,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,*,Overview of 2009 Quality Assurance Activities,Maryland Department of,Health and Mental Hygiene,November 19,2009,1,Overview of 2009 Quality Assu,Overview,2009 Quality review activities:,Systems Performance Review,EPSDT Record Reviews,HealthChoice Enrollee Satisfaction Surveys,Provider Satisfaction Survey,Healthcare Effectiveness Data and Information Set(HEDIS)Report,Value-Based Purchasing Performance Initiative,Consumer Report Card,Performance Improvement Projects,2,Overview2009 Quality review ac,Systems Performance Review,Since March 2003,CMS has required states to assess quality of care for Medicaid beneficiaries in managed care programs through review activities of the managed care organizations,including a review of organizational and structural performance,e.g.a Systems Performance Review(SPR).An External Quality Review Organization(EQRO)must carry out the tasks for the Medicaid program to determine the degree of compliance with regulations,and provide quality assurance oversight.The Department contracts with Delmarva Foundation as our EQRO to conduct the SPR.,The 2008 SPR consisted of 11 standards.The Department returned the Health Education standard as an active assessment area.,3,Systems Performance ReviewSinc,System Performance Review(continued),The criteria applied to each standard is reviewed and updated annually to ensure compliance with any new regulations and to incorporate mutually agreed upon recommendations of the EQRO.,Each MCO was rated separately on compliance with each standard.,The minimum compliance rate was set for all standards at 100%,with the,exception of the Fraud and Abuse standard,which again increased 10 points from the previous year,to 90%.,For any standard,or components of a standard that did not meet the minimum compliance level,the MCO was required to develop and implement an approved Corrective Action Plan(CAP).,4,System Performance Review(con,Systems Performance Review,Standards,MCO Aggregate,CY 2007,MCO Aggregate,CY 2008,ACC,DIA,MSFC,JMS,MPC,PPMCO,UHC,1.Systematic Process,100%,100%,100%,100%,100%,100%,100%,100%,100%,2.Governing Body,100%,100%,100%,100%,100%,100%,100%,100%,100%,3.Oversight of Delegated Entities,98%*,90%*,86%*,64%*,100%,100%,100%,79%*,100%,4.Credentialing,96%*,92%*,97%*,80%*,100%,87%*,87%*,95%*,97%*,5.Enrollee Rights,99%*,99%*,100%,100%,100%,100%,100%,100%,96%*,6.Availability and Access,100%,99%*,100%,95%*,100%,100%,100%,100%,100%,7.Utilization Review,94%*,95%*,98%*,88%*,100%,98%*,98%*,90%*,95%*,8.Continuity of Care,100%,98%*,100%,88%*,100%,100%,100%,100%,100%,9.Health Education Plan,Exempt,99%*,100%,96%*,100%,100%,100%,100%,100%,10.Outreach Plan,95%*,99%*,100%,96%*,100%,100%,96%*,100%,100%,11.Fraud and Abuse,96%,97%,100%,89%*,100%,100%,97%,95%,97%,5,Systems Performance ReviewStan,EPSDT Record Reviews,Medical record reviews of 2,618 children under the age of 21 were performed by Delmarva Foundation.Nurse reviewers went onsite to 416 provider offices.,Adherence to Early and Periodic Screening,Diagnosis and Treatment standards in the following 5 components were the focus of the review:,Health and Developmental History,Comprehensive Physical Exam,Laboratory Tests,Immunizations,Health Education and Anticipatory Guidance,MCOs must demonstrate at least a rate of 70%compliance by component;otherwise,a Corrective Action Plan(CAP)is required.Last year,3 MCOs developed CAPS for lab testing;2008 scores increased for those MCOs by 8.8%-14.5%.No CAPs were indicated following this years review.,6,EPSDT Record ReviewsMedical re,EPSDT Record Reviews(continued),Component,Aggregate Scores,CY 2007,Aggregate Scores,CY 2008,Health and Developmental History,81%,85%,Comprehensive Physical Exam,91%,92%,Laboratory Tests/At Risk Screenings,(PKU,lead,anemia,risk assts.For TB,cholesterol,STD,etc.),78%,79%,Immunizations,93%,90%,Health Education and Anticipatory Guidance,89%,89%,7,EPSDT Record Reviews(continue,Enrollee Satisfaction Surveys,DHMH conducts an enrollee satisfaction survey annually using the Consumer Assessment of Healthcare Providers and Systems(CAHPS)survey instruments,to evaluate members satisfaction with their health plans.,WB&A conducted the survey for DHMH with adults ages 18 or older,and children ages 17 or younger.All members surveyed were enrolled in HealthChoice for at least the last 5 of 6 months of 2008.,Surveys included question sets covering:,Getting Needed Care,Getting Care Quickly,Shared Decision-making,How Well Doctors Communicate,Coordination of Care,8,Enrollee Satisfaction Surveys,Enrollee Satisfaction Surveys(continued),In 2009,CAHPS surveys were mailed to 11,952 Medicaid adults and 18,187 Medicaid children.Completed surveys yielded 3,746 adult and 4,830 child questionnaires for analysis.This represents an adult r