Peach State Health Plan: performance improvement projects report SFY 2012 [Oct. 2011]

State of Georgia
Department of Community Health Georgia Families Program
Peach State Health Plan
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 ................................................................................................. 2-9 Member Satisfaction .................................................................................................................... 2-10 Provider Satisfaction .................................................................................................................... 2-10
3. STRENGTHS.......................................................................................................................... 3-1
Individual PIP Strengths ................................................................................................................... 3-1 Global PIP Strengths ........................................................................................................................ 3-2
4. OPPORTUNITIES FOR IMPROVEMENT ....................................................................................... 4-1
Individual PIP Issues ........................................................................................................................ 4-1 Global PIP Issues ............................................................................................................................. 4-1
Appendix A. PIP-SPECIFIC VALIDATION SCORES....................................................................... A-1

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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).

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Performance Improvement Project Validation Report Peach State Health Plan
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 Peach State Health Plan's (Peach State) PIPs. Peach State 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.

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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 Peach State 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 Peach State 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 Peach State beginning in 2006 to provide services to the Georgia Families Program (Medicaid and PeachCare for KidsTM) population. Peach State, a CMO, serves the eligible population in the Atlanta, Central and Southwest 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 Peach State's PIPs for four years, the number of PIPs, study topics and study methods has evolved over time.
Peach State 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 Lead Screening in Children

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.

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BACKGROUND
Member Satisfaction Provider Satisfaction Well-Child Visits
The effectiveness of Peach State'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
Childhood Obesity

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.
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.

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BACKGROUND

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

PIP Study Indicator Description
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 Peach State PIP topic was Provider Satisfaction. Peach State 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

#26

"Ease of getting appointment with a specialist"

Member

#30

"Getting care, tests, or treatments necessary"

Member

#32

"Getting information/help from customer service"

Member

#33

"Treated with courtesy and respect by customer service staff"

Provider

#5*

"Timeliness to answer questions and/or resolve problems"

Provider

#6*

"Quality of the provider orientation process"

Provider

#18*

"Health plan takes physician input and recommendations seriously"

Provider

#34*

"Accuracy of claims processing"

* Providers and members 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 Peach State's PIP Summary Forms. These forms provided detailed information about Peach State'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 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

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BACKGROUND
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

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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, Peach State 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, Peach State'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, Peach State 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 Peach State achieves improvement in the study outcomes for all PIPs submitted for validation in the future, HSAG worked with DCH to modify the existing PIP validation 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), Peach State 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 remeasurement 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 Peach State 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 Peach State would receive if HSAG validated the PIP using the modified validation scoring methodology described above.

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2. FINDINGS
for Peach State Health Plan

Aggregate Validation Findings

HSAG organized, aggregated, and analyzed Peach State'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 Peach State Health Plan

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%

100%

100%

100%

100%

90%

90%

100%

100%

98%

100%

94%

92%

94%

98%

98%

96%

Percentage Score of Critical Elements Met

Current Tool New Tool

100%

100%

100%

100%

100%

100%

100%

86%

100%

100%

100% 100% 100% 100%

100% 87% 100% 93%

Validation Status

Current Tool Met Met Met Met

New Tool Met Met Met
Partially Met

Met

Met

Met

Met

Met

Not Met

Met

Met

Met

Not Met

Using the current tool, all PIPs received an overall Met validation status. When the scoring methodology of the new tool was applied, one PIP--Childhood Obesity--received a Partially Met validation status since not all of the study indicators demonstrated statistically significant improvement. The Well-Child Visits PIP received a Not Met validation status since the single study indicator did not achieve statistically significant improvement. The Member Satisfaction PIP received a Not Met validation status since the one study indicator assessed for sustained improvement did not achieve sustained improvement.

Table 2-2 displays the combined validation results for all nine Peach State PIPs validated during FY 2012. This table illustrates the CMO's application of the PIP process and its success in the implementation of 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

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FINDINGS

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 2-2Performance Improvement Project Validation Results for Peach State Health Plan (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) 100% (54/54)

100% (18/18) 100% (54/54)

IV. Correctly Identified Study Population

100% (26/26)

100% (26/26)

Design Total

100% (148/148)

100% (148/148)

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% (36/36)

100% (36/36)

Implementation Total

100% (143/143)

100% (143/143)

VIII. Sufficient Data Analysis and Interpretation

97% (76/78)

97% (76/78)

Outcomes IX. Real Improvement Achieved

67% (24/36)

75% (27/36)

X. Sustained Improvement Achieved

100% (6/6)

67% (2/3)

Outcomes Total

88% (106/120)

90% (105/117)

Percentage Score of Applicable Evaluation Elements Met

97% (397/411)

97% (396/408)

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 six PIPs were evaluated for sustained improvement using the current tool. Only three of those six PIPs could be evaluated for sustained improvement using the new tool, For the new tool, the CMO must first achieve statistically significant improvement in order to be evaluated for sustained improvement in a subsequent remeasurement period.

Overall, 97 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 97 percent score demonstrates a sound application of the PIP process. While Peach State's strong performance in the Design and

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FINDINGS
Implementation stages indicated that each PIP was designed appropriately to measure outcomes and improvement, Peach State was less successful in the Outcomes stage. The following subsections highlight HSAG's validation findings associated with each of the three PIP stages.
Design
Peach State met 100 percent of the requirements across all nine PIPs for all four activities within the Design stage. Overall, Peach State 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 Peach State's improvement strategies. The solid design of the PIPs allowed successful progression to the next stage of the PIP process.
Implementation
Peach State 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
Peach State 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.
Using the current tool, all six PIPs (Adults' Access to Care, Childhood Immunizations, Lead Screening in Children, Well-Child Visits, Member Satisfaction and Provider Satisfaction) that were 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 three PIPs (Adults' Access to Care, Member Satisfaction and Provider Satisfaction) that achieved statistically significant improvement in a prior measurement period for sustained improvement. Only two of the three PIPs (Adults' Access to Care and Provider Satisfaction) sustained the statistically significant improvement over that subsequent measurement period.

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FINDINGS

PIP-Specific Outcomes

Analysis of Results

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

Table 2-3--HEDIS-based Performance Improvement Project Outcomes for Peach State Health Plan

PIP Study Indicator

Baseline Period (1/1/0812/31/08)

Remeasurement 1 (1/1/0912/31/09)

Remeasurement 2 (1/1/1012/31/10)

Sustained Improvement
Current New Tool^ Tool

The percentage of members 2044 years of age who had an ambulatory or preventive care visit.
The percentage of children who received the recommended vaccinations based on the Childhood Immunization Status-- Combo 2 (4:3:1:2:3:1) guidelines.
The percentage of children 2 years of age who received one blood lead test (capillary or venous) on or before their second birthday.

Adults' Access to Care

78.8%

84.3%*

Childhood Immunizations

62.8%

67.6%

Lead Screening in Children

57.2%

62.3%

84.3% 81.4%* 68.5%

Yes

Yes

Yes



Yes



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.
PIP Study Indicator

51.6%

52.3%

53.9%

Yes



Baseline Period (1/1/0912/31/09)

Remeasurement 1 (1/1/1012/31/10)

Remeasurement 2 (1/1/1112/31/11)

Sustained Improvement
Current New Tool^ Tool

Annual Dental Visits

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

33.8%

38.8%*







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

60.2%

63.6%*







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FINDINGS

PIP Study Indicator

Baseline Period (1/1/0912/31/09)

Remeasurement 1 (1/1/1012/31/10)

Remeasurement 2 (1/1/1112/31/11)

Sustained Improvement
Current Current Tool^ Tool^

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.

32.1%

29.0%







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.

36.7%

45.5%*







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 physical activity.

28.2%

32.0%







Emergency Room Utilization

The number of emergency room

visits that did not result in an inpatient stay per 1,000 member

57.4

months

54.7*







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.

Rates did not include the PeachCare for KidsTM population.

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

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. Peach State's choice of interventions, the combination of intervention types, and the sequence of intervention implementation are all essential to its overall success.
Comparisons to HEDIS benchmarks were made using the Medicaid HEDIS 2010 Audit, Means, Percentiles and Ratios.

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FINDINGS

Adults' Access to Care
The Adults' Access to Care PIP did not demonstrate any significant change from Remeasurement 1 to Remeasurement 2 for the percentage of adult members who accessed ambulatory or preventive care, and remained at 84.3 percent. Peach State's performance was 4.5 percentage points below the FY 2010 DCH target (88.8 percent) and was between the national HEDIS 2010 Medicaid 50th percentile and the 75th percentile (82.9 percent and 86.7 percent, respectively). However, the Remeasurement 2 results demonstrated that the CMO was able to sustain the statistically significant improvement that was first achieved from baseline to Remeasurement 1.
For the Adults' Access to Care PIP, Peach State identified both member and provider barriers but concentrated specifically on one barrier--providers' lack of knowledge regarding HEDIS measure requirements. Subsequently, the CMO developed several interventions that included educating providers and provider staff concerning the HEDIS requirements and appropriate billing. The Provider Incentive Program based on HEDIS metrics also included the Adults' Access to Care measure. The CMO attributed the PIP's success to the incentive program and plans to enhance the incentive program during CY 2012.

Emergency Room Utilization
The Emergency Room Utilization PIP study indicator outcome demonstrated a statistically significant decrease in emergency room visits from 57.4 per 1000 member months to 54.7 per 1000 member months, which represented an 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. Peach State's 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.
Peach State identified that members between the ages of 0 and 10 years were the highest users of the emergency room. The CMO focused its outreach efforts on this subgroup of members. Peach State implemented a member assessment program for new enrollees 1-to-10 years of age. Members received a call within 30 days of enrollment that assisted in identifying and addressing any barriers to obtaining care from the assigned primary care provider. While Peach State did implement some sub-group analyses, it did not provide great detail when describing its subgroup analyses and methods used to evaluate the effectiveness of its interventions. Intervention descriptions should provide enough detail that the intervention can be thoroughly evaluated during validation.
Additionally, Peach State identified that there was a lack of communication between the hospitals and the CMO. Peach State developed an ER Case Management Program to educate the members on the importance and advantages of a patient- centered medical home. The CMO noted that the hospitals do not have any contractual obligation to report emergency room visits to the CMO; therefore, Peach State implemented a voluntary program with hospitals to receive timely emergency room visit data for its members. Peach State also conducted a subgroup

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FINDINGS

analysis and determined that refusal to participate in the data exchange program with the ER Case Management Program staff did not vary by geographic location of the hospital. Most hospitals cited the lack of resources as the reason for their refusal to participate.

Children's Preventive Services
While the study indicator rates for three PIPs--Lead Screening in Children, Childhood Immunizations, and Well-Child Visits--increased from Remeasurement 1 to Remeasurement 2, the increase was only statistically significant for the childhood immunization rate. The calendar year (CY) childhood immunization rate exceeded the FY 2009 DCH target rate (72.0 percent) and exceeded the national HEDIS 2010 Medicaid 50th percentile (76.6 percent) for Combo 2.
Conversely, the CY 2010 outcomes for Lead Screening in Children and Well-Child Visits PIPs remained below the FY 2010 DCH target rates (80.1 percent and 67.9 percent, respectively). Furthermore, the study indicator rates for the Lead Screening in Children and Well-Child Visits PIPs were below the national HEDIS 2010 Medicaid 50th percentile (71.6 percent and 60.1 percent, respectively).
The Annual Dental Visits and Childhood Obesity PIPs initial submission was for the current FY 2012 validation. Peach State reported CY 2009 and CY 2010 data for both PIPs. The Annual Dental Visits PIP study indicator outcomes showed a statistically significant increase in the rates for both the 2-to-3-year-olds and for the 2-to-21-year-olds. Both study indicator outcomes were between the national HEDIS 2010 Medicaid 75th percentile and 90th percentile; however, the rate for the 2-to-3-year-olds was below the FY 2010 DCH target rate (41.9 percent). Only one of the three study indicators for the Childhood Obesity PIP--percentage of 3-to-17-year-olds with evidence of nutritional counseling--demonstrated a statistically significant increase. However, all three study indicator results were below the FY 2010 DCH target rates and also fell between the national HEDIS 2010 Medicaid 25th percentile and 50th percentile.
Peach State implemented the same quality improvement strategy 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. Peach State identified lack of member and provider awareness about the program, reduced plan/provider communication, and lack of supplemental data sources as the primary barriers to improvements in these measures.
In January 2010, Peach State established a Provider Incentive Program based on HEDIS metrics (initial implementation January 1, 2010). In October 2010, a Provider Bonus Program was instituted based on reducing the noncompliant member lists. The CMO plans to enhance the incentive program during CY 2012. Additionally, in the second quarter of CY 2010, Peach State launched a HEDIS "SWAT" team to support providers through face-to-face interactions in meeting HEDIS requirements.
Unique to the immunization rates, Peach State hired temporary employees to enter immunization data into a supplemental database. Additionally, vaccinations given at the hospital of delivery

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FINDINGS
were also captured and entered into the database. These system interventions may have contributed to the 13.8 percentage point increase documented for the immunization rates.
For the Annual Dental Visits PIP, Peach State provided a mobile van to perform dental screenings for noncompliant members in the Atlanta region. Additionally, Peach State partnered with a dental vendor to provide extended office hours for all noncompliant members 2-to-3 years of age in all regions.

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FINDINGS

Member and Provider Satisfaction

Table 2-4--Satisfaction-based Performance Improvement Project Outcomes for Peach State Health Plan

PIP Study Indicator 1. "Ease of getting appointment with a specialist" (Q26)

Baseline Period (9/1/0912/31/09)

Remeasurement 1 (9/1/1012/31/10)

Remeasurement 2 (9/1/1112/31/11)

Sustained Improvement
Current New Tool^ Tool

Member Satisfaction

71.7%

71.8%

83.7%*

Yes



2. "Getting care, tests, or treatments necessary" (Q30)

79.9%

81.1%

81.3%

Yes



3. "Getting information/help from customer service" (Q32)

68.5%

80.8%*

79.4%

Yes

No

4. "Treated with courtesy and respect by customer service staff" (Q33)

86.4%

90.4%

90.3%

Yes



PIP Study Indicator

Baseline Period (8/1/0710/30/07)

Remeasurement 1 (11/1/082/28/09)

Remeasurement 2 (9/29/0910/27/09)

Remeasurement 3 (9/28/10-11/15/10)

Sustained Improvement
Current New Tool^ Tool

Provider Satisfaction

1. The percentage of providers answering "Excellent" or "Very Good" to Q5-- "Timeliness to answer questions and/or resolve problems."

15.8%

28.0%*

32.3%

36.3%

Yes

Yes

2. Percentage of providers answering "Excellent" or "Very Good" to Q6-- "Quality of the provider orientation process."

14.2%

24.1%*

31.0%*

32.6%

Yes

Yes

3. Percentage of providers answering "Excellent" or "Very Good" to Q18-- "Health plan takes physician input and recommendations seriously."

10.7%

15.2%

24.5%*

25.8%

Yes

Yes

4. Percentage of providers answering "Excellent" or "Very Good" to Q34-- "Accuracy of claims processing."

12.1%

16.0%

28.8%*

26.0%

Yes

Yes

Members were requested to respond if they agreed with the statements regarding the CMO.
^ 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.

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.

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

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FINDINGS
Member Satisfaction
While two of the four study indicator outcomes for the Member Satisfaction PIP increased from Remeasurement 1 to Remeasurement 2, only the first study indicator (ease of getting appointment with specialist) achieved a statistically significant increase. Using the current tool, all four study indicators demonstrated sustained improvement. When the new tool was applied, only the third study indicator was assessed for sustained improvement. This indicator was the only one that had a subsequent measurement after achieving statistically significant improvement over baseline; however, the improvement was not sustained through the second remeasurement period.
For the first study indicator (ease of getting an appointment with a specialist), the CMO aggressively recruited practitioners in all regions. For the other three outcomes (getting care, tests, or treatments necessary; getting information/help from customer service; and treated with courtesy and respect by customer service staff), the CMO could not attribute its success to any specific intervention since the improvement was not statistically significant and was possibly due to chance.
Provider Satisfaction
For the Provider Satisfaction PIP, none of the study indicators demonstrated a statistically significant improvement from Remeasurement 2 to Remeasurement 3; however, the CMO was able to sustain the statistically significant improvement it had achieved from the baseline measurement period to Remeasurement 3. Peach State identified specific barriers and implemented targeted interventions for each study indicator outcome. The CMO attributed the overall success of the PIP to the following interventions:
Timeliness in answering questions and/or resolving problems--the CMO created a reimbursement committee to address payment policy and reimbursement issues.
Updated provider tools--the CMO distributed a provider manual, tip sheets, and billing guides, and upgraded the online tools.
High regard for physician input and recommendations--When Peach State decided to create a Customer Service Form, the CMO solicited input and recommendations for its content from physicians. The CMO then evaluated these recommendations and provided timely responses to the contributing physicians regarding the applicability of their recommendations to the final draft of the form.
Accuracy of claims processes--Peach State created a scorecard to identify provider billing errors. After the scorecards were distributed, providers were educated and retrained.

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3. STRENGTHS
for Peach State Health Plan

Individual PIP Strengths
The Adult's Access to Care PIP received a Met score for 100 percent of the evaluation elements in two of the three PIPs' validation stages--Design and Implementation. Peach State received a Met score for 92 percent of the evaluation elements in the Outcomes stage for this PIP. Furthermore, 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 Peach State's performance was 4.5 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.
In the Emergency Room Utilization PIP, Peach State was able to reduce the ER utilization rate by 2.7 visits per 1000 member months, which was statistically significant. The CMO used subgroup analyses to identify members with six or more ER visits and placed these members in the ER Case Management Program. Additionally, Peach State focused its efforts on developing a voluntary exchange of data between the hospitals and the CMO. While the CMO demonstrated success in improving the study indicator outcome, it may need to develop a method to facilitate the data exchange between the hospitals and the CMO that is less resource-intensive, thus encouraging more hospitals to participate in the program.
The Childhood Immunizations PIP received a Met validation status and also demonstrated Peach State's success in improving the childhood immunization rate. The rate increased 13.8 percentage points which was statistically significant and exceeded the FY 2009 DCH target rate (72.0 percent). Peach State provided extra resources to collect supplemental data which may have contributed to its success with this PIP.
For the Member Satisfaction PIP, the first study indicator demonstrated a statistically significant increase of 11.9 percentage points and represented an increase in member satisfaction with Peach State's provider panel. Peach State attributed the success of the PIP to aggressive provider recruitment efforts in all regions.
The Provider Satisfaction PIP received an overall Met validation status and represented an area of strength for Peach State. Performance on this PIP suggested a thorough application of the PIP study design and the development and implementation of appropriate interventions. Peach State was also successful in achieving real and sustained improvement for all four study indicator outcomes for the Provider Satisfaction PIP. This finding was Peach State's greatest strength. The improved outcomes from baseline to Remeasurement 3 illustrated the providers' increased satisfaction with the CMO's timeliness of answering questions and/or resolving problems, the quality of the provider orientation process, the CMO's response to providers' input and

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STRENGTHS
recommendations, and the accuracy of claims processing. Moreover, Peach State's implementation and evaluation of targeted Provider Satisfaction interventions suggested that the CMO could translate its success in achieving real and sustained improvement to other PIP topics.
Global PIP Strengths
All nine PIPs received an overall Met validation status using the current tool, which represented an area of strength for Peach State in documentation of its PIP and provided confidence in the technical aspects of the studies. The performance for these PIPs suggests a thorough application of the PIP Design stage. The sound study design of the PIPs created the 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, Peach State appropriately documented 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.

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4. OPPORTUNITIES FOR IMPROVEMENT
for Peach State Health Plan
Individual PIP Issues
To maintain high validation scores when the new scoring methodology is applied for PIPs submitted in 2012, Peach State will need to concentrate its efforts on the three PIPs that would not receive Met validation status--Childhood Obesity, Member Satisfaction and Well-Child Visits--due to either a lack of statistically significant improvement or a lack of sustained improvement. While Peach State 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.
Global PIP Issues
The CMO should be mindful that the submission of PIPs for validation will be an annual activity without an opportunity to resubmit. Peach State 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. Peach State 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.
Peach State's PIPs were well designed and documented; however, the implementation of improvement strategies has been ineffective in producing long-term, sustained change in outcomes. Peach State'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 revise improvement strategies, Peach State will not be able to sustain any improvement achieved in the PIP outcomes.
Peach State should include the methods used to evaluate the effectiveness of its interventions. Intervention descriptions should provide enough detail that the intervention can be thoroughly evaluated during validation.

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APPENDIX A. PIP-SPECIFIC VALIDATION RESULTS
for Peach State Health Plan
Table A-1--Peach State Health Plan'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% 100%

100% 100%

100% 100%

100% 100%

IV. Correctly Identified Study Population

100%

100%

100%

100%

100%

Design Total 100%

100%

100%

100%

100%

V. Valid Sampling Techniques

Not

Not

(if sampling was used)

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%

100%

100%

78%

100%

Outcomes

IX. Real Improvement Achieved

75%

100%

100%

25%

100%

X. Sustained Improvement Achieved

100%

Not Assessed

100%

Not Assessed

Not Assessed

Outcomes Total

92%

100%

100%

62%

100%

Validation Status

Met

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%
100%
100%
100% 100% 100%
100%
100% 100% 100%
75%
100% 93% Met

Member Satisfaction
100%
100%
100%
100% 100% 100%
100%
100% 100% 100%
25%
100% 79% Met

Provider Satisfaction
100%
100%
100%
100% 100% 100%
100%
100% 100% 100%
25%
100% 79% Met

Well-Child Visits 100%
100%
100%
100% 100% 100%
100%
100% 100% 100%
75%
100% 93% Met

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