physical health - nm human services · of the four physical health mcos’ programs for the period...

HINM-EQRO-14-03

Physical Health

Performance Measurement Program and Performance

Improvement Projects Audit Audit Period: July 1, 2012-June 30, 2013

Final Report: July 7, 2014

Prepared for the New Mexico Human Services Department under PSC 12-630-8000-0017

By HealthInsight New Mexico External Quality Review (EQR) staff:

Allen Buice, MA, PMP, CPHQ, Project Manager Debi Peterman, RN, MSN, Auditor

Greg Lujan, LISW, Auditor Jennifer Salazar, LPN, CBI, Auditor Gary Logsdon, MHA, CDP, Auditor

Sabrina Villalobos, BBA, Auditor Denise Anderson, MAOM, CQPA, Analyst

Amber Bennett, Communications Specialist Margaret White, RN, BSN, MSHA, EQR Director

Herb Koffler, MD, MS, EQR Medical Director Margy Wienbar, MS, Executive Director

5801 Osuna NE, Suite 200 Albuquerque, NM 87109-2587

www.healthinsightnm.com 505-998-9898

http://www.healthinsightnm.com/

of 69 PH PMP/PIPs Audit Final Report

Main Report July 7, 2014

Table of Contents Executive Summary .................................................................................................................... 4

Background ................................................................................................................................. 5

Purpose ...................................................................................................................................... 5

Audit Approach ........................................................................................................................... 6

Audit Tools ............................................................................................................................ 7

Audit Overview ...................................................................................................................... 8

Clarification and Rebuttal and Reconsideration ..................................................................... 8

Scoring Method ........................................................................................................................... 9

Performance Measurement Program Scoring Method ........................................................... 9

Performance Improvement Project Scoring Method ............................................................... 9

Calculation of Final Overall Score .........................................................................................10

Salud! Performance Measurement Program Audit Results ....................................................... 11

State Coverage Insurance Performance Measurement Program Audit Results......................... 12

Salud! Performance Improvement Projects Audit Results ......................................................... 13

State Coverage Insurance Performance Improvement Projects Audit Results .......................... 16

Outcome Measures ................................................................................................................... 19

Salud! and SCI Recommendations ........................................................................................... 19

Conclusion and Recommendations ........................................................................................... 19

Rebuttal and Reconsideration Review ..................................................................................19

Section A: Blue Cross Blue Shield of New Mexico (BCBS) ....................................................... 20

Salud! PMP Audit Results ......................................................................................................... 20

Salud! PIP Audit Results ........................................................................................................... 24

Salud! PIP #1: Childhood Immunizations- Combo 2 ..............................................................24

Salud! PIP #2: Breast Cancer Screening ..............................................................................26


Salud! Recommendations ......................................................................................................... 27

Performance Measures ........................................................................................................27

Performance Improvement Projects ......................................................................................27

Rebuttal and Reconsideration ................................................................................................... 27

Section B: Lovelace Health Plan (LHP) ..................................................................................... 28



Salud! PIP #1: Use of Appropriate Medications for People with Asthma (ages 5-11 years)...31

Salud! PIP #2: Utilizing Synagis in Improving Health and Reducing Hospitalizations in RSV Vulnerable Infants and Children ............................................................................................33





SCI PIP #1: Use of Appropriate Medications for People with Asthma (ages 5-50 years) .......37

SCI PIP #2: Improving the Frequency of Prenatal Care/Improving Birth Outcomes ..............39




Section C: Molina Healthcare (MHP) ......................................................................................... 42


Salud! Performance Improvement Program Audit Results ........................................................ 46

Salud! PIP #1: Annual Dental Visits ......................................................................................46


SCI Performance Measurement Program Audit Results ............................................................ 50

SCI Performance Improvement Projects Audit Results ............................................................. 52

SCI PIP #1: Diabetes HbA1c Testing ....................................................................................53

SCI PIP #2: Improving the Frequency of Prenatal Care/Improving Birth Outcomes ..............54




Performance Improvement Plans ..........................................................................................55


Section D: Presbyterian Health Plan (PHP) ............................................................................... 56




Salud! PIP #2: Hemoglobin A1c Testing ...............................................................................62



SCI PIP #1: Breast Cancer Screening ..................................................................................65

SCI PIP #2: Hemoglobin A1c Testing ...................................................................................67




Performance Improvement Projects ......................................................................................68




Executive Summary This report details the results of the external quality review (EQR) of the Medicaid Salud! and State Coverage Insurance (SCI) programs in New Mexico. Four Managed Care Organizations (MCOs) are contracted with the Human Services Department, Medical Assistance Division (HSD) to provide these services: Blue Cross Blue Shield of New Mexico (BCBS) Salud! program, Lovelace Community Health Plan (LHP), Molina Healthcare of New Mexico (MHP), and Presbyterian Health Plan (PHP). HSD requested that the audit for LHP be conducted separately from the other Physical Health (PH) MCOs. The remaining audits were completed in the spring of 2014. The rationale for this change in the scheduling of the PH audit was twofold. First, LHP’s contract would conclude on December 31, 2013, after which the contract was at an end and staff might not be available to conduct the onsite audit and rebut the findings. Second, BCBS, MHP, PHP, and United Healthcare (UHC) were in readiness review for Centennial Care go-live on January 1, 2014, and staff would be less available to conduct onsite audits in fall 2013 during the same time frame as the LHP audit. The differences in time frame were sensitive to contracting issues across the MCOs and were approved by HSD. This report covers the results of both audits.

HealthInsight New Mexico planned and implemented an audit to evaluate the MCOs’ performance in accordance with the HSD Letters of Direction (LOD) 14-03 and 14-11. The audit addressed the Performance Measurement Program (PMP) and Performance Improvement Projects (PIPs) for the BCBS Salud! program, LHP and MHP. PHP had Performance Measures (PMs) and PIPs examined for both the Salud! and SCI programs. The audit time frame was July 1, 2012, through June 30, 2013 (State Fiscal Year [SFY] 2013). The audit included a comprehensive desk review of the MCO reports, interventions, internal quality review materials, and other documentation. Table 1 shows the overall scores and compliance designations for SFY 2013. Complete findings and detailed scores are included in the section prepared for each MCO following this report.

Table 1: PMP1 and PIPs Audit Results Summary

Medicaid Salud! Demonstrated Compliance Levels

PMP Compliance

PIP #1 Compliance

PIP #2 Compliance

BCBS Salud! Full Full Full

LHP Salud! Full Moderate Full

MHP Salud! Full Full Full

PHP Salud! Full Full Full

Medicaid SCI Demonstrated Compliance Levels

PMP Compliance

PIP #1 Compliance

PIP #2 Compliance

LHP SCI Moderate Minimal Moderate

MHP SCI Full Full Full

PHP SCI Full Full Full

1 In this report, PMP refers to the overall performance measurement program, while PM refers only to individual

performance measures within the PMP.



Background The Centers for Medicare & Medicaid Services (CMS) and the Balanced Budget Act (BBA) require each state to promote quality services for its enrollees. This requires all MCOs rendering services to Medicaid consumers to have an external quality review audit. HealthInsight New Mexico is contracted with HSD to serve as its External Quality Review Organization (EQRO) to audit contracted MCOs for adherence to federal and state regulations and contractual obligations based on CMS-published protocols. HSD published the State of New Mexico Quality Assessment and Performance Improvement Strategy for Medicaid Services in May 2009.2 In the report, HSD outlines the strategy for Medicaid MCOs in New Mexico to exceed standards for access to care, clinical quality of care, and quality of service.

After years of traditional fee-for-service Medicaid, the state legislature mandated the creation of managed care programs to provide comprehensive medical and social services to the Medicaid population. The Salud! program was developed to comply with this mandate and was launched on July 1, 1997. The program was designed to improve the quality of health care, improve access to care, and make cost-effective use of state and federal funds.

In 2005, New Mexico launched the SCI program, which combined some features of Medicaid with a basic commercial plan. New Mexico has focused on fostering cooperation among federal, state, and private organizations to provide funding for, and access to, care for SCI participants. Elements of this program include health insurance for small businesses, nonprofit organizations, the self-employed, and adults who are not eligible for Medicaid.3 The state of New Mexico initiated a waiting list for SCI benefits in November 2009. HSD directed HealthInsight New Mexico to conduct a compliance audit of the four physical health MCOs’ programs for the period of SFY 2013.

The Salud! and SCI programs concluded on December 31, 2013, in preparation for the new Centennial Care Medicaid program implementation.

Purpose The purpose of this audit was to measure and score the MCO’s performance against selected quality standards in HSD Managed Care Regulations and contractual obligations. The objectives of the audit were to:

Measure and score the MCO’s performance against state-mandated quality standards

Review the MCO’s structures and processes

Evaluate whether or not each MCO is following its own established policies and procedures

Compare and analyze audit findings

Identify opportunities for improvement in both systems and processes

Make recommendations

2 The state has drafted a revised State Quality Strategy, which is in the public comment period as this report is being

written. 3 State of NM Quality Assessment and Performance Improvement Strategy for Medicaid Services, May 2009, pg. 4.



Audit Method The audit method was designed to align the audit process with the specifications in the MCOs’ contractual requirements and LODs 14-03 and 14-11 from HSD to HealthInsight New Mexico. Appropriate data collection and data analysis procedures, consistent with industry standards, were utilized to provide audit assurance and to identify areas requiring further investigation. Per CMS, the MCO must perform continuous quality improvement (CQI) functions that recognize opportunities for improvement, and CQI projects must include the following elements, based on CMS protocols:

Be performed using objective quality indicators

Be data driven

Employ continuous measurement

Implement programmatic improvements with repeated measurements of effectiveness As required in 42 CFR 438.240, PIPs must include the following components:

Measurement of performance using objective quality indicators

Implementation of system interventions to achieve improvement

Evaluation of the effectiveness of the interventions

Planning and initiation of activities for increasing or sustaining improvement The audit method was developed using New Mexico Administrative Code (NMAC) and CMS protocols for assessing performance. The final methodology consisted of the following sections:

Rationale (understanding of the regulations and LOD specifications)

Evidence required (documentation)

Interpretive guidelines

Data collection tools

Scoring criteria The first audit task included a review of MCO policies, procedures, and operations related to their comprehensive PMP. Nine 2012 PMs were selected by HSD for review in this audit. Some of the PMs have submeasures, which brought the total numbers of measures and submeasures reviewed to 18. They are as follows:

PM #1 Annual Dental Visit (combined rate)4 Number of people ages 2-21 years with dental visits

PM #2 Well Child Visits Number of infants from birth through 15 months with at least six well child visits

with a primary care provider (PCP) Number of children ages 3-6 years with at least one well child visit with PCP

PM #3 Children and Adolescent Access to Primary Care Providers Number of infants ages 12-24 months who had a visit with a PCP Number of children ages 25 months through 6 years who had a visit with a PCP Number of children ages 7-11 years who had a visit with a PCP during

measurement year or the year prior Number of adolescents ages 12-19 years who had a visit with a PCP during

measurement year or the year prior

4 This measure follows HEDIS specifications which break the rates up into various age stratifications then a combined

rate. The combined rate covers ages 2 through 21.



PM #4 Childhood Immunizations (Combo 2)5 Number of children 2 years of age who have completed Combo 2 immunizations

PM #5 Use of Appropriate Medications for People with Asthma Number of children ages 5-11 years diagnosed with chronic asthma and placed

on appropriate medications

PM #6 Breast Cancer Screening Number of women ages 40-69 years who had a mammogram to screen for

breast cancer

PM #7 Comprehensive Diabetes Care (ages 18-75) Number of members who received a Hemoglobin A1c (HbA1c) test Number of members with HbA1c in poor control (HbA1c greater than 9%) Number of members who received a retinal eye exam Number of members who received a Low Density Lipoprotein Cholesterol

(LDL-C) screening Numbers of members who received medical attention for nephropathy

PM #8 Timeliness of Prenatal and Postpartum Care Number of members who received a prenatal care visit in first trimester of

pregnancy or within 42 days of enrollment Number of members who received a postpartum visit on or between 21-56 days

after delivery

PM #9 Frequency of Ongoing Prenatal Care Number of members who received greater than 81 percent of expected prenatal

visits The assessment process included a review of targeted quality-related interventions for each individual measure. All of the PMs selected were Healthcare Effectiveness Data and Information Set (HEDIS®)6 defined. The second audit task included a review of each MCO’s quality improvement processes associated with two internal, clinically-related PIPs. The PIPs were selected by the individual MCO to demonstrate the effectiveness of the performance improvement processes established within the MCO. The objective of the audit was to evaluate all processes related to the CQI system of tracking, intervention, and evaluation and to assign scores accordingly.

Audit Tools The audit tools were developed based upon LOD 13-06 and the CMS EQR Protocol 2: Validation of Performance Measures Reported by the MCO and EQR Protocol 3: Validating Performance Improvement Projects Version 2.0, Sept. 2012. Specific scoring items from CMS protocols and components were incorporated in the tools.

5 Combo 2 is a set of immunizations that includes vaccinations for DTaP (diphtheria, tetanus, and pertussis), IPV

(polio), MMR (measles, mumps, rubella), HiB (Haemophilus influenza which causes childhood meningitis), and the VZV (Varicella zoster virus which causes chicken pox). 6 HEDIS is the abbreviation for the Healthcare Effectiveness Data and Information Set and is a registered trademark

of the National Committee for Quality Assurance (NCQA).



The audit tools were developed to address the selected quality standards in HSD Managed Care Regulations specific to each PM and PIP as delineated in the LOD. The audit tools were tested prior to implementation to increase accuracy, ease of use, and consistency. HealthInsight New Mexico auditors reviewed the tools in advance to facilitate familiarity with the tools prior to application and scoring. The tools were revised to adjust for the recommendations made during testing. The audit tools were approved by HSD prior to HealthInsight New Mexico requesting documentation from the MCO for the audit. The PMP tool was developed from CMS EQR Protocol 2. The tool was divided into two sections. The first section assessed the MCO’s data tracking processes, such as how the numerator and denominator are determined, how the data are collected, and how the reports are analyzed. The second section addressed the MCO’s CQI program requirements, such as how interventions are formulated, how barriers are identified and addressed, and how success is measured. The PIP tool was developed based on the CMS EQR Protocol 3. This tool assesses each project by completing the following 10 steps:

1. Review the Selected Study Topic 2. Review the Selected Study Question 3. Review the Selected Study Indicators 4. Review the Identified Study Population 5. Review Sampling Methods 6. Review Data Collection Procedures 7. Assess Improvement Strategies 8. Review Data Analysis and Interpretation of Study Results 9. Assess Whether Improvement is “Real” Improvement

10. Assess Sustained Improvement

Audit Overview As an overview of the audit process and expectations, the MCOs were given the following documents:

Audit timeline

Scoring method for both PMs and PIPs

Document request for document review items

Data submission roadmaps Questions from the MCOs were addressed on an individual basis.

Clarification and Rebuttal and Reconsideration Clarification regarding any items initially found not compliant in the PMs and PIPs was requested prior to scoring. Clarification questions were submitted and responses were received via email. Responses were considered in scoring. The MCOs were presented with a draft of the report and allowed to rebut findings and request reconsideration.



Scoring Method This section describes the PMP and PIP numerical system used for scoring the quality standards within each category and for calculating an overall score for performance.

Performance Measurement Program Scoring Method In assessing performance, the following indicators related to CQI functions were reviewed:

Assessment of methods for conducting the PMP for: Identification of systematic processes to extrapolate claims data Establishment of accurate calculation methods, including definition of numerators

and denominators Review and analysis of required reports

Evaluation of quality documents that demonstrate the CQI process for: Identification of strengths, weaknesses, and potential barriers to improvement Development and implementation of interventions Periodic reassessment to determine level of success for interventions

Performance Improvement Project Scoring Method In assessing PIP performance, the following areas were reviewed:

Assessment of methods used by the MCOs for conducting their PIPs

Verification of the data processes to confirm that the reported results are based on accurate source information

Assessment of consistent application of the CQI functions when developing targeted interventions designed to improve performance rates

Evaluation of quality documents that demonstrate the CQI process in relation to identifying opportunities for improvement, targeting appropriate populations, reviewing measurement methods, analyzing data, demonstrating implementation, and assessing reevaluation outcomes

Per CMS, PIPs must:

Use objective quality indicators

Implement system intervention to achieve results

Evaluate the effectiveness of interventions in creating sustained improvement

Be repeatedly measured over time



Calculation of Final Overall Score Each PM and PIP was assigned a number of points. The number of points earned by the MCO was divided by the number of available points to arrive at a percentage score. This score translated into one of the demonstrated compliance levels identified in Table 2 below. MCO-specific and maximum available scores can be found in Table 3. Each element in the scoring method was approved by HSD.

Table 2: Demonstrated Compliance Level Scale

Demonstrated Compliance Level

Score Description

Full Compliance 90-100% Met or exceeded standard

Moderate Compliance 80-89% Met most requirements of the standard but has deficiencies in certain areas

Minimal Compliance 50-79% Met some requirements of the standard but has significant deficiencies requiring corrective action

Noncompliance <50% Did not meet standard and requires corrective action



Salud! Performance Measurement Program Audit Results Each MCO was evaluated for its ability to collect accurate data, its evidence of CQI process implementation, and its demonstration of improvement in processes and outcomes for the Salud! program. All four MCOs earned Full Compliance levels. One issue considered during scoring is the effectiveness of interventions. If a rate had a negative change, then the interventions were considered to be ineffective. The effectiveness of interventions counts for 2.5 points out of 10. If there are multiple submeasures, then 2.5 is divided by the number of submeasures and each submeasure is added or subtracted separately. This is why two PMs can have different amounts deducted for the same infraction (negative rate change).

Table 3 reflects scores and demonstrated compliance levels of each MCO’s Salud! PMP.

Table 3: Salud! PMP Audit Results

Salud! PMP Audit 2013

Available Points

BCBS LHP MHP PHP

Data Tracking Process

HEDIS Interactive Data Submission System

4.00 4.00 4.00 4.00 4.00

HEDIS Compliance Audit 5.00 5.00 5.00 5.00 5.00

CQI Program

Annual Preventive Dental Visits (ages 2-21 years)

13.00 13.00 13.00 13.00 13.00

Well Child Visits (first 15 months; 3-6 years)

13.00 13.00 13.00 13.00 13.00

Children’s and Adolescents' Access to PCPs

13.00 13.00 13.00 13.00 13.00

Childhood Immunizations (Combo 2) 13.00 13.00 13.00 13.00 13.00

Use of Appropriate Medications for People with Asthma (ages 5-11)

13.00 13.00 13.00 13.00 9.75

Breast Cancer Screening 13.00 13.00 13.00 13.00 13.00

Diabetes Disease Management 13.00 11.05 13.00 13.00 13.00

Timeliness of Prenatal and Postpartum Care

13.00 13.00 13.00 13.00 13.00

Frequency of Ongoing Prenatal Care 13.00 13.00 6.50 13.00 9.75

Total Points Available 126 126 126 126 126

Total Points Scored 124.05 119.50 126.00 119.50

Final Percentage Score 98.45% 94.84% 100.00% 94.84%

Demonstrated Compliance Level Full Full Full Full

For details on individual MCO scores, please see the MCO-specific appendices attached to this report.



State Coverage Insurance Performance Measurement Program Audit Results As with the Salud! program, each MCO was evaluated for its ability to collect accurate data, evidence of CQI process implementation, and demonstration of improvement in processes and outcomes for the SCI program. As discussed earlier, BCBS did not administrate the SCI program. MHP and PHP earned Full Compliance levels and LHP earned a Moderate Compliance level. Table 4 reflects scores and demonstrated compliance levels of each MCO’s SCI PMP.

Table 4: SCI PMP Audit Scores

SCI PMP Audit 2013

Available Points

LHP MHP PHP

CQI Program

Breast Cancer Screening 13.00 9.75 13.00 13.00

Diabetes Disease Management 13.00 13.00 13.00 12.35

Timeliness of Prenatal and Postpartum Care 13.00 13.00 13.00 13.00

Frequency of Ongoing Prenatal Care 13.00 9.75 13.00 13.00

Total Points Available 52.00 52.00 52.00 52.00

Total Points Scored 45.50 52.00 51.35

Final Percentage Score 87.50% 100.00% 98.75%

Demonstrated Compliance Level Moderate Full Full




Salud! Performance Improvement Projects Audit Results Each MCO submitted 2 PIPs for this audit as follows: BCBS PIPs

1. Childhood Immunization Status 2. Breast Cancer Screening

LHP PIPs

1. Use of Appropriate Medications for People with Asthma 2. Utilizing Synagis in Improving Health and Reducing Hospitalizations in RSV7 Vulnerable

Infants and Children MHP PIPs

1. Annual Dental Visits 2. Breast Cancer Screening

PHP PIPs

1. Breast Cancer Screening 2. Comprehensive Diabetes Care (HbA1c Testing)

Each PIP was evaluated and scored for CQI processes, performance rates, and demonstrated improvement. The underlying PIPs are different, but they are scored for structure and method using the same criteria; therefore, comparisons can be made. For PIP #1 across BCBS, MHP, and PHP, all earned Full Compliance levels, and LHP earned a Moderate Compliance level. For PIP #2, all four MCOs earned Full Compliance levels. The resulting scores for each PIP are given in Tables 5 and 6 that follow. For some PIPs, a sampling methodology was not used for the measures and is indicated with an “N/A” for not applicable. A sampling methodology is not used when all members meeting the study criteria are included in the measure.

7 Respiratory syncytial virus is a major cause of lower respiratory tract infections in small children.



Table 5 shows the PIP #1 scores and compliance levels for the Salud! program with comparisons across MCOs for each step scored.

Table 5: Salud! PIP Scores and Compliance Levels

Salud! PIP #1 2013

Available Points

BCBS LHP MHP PHP

1. Review the Selected Study Topic

5.00 5.00 5.00 5.00 5.00

2. Review the Selected Study Question

5.00 5.00 5.00 5.00 5.00

3. Review the Study Indicators 10.00 10.00 10.00 10.00 10.00

4. Review the Identified Study Population

5.00 5.00 5.00 5.00 5.00

5. Review Sampling Methods 5.00 N/A N/A N/A 5.00

6. Review Data Collection Procedures

20.00 20.00 20.00 20.00 20.00

7. Assess Improvement Strategies 20.00 20.00 20.00 20.00 20.00

8. Review Data Analysis and Interpretation of Study Results

5.00 5.00 5.00 5.00 5.00

9. Assess Whether Improvement Is “Real” Improvement

15.00 15.00 7.50 15.00 15.00


10.00 10.00 0.00 10.00 10.00

Total Points Available 100.00 95.00 95.00 95.00 100.00



Compliance Level Full Moderate Full Full




Table 6 shows the PIP #2 scores and compliance levels for the Salud! program with comparisons across MCOs for each step scored.

Table 6: Salud! PIP Scores and Compliance Levels

Salud! PIP #2 2013

Available Points

BCBS LHP MHP PHP

1. Review the Selected Study Topic

5.00 5.00 5.00 5.00 5.00

2. Review the Selected Study Question

5.00 5.00 5.00 5.00 5.00

3. Review the Study Indicators 10.00 10.00 10.00 10.00 10.00

4. Review the Identified Study Population

5.00 5.00 5.00 5.00 5.00

5. Review Sampling Methods 5.00 N/A N/A N/A 5.00

6. Review Data Collection Procedures

20.00 20.00 20.00 20.00 20.00

7. Assess Improvement Strategies 20.00 20.00 20.00 20.00 20.00


5.00 5.00 5.00 5.00 5.00


15.00 15.00 15.00 15.00 15.00


10.00 10.00 10.00 10.00 10.00

Total Points Available 100.00 95.00 95.00 95.00 100.00



Compliance Level Full Full Full Full




State Coverage Insurance Performance Improvement Projects Audit Results BCBS did not administrate an SCI program during the audit period. Each of the other three MCOs submitted two PIPs for this audit as follows: LHP PIPs

1. Use of Appropriate Medications for People with Asthma 2. Improving the Frequency of Prenatal Care

MHP PIPs

1. Comprehensive Diabetes Care (HbA1c Testing) 2. Improving Postpartum Care

PHP PIPs

1. Breast Cancer Screening 2. Comprehensive Diabetes Care (HbA1c Testing)

Each PIP was evaluated and scored for CQI processes, performance rates, and demonstrated improvement. The underlying PIPs are different, but they are scored for structure and method using the same criteria; therefore, comparisons can be made. For PIP #1, MHP and PHP earned Full Compliance levels and LHP earned Minimal Compliance level. For PIP #2, MHP and PHP earned Full Compliance levels and LHP earned a Moderate Compliance level. The resulting scores for each PIP are given in Tables 7 and 8 that follow.



Table 7 shows the PIP #1 scores and compliance levels for the SCI program with comparisons across MCOs for each step scored.

Table 7: SCI PIP Scores and Compliance Levels

SCI PIP #1 2013

Available Points

LHP MHP PHP

1. Review the Selected Study Topic 5.00 5.00 5.00 5.00

2. Review the Selected Study Question 5.00 5.00 5.00 5.00

3. Review the Study Indicators 10.00 0.00 10.00 10.00

4. Review the Identified Study Population 5.00 0.00 5.00 5.00

5. Review Sampling Methods 5.00 N/A N/A NA

6. Review Data Collection Procedures 20.00 20.00 20.00 20.00

7. Assess Improvement Strategies 20.00 20.00 20.00 20.00


5.00 4.00 5.00 5.00


15.00 11.25 15.00 15.00

10. Assess Sustained Improvement 10.00 N/A 10.00 10.00




Compliance Level Minimal Full Full




Table 8 shows the PIP #2 scores and compliance levels for the SCI program with comparisons across MCOs for each step scored.

Table 8: SCI PIP Scores and Compliance Levels

SCI PIP #2 2013

Available Points

LHP MHP PHP



3. Review the Study Indicators 10.00 10.00 10.00 10.00


5. Review Sampling Methods 5.00 N/A N/A 5.00




5.00 5.00 5.00 5.00

9. Assess Whether Improvement is “Real” Improvement

15.00 7.50 15.00 15.00

10. Assess Sustained Improvement 10.00 0.00 10.00 10.00




Compliance Level Moderate Full Full




Outcome Measures The measurement and reporting of process measures is an important part of the quality improvement section of the HSD contracts with the MCOs. In 2009, HSD began discussions with the MCOs about adding health outcome measures to the PM and PIP evaluation processes. Each MCO was instructed to identify, measure, and report health care outcomes as well as performance rates. Since this is not yet a contractual requirement for the MCOs, HSD did not make reporting of health care outcomes a mandatory portion of this audit. BCBS, MHP, and PHP reported health care outcome measures for each PM. Health care outcome measures are discussed in more detail in the individual MCO sections later in this report.

Salud! and SCI Recommendations This audit was conducted to discover the extent to which each MCO met the quality standards set forth by HSD for the provision of Salud! and SCI services. It is recognized that the Salud! contract concluded at the end of calendar year 2013. The recommendations are for process improvement and can be extrapolated and transferred to other lines of business beyond the current Medicaid contract and into Centennial Care that began at the beginning of calendar year 2014. For details on individual MCO recommendations, see the MCO-specific appendices.

Conclusion and Recommendations Based on HealthInsight New Mexico’s review of CMS requirements, evidence acquired during this audit, interpretive guidelines, and the scoring methodology approved by HSD, HealthInsight New Mexico finds that, overall, the MCOs, with noted exceptions, continue to maintain high quality standards for the provision of clinical care to Medicaid members in New Mexico. Each MCO has processes in place designed to improve rates for each PM. Additional details and recommendations are provided in the individual MCO sections attached to this report.

Rebuttal and Reconsideration Review Each MCO was presented with a draft of the report and allowed to rebut findings and request reconsideration. For details on individual MCO comments, please see the MCO-specific appendices attached to this report.


Section A: BCBS July 7, 2014

Section A: Blue Cross Blue Shield of New Mexico (BCBS)

Salud! PMP Audit Results BCBS achieved full compliance for the Salud! Performance Measurement Program (PMP) audit. Table 1 reflects the scores for BCBS for the selected PMP standards for 2012 and 2013. BCBS demonstrated compliance in its processes and systems related to the required Performance Measures (PMs), and BCBS has Continuous Quality Improvement (CQI) programs established for targeting improvement within the PMs required for this audit.

An assessment of the interventions’ effectiveness impacted the MCO’s score. If a rate showed a negative pattern of change, then the interventions implemented were considered to be ineffective. If a measure had multiple scoring questions (submeasures), then each submeasure was evaluated separately. Because some PMs were broken down into submeasures, two PMs could have different amounts deducted for the same infraction (negative rate change).

Table 1: BCBS Salud! PMP Audit Scores and Compliance Levels with Historical Comparison

BCBS Salud! PMP Audit 2012/2013 Available

Points

2012 Actual Score

2013 Actual Score


HEDIS Interactive Data Submission System 4.00 4.00 4.00

HEDIS Compliance Audit 5.00 5.00 5.00

CQI Program

PM #1 Annual Preventive Dental Visits (ages 2-21 years)

13.00 13.00 13.00

PM #2 Well Child Visits (first 15 months; 3-6 years) 13.00 13.00 13.00

PM #3 Children and Adolescents' Access to Primary Care Physicians

13.00 13.00 13.00

PM #4 Childhood Immunization Status (Combo 2)8 13.00 13.00 13.00

PM #5 Use of Appropriate Medications for People with Asthma (ages 5-11 years)

13.00 13.00 13.00

PM #6 Breast Cancer Screening 13.00 13.00 13.00

PM #7 Comprehensive Diabetes Care 13.00 13.00 11.05

PM #8 Timeliness of Prenatal and Postpartum Care 13.00 13.00 13.00

PM #9 Frequency of Ongoing Prenatal Care 13.00 13.00 13.00

Total Points Available 126.00 126.00 126.00

Total Points Scored 126.00 124.05

Final Percentage Score 100.00% 98.45%

Compliance Level Full Full


(polio), MMR (measles, mumps, rubella), HiB (Haemophilus influenza which causes childhood meningitis), and the VZV (Varicella zoster virus which causes chicken pox).



Table 2 compares Salud! performance rates with minimum thresholds set by HSD. For 2013, BCBS scored above the HSD threshold for nine of 18 measures and submeasures for which HSD thresholds were established. The rates in red indicate rates that did not meet HSD thresholds for the given years. HSD reviews its thresholds yearly and revises periodically. HSD thresholds are displayed in Table 2 below.

Table 2: BCBS Salud! PM Performance Rates and Historical Comparison

BCBS Performance Measures 2012/2013

HSD Threshold

2012 Rate 2013 Rate

Annual Preventive Dental Visits

Combined 2-21 years 70.00% 61.70% 64.00%

Well Child Visits by Ages

First 15 months of life 62.00% 63.05% 63.05%

3-6 years 70.00% 56.07% 58.28%

PCP Access by Ages

12-24 months 97.00% 97.40% 97.20%

25 months-6 years 90.00% 85.24% 86.12%

7-11 years 90.00% 83.77% 85.22%

12-19 years 90.00% 84.79% 85.76%

Childhood Immunization Status (Combo 2)9 78.00% 75.28% 79.47%

Use of Appropriate Medications for People with Asthma (ages 5-11 years)

91.00% 96.88% 93.90%

Breast Cancer Screening 55.00% 50.79% 55.60%

Comprehensive Diabetes Care

HbA1c Testing 85.00% 82.33% 82.33%

HbA1c Test (Poor Control greater than 9.0%) 48.00% or less

39.66% 39.66%

Retinal Eye Exam 56.00% 53.88% 53.88%

LDL-C Screening 74.00% 72.41% 72.41%

Medical Attention for Nephropathy 75.00% 76.29% 76.29%

Timeliness of Prenatal Care 85.00% 87.67% 86.06%

Postpartum Care 60.00% 67.71% 63.05%

Frequency of Ongoing Prenatal Care (81% or more of expected visits)

60.00% 65.70% 50.84%


(polio), MMR (measles, mumps, rubella), HiB (Haemophilus influenza which causes childhood meningitis), and the VZV (Varicella zoster virus which causes chicken pox).



The following discussion focuses on performance rate changes between years 2012 and 2013 as shown in Table 2. BCBS remains below the HSD threshold on nine measures and submeasures and meets or exceeds the HSD threshold for the remaining nine measures and submeasures. The diabetes submeasure HbA1c Test (Poor Control greater than 9.00%) is an inverse measure; therefore, a decline in rate is an improvement. BCBS improved the rate of Annual Dental Visits by 2.30 percentage points. BCBS sends reminder mailings, including gift card incentives and fliers, and makes educational materials available to members. The BCBS Quality Improvement Team meets quarterly with DentaQuest for ongoing data analysis and root cause analysis to improve member outreach and preventive care rates. Discussions at the meetings include analysis of the dental provider network and brainstorming methods to encourage members to use their dental benefit. Both general dental education and individualized targeted member outreach are completed annually. An individualized member incentive program including gift cards was developed and implemented by the end of the third quarter 2012, and has continued annually ever since. This rate remains below the HSD threshold of 70 percent. The rates for Well Child Visits were split by age group. The rate for the first 15 months of life remained static at 63.05 percent, which met the HSD threshold of 62.00 percent. For the 3- to 6-year-old age group, the rate increased from 56.07 percent to 58.28 percent, which is below the HSD threshold of 70.00 percent. BCBS undertakes a series of interventions for this population. BCBS conducts targeted member outreach, which includes incentive fliers offering gift cards for the completion of the visit, automated telephonic outreach, and education pamphlets about the importance of well child visits.

PCP Access improved in a year-over-year comparison, but only the age stratification of 12-24 months met the HSD threshold. The interventions undertaken are similar to other performance measures, including incentive letters offering gift cards upon the completion of an annual visit, newsletter articles, and automated telephonic outreach.

BCBS sought to improve the Childhood Immunization Status rate. In addition to the standard interventions, a pilot study was completed to research the status of 17-month-old members who had seven or fewer vaccines documented in the New Mexico Statewide Immunization Information System (NMSIIS). Forty-four 17-month-old members were identified. A telephone survey was conducted: 17 (37%) of these members were reached, and 16 (36%) shared the name of his/her PCP. The PCPs were contacted, and as a result 15 immunization records were obtained, six of which were Combo 2 completed. Providers not documenting into NMSIIS were identified and the BCBS Network Services department provided follow-up education.

The Appropriate Use of Medications for Members with Asthma interventions appear to be similar to those undertaken for other measures, including member educational articles and automated telephone reminder calls. The rate declined 2.98 percentage points between the previous audit and the current audit, but the rate remains above the HSD threshold of 90.00 percent.

Breast Cancer Screening interventions focus on mobile mammography events. Mobile mammography events are coordinated and scheduled with Assured Imaging across the state of New Mexico to ensure that members have convenient access to mammogram screenings. Each month, 4 to 12 events are scheduled. Outreach mailings are sent to members to inform them of the events and the mobile mammogram provider completes telephone calls to members to



assist with scheduling an appointment. This provides additional convenience for the member and helps increase mammography event participation. Callers are knowledgeable and able to answer members’ questions related to screening mammograms, which helps reduce fear and knowledge deficit barriers to obtaining mammogram screening. The rate for this measure went from below the HSD threshold in the previous audit to above the threshold in the current audit.

For Comprehensive Diabetes Care, the rates have not been reported again. The previous year’s numbers still stand for audit purposes. Per documentation submitted by BCBS, HSD approved BCBS’s option to rotate measures to reduce the administrative burden. This is an option provided to health plans for measures that meet certain criteria.

For Timeliness of Prenatal and Postpartum Care, BCBS has the Special Beginnings program that promotes prenatal and postpartum care for mothers. The Special Beginnings program has dedicated maternity case managers and health care coordinators. Members can also now receive a free car seat when they attend 81 percent of prenatal visits. Both of these rates declined between the previous audit and the current audit. The Prenatal Care Timeliness outcome is above the HSD threshold, while the Postpartum Timeliness outcome is below the threshold.

For Frequency of Ongoing Prenatal Care, BCBS offers classes to young parents. BCBS case managers engage with community health worker programs including CARE NM, Families First, and First Born programs in order to fill the needs of the community.



Salud! PIP Audit Results BCBS submitted two PIPs for the Salud! program:

1. Childhood Immunization Status - Combo 2 2. Breast Cancer Screening

Per CMS, PIPs must:

1. Use objective quality indicators 2. Implement system interventions to achieve results 3. Evaluate the effectiveness of interventions for creating sustained improvement 4. Be repeatedly measured over time

Each PIP was evaluated and scored for CQI processes, performance rates, and demonstrated improvement. A performance rate represents the percentage of eligible members who received a specific treatment or service during the audit time frame. Performance rates are helpful in assessing the effectiveness of MCO interventions and for comparing trends with state and national levels. Table 3 shows the performance rates and comparisons for both of the Salud! PIPs submitted for review.

Table 3: BCBS Salud! PIP Performance Rates with Historical Comparison

PIP Topics

Baseline 2012 2013

Percentage Point

Difference of 2013

from 2012

Percentage Point

Difference of 2013

from Baseline

PIP #1

The proportion of eligible BlueSalud children who receive the recommended Childhood Immunizations-Combo 2 by their second year of life.

69.76% 75.28% 79.47% 4.19% 9.71%

PIP #2

The proportion of eligible BlueSalud women aged 40-69 years who obtain recommended screening mammograms no less often than every two years.

38.46% 50.79% 55.60% 4.81% 17.14%

Salud! PIP #1: Childhood Immunizations- Combo 2 As shown in Table 3, the PIP has demonstrated improved rates each year of its implementation so that now the rate is 9.71 percentage points above baseline. At the outset this measurement was below the HSD threshold, whereas it is now above the threshold of 78.00 percent.



As shown in Table 4 below, BCBS achieved 100.00 percent for this PIP. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation.

Table 4: Salud! PIP #1 Childhood Immunizations- Combo 2

PIP Analysis Criteria 2012

Available Points

2012 Score

2013 Available

Points

2013 Score



3. Review the Selected Study Indicators 10.00 10.00 10.00 10.00


5. Review Sampling Methods 5.00 N/A 5.00 N/A




5.00 5.00 5.00 5.00


10.00 10.00 15.00 15.00

10. Assess Sustained Improvement 15.00 N/A 10.00 10.00





BCBS divided the interventions into three categories: targeted to members, targeted to providers, and targeted at systems. There were over a dozen interventions targeted at members, including various educational activities, Consumer Advisory Board meetings, and Immunization Incentive programs where the New Mexico Statewide Immunization Information System (NMSIIS) was reviewed and BCBS followed up with members who did not have a documented vaccination. BCBS collaboratively supported the New Mexico Immunization Coalition and contributed to the annual “Got Shots? Protect Tots!” program, which encouraged providers to participate in the open childhood immunization clinic, assist with program coordination and offer handout materials. In 2012 and 2013, 1,750 coloring books and 500 placemats were donated as “give-aways” for those children receiving vaccines at the clinics. Additionally, the BCBS CareVan participated as a vaccine provider in Roswell and Hobbs during each event. System issues that were addressed included coordination of transportation issues, language assistance, and reimbursements for providers who kept their records on NMSIIS up-to-date. BCBS also reimbursed Vaccines for Children (VFC)-participating providers for vaccine administration.



The result of these interventions has been an ongoing increase in the rates of children receiving the Combo 2 immunizations.

Salud! PIP #2: Breast Cancer Screening As shown in Table 5 below, BCBS demonstrated full compliance (100.00%) for PIP #2 for 2013. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation. As shown in Table 3, the PIP has demonstrated improved rates each year of its implementation, so that now the rate is 17.14 percentage points above baseline. At the outset this measurement was below the HSD threshold, whereas it is now above the threshold of 55.00 percent.

Table 5: Salud! PIP #2 Breast Cancer Screening


Available Points

2012 Score

2013 Available

Points

2013 Score





5. Review Sampling Methods 5.00 5.00 5.00 N/A



8. Review Data Analysis and Interpretation of Study Results.

5.00 5.00 5.00 5.00


10.00 5.00 15.00 15.00

10. Assess Sustained Improvement 15.00 0 10.00 10.00




Compliance Level Moderate Full

As shown in Table 5 above, the 2012 score for this PIP improved due to an increase in the performance rates. BCBS broke the interventions into three categories: targeted to members, targeted to providers, and targeted at systems. Member-specific interventions included personalized, targeted educational/reminder calls, and new member packets with information on preventive care guidelines, translational assistance, and other educational materials regarding the importance of preventive care.



BCBS worked to organize a joint committee with other MCOs to increase deployment of mobile mammography (MM) services in areas of the state where access is limited. An HSD-approved flier that could be easily modified with specifics for separate MM events was developed. BCBS Medicaid also partnered with the BCBS commercial line of business so that Medicaid members could participate in Yes, Ma’am. Say Yes to Mammograms events held in Albuquerque and Santa Fe. BCBS sent information notices to all providers regarding access of all provider education materials, including preventive care guidelines available on the BCBS website. System issues that were addressed included coordination of transportation issues and the work of a Breast Cancer Screening Awareness campaign manager.

Outcome Measures HealthInsight New Mexico requested health care outcome measures for review, but those measures did not constitute a scored section of this audit. BCBS developed outcome measures for each PM to document the next level of care for their members. An example of an outcome measure provided was tracking the number of members diagnosed with dental cavities that went on to have restorative services. A second example of an outcome measure provided was tracking the number of members who received a Well Child Visit who had follow-up appointments with their PCP to address the diagnosis codes relating to symptoms concerning nutrition, metabolism, and delays in development.

Salud! Recommendations This audit was conducted to discover the extent to which BCBS met the quality standards set forth by HSD for the provision of Salud! services. Recommendations for improvement are listed separately for each PM and PIP. It is recognized that the Salud! contract concluded at the end of calendar year 2013. The following recommendations are for process improvement and can be extrapolated and transferred to other of BCBS’s Lines of Business beyond the current Medicaid contract and into Centennial Care.

Performance Measures It is recommended that BCBS research, implement and evaluate evidence-driven best practices to improve quality indicators for the following measures:


Timeliness of Prenatal Care

Postpartum Care

Frequency of Ongoing Prenatal Care (81.00% or more of expected visits)

Performance Improvement Projects

There are no recommendations for improvement from this audit.

Rebuttal and Reconsideration BCBS was offered the opportunity to comment on this report and to rebut any findings. BCBS accepted the findings of the audit and did not offer any rebuttals or requests for reconsideration.


Section B: LHP July 7, 2014

Section B: Lovelace Health Plan (LHP)

Salud! Performance Measurement Program Audit Results LHP achieved full compliance for the Salud! Performance Measurement Program (PMP) audit. Table 1 reflects the scores for LHP for the selected PMP standards for 2012 and 2013. LHP demonstrated compliance in its processes and systems related to the required Performance Measures (PMs), and LHP has Continuous Quality Improvement (CQI) programs established for targeting improvement within the PMs required for this audit.

An assessment of the interventions’ effectiveness impacted the MCO’s score. If a rate showed a negative pattern of change, then the interventions implemented were considered to be ineffective. If a measure had multiple scoring questions (submeasures), then each submeasure was evaluated separately. Because some PMs were broken down into submeasures, two PMs could have different amounts deducted for the same infraction (negative rate change).

Table 1: LHP Salud! PMP Audit Scores and Compliance Level with Historical Comparison

LHP Salud! PMP Audit 2012/2013 Available

Points

2012 Actual Score

2013 Actual Score


HEDIS®10 Interactive Data Submission System 4.00 4 4

HEDIS Compliance Audit 5.00 5 5

CQI Program

PM #1 Annual Preventive Dental Visits (ages 2-21 years) 13.00 13 13

PM #2 Well Child Visits (first 15 months; 3-6 years) 13.00 13 13


13.00 13 13

PM #4 Childhood Immunization Status (Combo 2)11 13.00 13 13


13.00 13 13

PM #6 Breast Cancer Screening 13.00 13 13

PM #7 Comprehensive Diabetes Care 13.00 13 13

PM #8 Timeliness of Prenatal and Postpartum Care 13.00 13 13

PM #9 Frequency of Ongoing Prenatal Care 13.00 13 6.5

Total Points Available 126.00 126 126

Total Points Scored 126.00 126 119.5


Compliance Level Full Full Full

10

HEDIS is the abbreviation for the Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA). 11

Combo 2 is a set of immunizations that includes vaccinations for DTaP (diphtheria, tetanus, and pertussis), IPV (polio), MMR (measles, mumps, rubella), HiB (Haemophilus influenza which causes childhood meningitis), and the VZV (Varicella zoster virus which causes chicken pox).



Table 2 compares LHP Salud! performance rates with minimum thresholds set by HSD. LHP scored above the HSD threshold for 10 of 18 measures and submeasures for which HSD thresholds were established. The rates in red indicate rates that did not meet HSD thresholds for the given years. HSD reviews its thresholds yearly and revises periodically. HSD thresholds are displayed in the table below.

Table 2: LHP Salud! PM Performance Rates and Historical Comparison

LHP Performance Measures 2012/2013

HSD Thresholds

2012 Rate

2013 Rate


Combined 2-21 years 70.00% 69.07% 71.49%



3-6 years 70.00% 64.97% 64.97%

PCP Access by Ages

12-24 months 97.00% 98.04% 98.55%

25 months-6 years 90.00% 89.45% 88.77%

7-11 years 90.00% 92.61% 91.82%

12-19 years 90.00% 90.68% 90.86%

Childhood Immunization Status (Combo 2) 78.00% 76.40% 81.51%


91.00% 92.41% 90.13%



HbA1c testing 85.00% 83.21% 83.21%

HbA1c test (Poor Control greater than 9.0%) 48.00% or less

43.07% 43.07%

Retinal eye exam 56.00% 43.08% 46.72%

LDL-C screening 74.00% 68.37% 68.37%

Medical attention for nephropathy 75.00% 73.48% 74.70%

Timeliness of prenatal care 85.00% 86.84% 87.06%

Postpartum care 60.00% 66.58% 65.50%

Frequency of ongoing prenatal care (81% or more of expected visits completed for each patient)

60.00% 70.53% 64.96%

The following discussion focuses on performance rate changes between years 2012 and 2013.



LHP improved the rates for Annual Dental Visits from 69.07 to 71.49 percent. This is a 2.42 percentage point increase in the rate, which is not statistically significant but did meet the HSD threshold of 70.00 percent. The rates for Well Child Visits were split by age group. The rate for the first 15 months of life remained static at 67.27 percent, which met the HSD threshold of 62 percent. For the 3- to 6-year-old age group, the rate remained static at 64.97 percent, which is below the HSD threshold of 70.00 percent. LHP met the HSD threshold for all age groups in the Children’s and Adolescents' Access to Primary Care Physicians (PCPs) measure, except the 25 months to 6 years age group. This age group rate declined less than 1 point to 88.77 percent and missed the HSD threshold of 90.00 percent. Childhood Immunizations (Combo 2) saw a rate increase from 76.40 to 81.51 percent, an increase of 5.11 percentage points, which is statistically significant and surpassed the HSD threshold of 78.00 percent. For the Use of Appropriate Medications in People with Asthma measure, LHP had an approximate drop of 2 percentage points to 90.13 percent, and that fell short of the HSD threshold of 91.00 percent. The Breast Cancer Screening rate continues to remain stable at 40.63 percent, which is less than the HSD threshold of 55.00 percent. There have been no statistically significant changes in the rate over the last several measurement periods. LHP noted several barriers to overcome, including member apathy toward the importance of screening, fear of a cancer diagnosis, cultural/language barriers, and economic barriers. LHP rates for three of the Comprehensive Diabetes Care submeasures remained static and two rates increased from last year. Four of the five submeasures did not meet the HSD thresholds. Retinal Eye Exam rates increased by 3.64 percentage points from 43.08 to 46.72 percent, which is below the HSD threshold of 56.00 percent. Medical attention for nephropathy increased by 1.22 percentage points to 74.70 but missed the HSD threshold of 75.00 percent. The rate for Timeliness of Prenatal Care increased slightly from 86.84 to 87.06 percent, which exceeded the HSD threshold of 85.00 percent. The rate for Postpartum Care decreased by 1.08 percentage points, from 66.58 to 65.50 percent, but still exceeded the HSD threshold of 60.00 percent. The rate for Frequency of Ongoing Prenatal Care fell 5.57 percentage points from 70.53 to 64.96 percent, but remains well above the HSD threshold of 60.00 percent.



Salud! Performance Improvement Projects Audit Results LHP submitted two PIPs for the Salud! program:

1. Use of Appropriate Medications for People with Asthma (ages 5-11) 2. Utilizing Synagis in Improving Health and Reducing Hospitalizations in RSV12 Vulnerable

Infants and Children Per CMS, PIPs must:


Implement system interventions to achieve results

Evaluate the effectiveness of interventions for creating sustained improvement

Be repeatedly measured over time Each PIP was evaluated and scored for CQI processes, performance rates and demonstrated improvement. A performance rate represents the percentage of eligible members who received a specific treatment or service during the audit time frame. Performance rates are helpful in assessing the effectiveness of MCO interventions and for comparing trends with state and national levels. Table 3 shows the performance rates and comparisons for both of the LHP Salud! PIPs submitted for review.

Table 3: LHP Salud! PIP Performance Rates with Historical Comparison

PIP Topics

Baseline 2012 2013

Percentage Point

Difference of 2013

from 2012

Percentage Point

Difference of 2013

from Baseline

PIP #1

Appropriate Medications for People with Asthma (ages 5-11 years)

92.66% 92.41% 90.13% -2.28% -2.53%

PIP #2

Utilizing Synagis in Improving Health and Reducing Hospitalizations in RSV Vulnerable Infants and Children (Infants receiving a full course of treatment)

65.25% 75.64% 80.00% 4.36% 14.75%

Salud! PIP #1: Use of Appropriate Medications for People with Asthma (ages 5-11 years) Respiratory syncytial virus (RSV) is a major cause of lower respiratory tract infections (i.e., bronchiolitis or pneumonia) among young children. Synagis is a prescription drug that is used to prevent RSV. This study was initiated to track and trend the use of Synagis prescriptions to

12

Although this is not a HEDIS measure, the MCO has the latitude to choose a PIP for auditing that improves processes but is not necessarily directly related to a published HEDIS measure.



reduce RSV and related hospitalization rates in infants and young children given this medication. As shown in Table 4 below, LHP demonstrated moderate compliance (81.58%) for PIP #1 for 2013. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation.

Table 4: Salud! PIP #1 Use of Appropriate Medications for People with Asthma (ages 5-11 years)


Available Points

2012 Score

2013 Available

Points

2013 Score









5.00 5.00 5.00 5.00


10.00 8.00 15.00 7.50

10. Assess Sustained Improvement 15.00 N/A 10.00 0




Compliance Level Full Full Full Moderate

Points were removed for ‘improvement’ and ‘sustained improvement’ because of rate declines from 92.41 percent to 90.13 percent for the measure. The rate has not changed a statistically significant amount either up or down from the baseline of 92.66 percent. More detailed rate information is available in Table 4 above. Step 10 was N/A last year and 0 this year because for assessment of sustained improvement three years’ worth of data is needed. The first year of a PIP, both Steps 9 and 10 are N/A because it is a baseline year and there is no improvement. The second year an assessment of improvement can be done, and the third year an assessment of whether or not the improvement was sustained can be made. LHP has identified a variety of potential barriers and has developed interventions to overcome them. Some of the barriers cited included lack of member awareness of recommended treatments, member socio-economic hardship, maintaining accurate member contact information, and lack of physician awareness of guidelines. Interventions include, but are not



limited to, health fairs targeted at current and potential members, outreach by disease management staff to members, and making educational resources available to physicians.

Salud! PIP #2: Utilizing Synagis in Improving Health and Reducing Hospitalizations in RSV Vulnerable Infants and Children As shown in Table 5, LHP demonstrated full compliance (100.00%) for PIP #2 for 2013. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation. Table 5: Salud! PIP #2 Utilizing Synagis in Improving Health and Reducing Hospitalizations

in RSV Vulnerable Infants and Children


Available Points

2012 Score

2013 Available

Points

2013 Score


2. Review the Selected Study Question 5.00 5.00 5,00 5.00







5.00 5.00 5.00 5.00


10.00 5.00 15.00 15.00





Compliance Level Full Moderate Full Full

As shown in Table 5 above, the score for this PIP improved due to an increase in the performance rates. Of the 70 infants referred for Synagis, 56 received the recommended dosage (80.00% compared to 75.64% last year). LHP has identified a variety of potential barriers and has developed interventions to overcome them. Many provider offices do not want to administer Synagis treatment at the office as they believe bringing at-risk children to an environment where there are both well and very sick children places the at-risk children at further risk of infection. These providers instead want home care to provide the treatment. As another barrier, parents/guardians may have difficulties transporting the infant to a provider office, as the infant may have various clinical needs such as oxygen, gastrointestinal tubes, or ventilator dependence. Also, parents continue to need education on signs and symptoms of respiratory infection, prevention of respiratory infection, and on the gravity or the necessity of having their infant receive all required doses.



State Coverage Insurance Performance Measurement Program Audit Results As shown in Table 6 below, LHP demonstrated moderate compliance (87.50%) for PMP for 2013. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation. An assessment of intervention effectiveness impacted the MCO’s score. If a rate showed a negative pattern of change, then the interventions implemented were considered to be ineffective. If a measure had multiple scoring questions (submeasures), then each submeasure was evaluated separately. Because some PMs were broken down into submeasures, two PMs could have different amounts deducted for the same infraction (negative rate change).

Table 6: SCI PMP Audit Scores, Compliance Level and Historical Comparison

LHP SCI PMP Audit

2012/2013 Available

Points

2012 Actual Score

2013 Actual Score

CQI Program








Demonstrated Compliance Level Full Full Moderate

Points were removed for “develops effective interventions” during the review of Breast Cancer Screening due to a negative performance rate trend since inception in 2009. Baseline performance rate in 2009 was 71.34 percent. There has been a steady downward trend to a current performance rate of 56.91 percent. Therefore, the interventions were not considered effective. Review of the Frequency of Ongoing Prenatal Care measure did not support giving credit for “develops targeted interventions” due to negative trending of performance rates. Baseline performance rate in 2011 was 81.34 percent. There has been a steady downward trend to a current performance rate of 68.30 percent. Therefore, the interventions were not considered effective.



Table 7 compares SCI performance rates with minimum thresholds set by HSD for the PM measures. The rates in red indicate rates that did not meet HSD thresholds for the given years. HSD reviews its thresholds yearly and revises periodically. The HSD thresholds are displayed in the table below.

Table 7: SCI PM Performance Rates and Historical Comparison

LHP Performance Measures 2012/2013

HSD Thresholds

2012 Rate

2013 Rate

PM #6 Breast Cancer Screening 55.00% 56.50% 56.91%

PM #7 Comprehensive Diabetes Testing

HbA1c Testing 85.00% 87.40% 87.59%


41.90% 41.85%

Retinal Eye Exam 56.00% 49.20% 49.64%

LDL-C Screening 74.00% 74.50% 79.56%


PM #8a Timeliness of Prenatal Care13 85.00% 90.52% 88.20%

PM #8b Postpartum Care 60.00% 74.88% 71.43%

PM #9 Frequency of Ongoing Prenatal Care 60.00% 73.46% 68.30%

The Breast Cancer Screening baseline performance rate in 2009 was 71.34 percent. There has been a steady downward trend to a current performance rate of 56.91 percent. Therefore, 3.25 points were deducted as the interventions were not considered effective. LHP does continue to exceed the HSD threshold of 55.00 percent. LHP implemented interventions including member education, mobile mammography units, and a targeted outreach campaign. Barriers cited include transportation issues, cultural taboos, and fear of a cancer diagnosis. For the Comprehensive Diabetes Testing measure, the rates for three of the submeasures remained static, LDL-C screening increased by nearly 5 percentage points, and Medical Attention for Nephropathy declined by nearly 3 percentage points. Four of the five submeasures met or exceeded the HSD thresholds. With a 49.64 percent rate, retinal eye exams remain under the HSD threshold of 56.00 percent. LHP continues to implement interventions including attending health fairs, calls to members to encourage testing, member education, and a provider pay-for-performance program. Barriers cited include outdated telephone numbers and addresses, low health literacy issues, and chronic disease management. There was a performance rate decrease (2.32 percentage points) for Timeliness of Prenatal Care from 90.52 to 88.20 percent and Postpartum Care declined from 74.88 to 71.43 percent (a 3.45 percentage point decrease). However, both rates continue to exceed the HSD threshold of 85.00 percent and 60.00 percent, respectively.

13

Timeliness of Prenatal and Postpartum Care are two rates that comprise one PM.



The performance rate of Frequency of Ongoing Prenatal Care declined a statistically significant amount, from the baseline of 81.34 percent in SFY 2010 to a current performance rate of 68.30 percent in 2013. Therefore 3.25 points were deducted for “effective interventions.” This performance rate does continue to exceed the HSD threshold of 60.00 percent. LHP continues to implement interventions including the Baby Love Program, member incentives such as free infant car seats for completion of prenatal visits, member education, and case management. Barriers include difficulty identifying pregnant women early in the pregnancy, out-of-date addresses and phone numbers, mobility of the population, and ongoing economic uncertainty.



State Coverage Insurance Performance Improvement Projects Audit Results LHP submitted two PIPs for the SCI Program:

1. Use of Appropriate Medications for People with Asthma (ages 5-50 years) 2. Improving the Frequency of Prenatal Visits/Improving Birth Outcomes

Per CMS, PIPs must:




Be repeatedly measured over time Each PIP was evaluated and scored for CQI processes, performance rates, and demonstrated improvement. A performance rate represents the percentage of eligible members who received a specific treatment or service during the audit time frame. Performance rates are helpful in assessing the effectiveness of MCO interventions and for comparing trends with state and national levels. Table 8 shows the performance rates and comparisons for both of the SCI PIPs submitted for review.

Table 8: LHP SCI PIP Performance Rate

Baseline 2012 Rate

2013 Rate

Percentage Point

Difference of 2013 from

2012

Percentage Point

Difference of 2013 from Baseline

PIP #1


86.36% 81.51% 83.02% 1.51% -3.34%

PIP #2

Frequency of Prenatal Visits to Improve Birth Outcomes

82.61% 73.50% 68.32% -5.18% -14.29%

SCI PIP #1: Use of Appropriate Medications for People with Asthma (ages 5-50 years) As shown in Table 9 below, LHP achieved minimal compliance (76.76%) for this PIP. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation.



Table 9: SCI PIP #1 Appropriate Medications for People with Asthma

(ages 5-50 years)


Available Points

2012 Score

2013 Available

Points

2013 Score



3. Review the Selected Study Indicators 10.00 10.00 10.00 0

4. Review the Identified Study Population 5.00 5.00 5.00 0





5.00 5.00 5.00 4.00


10.00 8.00 15.00 11.25

10. Assess Sustained Improvement 15.00 N/A 10.00 N/A




Compliance Level Full Full Full Minimal

Points were deducted for Step 3, “Selected Study Indicators,” due to no documentation of:

Objective, clearly defined, measurable objectives, and

Indicators that measure changes in health status, functional status, or enrollee satisfaction or valid proxies of the outcomes

Similarly, points were deducted for Step 4, “Identified Study Population,” as it was not clearly defined. The study population was identified by the MCO as “Specifications are per the year appropriate HEDIS Technical Specifications published by NCQA beginning with HEDIS 2010. The percentage of members 5-50 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year.” SCI is available to adults only (ages 19-64) and does not provide services for children. HEDIS specifications now delineate the age range as 5-64, not 5-50 years. In Step 8, “Review Data Analysis and Interpretation of Study Results,” 1 point was deducted because the analysis plan cited HEDIS specifications but the SCI product is not reported to HEDIS as is Medicaid. In Step 9, 3.25 points were deducted for “Assess Whether Improvement is ‘Real’ Improvement” due to no improvement in either the performance rate or the interventions. The total available points for this step increased from previous audits as focus has shifted from the structure of the PIPs to the outcome.



SCI PIP #2: Improving the Frequency of Prenatal Care/Improving Birth Outcomes As shown in Table 10 below, LHP demonstrated moderate compliance (81.58%) for SCI PIP #2. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation.

Table 10: LHP SCI PIP #2 Frequency of Prenatal Visits to Improve Birth Outcomes


Available Points

2012 Score

2013 Available

Points

2013 Score









5.00 5.00 5.00 5.00


10.00 8.00 15.00 7.50

10. Assess Sustained Improvement 15.00 0 10.00 0




Compliance Level Full Moderate Full Moderate

In Step 9, 7.5 points were deducted because the performance rate has continued to decline since the baseline rate of 82.00 percent was set in 2009 and no evidence of an analysis of interventions was provided. The current rate is 68.30 percent. In Step 10, “Assess Sustained Improvement,” points were deducted as there has been no documented improvement in rates or interventions. LHP identified numerous barriers for this measure that include, but are not limited to: identification of pregnant women early in their pregnancies; lack of access in rural areas; members’ financial problems; cultural and linguistic issues; and pregnant teens that are hesitant to seek treatment or are unaware of treatment availability.



LHP has implemented a variety of interventions designed to overcome the identified barriers. These interventions include locating and identifying pregnant women through the Baby Love Program; offering free car seats for completion of visits; providing a nurse advice line; streamlining the referral process; and implementing the Community Health Worker Program to outreach to pregnant members. Performance rates represent the percentage of eligible members who received a specific treatment or service during the audit time frame. Rates for both SCI PIPs are reported in Table 10.

Outcome Measures HealthInsight New Mexico requested health care outcome measures for review, but those measures did not constitute a scored section of this audit. LHP submitted the following information: “HEDIS® measure results are the outcomes LHP utilizes to measure performance and compare results to national and regionally developed benchmarks as well as local competitors.”

Salud! and SCI Recommendations This audit was conducted to discover the extent to which LHP met the quality standards set forth by HSD for the provision of Salud! and SCI services. Recommendations for improvement are listed separately for each PM and PIP. It is recognized that the Salud! and SCI contracts for LHP will be transitioned to MHP in August 2013. The following recommendations are for process improvement and can be extrapolated and transferred to other of LHP’s Lines of Business beyond the current Medicaid contract. Further, this information can benefit LHP staff that may be continuing similar quality improvement efforts both at LHP and at other organizations.

Performance Measures It is recommended that LHP research, implement, and evaluate evidence-driven best practices to improve quality indicators for the following measures:

Annual Preventive Dental Visits ages 2-21 in the Salud! population

Well Child Visits ages 3-6 years in the Salud! population

PCP Access in ages 25 months to 6 years

Childhood Immunizations in the Salud! population

Use of Appropriate Medications in People with Asthma ages 5-64 as applicable in the Salud! and SCI populations

Breast Cancer Screenings in the Salud! population

Comprehensive Diabetes Care in the Salud! and SCI population living with diabetes: HbA1c Testing Retinal Eye Exam LDL-C Screening Medical Attention for Nephropathy

It is recommended that LHP generate health care outcome measures for each PM.

Performance Improvement Projects It is recommended that LHP research, implement, and evaluate evidence-driven best practices to improve quality indicators for the following PIPs:


Frequency of Prenatal Visits to Improve Birth Outcomes



Rebuttal and Reconsideration LHP was offered the opportunity to comment on this report and to rebut any findings. LHP accepted the findings in this report without any rebuttals or requests for reconsideration.


Section C: MHP July 7, 2014

Section C: Molina Healthcare (MHP)

Salud! Performance Measurement Program Audit Results MHP achieved full compliance for the Salud! Performance Measurement Program (PMP) audit. Table 1 reflects the scores for MHP for the selected PMP standards for 2012 and 2013. MHP demonstrated compliance in its processes and systems related to the required Performance Measures (PMs), and MHP has Continuous Quality Improvement (CQI) programs established for targeting improvement within the PMs required for this audit.

An assessment of intervention effectiveness impacted the MCO’s score. If a rate showed a negative pattern of change, then the interventions implemented were considered to be ineffective. If a measure had multiple scoring questions (submeasures), then each submeasure was evaluated separately. Because some PMs were broken down into submeasures, two PMs could have different amounts deducted for the same infraction (negative rate change).

Table 1: MHP Salud! PMP Audit Scores and Compliance Level with Historical Comparison

MHP Salud! PMP Audit 2012/2013 Available

Points

2012 Actual Score

2013 Actual Score


HEDIS®14 Interactive Data Submission System 4.00 4.00 4.00


CQI Program

PM #1 Annual Preventive Dental Visits (ages 2-21 years) 13.00 13.00 13.00



13.00 13.00 13.00



13.00 13.00 13.00









14





Table 2 compares Salud! performance rates with minimum thresholds set by HSD. MHP scored above the HSD threshold for 16 of 18 measures and submeasures for which HSD thresholds were established. The rates in red indicate rates that did not meet HSD thresholds for the given years. HSD reviews its thresholds yearly and revises periodically.

Table 2: MHP Salud! PM Performance Rates and Historical Comparison

MHP Performance Measures 2012/2013

HSD Thresholds

2012 Rate

2013 Rate


Combined 2-21 years 70.00% 57.79% 71.48%



3-6 years 70.00% 70.20% 70.22%

PCP Access by Ages

12-24 months 97.00% 97.87% 98.54%

25 months-6 years 90.00% 89.01% 89.39%

7-11 years 90.00% 90.82% 91.61%

12-19 years 90.00% 90.49% 91.19%



91.00% 92.11% 89.35%



HbA1c Testing 85.00% 85.62% 85.37%

HbA1c Test (Poor Control greater than 9.0%)16 48.00% or less

47.87% 43.02%

Retinal Eye Exam 56.00% 57.30% 60.09%

LDL-C Screening 74.00% 75.28% 74.72%



Postpartum Care 60.00% 60.40% 62.90%


60.00% 69.03% 72.81%

The following discussion focuses on performance rate changes between years 2012 and 2013 and interventions undertaken to improve rates. For 2013, MHP was above the threshold for all but two measures or submeasures.

16

This is an inverse measure, meaning that a decreased rate is the desired outcome.



Rate declines were noted in the following four measures: Use of Appropriate Medications for People with Asthma (ages 5-11 years), HbA1c Testing, LDL-C Screening, and Medical Attention for Nephropathy. MHP improved the rates for the 2- to 21-year-old age stratification for dental visits by 13.69 percentage points. To achieve these gains, MHP focused on member education, provider contracting efforts in rural areas, and promotion of transportation benefits. The delegated entity for dental services was also required to submit a quarterly missed service listing of all members still needing an annual dental visit to QI department-focused mailings. For Well Child Visits, both age stratifications were above the HSD threshold and above last year’s rates. For this measure MHP continued to implement some of the same interventions employed in previous years, including the Rewards for Healthy Choices Program, providing missed services lists to providers for outreach, promotion of the Community Health Worker Program, and the Child Patient Appointment Reminder Card campaign. MHP also collaborated with selected clinics throughout the state to organize events where members who had missed services could obtain them during the event. For Primary Care Provider (PCP) Access, the results were positive with the exception of the 25 months to 6 years stratification, which remains below the HSD threshold. MHP employs many of the same interventions for this measure as for the Well Child Visits, including focusing on outreach efforts, member education, Community Health Workers, and missed service lists for providers. Additionally, MHP conducts annual member surveys of provider access and availability. Childhood Immunization Status continues to perform above the threshold. MHP employs many of the same successful interventions for this measure as for other measures. Also, MHP participates in the Got Shots? Protect Tots shot clinics and promotes entry of immunization data into the New Mexico Statewide Immunization Information System (NMSIIS). MHP collaborates with NMSIIS for quarterly data exchange of members’ immunization status. Use of Appropriate Medications for People with Asthma (ages 5-11 years) had a negative rate change that brought the measure below the HSD threshold. The measure was above the threshold in the previous audit but declined 2.76 percentage points in the current audit. MHP employed many of the same interventions that proved successful for other performance measures. Interventions specific to this PM include the Drake the Dragon educational campaign focused on members ages 4 to 15, contracting with Breathe America to increase access for members, and adding a benefit for using certified asthma educators to educate members on disease and treatment. Breast Cancer Screening remains above the HSD threshold and improved in a year-to-year comparison. Among other interventions, MHP employed various forms of appointment reminders, member alerts, and conducting “Mammovan” events in collaboration with contracted clinics around the state. MHP also promotes cultural sensitivity and knowledge of cultural issues that may impact care and self-exam recommendations. For Comprehensive Diabetes Care, MHP remains above the threshold for all submeasures. Among other interventions, MHP employed various forms of appointment reminders, member alerts, and collaboration with New Mexico Takes on Diabetes Coalition (NMTOD) and promotion of clinical recommendations by coalition. MHP’s outreach efforts also include Community



Healthcare Workers (CHWs) who encourage members to obtain recommended preventive care and chronic disease screenings.

Timeliness of Prenatal Care, Postpartum Care, and Frequency of Ongoing Prenatal Care (81.00% or more of expected visits) are all above HSD thresholds and are all improved over last year. MHP has employed a variety of interventions for new and expectant mothers, including identifying women with high-risk pregnancies and working more closely with them, the Motherhood Matters Program, and the Early Pregnancy Notification Program. Members receive a car seat when a number of postpartum visits has been completed within a specified time under the Rewards for Healthy Choices Incentive Program.



Salud! Performance Improvement Program Audit Results MHP submitted two PIPs for the Salud! program:

1. Annual Dental Visits 2. Breast Cancer Screening

Per CMS, PIPs must:




Be repeatedly measured over time

Each PIP was evaluated and scored for CQI processes, performance rates, and demonstrated improvement. A performance rate represents the percentage of eligible members who received a specific treatment or service during the audit time frame. Performance rates are helpful in assessing the effectiveness of MCO interventions and for comparing trends with state and national levels.

Table 3 shows the performance rates and comparisons for both of the Salud! PIPs submitted for review.

Table 3: MHP Salud! PIP Performance Rates with Historical Comparison

PIP Topics

Baseline 2012 2013

Percentage Point

Difference of 2013

from 2012

Percentage Point

Difference of 2013

from Baseline

PIP #1

The percentage of enrolled members 2-21 years of age who receive at least one preventive dental service

62.80% 70.13% 71.48% 1.35 8.68

PIP #2

The percentage of women 42-69 years of age who have received one or more mammograms during the measurement year or the year prior to the measurement year

50.78% 55.06% 55.16% 0.10 4.38

Salud! PIP #1: Annual Dental Visits As shown in Table 4 below, MHP achieved 100.00 percent for this PIP. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation. As shown in Table 3, this PIP has demonstrated improved rates each year of its implementation so that now the rate is 8.68 percentage points above baseline. At the outset this measurement was below the HSD threshold, while it is now above the threshold of 70.00 percent.



Table 4: MHP Salud! PIP #1 Annual Dental Visits


Available Points

2012 Score

2013 Available

Points

2013 Score









5.00 5.00 5.00 5.00


10.00 10.00 15.00 15.00






MHP has focused on the Annual Dental Visits PIP since 2004. There has been slow but steady improvement in the rate of members 2-21 years of age who received at least one preventive dental service. The industry benchmark is set at the 90th percentile and, according to HEDIS data, this rate has continued to increase and MHP’s improvements have largely kept pace. During the study period, the lowest point was Repeat Measurement 1 in 2005 at 50.86 percent. The highest point is the current repeat measurement at 71.48 percent. Since this PIP has shown ongoing improvement, no points were subtracted. This was the second year that this PIP was provided for review. The PIP will be discontinued if the MHP Quality Improvement Committee determines that there is no more room for continued improvement and no more interventions can be identified. This is the same process they follow for all PIPs. MHP continues to implement a variety of interventions for this PIP. MHP initiated a partnership with dental delegate DentaQuest to begin receiving lists of member children who had missed services. MHP sent information to the parents of 222 member children in Santa Fe County for missing services. A mailing was initiated to encourage completion of the well child check-up Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program, including annual dental services. A $20 Wal-Mart gift card incentive coupon for Rewards for Healthy Choices program was included in these mailings. Similar initiatives were undertaken in many counties across New Mexico.



MHP also undertook community activities such as Family Appreciation Day, which included dental health education. A variety of other educational activities were undertaken with both members and providers.

Salud! PIP #2: Breast Cancer Screening As shown in Table 5 below, MHP demonstrated full compliance (100.00%) for PIP #2 for 2013. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and forms the numerator for the rate calculation. This PIP has demonstrated improved rates each year of its implementation, so that now the rate is 4.38 percentage points above baseline. At the outset this measurement was below the HSD threshold, while it is now above the threshold of 55.00 percent.

Table 5: MHP Salud! PIP #2 Breast Cancer Screening


Available Points

2012 Score

2013 Available

Points

2013 Score









5.00 5.00 5.00 5.00


10.00 10.00 15.00 15.00





Compliance Level

Full Full

MHP has focused on this PIP since 2009 and has shown steady improvement in the rate of women ages 42-69 who received one or more screening mammograms (Breast Cancer Screen) during the measurement year or the year prior to the measurement year. No repeat measurement had a decline in the rate. MHP has submitted this PIP for review each year it has been a Salud! MCO. Since this PIP has shown ongoing improvement, no points were subtracted. During the study period, the lowest point was the baseline in 2009 at 50.78 percent. The highest point is the current repeat measurement at 55.16 percent.



MHP implemented a variety of interventions for this PIP, primarily around mobile mammography. There were multiple mobile mammography events around the state and members who were identified as not having had a mammogram were contacted. The contacts were made both by phone and by a Well Woman flier that offered a $20 Wal-Mart gift card upon completion of the mammogram. Members identified on the HEDIS® Missed Services Lists were loaded into the Molina Healthcare claims adjudication and call tracking software to allow MHP departments to conduct screening reminders while on live calls with member services. Other education was also provided to both members and providers on the importance of preventive care, including mammograms.



SCI Performance Measurement Program Audit Results MHP demonstrated full compliance for the SCI PMP audit. Table 6 reflects the scores for MHP for the selected PMP standards for 2012 and 2013. MHP has CQI programs established for targeting improvement within the PMs required for this audit and demonstrated compliance in its processes and systems related to these PMs.

The effectiveness of interventions accounted for a percentage of the MCO’s score. If a rate showed a negative pattern of change, then the interventions implemented were considered to be ineffective. If a measure had multiple scoring questions (submeasures), then each submeasure was evaluated separately. Because some PMs were broken down into submeasures, two PMs could have different amounts deducted for the same infraction (negative rate change).

Table 6: MHP SCI PMP Audit Scores, Compliance Level, and Historical Comparison

MHP SCI PMP Audit

2012/2013 Available

Points

2012 Actual Score

2013 Actual Score

CQI Program








Demonstrated Compliance Level Full Full



Table 7 compares SCI performance rates with minimum thresholds set by HSD. MHP scored above the HSD threshold for all measures and submeasures for which HSD thresholds were established. HSD reviews its thresholds yearly and revises them periodically. HSD thresholds are displayed in the table below.

Table 7: MHP SCI PM Performance Rates and Historical Comparison

MHP Performance Measures 2012/2013

HSD Thresholds

2012 Rate

2013 Rate



HbA1c Testing 85.00% 89.77% 90.05%

HbA1c (Poor Control greater than 9.0%) 48.00% or less

47.91% 41.67%

Retinal Eye Exam 56.00% 57.44% 62.73%

LDL-C Screening 74.00% 77.67% 82.18%


PM #8a Timeliness of Prenatal Care 85.00% 87.62% 86.96%



The following discussion focuses on performance rate changes between years 2012 and 2013 and interventions undertaken to improve rates. A rate decline was noted in the Timeliness of Prenatal Care measurement. All other measures and submeasures documented an increase in the performance rate. Breast Cancer Screening, which has been the focus of a longstanding PIP for the Salud! population, achieved further rate increases for the SCI population as well and now stands at 14.15 percentage points above the HSD threshold. Many of the interventions implemented have proven effective in previous years. These interventions focus on member education, outreach to members, providing multiple mobile mammography events, and incentives such as gift cards for completion of mammograms. Comprehensive Diabetes Care improved for each submeasure. Each submeasure, delineated in Table 7 above, is also above the HSD threshold. MHP undertakes multiple interventions to assist members in the management of their diabetes. In addition to member and provider education and outreach, MHP also participates with community partners in programs such as New Mexico Takes on Diabetes (NMTOD) and the Department of Health’s Diabetes Prevention and Control Program (DPCP) to further enhance efforts by all stakeholders. Timeliness of Prenatal and Postpartum Care and the Frequency of Ongoing Prenatal Care are all above baseline. Timeliness of Prenatal Care was the only rate to decline for the SCI population. MHP seeks out pregnant women for outreach through claims tracking to make sure they are receiving proper care. MHP also utilizes the Motherhood Matters Program and the High



Risk Pregnancy Program to reach out to women in need of prenatal and postpartum care. MHP also has an incentive program for women who complete certain activities.

SCI Performance Improvement Projects Audit Results MHP submitted two PIPs for the SCI Program:

1. Diabetes HbA1c Testing 2. Postpartum Care

Per CMS, PIPs must:





Table 8: MHP SCI PIP Performance Rates with Historical Comparison

PIP Topics Baseline 2012 2013

Percentage Point

Difference of 2013

from 2012

Percentage Point

Difference of 2013

from Baseline

PIP #1

Rate of diabetic members who have received an HbA1c Test during the measurement year.

84.64% 89.77% 90.05% 0.28 5.41

PIP #2

The rate of women who delivered a live birth between November 6 of the year prior to the measurement year and November 5 of the measurement year who had a postpartum visit on or between 21 and 56 days after delivery

32.00% 69.52% 70.65% 1.13 38.65



SCI PIP #1: Diabetes HbA1c Testing As shown in Table 9 below, MHP achieved 100.00 percent for this PIP. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation. As shown in Table 8, this PIP has demonstrated improved rates each year of its implementation, so that now the rate is 5.41 percentage points above baseline. At the outset, this measurement was below the HSD threshold, and it is now above the threshold of 85.00 percent.

Table 9: MHP SCI PIP #1 Diabetes HbA1c Testing


Available Points

2012 Score

2013 Available

Points

2013 Score









5.00 5.00 5.00 5.00


10.00 10.00 15.00 15.00






MHP has focused on this PIP since 2008 and has shown improvement in the rate of diabetic members who had an HbA1c test in the measurement year. During the study period, the lowest point was the baseline in 2008 at 84.64 percent. The highest point is the current repeat measurement at 90.05 percent. MHP implemented a variety of interventions for this PIP. For this measure, MHP continued to implement some of the same measures employed in previous years, including member and provider education and outreach to members. MHP also conducted the Rewards for Healthy Choices incentive program and undertook collaboration with New Mexico Takes on Diabetes Coalition (NMTOD) and promotion of clinical recommendations by the coalition.



A new intervention undertaken this year was a new contract with a vision vendor to conduct mobile retinal eye exams.

SCI PIP #2: Improving the Frequency of Prenatal Care/Improving Birth Outcomes As shown in Table 10 below, MHP demonstrated full compliance (100.00%) for PIP #2 for 2013. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation. As shown in Table 8, this PIP has demonstrated improved rates each year of its implementation so that now the rate is 38.65 percentage points above baseline. At the outset this measurement was below the HSD threshold, whereas it is now above the threshold of 60.00 percent.

Table 10: MHP SCI PIP #2 Frequency of Prenatal Visits to Improve Birth Outcomes


Available Points

2012 Score

2013 Available

Points

2013 Score









5.00 5.00 5.00 5.00


10.00 10.00 15.00 15.00






MHP has focused on this PIP since 2008 and has shown improvement in the rate of women who had a live birth within the measurement period and had a postpartum visit on or between 21 and 56 days after delivery. During the study period, the lowest point was the baseline in 2008 at 32.00 percent. The highest point is the current repeat measurement at 70.65 percent.



MHP implemented a variety of interventions for this PIP. MHP follows up with new mothers to make sure they are receiving proper care. MHP utilizes the Motherhood Matters Program and the Rewards for Healthy Choices Incentive Program to reach out to women in need of prenatal and postpartum care. MHP also offered incentives to providers for adequate coding for initial diagnosis of pregnancy, initial and subsequent prenatal visits, and postpartum care. MHP also sent reminder cards and/or texts for new mothers about their appointments. MHP also partnered with St. Joseph Community Health Collaboration to promote prenatal, postpartum, well child, dental care, and other health issues for at-risk families in Bernalillo County.

Outcome Measures HealthInsight New Mexico requested health care outcome measures for review, but those measures did not constitute a scored section of this audit. MHP developed outcome measures for each PM to document the next level of care for their members. An example of an outcome measures provided was tracking the rate of women who have a diagnosis of lumpectomy, partial mastectomy, or mastectomy resulting from a mammogram. A second example of an outcome measure provided was tracking the number of women who had timely prenatal care but gave birth to a low birth weight baby.

Salud! and SCI Recommendations This audit was conducted to discover the extent to which MHP met the quality standards set forth by HSD for the provision of Salud! and SCI services. Recommendations for improvement are listed separately for each PM and PIP. It is recognized that the Salud! and SCI contracts concluded at the end of calendar year 2013. The following recommendations are for process improvement and can be extrapolated and transferred to other of MHP’s Lines of Business beyond the current Medicaid contract and into Centennial Care.

Performance Measures It is recommended that MHP research, implement, and evaluate evidence-driven best practices to improve quality indicators for the following measures:

Use of Appropriate Medications for People with Asthma (ages 5-11 years) for the Salud! population.

Timeliness of Prenatal Care for the SCI Population.

Performance Improvement Plans

There were no recommendations for improvement from this audit.

Rebuttal and Reconsideration MHP was offered the opportunity to comment on this report and to rebut any findings. MHP accepted the findings of the audit and did not offer any rebuttals or requests for reconsideration.


Section D: PHP July 7, 2014

Section D: Presbyterian Health Plan (PHP)

Salud! Performance Measurement Program Audit Results PHP achieved full compliance for the Salud! Performance Measurement Program (PMP) audit. Table 1 reflects the scores for PHP for the selected PMP standards for 2012 and 2013. PHP demonstrated compliance in its processes and systems related to the required Performance Measures (PMs), and PHP has Continuous Quality Improvement (CQI) programs established for targeting improvement within the PMs required for this audit.

An assessment of intervention effectiveness impacted the MCO’s score. If a rate showed a negative pattern of change, then the interventions implemented were considered to be ineffective. If a measure had multiple scoring questions (submeasures), then each submeasure was evaluated separately. Because some PMs were broken down into submeasures, two PMs could have different amounts deducted for the same infraction (negative rate change).

Table 1: PHP Salud! PMP Audit Scores and Compliance Level with Historical Comparison

PHP Salud! PMP Audit 2012/2013 Available

Points

2012 Actual Score

2013 Actual Score


HEDIS®17 Interactive Data Submission System 4.00 4.00 4.00


CQI Program

PM #1 Annual Preventive Dental Visits (ages 2-21 years) 13.00 13.00 13.00



13.00 13.00 13.00



13.00 13.00 9.75








Compliance Level Full Full Full

17





Points were subtracted for PM #5 and PM #9 for declining rates, which indicated an ineffectiveness of interventions. Table 2 compares Salud! performance rates with minimum thresholds set by HSD. PHP scored above the HSD threshold for nine of 18 measures and submeasures for which HSD thresholds were established. The rates in red indicate rates that did not meet HSD thresholds for the given years. HSD reviews its thresholds yearly and revises periodically. HSD thresholds are displayed in the table below.

Table 2: PHP Salud! PM Performance Rates and Historical Comparison

PHP Performance Measures 2012/2013

HSD Thresholds

2012 Rate

2013 Rate


Combined 2-21 years 70.00% 71.51% 71.17%



3-6 years 70.00% 61.07% 58.64%

PCP Access by Ages

12-24 months 97.00% 98.28% 97.15%

25 months-6 years 90.00% 88.81% 88.56%

7-11 years 90.00% 91.23% 91.47%

12-19 years 90.00% 90.33% 91.19%



91.00% 89.99% 82.72%



HbA1c Testing 85.00% 84.67% 85.77%


41.06% 43.25%

Retinal Eye Exam 56.00% 50.55% 47.26%

LDL-C Screening 74.00% 72.45% 70.07%



Postpartum Care 60.00% 56.45% 57.91%


60.00% 61.56% 55.47%

The following discussion focuses on performance rate changes between years 2012 and 2013 and interventions undertaken to improve rates.



PHP was at or above the threshold for half of all measures or submeasures. PHP improved three of the PMs that did not meet the HSD thresholds last year to meet or exceed the current thresholds. Some interventions involved multiple PMs. For example, PHP provided educational materials for a variety of PMs at different health-related community events such as Run for the Zoo, City of Albuquerque Health Fair, Jewish Community Center Health Fair, and others. PHP’s interventions and initiatives focus on communication and education for children and adolescents, their parents, and their practitioners/providers. PHP targeted the parents of the children and adolescents of the identified age group to provide focused information to promote healthy growth and development. For Annual Dental Visits, PHP implemented a variety of member and provider education in addition to an automated telephone call reminder campaign. This measure declined slightly in comparison to the previous audit, but remains above baseline. For Well Child Visits, PHP conducted monthly reminder mailings for well-child visits via Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program letters. Both submeasures for this PM declined in a year-over-year comparison; however, the first 15 months of life age stratification remains above the HSD threshold. The 3-6 year old category remains below the HSD threshold. It has remained below the baseline since at least 2009. Well Child Visits were also promoted through the member newsletter and provider manual updates. For Children and Adolescent Access to Primary Care Physicians, interventions included promoting the Tot-to-Teen Health Check program in their preventive health care guidelines. None of the submeasures had substantial change in a year-over-year comparison. All of the age stratifications were above the HSD threshold except 25 months through 6 years, which missed the threshold by 0.25 of a percentage point. For Childhood Immunization Status, Combo 2, several interventions were undertaken, including member and provider newsletter articles on immunization requirements, and monthly reminder mailings for immunization recommendations. PHP also participated with various community partners, such as the Got Shots? Protect Tots Workgroup and the New Mexico Immunization Coalition Steering Committee. The performance rate for this measure improved 10.22 percentage points over the previous audit result, and is now above the HSD threshold. For Use of Appropriate Medications for People with Asthma (ages 5-11 years), PHP conducted asthma workshops and sent educational material to appropriate members. PHP also partnered with the New Mexico Council on Asthma (NMCOA) and Project Echo, which promotes the adoption of asthma educator codes for accurate billing. PHP has a member incentive program for completing an Asthma Action Plan with the PCP for a child. The performance rate for the asthma measure declined 7.27 percentage points and is below the HSD threshold. For Breast Cancer Screening, PHP focused on increasing the number and geographic distribution of mobile mammography events across New Mexico. PHP also engaged with community partners to collaborate on opportunities for screening events. PHP analyzed the available data to identify women in need of a first mammogram versus a subsequent mammogram. PHP also has a process to follow up with members who miss scheduled appointments. The performance rate for this measure increased by 3.73 percentage points. The rate remains below the HSD threshold.



For Comprehensive Diabetes Care, PHP has an optional “pay for performance” program for providers. PHP also implemented member incentives for completion of screening tests. PHP undertook a bus advertising campaign featuring healthy weight and other initiatives on the sides of buses in the Albuquerque area and engaged with community partners such as New Mexico Diabetes Advisory Council (NMDAC). PHP also developed Adult Diabetes Clinical Practice Guidelines. Of the five submeasures for this measure, three were above the HSD threshold. For Timeliness of Prenatal Care and Postpartum Care and Frequency of Ongoing Prenatal Care, outreach approaches included participation in health events targeted for the identified population and communicating all relevant health education to members. This population was managed through collaborative efforts with areas in the Presbyterian Delivery System and the Presbyterian Health Plan Provider Network, including primary care physicians (PCPs) from family practice/internal medicine, general physicians, OB/GYNs, nurse practitioners, and midwives. All three rates remain below their HSD thresholds and only Postpartum Care improved in a year-over-year comparison.



Salud! Performance Improvement Projects Audit Results PHP submitted two PIPs for the Salud! program:

1. Breast Cancer Screening 2. Hemoglobin A1c Testing

Per CMS, PIPs must:




Be repeatedly measured over time Each PIP was evaluated and scored for CQI processes, performance rates, and demonstrated improvement. A performance rate represents the percentage of eligible members who received a specific treatment or service during the audit time frame. Performance rates are helpful in assessing the effectiveness of MCO interventions and for comparing trends with state and national levels. Table 3 shows the performance rates and comparisons for both of the Salud! PIPs submitted for review.

Table 3: PHP Salud! PIP Performance Rates with Historical Comparison

PIP Topics

Baseline 2012 2013

Percentage Point

Difference of 2013

from 2012

Percentage Point

Difference of 2013

from Baseline

PIP #1

Breast Cancer Screening (Baseline year 2004)

48.03% 45.66% 49.39% + 3.73 + 1.36

PIP #2

Hemoglobin A1c Testing (Baseline year 2004)

76.47% 84.67% 85.77% + 1.10 + 9.30

Salud! PIP #1: Breast Cancer Screening As shown in Table 4 below, PHP achieved full compliance (94.74%) for this PIP. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation.



As shown in Table 3, this PIP has demonstrated fluctuating performance rates since its baseline rate of 48.03 percent. The current rate increased 3.73 percentage points over the previous year, but at 49.39 percent, it is only 1.36 percentage points above baseline.

Table 4: PHP Salud! PIP #1 Breast Cancer Screening


Available Points

2012 Score

2013 Available

Points

2013 Score





5. Review Sampling Methods 5.00 5.00 5.00 5.00




5.00 5.00 5.00 5.00


10.00 10.00 15.00 15.00






The performance rate for the PIP is 3.73 percentage points above the previous repeat measurement but remains 13.49 percentage points below the established industry baseline of 62.88 percent. The industry benchmark is the NCQA national average. The PIP is considered successful because it has generated improvement in the rates measured over both the baseline measure and in the last three repeat measurements. PHP has implemented multiple interventions for this PIP, focusing on member education and increased access to mobile mammography services across the state. In addition to mobile mammography, PHP works to increase employer group mobile mammography and practitioner office mobile offerings. PHP has also engaged in a collaborative effort with other MCOs to expand reach to the Salud! population.



Salud! PIP #2: Hemoglobin A1c Testing As shown in Table 5 below, PHP demonstrated full compliance (94.74%) for PIP #2 for 2013. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation. This PIP has demonstrated improved rates each year since its implementation, so that now the rate is 9.30 percentage points above baseline. At the outset, this measurement was below the HSD threshold, while it is now above the threshold of 85.00 percent.

Table 5: PHP Salud! PIP #2 Hemoglobin A1c Testing


Available Points

2012 Score

2013 Available

Points

2013 Score









5.00 5.00 5.00 5.00


10.00 10.00 15.00 15.00






The performance rate for the PIP is 1.10 percentage points above the previous repeat measurement, but remains 5.34 percentage points below the established industry benchmark of 91.11 percent. The industry benchmark is the NCQA national average. The PIP is considered successful because it has generated improvement in the rates measured over both the baseline measure and in the last three repeat measurements. Member interventions included telephone call campaigns, member engagement efforts, health promotion activities via health fairs, maintaining current disease management levels of outreach, and member contact for Healthy Solutions Lifestyle coaching. PHP operated a weight management program and Health Solution Lifestyle Coaching program. PHP also partnered with other community stakeholders for the Take Control of Your Diabetes conference and the Diabetes Community Walks with Albuquerque Prescription Trails.



State Coverage Insurance Performance Measurement Program Audit Results PHP demonstrated full compliance (98.75%) for the SCI PMP audit. Table 6 reflects the scores for the selected PMP standards for 2012 and 2013. PHP has CQI programs established for targeting improvement within the PMs required for this audit and demonstrated compliance in its processes and systems related to these PMs. The effectiveness of interventions accounted for a percentage of the MCO’s score. If a rate showed a negative pattern of change, then the interventions implemented were considered to be ineffective. If a measure had multiple scoring questions (submeasures), then each submeasure was evaluated separately. Because some PMs were broken down into submeasures, two PMs could have different amounts deducted for the same infraction (negative rate change).

Table 6: PHP SCI PMP Audit Scores, Compliance Level, and Historical Comparison

PHP SCI PMP Audit

2012/2013 Available

Points

2012 Actual Score

2013 Actual Score

CQI Program








Demonstrated Compliance Level Full Full

Points were subtracted for Retinal Eye Exams under Comprehensive Diabetes Care. There was a small rate decline in a year-over-year comparison, but the rate is 18.77 percentage points below the HSD threshold, thus indicating ineffective interventions. The effectiveness of interventions is worth 3.25 points. There are five submeasures. The 3.25 points are divided by 5 and so each submeasure has a value of 0.65 each.



Table 7 compares SCI performance rates with minimum thresholds set by HSD. For 2013, PHP scored above the HSD threshold on all but one of the measures and submeasures for which HSD thresholds were established. The rates in red indicate rates that did not meet HSD thresholds for the given years. HSD reviews its thresholds yearly and revises periodically. Only the 2013 HSD thresholds are displayed in the table below.

Table 7: PHP SCI PM Performance Rates and Historical Comparison

PHP Performance Measures 2012/2013

HSD Thresholds

2012 Rate

2013 Rate



HbA1c Testing 85.00% 88.14% 88.32%


45.58% 40.33%

Retinal Eye Exam 56.00% 38.72% 37.23%

LDL-C Screening 74.00% 77.29% 77.55%


PM #8a Timeliness of Prenatal Care19 85.00% 85.38% 90.80%



From the documentation submitted, the interventions undertaken for these measures are the same as those for the Salud! program. For reasons that remain unclear, the interventions appear to be more effective for the SCI population than for the Salud! population.

19

Timeliness of Prenatal and Postpartum Care are two rates that comprise one PM.



State Coverage Insurance Performance Improvement Projects Audit Results PHP submitted two PIPs for the SCI program:

1. Breast Cancer Screening 2. Hemoglobin A1c Testing

Per CMS, PIPs must:





Table 8: PHP SCI PIP Performance Rate

PIP Topics Baseline 2012 Rate

2013 Rate

Percentage Point

Difference of 2013 from 2012

Percentage Point Difference

of 2013 from Baseline

PIP #1

Breast Cancer Screening

62.41% 59.38% 62.98% + 3.60 + 0.57

PIP #2

Hemoglobin A1c Testing

87.34% 88.14% 88.32% + 0.18 + 0.98

SCI PIP #1: Breast Cancer Screening As shown in Table 9 below, PHP achieved Full Compliance (94.74%) for this PIP. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and form the numerator for the rate calculation. As shown in Table 8, this PIP has demonstrated fluctuating performance rates each year since its implementation, so that now the rate is 0.57 percentage points above baseline. At the outset, this measurement was above the HSD threshold and it is currently 7.98 percentage points above the threshold of 55.00 percent.



Table 9: PHP SCI PIP #1 Breast Cancer Screening


Available Points

2012 Score

2013 Available

Points

2013 Score









5.00 5.00 5.00 5.00


10.00 5.00 15.00 15.00


Total Points Available 100.00 100.00 100 100.00



Compliance Level Moderate Full

This PIP has succeeded in increasing the rate of eligible women who receive mammograms in the repeat measurements for 2011 and 2012. The reason given for the initial rate decline was a large increase in the population hindered member education and member compliance efforts. A population increase is cited as a contributing factor in all years except the current repeat measurement. The interventions undertaken with this population are the same as for Salud!. No SCI-specific interventions were identified.



SCI PIP #2: Hemoglobin A1c Testing As shown in Table 10 below, PHP demonstrated full compliance (94.74%) for SCI PIP #2 for 2013. The total points available are the sum of all the points that can be scored for all criteria and form the denominator for the score calculation. The total points scored are the sum of all the points that the MCO was assigned for all criteria and the total forms the numerator for the rate calculation. This PIP has demonstrated stable rates each year since its implementation, so that now the rate is 0.98 percentage points above baseline. At the outset, this measurement was above the HSD threshold of 85.00 percent. It remains above the threshold of 85.00 percent at 88.32 percent.

Table 10: PHP SCI PIP #2 Hemoglobin A1c Testing


Available Points

2012 Score

2013 Available

Points

2013 Score









5.00 5.00 5.00 5.00


10.00 10.00 15.00 15.00






The performance rate for the PIP is 0.18 of a percentage point above the previous repeat measurement and 3.32 percentage points above the HSD threshold. The PIP is considered successful because it has generated improvement in the rates measured over both the baseline measure and in the last two repeat measurements. The interventions undertaken with this population are the same as for Salud!. No SCI-specific interventions were identified.



Outcome Measures HealthInsight New Mexico requested health care outcome measures for review, but those measures did not constitute a scored section of this audit. One example of an outcome measure provided is tracking the relationship between PCP visits and Emergency Department and Urgent Care Facility usage. The intent of the measure is to determine if increasing PCP utilization can decrease utilization in the other two visit types. A second example of an outcome measure provided was tracking the number of women who had timely prenatal care but gave birth to a low birth weight baby.

Salud! and SCI Recommendations This audit was conducted to discover the extent to which PHP met the quality standards set forth by HSD for the provision of Salud! and SCI services. Recommendations for improvement are listed separately for each PM and PIP. It is recognized that the Salud! and SCI contracts concluded at the end of calendar year 2013. The following recommendations are for process improvement and can be extrapolated and transferred to other of PHP’s Lines of Business beyond the current Medicaid contract and into Centennial Care.

Performance Measures It is recommended that PHP research, implement, and evaluate evidence-driven best practices to improve quality indicators for the following measures:

Use of Appropriate Medications for People with Asthma (ages 5-11 years) for the Salud! population

Frequency of Ongoing Prenatal Care for the Salud! population

Retinal Eye Exams for the SCI population

Performance Improvement Projects

There were no recommendations for improvement from this audit.

Rebuttal and Reconsideration PHP was offered the opportunity to comment on this report and to rebut any findings. The PHP rebuttals are below, followed by HealthInsight New Mexico’s responses. PHP Rebuttal: PHP stated that the rates for HbA1c testing were incorrectly reported and provided the new rates. HealthInsight New Mexico Response: The table has been updated with the new information. This change did not necessitate a change in scoring. PHP Rebuttal: PHP submitted revised study questions for each PIP. The new study question for the Salud! and SCI Breast Cancer Screening PIPs now reads:

Do the identified targeted member and provider interventions to expand mobile mammography and provide breast cancer education demonstrate an increase over the prior year in the rate of eligible women who received a mammogram during the measurement period?



The new study question for the Salud! and SCI Comprehensive Diabetes Care PIPs now reads: Do the identified targeted interventions to engage and educate members as well as improve provider data submission and access to diabetes resources and use of Clinical Practice Guidelines demonstrate an increase over the prior year in the rate of eligible members who completed a Hemoglobin A1c test during the measurement year?

HealthInsight New Mexico Response: HealthInsight New Mexico recognizes PHP’s ongoing efforts to improve the efficacy and precision of PIPs. The revised questions are accepted and the score has been changed accordingly.

physical health - nm human services · of the four physical health mcos’ programs for the period...

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