Peach State Health Plan: performance improvement projects report SFY 2013 [Nov. 2012]

State of Georgia
Department of Community Health Georgia Families Program
Peach State Health Plan
PERFORMANCE IMPROVEMENT PROJECTS REPORT
SFY 2013
November 2012

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 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 Annual Dental Visits .....................................................................................................................2-7 Childhood Immunizations .............................................................................................................2-8 Childhood Obesity ........................................................................................................................2-9 Emergency Room Utilization ......................................................................................................2-10 Lead Screening in Children ........................................................................................................2-10 Well-Child Visits .........................................................................................................................2-11 Member and Provider Satisfaction..............................................................................................2-12 Member Satisfaction...................................................................................................................2-13 Provider Satisfaction ..................................................................................................................2-14
3. Strengths ............................................................................................................................ 3-1 Individual PIP Strengths .................................................................................................................3-1 Global PIP Strengths ......................................................................................................................3-1
4. Opportunities for Improvement ........................................................................................... 4-1 Individual PIP Opportunities for Improvement .................................................................................4-1 Global Opportunities for Improvement ............................................................................................4-1
Appendix A. PIP-Specific Validation Results ...................................................................... A-1

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Health Services Advisory Group, Inc.

Page ii

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).

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Health Services Advisory Group, Inc.

Page ii

Performance Improvement Project Validation Report Peach State Health Plan

1. BACKGROUND
The Georgia Department of Community Health (DCH) is responsible for administering the Medicaid program and the Children's Health Insurance Program (CHIP) for the State of Georgia and overseeing quality improvement activities. The State refers to its Medicaid managed care program as Georgia Families and to its CHIP program as PeachCare for Kids. For the purposes of this report, "Georgia Families" refers to all Medicaid and CHIP members enrolled in managed care.
The Georgia Families Managed Care Program serves the majority of Georgia's Medicaid and CHIP populations. The DCH requires its Georgia Families 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 targeted areas of clinical or nonclinical care or service provided to members, and to report the status and results of each PIP annually. Peach State Health Plan (Peach State) is one of the Georgia Families CMOs.
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 assure appropriate access to high quality care for 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 measure rates provide 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 External Quality Review Organization (EQRO), to conduct the validation of Peach State's PIPs. Peach State submitted PIPs to HSAG between June 29, 2012, and August 3, 2012, and HSAG validated the PIPs between July 2, 2012,

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 1-1
Health Services Advisory Group, Inc.

BACKGROUND
and August 10, 2012. The validated data represents varying measurement time periods as described in Table 2-3 and Table 2-4.
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 outcomes of the PIPs. 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) and achieved statistically significant improvement over the baseline rate. 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 Kids) population. Prior to 2012, Peach State served the eligible populations in the Atlanta, Central and Southwest CMO service regions of Georgia. In early 2012, the CMO expanded coverage statewide and added the north, east and southeast regions. This new membership is not included in the performance improvement project rates in this report.
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 five years, the number of PIPs, study topics and study methods has evolved over time.
Peach State submitted nine (9) PIPs for validation. The PIP topics include:
Adults' Access to Care Annual Dental Visits Childhood Immunizations
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.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 1-2
Health Services Advisory Group, Inc.

BACKGROUND

Childhood Obesity Emergency Room Utilization Lead Screening in Children 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 (November 2011), the DCH identified the improvement and enhancement of the quality of patient care provided through ongoing, objective, and systematic measurement, analysis and improvement of performance as one of its four performance-driven goals. The goals are designed to demonstrate success or identify challenges in achieving intended outcomes related to providing quality, accessible, and timely services. The June 29, 2012, through August 3, 2012 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 and management of disease. They include: Annual Dental Visits, Childhood Immunizations, Childhood Obesity, Lead Screening in Children and WellChild 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 Topics

PIP Study Indicator Descriptions

Adults' Access to Care

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

Annual Dental Visits

The percentage of members who had at least one dental visit: 23 years of age; and 221 years of age.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 1-3
Health Services Advisory Group, Inc.

BACKGROUND

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

PIP Study Topics

PIP Study Indicator Descriptions

Childhood Immunization

The percentage of children 2 years of age who had the following vaccines by their second birthday: 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).

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, nutrition counseling and physical activity counseling.

Emergency Room Utilization

The number of emergency department visits that did not result in an inpatient stay, per 1,000 member months.

Lead Screening in Children

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.

Well-Child Visits

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 CMO.

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 validations from Peach State's PIP Summary Forms. These forms provided detailed information about Peach State's PIPs related to the activities they completed.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 1-4
Health Services Advisory Group, Inc.

BACKGROUND
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 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

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 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, 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 the baseline rate and sustain the 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 improvement is achieved.
HSAG's Validation Scoring Methodology
During SFY 2012, HSAG worked with DCH to modify the existing PIP validation methodology. The modifications were designed to ensure Peach State achieves improvement in the study outcomes for all PIPs submitted for validation. Changes were made to the validation activities for Activity VIII (sufficient data analysis and interpretation). Peach State must now present study results that are accurate, clear and easily understood. Furthermore, 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. Changes were also made to the validation activities for Activity IX (real improvement achieved) and this activity is now a critical element for all PIPs that progress to this stage. Any PIP that does not achieve statistically significant improvement will not receive an overall Met validation status. Peach State's study indicator outcomes must achieve statistically significant improvement over the baseline rate. Finally, changes were made to the validation activities 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 must achieve statistically significant improvement and report a subsequent measurement period with documented sustained improvement. All study indicators must now achieve statistically significant improvement and sustain this improvement to receive a Met score for Activity X.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 1-6
Health Services Advisory Group, Inc.

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 review, HSAG determined the overall methodological validity of the PIPs, as well as the overall success in achieving improved study indicator outcomes. The results 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
95% 92% 98% 80% 97% 98% 85% 96% 86%

Percentage Score of Critical Elements Met
92% 92% 100% 79% 100% 100% 86% 93% 86%

Validation Status
Partially Met Partially Met
Met Partially Met
Met Met Partially Met Partially Met Not Met

Not all PIPs received an overall Met validation status. Both the Adults Access to Care and Provider Satisfaction PIPs received a Partially Met validation status due to the incomplete causal/barrier analysis and intervention evaluation processes. The Annual Dental Visits PIP received a Partially Met validation status due to the CMO documenting inaccurate data and statistical testing values in the data table of Activity IX. Although the CMO documented inaccurate numerators and denominators in its PIP Summary Form, the CMO correctly reported its study indicator rates in the PIP. This was validated by HSAG through a comparison of the Peach State's PIP reported rates to its audited performance measure rates submitted to NCQA.
The CMO's Member Satisfaction PIP received a Partially Met status because only two of its four study indicators achieved statistically significant improvement over baseline. For the Childhood Obesity PIP, the CMO reported incorrect statistical testing values, and only one of its three study indicators achieved improvement that was statistically significant. The CMO's Well-Child Visits PIP received a Not Met validation status. The Well-Child Visits PIP study indicator demonstrated a decline in performance in the most recent remeasurement period with the rate falling below the baseline. Due to this decline and the study indicator not yet achieving statistically significant improvement, the PIP received an overall Not Met validation status.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-1
Health Services Advisory Group, Inc.

FINDINGS

Table 2-2 displays the combined validation results for all nine Peach State PIPs validated during FY 2013. 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. Additionally, HSAG calculated an overall score across all activities. Appendix A provides the detailed scores from the validation 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

I. Appropriate Study Topic

Design

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

IV. Correctly Identified Study Population

Design Total

V.

Valid Sampling Techniques (if sampling was used)

Implementation VI. Accurate/Complete Data Collection

VII. Appropriate Improvement Strategies

Implementation Total

VIII. Sufficient Data Analysis and Interpretation

Outcomes IX. Real Improvement Achieved

X. Sustained Improvement Achieved

Outcomes Total

Percentage Score of Applicable Evaluation Elements Met

100% (50/50) 100% (18/18) 100% (54/54) 100% (25/25) 100% (147/147) 100% (36/36) 100% (71/71)
44% (16/36) 86% (123/143)
94% (73/78)
75% (27/36) 100%
(6/6) 88% (106/120) 92% (376/410)

Overall, 92 percent of the evaluation elements across all nine PIPs received a score of Met. The 92 percent score demonstrates a sound application of the PIP process. While Peach State's strong performance in the Design stage indicated that each PIP was designed appropriately to measure outcomes and improvement, Peach State was less successful in the Implementation and

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-2
Health Services Advisory Group, Inc.

FINDINGS
Outcomes stages. 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 86 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 documented conducting causal/barrier analysis; however, not all of the analysis conducted by the CMO was appropriate. Several of the interventions implemented by Peach State were not relevant to the identified barriers and the CMO lacked a process to evaluate the efficacy of its interventions.
Outcomes
This year, six PIPs (Adults' Access to Care, Childhood Immunizations, Annual Dental Visits, ER Utilization, Lead Screening in Children and Provider Satisfaction) were evaluated for sustained improvement, and all six achieved sustained improvement. Sustained improvement is defined as statistically significant improvement in performance over baseline that is maintained or increased for at least one subsequent measurement period.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-3
Health Services Advisory Group, Inc.

FINDINGS

PIP-Specific Outcomes

Analysis of Results

Table 2-3 displays the study indicator rates for each measurement period of the PIP, including the baseline period and each subsequent remeasurement period, through Remeasurement 3. Statistically significant changes between remeasurement periods are noted with an upward or downward arrow. If the PIP achieved statistically significant improvement over the baseline rate, it was then reviewed for sustained improvement. Sustained improvement is defined as statistically significant improvement in performance over baseline for all study indicators that 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 for all study indicators. PIPs that did not achieve statistically significant improvement (i.e., did not meet the criteria to be assessed for sustained improvement) were not assessed (NA).

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

PIP Study Indicator

Baseline Period Remeasurement 1 Remeasurement 2 Remeasurement 3 Sustained (1/1/0812/31/08) (1/1/0912/31/09) (1/1/1012/31/10) (1/1/1112/31/11) Improvement^

Adults' Access to Care

The percentage of members 2044

years of age who had an ambulatory

78.8%

84.3%*

84.3%

84.8%

Yes

or preventive care visit.

Childhood Immunizations

The percentage of children 2 years of

age who had the following vaccines by

their second birthday: four diphtheria,

tetanus and acellular pertussis (DTaP); three polio (IVP); one measles, mumps

62.8%

67.6%

81.4%*

80.6%

Yes

and rubella (MMR); two H influenza

type B (Hib); three hepatitis B; and one

chicken pox (VZN).

Lead Screening in Children

The percentage of children 2 years of

age who had one or more capillary or venous lead blood tests for lead

57.2%

62.3%

68.5%

70.8%

Yes

poisoning by their second birthday.

Well-Child Visits

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

51.6%

52.3%

53.9%

50.5%

NA

care provider (PCP) during their first

15 months of life.

NA Statistically significant improvement over baseline and a subsequent measurement must occur for all study indicators before sustained improvement can be assessed.

Rates did not include the PeachCare for Kids population.

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

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-4
Health Services Advisory Group, Inc.

FINDINGS

Table 2-4 displays the study indicator rates for Peach State's three PIPs that progressed to Remeasurement 2.

Table 2-4--HEDIS-Based Performance Improvement Project Outcomes for Peach State Health Plan

PIP Study Indicator

Baseline Period Remeasurement 1 (1/1/0912/31/09) (1/1/1012/31/10)

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

Sustained Improvement^

Annual Dental Visits

The percentage of members 2

3 years of age who had at least

33.8%

38.8%*

43.9%*

Yes

one dental visit.

The percentage of members 2

21 years of age who had at

60.2%

63.6%*

67.5%*

Yes

least one dental visit.

Childhood Obesity

The percentage of members 3 17 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%

22.7%*

NA

The percentage of members 3

17 years of age who had an

outpatient visit with a PCP or OB/GYN and who had

36.7%

45.5%*

40.7%

NA

evidence of counseling for

nutrition.

The percentage of members 3 17 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%

29.4% NA

Emergency Room Utilization

The number of emergency

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

57.4

member months

54.7*

52.5%*

Yes

NA Statistically significant improvement over baseline and a subsequent measurement must occur for all study indicators before sustained improvement can be assessed.

Rates did not include the PeachCare for Kids population.

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

* Designates statistically significant decline in performance over the prior measurement period (p value < 0.05).
^ Sustained improvement is defined as statistically significant improvement in performance over baseline for all study indicators that 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 for all study indicators.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-5
Health Services Advisory Group, Inc.

FINDINGS

Peach State was not successful in achieving the desired outcomes for all study indicators. 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.
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. Deficiencies were identified during the validation process in each of these areas and will be explained in further detail below.
The following section discusses the improvement strategies the CMO implemented in conjunction with the PIPs' study indicator results. Comparisons to HEDIS benchmarks were made using the Medicaid HEDIS 2010 Audit, Means, Percentiles and Ratios (reflecting the 2009 calendar year [CY]).

Adults' Access to Care
The Adults' Access to Care PIP did not demonstrate any significant change from Remeasurement 2 to Remeasurement 3 for the percentage of adult members who accessed ambulatory or preventive care, with its rate increasing slightly to 84.8 percent. Peach State's performance was 3.7 percentage points below the CY 2011 DCH target (88.5 percent) and fell between the national HEDIS 2010 Medicaid 50th percentile and the 75th percentile (82.9 percent and 86.7 percent, respectively). However, Remeasurement 3 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 conducted a drill-down analysis by member demographic, geographic criteria, and provider. Based on the data from this analysis, barriers were grouped and organized by providers or members. The CMO then determined, through its HEDIS Steering Committee, that many of its ongoing interventions would continue and become standardized processes.
For this PIP, HSAG's validation activities found that the CMO identified coding as a barrier to improvement with this PIP. Peach State documented provider face-to-face training sessions with provider office staff to provide instruction on using accurate billing codes and CPT coding guidelines, including CPT II codes as the intervention to address this barrier. However, the technical specifications for this PIP indicator count any visit to any provider in an ambulatory care setting as compliant and CPT II codes have no value for this measure. Therefore, it does not appear that Peach State's barrier analysis was correct in identifying coding as one of the barrier for this PIP. The low rate for this PIP indicator reflects adult members that simply did not access care with any outpatient provider in any setting.
System barriers identified by the CMO included data opportunities such as capturing supplemental data and incorporating historical claims data received from the State. HSAG could not find the rationale for how a supplemental data source would improve data capture as the CMO did not fully explain what types of outpatient and/or ambulatory services were being

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-6
Health Services Advisory Group, Inc.

FINDINGS
provided to adult members that were not already being captured as a claim or encounter. Additionally, members must be continuously enrolled in the CMO with only a one-month allowable gap. Historical claims data would only be beneficial if the member received an outpatient service from a provider during a one-month gap in enrollment. The CMO would need to conduct or provide additional data analysis to demonstrate the percentage of adult members who did not have a visit in the measurement year and who also had a one-month break in enrollment to determine if this truly is a barrier that is impacting the rate. The CMO referenced standardizing its Provider Incentive Program, yet this intervention was not included in the grid of implemented interventions and was not explained in terms of the barriers and strategy of the intervention for this measure.
For member interventions, Peach State documented interventions addressing members' lack of knowledge of the recommended adult preventive visit schedule and lack of transportation to scheduled appointments. The CMO initiated efforts to conduct member outreach events and to collaborate with OptiCare to outreach "non-compliant" members to encourage and schedule eye exams (ambulatory visits). HSAG suggests that Peach State consider conducting a small focus group with adult members that did not access care in the last remeasurement year to gain a better understanding of why these members did not seek care. This activity may also be helpful in understanding what would motivate a member to access care. It is difficult without speaking directly with members to determine if members truly lack the knowledge to seek care or whether there are other barriers preventing them from obtaining care. Soliciting member input is an important investment for the CMO to make in order to improve results related to this PIP indicator.
Peach State documented that "those interventions believed to be successful and positively affect our barriers were standardized" and "the provider incentive program was standardized because it was believed to positively affect our provider efforts to increase rates." However, the PIP documentation did not provide any evidence of how Peach State determined which interventions were effective and how it determined that these particular interventions would become standardized processes. Since the rates have been stagnant since Remeasurement 1, Peach State should give thorough consideration as to how it will evaluate the efficacy of each intervention. This evaluation would also enable Peach State to better target its resources toward interventions that have an opportunity to positively impact the rates.
Annual Dental Visits
The Annual Dental Visits increased in the most recent measurement period and the increase was statistically significant. Both study indicators achieved real and sustained improvement over the baseline rate. In addition, the rate for Study Indicator 2 (members 221) exceeded the CY 2011 DCH target rate of 64.1 percent and the national HEDIS 2010 Medicaid 90th percentile of 64.1 percent.
Peach State incorporated an additional workgroup in 2011 solely focused on improving compliance with dental visits. This group reviewed the data, conducted analysis, identified barriers, and developed improvement strategies. One of the new interventions implemented was collaborating with DentaQuest on providing dental services to members via a mobile van. It was

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-7
Health Services Advisory Group, Inc.

FINDINGS
noted that Peach State linked this intervention to "member barriers regarding transportation, scheduling appointments, and compliance." It was not clear to HSAG how the mobile van addressed scheduling appointments and compliance. The effort did appear to be directed at improving access as the mobile van offered extended hours. Peach State has an opportunity to provide greater detail when describing its barriers and how interventions specifically target the identified barriers. Peach State should also look for opportunities to measure the effectiveness of its interventions, such as how many additional members received an annual dental visit as a result of the mobile van effort, etc.
Childhood Immunizations
Peach State demonstrated improvement that was statistically significant over the baseline rate, despite the non-significant decline at Remeasurement 3. However, the CY 2011 rate did not achieve the DCH target rate. Two of the barriers that Peach State identified were "member lack of motivation to obtain required immunizations" and "provider lack of motivation to provide required immunizations." Peach State's documentation in the PIP did not provide any evidence on how it determined this lack of member and provider motivation barrier. The CMO then partnered with its corporate quality improvement staff to implement a member/provider incentive program targeting non-compliant members to obtain the needed immunizations. Peach State should provide detailed information about how it determined that providers are not motivated. The CMO should consider evaluating its provider incentive program to determine if this incentive is having the desired effect.
Additionally, the PIP documentation stated that the Steering Committee evaluated the CY 2011 data, and those interventions believed to be successful and that were having a positive effect on the barriers would become standardized. Other than documenting that the committee had a "thorough discussion," Peach State did not specify the mechanisms and tools used by the committee to identify barriers or determine the efficacy of these interventions. It should be noted that several of the interventions were not implemented until the last three months of 2011. With this timing, many of the interventions had not been in place long enough to have made an impact on the reported results.
Peach State should discuss its plans for continuing its momentum in driving improvement for this study indicator and achieving the DCH target. The CMO could research Web sites of organizations such as the American Academy of Pediatrics to locate ideas for future interventions. A stepped intervention for well-child care and immunizations has proven to be successful. The objective of this AAP intervention is to test a stepped approach involving reminder/recall/case management to increase infant well-child visits and immunizations. The intervention consisted of a randomized, controlled, practical clinical trial with 811 infants born in an urban safety-net hospital and followed through 15 months of age. Step 1, all infants, involved language-appropriate reminder postcards for every well-child visit. Step 2, infants who missed an appointment or immunization, involved a telephone call reminder plus postcard and telephone recall. Step 3, infants who were still behind on preventive care Steps 1 and 2, involved intensive case management and home visitation.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-8
Health Services Advisory Group, Inc.

FINDINGS
Peach State may also consider analyzing data among its pediatric providers to determine those providers who have lower immunization rates, then consult with the low-performing providers to determine strategies to overcome any provider-related barriers.
Childhood Obesity
The CY 2011 outcomes for the Childhood Obesity PIP were below CY 2010 results for all three study indicators. In addition, none of the CY 2011 rates for these three PIPs achieved the CY 2011 DCH target rates and were below the national HEDIS 2010 Medicaid 50th percentile.
According to the PIP documentation provided by Peach State, the CMO standardized all interventions determined to positively impact the rates for all three study indicators. The CMO did not provide documentation of its evaluation of each of the interventions to determine the intervention's efficacy. Given the statistically significant decline for Study Indicator 1and the statistically flat performance for Study Indicators 2 and 3, it appeared that few, if any, of the interventions implemented to address previously identified barriers (such as member newsletters, reminder calls to non-compliant members, and educational materials to providers) were effective.
Although Peach State's PIP submission included a description of the new HEDIS Steering Committee that it formed to analyze data, identify barriers and opportunities for improvement, and discuss and implement interventions, the CMO did not specify the mechanisms and tools it used to identify barriers or evaluate the efficacy of the interventions. For instance, one of the barriers noted by Peach State was "lack of member motivation to complete preventive visits." As with the Childhood Immunizations PIP, the CMO did not specify how it measured member motivation to determine this was a specific barrier. Furthermore, the denominator for the three Childhood Obesity study indicators consists of the number of Peach State Medicaid enrolled members ages 317 who had a PCP or OB/GYN visit during the measurement period. Therefore, the numerator can only be derived from members who actually had a PCP or OB/GYN visit during the measurement period and had body mass index (BMI) percentile, nutrition counseling, and counseling for physical activity documented in the file. Since the indicators for this PIP can only be calculated from those members who had a visit with a PCP or OB/GYN during the measurement period, one could argue that members were motivated to have at least one visit with a PCP or OB/GYN. The CMO should re-evaluate the "lack of member motivation to complete preventive visits" barrier for this particular PIP and focus its resources on ensuring that providers perform the necessary services required for these indicators.
For many of the barriers listed in 2010, Peach State noted that there was a lack of physician awareness of prevention and treatment recommendations for childhood obesity and also noted a lack of provider knowledge regarding Clinical Practice Guidelines content and availability as an additional barrier. There was no indication in the current PIP documentation whether or not the interventions to address these issues were effective. Given the statistically significant decline in Indicator 1 and statistically flat performance for Indicators 2 and 3, it does not appear that any of the interventions implemented by the CMO to address these previously identified barriers were effective. Also, for providers that demonstrate a lack of knowledge regarding Clinical Practice

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-9
Health Services Advisory Group, Inc.

FINDINGS
Guidelines and prevention and treatment of childhood obesity, HSAG would expect that these providers be brought up for review by the Quality Committee or Credentialing Committee.
Emergency Room Utilization
The focus of this PIP was to decrease the rate of ER visits that did not result in an inpatient stay, per 1000 member months. The Emergency Room Utilization PIP study indicator outcome demonstrated a statistically significant decrease in emergency room (ER) visits from 54.7 per 1000 member months to 52.5 per 1000 member months, which represented an improvement (lower rates indicate better performance for this indicator). Peach State's emergency room utilization was below the CY 2011 DCH target (58.5 percent) and the national HEDIS 2010 Medicaid 25th percentile (58.5 per 1000 member months). For this measure, the HEDIS 2010 Medicaid 25th percentile represents lower utilization.
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 and educational efforts on this subgroup of members. Peach State enhanced its ER Case Management program by reducing the member identification from 6 visits in 6 months to 2 visits within 60 days. All members who have an emergency room visit for an avoidable diagnosis receive an educational mailing. On the second visit within 60 days, members are contacted and offered case management and the PCP is notified. Peach State expanded the number of partnerships with hospitals for emergency room notification.
The CMO specifically documented interventions that were focused on members ages 1 through 10 and members who had two ER visits within 60 days. Further analysis of these subgroups may help determine which, if any, interventions directly impacted the results for these subgroups. The study indicator did demonstrate a decline in the ER utilization rate; however, this decline may not be the direct result of the implemented interventions given the CMO's focus on the subgroups. Additionally, the organizational barriers identified by Peach State were not addressed. If claims lag concerns are an appropriate priority barrier for this PIP, the CMO should implement interventions accordingly. In addition, there was no evidence in the documentation that any internal communication occurred between the four groups/committees that discuss barriers, develop interventions, and review results. It appeared through the documentation that these groups/committees work independently of each other. An improved internal communication and intra-departmental collaboration process may assist Peach State to avoid the duplication of improvement efforts.
Lead Screening in Children
For the Lead Screening in Children PIP, the study indicator achieved statistically significant improvement over the baseline rate; however, the most recent measurement period rate of 70.8 percent was below the CY 2011 DCH target rate (81 percent). The lead screening rate was between the national HEDIS 2010 Medicaid 25th and 50th percentiles (57.6 and 71.6 percent, respectively). To improve blood lead screening rates, Peach State implemented member, provider, and organizational interventions, with many of these interventions also being implemented for the Well-Child Visits PIP. For members, the CMO provides live and TeleVox

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-10
Health Services Advisory Group, Inc.

FINDINGS

reminder calls to non-compliant members to assist in scheduling appointments or arranging transportation. During TeleVox calls, members were reminded about blood lead screening, as well as the importance of well-child visits. Peach State offered a $25 member incentive program targeted at non-compliant members who complete the required blood level testing on or before the age of two, and continues its community outreach efforts through health fairs. The Health Check Days events initiated in 2010 targeted non-compliant members and included a well-child exam and blood lead screening.
For its providers, the CMO implemented an incentive/bonus program targeted toward noncompliant members' completion of the required blood lead testing. Peach State continues its distribution of education materials for accurate coding/billing.
As part of a system-wide intervention, Peach State implemented a new data mining software system in 2010 in addition to a process for capturing monthly lead registry and historical data. Due to the importance of capturing all data, this system intervention is likely to have contributed to the CY 2010 and CY 2011 rate increases.
Well-Child Visits
The CMO achieved improvement for the first and second remeasurement periods; however, the Well-Child Visit study indicator demonstrated a decline at Remeasurement 3 with the rate falling below the baseline. The rate of 50.5 percent was also below the national HEDIS 2010 25th percentile. The CMO documented that the interventions for this PIP focused on the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. Peach State reported a lack of member and provider awareness about the EPSDT program, poor plan-to-provider communication, and the need to capture additional data as the primary barriers to improvement. The CMO developed a database to capture medical record data, enhanced collaboration between quality improvement and member connection departments, increased member outreach events, and hired additional staff to contact non-compliant members. Additionally, Peach State partnered with Southside Medical Center's mobile clinic in a pilot program to conduct mobile well-child visits. These interventions addressed some, but not all, of the barriers listed in the PIP. There was no evidence in the PIP documentation of an implemented intervention that focused on poor planto-provider communication. Peach State partnered with Southside Medical Center's mobile clinic in a pilot program with the goal of improving the well-child visit rate. Since this was a pilot program, the CMO should have been conducting an analysis to determine how many of its members are seen at Southside and evaluating whether or not this was an effective intervention. The plan should have determined how many of the "invited" members attended the mobile clinic. The CMO did not implement this intervention until December 2011. Due to the timing of this intervention, it would not have had an impact on the reported CY 2011 results.
Again, Peach State documented that "the plan has standardized those successful interventions that have been selected as ongoing and will continue to monitor the success of these interventions." There was no evidence in the documentation of how the CMO determined the efficacy of these "successful" interventions. With the decline in performance, the CMO should be evaluating the efficacy of these interventions, making the necessary revisions, and implementing new and improved strategies. Peach State should ensure that the PIP documentation reflects the process used to conduct this evaluation.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-11
Health Services Advisory Group, Inc.

FINDINGS

The CMO implemented a member and provider incentive program for its Lead Screening in Children PIP. The plan should consider implementing a similar incentive program for members/providers who complete all six well-child visits within the first 15 months of life.

Member and Provider Satisfaction

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

PIP Study Indicator

Baseline Period Remeasurement 1 Remeasurement 2 Remeasurement 3 Sustained (9/1/0912/31/09) (9/1/1012/31/10) (9/1/1112/31/11) (9/1/1212/31/12) Improvement^

Member Satisfaction

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

71.7%

71.8%

83.7%*

75.7%

NA

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

79.9%

81.1%

81.3%

82.2%

NA

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

68.5%

80.8%*

79.4%

73.4%

NA

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

86.4%

90.4%

90.3%

91.3%

NA

PIP Study Indicator

Baseline Period Remeasurement 1 Remeasurement 2 Remeasurement 3 Remeasurement 4 Sustained (8/1/0710/30/07) (11/1/082/28/09) (9/29/0910/27/09) (9/28/1011/15/10) (9/28/1111/15/11) Improvement^

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

15.8%

Provider Satisfaction

28.0%*

32.3%

36.3%

38.0%

Yes

2. Percentage of providers answering "Excellent" or "Very Good" to Q6-- "Quality of the provider orientation process."
3. Percentage of providers answering "Excellent" or "Very Good" to Q18-- "Health plan takes physician input and recommendations seriously."

14.2% 10.7%

24.1%* 15.2%

31.0%* 24.5%*

32.6% 25.8%

35.6%

Yes

29.1%

Yes

4. Percentage of providers

answering "Excellent" or "Very Good" to Q34--

12.1%

16.0%

28.8%*

26.0%

29.7%

Yes

"Accuracy of claims

processing."

NA Statistically significant improvement over baseline and a subsequent measurement must occur for all study indicators before sustained improvement can be assessed.

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

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

^ Sustained improvement is defined as statistically significant improvement in performance over baseline for all study indicators that 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 for all study indicators.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-12
Health Services Advisory Group, Inc.

FINDINGS

Member Satisfaction
Two of the four study indicator outcomes (Study Indicator 2 and Study Indicator 4) for the Member Satisfaction PIP increased from Remeasurement 2 to Remeasurement 3. Neither increase was statistically significant. Study Indicator 1 and Study Indicator 3 declined from Remeasurement 2 to Remeasurement 3. Study Indicator 1 achieved statistically significant improvement over the baseline rate at Remeasurement 2, while Study Indicator 3 achieved statistically significant improvement over the baseline rate at Remeasurement 1. The recent declines in performance at Remeasurement 3 eliminated the statistically significant improvement above the baseline rate criteria. Statistically significant improvement over baseline and a subsequent measurement must occur for all study indicators before sustained improvement can be assessed. This condition was not met for the Member Satisfaction PIP; therefore, sustained improvement was not assessed.
Peach State documented that a multidisciplinary committee composed of staff from its Member Solutions, Quality Improvement, Contracting, Medical Management, Communications, Provider Solutions, and Appeals and Grievances departments used brainstorming techniques along with internal Member Solutions (team/group) staff discussions. Specific interventions were developed to enhance customer service representatives' interactions and improve communication with members. Peach State concluded that member expectations regarding overall satisfaction correlated with the indicators selected for this study. The indicators were grouped into two categories. Study Indicators 1 and 2 were related to members getting needed care, and Study Indicators 3 and 4 were related to customer service.
Peach State documented that the decline in performance at Remeasurement 3 for Study Indicators 3 and 4 prompted further barrier analysis; however, the CMO did not document what type of barrier analysis was conducted or the results of the barrier analysis. The CMO did document that it felt some of the current interventions (on-hold messages and referrals to the Web site) were successful, and those interventions were standardized. The documentation did not include how the CMO measured the efficacy of these standardized interventions.
Peach State documented that it developed interventions specific to enhancing customer service representatives' interactions and communications with members, as well as reviewing opportunities to improve members' ability to obtain needed care. The barriers identified by Peach State included the need to (1) further improve members' ability to get care, (2) further enhance the assistance members receive from customer service representatives (CSRs), (3) revise CSR monitoring to ensure that members are treated appropriately, and (4) receive feedback from members in order to respond to discrepancies in a timely manner. The study indicators for this PIP addressed two different areas of improvement: members getting needed care (Study Indicators 1 and 2) and customer service (Study Indicators 3 and 4). However, the interventions appeared to be heavily focused toward customer service and making adjustments to the way CSRs perform their job. Peach State mentioned several times in the PIP documentation that provider recruiting was important, and it would seem reasonable that ease of getting an appointment (Study Indicator 1) may be directly related to the availability of providers. However, there was only one ongoing intervention related to recruiting; and there was no evidence that Peach State revisited its recruiting process to determine if it was successful or to determine if hiring more providers influenced the outcomes. The CMO mentioned that it

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-13
Health Services Advisory Group, Inc.

FINDINGS
revisited its causal/barrier analysis process but did not provide updated results or new barriers to be addressed. The CMO explained that the study indicators were chosen because they were directly related to the two different areas of improvement selected; however, the correlation between the study indicators and the two areas of improvement was not obvious and should have been better explained in the PIP documentation.
Provider Satisfaction
For the Provider Satisfaction PIP, all of the study indicators demonstrated improvement from Remeasurement 3 to Remeasurement 4 and achieved sustained improvement: however, with provider satisfaction rates at 2939 percent, an opportunity for improvement still exists for this PIP. The CMO documented that its quality committee used brainstorming to identify the barriers. In the PIP documentation, there was no mention of using data mining or drill-down data analysis to determine what barriers aligned with the specific survey questions. Peach State indicated that it looked at key drivers from the survey, which is not the same as using a drill-down analysis to identify barriers to improvement. It appeared that the plan conducted a key driver analysis and used the results to identify opportunities for improvement and select the study indicators.
There was no drill-down analysis to determine barriers for the orientation process or barriers to claims processing, and there was no process to evaluate the efficacy of the interventions that were implemented. The plan repeated barriers that appeared to be generic and were weakly linked to the study indicators. The barriers listed were dated from 2008 and 2009. With these dates, it did not appear, based on the PIP documentation, that Peach State had conducted a recent causal/barrier analysis.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 2-14
Health Services Advisory Group, Inc.

3. STRENGTHS
for Peach State Health Plan
Individual PIP Strengths
For the Emergency Room Utilization PIP, Peach State was able to reduce the ER utilization rate by 2.2 visits per 1000 member months, which was statistically significant (lower rates indicate better performance for this indicator). Peach State's emergency room utilization was below the CY 2011 DCH target (58.5 percent) and the national HEDIS 2010 Medicaid 25th percentile (58.5 per 1000 member months). For this measure, the HEDIS 2010 Medicaid 25th percentile represents lower utilization. The CMO conducted an appropriate drill-down analysis for this PIP which identified that members between the ages of 0 and 10 years were the highest users of the emergency room. The CMO focused its outreach and educational efforts on this subgroup of members.
The Childhood Immunizations PIP received an overall Met validation status and the PIP was designed with a strong foundation to build upon. Peach State increased its childhood immunization rate from 62.8 percent at baseline to 80.6 at Remeasurement 3. This increase of 17.8 percentage points was statistically significant.
In the Lead Screening in Children PIP, Peach State was able to increase its lead screening rate from 57.2 percent at baseline to 70.8 percent at Remeasurement 3.This increase of 13.6 percentage points was statistically significant. The CMO conducted a drill-down analysis of member and provider characteristics including geographic distribution of compliant and noncompliant members, and determined that there were no subgroups within the membership that required specific targeted interventions. For blood lead screenings, Peach State implemented member, provider, and organizational interventions, with many of these interventions also implemented for the Well-Child Visits PIP. The CMO continued current interventions and improved collaboration between its own departments that interact with members and/or providers through individual encounters, health/member events, and/or distribution of educational materials. Peach State also implemented a new data mining software system in 2010 in addition to a process that captured monthly lead registry and historical data. Due to the importance of capturing all data, this system intervention is likely to have contributed to the CY 2010 and CY 2011 rate increases.
Global PIP Strengths
Peach State demonstrated a thorough application of the PIP Design stage (Activities I through VI). The sound study design creates the foundation for the CMO to progress to subsequent PIP stages--implementing improvement strategies and achieving real and sustained study indicator 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.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 3-1
Health Services Advisory Group, Inc.

4. OPPORTUNITIES FOR IMPROVEMENT
for Peach State Health Plan
Individual PIP Opportunities for Improvement
Peach State has an opportunity to improve reporting and documentation of accurate data and statistical testing components for its Annual Dental Visits and Childhood Obesity PIPs which both received a Partially Met. The CMO should ensure that the data, including numerators, denominators, rates, and statistical testing values are accurate and align with what has been reported in its Interactive Data Submission System (IDSS).
Peach State will need to concentrate its efforts on the three PIPs that received a Partially Met or Not Met validation status due to the lack of statistically significant improvement--Childhood Obesity, Member Satisfaction and Well-Child Visits. The CMO should build upon its strengths and lessons learned from other PIPs that have achieved real and sustained improvement.
For the Adults Access to Care and Provider Satisfaction PIPs, Peach State needs to concentrate on its causal/barrier analysis and intervention evaluation processes currently in place. Some of the interventions implemented provided no value to these measures.
Global Opportunities for Improvement
The CMO should ensure that data reported in all PIPs are accurate and align with what has been reported in its IDSS.
Peach State should conduct an annual causal/barrier and drill-down analysis in addition to periodic analyses of its most recent data. The CMO should include the updated causal/barrier analysis outcomes in its PIPs.
The CMO should be cognizant of the timing of interventions. Interventions implemented in the last few months of the year will not have been in place long enough to have an impact on the results.
For any intervention implemented, the CMO should have a process in place to evaluate the efficacy of the intervention to determine if it is having the desired effect. This evaluation process should be detailed in the PIP documentation. If the interventions are not having the desired effect, the CMO should discuss how it will be addressing these deficiencies and what changes will be made to its improvement strategies.
The plan should ensure that the intervention implemented for a specific barrier is truly relevant to that barrier. For example, member-focused interventions will not impact a study indicator measuring the quality of service provided by a PCP.
For member satisfaction study indicators that have not been assessed for sustained improvement, the CMO should consider hosting focus group discussions (i.e., one focused on provider satisfaction and one focused on member satisfaction). These focus groups would enable the

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 4-1
Health Services Advisory Group, Inc.

BACKGROUND
CMO to interact with potential satisfaction survey participants and gain valuable input on the specific areas that cause dissatisfaction with services provided. Once areas of dissatisfaction are identified, the CMO should implement system changes to combat those areas.

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page 4-2
Health Services Advisory Group, Inc.

APPENDIX A. PIP-SPECIFIC VALIDATION RESULTS
for Peach State Health Plan

Table A-1--Peach State Health Plan's SFY 2013 PIP Performance

Study Stage

Activity

Design Implementation Outcomes

I. Appropriate Study Topic
II. Clearly Defined, Answerable Study Question(s)
III. Clearly Defined Study Indicator(s)
IV. Correctly Identified Study Population
Design Total
V. Valid Sampling Techniques (if sampling was used)
VI. Accurate/Complete Data Collection
VII. Appropriate Improvement Strategies
Implementation Total
VIII. Sufficient Data Analysis and Interpretation
IX. Real Improvement Achieved
X. Sustained Improvement Achieved
Outcomes Total

Validation Status

Adults' Access to
Care 100%
100%
100%
100% 100%
Not Applicable
100%
50% 78% 100%
100%
100% 100% Partially Met

Percentage of Applicable Evaluation Elements Scored Met

Annual

Childhood Childhood

Dental Visits Immunizations Obesity

100%

100%

100%

ER Utilization
100%

Lead Screening in
Children
100%

Member Satisfaction
100%

Provider Well-Child Satisfaction Visits

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%
100% 100%
Not Applicable
100%
75% 89% 75%
100%
100% 85% Partially Met

100% 100% 100% 100% 100% 75% 95% 100% 100%
100% 100% Met

100%

100%

100% 100% 100%
100%

100%
100% Not
Applicable
100%

0% 80% 67%

75% 89% 100%

25%
Not Assessed
54% Partially
Met

100%
100% 100% Met

100% 100% 100% 100% 100% 75% 95% 100% 100%
100% 100% Met

100%

100%

100% 100% 100%

100% 100% 100%

100%

100%

0% 78% 100%

50% 89% 100%

25%
Not Assessed
77%
Partially Met

100%
100%
100% Partially
Met

100%
100% 100% 100%
100%
0% 80% 100%
25% Not Assessed 77% Not Met

Peach State Health Plan SFY 2013 PIP Validation Report State of Georgia

PeachState_GASFY2013_CMO_PIP-Val_Report_F1_1112 Page A-1
Health Services Advisory Group, Inc.