External Quality Review of MO HealthNet Managed Care in Missouri CY 2016

2.5 MB·English

by  Missouri Department of Social Services, MO HealthNet Division

2016
MO HealthNet Managed
Care Program
External Quality Review

Amy McCurry Schwartz, Esq., MHSA, EQRO Project Director
Mona Prater, MPA, EQRO Assistant Project Director

Contract Number: C312155001
Review Period: January 1, 2016 to December 31, 2016
Draft Submitted on: September 29, 2017
Final Submitted on: December 15, 2017
Submitted by: Behavioral Health Concepts, Inc.
Prepared and Submitted by:

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

1804 Southwest Blvd., Suite D
Jefferson City, MO 65109
[phone]: Toll-free Ph.
http://www.BHCeqro.com
Email: [email protected]
MO HealthNet Managed Care: External Quality Review
Report of Findings – 2016 Table of Contents

TABLE OF CONTENTS
LIST OF TABLES ............................................................................................................ 5
LIST OF FIGURES ......................................................................................................... 7
1.0 EXECUTIVE SUMMARY ....................................................................................... 9
I.1 Introduction .................................................................................................................................... 11
1.2 Validating Performance Improvement Projects ..................................................................... 12
1.3 Validation of Performance Measures ....................................................................................... 15
1.4 Compliance with Medicaid Managed Care Regulations ....................................................... 19
1.5 MO HealthNet MCHP Case Management Performance Review ...................................... 20
1.6 Managed Care Heath Plan Report Card ................................................................................. 25
2.0 VALIDATING PERFORMANCE IMPROVEMENT PROJECTS (PIPS) ... 27
2.1 Purpose and Objectives .............................................................................................................. 29
2.2 Findings ........................................................................................................................................... 29
2.3 Conclusions.................................................................................................................................... 46
3.0 VALIDATION OF PERFORMANCE MEASURES ........................................ 51
3.1 Purpose and Objectives .............................................................................................................. 53
3.2 Findings ........................................................................................................................................... 53
3.3 Conclusions.................................................................................................................................... 76
4.0 COMPLIANCE WITH MEDICAID MANAGED CARE
REGULATIONS ........................................................................................................... 79
4.1 Purpose and Objectives .............................................................................................................. 81
4.2 Findings ........................................................................................................................................... 84
4.3 Conclusions.................................................................................................................................... 90
5.0 MO HEALTHNET MCHP CASE MANAGEMENT ........................................... 95
5.1 Case Management– Special Project .......................................................................................... 97
5.2 Findings ......................................................................................................................................... 100
5.3 Observations for All MCHPs ................................................................................................... 112
Performance Management Solutions Group 3
A division of Behavioral Health Concepts, Inc.
MO HealthNet Managed Care: External Quality Review
Report of Findings – 2016 Table of Contents

6.0 AETNA BETTER HEALTH OF MISSOURI ................................................................ 119
6.1 Performance Improvement Projects ...................................................................................... 121
6.2 Validation of Performance Measures ..................................................................................... 145
6.3 MCHP Compliance with Managed Care Regulations ......................................................... 154
7.0 HOME STATE HEALTH ........................................................................................... 159
7.1 Performance Improvement Projects ...................................................................................... 161
7.2 Validation of Performance Measures ..................................................................................... 187
7.3 MCHP Compliance with Managed Care Regulations ......................................................... 195
8.0 MISSOURI CARE HEALTH PLAN ............................................................................ 201
8.1 Performance Improvement Projects ...................................................................................... 203
8.2 Validation of Performance Measures ..................................................................................... 230
8.3 MCHP Compliance with Managed Care Regulations ......................................................... 237

Performance Management Solutions Group 4
A division of Behavioral Health Concepts, Inc.
MO HealthNet Managed Care: External Quality Review
Report of Findings – 2016 Table of Contents

LIST OF TABLES

Table 1- Summary Performance Improvement Validation Findings by MCHP. ......................................... 12
Table 2 - 2016 Managed Care Report Card. ..................................................................................................... 25
Table 3 - Performance Improvement Validation Findings by MCHP. .......................................................... 43
Table 4 - Validity and Reliability of Performance Improvement Project Results. ..................................... 47
Table 5 - Summary of EQRO Final Audit Ratings: HEDIS 2016 Performance Measures. ...................... 55
Table 6 - Data Submission for HEDIS 2016 Prenatal Measure. ................................................................... 56
Table 7 - Data Submission for HEDIS 2016 Postpartum Measure. .............................................................. 57
Table 8 - Data Submission and Final Validation for 2015 EDV Medical report (combined rate). ........ 60
Table 9 - Data Submission and Final Validation for 2016 EDV Medical report (combined rate). ........ 60
Table 10 - Data Submission & Final Validation - 2015 EDV Behavioral Health report (combined rate).
.................................................................................................................................................................... 63
Table 11 - Data Submission & Final Validation - 2016 EDV Behavioral Health report (combined rate)
.................................................................................................................................................................... 63
Table 12 - Data Submission & Final Validation - 2015 EDV Substance Abuse report (combined rate).
.................................................................................................................................................................... 65
Table 13 - Data Submission & Final Validation - 2016 EDV Substance Abuse report (combined rate).
.................................................................................................................................................................... 66
Table 14 - Data Submission and Final Validation - 2015 EDU Medical report (combined rate)........... 69
Table 15 - Data Submission and Final Validation - 2016 EDU Medical report (combined rate)........... 69
Table 16 - Data Submission & Final Validation - 2015 EDU Behavioral Health report (combined
rate). .......................................................................................................................................................... 71
Table 17 - Data Submission & Final Validation - 2016 EDU Behavioral Health report (combined
rate). .......................................................................................................................................................... 71
Table 18 - Data Submission & Final Validation - 2015 EDU Substance Abuse report (combined rate).
.................................................................................................................................................................... 73
Table 19 - Data Submission & Final Validation - 2016 EDU Substance Abuse report (combined rate).
.................................................................................................................................................................... 73
Table 20 - Subpart D: Quality Assessment and Performance Improvement: Access Standards. ......... 87
Table 21 - Subpart D: Quality Assessment and Performance Improvement: Measurement and
Improvement. .......................................................................................................................................... 89
Table 22 – Case Management Numbers by Case Type/MCHP Enrollment. ............................................. 99
Table 23 - Estimate of Bias in Reporting of Aetna Better Health HEDIS 2015 and 2016 Measures. 150
Table 24 - Final Audit Rating for Aetna Better Health Performance Measures. .................................... 151
Table 25 - Aetna Better Health Compliance Ratings for Compliance Review Years (2014-2016). .. 155
Performance Management Solutions Group 5
A division of Behavioral Health Concepts, Inc.
MO HealthNet Managed Care: External Quality Review
Report of Findings – 2016 Table of Contents

Table 26 - Estimate of Bias in Reporting of Home State Health HEDIS 2015 and 2016 Measures. . 192
Table 27 - Final Audit Rating for Home State Health Performance Measures. ...................................... 193
Table 28 - Home State Health Compliance Ratings for Compliance Review Years (2014-2016). .... 196
Table 29 - Estimate of Bias in Reporting of Missouri Care HEDIS 2015 and 2016 Measures. ........... 234
Table 30 - Final Audit Rating for Missouri Care Performance Measures. ............................................... 235
Table 31 - Missouri Care Compliance Ratings for Compliance Review Years (2014-2016). ............. 238

Performance Management Solutions Group 6
A division of Behavioral Health Concepts, Inc.
MO HealthNet Managed Care: External Quality Review
Report of Findings – 2016 Table of Contents

LIST OF FIGURES

Figure 1 – Performance Improvement Projects Meeting Sustained Improvement. ................................. 15
Figure 2 - Managed Care Program HEDIS 2016 Prenatal. .............................................................................. 18
Figure 3 - Managed Care Program HEDIS Postpartum Care. ....................................................................... 18
Figure 4 – Summary of MCHP Compliance with Federal Regulations 2012-2016. .................................. 20
Figure 5 – Change in All MCHP Case Management Rates. ............................................................................ 22
Figure 6 - Managed Care Program HEDIS 2016 Prenatal. .............................................................................. 57
Figure 7 - Managed Care Program HEDIS Postpartum Care. ....................................................................... 58
Figure 8 – Statewide Comparison for EDV – Medical measure. .................................................................. 61
Figure 9 – Statewide Comparison for EDV – Behavioral Health measure. ............................................... 64
Figure 10 – Statewide Comparison for EDV – Substance Abuse measure. ............................................... 66
Figure 11 – Statewide Comparison for EDU – Medical measure. ................................................................ 70
Figure 12 – Statewide Comparison for EDU – Behavioral Health measure. ............................................. 72
Figure 13 – Statewide Comparison for EDU – Substance Abuse measure. .............................................. 74
Figure 14 – OB Case Review Results Aetna Better Health. ....................................................................... 101
Figure 15 – OB Case Review Results Missouri Care. .................................................................................. 103
Figure 16 – OB Case Review Results Home State Health. ....................................................................... 104
Figure 17 – Other/SHCN Case Review Aetna Better Health. ................................................................... 105
Figure 18 – Other/SHCN Case Review Missouri Care. .............................................................................. 107
Figure 19 – Other/SHCN Case Review Home State Health...................................................................... 108
Figure 20 – Lead Case Review Aetna Better Health. ................................................................................... 109
Figure 21 – Lead Case Review Missouri Care. .............................................................................................. 110
Figure 22 – Lead Case Review Home State Health. ..................................................................................... 111
Performance Management Solutions Group 7
A division of Behavioral Health Concepts, Inc.
MO HealthNet Managed Care: External Quality Review Section 1
Report of Findings – 2016 Executive Summary

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Performance Management Solutions Group
8
A division of Behavioral Health Concepts, Inc.
MO HealthNet Managed Care: External Quality Review Section 1
Report of Findings – 2016 Executive Summary

1.0 EXECUTIVE SUMMARY

Performance Management Solutions Group
9
A division of Behavioral Health Concepts, Inc.
MO HealthNet Managed Care: External Quality Review Section 1
Report of Findings – 2016 Executive Summary

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Performance Management Solutions Group
10
A division of Behavioral Health Concepts, Inc.