External Quality Review of MO HealthNet Managed Care in Missouri CY 2007

3.4 MB·English

by  Missouri Department of Social Services, MO HealthNet Division

2007
MOHealthNet Managed
Care Program
External Quality
Review

Amy McCurry Schwartz, Esq., MHSA, EQRO Project Director
Mona Prater, MPA, EQRO Assistant Project Director
Stephani Worts, MBA, EQRO Research Analyst

Contract Number: C301154801, Amendment 007
Review Period: January 1, 2007 to December 31, 2007
Draft Submitted on: October 3, 2008
Final Draft Submitted on: November 26, 2008

Final Copy Submitted on: December 30, 2008
Submitted by: Behavioral Health Concepts, Inc.
Performance Management Solutions Group
Prepared and Submitted by:

The Performance Management Solutions Group
Is a division of Behavioral Health Concepts, Inc.

2716 Forum Blvd, Suite 4
Columbia, MO 65203
[phone] :Local Ph.
[phone] :Toll-free Ph.
[phone] :Fax
http://www.PMSGinfo.com
http://www.BHCinfo.com
Email: [email protected]
TABLE OF CONTENTS

LIST OF ACRONYMS ................................................................................................... XII
GLOSSARY AND OPERATIONAL DEFINITIONS ........................................... XV
LIST OF TABLES ..........................................................................................................X IX
LIST OF FIGURES ..................................................................................................... XXIII
1.0 EXECUTIVE SUMMARY .......................................................................................2 6
I.1 Introduction ........................................................................................................ 28
1.2 Preparation for the 2007 External Quality Review ....................................... 31
Preparation with the State Medicaid Agency ........................................................... 31
Preparation of MO HealthNet Managed Care Health Plans .................................. 31
Development of Worksheets, Tools, and Rating Criteria .......................................... 32
1.3 Validation of Performance Improvement Projects ..................................... 35
Access to Care ................................................................................................................ 35
Quality of Care ................................................................................................................ 37
Timeliness of Care ............................................................................................................ 37
Recommendations ......................................................................................................... 39
1.4 Validation of Performance Measures ........................................................... 40
Quality of Care ................................................................................................................ 40
Access to Care ................................................................................................................ 41
Timeliness of Care ............................................................................................................ 42
Recommendations ......................................................................................................... 42
1.5 Encounter Data Validation ............................................................................. 43
Strengths ........................................................................................................................... 45
Areas for Improvement .................................................................................................. 45
Recommendations ......................................................................................................... 46
1.6 MO HealthNet MCHP Compliance with Managed Care Regulations .... 48
Quality of Care ................................................................................................................ 49
Access to Care ................................................................................................................ 50
Timeliness of Care ............................................................................................................ 50
Recommendations ......................................................................................................... 52
2.0 VALIDATION OF PERFORMANCE IMPROVEMENT PROJECTS
(PIPS) ................................................................................................................................... 55
2.1 Definition ............................................................................................................ 57
2.2 Purpose and Objectives .................................................................................. 58
2.3 Technical Methods ........................................................................................... 58
Time Frame and Selection ............................................................................................. 59
Preparation of MO HealthNet Managed Care Health Plans .................................. 59
Reviewers .......................................................................................................................... 61
iii
Performance Management Solutions Group
A division of Behavioral Health Concepts, Inc.
2.4 Procedures for Data Collection ..................................................................... 61
Analysis .............................................................................................................................. 63
2.5 Findings .............................................................................................................. 65
Step 1: Selected Study Topics ...................................................................................... 66
Step 2: Study Questions ................................................................................................. 70
Step 3: Study Indicators ................................................................................................. 71
Step 4: Study Populations ............................................................................................. 71
Step 5: Sampling Methods ............................................................................................ 72
Step 6: Data Collection Procedures ........................................................................... 73
Step 7: Improvement Strategies .................................................................................. 74
Step 8: Data Analysis and Interpretation of Study Results ....................................... 74
Step 9: Validity of Improvement .................................................................................. 76
Step 10: Sustained Improvement ................................................................................ 77
2.6 Conclusions ....................................................................................................... 77
Access to Care ................................................................................................................ 79
Quality of Care ................................................................................................................ 80
Timeliness of Care ............................................................................................................ 80
Recommendations ......................................................................................................... 81
3.0 VALIDATION OF PERFORMANCE MEASURES .........................................8 3
3.1 Definition ............................................................................................................ 85
3.2 Purpose and Objectives .................................................................................. 85
Reviewers .......................................................................................................................... 85
3.3 Technical Methods ........................................................................................... 86
HEDIS 2007 Adolescent Well-Care Visits (AWC) ......................................................... 88
HEDIS 2007 Follow-Up After Hospitalization for Mental Illness (FUH) ........................ 91
HEDIS 2007 Annual Dental Visit (ADV).......................................................................... 95
Methods of Calculating Performance Measures ...................................................... 97
Time Frame ....................................................................................................................... 99
Procedures for Data Collection .................................................................................... 99
3.4 Findings ............................................................................................................ 115
HEDIS 2007 Annual Dental Visit ................................................................................... 116
HEDIS 2007 Adolescent Well-Care Visits .................................................................... 133
HEDIS 2007 Follow-Up After Hospitalization for Mental Illness ................................ 160
3.5 Conclusions ..................................................................................................... 183
Quality of Care .............................................................................................................. 183
Access to Care .............................................................................................................. 185
Timeliness of Care .......................................................................................................... 185
Recommendations ....................................................................................................... 186
4.0 VALIDATION OF ENCOUNTER DATA ...................................................... 187
4.1 Definition .......................................................................................................... 189
iv
Performance Management Solutions Group
A division of Behavioral Health Concepts, Inc.
4.2 Purpose and Objectives ................................................................................ 189
4.3 Technical Methods ......................................................................................... 193
Time Frame ..................................................................................................................... 193
Procedures for Data Collection .................................................................................. 193
Analyses .......................................................................................................................... 194
4.4 Findings ............................................................................................................ 197
4.5 Conclusions ..................................................................................................... 231
Strengths ......................................................................................................................... 231
Areas for Improvement ................................................................................................ 232
Recommendations ....................................................................................................... 233
5.0 MO HEALTHNET MCHP COMPLIANCE WITH MANAGED CARE
REGULATIONS ........................................................................................................... 236
5.1 Purpose and Objectives ................................................................................ 238
5.2 Technical Methods ......................................................................................... 239
Planning Compliance Monitoring Activities ............................................................. 239
Obtaining Background Information from the State Medicaid Agency .............. 244
Document Review ........................................................................................................ 244
Conducting Interviews ................................................................................................. 245
Collecting Accessory Information .............................................................................. 246
Analyzing and Compiling Findings ............................................................................. 247
Reporting to the State Medicaid Agency ................................................................ 248
Compliance Ratings ..................................................................................................... 248
5.3 Findings ............................................................................................................ 250
Enrollee Rights and Protections .................................................................................. 250
Compliance Interviews – Member Services staff and Case Management
(Behavioral Health) ....................................................................................................... 256
Quality Assessment and Performance Improvement: Access Standards .......... 257
Member Service Staff and Case Manager Interviews ........................................... 263
Quality Assessment and Performance Improvement: Structure and Operation
Standards ........................................................................................................................ 263
Quality Assessment and Performance Improvement: Measurement and
Improvement ................................................................................................................. 267
Grievance Systems ....................................................................................................... 272
5.4 Conclusions ..................................................................................................... 275
Quality of Care .............................................................................................................. 276
Access to Care .............................................................................................................. 277
Timeliness of Care .......................................................................................................... 278
Recommendations ....................................................................................................... 279
6.0 BLUE-ADVANTAGE PLUS OF KANSAS CITY .......................................................... 282
6.1 Performance Improvement Projects ........................................................... 284
v
Performance Management Solutions Group
A division of Behavioral Health Concepts, Inc.
Methods .......................................................................................................................... 284
Document Review ......................................................................................................................................................................... 284
Interviews .......................................................................................................................................................................................2 84
Findings ........................................................................................................................... 285
Conclusions .................................................................................................................... 295
Quality of Care ............................................................................................................................................................................... 295
Access to Care ................................................................................................................................................................................ 295
Timeliness of Care ......................................................................................................................................................................... 297
Recommendations ......................................................................................................................................................................... 297
6.2 Validation of Performance Measures ......................................................... 298
Methods .......................................................................................................................... 298
Document Review ......................................................................................................................................................................... 298
Interviews .......................................................................................................................................................................................3 00
Findings ........................................................................................................................... 300
Data Integration and Control ...................................................................................................................................................... 302
Documentation of Data and Processes ...................................................................................................................................... 302
Processes Used to Produce Denominators ............................................................................................................................... 304
Processes Used to Produce Numerators .................................................................................................................................... 304
Sampling Procedures for Hybrid Methods ................................................................................................................................ 306
Submission of Measures to the State .......................................................................................................................................... 306
Determination of Validation Findings and Calculation of Bias .............................................................................................. 306
Final Audit Rating ......................................................................................................................................................................... 307
Conclusions .................................................................................................................... 307
Quality of Care ............................................................................................................................................................................... 307
Access to Care ................................................................................................................................................................................ 308
Timeliness of Care ......................................................................................................................................................................... 309
Recommendations ......................................................................................................................................................................... 310
6.3 Validation of Encounter Data ...................................................................... 311
Findings ........................................................................................................................... 311
Conclusions .................................................................................................................... 319
Strengths ......................................................................................................................................................................................... 319
Areas for Improvement ................................................................................................................................................................ 319
Recommendations ......................................................................................................................................................................... 319
6.4 MO HealthNet MCHP Compliance with Managed Care Regulations .. 320
Methods .......................................................................................................................... 320
Document Review ......................................................................................................................................................................... 321
Interviews .......................................................................................................................................................................................3 21
Findings ........................................................................................................................... 322
Enrollee Rights and Protections .................................................................................................................................................. 322
Behavioral Health .......................................................................................................................................................................... 328
Quality Assessment and Performance Improvement .............................................................................................................. 332
Conclusions .................................................................................................................... 344
Quality of Care ............................................................................................................................................................................... 344
Access to Care ................................................................................................................................................................................ 344
Timeliness of Care ......................................................................................................................................................................... 346
Recommendations ......................................................................................................................................................................... 346
7.0 CHILDREN’S MERCY FAMILY HEALTH PARTNERS ............................................... 348
7.1 Performance Improvement Projects ........................................................... 350
Methods .......................................................................................................................... 350
Document Review ......................................................................................................................................................................... 350
Interviews .......................................................................................................................................................................................3 50
Findings ........................................................................................................................... 352
vi
Performance Management Solutions Group
A division of Behavioral Health Concepts, Inc.
Conclusions .................................................................................................................... 357
Quality of Care ............................................................................................................................................................................... 357
Access to Care ................................................................................................................................................................................ 358
Timeliness of Care ......................................................................................................................................................................... 358
Recommendations ......................................................................................................................................................................... 358
7.2 Validation of Performance Measures ......................................................... 360
Methods .......................................................................................................................... 360
Document Review ......................................................................................................................................................................... 360
Interviews .......................................................................................................................................................................................3 61
Findings ........................................................................................................................... 361
Data Integration and Control ...................................................................................................................................................... 363
Documentation of Data and Processes ...................................................................................................................................... 363
Processes Used to Produce Denominators ............................................................................................................................... 364
Processes Used to Produce Numerators .................................................................................................................................... 364
Sampling Procedures for Hybrid Methods ................................................................................................................................ 366
Submission of Measures to the State .......................................................................................................................................... 366
Determination of Validation Findings and Calculation of Bias .............................................................................................. 366
Final Audit Rating ......................................................................................................................................................................... 366
Conclusions .................................................................................................................... 367
Quality of Care ............................................................................................................................................................................... 367
Access to Care ................................................................................................................................................................................ 369
Timeliness of Care ......................................................................................................................................................................... 369
Recommendations ......................................................................................................................................................................... 370
7.3 Validation of Encounter Data ...................................................................... 371
Findings ........................................................................................................................... 371
Conclusions .................................................................................................................... 378
Strengths ......................................................................................................................................................................................... 378
Areas for Improvement ................................................................................................................................................................ 378
Recommendations ......................................................................................................................................................................... 380
7.4 MO HealthNet MCHP Compliance with Managed Care Regulations .. 381
Methods .......................................................................................................................... 381
Document Review ......................................................................................................................................................................... 381
Interviews .......................................................................................................................................................................................3 83
Findings ........................................................................................................................... 385
Enrollee Rights and Protections .................................................................................................................................................. 385
Behavioral Health .......................................................................................................................................................................... 390
Quality Assessment and Performance Improvement .............................................................................................................. 390
Conclusions .................................................................................................................... 403
Quality of Care ............................................................................................................................................................................... 403
Access to Care ................................................................................................................................................................................ 405
Timeliness of Care ......................................................................................................................................................................... 405
Recommendations ......................................................................................................................................................................... 405
8.0 HARMONY HEALTH PLAN OF MISSOURI ............................................................... 408
8.1 Performance Improvement Projects ........................................................... 410
Methods .......................................................................................................................... 410
Document Review ......................................................................................................................................................................... 410
Interviews .......................................................................................................................................................................................4 10
Findings ........................................................................................................................... 411
Conclusions .................................................................................................................... 418
Quality of Care ............................................................................................................................................................................... 418
Access to Care ................................................................................................................................................................................ 418
Timeliness of Care ......................................................................................................................................................................... 418
Recommendations ......................................................................................................................................................................... 419
vii
Performance Management Solutions Group
A division of Behavioral Health Concepts, Inc.
8.2 Validation of Performance Measures ......................................................... 420
8.3 Validation of Encounter Data ...................................................................... 421
Findings ........................................................................................................................... 421
Conclusions .................................................................................................................... 426
Strengths ......................................................................................................................................................................................... 426
Areas for Improvement ................................................................................................................................................................ 426
Recommendations ......................................................................................................................................................................... 426
8.4 MO HealthNet MCHP Compliance with Managed Care Regulations .. 428
Methods .......................................................................................................................... 428
Document Review ......................................................................................................................................................................... 430
Interviews .......................................................................................................................................................................................4 31
Findings ........................................................................................................................... 432
Enrollee Rights and Protections .................................................................................................................................................. 432
Quality Assessment and Performance Improvement .............................................................................................................. 437
Conclusions .................................................................................................................... 448
Quality of Care ............................................................................................................................................................................... 448
Access to Care ................................................................................................................................................................................ 448
Timeliness of Care ......................................................................................................................................................................... 450
Recommendations ......................................................................................................................................................................... 450
9.0 HEALTHCARE USA .................................................................................................. 453
9.1 Performance Improvement Projects ........................................................... 455
Methods .......................................................................................................................... 455
Document Review ......................................................................................................................................................................... 455
Interviews .......................................................................................................................................................................................4 55
Findings ........................................................................................................................... 457
Conclusions .................................................................................................................... 462
Quality of Care ............................................................................................................................................................................... 462
Access to Care ................................................................................................................................................................................ 462
Timeliness of Care ......................................................................................................................................................................... 464
Recommendations ......................................................................................................................................................................... 464
9.2 Validation of Performance Measures ......................................................... 465
Methods .......................................................................................................................... 465
Document Review ......................................................................................................................................................................... 465
Interviews .......................................................................................................................................................................................4 67
Findings ........................................................................................................................... 467
Data Integration and Control ...................................................................................................................................................... 469
Documentation of Data and Processes ...................................................................................................................................... 470
Processes Used to Produce Denominators ............................................................................................................................... 470
Processes Used to Produce Numerators .................................................................................................................................... 471
Sampling Procedures for Hybrid Methods ................................................................................................................................ 472
Submission of Measures to the State .......................................................................................................................................... 472
Determination of Validation Findings and Calculation of Bias .............................................................................................. 472
Final Audit Rating ......................................................................................................................................................................... 474
Conclusions .................................................................................................................... 475
Quality of Care ............................................................................................................................................................................... 475
Access to Care ................................................................................................................................................................................ 475
Timeliness of Care ......................................................................................................................................................................... 477
Recommendations ......................................................................................................................................................................... 477
9.3 Validation of Encounter Data ...................................................................... 479
Findings ........................................................................................................................... 479
Conclusions .................................................................................................................... 489
viii
Performance Management Solutions Group
A division of Behavioral Health Concepts, Inc.
Strengths ......................................................................................................................................................................................... 489
Areas for Improvement ................................................................................................................................................................ 489
Recommendations ......................................................................................................................................................................... 489
9.4 MO HealthNet MCHP Compliance with Managed Care Regulations .. 491
Methods .......................................................................................................................... 491
Document Review ......................................................................................................................................................................... 492
Interviews .......................................................................................................................................................................................4 94
Findings ........................................................................................................................... 496
Enrollee Rights and Protections .................................................................................................................................................. 496
Behavioral Health .......................................................................................................................................................................... 504
Quality Assessment and Performance Improvement .............................................................................................................. 507
Conclusions .................................................................................................................... 519
Quality of Care ............................................................................................................................................................................... 519
Access to Care ................................................................................................................................................................................ 520
Timeliness of Care ......................................................................................................................................................................... 520
Recommendations ......................................................................................................................................................................... 522
10.0 MERCY CAREPLUS .................................................................................................. 524
10.1 Performance Improvement Projects ......................................................... 526
Methods .......................................................................................................................... 526
Document Review ......................................................................................................................................................................... 526
Interviews .......................................................................................................................................................................................5 26
Findings ........................................................................................................................... 527
Conclusions .................................................................................................................... 537
Quality of Care ............................................................................................................................................................................... 537
Access to Care ................................................................................................................................................................................ 538
Timeliness of Care ......................................................................................................................................................................... 540
Recommendations ......................................................................................................................................................................... 540
10.2 Validation of Performance Measures ....................................................... 542
Methods .......................................................................................................................... 542
Document Review ......................................................................................................................................................................... 542
Interviews .......................................................................................................................................................................................5 43
Findings ........................................................................................................................... 543
Data Integration and Control ...................................................................................................................................................... 544
Documentation of Data and Processes ...................................................................................................................................... 546
Processes Used to Produce Denominators ............................................................................................................................... 546
Processes Used to Produce Numerators .................................................................................................................................... 546
Sampling Procedures for Hybrid Methods ................................................................................................................................ 547
Submission of Measures to the State .......................................................................................................................................... 547
Determination of Validation Findings and Calculation of Bias .............................................................................................. 547
Final Audit Rating ......................................................................................................................................................................... 548
Conclusions .................................................................................................................... 548
Quality of Care ............................................................................................................................................................................... 549
Access to Care ................................................................................................................................................................................ 549
Timeliness of Care ......................................................................................................................................................................... 550
Recommendations ......................................................................................................................................................................... 550
10.3 Validation of Encounter Data .................................................................... 552
Findings ........................................................................................................................... 552
Conclusions .................................................................................................................... 560
Strengths ......................................................................................................................................................................................... 560
Areas for Improvement ................................................................................................................................................................ 560
Recommendations ......................................................................................................................................................................... 561
10.4 MO HealthNet MCHP Compliance with Managed Care Regulations 562
ix
Performance Management Solutions Group
A division of Behavioral Health Concepts, Inc.
Methods .......................................................................................................................... 562
Document Review ......................................................................................................................................................................... 564
Interviews .......................................................................................................................................................................................5 65
Findings ........................................................................................................................... 567
Enrollee Rights and Protections .................................................................................................................................................. 567
Behavioral Health .......................................................................................................................................................................... 572
Quality Assessment and Performance Improvement .............................................................................................................. 572
Conclusions .................................................................................................................... 586
Quality of Care ............................................................................................................................................................................... 586
Access to Care ................................................................................................................................................................................ 588
Timeliness of Care ......................................................................................................................................................................... 588
Recommendations ......................................................................................................................................................................... 588
11.0 MISSOURI CARE ....................................................................................................... 591
11.1 Performance Improvement Projects ......................................................... 593
Methods .......................................................................................................................... 593
Document Review ......................................................................................................................................................................... 593
Interviews .......................................................................................................................................................................................5 93
Findings ........................................................................................................................... 594
Conclusions .................................................................................................................... 602
Quality of Care ............................................................................................................................................................................... 602
Access to Care ................................................................................................................................................................................ 602
Timeliness of Care ......................................................................................................................................................................... 602
Recommendations ......................................................................................................................................................................... 603
11.2 Validation of Performance Measures ....................................................... 604
Methods .......................................................................................................................... 604
Document Review ......................................................................................................................................................................... 604
Interviews .......................................................................................................................................................................................6 05
Findings ........................................................................................................................... 605
Data Integration and Control ...................................................................................................................................................... 606
Documentation of Data and Processes ...................................................................................................................................... 607
Processes Used to Produce Denominators ............................................................................................................................... 607
Processes Used to Produce Numerators .................................................................................................................................... 609
Sampling Procedures for Hybrid Methods ................................................................................................................................ 610
Submission of Measures to the State .......................................................................................................................................... 610
Determination of Validation Findings and Calculation of Bias .............................................................................................. 610
Final Audit Rating ......................................................................................................................................................................... 610
Conclusions .................................................................................................................... 612
Quality of Care ............................................................................................................................................................................... 612
Access to Care ................................................................................................................................................................................ 614
Timeliness of Care ......................................................................................................................................................................... 614
Recommendations ......................................................................................................................................................................... 616
11.3 Validation of Encounter Data .................................................................... 617
Findings ........................................................................................................................... 617
Conclusions .................................................................................................................... 625
Strengths ......................................................................................................................................................................................... 625
Areas for Improvement ................................................................................................................................................................ 626
Recommendations ......................................................................................................................................................................... 626
11.4 MO HealthNet MCHP Compliance with Managed Care Regulations 627
Methods .......................................................................................................................... 627
Document Review ......................................................................................................................................................................... 627
Interviews .......................................................................................................................................................................................6 28
Findings ........................................................................................................................... 630
Enrollee Rights and Protections .................................................................................................................................................. 630
x
Performance Management Solutions Group
A division of Behavioral Health Concepts, Inc.