Emerging Practices in Medicaid Primary Care Case Management Programs

Chapter 5:
Quality Improvement

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Contents

• Quality Monitoring
• Member Services
• Disease Management

Endnotes

States are increasingly active in monitoring and encouraging quality improvements in PCCM; many are using methods similar to those used within MCOs or to those used to manage their MCO contractors. Many of the case-study states have developed processes for monitoring quality and for passing this information back to PCPs in order that they can improve their performances. Some use HEDIS measures; some compare across PCCM and MCO programs or across Medicaid and commercial populations. Also, states are implementing a greater number of strategies for serving members, such as member help lines, nurse advice lines, greater educational efforts, and health assessments.

Quality Monitoring

The case-study states conduct a variety of activities related to quality monitoring and improvement, many of which have traditionally been associated with MCOs. As Chart L indicates, all eight states conduct member satisfaction surveys (often the CAHPS survey) and/or focus groups. All monitor 24-hour access; most monitor utilization. Six (Florida, Iowa, North Carolina, Oklahoma, Texas, and Virginia) conduct focused studies (on such state-chosen topics as asthma, immunization [either children or older adults], prenatal care and pregnancy outcomes, access for populations with special needs, hypertension, diabetes, dementia, and EPSDT screening); Maine has contracted an NCQA reviewer to improve methods for designing, tracking, and reporting these studies. Oklahoma is nearing completion on an encounter data validation study for their capitated PCCMs. Five (Florida, North Carolina, Oklahoma, Texas, and Virginia) have contracted with external quality review organizations (EQROs) to conduct reviews of medical records; ⁽²⁴⁾ three of these states (Florida, Texas, and Virginia) also conduct medical records reviews internally. Iowa and Maine also conduct internal medical records reviews.

Chart L:
Quality Activities

State	Program	Quality Activities Included
Alabama	Patient 1st	Claims data examined for utilization (Medicaid agency), computer generated survey on Medicaid beneficiaries based on services received (e.g., ER use), monitoring 24-hour access
Florida	MediPass	Random medical records reviews (independent agency and Medicaid), disease management, focused studies, member surveys/focus groups, monitoring 24-hour access
Iowa	MediPASS	Focused studies, member surveys/focus groups, monitoring 24-hour access, HEDIS measurements, random medical record review, Managed Health Care Advisory Committee review and oversight of all quality activities
Maine	Maine PrimeCare	Random medical records reviews (Medicaid agency), CAHPS surveys, 24-hour access monitoring
	MaineNET/ Partnership	PCP must do annual preventive screen, results sent to be used as quality indicator
North Carolina	ACCESS I	Random medical records reviews (PRO), focused studies, member surveys/focus groups, HEDIS (generated from claims data), monitoring 24-hour access
	ACCESS II	Uniform standards of care, standard set of performance measures, local responsibility for quality (work with providers on-site), uses NCQA to credential PCCM in some networks, pediatric asthma care and diabetes care quality measurement projects
	ACCESS III
Oklahoma	SoonerCare Choice PCCM Model	PRO review (random medical records reviews), uses HEDIS to compare PCCM and MCOs in urban areas, focused studies surveys/focus groups, QARI and modified QISMC, quality assurance committee, encounter data validation study in process, monitoring 24-hour access, enrollee surveys
Texas	Texas Health Network	PCCMs credentialed and recredentialed every 2 years using QARI, Texas Dept. of Health, and NCQA standards, random medical records reviews (independent agency and Medicaid), member surveys/focus groups, focused studies, Quality Management/ Improvement Committee meets quarterly, special project on diabetes, complaints, appeals, auditing 24-hour access, annual community health needs assessments
	STAR+PLUS
Virginia	MEDALLION	Random medical records reviews (PRO and Medicaid), disease management program evaluates health outcomes, focused studies, member surveys, drafting provider profiling reports, monitoring 24-hour access

Iowa's Birth Outcomes Study is an example of a focused study. The goal of the study was to compare risk-adjusted quality of care provided to Medicaid mothers and babies in fee-for-service, PCCM, and MCOs. All included records were of mothers who were enrolled for at least 18 months of Medicaid eligibility, including during the pregnancy, and enrolled in the same MCO during the last two months of pregnancy. The study was performed in two stages: comparing outcomes of PCCM and MCO programs in 1999, and MCO and fee-for-service in 2000. In 1999, the sample included 741 PCCM members and 532 MCO members. Conclusions included: PCCM neonates had longer lengths of stay for very low birth weights, but MCO neonates had longer stays for low birth weights; slightly less than 50 percent of mothers in both payment systems had received adequate prenatal care; and maternal and neonatal mortality outcome scores in both programs were better than national averages.

Some states have implemented certain program components/features that are showing success in quality monitoring and improvement.

• Provider profiling: Maine uses provider profiling as part of its incentive payment system for physicians in the PCCM program. On a quarterly basis, pediatricians, family practices/group practices, internists, and OB/GYNs receive scores for measures related to each of the goals shown in Chart M. They are then ranked with other members of their provider group. Quarterly payments are made to physicians within the top 20^th percentile within each provider group. (For more information on the payment structure, please see the Finance section of this report.) Although in cases of group practices or physicians working for hospitals, the physicians may not see the payments; the profile reports are sent directly to each physician. Both state officials and a physician interviewed for this study agreed that physicians appreciate obtaining this information. State officials noted that PCPs pay close attention to the scores and rankings; the state receives approximately 25 calls after each profile is released from physicians seeking ways to improve their scores.
• Texas also distributes provider profiles, which are risk-adjusted and have peer group comparisons, to providers. Outliers are identified and education performed. Alabama will begin distributing provider profiles in Spring 2001. MaineNET monitors practice profiles in demographics, clinical practice, quality indicators, utilization, and cost; however, this information is for state use only. Virginia and North Carolina are currently determining the indicators to be included in future provider profiles. A physician from a state without provider profiling who was interviewed for this study asserted that he would appreciate having the opportunity to compare his performance with that of his peers.

• Local accountability: North Carolina's ACCESS II and III networks are required to follow uniform standards founded on evidence-based best practices measured through a standard set of performance measures. Each network is responsible for quality monitoring and improvement; state staff work on-site with these networks to facilitate a rapid cycle quality improvement process. ⁽²⁵⁾ Local networks define and select performance measures. Examples of quality improvement initiatives include: identifying and decreasing inappropriate emergency room use, improving processes for referrals and prescriptions, managing inpatient admissions through education and follow-up, developing a health screening process to identify members needing case management, and program-wide asthma and diabetes disease management programs.
• Use of HEDIS/other measures: Iowa, Maine, North Carolina, and Oklahoma use HEDIS measures to monitor PCCM providers. Oklahoma uses this data to compare its PCCM and MCO Medicaid programs in urban areas. Maine compares PCCM, MCO, and fee-for-service Medicaid programs, as well as commercial programs, across 15 measures. Iowa uses HEDIS for internal analysis; the first series of results were provided through an independent organization in August 2000.

Oklahoma formerly used QARI and now relies on modified QISMC standards to compare PCCM and MCOs. Texas uses QARI standards. Oklahoma will soon begin on-site reviews with a sample of providers; focus areas will include finance, care management, professional services, and member services.

• Advisory committees: Alabama, Iowa, Maine, and Texas have quality improvement committees, usually composed of participating physicians. Oklahoma's newly formed committee looks at all forms of Medicaid (fee-for-service, PCCM, and MCO) and has a physician participating in PCCM. Maine PrimeCare has a physician advisory committee; MaineNET/Partnership has a clinical advisory group which requires the participation of at least one PCP from each pilot site. These advisory committees deal with issues other than those strictly of quality, such as confidentiality concerns. (For more information on these committees, see the Primary Care Providers section of this report.)
• Community health needs assessments: Texas counties conduct annual community health needs assessments in six regions, surveying both members and physicians. These assessments form the basis for planning educational efforts. Educational topics resulting from these assessments include pediatric illnesses, otitis media, and sexually transmitted diseases (STDs).
• Targeted surveys (in addition to all-member satisfaction surveys): Alabama generates a list (from computer databases) of Medicaid beneficiaries who have used specific services (e.g., emergency room) and sends surveys to the people on this list. This survey asks four or five questions on such issues as patient wait times and satisfaction. State officials use the survey as a concentrated way to determine specific needs for a doctor or service.
  

Florida, Virginia, Texas, and Maine conduct periodic provider surveys to gauge their satisfaction with the PCCM program; Maine surveys both PCPs and office staff. Maine PrimeCare is in the process of piloting a FAACT survey to assess the delivery of care to children up to the age of four and will be surveying adolescent members using a tool also developed by FAACT.

• Pharmacy management: Florida, Oklahoma, Texas, and Maine have pharmacy management structures in place for their Medicaid managed care programs, including PCCM. Florida limits the number of brand-name pharmaceuticals (for which a generic equivalent exists) to four in both the PCCM and fee-for-service Medicaid programs, after which the PCP must get prior authorization. Texas identifies overutilizers of pharmacy services and performs outreach, often linking the member with plan services that include member education and case management. All MaineNET PCPs must participate in the MaineNET Pharmacy Management Program, which focuses on polypharmacy and medication review, appropriate prescribing within targeted chronic conditions, and cost-effective prescribing within targeted major drug categories, through information provided by the Medicaid Physician Directed Drug Initiative. The state provides ongoing pharmacy reports for each MaineNET member to his/her PCP, including all prescriptions filled. The Maine Medicaid agency's narcotics project for pain management has a physician to oversee the pharmacy use of beneficiaries (including Maine PrimeCare members) who have large numbers of pain prescriptions, such as oxycontin.

Member Services

Services designed to facilitate membership are essential components of high quality health care. Some member services are offered in all the case-study states - complaint and grievance processes, member help lines run internally or by enrollment brokers, enrollee interpreter/translation services, new member handbooks and materials, and the provision of lists of participating PCPs to new members. Chart N lists some of the member services offered in the case-study states.

Chart N:
Member Services

State	Program	Member Services Included
Alabama	Patient 1st	Member hotline, grievance/complaint process, targeted case management for medically at-risk or non-compliant patients, enrollee interpreter/translation services
Florida	MediPass	Member hotline, grievance/complaint process, disease management, enrollee interpreter/translation services
Iowa	MediPASS	Member hotline, grievance/complaint process, newsletter mailings, member handbook and Medicaid guide routinely sent to members, enrollee interpreter/translation services
Maine	Maine PrimeCare	Member hotline, grievance/complaint process, enrollee interpreter/translation services
	MaineNET/ Partnership	MaineNET: PRA-Plus screen, preventive health screen complaint/grievance process, enrollee interpreter/translation services Partnership: above, plus local care coordinator works with physician
North Carolina	ACCESS I	Member hotline, grievance/complaint process, local managed care representative serves as resource for each county, enrollee interpreter/translation services
	ACCESS II	Incentives for members to see PCCMs, member hotline, grievance/complaint process, local managed care representative serves as resource for each county, enrollee interpreter/translation services
	ACCESS III
Oklahoma	SoonerCare Choice PCCM Model	Member services department, nurse advice hotline, grievance/ complaint process, case management, member handbook, enrollee hotline, information mailings on benefits and preventive health topics, enrollee interpreter/translation services
Texas	Texas Health Network	Nurse advice hotline, customer service help line, prenatal care line for new pregnant members, utilization management help line, grievance/complaint process, ombudsman program (Harris service area only), case management, outreach workers link with health-related and socioeconomic community resources, community-based member health education, community I&R database, case management staff coordinate care for all members who meet criteria, member education materials, newsletter, enrollee interpreter/translation services
	STAR+PLUS
Virginia	MEDALLION	Member hotline, grievance/complaint process, enrollee interpreter/translation services

Additional efforts made by the case-study states include:

• Special hotlines: Oklahoma and Texas have 24-hour/7-day nurse advice lines, in addition to member services hotlines. In Oklahoma, members calling the hotline to determine whether to seek emergency room care are triaged by the nurse, who faxes the state a copy of the recommendation he/she made to the caller. Oklahoma's nurse advice line also calls 10 percent of new members monthly to orient new members; the state plans to increase this to 100 percent of new members in Spring 2001. Oklahoma has a specially dedicated member services department. In Texas, the nurse advice line promotes coordination of care through a faxed summary of the call to the PCP for members who are triaged to emergent or urgent care. Texas also has a 24-hour/7-day utilization management help line for precertification and authorization and a prenatal care line to facilitate appointment setting for newly enrolled pregnant women.
• Incentives: Some of the networks in North Carolina's ACCESS II and III programs offer incentives for members to make and keep appointments. These incentives include diapers and gasoline coupons. Oklahoma has an EPSDT bonus payment system (discussed in greater detail in the Finance section of this report).
• Newsletters: Iowa, Maine, and Texas send quarterly newsletters to all PCCM members. These newsletters include healthy promotion messages; Texas' (which is printed in English and Spanish) includes a cartoon character designed to appeal to children. Iowa also sends letters to beneficiaries to provide education about the appropriate use of the health care system. Maine's enrollment broker distributes the newsletter as well as handles member requests for information.
• Special education efforts: In both the Texas Health Network and STAR+PLUS, Texas gears educational efforts to the needs of the community (as identified in the annual health needs assessment). Outreach staff employed by the plan administrator in each service area conduct new member orientations, EPSDT education, and follow up when a member is overdue for a screen or has sought services inappropriately from an ER. Outreach and education activities occur in places frequented by Medicaid beneficiaries, including their homes. These staff also work with community based organizations to link members to nonmedical services, such as GED classes, housing, child care, and donated housewares. One current project is the Reach Out and Read Program, which distributes books through PCPs' offices. Maine's enrollment broker conducts community outreach and education efforts to increase members' understanding of managed care and EPSDT.

Oklahoma does extensive outreach to newly eligible Aged/Blind/Disabled (ABD) Medicaid beneficiaries, including outbound telephone calls, direct mail, and enrollment fairs. Exceptional Needs Coordinators and other state medical staff complete health profiles of these new members whenever possible. Each profile is sent to the enrollee's chosen PCP, in order to provide that PCP with a medical history of his/her new patient

• Ombudsman program: In the Harris County service area of Texas, STAR+PLUS members can obtain help from the Client Advocate program. The program is designed to represent the beneficiary's interests and facilitates communication between the beneficiary and the provider. Special attention is given to SSI members.

Disease Management

Disease management strategies can be seen as both a form of quality improvement and a type of member services. The system is better served through appropriate utilization of services leading to lower overall costs; the chronically ill person is better served by having systematic health care that is state-of-the-art for his/her particular illness.

Three case-study states (Florida, North Carolina, and Oklahoma) have developed formalized disease management structures and approaches. Florida has chosen to contract with disease management organizations; sites in North Carolina's ACCESS II and III programs and Oklahoma's program have chosen to develop internal programs. Texas has implemented a special project on diabetes as a pre-curser to a formal disease management program. The Virginia Medicaid agency has a disease management program, but this is considered separate from its PCCM program; the two programs intersect if the PCCM member happens to require disease management assistance.

Florida has hired disease management organizations (DMOs) to serve patients with six chronic illnesses.

• HIV/AIDS (one vendor covers all but two counties; second vendor covers remaining two counties)
• Hemophilia (two providers)
• End stage renal disease (ESRD) (one provider)
• Congestive heart failure (one provider currently under contract; state is negotiating with second provider)
• Diabetes (statewide)
• Asthma (one provider)

Each contractor must guarantee the state 6.5 percent annual savings compared to adjusted baseline per member per month spending for PCCM members with these illnesses.

Approximately 100,000 Floridian PCCM members qualify for one of these DM programs. On a monthly basis, the Medicaid agency analyzes the claims of PCCM members to identify CPT codes that relate to the six illnesses listed above. The state created a claims analysis hierarchy with the first cut for HIV/AIDS, the second for hemophilia, and on down the list. Therefore, a person with both HIV/AIDS and asthma will be served by the HIV/AIDS DMO. The names of individuals with these CPT codes are sent to the appropriate DMOs, which are required to send letters within 30 days informing these individuals about the program. These individuals are automatically enrolled unless they choose to opt out. The DMOs are required to work with the individuals' PCPs. Many DMOs offer additional benefits to participants, such as glucometers for people with diabetes.

The Florida HIV/AIDS DMO distributed to physicians a CD-ROM with state-of-the-practice protocols and guidelines. It provides a comprehensive source of the most up-to-date information for the medical community and a baseline of information in support of the DM initiative. ⁽²⁶⁾

All North Carolina's ACCESS II and III sites have implemented internal asthma disease management programs. One site is currently running diabetes disease management programs; all sites will have such programs within the next year. The sites chose asthma as the first DM initiative based on the following principles: ⁽²⁷⁾

• There are enough Medicaid members with the disease to obtain a return on investment.
• Evidence exists that best practices lead to predictable and improved outcomes.
• Appropriate evidenced-based practice guidelines are available.
• Physicians will support the process.
• Patient education and support can improve outcomes.
• Best practices and outcomes are measurable, reliable, and relevant.
• There is room for improvement — a gap exists between best practice and everyday practice.
• The ability exists to measure baseline and thus to be able to measure improvement.

The core elements of the Asthma Disease Management Program were developed by the sites themselves with the help of state staff. The four core elements are listed below and further detailed in Appendix B.

• Build capacity for routine assessment of asthma.
• Reduce unintended variation of care and establish consistency of care.
• Build capacity to educate patients, families, and school personnel about asthma.
• Regularly report outcomes and process measures to all providers and staff.

With these core elements in place, the participating sites implemented a number of asthma management initiatives.

• A health risk assessment process;
• An asthma action/management plan;
• A process to ensure that a copy of the asthma action plan goes to the patient and family, PCP, and local school/day care;
• An arrangement with durable medical equipment providers to stock and provide peak flow meters and spacers to Medicaid beneficiaries while they are in the PCP's office;
• Patient education materials on asthma management;
• Home and environment assessments on the at-risk asthma population;
• Provider and provider staff education sessions;
• Asthma management forms for the PCP and medical records that coordinate care and ease the burden of paperwork; and
• Shared office processes and best practices.

The group also developed quarterly performance measures for the Asthma Disease Management Program. These take into account both outcomes (e.g., emergency room use rate for asthma) and process (e.g., proportion of asthma patients with an asthma management plan). Outcome information is gathered from claims data. Process information is obtained through chart reviews.

In Oklahoma, participating physicians assess their practices related to diagnosis and treatment. They are expected to follow the National Asthma Education and Prevention (NAEP) guidelines recommended by the National Heart, Lung, and Blood Institute. The state offers on-site assistance, patient education, and monitoring materials. Physicians benefit from participation because they are able to apply what they learn, along with the program materials (encounter forms, self-assessment and action plans, patient education brochures) to their entire asthma patient population. Oklahoma is also considering a collaborative on depression and a diabetes disease management program.

Endnotes

24. Maine used an EQRO in the past; these reviews are now conducted by state staff.

25. The model of rapid cycle quality improvement was developed by the Institute for Healthcare Improvement. It focuses on the processes of "plan, do, study, and act", and stresses setting aims, establishing measures, and making system changes to remove barriers to care.

26. Vernon K. Smith, Terrisca Des Jardins, and Karin A. Peterson, Exemplary Practices in Primary Care Case Management: A Review of State Medicaid PCCM Programs (Princeton, NJ: Center for Health Care Strategies, Inc., 2000), 62.

27. Bulleted North Carolina information in this section taken from: Department of Health and Human Services, "ACCESS II and III Plans Asthma Disease Management Program", ACCESS II and III Update no. 2 (July 2000), 1-8.

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