previous year.

Credentialing and Re- credentialing

Report number of facilities credentialed during the measurement period. Indicate if none.

Delegation of Activities Describe identified improvements or corrective actions for all delegated functions as needed.

Corrective Action Plans Provide the completion date or targeted date for completion.

Previous Year’s Recommendations

Address all previous year’s recommendations, describe how each was incorporated into the QAPI program, and describe actions to meet the recommendation.


5. Quality-of-care Evaluation by Program

This section presents results from the EQRO’s quality-of-care evaluations of Texas Medicaid

and CHIP programs using administrative, hybrid, and survey measures.

Numerous administrative, hybrid, and survey measures also serve as HHS dashboard

standards’ measures; the EQRO uses the dashboard to monitor performance at the program,

health plan, and service area levels. Each year based on recommendations by the EQRO, HHS

updates HHS dashboard standards’ measures for each program. Tables in this section include

comparisons of statewide performance with the HHS dashboard standards for the appropriate

comparison year. These standards are intended as reasonable goals for the health plans

participating in each program. More information on the HHS dashboard standards methodology

can be found in Section 8.2.

5.1. Quality-of-care Evaluation Methods

5.1.1. Administrative and Hybrid Measures

The EQRO used three data sources to calculate administrative quality-of-care indicators: (1)

member-level enrollment information, (2) member-level health care claims and encounter data,

and (3) member-level pharmacy data. Additionally, medical records provided data for the hybrid

measures. The enrollment files contain information about each member’s age, sex, health plan,

and months of enrollment. The member-level claims and encounter data contain CPT codes,

ICD-10-CM codes, place-of-service codes, and other information necessary to calculate the

quality-of-care indicators. The member-level pharmacy data detail filled prescriptions, including

drug name, dose, date filled, number of days prescribed, and refill information.

Administrative and hybrid quality-of-care indicators in this report include:

1) HEDIS® 2016 measures,

2) AHRQ PDIs and PQIs, and

3) 3M™ Health Information Systems measures of PPEs:

a) potentially preventable hospital admissions (PPA),

b) potentially preventable readmissions within 30 days (PPR),

c) potentially preventable emergency department visits (PPV), and

d) potentially preventable complications (PPC).

Section 8.3 provides an overview of the three indicators and the methodology used.

5.1.2. Survey Measures

The EQRO conducts biennial surveys to measure experiences and satisfaction of adult

members and caregivers of child and adolescent members in Texas Medicaid and CHIP. During

calendar year 2016, the EQRO conducted STAR adult, STAR+PLUS, and STAR Health

member surveys.


Survey sampling

The EQRO selected participants for the Consumer Assessment of Healthcare Providers and

Systems (CAHPS®) surveys from stratified random samples of child members (17 years or

younger) or adult members (18 years or older) who were continuously enrolled in the same

health plan for at least six months. The EQRO then stratified the samples to include

representation from each MCO operating in the program for which the survey was conducted.27

The targeted number of completed surveys was 250 per MCO and 300 for STAR Health. This

sample size permits an approximately +/- 6 percent margin of error for an MCO with a

population of 5,000 members.

For all survey samples, members with no more than one 30-day gap during the sampling

enrollment period were eligible for inclusion. The EQRO determined member age based on the

last day of the enrollment period. Table 9 lists the member surveys conducted by the EQRO in

calendar year 2016, and their enrollment and fielding periods.

Table 9. Member and Caregiver Survey Enrollment and Fielding Periods, 2015-2016

Year Survey Enrollment period Fielding period

2016 STAR Adult Member Survey

October 2015 – March 2016

May 2016 – August 2016

STAR+PLUS Adult Member Survey October 2015 – March 2016


STAR Health Child Caregiver Survey November 2015 – April 2016

June 2016 – July 2016

Survey data collection

The EQRO contracted with the University of Florida Survey Research Center (UFSRC) and the

National Opinion Research Center at the University of Chicago (NORC) to conduct the 2016

member and caregiver satisfaction surveys using computer-assisted telephone interviewing

(CATI). For all satisfaction surveys, the EQRO sent advance notification letters written in

English and Spanish to members or caregivers requesting their participation. Calling began

approximately four days following each advance mailing.

The CAHPS® Health Plan Survey is a widely used instrument for measuring and reporting

consumer experiences with theirs or their child or adolescent's health plan and providers. The

survey includes several questions that indicate health plan performance (such as personal

doctor and health plan ratings), and permits calculation and reporting of composite measures

combining results for closely related survey items. This report presents the 2016 CAHPS®

ratings from the member surveys for personal doctors, specialists, health plans, and overall

health care in each program assessed, as well as composite measures that address the

following: (1) Getting Needed Care, (2) Getting Care Quickly, (3) How Well Doctors

Communicate, (4) Health Plan Information and Customer Service, and (5) Shared Decision-

Making.


The surveys, which also included EQRO-developed items on caregiver and member

demographic and household characteristics, were which were given to more than 130,000

Medicaid and CHIP members in Texas. The questions were adapted from the National Health

Interview Survey, The Behavioral Risk Factor Surveillance System, and the National Survey of

America's Families.28,29,30 Respondents were also asked to report height and weight, needed to

calculate BMI.

Survey data analysis

The EQRO generally follows both AHRQ and NCQA specifications for scoring the CAHPS®

ratings and composites. Data is collected via an NCQA-certified vendor using a CATI system.

Results in this report follow AHRQ reporting specifications, which produce scores that represent

the percentage of members who rated their health care a “9” or “10” (on a scale from 0 to 10

with higher scores indicating greater satisfaction), and who “always” had positive experiences in

a given composite domain. Surveys administered in 2016 follow a combined “usually” and

“always” reporting format. These scores are compared with Medicaid and CHIP national data

available for the appropriate year and population through the AHRQ CAHPS® Online Reporting

System.31

For all survey projects, the EQRO calculated descriptive statistics and conducted statistical tests

using the software package SPSS 23.0 (Chicago, IL: SPSS, Inc.).


5.2. STAR Program

5.2.1. Access to and Utilization of Care in STAR

Table 10 presents statewide performance in 2015 across all MCOs participating in the STAR

program on measures of well-care visits for children and adolescents, prevention and screening,

and Prenatal and Postpartum Care. The rates for Adolescent Well-Care Visits (AWC) were

higher when compared to the national Medicaid population, and the program rate exceeded the

HHS dashboard standard.

The rates for child and adolescent access to primary care practitioners were lower than their

HHS dashboard standards. The rates for Prenatal and Postpartum Care were also lower than

their HHS dashboard standard. The percentile rating for Prenatal and Postpartum Care:

Prenatal Care was in the 66th to 89th percentile, while the rate for Prenatal and Postpartum Care:

Postpartum Care was between the 33rd and 65th.

Figure 13 through Figure 15 trend access to and utilization of primary care from 2011 through

2015. With the exception of AWC, all other access and utilization measures had stable trend

lines over the past five years. The rate for AWC increased from 57.6 percent in 2011 to 70.7

percent in 2015.


Table 10. STAR – HEDIS® Access and Utilization Measures, 2015

vi Higher values indicate stronger performance. vii Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles

Measure 2015 Ratevi

HHS Dashboard

Standard 2015

HEDIS® 2016 Percentile

Ratingvii

Adults’ Access to Preventive / Ambulatory Health Services

85.4% N/A

Children and Adolescents' Access to Primary Care Practitioners, 12-24 months

96.3% 99%

Children and Adolescents' Access to Primary Care Practitioners, 25 months to 6 years

89.8% 95%

Children and Adolescents' Access to Primary Care Practitioners, 7-11 years

93.2% 96%


91.8% 95%

Initiation & Engagement of Alcohol & Other Drug Dependence Treatment, Initiation

38.8% 43%

Initiation & Engagement of Alcohol & Other Drug Dependence Treatment, Engagement

11.9% 14%

Prenatal and Postpartum Care, Timeliness of Prenatal Care

87.8% 89%

Prenatal and Postpartum Care, Postpartum Care 64.8% 66%

Well-Child Visits in the First 15 Months of Life, Six or More Visits

54.7% 69%

Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life 81.2% 83%

Adolescent Well-Care Visits 70.7% 65%


Figure 13. STAR – HEDIS® Access to and Utilization of Primary Care, 2011-2015

Children’s Access to Physicians: Well-Child Visits in the First 15 Months All Members of Life, Six or More Visits

100% 100%

80% 92.3% 91.6% 91.6% 92.9% 91.8% 80%

60% 60%

60.8% 62.2%56.4% 58.5%

40% 40% 54.7%

20% 20%

0% 0%

2011 2012 2013 2014 2015 2011 2012 2013 2014 2015

Well-Child Visits in the 3 rd, 4th, 5th and 6th Adolescent Well-Care VisitsYears of Life

100%100%

80%80%

80.3% 81.2%78.9% 60% 68.7% 70.7%60% 73.7% 73.2% 64.5%

57.6% 58.0%40%40%

20% 20%

0% 0%

2011 2012 2013 2014 2015 2011 2012 2013 2014 2015


Figure 14. STAR – HEDIS® Initiation & Engagement of Alcohol & Other Drug Dependence Treatment, 2011-2015

39.4% 38.0% 37.6% 38.5% 38.8%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

IET-Initiation

10.9% 10.1% 10.7% 10.4% 11.9%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

IET-Engagement (Total)

Figure 15. STAR – HEDIS® Prenatal and Postpartum Care, 2011-2015

72.1% 74.4%

88.9% 90.1% 87.8%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Timeliness of Prenatal Care

58.7%66.2%

58.6%65.0% 64.8%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Postpartum care


Table 11 shows utilization rates in 2015 across all MCOs participating in the STAR program.

Higher rates do not necessarily indicate stronger performance. The two components of the

HEDIS® Ambulatory Care (AMB) measure summarize utilization of two types of ambulatory

care: outpatient visits per 1,000 member-months; and emergency department visits per 1,000

member-months. HEDIS® Inpatient Utilization (IPU) measures acute inpatient care and services

per 1,000 member-months in the following four categories: total inpatient, maternity, surgery,

and medicine. HEDIS® Mental Health Utilization (MPT) identifies mental health services per 100

member-years during the one-year measurement period in the following categories: inpatient

services, intensive outpatient or partial hospitalization servicesviii, and outpatient or emergency

department services. The rates reported here reflect all service categories combined for each

measure.

Table 11. STAR – HEDIS® Utilization of Care Measures, 2015

Measure 2015 Rateix


Ratingx

HEDIS® Ambulatory Care, Outpatient Visits (per 1,000 member-months)

367.7

HEDIS® Ambulatory Care, Emergency Department Visits (per 1,000 member-months)

54.1

HEDIS® Inpatient Utilization, Total Inpatient Discharges (per 1,000 member-months)

6.6

HEDIS® Mental Health Utilization, Any Services (per 100 member-years)xi

13.2

viii The MCOs may choose to cover these two services, but they are not Medicaid coverable services. ix Higher or lower values do not necessarily indicate better quality of care. x Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles xi One member-year is equivalent to 12 member-months.


Table 12 shows five AHRQ PDIs across all MCOs participating in the STAR program. These

measures are derived from hospital inpatient discharge data and can identify areas of potential

concern, such as unexpectedly high rates of complications or health care needs that could be

met in the community without hospitalization. MCOs with rates at the higher end of the range

should examine their results more closely to determine if there are opportunities for

improvement.

Table 12. STAR – AHRQ Pediatric Quality Indicatorsxii, 2015

Measure 2015 Rate Range

Asthma Admission Rate 7.8 4.1 - 26.0

Diabetes Short-Term Complications Admission Rate 2.5 1.4 - 8.7

Gastroenteritis Admission Rate 3.7 1.5 - 11.8

Perforated Appendix Admission Rate

(per 100 admissions for appendicitis) 61.6 29.9 - 82.7

Urinary Tract Infection Admission Rate 3.1 0.0 - 7.6

xii Per 100,000 member-months


The EQRO calculated statewide performance across all MCOs participating in the STAR

program on measures of PPEs. The EQRO calculated these measures using 3M™ Health

Information Systems software. A description of all PPEs and how they are calculated can be

found in Section 8.3.3.

Figure 16 shows weighted statewide PPA per 1,000 member-months in STAR for 2011 through

2015. In 2015, 15,746 STAR members had 17,045 PPAs. The overall weighted PPA rate in

2015 was 0.3900 and the rate has decreased each year since 2012. Table 13 presents the

most common reasons for PPAs for STAR in 2015.

Figure 16. STAR – Weighted 3M™ Potentially Preventable Hospital Admissions, per 1,000 Member-months, 2011-2015xiii

Table 13. STAR – 3M™ Potentially Preventable Hospital Admissions, Most Common Reasons, for 2015

PPA Reason % of PPAs

in STAR

1 Asthma 15.1%

2 Other Pneumonia 14.6%

3 Cellulitis & Other Bacterial Skin Infections 10.8%

4 Seizure 7.1%

5 Diabetes 6.9%

6 Non-Bacterial Gastroenteritis, Nausea & Vomiting 6.6%

7 Bipolar Disorders 6.4%

8 Kidney & Urinary Tract Infections 6.4%

9 Major Depressive Disorders & Other/Unspecified Psychoses 6.0%

10 Infections Of Upper Respiratory Tract 5.5%

Figure 17 shows weighted PPR chains per 1,000 candidate admissions in STAR for 2011 to

2015. In 2015, 4,748 STAR members had 4,955 admissions with PPRs. The overall weighted

xiii Lower values indicate stronger performance.


PPR rate was 0.1576, and the rate has been declining since 2013. Table 14 presents the most

common admission reasons with PPRs for STAR in 2015

Figure 17. STAR – Weighted 3M™ Potentially Preventable Readmission Chains per 1,000 Candidate Admissions, 2011-2015xiv

0.1562

0.21090.2288

0.2019

0.1576

0

0.05

0.1

0.15

0.2

0.25

2011 2012 2013 2014 2015

Table 14. STAR – 3M™ Most Common Admission Reasons Associated with Potentially Preventable Readmission, for 2015

PPR Reason % of PPRs

in STAR

1 Medical readmission for acute medical condition or complication that may be related to or have resulted from care during initial admission or in post-discharge period after initial admission

42.5%

2 Mental health or substance abuse readmission following an initial admission for a substance abuse or mental health diagnosis

30.7%

3 Medical readmission for a continuation or recurrence of the reason for the initial admission, or for a closely related condition

15.1%

4 All other readmissions for a chronic problem that may be related to care either during or after the initial admission

4.8%

5 Readmission for mental health reasons following an initial admission for a non-mental health, non-substance abuse reason

2.6%

6 Readmission for surgical procedure to address a complication that may be related to or may have resulted from care during the initial admission

1.6%

7 Ambulatory care-sensitive conditions as designated by AHRQ 1.5%

8 Readmission for surgical procedure to address a continuation or a recurrence of the problem causing the initial admission

1.2%

9 Readmission for a substance abuse diagnosis reason following an initial admission for a non-mental health, non-substance abuse reason

0.2%

xiv Lower values indicate stronger performance.


Figure 18 Shows weighted PPV per 1,000 member-months in STAR for 2011 to 2015. In 2015,

715,198 STAR members had 1,131,399 PPVs. The overall weighted PPV rate was 9.2211 and

the rate has remained relatively constant since 2012. Table 15 presents the most common

reasons for PPVs for STAR in 2015.

Figure 18. STAR – Weighted 3M™ Potentially Preventable Emergency Department Visits per 1,000 Member-months, 2011-2015xv

Table 15. STAR – 3M™ Most Common Potentially Preventable Emergency Department Visits Reasons, for 2015

PPV Reason % of PPVs

in STAR

1 Infections of Upper Respiratory Tract & Otitis Media 26.0%


3 Other Skin, Subcutaneous Tissue & Breast Disorders 6.0%

4 Signs, Symptoms & Other Factors Influencing Health Status 5.8%

5 Level I Other Ear, Nose, Mouth, Throat & Cranial/Facial Diagnoses 4.4%

6 Level II Other Musculoskeletal System & Connective Tissue Diagnoses 4.3%

7 Abdominal Pain 4.3%

8 Viral Illness 4.1%

9 Contusion, Open Wound & Other Trauma to Skin & Subcutaneous Tissue 3.7%

10 Acute Lower Urinary Tract Infections 2.9%

xv Lower values indicate stronger performance.

6.7794

9.5378 9.3859 9.4115 9.2211

0

2

4

6

8

10

12

2011 2012 2013 2014 2015


Figure 19 shows weighted PPC per 1,000 at-risk admissions for STAR, for 2013 to 2015. In

2015, 4,588 STAR members had 5,148 PPCs, and the overall weighted PPC rate was 0.0381.

Table 16 presents the most common reasons for PPCs for STAR in 2015.

Figure 19. STAR – Weighted 3M™ Potentially Preventable Complications per At-Risk Admissions, 2013-2015xvi

Table 16. STAR –3M™ Most Common Potentially Preventable Complications, for 2015

PPC Reason % of PPCs

in STAR

1 Obstetrical Hemorrhage without Transfusion 26.7%

2 Obstetric Lacerations & Other Trauma without Instrumentation 18.9%

3 Obstetrical Hemorrhage with Transfusion 10.7%

4 Medical & Anesthesia Obstetric Complications 8.9%

5 Delivery with Placental Complications 5.9%

6 Obstetric Lacerations & Other Trauma with Instrumentation 5.1%

7 Other Complications of Obstetrical Surgical & Perineal Wounds 4.2%

8 Major Puerperal Infection and Other Major Obstetric Complications 2.7%

9 Urinary Tract Infection 2.5%

10 Renal Failure without Dialysis 1.4%

xvi Lower values indicate stronger performance.

0.04870.0517

0.0381

0

0.01

0.02

0.03

0.04

0.05

0.06

2013 2014 2015


5.2.2. Effectiveness of Care in STAR

Table 17 shows statewide performance in 2015 across all MCOs participating in the STAR

program on measures of effectiveness. In 2015, the rate of four child and adolescent measures

were higher than their corresponding HHS dashboard standard. The rate Weight Assessment &

Counseling for Nutrition & Physical Activity for Children & Adolescents (WCC), BMI Percentile

was between the 10th and 32nd percentiles. The rate for Follow-Up Care for Children

Prescribed ADHD Medication (ADD) in the initiation or continuation/maintenance phase was

between the 66th and 89th percentiles.

Figure 20 through Figure 22 trend children and adolescent effectiveness of care measures

through 2015. There has been a steady increase in the rate of ADD in the initiation phase and

continuation/maintenance phase.


Table 17. STAR – HEDIS® Effectiveness of Care Measures for Children and Adolescents, 2015

xvii Higher values indicate stronger performance. xviii Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles

Measure 2015 Ratexvii

HHS Dashboard

Standard 2015

HEDIS® 2016 Percentile Ratingxviii

Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents, BMI Percentile

58.4% 52%

Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents, Counseling for Nutrition

64.0% 65%

Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents, Counseling for Physical Activity

55.1% 49%

Childhood Immunization Status, Combination 4 69.4% 76%

Childhood Immunization Status, Combination 10 29.8% N/A

CHIPRA® Developmental Screening in the First Three Years of Life

45.3% N/A N/A

Medication Management for People with Asthma, Medication Compliance 75% of Treatment Period

16.4% 29%

Asthma Medication Ratio, Total Controller Medication Ratio >50%

68.8% 82%

Appropriate Testing for Children with Pharyngitis 63.9% 68%

Follow-Up Care for Children Prescribed ADHD Medication, Initiation Phase 47.9% 47%

Follow-Up Care for Children Prescribed ADHD Medication, Continuation and Maintenance Phase 63.6% 62%

Appropriate Treatment for Children with Upper Respiratory Infection 86.6% 87%


Figure 20. STAR – HEDIS® Effectiveness of Care: Prevention and Screeningxixxx

49.5% 48.7%58.4%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

BMI Screening

65.3%58.3%

64.0%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Counseling on Nutrition

47.9% 49.2%55.1%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Counseling on Physical Activity

74.1% 75.8%69.4%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Childhood Immunization Status, Combination 4

42.6%48.9% 52.0%

45.3%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Developmental Screening

xix Because some health plans rotate their results from the prior year, data points for 2014 are missing. As a result, no

meaningful statewide rate exists.

xx Developmental Screening is a CHIPRA® measure.


Figure 21. STAR – HEDIS® Effectiveness of Care for Respiratory Conditions, 2011-2015

23.5%15.4% 15.5% 16.4%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Medication Management for People with Asthma (75%)

67.4%

81.6%

60.9%68.8%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Asthma Medication Ratio

57.6% 57.3% 57.5% 61.9% 63.9%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Appropriate Testing for Children with Pharyngitis

82.6% 83.3% 83.1% 85.6% 86.6%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Appropriate Treatment for Children with Upper Respiratory Infection

Figure 22. STAR – HEDIS® Follow-up Care for Children Prescribed ADHD Medication, 2011-2015

36.6% 39.1%46.8% 49.9% 47.9%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Initiation Phase

48.1% 50.9%

61.7%67.3% 63.6%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Continuation and Maintenance Phase


Table 18 shows other 2015 effectiveness of care measures. The HEDIS measure rate for

Follow-Up After Hospitalization for Mental Illness (FUH), 7-day and 30-day was lower than their

HHS dashboard standard. These two measures fell between the 10th and 32nd percentiles. While

the rate of diabetes testing was higher than the HHS dashboard standard, the rate of

Comprehensive Diabetes Care (CDC), HbA1c Control was lower than its corresponding HHS

dashboard standard. The rates for CDC Eye Exam and CDC Medical Attention for Nephropathy

were between the 10th and 32nd percentiles.

Table 18. STAR – HEDIS® Effectiveness of Care Measures, 2015

xxi Higher values indicate stronger performance. xxii Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles

Measure 2015 Ratexxi

HHS Dashboard

Standard 2015


Ratingxxii

Cervical Cancer Screening 65.6% 70%

Chlamydia Screening in Women 50.2% 58%

Controlling High Blood Pressure 44.0% 56%

Comprehensive Diabetes Care, HbA1c Testing 84.0% 83%

Comprehensive Diabetes Care, HbA1c Control (<8%) 31.6% 48%

Comprehensive Diabetes Care, Eye Exam 40.8% 53%

Comprehensive Diabetes Care, Medical Attention for Nephropathy

88.9% 79%

Follow-Up After Hospitalization for Mental Illness, 7 Days

35.6% 44%


56.0% 64%

Avoidance of Antibiotic Therapy for Adults with Acute Bronchitis

22.9% 24%


Figure 23 shows effectiveness of care measures from 2011 through 2015. Figure 24 shows

CDC from 2011 through 2015. There was a marked increase in CDC, Medical Attention for

Nephropathy from 66.7 percent in 2014 to 88.9 percent in 2015.

Figure 23. STAR – HEDIS® Effectiveness of Care Measures, 2011-2015xxiii

58.9%

69.7%

56.5%

68.8% 65.6%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Cervical Cancer Screening

51.1% 53.4% 51.5% 50.2% 50.2%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Chlamydia Screening

43.6% 41.8% 43.8% 44.0%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Controlling Blood Pressure

18.6% 18.9% 19.5% 20.6% 22.9%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Avoidance of Antibiotics for Bronchitis

30.5% 32.4% 32.2%37.5% 35.6%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Follow-up After Hospitalization for Mental Illness, 7 Days

50.5% 54.7% 54.0%61.5%

56.0%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Follow-up After Hospitalization for Mental Illness, 30 Days

xxiii Because some health plans rotate their results from the prior year, data points for 2014 are missing. As a result, no meaningful statewide rate exists.


Figure 24. STAR – HEDIS® Comprehensive Diabetes Care, 2011-2015

72.8%79.4% 80.7% 80.7% 84.0%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

HbA1c Testing

29.1% 27.2%33.4% 33.4% 31.6%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

HbA1c Control (<8%)

36.4% 33.8% 37.6% 38.6% 40.8%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Eye Exam

72.9%65.0%

74.4%66.7%

88.9%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Monitoring for Nephropathy


5.2.3. Satisfaction with Care in STAR

Table 19 presents CAHPS® composites and ratings from the member survey conducted with

adult members in STAR in 2016. Rates for the 2016 CAHPS® composites represent the

percentage of members who “usually” or “always” had positive experiences with the given

domain. Results represent the percentage of members who rated their care a “9” or “10” (on a

scale from 0 to 10, with higher scores indicating greater satisfaction). The survey found high

levels of member satisfaction with regard to communicating with doctors and getting help and

information from health plan customer service, as well as generally positive ratings of care that

met or exceeded CAHPS® Medicaid national rates.

Figure 25 and Figure 26 trend CAHPS® composites and ratings from 2012 through 2016.

There has been a steady increase in adult STAR member satisfaction with “Getting Needed

Care” and “Customer Service.”

Table 19. STAR – CAHPS® Adult Member Satisfaction with Care, 2016

Survey Question

Percentage rate of

“Always” for STAR Adult Members xxiv

HHS Dashboard

Standard 2016

CAHPS® Adult

Medicaid 201632

Getting Needed Care 53.5% N/A 54%

Getting Care Quickly 57.2% N/A 58%

How Well Doctors Communicate 79.1% 77% 74%

Shared Decision Making 80.5% N/A N/A

Health Plan Information and Customer Service

72.4% N/A 67%

Coordination of Care 53.6% N/A 56%

Health Promotion and Education 67.8% N/A 72%

Health Care Rating 57.3% N/A 53%

Personal Doctor Rating 67.6% 67% 65%

Specialist Rating 66.9% N/A 65%

Health Plan Rating 61.1% 64% 57%

xxiv Higher values indicate stronger performance.


Figure 25. STAR – CAHPS® Member Satisfaction with Care Composites and Question Summary Rates, 2012-2016

46.3%52.6% 53.5%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Getting Needed Care

52.5%62.4%

57.2%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Getting Care Quickly

79.8% 77.4% 79.1%

0%

20%

40%

60%

80%

100%

2012 2014 2016

How Well Doctors Communicate

62.3%70.8% 72.4%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Customer Service

45.7%54.8% 53.6%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Coordination of Care


Figure 26. STAR – CAHPS® Member Satisfaction with Care Ratings, 2012-2016

53.5% 53.5% 57.3%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Health Care Rating

63.4% 66.2% 67.6%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Personal Doctor Rating

64.1% 65.4% 66.9%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Specialist Rating

60.1% 61.3% 61.1%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Health Plan Rating


5.3. CHIP Program

5.3.1. Access to and Utilization of Care in CHIP

Table 20 presents statewide performance in 2015 across all MCOs participating in the CHIP

program on measures of access to a PCP. The rates for W34 and AWC were higher than their

HHS dashboard standard. Percentiles were between the 66th and 89th. With the exception of 12-

24 months, the rates for all other HEDIS Children and Adolescents' Access to Primary Care

Practitioners were below their HHS dashboard standard.

Figure 27 trends access to and utilization measures from 2011 through 2015. The EQRO noted

an increase in AWC since 2011. From 2012 to 2013, the rates of W34 rose nearly 10 percent

and have continued to increase since then.

Table 20. CHIP – HEDIS® Access and Utilization Measures, 2015

xxv Higher values indicate stronger performance.

Measure 2015 Ratexxv

HHS Dashboard

Standard 2015

Children and Adolescents' Access to Primary Care Practitioners, 12 to 24 months

97.6% 96%


89.6% 95%

Children and Adolescents' Access to Primary Care Practitioners, 7-11

93.6% 95%

Children and Adolescents' Access to Primary Care Practitioners, 12-19

92.2% 93%

Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life

80.1% 76%



Figure 27. CHIP – HEDIS® Access to and Utilization of Primary Care, 2011-2015xxvi

88.6% 88.7% 91.5% 92.2% 91.7%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Children's Access to Physicians: All Members

66.1% 66.5%76.1% 80.1%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015


47.8% 51.0%58.2% 61.3% 64.5%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Adolescent Well-Care Visits

xxvi There is no data point in 2014 for W34 because some plans rotated their results for 2014 while others did not

which resulted in no well-defined statewide rate.


Table 21 shows utilization rates in 2015 across all MCOs participating in the CHIP program.

Higher rates do not necessarily indicate stronger performance. Rather, the NCQA recommends

examining the utilization rates to assess general patterns of service use. The two components

of HEDIS® AMB presented summarize utilization of two types of care: outpatient visits per

1,000 member-months, and emergency visits per 1,000 member-months. HEDIS® IPU

measures acute inpatient care and services per 1,000 member-months in the following four

categories: total inpatient, maternity, surgery, and medicine. The rates reported here combine

all service categories for each measure. The percentile rating for all three measures was below

the 10th percentile.

Rates of utilization varied among health plans:

Outpatient visits per 1,000 member-months ranged from 193.95 for CHRISTUS Health Plan

to 290.69 for Driscoll Health Plan.

Emergency department visits per 1,000 member-months ranged from 18.69 for Community

Health Choice to 32.17 for Blue Cross Blue Shield of Texas.

Acute inpatient discharges per 1,000 member-months ranged from 0.61 for Molina

Healthcare of Texas, Inc. to 1.45 for FirstCare.

Table 21. CHIP – HEDIS® Utilization of Care Measures, 2015

Measure 2015

Ratexxvii

Ambulatory Care, Outpatient Visits (per 1,000 member-months) 244.7

Ambulatory Care, Emergency Department Visits (per 1,000 member-months)

23.4

Inpatient Utilization Total Inpatient Discharges (per 1,000 member-months)

0.9

xxvii Higher or lower values do not necessarily indicate better quality of care.


Table 22 shows five AHRQ PDIs. These measures are derived from hospital inpatient discharge

data and can identify areas of potential concern, such as unexpectedly high rates of

complications or health care needs that could be met in the community without hospitalization.

Numerators for all PDIs were small for most health plans. MCOs at the higher end of the range

should examine their rates more closely to determine if there are opportunities for improvement.

Table 22. CHIP – AHRQ Pediatric Quality Indicatorsxxviii, 2015


Asthma Admission Rate 5.0 0.0 – 22.3

Diabetes Short-Term Complications 2.9 0.0 – 16.6

Gastroenteritis Admission Rate 1.5 0.0 – 7.7

Perforated Appendix Admission Rate xxix (per 100 admissions for appendicitis)

65.1 58.2 – 63.3

Urinary Tract Infection 1.1 0.0 – 2.9

xxviii Per 100,000 member-months xxix All but two plans had low denominators (LD). The statewide rate is outside the range of non-LD plans.


The EQRO calculated statewide performance across all MCOs participating in the CHIP


Information Systems software. A description of all PPEs are found in Section 8.3.3.

Figure 28 shows weighted statewide PPAs per 1,000 member-months in CHIP from 2011 to

2015. In 2015, 1,190 CHIP members had 1,252 PPAs. The overall weighted PPA, in 2015, was

0.2424, and the rate has fluctuated year-over-year but is lower than it was in 2011.Table 23

presents the most common reasons for PPAs among all members in CHIP in 2015.

Figure 28. CHIP – Weighted 3M™ Potentially Preventable Hospital Admissions, per 1,000 Member-months, 2011-2015xxx

Table 23. CHIP – 3M™ Potentially Preventable Hospital Admissions, Most Common Reasons, for 2015

PPA Reason % of PPAs

in CHIP

1 Asthma 16.4%


3 Diabetes 10.7%


5 Major Depressive Disorders & Other/Unspecified Psychoses 8.6%

6 Seizure 7.7%


8 Infections of Upper Respiratory Tract 4.8%



Figure 29 shows weighted PPR chains per 1,000 candidate admissions in CHIP from 2011 to

2015. In 2015, 223 CHIP members had 228 admissions with PPRs. The overall weighted PPR

xxx Lower values indicate stronger performance.


was 0.0641 and has remained relatively stable since 2012. Table 24 presents the most

common reasons for PPRs among all members in CHIP in 2015.

Figure 29. CHIP – Weighted 3M™ Potentially Preventable Readmission Chains per 1,000 Candidate Admissions, 2011-2015xxxi

Table 24. CHIP – 3M™ Most Common Admission Reasons Associated with Potentially Preventable Readmission, for 2015

PPR Reason % of PPRs

in CHIP


56.6%


14.9%


10.5%


6.8%


6.8%


2.0%


1.7%

8 Ambulatory care sensitive conditions as designated by AHRQ 0.7%

Figure 30 shows weighted PPV per 1,000 member- months in CHIP from 2011 to 2015. In

2015, 45,581 CHIP members had over 58,000 PPVs. The overall weighted PPV was 4.1906

and has remained relatively stable since 2012. Table 25 presents the most common reasons for

PPVs among all members in CHIP in 2015.

xxxi Lower values indicate stronger performance.

0.0539

0.0648 0.06760.0627 0.0641

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

2011 2012 2013 2014 2015


Figure 30. CHIP – Weighted 3M™ Potentially Preventable Emergency Department Visits per 1,000 Member-months, 2011-2015xxxii

Table 25. CHIP – 3M™ Most Common Potentially Preventable Emergency Department Visits Reasons, for 2015

PPV Reason % of PPVs

in CHIP


2 Non-bacterial Gastroenteritis, Nausea & Vomiting 7.8%





7 Level I Other Ear, Nose, Mouth, Throat & Cranial/Facial Diagnoses 4.5%



10 Splint, Strapping and Cast Removal 3.3%

In 2015, only 16 CHIP members had PPCs. The overall weighted PPC was 0.0055. Table 26

presents the most common reasons for PPCs among all members in CHIP in 2015.

xxxii Lower values indicate stronger performance.

3.1608

4.28533.9540 4.0175

4.1906

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

2011 2012 2013 2014 2015


Table 26. CHIP – 3M™ Most Common Potentially Preventable Complications, for 2015

PPC Reason % of PPCs

in CHIP

1 Shock 17.7%

2 Infections Due to Central Venous Catheters 17.7%

3 Septicemia & Severe Infections 11.8%

4 Other Surgical Complication - Moderate 11.8%

5 Acute Pulmonary Edema and Respiratory Failure without Ventilation 5.9%

6 Other Pulmonary Complications 5.9%

7 Other Gastrointestinal Complications without Transfusion or Significant Bleeding 5.9%

8 Genitourinary Complications Except Urinary Tract Infection 5.9%


10 Medical & Anesthesia Obstetric Complications 5.9%


5.3.2. Effectiveness of Care in CHIP


Table 27. CHIP – HEDIS® Effectiveness of Care Measures, 2015

Measure 2015 Rate

HHS Dashboard

Standard 2015


55.1% 52%


59.1% 60%


51.7% 47%




45.6% N/A




19.6% 29%


78.3% 85%

Follow-Up Care for Children Prescribed ADHD Medication, Initiation Phase

42.2% 45%

Follow-Up Care for Children Prescribed ADHD Medication, Continuation and Maintenance Phase

54.6% 59%

Follow-Up After Hospitalization for Mental Illness, 7 Days 38.0% 44%



84.3% 87%

presents statewide care effectiveness performance in 2015 across all MCOs participating in

CHIP. The rates for CDC BMI Percentile, CDC Counseling for Physical Activity, and Appropriate

Testing for Children with Pharyngitis (CWP) were higher than their HHS dashboard standard.

The rates for all other measures were lower than their HHS dashboard standard. The CHIP

population is not necessarily comparable to the national Medicaid population, and benchmark

comparisons are provided for reference only.


Figure 31 through Figure 33 shows the HEDIS® Effectiveness of Care measures from 2011

through 2015. Since 2011, there has been a steady increase in the rates for CWP and

Appropriate Treatment for Children with Upper Respiratory Infection. The trend lines for the

other measures have remained relatively stable over this period.


Table 27. CHIP – HEDIS® Effectiveness of Care Measures, 2015

Measure 2015

Ratexxxiii

HHS Dashboard

Standard 2015


55.1% 52%


59.1% 60%


51.7% 47%




45.6% N/A




19.6% 29%


78.3% 85%


42.2% 45%


54.6% 59%




84.3% 87%

xxxiii Higher values indicate stronger performance.


Figure 31. CHIP – HEDIS® Effectiveness of Care: Prevention and Screening, 2011-2015xxxivxxxv

45.8% 46.2%55.1%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

BMI Screening

60.0%53.2%

59.1%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Counseling on Nutrition

46.4% 47.2%51.7%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Counseling on Physical Activity

31.4% 31.8% 34.0% 33.5% 34.3%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Chlamydia Screening

71.4%76.7% 73.9%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Childhood Immunization Status, Combination 4

34.9%

48.9% 49.9% 45.6%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015


xxxiv Because some plans rotate their measure results, 2014 data points for WCC and CIS combo 4 are missing. As a

result, there is no well-defined statewide rate.

xxxv Developmental Screening is a CHIPRA® measure.


Figure 32. CHIP – HEDIS® Effectiveness of Care for Respiratory Conditions, 2011-2015

58.1% 60.3% 62.3%67.2% 68.4%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015


16.7% 16.9% 18.5% 19.6%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015


74.1%

84.6%

72.2%78.3%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015


75.6% 77.8% 79.4% 82.7% 84.3%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015



Figure 33. CHIP – HEDIS® Effectiveness of Care for Behavioral Health Conditions, 2011-2015

35.4% 34.3%42.8% 43.0% 42.2%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Follow-Up for Children Prescribed ADHD Medication, Initiation Phase

49.5%44.9%

58.5% 56.8% 54.6%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Follow-Up for Children Prescribed ADHD Medication, Continuation / Maintenance

36.0% 37.7% 39.3% 41.8% 38.0%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Follow-Up After Hospitalization for Mental Illness - 7 days

59.5% 57.8% 59.9% 63.8%57.3%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Follow-Up After Hospitalization for Mental Illness - 30 days


5.4. STAR+PLUS Program

5.4.1. Access to and Utilization of Care in STAR+PLUS

Table 28 shows statewide performance in 2015 across all MCOs participating in the

STAR+PLUS program on measures of access and prevention. Figure 34 shows the rates for

access and prevention measures from 2011 through 2015. The HEDIS® 2016 percentile ratings

are based on national health plan performance in 2015. It is important to note that the

STAR+PLUS program is designed to serve a population with generally greater health care

needs, one that is not necessarily comparable to the national Medicaid population. National

benchmark comparisons are provided for reference only; high rates of utilization and other

indicators of greater health care needs are expected. Adults' Access to Preventive / Ambulatory

Health Services and Initiation and Engagement of Alcohol and Other Drug Dependence

Treatment in STAR+PLUS in 2015 was between the 33rd and 65th percentiles on the HEDIS®

national benchmark percentiles for Medicaid. Other access and prevention measures were

between the 10th and 32nd percentiles on the HEDIS® national benchmarks for Medicaid. Adult

BMI Assessment has steadily increased since 2012 from 65.2 percent to 79.9 percent. The

other measures stayed relatively stable.

Table 28. STAR+PLUS – HEDIS® Access and Preventive Care Measures, 2015

xxxvi Higher values indicate stronger performance. xxxvii Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles

Measure

2015 Ratexxxvi

HHS Dashboard Standard 2015

HEDIS® 2016 Percentile Ratingxxxvii

Adult BMI Assessment 79.9% 74%

Breast Cancer Screening 53.0% 51%

Cervical Cancer Screening 42.0% 67%

Adults' Access to Preventive / Ambulatory Health Services

84.6% N/A


36.5% 43%


4.7% 14%


Figure 34. STAR+PLUS – HEDIS® Access and Preventive Care Measures, 2011-2015

65.2%73.9%

78.1% 79.9%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Adult BMI Assessment

45.9% 46.1%51.3% 52.7% 53.0%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Breast Cancer Screening

40.3% 43.7% 46.0% 44.2% 42.0%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015


81.3% 79.9% 83.8% 84.5% 84.6%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Adults' Access to Preventive / Ambulatory Health Services

34.6% 33.2% 34.6% 34.9% 36.5%

0%

10%

20%

30%

40%

50%

2011 2012 2013 2014 2015

Initiation & Engagement of Alcohol & Other Drug Dependence Treatment –

Initiation

5.5% 4.6% 4.4% 4.5% 4.7%

0%

10%

20%

30%

40%

50%

2011 2012 2013 2014 2015

Initiation & Engagement of Alcohol & Other Drug Dependence Treatment –

Engagement


Table 29 shows utilization rates in 2015 across all MCOs participating in the STAR+PLUS

program. It is important to note that higher rates of utilization do not necessarily indicate higher

quality of care. The rates reported here reflect all service categories combined for each

measure.

Table 29. STAR+PLUS – HEDIS® Utilization of Care Measures, 2015

Measure 2015

Ratexxxviii

HEDIS® 2016 Percentile Ratingxxxix

Ambulatory Care, Outpatient Visits (per 1,000 member-months) 570.5


115.7

Inpatient Utilization, Total Inpatient Discharges (per 1,000 member-months)

23.6

Mental Health Utilization, Any Services (per 100 member-years)

35.0

Rates of utilization varied among health plans:

Outpatient visits per 1,000 member-months ranged from 553.0 for Amerigroup to 598.1 for

Superior HealthPlan.

Emergency department visits per 1,000 member-months were consistent across health

plans, ranging from 108.9 for Superior HealthPlan to 123.4 for UnitedHealthcare Community

Plan.

Acute inpatient discharges per 1,000 member-months ranged from 20.6 for Molina

Healthcare of Texas to 26.9 for UnitedHealthcare.

Mental health services per 100 member-years ranged from 30.6 for Molina Healthcare of

Texas to 37.8 for Superior HealthPlan.

xxxviii Higher or lower values do not necessarily indicate better quality of care. xxxix Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles


Table 30 shows 12 AHRQ PQIs across all STAR+PLUS MCOs. These measures are derived

from hospital inpatient discharge data and can identify areas of potential concern, such as

unexpectedly high rates of complications or health care needs that could be met in the

community without hospitalization.

Table 30. STAR+PLUS – AHRQ Prevention Quality Indicatorsxl, 2015


Diabetes Short-term Complications Admission Rate 42.6 31.4 – 51.3

Perforated Appendix Admission Rate (per 100 admissions for appendicitis)

35.3 23.3 – 43.9

Diabetes Long-term Complications Admission Rate 54.0 39.4 – 59.4

Chronic Obstructive Pulmonary Disease or Asthma in Older Adults Admission Rate

173.9 134.6 – 214.1

Hypertension Admission Rate 19.5 18.0 – 21.3

Heart Failure Admission Rate 118.4 94.7 – 134.0

Dehydration Admission Rate 33.4 25.5 – 36.8

Bacterial Pneumonia Admission Rate 59.8 45.9 – 65.9

Urinary Tract Infection Admission Rate 40.7 30.4 – 46.1

Uncontrolled Diabetes Admission Rate 8.4 5.9 – 9.0

Asthma in Younger Adults Admission Rate 15.8 13.3 – 19.1

Rate of Lower-extremity Amputation among Patients with Diabetes

12.1 8.8 – 15.7

xl Per 100,000 member-months unless noted otherwise.


The EQRO calculated statewide performance across all MCOs participating in the STAR+PLUS


Information Systems software. A description of all PPEs are in Section 8.3.3.

Figure 35 shows weighted statewide PPA per 1,000 member-months in STAR+PLUS from

2011 through 2015. In 2015, 14,823 STAR+PLUS members had 19,373 PPAs. The overall

weighted PPA, in 2015, was 8.35 and has increased since 2011.

7.40408.4653 8.4271

7.80368.3487

0

2

4

6

8

10

2011 2012 2013 2014 2015

Table 31 presents the most

common reasons for PPAs among all members in STAR+PLUS in 2015.

Figure 35. STAR+PLUS – Weighted 3M™ Potentially Preventable Hospital Admissions, per 1,000 Member-months, 2011-2015xli

Table 31. STAR+PLUS – 3M™ Potentially Preventable Hospital Admissions, Most Common Reasons, for 2015

PPA Reason % of PPAs in STAR+PLUS

1 Chronic Obstructive Pulmonary Disease 10.4%

2 Heart Failure 10.2%

3 Schizophrenia 7.6%



6 Diabetes 5.9%

7 Seizure 5.4%

8 Sickle Cell Anemia Crisis 4.6%



xli Lower values indicate stronger performance.


Figure 36 shows weighted PPR chains per 1,000 candidate admissions from 2011 through

2015. In 2015, 6,193 STAR+PLUS members had 7,244 admissions with PPRs. The overall

weighted PPR rate was 4.6088.

3.5008

5.5241 5.4055

4.22174.6088

0

1

2

3

4

5

6

7

8

2011 2012 2013 2014 2015

Table 32 presents the most common reasons for PPRs among all members in STAR+PLUS in

2015.

Figure 36. STAR+PLUS – Weighted 3M™ Potentially Preventable Readmission Chains per 1,000 Candidate Admissions, 2011-2015xlii

Table 32. STAR+PLUS – 3M™ Most Common Admission Reasons Associated with Potentially Preventable Readmission, for 2015

PPR Reason % of PPRs in STAR+PLUS


32.6%

2 Medical readmission for acute medical condition or complication that may be related to or may have resulted from care during initial admission or in post-discharge period after initial admission

25.3%


20.6%


8.2%



4.4%


2.1%


1.3%

9 Readmission for a substance abuse diagnosis reason following an initial admission for a non-mental health, non-substance abuse reason

1.1%

xlii Lower values indicate stronger performance.


Figure 37 shows PPV per 1,000 member-months from 2011 through 2015. In 2015, 95,983

STAR+PLUS members had 247,903 PPVs. The overall PPV weighted rate was 23.32 and has

remained stable since 2011. Table 33 presents the most common reasons for PPVs among all

members in STAR+PLUS in 2015.

Figure 37. STAR+PLUS – Weighted 3M™ Potentially Preventable Emergency Department Visits per 1,000 Member-months, 2011-2015xliii

Table 33. STAR+PLUS – 3M™ Most Common Potentially Preventable Emergency Department Visits Reasons, for 2015

PPV Reason % of PPVs in STAR+PLUS


2 Chest Pain 7.8%



5 Acute Lower Urinary Tract Infections 3.7%



8 Lumbar Disc Disease 3.2%



xliii Lower values indicate stronger performance.

23.314124.3693 23.9927 23.9517 23.3218

0

5

10

15

20

25

30

2011 2012 2013 2014 2015


Figure 38 shows weighted PPC per 1,000 at-risk admissions for STAR+PLUS from 2013

through 2015. In 2015, 2,274 STAR+PLUS members had 2,419 PPCs. The overall weighted

PPC rate was 1.2746.

Table 34 presents the most common reasons for PPCs among all members in STAR+PLUS in

2015.

Figure 38. STAR+PLUS – Weighted 3M™ Potentially Preventable Complications per At-Risk Admissions, 2013-2015xliv

1.32341.2110

1.2746

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

2013 2014 2015

Table 34. STAR+PLUS – 3M™ Most Common Potentially Preventable Complications, for 2015

PPC Reason % of PPCs in STAR+PLUS

1 Renal Failure without Dialysis 17.2%

2 Urinary Tract Infection 8.2%

3 Acute Pulmonary Edema and Respiratory Failure without Ventilation 6.9%

4 Septicemia & Severe Infections 6.4%

5 Shock 5.1%

6 Pneumonia & Other Lung Infections 4.6%

7 Ventricular Fibrillation/Cardiac Arrest 4.5%

8 Acute Pulmonary Edema and Respiratory Failure with Ventilation 4.0%

9 Peri-Operative Hemorrhage & Hematoma without Hemorrhage Control Procedure or I&D Procedure

3.1%

10 Aspiration Pneumonia 2.4%

xliv Lower values indicate stronger performance.


5.4.2. Effectiveness of Care in STAR+PLUS

Table 35 shows statewide performance in 2015 across all MCOs participating in the

STAR+PLUS program on measures of effectiveness of care. Figure 39 shows STAR+PLUS

HEDIS® effectiveness measures from 2011 through 2015.xlv

Members in STAR+PLUS with asthma who were compliant with their medication (75 percent of

treatment period) had a rate below the HHS dashboard standards in 2015. This rate fell

between the 66th and 89th percentile on the HEDIS® national benchmark percentiles for

Medicaid. The rate of testing HbA1c levels in members with Type 1 or Type 2 diabetes was in

the middle tertile of Medicaid health plans nationally, and exceeded the HHS dashboard

standard. Control of HbA1c levels (less than eight percent) performance was between the 33rd

and 65th percentiles nationally and did not meet the HHS dashboard standard.

Members in STAR+PLUS with asthma who were compliant with their medication (75 percent of

treatment period) ranged from 33.3 percent to 38.5 percent (Molina Healthcare of Texas, Inc

and Amerigroup respectively). The rate of AMR, Total Controller Medication Ratio greater than

50 percent fluctuated since 2012. In 2015, the rate ranged from 53.8 percent (Amerigroup and

UnitedHealthcare Community Plan) to 64.5 percent (Cigna-HealthSpring).

xlv Four statin measures: (1) Total statin therapy, (2) Total adherence, (3) Received statin therapy, and (4) Statin

adherence were not run in prior years; therefore, the HHS dashboard standard is not yet set and no trend data is

available.


Table 35. STAR+PLUS – HEDIS® Effectiveness of Care Measures, 2015

xlvi Higher values indicate stronger performance. xlvii Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles

Measure 2015 Ratexlvi

HHS Dashboard

Standard 2015

HEDIS® 2016 Percentile Ratingxlvii

Use of Spirometry Testing in the Assessment and Diagnosis of Chronic Obstructive Pulmonary Disease

27.4% N/A

Pharmacotherapy Management of Chronic Obstructive Pulmonary Disease Exacerbation, Bronchodilators

86.1% N/A

Pharmacotherapy Management of Chronic Obstructive Pulmonary Disease Exacerbation, Systemic Corticosteroids

69.0% N/A

Medication Management for People with Asthma, Medication Compliance 75% of Treatment Period (total)

35.5% 43%


56.9% 62%

Controlling Blood Pressure 47.6% 56%

Statin Therapy for Patients with Cardiovascular Disease, Total Statin Therapy

73.2% N/A N/A

Statin Therapy for Patients with Cardiovascular Disease, Total Adherence

52.3% N/A N/A

Comprehensive Diabetes Care, HbA1c Testing 86.3% 83%

Comprehensive Diabetes Care, HbA1c Control (<8%)

45.6% 48%

Comprehensive Diabetes Care, Eye Exams 43.1% 53%

Comprehensive Diabetes Care, Medical Attention for Nephropathy

91.3% 82%


Figure 39. STAR+PLUS – HEDIS® Effectiveness of Care Measures, 2011-2015

43.4%36.5% 34.8% 35.5%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Medication Management for People with Asthma, Compliance 75% of Treatment

Period

53.2%61.5%

50.6%56.9%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015


45.5% 46.2% 45.6% 47.6%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Controlling Blood Pressure

78.1% 80.9% 83.0% 86.5% 86.3%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Comprehensive Diabetes Care,HbA1c Testing

28.3% 30.4%

42.3% 45.6%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015

Comprehensive Diabetes Care,HbA1c Control (<8%)

37.1% 34.3%42.1% 43.4% 43.1%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Comprehensive Diabetes Care,Eye Exams

81.4% 80.0% 82.1% 83.3%91.3%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Comprehensive Diabetes Care,Medical Attention for Nephropathy


Table 36 Table 36. STAR+PLUS – HEDIS® Effectiveness of Behavioral Health Care Measures, 2015

xlviii Higher values indicate stronger performance. xlix Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles

Measure 2015 Ratexlviii

HHS Dashboard

Standard 2015


Ratingxlix

Antidepressant Medication Management, Acute Phase

45.1% 59%

Antidepressant Medication Management, Continuation Phase

31.4% 47%

Follow-Up After Hospitalization for Mental Illness, 7 days

28.8% 44%

Follow-Up After Hospitalization for Mental Illness, 30 days

48.9% 64%


Figure 40. STAR+PLUS – HEDIS® Effectiveness of Behavioral Health Care Measures, 2011-2015

53.3%59.5%

43.7% 42.5% 45.1%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Antidepressant Medication Management,Acute Phase

35.7%46.8%

30.5% 30.0% 31.4%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Antidepressant Medication Management, Continuation Phase

36.1%30.5% 29.8% 34.3%

28.8%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015


58.8%54.2% 51.3%

57.5%48.9%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015


5.4.3. Satisfaction with Care in STAR+PLUS


Table 37 provides results from the 2015 CAHPS® survey of adults in STAR+PLUS. The

following rates represent the percentage of Medicaid-only members who “always” had positive

experiences with the given domain.


Figure 41 through Figure 43 show STAR+PLUS satisfaction with care from 2012.

Rates on measures “Getting care quickly,” “How well doctors communicate,” “Health plan

information and customer service,” “Coordination of care,” “Health care,” “Personal doctor,”

“Specialist,” and “Health plan” were higher than those observed in the national Medicaid

population.


Table 37. STAR+PLUS – CAHPS® Medicaid-only Member Satisfaction with Care, 2016

Survey Question

Percentage rate of “Always” for

STAR+PLUS Medicaid-only

Membersl

HHS Dashboard Standard

2016 Rates

National CAHPS® Adult

Medicaid 2016 Rates33





73.4% N/A 67%

Shared Decision Making 74.9% N/A N/A



Health Care Rating 53.4% N/A 53%

Personal Doctor Rating 68.7% 70% 65%

Specialist Rating 71.3% N/A 65%

Health Plan Rating 57.6% 61% 57%

Good Access to Special Therapies 32.5% 33% N/A

Good Access to Service Coordination 53.6% 41% N/A

Good Access to Behavioral Health Treatment or Counseling

50.9% 44% N/A

l Higher values indicate stronger performance.


Figure 41. STAR+PLUS – CAHPS® Member Satisfaction with Care Composites and Question Summary Rates, 2012-2016

42.3%50.9% 54.7%

74.9%65.7%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Getting Needed Care

58.4%63.7% 62.0%

85.4%

69.9%

0%

20%

40%

60%

80%

100%

2012 2014 2016


72.4% 75.2% 79.0%

88.3%81.8%

0%

20%

40%

60%

80%

100%

2012 2014 2016



51.6% 53.4%60.9%

58.6%

72.6%

0%

20%

40%

60%

80%

100%

2012 2014 2016



54.1%64.2%

73.4%

79.9%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Customer Service


Figure 42. STAR+PLUS – CAHPS® Member Satisfaction with Care Ratings, 2012-2016

47.7%52.4% 53.4%

58.7% 58.8%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Health Care Rating

63.6% 66.7% 68.7%

74.1% 73.6%

0%

20%

40%

60%

80%

100%

2012 2014 2016


56.7%

70.2% 71.3%

78.3% 78.8%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Specialist Rating


55.0% 56.5% 57.6%

62.1% 64.1%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Health Plan Rating


Figure 43. STAR+PLUS – CAHPS® Satisfaction with Care Coordination and Access to Care, 2012-2016

50.2%58.1% 53.6%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Good Access to Service Coordination

Medicaid-only

43.2% 42.1%50.9%

60.6%51.1%

0%

20%

40%

60%

80%

100%

2012 2014 2016




5.5. STAR Health Program

5.5.1. Access to and Utilization of Care in STAR Health

Table 38 presents statewide performance in 2015 for the STAR Health program on measures of

access to care. Superior HealthPlan is the exclusive provider for the program. Children and

adolescents in STAR Health generally had excellent access to care in 2015 compared to the

national Medicaid population, with ratings at the 90th percentile or higher.

Table 38. STAR Health – HEDIS® Access to Care, 2015

Measure 2015 Rateli

HHS Dashboard

Standard 2015


Ratinglii

Children and Adolescents' Access to Primary Care Practitioners, 12-24 months

99.0% 98%


96.6% 96%


99.2% 98%


97.9% 98%


57.2% N/A


16.0% N/A

Use of First Psychosocial Care for Children and Adolescents on Antipsychotics

91.4% N/A


60.2% 64%


87.4% 89%


li Higher values indicate stronger performance. lii Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles


Figure 44 shows access to and utilization measures from 2011 through 2015. The rates for

Children and Adolescents' Access to Primary Care Practitioners remained steady. From 2014,

the rate of developmental screening fell approximately 8 percent and well-child visits within the

first 15 months fell 4.2 percent.

Figure 44. STAR Health – HEDIS® Access to and Utilization of Primary Care, 2011-2015liii

96.5% 96.5% 97.2% 97.6% 97.7%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Children’s Access Physicians: All Members

51.4% 54.6% 52.1%

64.4% 60.2%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015


85.9% 87.4% 89.2% 89.1% 87.4%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015


70.5% 73.6% 74.0% 70.4% 73.7%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Adolescent Well-Care Visits

49.4%56.2%

48.2%

0%

20%

40%

60%

80%

100%

2013 2014 2015


liii Developmental screening is a CHIPRA measure and was not measured prior to 2013.


Table 39 shows 2015 utilization rates for STAR Health. Outpatient visits and MPT rated in the

90th percentile or higher.

Table 39. STAR Health – HEDIS® Utilization of Care Measures, 2016

Measure 2015 Rateliv


Ratinglv

Ambulatory Care, Outpatient Visits (per 1,000 member-months)

482.6


64.3

Mental Health Utilization, Any Services (per 100 member-years) 82.3

Table 40 shows results for five AHRQ PDIs in STAR Health in 2015. PDIs ranged from 11

events (Perforated Appendix Admission Rate) to 22 events (Urinary Tract Infection) statewide.

Table 40. STAR Health – AHRQ Pediatric Quality Indicators, 2015lvi

Measure 2015 Ratelvii

Asthma Admission Rate 5.5

Diabetes Short-Term Complications 8.3

Gastroenteritis Admission Rate 5.1

Perforated Appendix Admission Rate (per 100 admissions for appendicitis)

LD

Urinary Tract Infection 6.2

liv Higher or lower values do not necessarily indicate better quality of care. lv Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles

lvi Per 100,000 member-months unless noted otherwise lvii Lower values indicate stronger performance.


The EQRO calculated statewide performance in the STAR Health program on measures of

PPEs. The EQRO calculated these measures using 3M™ Health Information Systems software.

A description of all PPEs is in Section 8.3.3.

Figure 45 trends weighted statewide PPA per 1,000 member-months in STAR Health from

2011 through 2015. In 2015, 1,195 STAR Health members had 1,429 PPAs. The overall

weighted rate was 2.7524 and the rate decreased from its high in 2014.

2.6334 2.6000

3.3546

3.7922

2.7524

0

1

2

3

4

5

2011 2012 2013 2014 2015

Table 41 presents the

most common reasons for PPAs among all members in STAR Health in 2015.

Figure 45. STAR Health – Weighted 3M™ Potentially Preventable Hospital Admissions, per 1,000 Member-months, 2011-2015lviii

Table 41. STAR Health – 3M™ Potentially Preventable Hospital Admissions, Most Common Reasons, for 2015

PPA Reason % of PPAs in STAR Health


2 Major Depressive Disorders & Other / Unspecified Psychoses 12.4%

3 Seizure 3.7%


5 Diabetes 2.6%

6 Schizophrenia 2.1%


8 Depression Except Major Depressive Disorder 1.8%

9 Infections of Upper Respiratory Tract 1.8%

10 Asthma 1.5%

Figure 46 shows weighted PPR chains per 1,000 candidate admissions in STAR Health from

2011 to 2015. In 2015, 543 STAR Health members had 586 admissions with PPRs. The overall

lviii Lower values indicate stronger performance.


weighted PPR rate was 1.5108 and the rate has decreased since 2011. Table 42 presents the

most common PPRs among all members in STAR Health in 2015.

Figure 46. STAR Health – Weighted 3M™ Potentially Preventable Readmission Chains per 1,000 Candidate Admissions, 2011-2015lix

1.79601.6770

1.43431.6185

1.5108

0

0.5

1

1.5

2

2011 2012 2013 2014 2015

Table 42. STAR Health – 3M™ Most Common Admission Reasons Associated with Potentially Preventable Readmission, for 2015

PPR Reason % of PPRs in STAR Health


87.8%


4.9%


3.9%


1.5%


1.0%



0.4%


0.3%

lix Lower values indicate stronger performance.


Figure 47 shows weighted PPV per 1,000 member-months in STAR Health from 2011 to 2015.

In 2015, 9,802 STAR Health members had over 15,000 PPVs. The overall weighted PPV rate

was 11.4060 and the rate has steadily increased since 2011. Table 43 presents the most

common PPVs among all members in STAR Health

Figure 47. STAR Health – Weighted 3M™ Potentially Preventable Emergency Department Visits per 1,000 Member-months, 2011-2015lx

7.3865

9.841610.3160 10.3978

11.4060

0

2

4

6

8

10

12

2011 2012 2013 2014 2015

Table 43. STAR Health – 3M™ Most Common Potentially Preventable Emergency Department Visits Reasons, for 2015

PPV Reason % of PPVs in STAR Health




4 Non-bacterial Gastroenteritis, Nausea & Vomiting 5.9%



7 Level I Other Ear, Nose, Mouth, Throat & Cranial / Facial Diagnoses 3.9%




lx Lower values indicate stronger performance.


In 2015, 17 STAR Health members had 17 PPCs. The overall weighted PPC rate was 0.0457

per 1,000 at-risk admissions. Table 44 presents the most common PPCs among all members in

STAR Health in 2015.

Table 44. STAR Health – 3M™ Most Common Potentially Preventable Complications, for 2015

PPC Reason % of PPCs in STAR Health

1 Infections Due to Central Venous Catheters 16.7%

2 Shock 11.1%

3 Obstetrical Hemorrhage without Transfusion 11.1%

4 Delivery with Placental Complications 11.1%

5 Pneumonia & Other Lung Infections 5.6%

6 Pressure Ulcer 5.6%

7 Cellulitis 5.6%

8 Infection, Inflammation and Clotting Complications of Peripheral Vascular Catheters and Infusions

5.6%


10 Obstetric Lacerations & Other Trauma without Instrumentation 5.6%


5.5.2. Effectiveness of Care in STAR Health

Table 45 shows statewide performance in 2015 for the STAR Health program. Superior

HealthPlan is the exclusive provider. The STAR Health population is not necessarily

comparable to the national Medicaid population, and benchmark comparisons are provided for

reference only. Overall, medication compliance for people with asthma and total controller

mediation were rated at the 90th percentile or higher. The rates for ADD were below their HHS

dashboard standard; however nationally these rates were at the 90th percentile or higher. The

rates for FUH were lower than their HHS dashboard standards.

Figure 48 trends the effectiveness of care for respiratory conditions. The rate for MMA saw an

increase of 9.1 percent from 2014. The rates for the other measures remained relatively steady.

Figure 49 trends the effectiveness of care for BH through 2015. There has been a steady

increase through 2015 for the acute phase of Antidepressant Medication Management. All other

measures remained relatively stable since 2014.


Table 45. STAR Health – HEDIS® Effectiveness of Care Measures, 2015

Measure 2015

Ratelxi HHS Dashboard

Standard 2015 HEDIS® 2016

Percentile Ratinglxii


55.2% N/A

Medication Management for People with Asthma, Medication Compliance 75% of Treatment Period (total)

50.8% 50%


74.0% N/A

Antidepressant Medication Management,

Acute Phase 48.9% N/A

Antidepressant Medication Management

Continuation Phase 23.9% N/A


86.3% 88%


90.3% 93%


57.1% 63%


78.6% 87%

Metabolic Monitoring for Children and Adolescents on Antipsychotics

44.2% N/A

Use of Multiple Concurrent Antipsychotics in Children and Adolescents

1.39%lxiii N/A

Appropriate Treatment for Children With Upper Respiratory Infection

83.4% N/A

CHIPRA® Developmental Screening in the First Three Years of Life, All Ages

48.2% N/A N/A

lxi Higher values indicate stronger performance. lxii Texas result in relation to HEDIS® national percentiles for Medicaid = 90th percentiles and above = 66th to 89th percentiles = 33rd to 65th percentiles = 10th to 32nd percentiles = Below 10th percentiles lxiii Lower values indicate stronger performance.


Figure 48. STAR Health – HEDIS® Effectiveness of Care for Respiratory Conditions, 2011-2015lxiv

51.6% 54.2% 53.5%58.3% 55.2%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015


78.9% 79.7% 81.2% 82.1% 83.4%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015


49.6%43.4% 41.7%

50.8%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015


79.5% 83.3%

72.9% 74.0%

0%

20%

40%

60%

80%

100%

2012 2013 2014 2015


lxiv Calendar year 2011 rates for AMR and MMA were not calculated for STAR Health.


Figure 49. STAR Health – HEDIS® Effectiveness of Care for Behavioral Health Conditions, 2011-2015

60.9% 62.8% 59.1% 60.8% 57.1%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015


55.9% 52.4%

87.8% 89.1% 86.3%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Follow-Up for Children Prescribed ADHD Medication, Initiation Phase

59.9% 58.8%

92.7% 92.8% 90.3%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015

Follow-Up for Children Prescribed ADHD Medication, Continuation / Maintenance

85.7% 87.2% 85.8% 83.3%78.6%

0%

20%

40%

60%

80%

100%

2011 2012 2013 2014 2015



5.5.3. Satisfaction with Care in STAR Health

Table 46 provides results from the CAHPS® survey conducted with caregivers of children and

adolescents in STAR Health in 2016. The following rates represent the percentage of members

who “usually” or “always” had positive experiences with the given domain. Figure 50 and

Figure 51 show STAR Health caregiver satisfaction of care from 2012.

Rates on measures of personal doctor and specialists were greater than the national Medicaid

average. Caregivers also rated: “Getting needed care”; “Getting care quickly”; “How well doctors

communicate”; “Health plan information and customer service”; “Care coordination”; and “Health

promotion and education” higher than the national Medicaid average. However, health plan

ratings were lower than the national Medicaid average.

Table 46. STAR Health – CAHPS® Caregiver Satisfaction with Care, 2016

Survey Question

Percentage rate of

“Always” for STAR Health

Caregiver Members lxv

HHS Dashboard

Standard 2016

CAHPS® Child Medicaid

201634





74.0% N/A 68%



Rating of All Health Care ‘9’ or ‘10’ 67.4% N/A 67%

Rating of Personal Doctor ‘9’ or ‘10’ 75.4% 72% 74%

Rating of Specialist ‘9’ or ‘10’ 76.0% N/A 70%

Rating of Health Plan ‘9’ or ‘10’ 62.0% 67% 68%


63.5% 63% N/A

lxv Higher values indicate stronger performance.


Figure 50. STAR Health – CAHPS® Member Satisfaction with Care, Composites and Question Summary Rates, 2012-2016

67.7%63.2% 63.9%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Getting Needed Care

83.8%78.0% 76.3%

0%

20%

40%

60%

80%

100%

2012 2014 2016


83.6% 81.1%86.0%

0%

20%

40%

60%

80%

100%

2012 2014 2016


61.8%

75.0% 74.0%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Customer Service

59.7%52.3%

63.1%

0%

20%

40%

60%

80%

100%

2012 2014 2016



Figure 51. STAR Health – CAHPS® Member Satisfaction with Care, Ratings, 2012-2016

66.9%61.2%

67.4%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Health Care Rating

73.5% 71.3% 75.4%

0%

20%

40%

60%

80%

100%

2012 2014 2016


62.9% 61.2%

76.0%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Specialist Rating

71.0%

60.2% 62.0%

0%

20%

40%

60%

80%

100%

2012 2014 2016

Health Plan Rating


5.6. Medicaid and CHIP Dental Programs

5.6.1. Access to and Utilization of Care in Medicaid and CHIP Dental Programs


Table 47 shows rates of dental services access and utilization for the Medicaid and CHIP dental

programs dental programs, along with HHS dashboard standards where applicable. The rates

for all CHIP Dental measures were lower than their HHS dashboard standards. The rates for all

Medicaid Dental Annual Dental Visits (ADV) were higher, but the rate for Preventive Dental

Services was lower, than the corresponding HHS dashboard standards.


Table 47. Medicaid Dental and CHIP Dental – Access and Utilization Measures, 2015

Measure

2015 Ratelxvi HHS Dashboard Standard

2015

Medicaid CHIP Medicaid CHIP

Annual Dental Visit, 2-3 years 76.4% 71.5% 56% 80%lxvii

Annual Dental Visit, 4-6 years 81.3% 77.7% 77% 88%ii




Annual Dental Visit, 19-21 years 51.1% N/A 47% N/A

First Dental Home Services Visit 68.4% N/A 73% N/A

Continuity of Care 59.6% 54.1% TBD TBD

Topical Fluoride 41.8% 37.5% TBD TBD

Preventive Dental Service 76.0% 72.6% 85%ii 80%ii

Sealant on a Permanent First Molar, 6-9 years

27.0% 21.1% 35%ii 30%ii

Sealant on a Permanent Second Molar, 10-14 years

15.8% 11.7% 30%ii 25%ii

Texas Health Steps

Annual Dental Checkupslxviii 58.3% N/A 65%ii N/A

Dental Checkup within 90 Days of Enrollment

26.6% N/A 40%ii N/A

lxvi Higher values indicate stronger performance. lxvii This is a 2015 P4Q measure. The dashboard standard is the attainment goal; however actual performance will follow the P4Q methodology. Therefore, the listed standard is for reference only.

lxviii The recommended standard for Texas Health Steps dental checkups is twice per year. This measure combines

the rate of meeting or exceeding this standard at full weight with the rate of receiving exactly one Texas Health Steps dental checkup at half weight.


5.6.2. Satisfaction with Care in Medicaid and CHIP Dental Programs

Table 48 provides results from the Medicaid and CHIP Dental Caregiver Survey conducted in

2015. Findings are shown in four domains of dental care: (1) care from dentists and staff,

(2) access to dental care, (3) dental plan costs and services, and (4) caregiver ratings. For all

but the latter, the results represent the percentage of caregivers who responded “always” to the

question.

The vast majority of members positively rated the care they received from their dentist or staff.

The lowest-rated measure for both Medicaid and CHIP was “Regular dentist spent enough time

with patient,” 79.9 and 79 percent respectively. The highest-rated was “regular dentist treated

patient with courtesy and respect,” 92.2 and 92.5 percent respectively.

Nearly three-quarters of members reported being able to get a dental appointment as soon as

needed: Medicaid Dental 76.5 percent and CHIP Dental 73 percent. Less than 15 percent of

Medicaid Dental and CHIP Dental members had to wait more than 15 minutes for a dental

appointment.

Only 58 percent of Medicaid Dental members and 48.8 percent of CHIP Dental members

reported that the information caregiver “usually” or “always” received all information from a toll-

free number, written material, or website. However, the vast majority of members stated the

dental plan customer service staff treated them with respect.


Table 48. Medicaid Dental and CHIP Dental – Caregiver Satisfaction with Care, 2015

Measure Medicaid Dentallxix

CHIP Dental i

Care from Dentists and Staff – Responses of “Always”

Regular dentist explained things in a way that was easy to understand. 84.9% 83.1%

Regular dentist listened carefully. 86.6% 84.5%

Regular dentist treated patient with courtesy and respect. 92.2% 92.5%

Regular dentist spent enough time with patient. 79.9% 79.0%

Dentists or dental staff did everything they could to help patient feel as

comfortable as possible during dental work. 82.8% 80.5%

Dentists or dental staff explained what they were doing during

treatment. 86.0% 81.5%

Access to Dental Care – Responses of “Always”

Member able to get a dental appointment as soon as needed. 76.5% 73.0%

Member waited more than 15 minutes in waiting room for a dental

appointment. 12.8%lxx 14.2%ii

Member was informed of reason for delay or length of delay if wait was

longer than 15 minutes. 24.9% 27.0%

Dental Plan Costs and Services - Responses of “Usually” or

“Always”

Dental plan covered all services caregiver thought were covered. 85.6% 64.4%

The toll-free telephone number, written materials or website provided

all information caregiver wanted. 58.0% 48.8%

Dental plan’s customer service gave caregiver all information or help

needed. 72.3% 65.8%

Dental plan’s customer service staff treated caregiver with courtesy

and respect. 92.8% 85.0%

Dental plan covered needed services for member and family. 84.6% 62.6%

Information from dental plan helped caregiver find a dentist they were

happy with. 80.8% 74.1%

Caregiver Ratings

Dentist Rating (9 or 10) 77.5% 72.2%

Dental Care Rating (9 or 10) 79.4% 70.1%

Access to Dental Care Rating (9 or 10) 76.0% 70.0%

Dental Plan Rating (9 or 10) 82.2% 69.1%

lxix Higher values indicate stronger performance. lxx Lower values indicate stronger performance.


6. Focus Studies and Special Projects

This section provides an overview of the focus studies that were conducted by the EQRO in

2016.

6.1. HCBS Settings Assessment Survey

Introduction

Effective March 17, 2014, CMS issued a final rule under which states may provide HCBS LTSS.

Under 42 CFR§441.301, states must meet new requirements for HCBS LTSS by March 17,

2019.

To assist HHS in meeting these requirements, the EQRO conducted in-person interviews with

STAR+PLUS members who, through the HCBS waiver program, reside in assisted living

facilities (ALF) and adult foster care (AFC) homes.

Methodology

Survey participants were selected from the population of members in STAR+PLUS or a

Medicare-Medicaid Plan (MMP) who receive 24-hour residential services in an ALF or AFC. For

inclusion, members must have been continuously enrolled in STAR+PLUS or an MMP

(regardless of health plan) from July 1, 2015 through December 1, 2015, and either: (1)

received assisted living services (service code T2031) in the same facility during each month of

the enrollment period or (2) received AFC services (service code S5140) in the same facility

during each month of the period. The EQRO sampled members across four quotas defined by

each combination of residential setting (ALF or AFC) and geographic location (urban or rural).

The EQRO contracted with NORC to conduct face-to-face interviews with eligible members at

the resident's ALF or AFC or another location requested by the participant. Three types of

interviews were possible: (1) resident interviews conducted with the member; (2) interviews

conducted with a member unable to verbally communicate, with the assistance of an interpreter;

and (3) interviews conducted with a proxy respondent in cases where the member was unable

to participate.

HHS developed the interview tool with assistance from the EQRO to assess member or proxy

experience with residential services using a structured format. The tool consisted of 100 closed-

ended and two open-ended questions divided into six domains: (1) choice of home; (2)

employment; (3) service plans and options; (4) respect, dignity, and privacy; (5) community

integration; and (6) choice, control, and rights.

NORC conducted the interviews from July to September of 2016. The number of completed

interviews was: 181 for ALF Urban, 38 for AFC Urban, 126 for ALF Rural, and 4 for AFC Rural.

The response rate was 79.3 percent.

Results

Of all respondents: 51.9 percent were female, 64.5 percent were white, non-Hispanic, and the

mean age was 63 years.


Across quotas, more than half (57.5 percent) of respondents stated that they liked most if not all

things in their home. Nearly three-quarters of survey respondents (73.9 percent) stated that it

was their choice to live in that home.

Figure 52 presents a comparison of ALF urban and ALF rural residents on three important

satisfaction and experience measures: (1) whether or not a resident living in a facility with 50

beds or less liked his or her home, (2) whether the member looked at other homes prior to

moving to a facility with 50 beds or fewer, and (3) whether the member chose the services in his

or her plan. An approximately equal percentage of urban and rural ALF residents liked their

home and chose the services on their plan for home- and community-based services. However,

nearly double the percentage of ALF urban residents stated they looked at other homes prior to

moving to a facility with 50 beds or fewer.

Figure 52. HCBS Settings Survey – Satisfaction and Decision-Making between ALF Urban and ALF Rural Residents

Findings from this study are also being used by HHS to validate responses to a survey of ALF

and AFC providers conducted by HHS

6.2. STAR Kids Pre-Implementation Study

Introduction

STAR Kids is a new Medicaid managed care program implemented on November 1, 2016 for

children, adolescents, and young adults under age 21 who have a disability. Most of the

members transitioned from fee-for-service (FFS) or STAR+PLUS, and many are also enrolled in

a waiver program for HCBS. Through STAR Kids, these members now receive benefits such as

prescription drugs, hospital care, primary and specialty care, preventive care, personal care

services, private duty nursing, and durable medical equipment and supplies through a STAR

Kids MCO. Individuals on the Medically Dependent Children Waiver also receive waiver

87.2%

53.4% 53.1%

82.5%

23.5%

56.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Like home (50 beds or less) Member looked at other homeprior to moving to facility with

50 beds or fewer

Member chose services inplan

ALF Urban ALF Rural


services through their MCO. The EQRO is conducting a multi-year focus study to evaluate

implementation of STAR Kids, comparing results before and after implementation on survey and

administrative measures. In 2016, the EQRO conducted a pre-implementation telephone survey

of caregivers of individuals eligible for STAR Kids.

Caregiver Survey

The EQRO sampled STAR Kids-eligible Medicaid members from any of the following service

groups: (1) FFS-Supplemental Security Income (SSI), (2) STAR+PLUS-SSI, (3) Medically

Dependent Children Program Waiver, and (4) Medicaid waiver programs for people with

Intellectual and Development Disabilities.lxxi

The EQRO contracted with the UFSRC to administer telephone surveys with parents or

guardians of STAR Kids-eligible members with the goal 200 to 250 completed surveys in each

service group quota. The number of completed surveys allows for inferences for each individual

service group population with a maximum 7 percent margin of error (95 percent confidence

interval).

The telephone survey included items from the CAHPS survey and modified items from the

National Survey of Children with Special Health Care Needs to assess caregiver experiences

and satisfaction with their child’s care in the last six months.

Administrative Measures

The EQRO will review academic and policy literature to create a list of administrative measures

that are appropriate to the STAR Kids population. These include measures from: (1) the HEDIS,

(2) the AHRQ PDIs; and (3) 3M measures of PPEs. These measures assess processes and

outcomes for acute care. The EQRO has access to needed claims and encounter data for acute

care measures for all four service groups.

Results

The EQRO is currently completing analyses for the caregiver survey and the summary of

administrative measures. Results for the STAR Kids pre-implementation study will be available

for review in mid-2017.

6.3. National Core Indicators – Aging and Disabilities Study

Introduction

The National Association of States United for Aging and Disabilities (NASUAD) is the

membership organization for state aging and disability directors. Since 2012, NASUAD has

been working in collaboration with the Human Services Research Institute (HSRI) and the

National Association of State Directors of Developmental Disabilities Services to build the NCI-

AD study. NCI-AD is an initiative designed to support states’ interest in assessing the

performance of their programs and delivery systems and improving services for older adults,

individuals with physical disabilities, and caregivers. The primary aim of NCI-AD is to collect and

lxxi The four waiver programs are: Community Living Assistance and Support Services, Deaf Blind with Multiple Disabilities, Home and Community-based Services, and Texas Home Living.


maintain valid and reliable data that give states a broad view of how their publicly funded LTSS

impact the quality of life and outcomes of service participants. Texas is one of 16 states to

participate in the NCI-AD study.

Data for the project is gathered through yearly in-person consumer surveys administered by

state agencies to a sample of at least 400 participants. They include older adults and individuals

with physical disabilities accessing publicly funded services through skilled nursing facilities,

Medicaid waivers, Medicaid state plans, and/or state-funded programs, as well as older adults

served by Older Americans Act (OAA) programs. HSRI interprets each state’s data and

produces reports to help states strengthen LTSS policy, inform quality assurance activities, and

compare their performance with national norms.

Methods

The EQRO worked with the HHS to administer the baseline NCI-AD survey with members in its

Medicaid managed care program for older adults (STAR+PLUS), the Program of All-Inclusive

Care for the Elderly (PACE), and individuals receiving services through the OAA.

The EQRO contracted with NORC to help collect the data. The NCI-AD Consumer Survey

instrument included an in-person survey as well as a background survey to gather data about

the consumer from agency records. The in-person survey included subjective satisfaction-

related questions that can only be answered by the consumer, and objective questions that

could be answered by the consumer or his or her proxy if needed. The survey also included an

interviewer feedback form to capture interviewers’ experiences and solicit their feedback on any

problematic questions or wording.

Results

Data collected through this survey will fill a gap in an otherwise comprehensive managed care

quality assurance system. This data will help demonstrate MCO performance to external

parties, including state and federal stakeholders.

6.4. House Bill 3823 Patient Experience Analysis in STAR+PLUS versus PACE

Introduction

PACE is a community-based managed care program that operates on capitation-based waivers

from Medicare and Medicaid for frail, older individuals with chronic conditions who need LTSS.

The primary purpose of PACE is to keep nursing home-eligible adults 55 and older living in the

community at the highest possible level of function and quality of life.35,36 To date, the PACE

model has been shown to reduce rates of certain types of hospitalizations nationally, although

programs have not achieved cost savings due to high capitation rates.37,38,39 In Texas, PACE

operates in three areas– Amarillo/Canyon, El Paso, and Lubbock. As of June 2015, the program

served more than 1,000 members. Individuals living in PACE areas who qualify for either PACE

or STAR+PLUS have the option of enrolling in either program.

Under the 84th Texas State Legislature of 2015, House Bill (HB) 3823 directs HHS to evaluate

the PACE program, comparing costs and outcomes to those for members in STAR+PLUS. To


assist HHS in this evaluation, the EQRO conducted a secondary analysis of in-person survey

results collected from STAR+PLUS and PACE members or their proxies as part of the 2015

NCI-AD study.40

Methodology

The EQRO conducted two analyses on a sub-set of the 2015 NCI-AD survey data: (1) a

descriptive analysis of client characteristics and satisfaction outcomes, shown for PACE and

STAR+PLUS members; and (2) an analysis using logistic regression to assess the association

between program membership and several selected satisfaction outcomes, controlling for client

characteristics.

Results

When controlling for client characteristics, PACE members were significantly more likely than

STAR+PLUS members to report positive outcomes on several measures of access to care, as

shown on

Table 49.

However, PACE members were significantly less likely than STAR+PLUS members to have

reported good access to PCPs, after controlling for client characteristics. Among those who had

a PCP, PACE members were 66 percent less likely than STAR+PLUS members to report they

could get an appointment to see their PCP when needed (Odds Ratio = 0.34).

Finally, with regard to quality of life, PACE members were nearly twice as likely as STAR+PLUS

members to report feeling “in control” of their lives (Odds Ratio = 1.97).

Caveat

Comparisons of satisfaction and quality of life measures between STAR+PLUS and PACE

members were limited because the groups were not directly comparable in terms of health or

functional status. While all PACE members meet nursing facility level of care, most of the

STAR+PLUS members in this study did not meet nursing facility level of care. Furthermore,

controlling for health status using Clinical Risk Groups (CRG) in statistical models was not

possible because CRGs require the use of claims data, and PACE sites do not submit claims

data to the state. In future NCI-AD studies (beginning in July 2017), the EQRO will be changing

the sampling strategy to address this concern; the sample of STAR+PLUS members will be

limited to only those STAR+PLUS members who are also enrolled in the HCBS program (which

requires the member meet the nursing facility level of care criteria).

Table 49. Comparison of Select Access to Care Measures for PACE and STAR+PLUS Members

PACE STAR+PLUS

% %


Can you reach your case manager/care coordinator when you need to?

Yes, always 91.7 68.5

Do you currently have a personal emergency response system?

Needs one or has one but needs an upgrade 12.7 43.7

Do you have transportation to get to medical appointments when you need to?

Yes 98.2 91.2

Have you had a physical exam/wellness visit in the past year?

Yes 92.6 80.4

6.5. STAR+PLUS HCBS Waiver – Service Validation Study

Ensuring that STAR+PLUS HCBS Waiver services are delivered in accordance with members’

individual service plans (ISP) is one of six objectives outlined by HHS and the EQRO. This

report builds upon and refines service validation studies conducted by the EQRO in 2015, using

validated ISP data for all five STAR+PLUS MCOs covering ISPs with start dates in calendar

year 2014. This study addresses limitations of the prior report, which did not include all

STAR+PLUS MCOs due to ISP data quality issues, and assessed only the presence/absence of

authorized ISP services in claims and whether rendered services were lesser or greater than

authorized. In addition to these measures, the report quantifies the extent to which rendered

services match authorized ones.

The EQRO used electronic ISP data submitted by the STAR+PLUS MCOs in July 2015 and

January 2015, with service start dates ranging from January 2014 through December 2014. The

EQRO data analytics team performed an initial quality review of the data to ensure that

complete claims and encounter data would be available for validation of ISP services in future

studies. The ISP data were provided at the individual service level, rather than the member

level. Each member has a number of ISP service records in the data equal to his or her number

of ISP-approved services.

The report provides results of the preliminary service validation analysis (for each of the five

STAR+PLUS MCOs – Amerigroup, Cigna-HealthSpring, Molina, Superior, and

UnitedHealthcare) in which the volume and cost of approved services authorized in the ISPs

were compared with services rendered in corresponding claims and encounter data.

The EQRO has completed analyses for the service validation study, and the results will be

available pending HHS review and approval in mid-2017.


6.6. Senate Bill 760 Background Report

CMS requires all states to submit reports that address the adequacy of health care services

provided by the MCOs using standards set forth by each state.

On September 1, 2015, Senate Bill (SB) 760 of the 84th Texas Legislature established provider

access requirements for Medicaid MCOs to ensure access to care. SB 760 requires Texas HHS

to implement several network adequacy initiatives in Medicaid managed care. They include

reporting MCO recipients’ access to providers in the MCO provider networks, MCO compliance

with certain access standards, provider-to-recipient ratios in MCO provider networks, and

relevant access benchmarks in these and other measures to identify possible deficiencies.41 In

2016, the EQRO wrote a Quarterly Topic Report that sought to: (1) identify best practices for

provider access standards, (2) evaluate existing and novel tools for assessing network

adequacy, and (3) explore alternative definitions of provider access utilized in other states and

health care organizations.

Identification of Best Practices for Provider Access Standards

Federal regulations allow states to establish their own access-to-care standards. HHS requires

MCOs to comply with access-to-care standards as noted in the Uniform Managed Care Contract

(UMCC) and set forth by the Texas Department of Insurance.42 CMS oversees state Medicaid

programs but does not set national standards for access to care. However, CMS requires states

to develop standards for evaluating MCOs.43,44

Considerable variability exists across states in provider access standards. For example, the

maximum distance a recipient should travel ranges from five to -mile100-miles and travel time

ranges from 30 to 60 minutes. The number of recipients to provider ranges from 100 to 2,500.

Finally, the maximum wait time for PCPs or specialists ranges from 10 to 60 days, and one to

four days for urgent care.

Evaluation of Existing and Novel Tools for Assessing Network Adequacy

Practices for assessing network adequacy vary across federal, CMS, and state regulations.

CMS requires MCOs to establish, monitor, and maintain their network adequacy standards by

considering multiple factors, including: anticipated Medicaid enrollment, expected utilization of

services taking into account characteristics and health needs of the covered population, number

and types of professionals needed to provide services, number of network providers not

accepting new Medicaid patients, geographic location, accessibility of providers in relation to

recipients, ability of providers to communicate with recipients with limited English in their

preferred language, ability of providers to ensure access for recipients with physical or mental

disabilities, and availability of triage lines, telemedicine, e-visits, and other technological

solutions.45 CMS also requires states to submit an Access Monitoring Review Plan to improve

oversight of network adequacy.46

Exploration of Alternative Definitions of Provider Access

The EQRO reviewed definitions used by CMS Medicare Advantage, the National Association for

Insurance Commissioners, the NCQA, and commercial health insurance plans. Overall,


definitions of network adequacy or provider access vary greatly across states and different

regulators. The EQRO did not find alternative access-to-care provisions specific to each of the

nine parameters outlined in SB760 (preventive care, primary care, specialty care, after-hours

urgent care, chronic care, LTSS, nursing services, therapy services, and any other services

identified by Texas HHS). Parameters discussed in the literature are generally limited to PCPs

and specialists.

6.7. Appointment Availability

Introduction

Ensuring that beneficiaries of public insurance programs receive timely appointments for

primary and specialist care is an important component of QI efforts that address access. The

providers in the MCO networks must deliver timely access to all covered services in accordance

with the standards for appointment wait times. In the Access to Care study of 32 states

contracted with Medicaid MCOs, the Federal Office of the Inspector General (OIG) reported

about half (49 percent) of the 1,800 PCPs contacted for the study offered new patient

appointments, 43 percent did not participate in the health plan, and 8 percent were not

accepting new patients.47 The OIG reported a median wait time of 10 days for a primary care

appointment. In another multi-state study including Texas,48 less than two-third of the Medicaid

enrollees were able to secure an appointment with a PCP. Median wait times to get these

appointments ranged from 5 to 8 days.

According to Section 8.1.3 of the Texas UMCC, MCOs that participate in Medicaid and CHIP

must assure that all members have access to all covered services on a timely basis, consistent

with medically appropriate guidelines and accepted practice parameters, which specifies

maximum wait times for several levels and types of care (Table 50).49

Table 50. Appointment Standards Defined in the Texas Medicaid Uniform Managed Care Contract

Level/Type of care Time to treatment

Urgent care (child and adult) Within 24 hours

Routine primary care (child and adult) Within14 calendar days

Preventive health services for newborn members No later than 14 calendar days after enrollment

Preventive health services for new child members No later than 90 calendar days after enrollment

Initial outpatient behavioral health visits (child and adult)

Within 14 calendar days

Preventive health services for adults Within 90 calendar days

Prenatal care (not high-risk) Within 14 calendar days

Prenatal care (high risk) Within 5 calendar days

Prenatal care (new member in 3rd trimester) Within 5 calendar days

Vision care (ophthalmology, therapeutic optometry) Access without PCP referral


Methodology

This study uses the secret shopper methodology to assess availability of appointments and

responsiveness of staff at sampled provider offices. Various studies50,51 have found this

methodology to be a valid, reliable, effective, and efficient way to determine service

accessibility. The EQRO hired and trained four staff members to pose as potential new patients

telephoning provider offices to schedule an appointment. The process included developing

several scripts to elicit and record data needed to assess compliance with appointment

standards. No appointments were actually scheduled.

The EQRO developed the telephone scripts after review of a similar study also conducted by

the ICHP for the Florida Healthy Kids Corporation. Independent instruments are used to collect

data for different studies based on member populations and provider types. These tools use an

online entry system for convenient and reliable data collection. HHS reviewed and approved all

instruments prior to the start of data collection.

Results


Table 51 describes the overall weighted percentages of providers who met the UMCC standard

by provider type and program. Percent compliance ranged from 40.9 percent (STAR Adult

prenatal high risk and third trimester sub-studies) to 99.9 percent (CHIP PCP preventive care).

STAR+PLUS had the lowest compliance percentages for PCP and vision care and the highest

for BH care.


Table 51. Percentage of Providers (Type) who Met the UMCC Appointment Standard Overall (Weighted Percentages) by Program

Provider Type CHIP STAR STAR+ PLUS

Child Adult

Behavior Health Care 73.4 65.4 69.4 79.4

PCP Preventive Care 99.9 99.8 99.4 96.8

PCP Routine Care 80.7 94.0 85.7 77.2

PCP Urgent Care 99.8 99.3 97.9 95.7

Vision Care 91.2 91.4 - 89.4

Low-risk prenatal care - - 74.9 -

High-risk prenatal care - - 40.9 -

Third-trimester prenatal care - - 40.9 -

For the 2015 appointment availability studies (STAR, CHIP, and STAR+PLUS), the EQRO

received the directories for all programs and all provider types in July 2015. For CHIP, data

collection started approximately five months after receiving the directories and included PCP,

vision care providers, and BH providers. For STAR+PLUS, data collection started approximately

nine months after receiving the directories and included PCP, vision care providers, and BH

providers. The lag between the receipt of the directories and the start of data collection adds

another caveat regarding the accuracy of the directories. A different approach will be used for

future appointment availability studies: HHS will supply the EQRO with a new set of directories

for each provider type (e.g., PCPs, vision, BH) about six weeks before data collection begins.

Data collection will then occur by provider type for each program to assure the use of the most

currently available directories.

6.8. MCO Report Cards

Introduction

To support the state's ongoing efforts to improve consumer choice in Texas Medicaid and CHIP,

the EQRO produced annual MCO report cards starting in calendar year 2013. The MCO report

cards are designed to assist Medicaid and CHIP enrollees and their caregivers in choosing a

health plan and are in line with federal requirements to provide quality ratings and member

satisfaction information to consumers to facilitate comparison of health plans.

Other state Medicaid programs also have adopted consumer report cards for health plans.

These states include California, Maryland, New York, and Ohio. Each MCO report card covers

one service delivery area and presents results for all MCOs operating in that area and program.

Enrollment packets for new members include the MCO report cards for health plan options

available to enrollees in their service area in addition to other information pertinent to enrollees’


health plan options. The MCO report cards are also available on the HHS website. It is possible

for a health plan to score strongly in one service area and weakly in another.

The EQRO selected measures on the report cards with input from focus groups of Texas

Medicaid members and their caregivers to identify how consumers make choices and evaluate

options for health care. The MCO report cards are divided into quality domains important to

individual consumers and results are presented in a manner appropriate to the literacy and

linguistic needs of the Texas Medicaid and CHIP populations. On each MCO report card,

measures are grouped into four domains – Getting help from doctors and the health plan,

Getting checkups and tests, Getting help with health issues, and Getting services from the

health plan. Members score the health plans on each measure using a three-star rating system

reflecting health plan performance in the service delivery area relative to the statewide

performance. Stars are assigned to health plans as follows:

One star – Health plan is in the bottom one-third percentile and below the 95 percent

confidence interval for the statewide mean.

Two stars – Health plan is in the middle one-third percentile or inside the 95 percent


Three stars – Health plan is in the top one-third percentile and above the 95 percent


Methodology

The EQRO produced two MCO report cards for STAR: one focused on measures important for

children and adolescents and one on measures important for adults. The four MCO report cards

featured items most likely to inform consumer decisions for the different populations, as shown

in Table 52. Five items were derived from surveys of members and caregivers: Getting Timely

Care, Getting Needed Care, Talking with Doctors, Personal Doctor Rating, and Health Plan

Rating. Twelve items were derived from claims and encounter data using only administrative

data: Checkups for Infants, Checkups for Children and Teens, Checkups for Adults, Asthma,

Attention Deficit Hyperactivity Disorder, Prenatal Care, New Mother Care, Breast Cancer

Screening, Cervical Cancer Screening, Chronic Obstructive Pulmonary Disease, Depression,

and Diabetes. The Overall Performance Rating accounted for both member experience and

satisfaction surveys and administrative claims and encounter data. This overall rating was

calculated using the specifications from the September 2016 NCQA Health Insurance Plan

Rating Methodology.52

Definitions of each item can be found in Section 8.4.


Table 52. MCO Report Cards by Program, 2016

Measure CHIP STAR Child STAR Adult STAR+PLUS

Getting Timely Care

Getting Needed Care

Talking with Doctors


Health Plan Rating

Checkups for Infants

Checkups for Children and Teens

Checkups for Adults

Asthma

Attention Deficit Hyperactivity Disorder

Prenatal Care

New Mother Care

Breast Cancer Screening


Chronic Obstructive Pulmonary Disease

Depression

Diabetes

Overall Performance Rating

To ensure sufficient sample sizes for survey measures at the plan code level, the EQRO

annually conducts abbreviated annual MCO report card surveys. In 2016, the EQRO conducted

stand-alone STAR Adult and STAR+PLUS annual MCO report card surveys targeting 200

completed surveys per plan code. The EQRO supplemented the STAR Child and CHIP surveys

with results from the biennial caregiver surveys of those populations and fielded annual MCO

report card surveys in plan codes that did not reach 200 completed surveys. Table 53 shows

the enrollment and fielding periods for these abbreviated surveys.


Table 53. Member and Caregiver Annual MCO Report Card Survey Enrollment and Fielding Periods, 2016

Year Survey Enrollment period Fielding period

2016 CHIP Caregiver Annual MCO Report Card Survey

September 2015 – February 2016


STAR Child Caregiver Annual MCO Report Card Survey

September 2015 – February 2016


STAR Adult Annual MCO Report Card

Survey



STAR+PLUS Annual MCO Report Card Survey



Results

The MCO report cards produced by the EQRO for 2016 will be available to new enrollees in

both printed and online versions in early 2017.

6.8.1. MCO Report Card Evaluation Survey

Introduction

The Texas Medicaid MCO Report Card Evaluation Survey focuses on the MCO experiences of

new enrollees, the MCO report cards, and the enrollment packet mailed to new enrollees. While

public reporting has the potential to help consumers make informed decisions, little evidence

exists to show the impacts of such reporting. This survey retroactively examines how the

Medicaid enrollees read, understood, and utilized the report cards and how the report cards

impacted their health plan decision-making.

Methodology

The EQRO fielded a pilot study in November and December 2015 and full survey in May and

June 2016. The EQRO collected data using a CATI survey of adults (18 through 64 years old)

enrolled in STAR or STAR+PLUS and caregivers of children (17 years and younger) enrolled in

STAR or CHIP. Members or caregivers of members who were dually eligible for Medicare and

Medicaid were excluded. The EQRO drew four statewide, simple random samples of new

enrollees by program, with 200 targeted completes per quota.

All survey tools included measures on new members’ utilization of the MCO report card, their

process for selecting a health plan, and their experiences with the general enrollment process

for Medicaid/CHIP in the following domains:

• Reasons for joining Medicaid or CHIP

• Reasons for selecting the new health plan

• Recall and understanding of the MCO report card

• Whether and how members or caregivers used the MCO report card


• Ease of understanding the MCO report card

• Usability of the MCO report card

• Relevance of the topics presented on the MCO report card

• Initial satisfaction with the new health plan

• Use of the overall enrollment packet

Results

Across programs, members indicated that the need for general health care coverage was a

major reason for joining Medicaid or CHIP. STAR adult members also selected “other” reasons

and noted pregnancy as one of the main reasons. STAR+PLUS members selected “chronic

medical conditions” and “urgent care” as additional reasons. Across programs, most members

and caregivers thought they made the right decision (74.5 to 90.5 percent) and were either

“satisfied” or “very satisfied” with the health plan they chose (77.6 to 93 percent).

Across programs, roughly half of members or caregivers recalled receiving the MCO report card

in the enrollment packet and four in ten remembered the MCO report card instructions. Across

programs, fewer than one-third of members or caregivers said they used the MCO report card

and one-half of these used the star ratings when deciding on a health plan. One of the main

reasons members and caregivers gave for not using the MCO report card was that they had

already chosen their health plan before receiving the new enrollee package.

Across programs, most members or caregivers who remembered the MCO report cards said the

instructions, topics on the MCO report card, and star ratings were easy to understand; star

ratings were an appropriate way to show how well a health plan was doing; it was easy to

compare health plans; and it was easy to understand the MCO report card overall.

Each report card includes information for particular topics chosen for the population. Fewer than

one-half of respondents who remembered the MCO report cards rated each individual item as

personally relevant, with two exceptions among STAR+PLUS members. Slightly more than one-

half of STAR+PLUS members rated “talking with doctors” and “getting specialist care” as

relevant. Across programs, members and caregivers liked a wide range of MCO report card

aspects. However, a minority of respondents (4.9 to 24.6 percent) specified at least one thing

they did not like about the MCO report cards. In STAR+PLUS, in particular, one-quarter of

members stated that topics they care most about were not presented on the MCO report card,

and 15 percent stated the MCO report card was too complicated to understand.

6.9. Primary Care Provider Referral Pilot Study

Introduction


The purpose of the statewide pilot study was to examine PCPs’ experiences in making referrals

for specialty care for adults and children in STAR. The EQRO examined three research

questions:

1. What barriers do STAR PCPs experience in obtaining specialty referrals for their

Medicaid patients?

2. For which pediatric and adult specialties do STAR PCPs have the most difficulty

obtaining referrals? For these specialties

a. What percentage of PCPs report it is “very difficult” to obtain a specialty referral?

b. What is the average provider-reported time to receive a specialty referral? and

3. To what extent does difficulty or ease in obtaining referrals vary by county-level provider

density?

Methodology

The EQRO conducted a statewide pilot study of a sample of PCPs in the STAR program,

stratified by county-level PCP density groupings. The EQRO defined PCPs as individuals or

facilities listed as family medicine, internal medicine, pediatrics, and/or obstetrics/gynecology

providers in member-facing STAR provider directories. Using information obtained from STAR

enrollment data and STAR provider directories obtained in Fall 2015, the EQRO grouped

counties into three PCP densities.53,54 Table 54 describes the sampling description.

Table 54. Sampling Description, Primary Care Provider Referral Pilot Study

Statewide study

group

Density per

1,000 STAR

enrollees

Counties

(N)

PCPs in

population

(N)

Target

sample of

PCPs

Actual

sample of

PCPs

Low PCP density < 7.0 125 9,059 369 66

Mid PCP density 7.0 to 12.9 67 7,502 365 46

High PCP density > 13.0 36 5,023 357 37

TOTAL Mean: 10.4 228 21,584 1,091 149

The EQRO followed the Dillman Method to collect data, mailing surveys to 1,560 randomly

selected PCPs based on a power analysis; the oversample assumed a 70 percent response

rate, as the EQRO has achieved in other studies.55 The method required five separate points of

contact (initial survey packet, first and second reminder postcard, reminder phone call, final

survey packet).56,57 The EQRO provided a $15 prepaid gift card with the initial mailing in an

attempt to improve response rates. Surveys were returned by mail, email, or fax; or completed

online using a web-based survey tool. The primary survey tool collected basic information about

the provider’s practice, use of health information technology to make referrals, patients, overall

satisfaction and experiences with making specialist referrals for selected conditions, and

barriers to making specialist referrals.


The EQRO calculated descriptive statistics for the variables of interest overall and by PCP

density. The EQRO used chi-square tests to determine significant differences in specialty

referral difficulty according to provider density. The EQRO calculated weights by county-level

PCP density because the sample of PCPs was selected across three groups of county-level

PCP densities (low, mid, high). This weighting ensures that statewide program-level results are

more generalizable to the actual STAR provider population. Results are reported separately for

PCPs that treat pediatric versus adult patients. When a PCP treated both, the EQRO included

them in both analyses.

Results

A total of 192 providers returned a survey out of 1,560 surveys mailed. Of these, 149 were

PCPs who indicated a current relationship with one or more Medicaid MCOs. Due to the

EQRO’s inability to fully assess which providers declined to participate, which providers did not

receive a survey, and which were not eligible(e.g., not participating in STAR, not a PCP, not in

the MCO network), an accurate response rate could not be calculated. The EQRO encountered

low PCP responses due to limitations of the directories, including incorrect or outdated contact

information, PCPs who were no longer participating in Medicaid, and some providers who were

not PCPs. Due to the volume of returned letters and lower-than-expected participation, the

EQRO attempted to telephone 1,216 sampled providers to obtain updated addressor alternative

contact information; many PCPs requested surveys via e-mail or fax instead of mail. PCPs who

participated were located in 13 service areas (SAs), contracted with 19 MCOs, and represented

different settings (e.g., family practice, group practice) and facility types and sizes. However,

small and generally unequal sample sizes make it impractical to draw further comparisons.

Provider process satisfaction ratings

The EQRO assessed provider satisfaction with three processes related to making specialty

referrals – credentialing, prior authorization, and payment timeliness—on a scale of 1 (very

dissatisfied) to 5 (very satisfied). Table 55 shows the percentage of PCPs who rated their

satisfaction with each process as a “4” or “5”, separately for specialty referrals for children and

adults.


Table 55. Provider Process Satisfaction Ratings of “4 or 5” (Weighted Percentages)

Referral processes Pediatric Patients Adult Patients

Credentialing 55.7% 57.1%

Prior authorization 42.0% 38.2%

Payment timeliness 64.2% 61.7%

Barriers experienced by PCPs in obtaining specialty referrals

Table 56 lists the top four barriers in obtaining specialty referrals reported by PCPs working with

pediatric and/or adult patients.

Table 56. Top Four Specialty Referral Barriers Reported by PCPs with Pediatric and Adult Patients (Weighted Percentages)

Barriers Pediatric Patients Adult Patients

Number or quality of

participating specialists

38.6% 29.4%

Searching for or identifying

available specialists

16.4% 11.4%

Referral process or

insurance coverage

12.3% 5.0%

Distance to specialist 10.6% 6.1%


Specialties reported by PCPs as “very difficult” for obtaining referrals

Among pediatric providers, specialists for whom PCPs found it “very difficult” to obtain referrals

included “other” pediatric mental health conditions (45.2 percent), learning disabilities

(34.4 percent), and developmental specialists (30.2 percent). Across all specialties, pediatric

providers reported an average wait time of 25 days (range from 6.4 days to 45 days). All results

are weighted.

Among adult providers, specialists for whom PCPs found it “very difficult” to obtain referrals

included adult mental health conditions (48.4 percent) and adult Type I or Type II diabetes

(19.9 percent). Across all specialties, adult providers reported an average wait time of 18.3 days

(range from 9.4 days to 34.2 days).

To what extent does difficulty or ease in obtaining referrals vary by county-level provider

density?

The EQRO re-categorized referral difficulty variables as a binary variable such that 0 = ‘easy

referral’ (combining ‘very easy’ or ‘somewhat easy’), and 1 = ‘difficult referral’ (combining ‘very

difficult’ or ‘somewhat difficult’). The EQRO tested 11 pediatric specialties and 7 adult

specialties. Only pediatric attention deficit hyperactivity disorder specialist referrals by PCP

density showed a significant difference (p=0.02), with more PCPs in low density areas reporting

“difficult referrals” (Table 57).

Table 57. Pediatric Attention Deficit Hyperactivity Disorder Specialist Referrals by PCP Density (Weighted Percentages)

County-level density Easy referral Difficult referral

Low density 19.1% 80.9%

Mid density 46.9% 53.1%

High density 44.4% 55.6%


7. Fiscal Year 2016 Findings and Recommendations

This section provides the EQRO’s findings and recommendations by: (1) Access to and

Utilization of Care, (2) Effectiveness of Care, and (3) Satisfaction with Care.

7.1. Access to and Utilization of Care Recommendations

Finding 1: Well-Child Visits: Across programs, the rate of W34 was at least 80 percent. In

STAR Health, Texas is in the 90th percentile or higher for W34 and in the 66th to 89th percentiles

for STAR and CHIP. There was variability in the W34 rates across health plans. In STAR, the

W34 rate ranged from 66.4 percent for Scott & White Health Plan to 86.2 percent for

UnitedHealthcare. In CHIP, the W34 rate ranged from 66 percent for Blue Cross Blue Shield of

Texas to 85.9 percent for El Paso First Health Plan. Alternatively, the rates for W15 was

considerably lower across programs: 54.7 percent for STAR and 60.2 percent for STAR Health.

In STAR, the rates ranged from 45.6 percent for Blue Cross Blue Shield of Texas to 68.2

percent for Driscoll Health Plan.

Recommendation 1: Despite Texas performing well in the W34 measure, efforts should

be made to implement PIPs, particularly among the lower performing MCOs, to address

W34 the 90th percentile or higher in STAR and CHIP relative to Medicaid managed care

plans nationally that report to NCQA. Strategies that the better-performing MCOs are

using should be shared with the lower performing MCOs. The lower-performing MCOs

should conduct a root-cause analysis or create driver diagrams and examine whether

the strategies used by the higher-performing MCOs might be helpful for their members.

Recommendation 2: In 2014, UnitedHealthcare was the only MCO to have a PIP to

address W15 rates. In 2017, eight MCOs have PIPs to address W15 rates for CHIP and

STAR. Efforts should be made to monitor the W15 rates once these PIPs are

implemented.

Recommendation 3: HHS and the MCOs should explore methods to increase the

validity of their member-facing directories. Increasing the accuracy of the directories will

assist members in identifying providers and explore if they improve the W34 and W15

rates.

Rationale 1: In the appointment availability and the PCP referral pilot study, the

EQRO found many instances of inaccurate directories. For example, in the

Appointment Availability, PCP sub-study, nearly one-quarter (24.4 percent) of

providers called stated that they were not a PCP. An additional 9.0 percent

stated they did not accept Medicaid while 6.0 percent stated they did not accept

the health-plan named during the call.

Finding 2: Prenatal and Post-Partum Care: Within the STAR program, Texas overall has a

Prenatal and Postpartum Care rate of 87.8 percent for timeliness of prenatal care, which is

around 76th percentile nationally (Table 10). While the rate for STAR prenatal care was 87.8

percent, the rates for STAR+PLUS and STAR Health were considerably lower (64.3 percent

and 63.6 percent respectively). The Prenatal and Postpartum Care rate demonstrates variability


across programs. Additionally, less than a quarter of STAR members (23.6 percent) participated

in in high-risk obstetric programs, and even fewer CHIP members (6.8 percent) participated.

Recommendation 1: HHS and the MCOs should explore methods to address barriers

to prenatal care across the programs. HHS could identify the best practices used in

STAR MCOs and share these with lesser-performing MCOs.

Rationale 1: In a study of Medicaid managed care enrollees in Massachusetts

using the HEDIS PPC measure, people with disabilities and/or those who had a

diagnosis of substance abuse or dependence had decreased odds of receiving

timely prenatal care.58 For children in foster care, external factors, such as what

role the foster parents play and what services are covered under Medicaid, might

limit the rates for prenatal care for foster children and should be explored.59

Recommendation 2: HHS and the MCOs could explore the barriers to participating

high-risk prenatal care management. Increased participation in the programs could

improve the quality of care and medication management.

Rationale 1: Results from the 2014 PIPs could have been used to develop 2016

and 2017 PIPs. However, in 2014, there were no PIPs that addressed barriers to

prenatal and postpartum care. For STAR+PLUS and for STAR Health, there

were no PIPs addressing prenatal and post-partum care in 2014. Further none

were planned for 2016 or 2017.

Finding 3: Substance Use and Behavioral Health-Related Access to Care For Texas

overall, access to substance use and BH related access to specialty care has varied by

program. The rates for IET and APP varied by program and MCO. The rates for IET ranged

from 36.5 percent for STAR+PLUS to 57.2 percent for STAR Health. The rates for APP ranged

from 32.9 percent for STAR+PLUS to 91.5 percent for STAR Health. While the IET rates were

lowest for STAR+PLUS members, the participation rates for mental and BH programs was

highest in STAR+PLUS (41.6 percent) and lower for STAR and CHIP members (9.4 percent

and 2.1 percent respectively).

Recommendation 1: HHS and the MCOs should explore ways to increase access to

behavioral and specialty health care for IET overall and for APP in STAR+PLUS. A

positive step includes the development of PIPs addressing BH that will be implemented

in 2017.

Rationale 1: In the PCP referral study, PCPs identified BH specialists as the

most difficult specialty to access when making patient referrals. PCPs identified

the following barriers when making BH specialty referrals: number or quality of

participating specialists, the search for or identification of available specialists,

the referral process involved with the MCO, and distance to specialist (Table 56).

Rationale 2: The overall compliance for BH care in the Appointment Availability

study varied from 65.4 percent for STAR child members to 79.4 for STAR+PLUS

members (


Table 51).

Rationale 3: In 2014, there were no PIPs in place to address the IET rates.

However, in the 2017 PIP topics, five MCOs have a BHPIP for either STAR or

CHIP. From the AI, 20 of the 22 MCOs stated they had a BH component. The

MCOs also stated that the limited number of behavioral specialists, especially in

the rural service areas, was one of their primary barriers to BH care access. The

EQRO recommends carefully assessing the extent to which the PIP interventions

correspond to evidence-based best practices for improving BH care particularly

as it relates to the IET and APP measures. In addition, the interventions should

be carefully reviewed in terms of their potential effectiveness to improve access

to care in rural areas.

Recommendation 2: HHS and the MCOs could explore the barriers to participating in

the BH management programs. Increased participation in the programs could improve


Finding 4: Occurrence of Potentially Preventable Events: The trends for the rates of PPEs

varied by program. The majority of PPE reasons have remained constant since 2014. The

health plans have had PIPs addressing the PPEs since 2014.

Recommendation 1: HHS and the MCOs should explore why the PPE rates have

leveled off and explore the implications of having the PPEs level off.

Rationale 1: While the rates of some PPEs in STAR have steadily declined, the

rate of weighted PPVs has remained relatively stable since 2012. While the

stability in and of itself may not be indicative of a health care quality concern, the

MCOs and HHS should examine the reasons for the PPVs to determine if further

improvements can be made.

Recommendation 2: HHS and the MCOs should explore and monitor possible reasons

for different PPE rates by race and age.

Rationale 1: In 2014, HHS and the health plans have already developed PIPs to

address PPA and PPV rates. By monitoring the success of these PIPs, HHS and

the health plans can modify the PIPs to improve equity by demographic status.

Rationale 2: In STAR, the weighted PPV rate varied by race from 11.85 for

White, non-Hispanic to 4.95 for Asian. The weighted PPA rate increased by age

group in STAR.

7.2. Effectiveness of Care Recommendations

Finding 1: Asthma: Since 2012, the rates for MMA and the AMR has remained relatively stable

or decreased despite the fact that health plans listed asthma as the second most common topic

among PIPs in 2014. Moreover, asthma remains a leading reason for PPA within STAR and

CHIP warranting further exploration about ways to improve asthma care. Compounding the high

rates of asthma PPAs is that member participation in asthma programs ranged from 52.6

percent in STAR+PLUS to 14.9 percent in CHIP.


Recommendation 1: In STAR, despite the fact that Texas is rated within the 66th and

89th percentile nationally for AMR, efforts should be made to increase the rates for MMA.

Rationale 1: In STAR since 2013, the rate of medication management has

increased by 1 percent, while the AMR has increased to 68.8 percent after falling

to 60.9 percent in 2014. While the improvement in the AMR is noteworthy,

asthma-related PPAs represent an opportunity to continue to develop

interventions to improve asthma care.

Rationale 2: The number one PPA reason for STAR and CHIP in 2015 was

asthma (Table 13). In 2017, only three MCOs have asthma as a PIP topic:

Driscoll and Texas Children’s have a PIP for CHIP and Scott & White and Texas

Children’s have a PIP in STAR that address asthma.

Recommendation 2: In addition, efforts should be made to determine barriers to

members enrolling in the Asthma Disease Management Programs. It is possible that

enrollment in these programs might improve medication management.

Finding 2a: Mental Health Follow-Up After Hospitalization: The rates for mental health

follow-up vary by program. For at-risk populations in the STAR+PLUS and STAR Health

programs, the rates of FUH are lower than in 2011. Additionally, the rate for FUH varied by

program and MCO. For example, the STAR overall FUH rate within 30 days was 56.0 percent

and for STAR+PLUS was 48.9 percent. Within program rates also varied. In STAR, the rates for

FUH ranged from 32.4 percent for CHRISTUS to 71.2 percent for Blue Cross Blue Shield of

Texas. Of note, three MCOs have a PIP for STAR to address follow-up, and Superior has a PIP

in place for STAR Health.

Finding 2b: Mental Health-Related Potentially Preventable Admissions and

Readmissions: Bipolar disorders and major depressive disorders accounted for at least 12

percent of the PPAs in 2015. Additionally, readmission for mental health or substance abuse

following an initial admission for mental health or substance abuse accounted for nearly one-

third of PPR reasons in 2015 (Table 14). As noted above, participation in behavioral disease

management programs was below 50 percent across all programs.

Recommendation 1: HHS and MCOs should explore how to expand the current

programs/practices for community-based mental health treatment and counseling to

reduce the number of members with PPAs and PPRs and to improve follow-up after an

inpatient mental health stay. In addition, MCOs should explore barriers to participation in

the BH management disease programs.

Rationale 1: From the AIs, only eight of 19 MCOs reported having a follow-up

protocol in place post BH care encounters. Some examples of MCO follow-up

protocols include: getting medication, following discharge instructions, making

sure the members follow up with their PCP, and facilitating communication

between the member and care coordinator.


7.3. Satisfaction with Care Recommendations

Finding 1: Coordination of Care: The rate for member satisfaction with care coordination has

varied by program. In STAR+PLUS there was a steady increase for Medicaid-only (from 51.6

percent to 60.9 percent) and dual-eligible members (58.6 percent to 72.6 percent) from 2012 till

2016. In STAR there was an increase in the rate of satisfaction with care coordination then a

slight decrease from 2014 to 2016. In STAR Health from 2012 to 2016 there was relatively no

change in the rate of care coordination satisfaction.

Recommendation 1: Because of the overall increase in satisfaction of care

coordination, HHS and the MCOs should explore evidenced base best practices that can

be implemented in lower performing MCOs.

Rationale 1: For example, Cook Children Health Plan uses a multidisciplinary,

culturally diverse team model that consists of a registered nurse, social workers,

BH case manager, and certified community health workers to coordinate BH

care.

Recommendation 2: HHS should continue gathering data and report on the findings for

the culturally competency items, from the CAHPS measures in the member surveys as a

means to improve care coordination.

Rationale 1: HHS has been proactive in collection of cultural competency data.

HHS is already collecting data on: (1) if the member feels they are being treated

unfairly because of their race/ethnicity, (2) type of health insurance (such as

Medicaid), and (3) whether or not the member speaks English.


8. Appendices

8.1. Managed Care Expansion Since SB 7

September 2011

STAR expanded into an additional 28 counties contiguous to six of the then-current Medicaid managed care service areas. STAR+PLUS expanded into 21 counties contiguous to six of the then-current Medicaid managed care service areas.

March 2012

STAR expanded to cover areas formerly served by the Primary Care Case Management program. STAR, STAR+PLUS, and CHIP began covering pharmacy benefits. Most children and young adults in Medicaid began receiving dental benefits through managed care.

March 2014 Cognitive rehabilitation therapy added to the STAR+PLUS Home and Community-Based Services waiver service array.

September 2014

STAR+PLUS expanded statewide and began offering acute-care services for individuals with an intellectual disability or related condition. Adults with disabilities transferred from STAR to STAR+PLUS for basic medical services, LTSS, and service coordination. Adults enrolled in Community-Based Alternatives, Primary Home Care, and Day Activity Health Services began receiving care through STAR+PLUS health plans.

March 2015 Nursing facility services integrated into STAR+PLUS.

November 2016 STAR Kids60 begins providing acute and community-based medical assistance benefits to children and young adults with disabilities.

December 2016 NorthSTAR ceased operations. Members receiving BH services in the Dallas service area migrated to other programs.


8.2. HHS Performance Indicator Dashboard Standards

The EQRO calculated recommendations for performance standards in 2017 using the same

methodology employed in 2016. For administrative measures, the EQRO determined

recommendations in each program by comparing the state mean for each to NCQA HEDIS®

percentiles. The EQRO determined which NCQA HEDIS® percentile band each measure

performance occupied. The recommendation for the comparison standard for each measure for

2016 used the more stringent of the rounded higher bound of this band or the 50th percentile

benchmark. NCQA HEDIS® provides mean and 5th, 10th, 25th, 33rd, 50th, 66th, 75th, 90th,

and 95th percentiles for benchmark comparisons. In cases where the state mean was higher

than the 95th percentile, the EQRO used the 95th percentile as the recommended comparison

standard. Because there are no national standards for AHRQ PDI and PQI measures, the

recommended comparison for each program was five percent less than the state mean for each

measure. If the calculated standard for 2017 fell below the standard set for 2016, the EQRO

retained the previous year’s standard. For all administrative 2016 P4Q measures, the EQRO

listed incremental improvement goals separately in Chapter 6.2. The EQRO calculated 12 of the

Uniform Managed Care Manual (UMCM) with the P4Q documentation for 2016 standards as if

each measure was new to the dashboard to account for changes made by the MCOs to reach

P4Q goals. Therefore these measures were not compared to the most recent 2015 standards.

For survey measures, recommendations are determined for each program by comparison to

AHRQ CAHPS® percentiles. As with administrative measures, the EQRO compared the

statewide mean to the AHRQ CAHPS® percentile bands for top box reporting (proportion of

respondents answering "always" on a never-to-always scale) or the proportion of respondents

rating each category as 9 or 10 on a 0 to 10 scale. The next percentile band upper bound is the

recommended standard for 2017. AHRQ CAHPS® provides the percentiles for comparison

benchmarks. As with administrative measures, all standards were set no lower than the 50th

percentile. In cases where the statewide mean was higher than the 95th percentile, the 95th

percentile threshold was used as the recommended comparison. For measures where no

national benchmark is available, the EQRO calculated the standard by taking the statewide rate

and increasing it by five percent (multiplying statewide performance by 1.05). As with

administrative measures, if the calculated standard for 2017 fell below the standard set for

2016, the EQRO retained the previous years.

The recommended comparison for all components of HEDIS® ADV measure was the 95th

percentile benchmark for Medicaid Dental with the exception of measures in which the previous

year’s standard was more stringent. ADV will be a P4Q measure for CHIP Dental. The

incremental improvement goal will be listed with the P4Q documentation in Chapter 6.2.13 of

the UMCM. Cost and utilization measures were calculated for monitoring purposes only and not

assigned a standard. The Medicaid Dental measure “% of members (1 year - 20 years)

receiving more than two THSteps Dental Checkups per year” was likewise not assigned a

standard. Because there is no AHRQ CAHPS® range for the dental satisfaction survey

measure, the recommended standard was calculated by taking the score of the highest

performing dental plan and increasing the rate by five percent (multiplying score by 1.05). For


other measures, the standard was calculated by taking the score of the highest performing

dental plan and increasing the rate by five percent (multiplying score by 1.05). As with all other

recommendations, if the calculated standard for 2017 fell below that the set for 2016, the

previous year’s was retained. However, as with administrative P4Q measures, the 2017

standard was calculated as if a new measure and not compared to the most recent 2015

standard to account for changes made by the MCOs.

8.3. Quality-of-care Administrative and Hybrid Measures

8.3.1. HEDIS® 2016

The EQRO calculated rates for HEDIS® measures using NCQA-certified software. Results are

based on administrative data only, with the exception of the hybrid HEDIS® measures, for which

audited rates were provided by individual Medicaid and CHIP health plans. The statewide

(program-level) rates reflect the total program population eligible for the administrative

measures. The statewide rates for the hybrid measures are weighted averages based on the

eligible population for each measure. Statewide rates are not available for certain hybrid

measures where MCOs rotated measures (i.e., used prior-year results, following NCQA

specifications).


Table 58 lists the HEDIS® hybrid measures calculated using calendar year 2015 data.

Table 58. HEDIS® Hybrid Measures, 2015

Measure STAR STAR+PLUS CHIP STAR Health

Adult BMI Assessment

Adolescent Well-Care

Controlling High Blood Pressure (<140/90)

Comprehensive Diabetes Care, HbA1c Testing

Comprehensive Diabetes Care, HbA1c Control (<8%)

Childhood Immunization Status

Prenatal and Postpartum Care, Timeliness of Prenatal Care

Prenatal and Postpartum Care, Postpartum Care


Weight Assessment and Counseling in Children

Results for the HEDIS® measures calculated by the EQRO are compared to benchmark

percentiles gathered and compiled by NCQA from Medicaid managed care plans nationally.

These reported rates combine administrative and hybrid results, reflecting a mix of different

methodologies. Limited information is available about the health and sociodemographic

characteristics of members enrolled in Medicaid plans nationally. Submission of HEDIS® data to

NCQA is a voluntary process; therefore, MCOs that submit HEDIS® data may not be fully

representative of the industry. Health plans participating in NCQA HEDIS® reporting tend to be

older, are more likely to be federally qualified, and more likely to be affiliated with a national

managed care company than U.S. MCOs overall NCQA calculates national means and

percentiles for HEDIS® measures and licenses the resulting benchmark thresholds through the

Quality Compass® database.lxxii Tables in this report presenting results on HEDIS® measures

include a percentile rating comparing calendar year 2015 program-level rates with the NCQA

national HEDIS® 2016 Medicaid percentiles. The rating system is as follows:

= 90th percentile and above

= 66th to 89th percentile

= 33rd to 65th percentile

= 10th to 32nd percentile

= Below 10th percentile

8.3.2. AHRQ Pediatric Quality Indicators and Prevention Quality Indicators

Table 59 describes the full set of adult PDIs and PQIs includes rates of inpatient admissions.

lxxii Quality Compass is a registered trademark of NCQA.


Table 59. AHRQ Pediatric Quality Indicators and Prevention Quality Indicators

Quality Indicator STAR CHIP STAR+PLUS

STAR Health

Pediatric Quality Indicator

Asthma admission rate

Diabetes short-term complications admission rate

Gastroenteritis admission rate

Perforated appendix admission rate

Urinary tract infection admission rate

Prevention Quality Indicator

Diabetes, short-term complications admission rate

Perforated appendix admission rate

Diabetes long-term complications admission rate

Chronic obstructive pulmonary disease or asthma in older adults admission rate

Hypertension admission rate

Heart failure admission rate

Low birth weight admission rate

Dehydration admission rate

Bacterial pneumonia admission rate

Urinary tract infection admission rate

Uncontrolled diabetes admission rate

Asthma in younger adults admission rate

Lower-extremity amputation among patients with diabetes rate

8.3.3. 3M™ Health Information Systems measures

The 3M measures of PPEs evaluate health outcomes, safety, efficiency, and utilization rates,

and the costs associated with potentially avoidable care. The EQRO calculated performance

across all MCOs participating in the program on PPE measures, using 3M™ Health Information

Systems software. These events were: hospital admissions, readmissions within 30 days,

emergency department visits, complications, and ancillary services. The PPE measures assess

the frequency and cost of visits that might have been prevented with better primary and

outpatient care. Of course,, not all events classified as potentially preventable will have been

so.so Program-level rates are expressed as the weighted actual number of visits per 1,000

member-months, with lower rates indicating better performance. Weights are assigned based

on resource utilization to account for different PPEs and their health system impacts. Events

requiring more health care resources (e.g., hospital bed-hours) are weighted more heavily.


Actual-to-expected ratios are calculated so a health plan that sees fewer PPEs than the

program as a whole will have a ratio of less than one, while a plan with more PPEs than its

overall its overall program will have a ratio greater than one. To ensure statistical validity and

interpretability of results, health plans seeing too few actual or expected PPEs or admissions at

risk are not reported here.

PPAs and PPVs, focus on events caused by inadequate access to care or poor coordination of

care. PPRs focus on events caused by deficiencies or errors in care or treatment provided

during a hospital stay or from inadequate post-hospital discharge follow-up.

PPAs involve ambulatory-sensitive conditions, including a more comprehensive definition than

the list maintained by AHRQ. They are identified primarily from the reason for admission as

documented using the assigned All Patient Refined Diagnosis-Related Groups (APR-DRGs).

Results are risk-adjusted based on the health status of members in the population as defined by

CRG.

PPRs are return hospitalizations caused by deficiencies in the care during the initial hospital

stay or poor coordination of services at the time of discharge and during follow-up. The

readmission must be clinically related to the initial admission (based on APR-DRG), and occur

during the defined readmission period. For quality-of-care reporting, the EQRO used a 30-day

readmission interval. Because not all admissions have the same risk of readmission, results are

risk-adjusted based on the APR-DRG of the initial admission.

PPVs account for conditions that could be treated effectively with adequate patient monitoring

and follow-up. They are identified using the Enhanced Ambulatory Patient Grouping assigned

by the 3M software to the emergency department encounter. Results are risk-adjusted based on

the health status of members in the population as defined by CRG.

PPCs are harmful events that occur after a patient is admitted. These include Medicare hospital-

acquired conditions,lxxiii Medicaid health care-acquired conditions,lxxiv and other patient safety

indicators. They are assigned based on secondary diagnoses that were not present on

admission, and determined to be preventable based on the initial condition and procedures. The

results are risk-adjusted based on the APR-DRG assigned to the admission.

While any particular event identified as potentially preventable may or may not actually have

been, high numbers of PPEs can indicate deficiencies in quality of care. Resource use related

to these events is also important, and includes consideration of the relative weight of different

events. For this reason, the EQRO reports all five types of measures using relative weights,

which are based on standardized costs associated with the APR-DRG for potentially

preventable admissions and readmissions, the Enhanced Ambulatory Patient Grouping for

PPAs and the assigned category for PPCs.

Assessment of performance on these measures at the health plan level uses the actual-to-

expected ratio, which represents the number of actual visits relative to the number of visits that

lxxiii A list of hospital-acquired conditions can be found at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html lxxiv A list of health care-acquired conditions can be found at: http://www.medicaid.gov/medicaid-chip-program-information/by-topics/financing-and-reimbursement/provider-preventable-conditions.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/financing-and-reimbursement/provider-preventable-conditions.html

http://www.medicaid.gov/medicaid-chip-program-information/by-topics/financing-and-reimbursement/provider-preventable-conditions.html


would be expected based on the case-mix of the health plan membership. An actual-to-

expected ratio less than 1 means there were fewer than expected preventable events, while a

ratio greater than 1 means there were more than expected.


8.4. MCO Report Card Item Definitions

The definition of each item varied slightly among programs to account for data availability and

relevance to the different populations:

Getting Timely Care used both components of the CAHPS® Getting Care Quickly composite

for the STAR Child, CHIP, and STAR+PLUS report cards, and only the access to routine

non-emergent care component for the STAR Adult MCO report cards.

Getting Needed Care used both components of the CAHPS® Getting Needed Care

composite for the STAR+PLUS report cards, and only the access to routine non-specialist

care component for the STAR Adult MCO report cards.

Talking with Doctors used the components of the CAHPS® How Well Doctors Communicate

composite for STAR Child, CHIP, and STAR+PLUS.

Personal Doctor Rating used the CAHPS® Rating of Personal Doctor individual item, with

positive responses taken as rating a member or child's personal doctor as 9 or 10 on a 0-10

scale.

Health Plan Rating used the CAHPS® Rating of Health Plan individual item, with positive

responses taken as rating a member or child's health plan as 9 or 10 on a 0-10 scale.

Checkups for Infants used HEDIS® W15.

Checkups for Children and Teens used an equally weighted composite of HEDIS® W34 and

HEDIS®AWC.

Checkups for Adults used HEDIS® Adults' Access to Preventive / Ambulatory Health

Services.

Asthma used the quality index component of HEDIS® Relative Resource Use for People with

Asthma, including HEDIS® Use of Appropriate Medications for People with Asthma, All

Ages, HEDIS®MMA, and HEDIS®AMR.

Attention Deficit Hyperactivity Disorder used HEDIS® ADD, Initiation Phase.

Prenatal Care used HEDIS® Prenatal and Postpartum Care, Timeliness of Prenatal Care.

New Mother Care used HEDIS® Prenatal and Postpartum Care, Postpartum Care.

Breast Cancer Screening used HEDIS® Breast Cancer Screening.

Cervical Cancer Screening used HEDIS® Cervical Cancer Screening.

Chronic Obstructive Pulmonary Disease used the quality index component of HEDIS®

Relative Resource Use for People With COPD, including both components of HEDIS®

Pharmacotherapy Management of COPD Exacerbation and HEDIS® Use of Spirometry

Testing in the Assessment and Diagnosis of COPD.

Depression used an equally weighted composite of both components of HEDIS®

Antidepressant Medication Management.

Diabetes used four measures in the quality index component of HEDIS® Relative Resource

Use for People With Diabetes: HEDIS® CDC, HbA1c Testing, HEDIS®CDC, HbA1c Control

(<8%). HEDIS® CDC, Eye Exams, and HEDIS® CDC, Medical Attention for Nephropathy.

Overall Performance Rating was a weighted composite measure calculated using a subset

of those used by NCQA to calculate Health Insurance Plan Ratings, including survey,

administrative, and hybrid measures. Measures were chosen for each of the four report

cards according to importance to the population, HHS priorities, and data availability.


Weighting followed NCQA Health Insurance Plan Ratings methodology: 1 point for process

measures, 1.5 points for patient experience measures, and 3 points for outcome

measures.61 Stars were assigned according to relative performance as with the other items

on the report cards.


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12 The set of HEDIS® measures run for STAR Health was more limited than the set run for STAR and CHIP. The following quality-of-care measures, which may be applied to children, were not run for STAR Health on calendar year 2015 data: Inpatient Utilization–General Hospital/Acute Care. Additionally, the following measures were run using only administrative data without supplementation with medical records to calculate a hybrid rate, and are not reported here: Childhood Immunization Status, Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents.

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15 Please note, the results of the PIPs will be reported in the addendum to this report. There are four sets of PIPs discussed in this report and the addendum: 1) the 2-year, 2014 PIPs, which started in January 2014 and continued through December of 2015; 2) the 3-year, 2014 PIPs, which started in January 2014 and continued through December 2016; 3) the 2016 PIPs, which started in January 2016 and will continue through December 2017; and 4) the 2017 PIPs, which started in January 2017 and will continue through December 2019. The 2-year and staggered implementation of the PIPs and allows the opportunity to evaluate and assess outcomes over time while still being able to initiate new PIPs to address opportunities for improvement that are identified through the evaluation of performance measurement.

16 The EQRO’s encounter data validation studies were conducted on an annual basis until 2012, at which time they shifted to a biennial schedule.

17 CMS (2012). Available at: https://www.medicaid.gov/medicaid/quality-of-care/downloads/eqr-protocol-3.pdf

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23 Texas HHS. 2008.

24 CMS. 2012. Preview of Nursing Home Quality Assurance & Performance Improvement (QAPI) Guide – QAPI at a Glance. Available at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-05.pdf.

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26 CMS. 2012.

27 CAHPS® specifications indicate 300 completed surveys per comparison group. To ensure feasibility of large-scale surveys in STAR and CHIP, the external quality review organization determined that 250 completed surveys per comparison group would allow for reliable comparisons among the health plans.

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29 CDC. 2015. Behavioral Risk Factor Surveillance System. Available at: https://www.cdc.gov/brfss/questionnaires/pdf-ques/2015-brfss-questionnaire-12-29-14.pdf.

30 Urban Institute. 2008. National Survey of America’s Families. Available at: http://www.urban.org/center/anf/nsaf.cfm.

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33 AHRQ 2016.

34 AHRQ 2016.

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36 CMS. 2008. Quick Facts about Programs of All-Inclusive Care for the Elderly (PACE). CMS Publication No. 11341. Available at: http://www.npaonline.org/sites/default/files/PDFs/PACE Quick Facts.pdf.

37 Eggbeer, B., Bowers, K., & Morris, D. 2013. Dual-eligible reform: a step toward population health management. Healthcare Financial Management: Journal of the Healthcare Financial Management Association, 67(4): 90-4.

38 Wieland, D., Kinosian, B., Stallard, E., & Boland, R. 2013. Does Medicaid pay more to a program of all-inclusive care for the elderly (PACE) than for fee-for-service long-term care? The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 68(1): 47-55.

39 Chatterji, P., Burstein, N., Kidder, D., & White, A. J. 1998. Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) Demonstration: The Impact of PACE on Participant Outcomes. Cambridge, MA: Abt Associates Inc.

40 The 2015 NCI-AD survey also included a quota for members in the Older Americans Act (OAA). The EQRO excluded completed surveys in the OAA quota from this secondary data analysis.

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41 Schwertner et al, 2015.

42 Texas HHS. 2016. “Uniform Managed Care Terms & Conditions.” Available at: https://hhs.texas.gov/sites/hhs/files/documents/services/health/medicaid-chip/programs/contracts/uniform-managed-care-contract.pdf.

43 Federal Register. 2015. “Medicaid program: Methods for assuring access to covered Medicaid services.” Available at, https://www.federalregister.gov/articles/2015/11/02/2015-27697/medicaid-program-methods-for-assuring-access-to-covered-medicaid-services.

44 Federal Register. 2016. “Medicaid and CHIP Managed Care Final Rule.” Available at, https://www.federalregister.gov/articles/2016/05/06/2016-09581/medicaid-and-childrens-health-insurance-program-chip-programs-medicaid-managed-care-chip-delivered

45 Federal Register, 2016.

46 Federal Register, 2015.

47 Levinson, D.R. 2014. Access to Care: Provider availability in Medicaid Managed Care. HHS – Office of Inspector General. OEI-02-13-00670. Available at: http://oig.hhs.gov/oei/reports/oei-02-13-00670.pdf.

48 Steinman, K.J., Kelleher, K., Dembe, A.E., Wickizer, T.M., & Hemming, T. 2012. “The use of a "mystery shopper" methodology to evaluate children's access to psychiatric services.” Journal of Behavioral Health Services & Research 39(3):305–313.

49 Texas HHS. 2017. Uniform Managed Care Contract – Version 2.22. Available at: https://hhs.texas.gov/sites/hhs/files/documents/services/health/medicaid-chip/programs/contracts/uniform-managed-care-contract.pdf.

50 Steinman,K.J., Kelleher,K., Dembe, A.E.,Wickizer , T.M., & Hemming,T. 2012. “The use of a "mystery shopper" methodology to evaluate children's access to psychiatric services.” Journal of Behavioral Health Services & Research 39(3):305–313.

51 Levinson. 2014.

52 NCQA. (2016). NCQA Health Insurance Plan Ratings Methodology. Available at: https://www.ncqa.org/Portals/0/Report%20Cards/Health%20Plan%20Ratings/HPR%202016%20Methodology%20Overview.pdf?ver=2016-08-02-150340-867.

53 The EQRO calculated grouping cutoffs in ArcGIS using the geometric interval method.

54 The pilot study groupings exclude counties with a STAR PCP density of 0 per 1,000 members, as these counties cannot be included in a PCP provider survey. The groupings also exclude: (1) clinics in the member-facing directories for which no named PCPs were also listed, and therefore the number of PCPs in the clinic could not be estimated (< 1 percent of all unduplicated STAR PCPs); and (2) providers whose addresses could not be geocoded to a street (6 percent of all unduplicated STAR PCPs).

https://hhs.texas.gov/sites/hhs/files/documents/services/health/medicaid-chip/programs/contracts/uniform-managed-care-contract.pdf


https://www.federalregister.gov/articles/2015/11/02/2015-27697/medicaid-program-methods-for-assuring-access-to-covered-medicaid-services

https://www.federalregister.gov/articles/2015/11/02/2015-27697/medicaid-program-methods-for-assuring-access-to-covered-medicaid-services

https://www.federalregister.gov/articles/2016/05/06/2016-09581/medicaid-and-childrens-health-insurance-program-chip-programs-medicaid-managed-care-chip-delivered

https://www.federalregister.gov/articles/2016/05/06/2016-09581/medicaid-and-childrens-health-insurance-program-chip-programs-medicaid-managed-care-chip-delivered

http://oig.hhs.gov/oei/reports/oei-02-13-00670.pdf



https://www.ncqa.org/Portals/0/Report%20Cards/Health%20Plan%20Ratings/HPR%202016%20Methodology%20Overview.pdf?ver=2016-08-02-150340-867

https://www.ncqa.org/Portals/0/Report%20Cards/Health%20Plan%20Ratings/HPR%202016%20Methodology%20Overview.pdf?ver=2016-08-02-150340-867


55 Bynum SA, Stars SA, Malo T, Giuliano AR, Shenkman E, Vadaparampil ST. 2013. “Factors

Associated with Medicaid Providers’ Recommendation of the HPV Vaccine to Low-Income Adolescent Girls.” Journal of Adolescent Health. PMCID: PMC3946969.

56 Messer BL, Edwards ML, Dillman DA, TECHNICAL REPORT 12-001, January 2012. Determinants of Item Nonresponse to Web and Mail Respondents in Three Address-Based Mixed-Mode Surveys of the General Public. Available at: http://www.sesrc.wsu.edu/dillman/papersweb/2012.html.

57 Messer BL, Dillman DA. “Surveying the General Public Over the Internet Using Address-Based Sampling and Mail Contact Procedures.” 2011. Public Opinion Quarterly 75(3):429-57.

58 Weir, S; Posner, H., Zhang, J.; Willis, G.; Baxter, J.; & Clark, R.; Predictors of Prenatal and Postpartum Care Adequacy in a Medicaid Managed Care Population, Women's Health Issues, Volume 21, Issue 4, July–August 2011, Pages 277-285.

59 Moore, K. (2012). Pregnant in foster care: Prenatal care, abortion, and the consequences for foster families. Columbia Journal of Gender and Law. 23(1). 29-64.

60 Texas HHS. 2016. Texas Medicaid and CHIP STAR Kids Overview. Available at: https://hhs.texas.gov/services/health/star-kids.

61 NCQA 2015.

http://www.sesrc.wsu.edu/dillman/papersweb/2012.html

http://heinonline.org/hol-cgi-bin/get_pdf.cgi?handle=hein.journals/coljgl23&section=6

http://heinonline.org/hol-cgi-bin/get_pdf.cgi?handle=hein.journals/coljgl23&section=6

https://hhs.texas.gov/services/health/star-kids

Documents

Texas Medicaid Managed Care and · Texas Medicaid Managed Care and Children’s Health Insurance Program. Summary of Activities and Trends in Health Care Quality. Contract Year 2016