Using EQROs to Improve the Quality of Preventive and Developmental Services Henry T. Ireys, Tara Krissik Anne Markus, Sara Rosenbaum Annual Conference of the National Academy of State Health Policy Denver, Colorado October, 2007
Children in Medicaid Managed Care z
28.8 million children in Medicaid in FY 2004*
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10 million children in Medicaid managed care plans*
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47 states with Medicaid managed care plans, as of December 2006**
_______ *Urban Institute and Kaiser Commission for the Uninsured, 2007 ** Centers for Medicaid and Medicare Services, 2006 2
Take-Home Message z
Heightened interest in the quality of medical care for Medicaid beneficiaries
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Emerging focus on assessing the quality of preventive and developmental services
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States need assistance in contractually defining scope of work for EQROs related to improving the quality of preventive and developmental services
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Overview of Presentation z
Policy context – Regulations issued by Centers for Medicare and Medicaid Services (CMS) took effect March 2003 – CMS toolkits published in late 2006
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Results from prior study
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Current work: Guidance for defining a scope of work for an EQRO
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Policy Context: Current CMS Regulations z
Obligate states to develop written strategy for assessing the quality of care for Medicaid beneficiaries in managed care plans
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Require states to – Adopt standardized methods for quality review activities – Specify mandatory, optional activities – Use specific protocols for conducting quality reviews
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Give states enhanced federal match
Role of External Quality Review Organizations (EQROs) z
CMS regulations encourage states to use EQROs to – Perform mandatory review activities ¾Determine MCO compliance with managed care regulations ¾Validate quality improvement projects completed by MCOs ¾Adopt standardized methods for quality review activities – Conduct optional activities, focused studies
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– Write comprehensive annual report, serve as technical resources
CMS Toolkits z
Two toolkits designed to help states – –
Develop quality strategies Translate strategies into EQRO contracts
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Did not focus on preventive and developmental services (or any other specific topic)
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Current work expands utility of these toolkits
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Previous Study z
Quantitative survey of state Medicaid directors
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Qualitative telephone interviews with staff from state agencies, MCOs, EQROs, providers in 5 states – Michigan – North Carolina – Oregon – Texas – Washington 8
Study Questions z
How many states have used, are planning to use EQROs for studies of well-child care?
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What factors improve chances for study of preventive and developmental services for children?
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What factors influence states’ capacity to conduct quality reviews of these services?
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What actions will promote further use of EQROs to improve the quality of services for children in Medicaid? 9
Principal Findings z
24 states commissioned 32 reports on preventive and developmental services in last 3 years – Lead screening – Overall EPSDT participation rates – Referral problems
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Most reports: Methodologically unsophisticated – Charts with no interpretation of the data – Only visit counts – No data on content of visit
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Current Study z
Met with an advisory panel to identify informational needs, select key informants
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Examined RFPs, reports, and contracts from 20+ states to identify strategies used to select and contract with EQROs
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Conducted telephone interviews with key informants in 3 states (IL, MN, WA)
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Findings z
Most states negotiate scope of work annually
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EQRO contracts: – Reference RFP & quality strategy – Include general statements (e.g., EQRO will recommend and evaluate a performance improvement project) – Do not specify scope of work
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Findings, continued z
Many states: – Do not contract with multiple EQROs – Do not contract specifically for child health – Find that their EQRO has little experience in measuring preventive and developmental services for children
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Skills Needed by EQROs z
Knowledge of child health provisions in Medicaid
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Experience in applying child health standards to performance measurement
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Measuring relevant outcomes
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Assessing quality of child health services via survey, administrative, qualitative data
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Scope of Work Specifics z
Determine MCO compliance with federal EPSDT regulations – Do MCOs require providers to use standard screening tools?
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Measure MCO performance in relation to delivery of preventive and developmental services – Which MCOs do a better job in reducing missed opportunities for detecting developmental problems or counseling parents about developmental issues?
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Scope of Work Specifics, cont’d z
Recommend, evaluate a performance improvement project for state MCOs – What programs could MCOs use to improve referral outcomes following positive developmental screen?
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Assess MCOs’ information systems – Can data systems report accurately on content, frequency of developmental screens?
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Conduct focused study – Screening rates for maternal depression?
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Implications z
Regulations offer substantial opportunities for assessing, improving the quality of preventive and developmental services if states – Undertake strategic planning – Obtain technical assistance – Involve providers
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Opportunities for states to focus on preventive and developmental services in – State quality strategies – Contracts with EQROs
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Guidance for States z
Commonwealth Fund toolkits to assist states with quality review activities – Using Federal Regulations – Developing a Quality Review Strategy – Contracting with an EQRO
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For report and toolkits, see Commonwealth Fund Web site: www.commonwealthfund.org
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Henry T. Ireys, Mathematica Policy Research 202/554-7536,
[email protected]
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