AMERIGROUP Community Care: performance improvement projects report SFY 2012 [Oct. 2011]

State of Georgia
Department of Community Health Georgia Families Program
AMERIGROUP Community Care
PERFORMANCE IMPROVEMENT PROJECTS REPORT
SFY 2012
October 2011

TABLE OF CONTENTS
1. BACKGROUND ...................................................................................................................... 1-1
CMO Overview ................................................................................................................................. 1-2 Study Rationale ................................................................................................................................ 1-2 Study Summary ................................................................................................................................ 1-3 Validation Overview.......................................................................................................................... 1-4 HSAG's New Validation Scoring Methodology ................................................................................. 1-6
2. FINDINGS ............................................................................................................................. 2-1
Aggregate Validation Findings ......................................................................................................... 2-1 Design ........................................................................................................................................... 2-3 Implementation............................................................................................................................... 2-3 Outcomes ....................................................................................................................................... 2-3
PIP-Specific Outcomes .................................................................................................................... 2-4 Analysis of Results ......................................................................................................................... 2-4 Adults' Access to Care ................................................................................................................... 2-6 Emergency Room Utilization .......................................................................................................... 2-6 Children's Preventive Services ...................................................................................................... 2-7 Member and Provider Satisfaction ................................................................................................. 2-8 Member Satisfaction ...................................................................................................................... 2-9 Provider Satisfaction ...................................................................................................................... 2-9
3. STRENGTHS.......................................................................................................................... 3-1
Individual PIP Strengths ................................................................................................................... 3-1 Global PIP Strengths ........................................................................................................................ 3-1
4. OPPORTUNITIES FOR IMPROVEMENT ....................................................................................... 4-1
Individual PIP Issues ........................................................................................................................ 4-1 Global PIP Issues ............................................................................................................................. 4-1
Appendix A. PIP-SPECIFIC VALIDATION SCORES....................................................................... A-1

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Health Services Advisory Group, Inc.

Page i

ACKNOWLEDGMENTS AND COPYRIGHTS
CAHPS refers to the Consumer Assessment of Healthcare Providers and Systems and is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). HEDIS refers to the Healthcare Effectiveness Data and Information Set and is a registered trademark of the National Committee for Quality Assurance (NCQA).

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Health Services Advisory Group, Inc.

Page ii

Performance Improvement Project Validation Report AMERIGROUP Community Care
1. BACKGROUND
The Georgia Department of Community Health (DCH) is responsible for administering the Medicaid managed care program for the State of Georgia and overseeing quality improvement activities. The DCH requires its contracted Care Management Organizations (CMOs) to conduct performance improvement projects (PIPs) as set forth in 42 CFR 438.240 to assess and improve the quality of a targeted area of clinical or nonclinical care or service provided to members, and to report the status and results of each PIP annually.
The validation of PIPs is one of three federally-mandated activities for state Medicaid managed care programs. The other two required activities include the evaluation of CMO compliance with State and federal regulations and the validation of CMO performance measures.
These three mandatory activities work together to ensure that the CMOs are providing quality care to their members. While a CMO's compliance with managed care regulations provides the organizational foundation for the delivery of quality health care, the calculation and reporting of performance measures provides a barometer of the quality and effectiveness of the care. When performance measures highlight areas of low performance, the DCH requires the CMOs to initiate PIPs to improve the quality of health care in targeted areas. PIPs are key tools in helping the DCH achieve goals and objectives outlined in its quality strategy; they provide the framework for monitoring, measuring and improving the delivery of health care.
The primary objective of PIP validation is to determine each CMO's compliance with requirements set forth in 42 CFR 438.240(b)(1), including:
Measurement of performance using objective quality indicators Implementation of system interventions to achieve improvement in quality Evaluation of the effectiveness of the interventions Planning and initiation of activities to increase or sustain improvement
To meet the federal requirement for the validation of PIPs, the DCH contracted with Health Services Advisory Group, Inc. (HSAG), the State's EQRO, to conduct the validation of AMERIGROUP Community Care's (AMERIGROUP) PIPs. AMERIGROUP submitted PIPs to HSAG between June 30, 2011, and August 1, 2011, and HSAG validated the PIPs between July 1, 2011, and August 3, 2011. The validated data represents varying measurement time periods as described in Table 2-3 and Table 2-4.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 1-1 Health Services Advisory Group, Inc.

BACKGROUND
HSAG reviewed each PIP using the Centers for Medicare & Medicaid Services (CMS) validation protocol1-1 and evaluated two key components of the quality improvement process, as follows:
1. HSAG evaluated the technical structure of the PIPs to ensure AMERIGROUP designed, conducted and reported PIPs using sound methodology consistent with the CMS protocol for conducting PIPs. HSAG's review determined whether a PIP could reliably measure outcomes. Successful execution of this component ensures that reported PIP results are accurate and capable of measuring sustained improvement.
2. HSAG evaluated the outcome of the PIP. Once designed, a PIP's effectiveness in improving outcomes depends on the systematic identification of barriers and the subsequent development of relevant interventions. Outcome evaluation determined whether AMERIGROUP improved its rates through implementation of effective processes (i.e., barrier analyses, intervention design and evaluation of results). A primary goal of HSAG's PIP validation is to ensure that the DCH and key stakeholders can have confidence that any reported improvement in outcomes is related to a given PIP.

CMO Overview
The DCH contracted with AMERIGROUP beginning in 2006 to provide services to the Georgia Families Program (Medicaid and PeachCare for KidsTM) population. AMERIGROUP, a CMO, serves the eligible population in the Atlanta, North, East and Southeast geographic regions of Georgia.

Study Rationale
The purpose of a PIP is to achieve, through ongoing measurements and interventions, significant improvement sustained over time in clinical or nonclinical areas. Although HSAG has validated AMERIGROUP's PIPs for four years, the number of PIPs, study topics and study methods has evolved over time.
AMERIGROUP submitted nine (9) PIPs for validation. Six of the nine PIPs were ongoing and three were new additions. The PIP topics include:
Adults' Access to Care Annual Dental Visits Childhood Immunizations Childhood Obesity Emergency Room Utilization

1-1 U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. EQR Managed Care Organization Protocol. Validating Performance Improvement Projects: A Protocol for Use in Conducting Medicaid External Quality Review Activities, Final Protocol, Version 1.0, May 2002.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 1-2 Health Services Advisory Group, Inc.

BACKGROUND
Lead Screening in Children Member Satisfaction Provider Satisfaction Well-Child Visits
The effectiveness of AMERIGROUP's performance improvement efforts was measured using study indicators that aligned with HEDIS performance measures.

Study Summary
As noted in its Quality Strategic Plan Update (January 2010), the DCH identified the improvement of performance measures in the PIP studies as a key objective. The June 30, 2011, through August 1, 2011 PIP submission included seven clinical PIPs: Adults' Access to Care , Annual Dental Visits, Childhood Immunizations, Childhood Obesity, Emergency Room Utilization, Lead Screening in Children and Well-Child Visits and two nonclinical PIPs: Member Satisfaction and Provider Satisfaction.
Five of the clinical PIP topics directly relate to performance measure outcomes that link to preventive health services delivery. They include: Annual Dental Visits, Childhood Immunizations, Childhood Obesity, Lead Screening in Children and Well-Child Visits. Children's primary health care is a vital part of the effort to prevent, recognize and treat health conditions that can result in significant developmental and health status consequences for children and adolescents. Timely screening and interventions can reduce future complications such as those related to obesity.
The other two clinical PIPs, Adults' Access to Care and Emergency Room Utilization represent an essential component in developing a relationship with a health care provider and establishing a medical home, as well as ensuring that members have access to and receive care from the most appropriate care setting. These PIP topics represent a key area of focus for improvement.
Table 1-1 outlines the key study indicators incorporated for the seven HEDIS-based PIPs.

Table 1-1--PIP Study Topics and Indicator Descriptions

PIP Study Topic Adults' Access to Care Annual Dental Visits
Childhood Immunization

PIP Study Indicator Description
The percentage of members 2044 years of age who had an ambulatory or preventive care visit.
The percentage of members who had at least one dental visit: 23 years of age and 221 years of age.
The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IVP); one measles, mumps and rubella (MMR); two H influenza type B (Hib); three hepatitis B; and one chicken pox (VZN) by their second birthday.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 1-3 Health Services Advisory Group, Inc.

BACKGROUND

PIP Study Topic Childhood Obesity Emergency Room Utilization Lead Screening in Children Well-Child Visits

PIP Study Indicator Description
The percentage of members 317 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, nutrition counseling and physical activity counseling.
The number of emergency department visits that did not result in an inpatient stay, per 1,000 member months.
The percentage of children 2 years of age who had one or more capillary or venous lead blood tests for lead poisoning by their second birthday.
The percentage of members who turned 15 months old during the measurement year and who had six or more well-child visits with a primary care provider (PCP) during their first 15 months of life.

Table 1-2 outlines the key study indicators incorporated for the two satisfaction-based PIPs.

The effectiveness of the Member Satisfaction PIP was measured using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey 4.0H, Child Version measures. This survey provided information on parents' experiences with their child's provider and the care management organization.

The final AMERIGROUP PIP topic was Provider Satisfaction. AMERIGROUP contracted with a vendor to produce and administer a survey to document the effectiveness of this performance improvement project.

Table 1-2--Satisfaction-based PIP Study Indicators

Survey Type

Question

Survey Question

Member

"In the last 6 months, did your child's doctor or other health provider talk

#10

with you about the pros and cons of each choice for your child's treatment

or health care?"

Member

"In the last 6 months, when there was more than one choice for your child's

#11

treatment or health care, did your child's doctor or other health provider ask

you which choice you thought was best for your child?"

Provider

#34C*

"Contacting the AMERIGROUP pharmacy call center to find out about formulary medications and alternatives to nonformulary medications."

* Providers were requested to respond if they agreed with the statement regarding the CMO.

Validation Overview
HSAG obtained the data needed to conduct the PIP validation from AMERIGROUP's PIP Summary Forms. These forms provided detailed information about AMERIGROUP's PIPs related to the activities they completed.
Each required activity was evaluated on one or more elements that form a valid PIP. The HSAG PIP Review Team scored each evaluation element within a given activity as Met, Partially Met, Not Met, Not Applicable, or Not Assessed. HSAG designated some of the evaluation elements deemed pivotal to the PIP process as critical elements. For a PIP to produce valid and reliable

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 1-4 Health Services Advisory Group, Inc.

BACKGROUND
results, all of the critical elements had to be Met. Given the importance of critical elements to the scoring methodology, any critical element that received a Not Met score resulted in an overall validation rating for the PIP of Not Met. A CMO would be given a Partially Met score if 60 percent to 79 percent of all evaluation elements were Met or one or more critical elements were Partially Met. HSAG provided a Point of Clarification when enhanced documentation would have demonstrated a stronger understanding and application of the PIP activities and evaluation elements. In addition to the validation status (e.g., Met) HSAG gave each PIP an overall percentage score for all evaluation elements (including critical elements). HSAG calculated the overall percentage score by dividing the total number of elements scored as Met by the total number of elements scored as Met, Partially Met and Not Met. HSAG also calculated a critical element percentage score by dividing the total number of critical elements scored as Met by the sum of the critical elements scored as Met, Partially Met and Not Met. Figure 1-1 illustrates the three study stages of the PIP process: Design, Implementation and Outcomes. Each sequential stage provides the foundation for the next stage. The Design stage establishes the methodological framework for the PIP. The activities in this section include development of the study topic, question, indicators and population. To implement successful improvement strategies, a strong study design is necessary.
Figure 1-1--PIP Study Stages
III. OUTCOMES
II. IMPLEMENTATION
I. DESIGN

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 1-5 Health Services Advisory Group, Inc.

BACKGROUND
Once the study design was established, the PIP process moved into the Implementation stage. This stage included data collection, sampling and interventions. During this stage, AMERIGROUP collected measurement data, evaluated and identified barriers to performance, and developed interventions targeted to improve outcomes. The implementation of effective improvement strategies is necessary to improve PIP outcomes. The final stage was Outcomes, which involved data analysis and the evaluation of real and sustained improvement based on reported results and statistical testing. Sustained improvement is achieved when outcomes exhibit statistical improvement over time and multiple measurements. This stage is the culmination of the previous two stages. If the study outcomes did not improve, AMERIGROUP's responsibility was to investigate the data it collected to ensure it had correctly identified the barriers and implemented targeted interventions to address the identified barriers. If it had not, AMERIGROUP would revise its interventions and collect additional data to remeasure and evaluate outcomes for improvement. This process becomes cyclical until sustained statistical improvement is achieved.
HSAG's New Validation Scoring Methodology
To ensure that AMERIGROUP achieves improvement in the study outcomes for all PIPs submitted for validation in the future, HSAG worked with the DCH to modify the existing PIP validation scoring methodology. These modifications will add emphasis to achieving improved study indicator outcomes while keeping the number of evaluation elements the same. The new PIP Validation Tool (new tool) is identical to the current PIP Validation Tool (current tool) for Activities I through VII. In Activity VIII (sufficient data analysis and interpretation), AMERIGROUP must present study results that are accurate, clear and easily understood. Sufficient data analysis and interpretation is now a critical element; therefore, if the study indicator results are not accurate, the PIP cannot receive an overall Met validation status. In Activity IX (real improvement achieved), the CMO must achieve statistically significant improvement for the study indicator outcomes between the baseline and re-measurement period. Real improvement achieved will now be a critical element for all PIPs that progress to this stage; therefore, any PIP that does not achieve statistically significant improvement will not receive an overall Met validation status. For Activity X (sustained improvement achieved), HSAG assesses each study indicator for sustained improvement after the PIP indicator achieves statistically significant improvement. For PIPs with multiple indicators, all indicators that can be assessed must achieve sustained improvement to receive a Met score for Activity X.
The new validation scoring methodology will be applied to the PIPs that AMERIGROUP will submit for validation from June 2012, through August 2012. In preparation for this change, HSAG first scored the PIPs using the current tool then with the new tool. The scores included in this report were calculated using the current tool and the scores using the new tool were provided for informational purposes only and reflect the validation scores AMERIGROUP would receive if HSAG validated the PIP using the modified validation scoring methodology described above.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 1-6 Health Services Advisory Group, Inc.

2. FINDINGS
for AMERIGROUP Community Care

Aggregate Validation Findings

HSAG organized, aggregated and analyzed AMERIGROUP's PIP data to draw conclusions about the CMO's quality improvement efforts. The PIP validation process evaluated both the technical methods of the PIP (i.e., the study design) and the outcomes associated with the implementation of interventions. Based on its technical review, HSAG determined the overall methodological validity of the PIPs using the current tool. Using the new tool, HSAG determined the overall methodological validity as well as the overall success in achieving improved study indicator outcomes. The scores provided in the new tool this year are for informational purposes only. The results using both tools are presented in Table 2-1.

Table 2-1--Performance Improvement Project Validation Scores for AMERIGROUP Community Care

PIP
Adults' Access to Care Annual Dental Visits Childhood Immunizations Childhood Obesity Emergency Room Utilization Lead Screening in Children Member Satisfaction Provider Satisfaction Well-Child Visits

Percentage Score of Evaluation Elements Met

Current Tool New Tool

97%

100%

76%

76%

100%

100%

94%

94%

100%

100%

94%

94%

94%

94%

98%

96%

96%

96%

Percentage Score of Critical Elements Met

Current Tool New Tool

100%

100%

90%

73%

100%

100%

100%

93%

100%

100%

100%

93%

100%

93%

100%

93%

100%

93%

Validation Status

Current Tool Met
Partially Met Met Met

New Tool Met
Partially Met Met
Partially Met

Met

Met

Met

Not Met

Met

Partially Met

Met

Not Met

Met

Not Met

Using the current tool, all PIPs received an overall Met validation status except for the Annual Dental Visits PIP which received a Partially Met validation status due to the omission of one of the study indicators.

When the scoring methodology of the new tool was applied, three PIPs--Annual Dental Visits, Childhood Obesity and Member Satisfaction received a Partially Met validation status. The new tool also scored down the Annual Dental Visits PIP for omitting a study indicator and not reporting the omitted study indicator results. For the Childhood Obesity and Member Satisfaction PIPs, not all of the study indicators demonstrated statistically significant improvement. The Lead Screening in Children and Well-Child Visits PIPs received a Not Met validation status since the single study indicator did not achieve statistically significant improvement. The Provider Satisfaction PIP received a Not Met validation status since the one study indicator assessed for sustained improvement did not achieve sustained improvement.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 2-1 Health Services Advisory Group, Inc.

FINDINGS

Table 2-2 displays the combined validation results for all nine AMERIGROUP PIPs validated during FY 2012. This table illustrates the CMO's application of the PIP process and its success in implementing the study. Each activity is composed of individual evaluation elements scored as Met, Partially Met, or Not Met. Elements receiving a Met score have satisfied the necessary technical requirements for a specific element. The validation results presented in Table 2-2 show the percentage of applicable evaluation elements that received a Met score by activity for both the current and new tool. Additionally, HSAG calculated an overall score across all activities. Appendix A provides the detailed validation scores from the current tool for each of the nine PIPs.

Table 2-2--Performance Improvement Project Validation Results for AMERIGROUP Community Care (N=9 PIPs)

Study Stage

Activity

Percentage of Applicable Elements Scored Met

Current Tool1

New Tool2

I. Appropriate Study Topic

100% (50/50)

100% (50/50)

Design

II. Clearly Defined, Answerable Study Question(s) III. Clearly Defined Study Indicator(s)

100% (18/18)
98% (53/54)

100% (18/18)
98% (53/54)

IV. Correctly Identified Study Population

100% (25/25)

100% (25/25)

Design Total

99% (146/147)

99% (146/147)

V.

Valid Sampling Techniques (if sampling was used)

100% (36/36)

100% (36/36)

Implementation VI. Accurate/Complete Data Collection

100% (71/71)

100% (71/71)

VII. Appropriate Improvement Strategies

100% (35/35)

100% (35/35)

Implementation Total

100% (142/142)

100% (142/142)

VIII. Sufficient Data Analysis and Interpretation

92% (72/78)

92% (72/78)

Outcomes IX. Real Improvement Achieved

64% (23/36)

58% (21/36)

X. Sustained Improvement Achieved

100% (2/2)

100% (2/2)

Outcomes Total

84% (97/116)

82% (95/116)

Percentage Score of Applicable Evaluation Elements Met

95% (385/405)

95% (383/405)

1 The current tool was used to score the CMO for the current validation year, FY 2012. 2 The new tool incorporated the revised scoring methodology for Activities VIII through X which will be used for next year's

validation, FY 2013, and is provided for informational purposes only.

Of the nine PIPs evaluated for real improvement, only two PIPs were evaluated for sustained improvement using the current tool.

Both of those PIPs were also evaluated for sustained improvement using the new tool.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 2-2 Health Services Advisory Group, Inc.

FINDINGS
Overall, 95 percent of the evaluation elements across all nine PIPs received a score of Met. This was true for both the current tool and the new tool. The 95 percent score demonstrates a sound application of the PIP process. While AMERIGROUP's strong performance in the Design and Implementation stages indicated that each PIP was designed appropriately to measure outcomes and improvement, AMERIGROUP was less successful in the Outcomes stage. The following subsections highlight HSAG's validation findings associated with each of the three PIP stages.
A compliance issue was noted in the June 2011 submission of one of AMERIGROUP's PIPs. The DCH required all CMOs to include two study indicators for the Annual Dental Visits PIP. However, AMERIGROUP only reported one study indicator and therefore did not meet this requirement. AMERIGROUP's lack of compliance with the DCH's submission requirements affected the scores for the Design stage (Activity III) and the Outcomes stage (Activities VIII and IX).
Design
AMERIGROUP met 100 percent of the requirements across all nine PIPs for three of the four activities within the Design stage. Activity III was scored down since AMERIGROUP did not report both required study indicators for the Annual Dental Visits PIP. Overall, AMERIGROUP designed scientifically sound studies that were supported by the use of key research principles. The technical design of each PIP was sufficient to measure and monitor PIP outcomes associated with AMERIGROUP's improvement strategies. The solid design of the PIPs allowed the successful progression to the next stage of the PIP process.
Implementation
AMERIGROUP met 100 percent of the requirements for the three activities within the Implementation stage. The CMO accurately documented and executed the application of the study design, and then successfully identified, developed and implemented interventions. With the successful implementation of appropriate improvement strategies, the CMO should be able to achieve improved outcomes in the future.
Outcomes
AMERIGROUP was successful in analyzing and interpreting its results; however, not all of the study indicator outcomes achieved statistically significant improvement. Without statistically significant improvement, the CMO either did not demonstrate improvement or it could not be determined whether the improvement was due to the implementation of the CMO's improvement strategy or due to chance.
Additionally, AMERIGROUP did not report results for one of the two study indicators in the Annual Dental Visits PIP. Therefore, this PIP did not meet DCH's submission requirements. In accordance with DCH requirements, HSAG assessed all required activities; however, without complete documentation and data for all activities, AMERIGROUP's Annual Dental Visits PIP

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 2-3 Health Services Advisory Group, Inc.

FINDINGS

did not meet the requirements necessary to receive a Met score. As a result, AMERIGROUP's validation scores were affected for this stage (i.e., Activity VIII--92 percent and Activity IX-- 64 percent of the evaluation elements receiving a Met score).
Using the current tool, the two PIPs (Adults' Access to Care and Childhood Immunizations) assessed for sustained improvement, achieved sustained improvement. Sustained improvement is defined as improvement in performance over baseline, which is maintained or increased for at least one subsequent measurement period. Additionally, the most current measurement period's results must reflect improvement when compared to the baseline results.
When the new tool's scoring methodology was applied, HSAG could only assess the two PIPs (Adults' Access to Care and Childhood Immunizations) that achieved statistically significant improvement in a prior measurement period for sustained improvement. Both PIPs sustained the statistically significant improvement over that subsequent measurement period.

PIP-Specific Outcomes

Analysis of Results

Table 2-3 and Table 2-4 display the outcome data for AMERIGROUP's nine PIPs.

Table 2-3--HEDIS-based Performance Improvement Project Outcomes for AMERIGROUP Community Care

PIP Study Indicator

Sustained Baseline Period Remeasurement 1 Remeasurement 2 Improvement^
(1/1/0812/31/08) (1/1/0912/31/09) (1/1/1012/31/10) Current New Tool^ Tool

Adults' Access to Care

The percentage of members 2044 years of age who had an ambulatory or preventive care visit.

81.2%

85.8%*

85.9%

Yes Yes

Childhood Immunizations

The percentage of children who received the recommended vaccinations based on the Childhood Immunization Status-- Combo 2 (4:3:1:2:3:1) guidelines.

29.8%

72.0%*

78.0%*

Yes Yes

Lead Screening in Children

The percentage of children 2 years of age who received one blood lead test (capillary or venous) on or before their second birthday.

68.2%

67.8%

65.7%





Well-Child Visits

The percentage of children who had six or more well-child visits with a PCP during their first 15 months of life.

62.3%

55.0%*

60.1%





AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 2-4 Health Services Advisory Group, Inc.

FINDINGS

PIP Study Indicator
Percentage of members 23 years of age who had at least one dental visit.

Sustained Baseline Period Remeasurement 1 Remeasurement 2 Improvement
(1/1/0912/31/09) (1/1/1012/31/10) (1/1/1112/31/11) Current New Tool^ Tool
Annual Dental Visits

NR

NR







Percentage of members 221 years of age who had at least one dental visit.

66.8%

69.1%*







Childhood Obesity

The percentage of members 317 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation.

13.7%

28.5%*







The percentage of members 317 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of counseling for nutrition.

40.7%

48.8%*







The percentage of members 317 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of counseling for physical activity.

35.6%

30.1%







Emergency Room Utilization

The number of emergency room visits that

did not result in an inpatient stay per 1000

60.9

member months

58.1*







The PIP did not report Remeasurement 1 results and could not be assessed for real or sustained improvement, or the PIP did not report Remeasurement 2 results and could not be assessed for sustained improvement.

Improvement over baseline must occur before sustained improvement can be assessed using the current tool. Using the new tool, statistically significant improvement over baseline must occur before sustained improvement can be assessed.

* Designates statistically significant improvement over the prior measurement period (p value < 0.05).

* Designates a statistically significant decrease in performance over the prior measurement period (p value < 0.05).

Caution should be used when comparing rates due to a methodology change. ^ Sustained improvement in the current tool is defined as improvement in performance over baseline, which is maintained or increased for
at least one subsequent measurement period. Additionally, the most current measurement period's results must reflect improvement when compared to the baseline results. Sustained improvement in the new tool is defined as statistically significant improvement in performance over baseline, which is maintained or increased for at least one subsequent measurement period. Additionally, the most current measurement period's results must reflect statistically significant improvement when compared to the baseline results. NR The CMO did not report the DCH-mandated study indicator results.

The following section discusses the improvement strategies the CMO implemented in conjunction with the PIP study indicator results. The identification of barriers through barrier analysis and the subsequent selection of appropriate interventions to address those barriers are necessary steps to improve outcomes. The CMO's choice of interventions, the combination of intervention types, and the sequence of intervention implementation are all essential to the CMO's overall success.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 2-5 Health Services Advisory Group, Inc.

FINDINGS
Comparisons to HEDIS benchmarks were made using the Medicaid HEDIS 2010 Audit, Means, Percentiles and Ratios.
Adults' Access to Care
The Adults' Access to Care PIP demonstrated no statistically significant improvement from Remeasurement 1 to Remeasurement 2. The percentage of adult members that accessed ambulatory or preventive care increased by 0.1 percentage point; therefore, the statistically significant improvement the CMO achieved from baseline to Remeasurement 1 was sustained through Remeasurement 2. However, the Remeasurement 2 study indicator result was 2.9 percentage points below the FY 2010 DCH target (88.8 percent) and between the national HEDIS 2010 Medicaid 50th percentile and 75th percentile (82.9 percent and 86.7 percent, respectively).
For the Adults' Access to Care PIP, AMERIGROUP identified member, provider and system barriers. The CMO continued distributing reports with missed opportunity information to providers, as well as lists of their members due for preventive care services. The CMO also targeted outreach to members who had not yet obtained their annual preventive care services. Based on a subgroup analysis by gender, the CMO identified the need for targeted interventions for female members and initiated an incentive program to increase female well check-ups. From Remeasurement 1 to Remeasurement 2, the CMO implemented two system interventions: hiring additional outreach staff and retaining a telephonic outreach supplier. The plan also added 97 PCPs to address geographic deficiencies.
Emergency Room Utilization
The Emergency Room Utilization PIP study indicator outcome demonstrated a statistically significant decrease in emergency room visits from 60.9 per 1000 member months to 58.1 per 1000 member months, which represented a statistically significant improvement. While the emergency room utilization measure included both emergent and nonemergent emergency room visits, the premise was that by reducing the nonemergent emergency room visits the overall utilization rate would decrease. AMERIGROUP emergency room utilization was above the FY 2010 DCH target (48.4 percent) and between the national HEDIS 2010 Medicaid 10th percentile and the 25th percentile (48.3 per 1000 member months and 58.5 per 1000 member months, respectively). For this measure, the HEDIS 2010 Medicaid 10th percentile is the top level of performance.
All interventions were implemented to provide improved education and outreach to providers and members. The CMO's strategy included targeting members seen in the ER for nonemergent care and targeting PCPs whose members demonstrated high daytime ER usage. After additional data analysis, the CMO identified that members with upper respiratory conditions such as asthma contributed to increased ER utilization rates. The focus of case management for these members was modified to encourage and strengthen the PCP-member relationship. Case managers were instructed on how to use AMERIGROUP's educational materials more effectively to help

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 2-6 Health Services Advisory Group, Inc.

FINDINGS
members better understand that opting to seek treatment from their PCP rather than the ER could lead to better health outcomes.
Children's Preventive Services
Statistically significant improvement was documented in the Annual Dental Visits and Childhood Immunization PIPs; the percentages of members receiving these services increased by 2.3 percentage points and 6.0 percentage points, respectively. The Annual Dental Visits PIP study indicator results exceeded the FY 2010 DCH target, and the Childhood Immunization PIP outcome exceeded the FY 2009 DCH target for these measures. Additionally, the rate for annual dental visits for members aged 2 to 21 years exceeded the national HEDIS 2010 Medicaid 90th percentile (64.1 percent). For the Childhood Obesity PIP, two of the three study indicators demonstrated statistically significant improvement. The third study indicator results decreased but the decrease was not statistically significant. However, all three study indicators fell below the FY 2010 DCH targets.
AMERIGROUP implemented many of the same quality improvement strategies for all of its children's preventive service PIPs--Childhood Immunizations, Lead Screening in Children, Well-Child Visits, Annual Dental Visits and Childhood Obesity. The interventions focused on the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program and addressed all study outcomes for these PIPs.
AMERIGROUP attributed its success in improving immunization rates to enhanced member, provider and system interventions. The outreach associates are now able to schedule appointments and transportation when they contact noncompliant members. Additionally, providers can submit names of members who have missed appointments to the CMO outreach staff, and the CMO staff will contact them and assist in overcoming any identified barriers. The CMO enhanced its EPSDT tracking system to better capture claims and encounter data. Additionally, AMERIGROUP added a step to its medical record review process to require providers with a non-passing score on any component to submit a corrective action plan for that component.
To increase annual dental visits, the CMO implemented several interventions to address members' access to dental visits. In response to GeoAccess studies and appointment time availability analyses, the CMO added mobile dental services and increased the hours of availability for dental services. Additionally, AMERIGROUP implemented an incentive program targeting noncompliant members.
For the Childhood Obesity PIP, AMERIGROUP continued its two-pronged approach and targeted interventions to both members and providers. High-volume providers received followup related to any deficiencies in assessing BMI or counseling for physical activity and nutrition. Members were provided educational materials and text messages sent to SafeLink cellular phones.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 2-7 Health Services Advisory Group, Inc.

FINDINGS

Member and Provider Satisfaction

Table 2-4--Satisfaction-based Performance Improvement Project Outcomes for AMERIGROUP Community Care

PIP Study Indicator

Sustained Baseline Period Remeasurement 1 Remeasurement 2 Improvement
(2/13/095/10/09) (2/17/105/2/10) (2/13/115/10/11) Current New Tool^ Tool

Member Satisfaction

1. The percentage of members responding "Yes" to Q10--"In the last six months, did your child's doctor or other health provider talk with you about the pros and cons of each choice for your child's treatment or health care?"

68.9%

60.3%

73.3%*





2. The percentage of members responding "Yes" to Q11--"In the last six months, when there was more than one choice for your child's treatment or health care, did your child's doctor or other health provider ask you which choice you thought was best for your child?"

61.1%

55.1%

58.3%





PIP Study Indicator

Sustained Baseline Period Remeasurement 1 Remeasurement 2 Improvement (9/1/0912/31/09) (9/1/1012/31/10) (9/1/1112/31/11) Current New
Tool^ Tool
Provider Satisfaction

Percentage of providers answering "Excellent" or "Very Good" to Q34C--"Contacting the AMERIGROUP pharmacy call center to find out about formulary medications and alternatives to nonformulary medications."

18.3%

19.3%







The PIP did not report Remeasurement 1 results and could not be assessed for real or sustained improvement, or the PIP did not report Remeasurement 2 results and could not be assessed for sustained improvement.

Improvement over baseline must occur before sustained improvement can be assessed using the current tool. Using the new tool, statistically significant improvement over baseline must occur before sustained improvement can be assessed.

A subsequent measurement period is required before sustained improvement can be assessed.

^ Sustained improvement in the current tool is defined as improvement in performance over baseline, which is maintained or increased for at least one subsequent measurement period. Additionally, the most current measurement period's results must reflect improvement when compared to the baseline results.
Sustained improvement in the new tool is defined as statistically significant improvement in performance over baseline, which is maintained or increased for at least one subsequent measurement period. Additionally, the most current measurement period's results must reflect statistically significant improvement when compared to the baseline results.

*Designates statistically significant improvement over the prior measurement period (p value < 0.05).

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 2-8 Health Services Advisory Group, Inc.

FINDINGS
Member Satisfaction
Both study indicators improved from Remeasurement 1 to Remeasurement 2; however, only the increase for Study Indicator 1 was statistically significant. While the second study indicator outcome increased slightly, the rate at Remeasurement 2 was below the baseline rate. For both scoring methodologies, neither outcome could be assessed for sustained improvement.
Based on the feedback provided to the CMO in last year's report, AMERIGROUP conducted numerous subgroup analyses and developed targeted interventions based on the results. Some of the results included:
1. AMERIGROUP identified that those members who rated their child's health status as excellent or very good were more satisfied than those who rated their child's health status lower. The CMO enhanced the case management and disease management programs to increase the dialogue between members and providers thereby allowing the members more input into the decision-making process.
2. AMERIGROUP identified differences in satisfaction by ethnicity, education and geographic region. The CMO actively recruited PCPs to address these differences (i.e., more Spanishspeaking physicians in counties where Spanish-speaking members constitute more than 10 percent of the population).
Provider Satisfaction
For the Provider Satisfaction PIP, the study indicator outcome improved from baseline to Remeasurement 1, although the improvement was not statistically significant.
AMERIGROUP performed a barrier analysis and identified providers' lack of knowledge regarding use of the pharmacy Web site as a barrier. The plan increased the functionality of the Web site and trained providers on its use. The CMO also identified that the process providers must use to appeal pharmacy denials was increasing their dissatisfaction. In August, 2010, AMERIGROUP implemented a new, less onerous reconsideration process.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 2-9 Health Services Advisory Group, Inc.

3. STRENGTHS
for AMERIGROUP Community Care

Individual PIP Strengths
The study indicator outcome for the Adults' Access to Care PIP, which improved significantly from baseline to the first remeasurement, reflected the effects of a strong quality improvement strategy. Through the second remeasurement period, the CMO was able to sustain the statistically significant improvement that was first achieved from baseline to Remeasurement 1. Although AMERIGROUP's performance was 2.9 percentage points below the FY 2010 DCH target (88.8 percent), the CMO's current success could continue to improve the CMO's general performance on the Adults' Access to Preventive/Ambulatory Health Services HEDIS measure.
The Childhood Immunizations PIP demonstrated AMERIGROUP's success in improving the childhood immunization rate. The rate increased 6.0 percentage points which was statistically significant and exceeded the FY 2009 DCH target rate (72.0 percent). AMERIGROUP implemented several new interventions that may have contributed to its success at achieving real and sustained improvement.
AMERIGROUP was able to improve the rate of annual dental visits for members aged 2 to 21 years. The improvement was statistically significant and above both the FY 2010 DCH target (59.8 percent) and the national HEDIS 2010 Medicaid 90th percentile (64.1 percent). The CMO implemented several interventions to address members' access to dental visits.
For the Childhood Obesity PIP, two of the three study indicators demonstrated statistically significant improvement. AMERIGROUP used a two-pronged approach and targeted interventions to both members and providers.
In the Emergency Room Utilization PIP, AMERIGROUP was able to reduce the ER utilization rate by 2.3 visits per 1000 member months, which was statistically significant. The CMO's strategy included targeting members seen in the ER for nonemergent care and targeting PCPs whose members demonstrated high daytime ER usage.
For the Member Satisfaction PIP, both study indicators improved from Remeasurement 1 to Remeasurement 2; however, only the increase for Study Indicator 1 was statistically significant. Based on the feedback provided to the CMO in last year's report, AMERIGROUP conducted numerous subgroup analyses and developed targeted interventions based on the results.

Global PIP Strengths
Eight of the nine PIPs received an overall Met validation status using the current tool, which represented an area of strength for AMERIGROUP in documentation of its PIP and provided confidence in the technical aspects of the studies. The performance on these PIPs suggests a thorough application of the PIP Design stage. The sound study design of the PIPs created the

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 3-1 Health Services Advisory Group, Inc.

STRENGTHS
foundation for the CMO to progress to subsequent PIP stages--implementing improvement strategies and accurately assessing study outcomes. The CMO appeared to appropriately select and conduct the sampling and data collection activities of the Implementation stage. These activities ensured that the CMO properly defined and collected the necessary data to produce accurate study indicator rates. Additionally, AMERIGROUP appropriately implemented improvement strategies, an activity which ensured that study outcomes could improve. Furthermore, in the Outcomes stage, the CMO properly analyzed and interpreted the outcome results.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 3-2 Health Services Advisory Group, Inc.

4. OPPORTUNITIES FOR IMPROVEMENT
for AMERIGROUP Community Care
Individual PIP Issues
AMERIGROUP has an opportunity to improve documentation related to study indicators and study outcomes for the Annual Dental Visits PIP, which received an overall validation status of Partially Met. Most importantly, the CMO should adhere to the DCH's PIP submission requirements, including the specified number, description and outcomes for the required study indicators. The CMO's noncompliance with these requirements in FY 2012 restricted HSAG's assessment of the PIP and its ability to provide feedback in preparation for the FY 2013 submission.
To maintain high validation scores when the new scoring methodology is applied for PIPs submitted in 2012, AMERIGROUP will need to concentrate its efforts on the six PIPs--Annual Dental Visits, Childhood Obesity, Lead Screening in Children, Member Satisfaction, Provider Satisfaction and Well-Child Visits that would not receive Met validation status due to either a lack of statistically significant improvement or the lack of sustaining the statistically significant improvement. While the CMO has conducted subgroup analyses, it will need to continue to evaluate any changes or disparities in rates to ensure that the appropriate interventions are being implemented.
AMERIGROUP should implement revised improvement strategies for its Lead Screening in Children and Well-Child Visits PIPs. The children's preventive service PIPs that were successful included topic-specific improvement strategies targeted directly at barriers unique to the study indicator outcomes.
Global PIP Issues
AMERIGROUP should be mindful that the submission of PIPs for validation will be an annual activity without an opportunity to resubmit. AMERIGROUP should carefully complete all necessary documentation. The CMO must ensure that the information it reports in the demographic page is accurate, complete and consistent with DCH's expectations of the study. The CMO should refer to the PIP Validation Tool and address all Points of Clarification and all Partially Met and Not Met scores before the next submission in 2012.
AMERIGROUP's focus should shift to the development of appropriate improvement strategies that are responsive to the changing member population and the changing needs of that population. Without continuous ongoing efforts to target improvement strategies using system interventions, AMERIGROUP will not be able to sustain any improvement achieved in the PIP outcomes.

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page 4-1 Health Services Advisory Group, Inc.

APPENDIX A. PIP-SPECIFIC VALIDATION SCORES
for AMERIGROUP Community Care

Table A-1--AMERIGROUP Community Care's FY 2012 PIP Performance1

Percentage of Applicable Evaluation Elements Scored Met

Study Stage

Activity

Adults' Access to
Care

Annual

Childhood Childhood

Dental Visits Immunizations Obesity

ER Utilization

I. Appropriate Study Topic

100%

100%

100%

100%

100%

Design

II. Clearly Defined, Answerable Study Question(s)
III. Clearly Defined Study Indicator(s)

100% 100%

100% 83%

100% 100%

100% 100%

100% 100%

IV. Correctly Identified Study Population

100%

100%

100%

100%

100%

Design Total 100%

94%

100%

100%

100%

V. Valid Sampling Techniques (if sampling was used)

Not

Not

Applicable Applicable

100%

100%

Not Applicable

Implementation VI. Accurate/Complete Data Collection

100%

100%

100%

100%

100%

VII. Appropriate Improvement Strategies

100%

100%

100%

100%

100%

Implementation Total 100%

100%

100%

100%

100%

VIII. Sufficient Data Analysis and Interpretation

100%

38%

100%

100%

100%

Outcomes

IX. Real Improvement Achieved

75%

25%

100%

25%

100%

X. Sustained Improvement Achieved

100%

Not Assessed

100%

Not Assessed

Not Assessed

Outcomes Total

92%

33%

100%

77%

100%

Validation Status

Met

Partially Met

Met

Met

Met

1 Scores and validation status for the PIPs are based on the current tool, and therefore, the current scoring methodology.

Lead Screening in Children
100%

Member Satisfaction
100%

100%

100%

100% 100% 100% 100%

100% 100% 100% 100%

100%
100% 100% 100%
25% Not Assessed 77% Met

100%
100% 100% 89%
75% Not Assessed 85% Met

Provider Satisfaction
100%
100%
100%
100% 100%
100%
100%
100% 100% 100%
75% Not Assessed 92% Met

Well-Child Visits 100%
100%
100%
100% 100%
100%
100%
100% 100% 100%
75% Not Assessed 92% Met

AMERIGROUP Community Care SFY 2012 PIP Validation Report State of Georgia

AMERIGROUP_GASFY2012_CMO_PIP-Val_Report_F2_1011 Page A-1 Health Services Advisory Group, Inc.