Georgia Families quality strategic plan update [July 2008]

Quality Strategic Plan UPDATE
July 2008

Georgia Families Quality Strategic Plan Update
Table of Contents
Table of Contents .................................................................................................................................. 2 GOAL 1......................................................................................................................................................... 4 Promotion of an organization wide commitment to quality of care and service GOAL 2......................................................................................................................................................... 7 Improve and enhance the quality of patient care through ongoing, objective, and systematic measurement, analysis, and improvement of performance GOAL 3....................................................................................................................................................... 17 Promotion of a system of health care delivery that provides coordinated and improved access to comprehensive healthcare, and enhanced provider and client satisfaction GOAL 4....................................................................................................................................................... 19 Promotion of acceptable standards of healthcare within managed care programs by monitoring internal/external processes for improvement opportunities

July 2008

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Georgia Families Quality Strategic Plan Update

Introduction and Overview
It is the goal of DCH to assure that the care provided within the managed care structure is of acceptable quality, assures accessibility, provides continuity, and maximizes efficiency. Specific activities to achieve these goals include:
Promotion of an organization wide commitment to quality of care and service Improvement and enhancement of the quality of patient care provided through ongoing, objective, and
systematic measurement, analysis, and implementation of performance improvement programs Promotion of a system of health care delivery that provides coordinated and improved access to
comprehensive health care, and enhanced provider and client satisfaction Promotion of acceptable standards of health care within managed care programs by monitoring
internal/external processes for improvement opportunities
Georgia has reached the midpoint of its CY 2008 Quality Strategic Plan. Thus, this is an appropriate time to inform stakeholders of our plans and activities (where we want to go and what we want our future to look like). This Quality Strategic Plan Update provides direction as well as Georgia's progress towards achieving our goals. In addition, we use color coded meters as quick snapshots of our status towards completing the Strategic Actions. Each meter demonstrates if the State is on schedule ( ), at risk of being behind schedule ( ), or critically delayed ( ).
Georgia Families Membership Update:
The following chart displays the distribution of the membership among the CMOs as of July 1, 2008:

Region Atlanta
Central North East Southeast Southwest

CMO AMERIGROUP Peach State WellCare Atlanta Region Total Peach State WellCare Central Region Total AMERIGROUP WellCare North Region Total AMERIGROUP WellCare East Region Total AMERIGROUP WellCare Southeast Region Total Peach State WellCare Southwest Region Total Georgia Families Total

Membership 101,485 162,384 182, 701 446,570 49,401 73,994 123,395 46,226 86,012 132,238 25,975 34,631 60,606 31,125 57,974 89,099 74,379 30,986 105,365 957,273

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Georgia Families Quality Strategic Plan Update

GOAL 1
Promotion of an organization wide commitment to quality of care and service Institute of Medicine (IOM) Aim(s) for Improvement: Safe, Equitable

Objective 1.1 Process Objective
Information on race, ethnicity, and primary language is accurately recorded when member enrolls with Medicaid or PeachCare for KidsTM

#
1.1.1
1.1.2

Strategic Action
Collaborate with internal DCH units and divisions to ensure compliance with Federal standards
Develop Plan to communicate, monitor and analyze CMO Compliance with federal guidelines

Target Completion
Date
08/31/2008
08/31/2008 10/31/2008

Meter

Status
Continue meetings with DCH Eligibility to establish crosswalk between fields collected by eligibility vendors to Federally defined fields for race, ethnicity, and primary language. In addition, DCH in partnership with the CMOs submitted a proposal to Center for Healthcare Strategies (CHCS) for a Healthcare Disparities grant. The CMOs are being kept up to date on progress of defining fields.

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Georgia Families Quality Strategic Plan Update

GOAL 1
Promotion of an organization wide commitment to quality of care and service Institute of Medicine (IOM) Aim(s) for Improvement: Safe, Equitable

Objective 1.2 Process Objective
Establish an External Quality Review Organization (EQRO) to provide independent evaluation of Georgia Families program

#

Strategic Action

1.2.1 Procure EQRO

1.2.2 1.2.3 1.2.4

Orient EQRO to GF goals and objectives; implement evaluation of CMOs EQRO complete evaluation presentation of Draft Report to DCH EQRO presentation of final report to DCH

Target Completion
Date
07/1/2008 07/18/2008 08/21/2008

Meter

Status

Final contract approval received
Collaborating with EQRO vendor to prepare for EQRO kick-off meeting

11/30/2008 1/15/2009

2/15/2009

1.2.5 Presentation of EQRO findings and analysis to DCH Board

12/11/2008 03/12/2009

1.2.6 1.2.7

Submission of Federally required EQRO Report to Centers for Medicare and Medicaid Services (CMS) EQRO Conference for DCH, CMOs, stakeholders, etc.

03/31/2009 04/15/2009

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Georgia Families Quality Strategic Plan Update

GOAL 1
Promotion of an organization wide commitment to quality of care and service Institute of Medicine (IOM) Aim(s) for Improvement: Safe, Equitable

Objective 1.3 Process Objective
Ensure CMO compliance with adoption and dissemination of three Clinical Practice Guidelines.

#
1.3.1
1.3.2

Strategic Action
Improve process to ensure that guidelines are based on valid and reliable clinical evidence and adopted in consultation with participating providers. Ensure guidelines are disseminated to CMO providers

Target Completion
Date
09/01/2008
10/01/2008

Meter

Status

DCH is actively revising Clinical Practice Guidelines policies to better define expectations of CMOs.

1.3.3 Monitor and trend CMO measurement of providers' adherence to guidelines

11/01/2008

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Georgia Families Quality Strategic Plan Update

GOAL 2
Improve and enhance the quality of patient care through ongoing, objective, and systematic measurement, analysis, and improvement of performance Institute of Medicine (IOM) Aim(s) for Improvement: Effective, Efficient, and Safe

Objective 2.1 Outcome Objective
Ensure the provision of quality care and ongoing improvement in health baseline and health outcomes through performance based measurement and performance driven objectives

#
2.1.1
2.1.2

Strategic Action
Review CMO annual evaluation of quality program: Identify and prioritize
opportunities for improvement within each CMO Review with each CMO and establish goals for next year Review and monitor progress toward goals Obtain CMO performance data across range of performance measures: Finalize state defined specifications for measures with Thomson Reuters and MMIS Obtain reports from Thomson Reuters for first year (October 2006 September 2007) Drill data by following categories:
o Race o Ethnicity o Gender o Age o Region o Urban/rural o Primary
language

Target Completion
Date
08/30/2008
10/30/2008 Ongoing
08/15/2008
11/30/2008
12/30/2008

Meter

Status
Each CMO has submitted annual Quality Program Evaluations. DCH is currently analyzing these reports.
DCH in collaboration with Thomson Reuters has defined specifications for 23 of the 46 performance measures. Transmission of valid encounter data from the CMOs is in progress with an expected completion date of November 2008

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Georgia Families Quality Strategic Plan Update

#
2.1.3
2.1.4 2.1.5

Strategic Action
Review performance data with internal/external stakeholders: DCH CMOs External stakeholders Prioritize performance measures and objectives based upon input from internal and external stakeholders Establish workgroups consisting of internal and external stakeholders to develop strategies to improve performance in selected areas.

Target Completion
Date
12/15/2008 1/31/2009 3/1/2009 12/01/2008 4/30/2009
12/01/2008 6/30/2009

Meter

Status
Transmission of valid encounter data from the CMOs is in progress with an expected completion date of November 2008
Workgroups will be established and convened by 6/30/2009

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Georgia Families Quality Strategic Plan Update

GOAL 2
Improve and enhance the quality of patient care through ongoing, objective, and systematic measurement, analysis, and improvement of performance Institute of Medicine (IOM) Aim(s) for Improvement: Effective, Efficient, and Safe

Objective 2.2 Outcome Objective
Children's Preventive Health: Over the next five years the state will strive to meet or exceed the Healthcare Effectiveness Data and Information Set (HEDIS) 2006 90th percentile in managed care eligible children with well-child visits during their first 15 months of life

#

Strategic Action

2.2.1 Analyze valid CMO FFY 07 encounter data for Well-Child Visit rate

Target Completion
Date
10/30/2008

Meter

Status
FFY 07 DATA (Georgia Families): 43.4 percent of children with six or more visits

Georgia's Baseline (pre Managed Care): 49.1 percent of children with six or more visits

NOTE: CMO encounter data used in this analysis is currently being assessed for volume, reasonability and validity

HEDIS 90th percentile: 48.6 percent of children with six or more visits

Georgia's 2013 Target: >48.6 percent of children with six or more visits

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Georgia Families Quality Strategic Plan Update

GOAL 2
Improve and enhance the quality of patient care through ongoing, objective, and systematic measurement, analysis, and improvement of performance Institute of Medicine (IOM) Aim(s) for Improvement: Effective, Efficient, and Safe

Objective 2.3 Outcome Objective
Children's Preventive Health: In collaboration with Georgia's Immunization program, over the next five years, the Division of Managed Care and Quality will demonstrate an improvement of 5 percentage points in the number of managed care eligible children less than 36 months of age compliant with the 4:3:1:3:3:1* immunization series.

#

Strategic Action

2.3.1 Analyze valid CMO FFY 07 encounter data for 4:3:1:3:3:1 Immunization rate
Georgia's Baseline (pre Managed Care): 77.0 percent

Target Completion
Date
10/30/2008

Meter

Status
FFY 07 DATA (Georgia Families): 80.5 percent

NOTE: CMO encounter data used in this analysis is currently being assessed for volume, reasonability and validity

HEDIS: 70.4 percent

Georgia's 2013 Target: 82.0 percent

*(4 DTaP [Diphtheria, Tetanus, and Pertussis], 3 Polio, 1 MMR [Measles, Mumps, and Rubella], 3 Hib [Haemophilus Influenza Type B], 3 Hep B [Hepatitis B], and I Varicella)

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Georgia Families Quality Strategic Plan Update

GOAL 2
Improve and enhance the quality of patient care through ongoing, objective, and systematic measurement, analysis, and improvement of performance Institute of Medicine (IOM) Aim(s) for Improvement: Effective, Efficient, and Safe

Objective 2.4 Outcome Objective
Children's Preventive Health: In collaboration with Georgia's Childhood Lead Poisoning Prevention Program (GCLPPP), the Division of Managed Care and Quality will demonstrate an improvement of 10 percentage points in the number of one year old and two year old managed care eligible children receiving a screening for blood lead over the next five years

#

Strategic Action

2.4.1 Analyze valid CMO FFY 07 encounter data for Lead rate
Georgia's Baseline (pre Managed Care): 9 15 months: 28.3 percent 21 - 27 months- 22.5 percent
CMS 416: Age <1: 3.0 percent Age 1-2: 37.8 percent

Target Completion
Date
10/30/2008

Meter

Status
FFY 07 DATA (Georgia Families): Age 9 15 months: 24.2 percent Age 21 27 months: 17.4 percent

NOTE: CMO encounter data used in this analysis is currently being assessed for volume, reasonability and validity

Georgia's 2013 Target: 9 15 months: 38.3 percent
21 - 27 months- 32.5 percent

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Georgia Families Quality Strategic Plan Update

GOAL 2
Improve and enhance the quality of patient care through ongoing, objective, and systematic measurement, analysis, and improvement of performance Institute of Medicine (IOM) Aim(s) for Improvement: Effective, Efficient, and Safe

Objective 2.5 Outcome Objective
Access to Preventive/Ambulatory Health Services: Within the next five years the Division of Managed Care and Quality will demonstrate an improvement of 10 percentage points in the ambulatory or preventive care visit. This will bring Georgia to the 90th percentile level for managed Medicaid plans for adults aged 21- 44 years old (based on HEDIS 2006).

#

Strategic Action

2.5.1

Analyze valid CMO FFY 07 encounter data for Members age 21 years and older with Access to Ambulatory or Preventive Care rate

Georgia's Baseline (pre Managed Care): 78.9 percent

HEDIS 90th percentile: Ages 20-44: 76.4 percent Ages 45-64: 81.4 percent Ages 65+: 79.5 percent

Georgia's 2013 Target: 88.9 percent

Target Completion
Date
10/30/2008

Meter

Status
FFY 07 DATA (Georgia Families): 77.5 percent

NOTE: CMO encounter data used in this analysis is currently being assessed for volume, reasonability and validity

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Georgia Families Quality Strategic Plan Update

GOAL 2
Improve and enhance the quality of patient care through ongoing, objective, and systematic measurement, analysis, and improvement of performance Institute of Medicine (IOM) Aim(s) for Improvement: Effective, Efficient, and Safe

Objective 2.6 Outcome Objective
Diabetes: Within the next five years, the State will demonstrate an improvement of 20 percentage points in the managed care eligible members ages 18 - 75 years with diabetes who had at least one HbA1c test. This will bring Georgia to the 75th percentile level for managed Medicaid plans (based on HEDIS 2006).

#

Strategic Action

2.6.1

Analyze valid CMO FFY 07 encounter data for rate of Members age 18-75 years with Diabetes who had at least one HbA1c test

Georgia's Baseline (pre Managed Care): 65.3 percent

HEDIS 75th percentile: 83.7 percent

Georgia's 2013 Target: 85.3 percent

Target Completion
Date
11/30/2008

Meter

Status
FFY 07 DATA (Georgia Families): XXX percent

NOTE: Analysis pending processing of CMO Pharmacy encounter data

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Georgia Families Quality Strategic Plan Update

GOAL 2
Improve and enhance the quality of patient care through ongoing, objective, and systematic measurement, analysis, and improvement of performance Institute of Medicine (IOM) Aim(s) for Improvement: Effective, Efficient, and Safe

Objective 2.7 Outcome Objective
Asthma: Within the next five years the State will demonstrate an improvement of five percentage points in the managed care eligible members with asthma that received appropriate medications. This will bring Georgia to the 90th percentile level for managed Medicaid plans (based on HEDIS 2006).

#

Strategic Action

2.7.1

Analyze valid CMO FFY 07 encounter data for rate of Members with Asthma that received appropriate medications

Georgia's Baseline (pre Managed Care): 88.5 percent

HEDIS 90th percentile: 92.5 percent

Georgia's 2013 Target: 93.5 percent

Target Completion
Date
10/30/2008

Meter

Status
FFY 07 DATA (Georgia Families): XXX percent

NOTE: Analysis pending processing of CMO Pharmacy encounter data

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Georgia Families Quality Strategic Plan Update

GOAL 2
Improve and enhance the quality of patient care through ongoing, objective, and systematic measurement, analysis, and improvement of performance Institute of Medicine (IOM) Aim(s) for Improvement: Effective, Efficient, and Safe

Objective 2.8 Outcome Objective
Maternal and Child Health: Within the next five years the state will demonstrate a 10 percent decrease in the rate of managed care low birth weight babies. This will lead to a reduction in the rate of low birth weight babies from 9.3/1000 to 8.4/1000 live births and ultimately improve Georgia's infant mortality rates

#

Strategic Action

2.8.1 Analyze valid CMO FFY 07 encounter data for rate of Low Birth Weight babies
Georgia's Baseline (state wide rate - pre Managed Care): 9.3 /per 1000
Healthy People 2010 baseline: 7.6 /per 1000
Georgia's 2013 Target: 8.4 /per 1000

Target Completion
Date
10/30/2008

Meter

Status
FFY 07 DATA (Georgia Families): 8.3/ per 1000

NOTE: CMO encounter data used in this analysis is currently being assessed for volume, reasonability and validity

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Georgia Families Quality Strategic Plan Update
GOAL 2
Improve and enhance the quality of patient care through ongoing, objective, and systematic measurement, analysis, and improvement of performance Institute of Medicine (IOM) Aim(s) for Improvement: Effective, Efficient, and Safe
Objective 2.9 Process Objective Coordinate with Georgia transparency web site to facilitate increased and informed decision making leading to improved health choices.

#
2.9.1

Strategic Action
Collaborate with DCH HITT (Health Information and Transparency Technology) team and CMOs to design information that will be available on website

Target Completion
Date
07/01/2008

Meter

Status
International Business Machines (IBM) procured as vendor for Georgia's HITT website.
Medicaid Managed Care plans collaborating commercial plans on proposed measures to be included in HITT website.

Managed care plans agreed to four satisfaction measures from CAHPS that will be used for phase I of the site.

2.9.2 2.9.3 2.9.4

Work with HITT team and CMOs to develop mechanisms and processes for transmittal of information to web site. Work with consumer groups, communications department, to educate members on availability and use of website. Implement site

09/01/2008 09/15/2008 10/01/2008

Collaborations continue with HITT team and IBM
Upon completion of site development, DCH will execute a communication plan for Georgia citizens including Medicaid Managed Care members.

July 2008

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Georgia Families Quality Strategic Plan Update

GOAL 3
Promotion of a system of health care delivery that provides coordinated and improved access to comprehensive healthcare, and enhanced provider and client satisfaction Institute of Medicine (IOM) Aim(s) for Improvement: Patient Centered and Timely
Objective 3.1 Outcome Objective Assure ongoing CMO quality management program.

#

Strategic Action

3.1.1

Review conformity of CMO quality program to CMS requirements- 42 CFR 438.240

3.1.2

Assure CMO compliance with requirement to achieve NCQA, URAC, JCAHO or AAAHC accreditation: Validate completion of
accreditation, or; If not accredited, review
status to assure on schedule to achieve accreditation by June 2009

Target Completion
Date
11/30/2008

Meter

Status

The procured EQRO vendor will be required to complete this task. The dates for completion of EQRO evaluation and reports have been modified thereby requiring modification of these dates.

08/31/2008

All three CMOs elected to obtain NCQA New Health Plan accreditation:
Amerigroup NCQA New Health Plan Accreditation effective of 10/08/2007
Wellcare NCQA New Health Plan review completed May 2008 (pending NCQA decision)
Peach State NCQA New Health Plan Accreditation survey scheduled for 09/17/2008

July 2008

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Georgia Families Quality Strategic Plan Update
GOAL 3
Promotion of a system of health care delivery that provides coordinated and improved access to comprehensive healthcare, and enhanced provider and client satisfaction Institute of Medicine (IOM) Aim(s) for Improvement: Patient Centered and Timely
Objective 3.2 Process Objective Develop plan for preferential auto-assignment to CMOs that have demonstrated improved quality of care

#

Strategic Action

3.2.1

Identify set of potential measures that can be used in quality auto-assignment algorithm

3.2.2 3.2.3
3.2.4 3.2.5

Compile baseline data from initial year of managed care implementation. Develop workgroup to establish measures, review and validate measures, and agree on measure set for quality algorithm. Group to include representatives from DCH, CMOs, provider organizations, member advocacy groups Establish methodology and weighting of measures for auto-assignment algorithm Implement measurement period

3.2.6 Implement change to autoassignment algorithm

Target Completion
Date
07/31/2008

Meter

Status

DCH has identified potential measures that can be used for Georgia Families quality autoassignment algorithm

10/31/2008

Currently review details of other State Medicaid quality auto-assignment algorithms Continue processing CMO encounter data

10/31/2008

11/30/2008
1/1/2009 12/31/2009
7/1/2010

July 2008

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Georgia Families Quality Strategic Plan Update

GOAL 4
Promotion of acceptable standards of healthcare within managed care programs by monitoring internal/external processes for improvement opportunities Institute of Medicine (IOM) Aim(s) for Improvement: Patient Centered, Safe and Efficient

Objective 4.1 Process Objective
Assure CMO compliance with contractual standards (Access to Care):
1. CMOs Maintain a Network of Appropriate Providers
2. CMOs ensure Timely Access to network providers
3. CMOs provide female members with direct in-network access to women's health specialist for covered care necessary to provide routine and preventive health care services.
4. CMO will authorize services for the member to be furnished adequately and timely by an out-ofnetwork provider, if their network is unable to provide medically necessary covered services to a particular member.
5. CMOs are required to provide for a second opinion in any situation when there is a question concerning a diagnosis or the options for surgery or other treatment of a health condition when requested by any member of the health care team, a member, parent(s) and/or guardian(s), or a social worker exercising a custodial responsibility.
6. CMOs are required to credential network providers in accordance with the standards of the National Committee for Quality Assurance (NCQA), Joint Commission on Accreditation Healthcare Organization (JCAHO), or American Accreditation Healthcare Commission/URAC.

#

Strategic Action

4.1.1

Assess CMO compliance with contractually required Geo access standards to identify areas for improvement and best practices:

Target Completion
Date
ongoing

Meter

Status
This oversight activity is done each quarter and is work in progress. The following reports are submitted to DCH and used to complete network analysis and validations. GeoAccess Report; PCP Assignment Report; Provider Listing: Provider Termination Report; CMO Network Development Recruitment Report; Provider Count Report; CMO Provider Maps; and Provider Access to Care Survey Tools.

July 2008

Provider Services staff works closely with the CMOs to ensure that members have access to care for all scopes of services. The below deficiency responses are reviewed to verify how members will access care
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Georgia Families Quality Strategic Plan Update

#

Strategic Action

July 2008

Target Completion
Date

Meter

Status
in areas where provider contracts do not exist.

1. Providers do not exist within contract access standard and NET services will be coordinated as necessary.

2. Providers do exist within contract access standard, but refusing to contract, single case agreements will be negotiated with willing providers and NET services will be coordinated as necessary. CMOs will need to submit a list of provider names, specialty, and county locations of providers that will be contracted for single case agreements.

3. Providers do exist, in process of Recruitment or
Contracting, Credentialing,
or Loading. In the meanwhile single case agreements will be negotiated with willing providers and NET services will be coordinated as necessary. CMOs will need to submit a list of provider names, specialty, and county locations of providers that will be contracted for single case agreements.

4. All Pediatric Provider network deficient areas will need to be submitted to DCH as follows: Submit counts of other primary care
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Georgia Families Quality Strategic Plan Update

#

Strategic Action

Target Meter

Completion

Date

Status
providers available to see pediatric population of members.

4.1.2

CMOs ensure Timely Access to network providers Assure CMO wait times for
provider appointments do not exceed contractually required standards


ongoing

5. All PCP Provider network deficient areas will need to be submitted to DCH as follows:
Submit counts of other primary care providers i.e. NP, PA, and FQHCs/RHC Clinics PCP providers. This oversight activity is done each quarter and is work in progress. DCH monitors the CMOs for compliance through the Timely Access submission report. DCH monitors this report quarterly to ensure that the CMOs have adequate network capacity for waiting times and appointments to PCPs routine visits / 21 days, PCP adult sick visit / 72 hours, PCP pediatric sick visit / 24 hours, Specialist 30 /days, Nonemergency Hospital / 30 days, Mental Health / 14 days, Urgent Care / 24 hours and Emergency /24-7 within these contractual guidelines

4.1.3

CMOs provide female members with direct in-network access to women's health specialist for covered care necessary to provide routine and preventive health care services Asses the following annually
and as necessary to ensure compliance and to identify areas of improvement and best practices:
GEO-Access reports PCP Assignment report

ongoing

July 2008

This oversight activity is done each quarter and is work in progress. DCH monitors the CMOs for compliance through the Quarterly GEO Access report which consists of Network Maps with percentages, Regional and County submission report of their actual member and provider count for counties, Network provider listing by specialty report, CMS Federal Provider Count report and Deficiency CAP Report to ensure network access coverage for OGBYN providers. The staff also uses the Appointment Wait Time Reports to ensure that OBGYN wait times are within 30 days in-accordance with GF contract.
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Georgia Families Quality Strategic Plan Update

#

Strategic Action

Target Meter

Completion

Date

Status

4.1.4 4.1.5

CMO will authorize services for the member to be furnished adequately and timely by an outof-network provider, if their network is unable to provide medically necessary covered services to a particular member. Asses the following annually
and as necessary to ensure compliance and to identify areas of improvement and best practices:
Disenrollment requests
due to lack of access to providers
CMO policies and
procedures
Complaints regarding
access to providers CMOs are required to provide for a second opinion in any situation when there is a question concerning a diagnosis or the options for surgery or other treatment of a health condition when requested by any member of the health care team, a member, parent(s) and/or guardian(s), or a social worker exercising a custodial responsibility. Asses the following annually
and as necessary to ensure compliance and to identify areas of improvement and best practices: Complaints regarding
coverage of second opinions CMO policies and procedures

ongoing 12/01/2008

This oversight activity is done each quarter and is work in progress. DCH monitors the CMOs for compliance through Quarterly Audits of CMOs Policy and Polices for updates/revisions, DCH Complaint Report, and the Provider Termination Report.

4.1.6 CMOs are required to credential network providers in accordance with the standards of the National

ongoing

DCH monitors the Network Provider Listing to compare with Quarterly Network Audits that are done on

July 2008

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Georgia Families Quality Strategic Plan Update

#

Strategic Action

Target Meter

Status

Completion

Date

Committee for Quality Assurance

random providers thru MHN network,

(NCQA), Joint Commission on

State Fraud Listing, State Exclusion

Accreditation Healthcare

website. This is all compared to the

Organization (JCAHO), or

CMOs web and printed directories to

American Accreditation

ensure network compliance.

Healthcare Commission/URAC.

Asses the following annually

and as necessary to ensure

compliance and to identify

areas of improvement and

best practices:

CMO Credential Meeting

Minutes

Adverse Disciplinary

Actions recorded on

providers

Expiration Dates for

provider licenses,

certifications, insurance

coverage report

CMO Provider Listing audit

to ensure credentials not

expired (e.g., Malpractice

Insurance, Drug

Enforcement

Administration, Board

Certification, etc.)

July 2008

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Georgia Families Quality Strategic Plan Update

GOAL 4 Promotion of acceptable standards of healthcare within managed care programs by monitoring internal/external processes for improvement opportunities
Institute of Medicine (IOM) Aim(s) for Improvement: Patient Centered, Safe and Efficient

Objective 4.2 Process Objective
Assure CMO compliance with contractual standards (Coordination of Care):
1. CMOs must have a process in place that ensures members have direct access to a specialist as appropriate for the member's condition and identified needs.
2. CMOs will provide coordination and continuity of care for ALL managed care children with special needs.

#

Strategic Action

4.2.1

CMOs must have a process in place that ensures members have direct access to a specialist as appropriate for the member's condition and identified needs.

4.2.2

Asses the following annually and as necessary to ensure compliance and to identify areas of improvement and best practices: CMO Direct Access to a Specialist policies and procedures
CMOs will provide coordination and continuity of care for ALL managed care children with special needs. Collaborate to identify
children with special needs utilizing the Child and Adolescent Health Measurement Initiative (CAHMI) screening tool Review Lessons Learned and Plans utilized by Other State Medicaid Agencies when implementing Care Coordination for Medicaid Managed Care members Partner with Other State

July 2008

Target Completion
Date
ongoing
07/01/2008 12/15/2008

Meter

Status
Work in progress- DCH monitors the CMOs for compliance through the Reviewing policy and Complaint Reports. DCH staff members work closely with the CMOs on all received provider complaints to ensure adequate and timely responses and to track and trend for CMO provider service areas of improvement.
Continue collaboration with DCH and enrollment broker to identify children with special healthcare needs
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Georgia Families Quality Strategic Plan Update

#

Strategic Action

Target Meter

Completion

Date

Agencies

Develop Plan (Specify

Expectations for CMOs)

Assist CMOs in Identifying

the Target Population

Develop methodology to

measure performance

Status

July 2008

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Georgia Families Quality Strategic Plan Update

GOAL 4 Promotion of acceptable standards of healthcare within managed care programs by monitoring internal/external processes for improvement opportunities
Institute of Medicine (IOM) Aim(s) for Improvement: Patient Centered, Safe and Efficient

Objective 4.3 Process Objective
Assure CMO compliance with contractual standards (Covered Services):
1. CMOs are required to provide medically necessary services and benefits pursuant to the Georgia State Medicaid State Plan and the Georgia Medicaid Policies and Procedures Manual. In addition, the CMO must ensure that coverage is provided for EPSDT eligible members when the provision of that service is necessary to correct or ameliorate a health condition identified during a Health Check (EPSDT) screen.
2. Prior Authorization and/or Pre-Certification for all non-emergent, out-of-network services may be required by the CMOs. The CMO may not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the diagnosis, type of illness or condition.

#
4.3.1

Strategic Action

Target Meter

Status

Completion

Date

Asses the following

10/30/2008

The CMOs report quarterly on EPSDT

periodically to identify areas

services (submitted via 416 format).

of improvement and best

DCH uses the data to monitor

practices:

performance of the CMOs.

CMO EPSDT policies

and procedures

Currently, DCH collaborating with

CMS 416 Report CMO EPSDT Report

Thomson Reuters to validate EPSDT data submitted by CMOs via encounters. In addition, DCH plans to

conduct another EPSDT onsite review

of Policies, materials, decisions, etc.

within the next couple of months and

update the Quality Strategic Plan with

the overall compliance percentage.

4.3.2

Prior Authorization and/or PreCertification for all nonemergent, out-of-network services may be required by the CMOs. The CMO may not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the diagnosis, type of illness or condition. Asses the following monthly
to identify areas of improvement and best practices:

11/30/2008

July 2008

DCH continues to do monthly analysis of CMO Prior Authorization reports.
In addition, DCH plans to conduct
follow-up onsite Prior Authorization audits and update the Quality Strategic Plan with the overall compliance percentage.
Current data indicates improvement in overall timeliness of prior authorization timeliness relative to initial year.
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Georgia Families Quality Strategic Plan Update

#

Strategic Action

Target Meter

Completion

Date

CMO Prior

Authorization/Pre-

Certification policies and

procedures

Status

July 2008

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Georgia Families Quality Strategic Plan Update

GOAL 4 Promotion of acceptable standards of healthcare within managed care programs by monitoring internal/external processes for improvement opportunities
Institute of Medicine (IOM) Aim(s) for Improvement: Patient Centered, Safe and Efficient
Objective 4.4 Process Objective
Assure CMO compliance with contractual standards (Grievance System):
1. In compliance with federal statutes, the CMOs must maintain records of grievances, whether received verbally or in writing, that include a short, dated summary of the problems, name of grievant, date of the grievance, date of the decision, and the disposition. CMOs are required to acknowledge receipt of each filed grievance and appeal in writing within 10 business days of receipt
2. DCH requires that individuals who make decisions on grievances that involve clinical issues are health care professionals who have the appropriate clinical expertise, as determined by DCH, in treating the member's condition or disease and who were not involved in any previous level of review or decision-making. Written notice of the disposition sent as expeditiously as the member's health condition requires but shall not exceed 90 calendar days of the filing date
3. Each CMO must ensure that the individuals who make decisions on appeals are individuals who were not involved in any previous level of review or decision-making; and who are health care professionals who have the appropriate clinical expertise in treating the member's condition or disease if deciding an appeal of a denial that is based on lack of medical necessity; or an appeal that involves clinical issues. Resolution of the appeal and written notice of the appeal resolution must be mailed as expeditiously as the member's appeal was received
4. The State will maintain an independent Administrative Law Hearing process as defined in the Georgia Administrative Procedure Act (O.C.G.A Title 50, Chapter 13) and as required by federal law, 42 CFR 200 et al. A member or authorized representative may request in writing a State Administrative Law Hearing within 30 calendar days of the date the Notice of Adverse Action is mailed by the Plan. The CMOs shall comply with decisions reached as a result of the Administrative Law Hearing process.
5. Continuation of member's benefits must be granted by the CMO if the member or the representative files the appeal timely and the member requests extension of the benefits
6. Peach Care for KidsTM, Georgia's SCHIP program, requires the member to initially request an appeal through the CMOs Grievance System. If resolution is not satisfactory to the member, the member must then file a request for appeal through Peach Care for KidsTM. The member may elect to present additional information in support of their appeal directly to a DCH appeal panel. The panel will consider information from the CMO, the independent physician review organization, and the member prior to issuing a determination

#
4.4.1

Strategic Action
On a periodic basis DCH will audit CMO grievances to assure compliance with federal and contractual requirements.

Target Completion
Date
12/31/2008

Meter

Status
2008 assessment will be scheduled to occur later this year.

July 2008

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Georgia Families Quality Strategic Plan Update
GOAL 4 Promotion of acceptable standards of healthcare within managed care programs by monitoring internal/external processes for improvement opportunities Institute of Medicine (IOM) Aim(s) for Improvement: Patient Centered, Safe and Efficient
Objective 4.5 Process Objective
Assure CMO compliance with contractual standards (Subcontractor Relations):
1. CMOs are required to obtain DCH approval prior to hiring or entering into an agreement with any subcontractor.
2. The State will request a list of subcontractors quarterly to include dates the contracts were executed.
3. DCH requires signed attestation statements from each CMO attesting that the activities of each of their approved subcontractors are being monitored.
4. Each CMO must conduct annual (and as needed) audits of their sub-contractors to ensure all delegated functions are being performed as required.

#
4.5.1

Strategic Action
CMOs are required to obtain DCH approval prior to hiring or entering into an agreement with any subcontractor. Asses the following periodically to identify areas of improvement and best practices:
CMO policies and procedures Develop plan for improvement Execute plan Evaluate plan Provide results/findings to stakeholders and public Document/Improve process to ensure compliance with plan

Target Completion
Date
10/15/2008

Meter

Status
CMOs currently provide DCH with notification requesting approval prior to hiring or entering into an agreement with any subcontractor.
DCH currently monitors the CMOs Subcontractor agreements and status as follows:
CMOs complete an Attestation Statement that is signed by a senior officer and indicates that the Subcontracted Vendors have been submitted to DCH for approval as well as the Subcontractor pricing.
DCH receives quarterly a Attestation Report from the CMOs that lists their current Subcontracted vendors
DCH provided the CMOs with the detailed report specifications for the Subcontractor Information Report
A detailed P&P has been written that addresses how the CMOs subcontracted vendors are monitored.

July 2008

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Georgia Families Quality Strategic Plan Update

#

Strategic Action

Target Meter

Completion

Date

Status

4.5.2

The State will request a list of subcontractors quarterly to include dates the contracts were executed. Asses the following
periodically to identify areas of improvement and best practices: CMO policies and
procedures Develop plan for
improvement Execute plan Evaluate plan Provide results/findings to
stakeholders and public Document/Improve process to ensure compliance with plan

10/15/2008

4.5.3

DCH requires signed attestation statements from each CMO attesting that the activities of each of their approved subcontractors are being monitored.

10/15/2008

July 2008

DCH will develop a plan for improvement of the CMO subcontractor monitoring process that includes execution, evaluation and a mechanism for assessing the results and findings for dissemination to the appropriate stakeholders as well as the public. The process will be reviewed that includes documentation of improvements that ensures and validates CMO compliance. The CMO contract with requires that a Subcontractor Information Report is submitted quarterly. The report specification document dictates that the following information must be included, i.e. CMO name, Subcontractor Name, Contracted Services Provided, Address Information, Telephone Numbers, Date of Contract, , Length of Contract, Date of CMO Audits, Audit (upon DCH request), the date that the CMO accepted the Subcontractor's Disaster Recovery Plan, and upon request a file copy of the Executed Contract.
DCH will develop a plan for improvement of the CMO subcontractor monitoring process that includes execution, evaluation and a mechanism for assessing the results and findings for dissemination to the appropriate stakeholders as well as the public. The process will be reviewed that includes documentation of improvements that ensures and validates CMO compliance. The CMOs currently submit an Attestation Statement to DCH that has been signed by a senior officer at a minimum quarterly or sooner.
DCH will develop a plan for
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Georgia Families Quality Strategic Plan Update

#

Strategic Action

Target Meter

Status

Completion

Date

Asses the following periodically

improvement of the CMO

to identify areas of improvement

subcontractor monitoring process that

and best practices:

includes execution, evaluation and a

CMO policies and

mechanism for assessing the results

procedures

and findings for dissemination to the

Develop plan for

appropriate stakeholders as well as

improvement

the public.

Execute plan Evaluate plan Provide results/findings to
stakeholders and public

The process will be reviewed that includes documentation of improvements that ensures and validates CMO compliance.

Document/Improve process

to ensure compliance with

plan

4.5.4

Each CMO must conduct annual (and as needed) audits of their sub-contractors to ensure all delegated functions are being performed as required. Assess the following periodically to identify areas of improvement and best practices CMO policies and procedures Develop plan for improvement Execute plan/Evaluate plan Provide results/findings to stakeholders and public Document/Improve process to ensure compliance with plan

10/15/2008

4.5.5

DCH will review CMO compliance with oversight of subcontractors and all delegated functions by review of all subcontractor related monitoring activities, CMO/subcontractor meeting minutes, and subcontractor monitoring results including CMO analysis, interpretation, and corrective actions. Asses the following
periodically to identify areas

July 2008

10/15/2008

DCH requires that each CMO conduct an audit (at least annually) that ensures that all delegated functions are being performed as required.
DCH will develop a plan for improvement of the CMO subcontractor monitoring process that includes a review process of the CMOs audits of their Subcontracted vendors as well as execution, evaluation and a mechanism for assessing the results and findings for dissemination to the appropriate stakeholders as well as the public. The process will be reviewed that includes documentation of improvements that ensures and validates CMO compliance. DCH currently monitors the CMOs compliance with their oversight of their identified subcontracted vendors. This review will be refined to include:
CMO/Subcontractor review schedule and actual dates
Meeting minutes List of participants Subcontractor monitoring
results Including CMO analysis,
interpretation, and
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Georgia Families Quality Strategic Plan Update

#

Strategic Action

Target Meter

Status

Completion

Date

of improvement and best

Corrective actions taken

practices:

CMO policies and

DCH will develop a plan for

procedures

improvement of the CMO

Develop plan for

subcontractor monitoring process that

improvement

includes execution, evaluation and a

Execute plan

mechanism for assessing the results

Evaluate plan Provide results/findings to
stakeholders and public Document/Improve process to ensure compliance with plan

and findings for dissemination to the appropriate stakeholders as well as the public. The process will be reviewed that includes documentation of improvements that ensures and

validates CMO compliance.

July 2008

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Georgia Families Quality Strategic Plan Update

GOAL 4 Promotion of acceptable standards of healthcare within managed care programs by monitoring internal/external processes for improvement opportunities
Institute of Medicine (IOM) Aim(s) for Improvement: Patient Centered, Safe and Efficient

Objective 4.6 Process Objective Assure CMO compliance with contractual standards (Structure and Operation):

#

Strategic Action

4.6.1 4.6.2

The CMO must make all of its books, documents, papers, provider records, medical records, financial records, data, surveys and computer databases available for examination and audit by authorized state or federal personnel. Any records requested must be produced immediately for onsite review or sent to the requesting authority by mail within 14 calendar days following a request. Asses the following
periodically to identify areas of improvement and best practices: CMO policies and
procedures Develop plan for
improvement Execute plan Evaluate plan Provide results/findings to
stakeholders and public Document/Improve process
to ensure compliance with plan DCH must have unlimited rights to use, disclose, and duplicate all information and data in any way relating to this contract in accordance with applicable state and federal laws and regulations.

July 2008

Target Completion
Date
10/15/2008
10/15/2008

Meter

Status
The DCH contract mandates that the CMOs provide all of its books, documents, papers, provider records, medical records, financial records, data, surveys and computer databases available for examination and audit by authorized state or federal personnel upon request within 14 calendar days by mail or immediately for an onsite review.
DCH will file all documents received and reviewed for authorized state personnel access.
DCH will develop a plan for improvement of the CMO subcontractor monitoring process that includes execution, evaluation and a mechanism for assessing the results and findings for dissemination to the appropriate stakeholders as well as the public. The process will be reviewed that includes documentation of improvements that ensures and validates CMO compliance.
The DCH contract with the CMOs stipulates in the section regarding Access to Records; that DCH ( Pursuant to the requirements of 42 CFR 434.6(a) (5) and 42 CFR 434.38,) has the right to have the CMO `make all of its books,
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Georgia Families Quality Strategic Plan Update
Asses the following periodically to identify areas of improvement and best practices: CMO policies and procedures
Develop plan for improvement
Execute plan Evaluate plan Provide results/findings to
stakeholders and public Document/Improve process
to ensure compliance with plan

4.6.3

DCH will conduct periodic audits of operational processes. Asses the following
periodically to identify areas of improvement and best practices: CMO policies and
procedures
July 2008

10/15/2008

documents, papers, Provider records, Medical Records, financial records, data, surveys and computer databases available for examination and audit by DCH, the State Attorney General, the State Health Care Fraud Control Unit, the State Department of Audits, or authorized State or federal personnel. Any records requested hereunder shall be produced immediately for onsite review or sent to the requesting authority by mail within fourteen (14) Calendar Days following a request. All records shall be provided at the sole cost and expense of the Contractor. DCH shall have unlimited rights to use, disclose, and duplicate all information and data in any way relating to this Contract in accordance with applicable State and federal laws and regulations.'
DCH will develop a plan for improvement of the:
CMO subcontractor monitoring process that including the
CMO policies and procedures, Complaints regarding
coverage of stakeholders and public, Execution, Evaluation and A mechanism for assessing the results and findings for dissemination to the appropriate stakeholders as well as the public. The process will be reviewed that includes documentation of improvements that ensures and validates CMO compliance. The DCH contract with the CMOs stipulates that "All contracts must ensure that the Contractor evaluates the prospective Subcontractor's ability to perform the activities to be delegated; monitors the Subcontractor's performance on an ongoing basis and subjects it to formal
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Georgia Families Quality Strategic Plan Update
Develop plan for improvement
Execute plan Evaluate plan Provide results/findings to
stakeholders and public Document/Improve process
to ensure compliance with plan

review according to a periodic schedule established by DCH and consistent with industry standards or State laws and regulations; and identifies deficiencies or areas for improvement and that corrective action is taken."
DCH will develop a plan for improvement of the CMO subcontractor monitoring process that includes execution, evaluation and a mechanism for assessing the results and findings for dissemination to the appropriate stakeholders as well as the public. The process will be reviewed that includes documentation of improvements that ensures and validates CMO compliance.

July 2008

Page 35

Georgia Families Quality Strategic Plan Update

GOAL 4 Promotion of acceptable standards of healthcare within managed care programs by monitoring internal/external processes for improvement opportunities
Institute of Medicine (IOM) Aim(s) for Improvement: Patient Centered, Safe and Efficient

Objective 4.7 Process Objective
Assure CMO compliance with contractual standards (Utilization Management):
The CMO must provide assistance to members and providers to ensure the appropriate utilization of resources, using the following program components: prior authorization and pre-certification, prospective review, concurrent review, retrospective review, ambulatory review, second opinion, discharge planning and case management.

#
4.7.1
4.7.2

Strategic Action
Develop regular report that documents case management, disease management and discharge planning activities of the CMOs
Perform audit of CMO disease management, case management, and discharge planning processes.
Perform quarterly review of CMO utilization data, evaluate trends for potential over or under utilization and to identify potential areas for improvement.

Target Completion
Date
11/30/2008
11/30/2008

Meter

Status
Initial draft of report specifications and audit tool has been completed. Need to complete final DCH review, review with CMOs, with plan to implement in Fall 2008.
Review of current trends indicates a higher trend for utilization of NICU beds for one CMO. The CMO indicates that they believe this is related to adverse selection of complicated pregnancies. DCH is currently attempting to validate this.

July 2008

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