Children's Medical Services Network Comments

Transcription

1 Children's Medical Services Network Comments Thank you for offering us an opportunity to review the proposed changes to the Medicaid reform performance measures. While we agree that it is extremely important to have measures of performance we feel that these measures should be appropriate for the population being served. Our comments and concerns regarding your proposed performance measures as they relate to the Children s Medical Services plan are provided as follows: The proposed performance measures are broadly applicable across plans that serve both children and adults. However, since Children s Medical Services only serves children some of the measures are not applicable. The overall burden of the large number of measures is high for a small plan with a specialized population. Meeting the sample size requirements will be difficult. For data to be reportable HEDIS requires a minimum sample size of 30. Due to the small number of enrollees in each county and other HEDIS requirements to be included in a sample it is highly unlikely for most of the measures that CMS will have 30 enrollees. Even for measures that CMS has sufficient enrollees to collect reportable data, it is not appropriate to use the data for comparison to other plans due to the differences in the ages and complexity of the CMS population. Rather than collecting data that is not reportable we suggest looking at other alternative reporting that will yield more useful quality and performance information. The following table identifies the measures that appear to be not appropriate for CMS if HEDIS must be used: Proposed measures not applicable to CMS BREAST CANCER SCREENING CERVICAL CANCER SCREENING NUMBER OF ENROLLEES ADMITTED TO STATE MENTAL HOSPITAL No CMS enrollees would meet age requirements No CMS enrollees would meet age requirements Would only apply to enrollees years old as children under 18 are not admitted to state hospitals. This would be a very small number.

2 AMOUNT OF TIME BETWEEN DISCHARGE FROM THE STATE MENTAL HOSPITAL AND FIRST DATE OF SERVICE CONTROLLING HIGH BLOOD PRESSURE COMPREHENSIVE DIABETES ANTIDPRESSANT MEDS MANAGEMENT CHLAMYDIA SCREENING ADULTS ACCESS TO PREVENTIVE/AMBULATORY Would only apply to enrollees years old as children under 18 are not admitted to state hospitals and there would be few, if any. Would not meet HEDIS for reporting and would not be comparable to other plans even if sufficient numbers although difficult to compute and there would be few, if any. Would not meet HEDIS for reporting and would not be comparable to other plans even if sufficient numbers although difficult to compute and there would be few, if any with new diagnosis, a requirement of HEDIS. Would not meet HEDIS for reporting and would not be comparable to other plans even if sufficient numbers although difficult to compute. CMS would probably not have sufficient sample size by county given that population is limited to those sexually active with continuous enrollment. Measure would be partially comparable as HEDIS requires that the measure be broken out by age group. Only 1 of the two age groups is comparable to CMS. Measure limited to those 18 or older. CMS does serve some over 18, but few if any by county with condition. Would not meet HEDIS for reporting and would not be comparable to other plans even if sufficient numbers although difficult to compute. Would be able to report on children s

3 PRENATAL AND POSTPARTUM FREQUENCY OF PRENATAL AGENCY SPECIFIED DATA ON DISEASE MANAGEMENT HIV/AIDS DIABETES CONGESTIVE HEART FAILURE HYPERTENSION ambulatory care if there is a sufficient sample size. CMS would not have sufficient sample size by county and comparisons would not be valid as would be comparing children to higher age groups who are healthy. CMS would not have sufficient sample size by county and as most would be high risk and not comparable to other populations. Frequency of visits should be higher as most should be referred to high risk program. None of the DM would be comparable to other plans who enroll adults Sample size may not be sufficient to meet required criteria. Sample size may not be sufficient to meet required criteria. Not applicable for children Not applicable for children Diabetes care is an important measure, however, HEDIS limits data collection to those 18 or older. We would prefer using a measure that is specific to children, and that the data not be compared to other plans since the type of diabetes and age groups would differ from other plans populations. The Institute of Child Health Policy has developed such a measure. There is duplication in the HEDIS requirements between Disease Management (DM) and general population measures for asthma and diabetes. Requiring HEDIS for DM would limit reporting for CMS diabetes DM. In addition some of the items do not apply to a pediatric population such as smoking cessation for younger children, self-monitoring of blood glucose, annual eye exam, lipid profile, foot exam and Microalbumin testing Using HEDIS for any of the DM programs would be problematic due to HEDIS enrollment requirements regarding time enrolled in DM as few would qualify and there would not be an adequate sample size.

4 Even if DM data is available in sufficient numbers to be reportable by county, comparing CMS to other plans is problematic. Most DM plans in the other reform areas are limited to adults whereas CMS will be serving mostly children although a few are 18 or older. It is unclear how far back in time a plan would have to look to determine some measures. For example a 5 year old child with AIDS enrolled in our plan in the last 18 months may have been tested two years ago while enrolled in a different plan, yet the our plan may not have the data from those tests. Is AHCA going to give more specifics about the non-hedis measures in the detail as specified by HEDIS and indicate if HEDIS standards on enrollment apply to time in DM for the DM indicators and if the time for HEDIS applies to the non-hedis indicators. For example, would the requirement for measuring CD4 levels every 3 to 6 months be retrospective on those enrolled or would it need to be reported quarterly or semi-annually on those enrolled three or six months who were enrolled at the start of time period for which reported. Will a data collection tool be provided? Is AHCA expecting a full written report on each DM project including: description of methodology for data collection, identification of population and sample, analysis of the data and results, root cause analysis, listing interventions implemented over time and planned interventions toward improvement? A measure on DM which is not being collected is the percent of those with a diagnosis that are enrolled in DM. This may be more important for evaluating plans than some of the measures proposed and easier to collect. CMS could then be compared to other plans. Although the other data is important, few plans may have sufficient enrollees meeting requirements for data to be reportable. Immunization data is inaccurate when based on claims data as most immunizations are not billed. At a minimum, data needs to be merged with immunization registry data to be accurate and even then the data would need to be supplemented with case file review as the registry is not complete. Parent self-report data can be inaccurate. Moving the time frame to July will mean that measures will be calculated on incomplete data. Almost all claims are in by six months after the close of the year, however providers have up to 12 months to submit. To meet the July deadline, analysis would have to be on three month claims data and that would leave little time if a mixed mode of data collection were indicated. Plans using mixed mode, usually only conduct record reviews on enrollees who do not meet the standard through claims review as record review is costly. Not conducting

5 a mixed mode could result in a plan comparing poorly to a plan that did record reviews having nothing to do with the quality of care. In the past, CMS has used CAHPS data to examine the family centeredness and cultural sensitivity of care. Will CMS have access to the CAHPS data so that these measures can be calculated and reported or would CMS have to collect this data in another survey to use for PIP or other purposes. In the past, CMS has compared care provided by CMS to care provided to those children with special needs in other plans. Are the baseline and other data being collected by AHCA including the special needs screener that was developed for use in CAHPS and approved by HEDIS? If not, could CMS supplement these surveys to include the screener? Without the screener, comparing CMS to other plans on the selected satisfaction measures is not appropriate as caregivers of special needs children tend to be more dissatisfied with care in general as a reflection of the health status of their children. Given that the needs of specialty plans such as CMS are unique, we would like to meet with you to discuss how measurement could be better targeted to the needs of CMS. If possible, we would like to schedule a meeting prior to the next general measurement meeting. We have a track record of performance measurement and strongly support efforts to document performance. Tobi L. Goodman Managed Care Unit Director Children's Medical Services Network 4052 Bald Cypress Way, Bin A06 Tallahassee, Fl (850) X2226; Fax (850) Tobi_Goodman@ doh.state.fl.us