Use of AHRQ's Prevention and Pediatric Quality Indicators in MCO Rate Setting (Text Version)

On September 14, 2009, David K. Kelley made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (232 KB).

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Slide 1

Use of AHRQ's Prevention and Pediatric Quality Indicators in MCO Rate Setting

Pennsylvania Office of Medical Assistance Programs (OMAP)
David K. Kelley MD,MPA
Chief Medical Officer, OMAP

Slide 2

Pennsylvania Medical Assistance

• Provides health care coverage to over 2.0 million consumers (14% of the Commonwealth's population)
• Operates a capitated managed care program - HealthChoices® - in 25 urban and suburban counties covering 1.1 million consumers
• Operates a managed FFS program in 42 rural counties for 290,000 consumers- Access Plus

Slide 3

Service Areas

• ACCESS Plus and Voluntary Managed Care (where available) - Yellow areas:
  • ERIE
  • CRAWFORD
  • WARREN
  • FOREST
  • McKEAN
  • POTTER
  • CAMERON
  • ELK
  • VENANGO
  • MERCER
  • BEDFORD
  • BLAIR
  • SOMERSET
  • CAMBRAN
  • JEFFERSON
  • CLINTON
  • LYCOMING
  • SULLIVAN
  • TIOGA
  • BRADFORD
  • WAYNE
  • WYOMING
  • PIKE
  • LUZERNE
  • CLARION
  • LACKAWANNA
  • MONTOUR
  • SUSQUEHANNA
  • MONROE
  • SCHUYLKILL
  • CLEARFIELD UPMC
  • JUNIATA
  • MIFFLIN
  • UNION
  • SNYDER
  • CENTRE
  • FRANKLIN
  • FULTON
  • HUNTINGDON
  • CARBON
  • COLUMBIA
• Mandatory Managed Care - HealthChoices - Blue areas:
  • INDIANA
  • NORTHAMPTON
  • PHILADELPHIA
  • DELAWARE
  • LAWRENCE
  • BUTLER
  • ARMSTRONG
  • FAYETTE
  • WESTMORELAND
  • ALLEGHENY
  • BEAVER
  • WASHINGTON
  • GREENE
  • LEHIGH
  • BUCKS
  • CHESTER
  • LANCASTER
  • DAUPHIN
  • YORK
  • ADAMS
  • BERKS
  • MONTGOMERY
  • PERRY
  • CUMBERLAND
  • LEBANON

Map showing the Pennsylvania service areas. The yellow areas of the map have FFS and in some counties there is Voluntary Managed Care. These areas are where ACCESS Plus Will replace the FFS delivery system. In the Blue Areas/ Counties there is currently Mandatory Managed Care these areas will remain the same. Providers on the edges of the blue and yellow may want to enroll in ACCESS Plus if you serve recipients residing over the county line that must choose ACCESS plus. For example a provider in Perry County may serve recipients in Juniata County where there is no voluntary MCO and All recipients will be in ACCESS Plus.

Slide 4

Medicaid Value Based Purchasing

• Efficiency adjustments to Managed Care Organization (MCO) rate setting
  • Inpatient
  • Emergency Department
  • Pharmacy
  • TPL/COB
• MCO pay for performance
• Nonpayment for related readmissions within 14 days
• Reduced or no payment for preventable serious adverse events

Slide 5

Why Inpatient Care

• Hospital costs account for 32% of MCO expenditures
• Cost-effective and appropriate use of hospital services is a cornerstone of a well run efficient MCO
• Quality driven outpatient care management leads to fewer admissions
• Goal is to identify potentially preventable hospitalizations using PQIs and PDIs

Slide 6

Inpatient Efficiency Adjustments

• Prevention Quality Indicators (14)
• Pediatric Quality Indicators (5)
• Other Ambulatory Care Sensitive Conditions
  • Cellulitis
  • Pelvic inflammatory disease
  • Ear, nose, throat conditions
• C-section mix adjustment

Slide 7

Prevention Quality Indicators (PQIs)

• Diabetes-
  • Uncontrolled diabetes
  • Short-term complications
  • Long-term complications
  • Lower extremity amputation
• Perforated Appendix
• Chronic Obstructive Pulmonary Disease
• Hypertension
• Congestive Heart Failure
• Low Birth Weight
• Dehydration
• Bacterial Pneumonia
• Urinary Tract Infection
• Angina
• Adult Asthma

Slide 8

Pediatric Quality Indicators (PDIs)

• Asthma
• Diabetes Short-term Complications
• Gastroenteritis
• Perforated Appendix
• Urinary Tract Infection

Slide 9

Adjustments

• Applied PQI and PDI exclusions
• Minimum duration of member enrollment
• Removed the sickest 25% using risk adjusted CDPS� scores
• Made an additional 50% credibility reduction in preventable costs in part to account for psych-social issues

Slide 10

Congestive Heart Failure

• Preventable admissions- 2,581
• Total dollars spent- $20.7 million
• Removal of members not enrolled minimum of 4 months with MCO
• Removal of "sickest quartile"
• Admissions after enrollment adjustment and risk assessment- 1,470
• Dollars spent after enrollment and risk adjustment- $10.6 million
• Dollars spent after 50% credibility factor- $5.3 million

Slide 11

Inpatient Efficiency Adjustments

• Similar analysis done for 17 PQIs and 5 PDIs
• Excluded Low Birth Weight PQI
• Total PQI/PDI dollars- $30.3 million
  • Asthma (PQI 15, PDI 14)- $8.0 million
  • CHF (PQI 08)- $5.3 million
  • Diabetes (PQI 01,03,14,16, PDI 15)- $4.9 million
  • Pneumonia (PQI 11)- $4.3 million
  • COPD (PQI)- $2.6 million

Slide 12

Inpatient Efficiency Adjustments

• Over 20,000 PQI/PDI admissions
• Over $153.9 million spent on preventable admissions
• Preventable admissions consume 13.7% of inpatient costs
• DPW adjusted 2.7% of inpatient spend ($30.3 million) from the MCO rates

Slide 13

Admissions Rates

• Asthma
  • 2007 Admits per 1000 member months= 4.49
  • 2008 Admits per 1000 member months= 4.51
• CHF
  • 2007 Admits per 1000 member months= 18.17
  • 2008 Admits per 1000 member months= 17.74
• Diabetes
  • 2007 Admits per 1000 member months= 5.33
  • 2008 Admits per 1000 member months= 5.58
• COPD
  • 2007 Admits per 1000 member months= 5.91
  • 2008 Admits per 1000 member months= 7.61

Slide 14

Conclusions-PQI Efficiency Adjustments

• Transparency- PQIs/PDIs in the public domain
• Can be used to evaluate the health system's coordination of outpatient care to prevent hospitalizations
• PQI/PDI efficiency adjustments can focus MCOs on targeted care management strategies
• Purchaser value in not paying for preventable inpatient stays