Value-Based Purchasing Final Report Calendar Year 2016
HealthChoice and Acute Care AdministrationDivision of HealthChoice Quality AssuranceMedicaid Managed CareOrganizationValue-Based PurchasingFinal ReportCalendar Year 2016Submitted by:Delmarva FoundationJanuary 2018
CY 2016 Value-Based Purchasing ReportCY 2016 Value-Based Purchasing ReportIntroductionThe Maryland Department of Health (MDH) began working with the Center for Health Care Strategies in1999 to develop a Value Based Purchasing Initiative (VBPI) for HealthChoice, Maryland’s Medicaidmanaged care program. VBP improves quality by awarding business and incentives to contractors basedon their performance along a range of dimensions. The goal of Maryland’s purchasing strategy is toachieve better enrollee health through improved managed care organization (MCO) performance.Appropriate service delivery is promoted by aligning MCO incentives with the provision of high-qualitycare, increased access, and administrative efficiency. Maryland’s VBP strategy aims to better coordinatea variety of quality improvement efforts toward a shared set of priorities that focus on the corepopulations served by HealthChoice. In addition, the state’s strategy meets the requirements of theBalanced Budget Act of 1997 (BBA).MDH contracted with Delmarva Foundation and MetaStar, Inc. (MetaStar), a NCQA–LicensedOrganization, to perform a validation of the CY 2016 VBP measurement data. Validation is the processby which an independent entity evaluates the accuracy of reported performance measure data anddetermines the extent to which specific performance measure calculations followed establishedspecifications. A validation (or audit) determination is assigned to each measure, indicating whether theresult is fully compliant, substantially compliant, or not valid. MetaStar performed the validation of theHEDIS –based VBP measurement data for all ten of the HealthChoice MCOs using the NCQA’s HEDIS Volume 5: HEDIS Compliance Audit: Standards, Policies, and Procedures. Delmarva Foundationvalidated the measures developed by MDH and calculated by The Hilltop Institute of University ofMaryland Baltimore County (Hilltop).Performance Measure Selection ProcessMDH identifies legislative priorities in selecting the performance measures. Measures may be added orremoved, based upon evolving MDH priorities and participant health care needs.MDH selects measures that are:1. Relevant to the core populations served by HealthChoice, including children, pregnant women,special needs children, adults with disabilities, and adults with chronic conditions;2. Prevention–oriented and associated with improved outcomes;Delmarva Foundation1
CY 2016 Value-Based Purchasing Report3. Measurable with available data;4. Comparable to national performance measures for benchmarking;5. Consistent with how CMS is developing a national set of performance measures for Medicaid MCOs;and6. Possible for MCOs to affect change.Value-Based Purchasing ValidationSeveral sources of measures (Table 1) are included in the CY 2016 VBP program. They are chosen fromNCQA’s HEDIS data set, encounter data, and data supplied by the HealthChoice MCOs, andsubsequently validated by Delmarva Foundation. The measure type and the presence of an existingaudit or validation process determined the validation activities undertaken.Table 1. CY 2016 VBP MeasuresPerformance MeasureDomainMeasureReportingEntityAdolescent Well CareUse of ServicesHEDIS MCOAdult BMI AssessmentEffectiveness of CareHEDIS MCOAmbulatory Care Services for SSI AdultsAccess to CareEncounter DataMDHAmbulatory Care Services for SSI ChildrenAccess to CareEncounter DataMDHBreast Cancer ScreeningEffectiveness of CareHEDIS MCOChildhood Immunization Status (Combo 3)Effectiveness of CareHEDIS MCOComprehensive Diabetes Care – HbA1 TestingEffectiveness of CareHEDIS MCOControlling High Blood PressureEffectiveness of CareHEDIS MCOImmunizations for Adolescents (Combo 1)Effectiveness of CareHEDIS MCOLead Screenings for Children Ages 12–23 MonthsEffectiveness of CareEncounter, LeadRegistry, & FeeFor Service DataMDHMedication Management for People with Asthma –Medication Compliance 75%Effectiveness of CareHEDIS MCOPostpartum CareAccess to CareHEDIS MCOWell Child Visits for Children Ages 3–6Use of ServicesHEDIS MCODelmarva Foundation2
CY 2016 Value-Based Purchasing ReportHEDIS Measure ValidationHealthChoice MCOs are required to produce and report audited HEDIS data under COMAR10.09.65.03B(2). Ten of the CY 2016 VBP measures are HEDIS measures and are validated under theHEDIS Compliance Audit. The goal of the HEDIS audit is to ensure accurate, reliable, and publiclyreportable data.The HEDIS Compliance Audit is conducted in three phases: offsite, onsite, and post onsite (reporting).The offsite audit phase includes a review of each MCO’s HEDIS Record of Administration, DataManagement and Processes (Roadmap). The Roadmap is used to supply information about an MCO’sdata systems and HEDIS data reporting structure and processes. Other activities of the offsite auditprocess include the selection of HEDIS measures to audit in detail (results are then extrapolated to therest of the HEDIS measures), investigation of measure rotation strategies, and validation of the medicalrecord review process by the certified audit firm.Prior to the onsite phase, MetaStar holds annual auditor conference calls with all MCOs to address anyNCQA changes or updates to the audit guidelines and provide technical assistance.During the onsite phase, auditors investigate issues identified in the Roadmap and observe the systemsused to collect and produce HEDIS data. The audit team interviews MCO staff; reviews MCOinformation system structure, protocols, and processes; and reviews MCO measure-specific datacollection processes with the MCO staff.The post onsite and reporting phase of the HEDIS Compliance Audit includes the issuance of a follow-upletter to the MCO that lists any items the auditors still require to complete the audit; a list of correctiveactions for problems found in the Roadmap or onsite, as well as the necessary completion dates; andpreliminary audit findings specifically indicating the measures at risk for a Not Reportable designation.When the MCO has provided all requested documents and performed the recommended correctiveactions, the auditor completes a final audit report and assigns audit designations indicating thesuitability of measures for public reporting. The four possible audit designations are explained in Table2. The final activity of the post onsite phase of the audit consists of the MCO submitting data to NCQA,using NCQA’s Interactive Data Submission System (IDSS).Delmarva Foundation3
CY 2016 Value-Based Purchasing ReportTable 2. HEDIS Compliance Audit DesignationsAudit FindingsDescriptionRate/ResultsReportable rate or numeric result for HEDIS measures.Reportable Measure0-XXXThe MCO followed the specifications but the denominatorwas too small to report a valid rate.Denominator 30.NAThe MCO did not offer the health benefits required bythe measure (e.g., specialty mental health).No BenefitNBThe MCO calculated the measure but the ratewas materially biased, orThe MCO was not required to report the measure.Not ReportableNRIn order to avoid duplicating efforts and placing undue administrative burden on the HealthChoiceMCOs, MDH used ten of the HEDIS audit measure determinations as VBP measure determinations. TheHEDIS measures in the VBP program are: Adolescent Well Care Adult BMI Assessment Breast Cancer Screening Childhood Immunization Status (Combo 3) Comprehensive Diabetes Care – HbA1c Testing Controlling High Blood Pressure Immunizations for Adolescents (Combo 1) Medication Management for People with Asthma – Medication Compliance 75% Postpartum Care Well Child Visits for Children Ages 3–6EQRO Measure ValidationThree CY 2016 VBP measures were calculated by The Hilltop Institute of University of MarylandBaltimore County (Hilltop), using encounter data submitted by the MCOs, Maryland Department of theEnvironment’s Lead Registry data, and Fee-for-Service data. The measures are: Ambulatory Care Services for SSI Adults Ambulatory Care Services for SSI Children Lead Screenings for Children Ages 12–23 MonthsDelmarva Foundation4
CY 2016 Value-Based Purchasing ReportDelmarva Foundation validated the measurement data for each of the above VBP measures, includingthe specifications for each encounter data-based measure, source code to determine algorithmiccompliance with the measure specifications, information regarding the encounter data processingsystem, and analysis of the encounter data process. Clarifications and corrections to source code wereconducted to ensure algorithmic compliance with VBP measure specifications.Validation determinations were used to characterize the findings of the EQRO. Table 3 indicates thepossible determinations of the EQRO-validated measures. To validate the rates calculated, two analystsand an analytic scientist with the Delmarva Foundation reviewed and approved the measure creationprocess and source code.Table 3. Possible Validation Findings for EQRO-Validated Measures (encounter data)ValidationDeterminationDefinitionFully Compliant(FC)Measure was fully compliant with State specifications and reportable.Substantially Compliant(SC)Measure was substantially compliant with State specifications and had onlyminor deviations that did not significantly bias the reported rate.Not Valid(NV)Measure deviated from state specifications such that the reported rate wassignificantly biased. This designation is also assigned to measures whereno rate was reported, although reporting of the rate was required.Not Applicable(NA)Measure was not reported because the entity did not have any Medicaidenrollees that qualified for the denominator.Validation ResultsValidation of the VBP measures results in a determination of the effect of bias on the resulting statistic.Validation determinations by MetaStar are reported using the audit designations and rationales outlinedby NCQA as part of the HEDIS Compliance Audit.All of the VBP measures audited by MetaStar were determined to be reportable for all MCOs with theexception of the Controlling High Blood Pressure Medication measure for UMHP.Table 4 shows the results of the EQRO-led validation activities related to the VBP measures. Hilltop wasresponsible for producing these VBP measures at the MCO level and working with the EQRO to validatethe measurement data. During the validation process undertaken by Delmarva Foundation, no issueswere identified that could have introduced bias to the resulting statistics.Delmarva Foundation5
CY 2016 Value-Based Purchasing ReportTable 4. EQRO VBP Measure Validation DeterminationsMeasureValidation DeterminationsAmbulatory Care Services for SSI AdultsFully CompliantAmbulatory Care Services for SSI ChildrenFully CompliantLead Screenings for Children Ages 12–23 MonthsFully CompliantCY 2016 Incentive/Disincentive Target Setting MethodologyThe following target setting methodology has been developed for the CY 2016 VBP measures: Targets for incentive, disincentive, and neutral ranges are based on the enrollments-weightedperformance average of all MCOs from two years prior (the base year). The enrollment weightassigned to each MCO is the 12-month average enrollment of the base year. The midpoint of the incentive and disincentive targets for each measure is the sum of the weightedaverage of MCO performance on each measure in the base year and 15% of the difference betweenthat number and 100%. The incentive target is calculated by determining the sum of the midpoint and 10% of the differencebetween the midpoint and 100%. The disincentive target is equal to the midpoint minus 10% of the difference between the midpointand 100%. If the difference between the incentive target and disincentive target is less than 4 percentagepoints, then the incentive and disincentive targets will be the midpoint /-2 percentage points.Delmarva Foundation6
CY 2016 Value-Based Purchasing ReportCY 2016 Incentive/Disincentive TargetsTable 5. CY 2016 VBP Measures and TargetsPerformance MeasureDataSource2016TargetAdolescent Well Care:% of adolescents ages 12-21 (enrolled 320 or more days)receiving at least one comprehensive well-care visit with a PCPor an OB/GYN practitioner during the measurement yearHEDIS Incentive: 73%Neutral: 68%–72%Disincentive: 67%Adult BMI Assessment:% of enrollees ages 18 to 74 who had an outpatient visit andwhose body mass index was documented during the measurementyear or the year prior to the measurement yearHEDIS Incentive: 88%Neutral: 85%–87%Disincentive: 84%Ambulatory Care Services for SSI Adults Ages 21–64 Years:% of SSI adults (enrolled 320 or more days) receiving at leastone ambulatory care service during the measurement yearEncounter DataIncentive: 87%Neutral: 84%–86%Disincentive: 83%Ambulatory Care Services for SSI Children Ages 0–20 Years:% of SSI children (enrolled 320 or more days) receiving at leastone ambulatory care service during the measurement yearEncounter DataIncentive: 86%Neutral: 83%–85%Disincentive: 82%Breast Cancer Screening:% of women 50–74 years of age who had amammogram to screen for breast cancerHEDIS Incentive: 71%Neutral: 66%–70%Disincentive: 65%Childhood Immunization Status (Combo 3):% of children who turned 2 years of age during the measurement year whowere continuously enrolled for 12 months immediately preceding theirsecond birthday and who had 4 DTaP, 3 IPV, 1 MMR, 2 H influenzatype B, 3 hepatitis B, 1 chicken pox vaccine (VZV), and pneumococcalconjugate by the time period specified and by the child’s 2nd birthdayHEDIS Incentive: 82%Neutral: 79%–81%Disincentive: 78%Comprehensive Diabetes Care – HbA1c Testing:% of enrollees 18–75 years of age with diabetes (type 1 andtype 2) who had a Hemoglobin A1c (HbA1c) testHEDIS Incentive: 92%Neutral: 89%–91%Disincentive: 88%Controlling High Blood Pressure:% of enrollees ages 18 to 85 who had a diagnosis of hypertension and whose bloodpressure was adequately controlled during the measurement yearHEDIS Incentive: 69%Neutral: 63%–68%Disincentive: 62%Immunizations for Adolescents (Combo I):% of adolescents 13 years of age during the measurement year who had one dose ofmeningococcal vaccine and either one Tdap or Td vaccine by their 13th birthdayHEDIS Incentive: 79%Neutral: 75%–78%Disincentive: 74%Lead Screenings for Children Ages 12–23 Months:% of children ages 12–23 months (enrolled 90 or more days) whoreceive a lead test during the current or prior calendar yearLead Registry,Encounter & Feefor Service DataIncentive: 69%Neutral: 64%–68%Disincentive: 63%Medication Management for People with Asthma –Medication Compliance 75%:% of enrollees 5-64 years of age during the measurement year who wereidentified as having persistent asthma and who were appropriatelyprescribed medication during the measurement yearHEDIS Incentive: 42%Neutral: 31%–41%Disincentive: 30%Postpartum Care:% of deliveries that had a postpartum visit on orbetween 21 and 56 days after deliveryHEDIS Incentive: 74%Neutral: 70%–73%Disincentive: 69%Well-Child Visits for Children Ages 3 – 6 Years:% of children ages 3–6 (enrolled 320 or more days) receiving at least onewell-child visit during the measurement year, consistent with AmericanAcademy of Pediatrics & EPSDT recommended number of visitsHEDIS Incentive: 88%Neutral: 85%–87%Disincentive: 84%Delmarva Foundation7
CY 2016 Value-Based Purchasing Report2016 Performance Measure ResultsThe CY 2016 performance results presented in Table 6 were validated by Delmarva Foundation andMDH’s contracted HEDIS Compliance Audit firm, MetaStar. The contractors determined the validityand the accuracy of the performance measure results. All measures were calculated in a manner thatdid not introduce bias, allowing the results to be used for public reporting and the VBP program. In CY2016, all eight HealthChoice MCOs qualified to participate in the initiative: AMERIGROUP Community Care (ACC) MedStar Family Choice, Inc. (MSFC) Jai Medical Systems (JMS) Priority Partners (PPMCO) Kaiser Permanente of the Mid-Atlantic States, Inc. UnitedHealthcare Community Plan (UHC)(KPMAS) University of Maryland Health Partners Maryland Physicians Care (MPC)(UMHP)Table 6 represents the CY 2016 VBP results for each of the MCOs. NCQA HEDIS Compliance Audit is a trademark of the National Committee for Quality Assurance.Delmarva Foundation8
CY 2016 Value-Based Purchasing ReportTable 6. MCO CY 2016 VBP Performance SummaryPerformanceMeasureAdolescent Well CareAdult BMI AssessmentAmbulatory CareServices for SSI AdultsAmbulatory CareServices for SSIChildrenBreast CancerScreeningChildhoodImmunization Status(Combo 3)ComprehensiveDiabetes Care –HbA1c TestingControlling High BloodPressureImmunizations forAdolescents(Combo 1)Lead Screenings forChildren Ages 12–23MonthsMedicationManagement forPeople with Asthma –MedicationCompliance 75%Postpartum CareWell Child Visits forChildren Ages 3–6CY 2016TargetIncentive: 73%Neutral: 68%–72%Disincentive: 67%Incentive: 88%Neutral: 85%–87%Disincentive: 84%Incentive: 87%Neutral: 84%–86%Disincentive: 83%Incentive: 86%Neutral: 83%–85%Disincentive: 82%Incentive: 71%Neutral: 66%–70%Disincentive: 65%Incentive: 82%Neutral: 79%–81%Disincentive: 78%Incentive: 92%Neutral: 89%–91%Disincentive: 88%Incentive: 69%Neutral: 63%–68%Disincentive: 62%Incentive: 79%Neutral: 75%–78%Disincentive: 74%Incentive: 69%Neutral: 64%–68%Disincentive: 63%Incentive: 42%Neutral: 31%–41%Disincentive: 30%Incentive: 74%Neutral: 70%–73%Disincentive: 69%Incentive: 88%Neutral: 85%–87%Disincentive: 84%ACCJMSKPMASMPCMSFCPPMCOUHCUMHPIncentive (I); Neutral (N); Disincentive D)80%(D)81%(D)83%(D)70%(D)BR – Biased Rate as reported by the HEDIS vendor.Delmarva Foundation9
CY 2016 Value-Based Purchasing Report2016 VBP Financial Incentive/Disincentive MethodologyAs described in the Code of Maryland Regulations 10.09.65.03, MDH uses financial incentives anddisincentives to promote performance improvement. There are three levels of performance for allmeasures: incentive, neutral, and disincentive. Financial incentives are earned when performance meetsor exceeds the incentive target for a measure. Conversely, disincentives are assessed when performanceis at or below the minimum target. All measures are evaluated separately and are of equal weight in themethodology. For any measure that the MCO does not meet the minimum target, a disincentive of 1/13of 1 percent of the total capitation amount paid to the MCO during the measurement year shall becollected. For any measure that the MCO meets or exceeds the incentive target, the MCO shall be paidan incentive payment of up to 1/13 of 1 percent of the total capitation amount paid to the MCO duringthe measurement year. The amounts are calculated for each measure and the total incentive paymentsmade to the MCOs each year may not exceed the total amount of disincentives collected from the MCOsin the same year plus any additional funds allocated by the MDH for a quality initiative.Table 7 represents the incentive and/or disincentive amounts provided to each MCO for eachperformance measure and the total incentive/disincentive amount for the CY 2016 VBP Program.Delmarva Foundation10
CY 2016 Value-Based Purchasing ReportTable 7. MCO CY 2016 VBP Incentive/Disincentive OUHCUMHPAdolescent Well Care 0 151,384.26( 153,603.15)806,400.09( 284,526.30)(994,323.72)( 594,996.30)( 134,303.46) 151,384.26 153,603.15 806,400.09 284,526.30 994,323.72 594,996.30 134,303.46Adult BMI Assessment837,019.53Ambulatory Care Servicesfor SSI Adults( 837,019.53) 151,384.26( 153,603.15) 0( 284,526.30) 0( 594,996.30)( 134,303.46)Ambulatory Care Servicesfor SSI Children 0 151,384.26( 153,603.15)( 806,400.09)( 284,526.30) 0( 594,996.30)( 134,303.46)Breast Cancer Screening 0 151,384.26 153,603.15 0 0 0( 594,996.30) 0Childhood ImmunizationStatus (Combo 3) 837,019.53 151,384.26( 153,603.15) 0 284,526.30 994,323.72( 594,996.30) 0Comprehensive DiabetesCare – HbA1c Testing( 837,019.53) 151,384.26 153,603.15 0 284,526.30 0( 594,996.30)( 134,303.46)Controlling High BloodPressure 0 151,384.26 153,603.15 806,400.09 284,526.30( 994,323.72) 0( 134,303.46)Immunizations forAdolescents (Combo 1) 837,019.53 151,384.26 153,603.15 806,400.09 284,526.30 994,323.72 594,996.30 134,303.46Lead Screenings for ChildrenAges 12–23 Months 0 151,384.26( 153,603.15)( 806,400.09)( 284,526.30)( 994,323.72)( 594,996.30)( 134,303.46)Medication Management forPeople with Asthma –Medication Compliance 75%( 837,019.53) 151,384.26( 153,603.15) 0( 284,526.30)( 994,323.72)( 594,996.30) 0Postpartum Care 837,019.53 151,384.26 153,603.15( 806,400.09) 0 0 0 0Well Child Visits forChildren Ages 3–6 837,019.53 151,384.26( 153,603.15)( 806,400.09)( 284,526.30)( 994,323.72)( 594,996.30)( 134,303.46)Total Incentive/Disincentive Amount 1,674,039.07 1,967,995.36( 153,603.15) 0( 284,526.30)( 1,988,647.44)( 4,164,974.07)( 671,517.29)Delmarva Foundation11
CY 2016 Value-Based Purchasing ReportMCO Performance By Individual Performance MeasuresThe graphs in Appendix 1 represent the performance rates for each VBP measure. Each graph presentseach MCO’s performance, the disincentive and incentive threshold, and the HealthChoice average. TheHealthChoice Average is an unweighted average of all MCO rates.Delmarva Foundation12
CY 2016 Value-Based Purchasing ReportAppendix 1Adolescent Well CareDelmarva FoundationA1-1
CY 2016 Value-Based Purchasing ReportAppendix 1Adult BMI AssessmentDelmarva FoundationA1-2
CY 2016 Value-Based Purchasing ReportAppendix 1Ambulatory Care Services for SSI Adults Ages 21 – 64 YearsDelmarva FoundationA1-3
CY 2016 Value-Based Purchasing ReportAppendix 1Ambulatory Care Services for SSI Children Ages 0 – 20 YearsDelmarva FoundationA1-4
CY 2016 Value-Based Purchasing ReportAppendix 1Breast Cancer ScreeningDelmarva FoundationA1-5
CY 2016 Value-Based Purchasing ReportAppendix 1Childhood Immunization Status—Combo 3Delmarva FoundationA1-6
CY 2016 Value-Based Purchasing ReportAppendix 1Comprehensive Diabetes Care – HbA1 TestingDelmarva FoundationA1-7
CY 2016 Value-Based Purchasing ReportAppendix 1Controlling High Blood PressureDelmarva FoundationA1-8
CY 2016 Value-Based Purchasing ReportAppendix 1Immunizations for AdolescentsDelmarva FoundationA1-9
CY 2016 Value-Based Purchasing ReportAppendix 1Lead Screenings for Children Ages 12 – 23 MonthsDelmarva FoundationA1-10
CY 2016 Value-Based Purchasing ReportAppendix 1Medication Management for People with Asthma – Medication Compliance 75%Delmarva FoundationA1-11
CY 2016 Value-Based Purchasing ReportAppendix 1Postpartum CareDelmarva FoundationA1-12
CY 2016 Value-Based Purchasing ReportAppendix 1Well-Child Visits for Children Ages 3 – 6 YearsDelmarva FoundationA1-13
10.09.65.03B(2). Ten of the CY 2016 VBP measures are HEDIS measures and are validated under the HEDIS Compliance Audit. The goal of the HEDIS audit is to ensure accurate, reliable, and publicly reportable data. The HEDIS Compliance Audit is conducted in th
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