fianl report external quality review of the hoosier healthwise 2020. 9. 4.¢  final report...

Download FIANL REPORT External Quality Review of the Hoosier Healthwise 2020. 9. 4.¢  FINAL REPORT 2015 External

Post on 07-Oct-2020

0 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

  • External Quality Review of Indiana’s

    Hoosier Healthwise Program and

    Healthy Indiana Plan for the

    Review Year Calendar 2014

    3030 North Third Street, Suite 200 Phoenix, AZ 85012 (602) 241-8520 www.burnshealthpolicy.com

  • FINAL REPORT 2015 External Quality Review of Indiana’s Hoosier Healthwise Program and Healthy Indiana Plan 

    Burns & Associates, Inc. March 31, 2016  

    ACKNOWLEDGMENTS

    The CY 2015 External Quality Review Team included the following individuals who served as reviewers and/or report contributors:

    Burns & Associates Staff Mark Podrazik, Principal

    Steven Abele, Senior Consultant Kara Suter, Senior Consultant Jesse Eng, SAS Programmer

    James Maedke, SAS Programmer Barry Smith, Analyst

    Additional Staff

    Linda Gunn, Ph.D., Subcontractor, A.G.S. Consulting, Inc. Kristy Lawrance, Subcontractor, Lawrance Policy Consulting

    Burns & Associates, Inc. would like to thank the staff at Anthem, MDwise and Managed Health Services for their assistance in providing documentation and assistance in planning for the onsite portion of this review. We would also like to thank Vickie Trout and Susan Beecher at the Office of Medicaid Policy and Planning for their assistance during the course of this study.

    This report is available at our website at

    www.burnshealthpolicy.com

    Inquiries may be sent to mpodrazik@burnshealthpolicy.com

    3030 NORTH THIRD STREET, SUITE 200 PHOENIX, AZ 85012 (602) 241-8520

  • FINAL REPORT 2015 External Quality Review of Indiana’s Hoosier Healthwise Program and Healthy Indiana Plan 

    Burns & Associates, Inc. March 31, 2016  

    TABLE OF CONTENTS

    Abbreviations List Executive Summary Section I: Overview of Indiana’s Medicaid Managed Care Programs Introduction ....................................................................................................................................I-1 Enrollment at a Glance ...................................................................................................................I-2 MCEs Contracted in the Hoosier Healthwise Program and Healthy Indiana Plan ........................I-3 Indiana Medicaid’s CY 2014 Quality Strategy Plan ......................................................................I-4

    Section II: Approach to this Year’s External Quality Review Background .................................................................................................................................. II-1 EQR Activities in CY 2015 ......................................................................................................... II-2 The EQR Review Team ............................................................................................................... II-3

    Section III: Validation of Performance Measures Introduction ................................................................................................................................. III-1 Findings ...................................................................................................................................... III-3

    Section IV: Validation of Performance Improvement Projects Introduction ................................................................................................................................. IV-1 Review of Performance Improvement Projects .......................................................................... IV-1 Anthem QIP Findings ................................................................................................................. IV-3 MHS QIP Findings ..................................................................................................................... IV-8 MDwise QIP Findings .............................................................................................................. IV-13 Recommendations to the MCEs and the OMPP Related to Validation of Quality Improvement Projects .................................................................................................. IV-16

    Section V: Focus Study on Service Authorization Processes Comparison of Authorization Processes and Staffing at Each MCE ........................................... V-1 Overview of Authorization Process Flows Consistent Across the MCEs ................................... V-3 Turnaround Time Requirements .................................................................................................. V-8 Application of Clinical Guidelines in the Authorization Process ................................................ V-8 Review of CY 2014 Authorizations ........................................................................................... V-11 Methodology for Defining the Study Sample and Review Process ........................................... V-26 Findings from the Review of the Study Sample ........................................................................ V-28 Recommendations to the MCEs and the OMPP Related to Service Authorization Processes .. V-40

    Section VI: Focus Study on Potentially Preventable Hospital Readmissions Background on Potentially Preventable Readmissions (PPRs) .................................................. VI-1 Methodology for Defining the Study Sample ............................................................................. VI-3 Findings from the Review of the Study Sample ......................................................................... VI-7 Recommendations to the MCEs and the OMPP Related to PPRs ............................................ VI-14

  • FINAL REPORT 2015 External Quality Review of Indiana’s Hoosier Healthwise Program and Healthy Indiana Plan 

    Burns & Associates, Inc. March 31, 2016  

    Section VII: Focus Study on Potentially Preventable Emergency Department Visits Background on Potentially Preventable Emergency Department Visits (PPVs) ...................... VII-1 Methodology for Defining the Study Sample ........................................................................... VII-1 Findings from the Review of the Study Sample ....................................................................... VII-4 Recommendations to the MCEs and the OMPP Related to PPVs .......................................... VII-16

    Appendix A: 2015 EQR Guide Appendix B: Review Tool for Authorization Sample

  • FINAL REPORT 2015 External Quality Review of Indiana’s Hoosier Healthwise Program and Healthy Indiana Plan 

    Burns & Associates, Inc. March 31, 2016  

    ABBREVIATIONS LIST Abbreviation Meaning Abbreviation Meaning

    ACRG Aggregated Clinical Risk Group JIVA The name of software used by MDwise ALOS Average Length of Stay LCSW Licensed Clinical Social Workers AMB Ambulatory Care LMFT Licensed Marriage and Family Therapist

    APR-DRG All Payer Refined Diagnosis Related Group MCE Managed Care Entity ASAM American Society of Addiction Medicine MCG Milliman Care Guidelines B&A Burns & Associates, Inc. MCO Managed Care Organization BH Behavioral Health MHS Managed Health Solutions

    BHM Name of a company that works with MHS MS-DRG Multiple Severity Diagnosis Related Group CAHPS Consumer Assessment of Healthcare NCQA National Committee on Quality Assurance

    Providers and Systems NICU Neonatal Intensive Care Unit CHIP Children's Health Insurance Program NRT Nicotine Replacement Therapy CM Care Management/Case Management OMPP Office of Medicaid Policy and Planning

    CMHC Community Mental Health Center P4O Pay For Outcomes CMCS An organization that is contracted to PCCM Primary Care Case Management

    perform authorization reviews for PE Presumptive Eligibility MDwise and Anthem PIHPs Prepaid Inpatient Health Plans

    CMS Centers for Medicare and Medicaid Services PIPs Performance Improvement Projects COPD Chronic Obstructive Pulmonary Disease PMP Primary Medical Provider CPT Current Procedural Terminology PMPM Per Member Per Month CRG Clinical Risk Group POWER Personal Wellness and Responsibility Acct CY Calendar Year PPR Potentially Preventable Readmissions

    DME Durable Medical Equipment PPV Potentially Preventable Emergency Dept Visit EAPG Enhanced Ambulatory Patient Grouping QI Quality Improvement

    ED Emergency Department QIP Quality Improvement Project EPSDT Early Periodic Screening, Diagnosis and Treatment QNXT The name of software used by CMCS

    EQR External Quality Review RCP Right Choices Program EQRO External Quality Review Organization RM Re-measurement Year FPL Federal Poverty Level RY Reviewed Year

    FQHC Federally Qualified Health Center SAS Statistical Analysis System FSSA Family and Social Services Administration SMA State Medicaid Agency

    HCPCS Healthcare Common Procedure Coding System SOI Severity of Illness H S A Health Savings Account TANF Temporary Assistance for Needy Families HEDIS Healthcare Effectiveness Data and Information Set TAT Turnaround Time HHW Hoosier Healthwise URAC Utilization Review Accreditation Commission HIP Healthy Indiana Plan WMDS The name of software used by Anthem IRR Inter-Rater Reliability

  • FINAL REPORT 2015 External Quality Review of Indiana’s Hoosier Healthwise Program and Healthy Indiana Plan 

    Burns & Associates, Inc. i March 31, 2016  

    EXECUTIVE SUMMARY As the state agencies responsible for Indiana’s Medicaid program, the Family and Social Services Administration (FSSA) and the Indiana Office of Medicaid Policy and Planning (OMPP