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Rhode
Island is Paying for Performance. RIte Care
is the Rhode Island managed care program for
families covered by Medicaid, including uninsured
families with incomes up to 185 percent of poverty
and uninsured pregnant women and children under
19 with family incomes up to 250 percent of
poverty. Since 1994, the program has sought
to improve access to and quality of care and
outcomes while containing costs. Since 1998,
contracts with health plans has specified administrative,
access, and clinical performance measures, with
each measure having a standard (current 19 of
these “benchmarks”). Under the Performance
Incentive Program, health plans can earn payments
over and above their capitation as rewards /
incentives for improving performance. For EPSDT,
the standard include: a) 85 percent of members
under age two are immunized according to schedule,
b) members between [ages] 6 and 20 are provided
EPSDT age-appropriate screenings, and c) new
members under age 18 receive a first visits
with a [primary care provider] PCP within 90
days of enrollment. The state also is piloting
measure related to emergency room visits for
child enrollees with asthma, and first outpatient
pediatric visit of infants born into RIte Care.
Visit the RIte Care Research and Evaluation
Home Page at Washington
State Focuses on Four Domains. Each year Washington
evaluates preventive health care delivered by
managed care organizations through study of
the content well-child checkups to infants,
children, and adolescents covered by Medicaid.
To qualify, a well-child checkup must meet state
Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) requirements at each visit
by addressing a minimum number of elements within
four health “domains”—physical
health, developmental health, mental health,
and health education. To count as an EPSDT screening
visit, the provider must document the core elements
in each the four health domains were addressed
during the visit. Traditionally, providers have
done well documenting one or two domains—chiefly
the physical health and developmental health—but
have been less successful in documenting mental
health and health education. The state has found
that using structured exam forms with age specific
items increases the likelihood that all four
domains will be addressed and documented. Evaluators
have found that focusing by age provides for
more reliable benchmarking. For more information,
go to OMPRO.
OMPRO is a nonprofit organization dedicated
to improving the quality and effectiveness of
health care; it is Washington’s external
quality review organization (EQRO). Dr. Anita
Bobinet is the EPSDT Project Coordinator, Health
Services Quality Assessment Department, OMPRO.
Keeping
Track in Arizona. Arizona’s Health
Care Cost Containment System (AHCCS) developed
age-specific EPSDT tracking forms, designed
to help providers deliver comprehensive, age-appropriate,
screening exams. With input from managed care
organizations (MCO) and pediatric leaders, the
form identifies the components of EPSDT called
for at each visit. When the form is completed
during the visit, one copy is kept in the child’s
medical record and the other copy is set to
the MCO. The MCO is, in turn, responsible for
ensuring that the EPSDT screens are performed
on schedule, with adequate content, and the
completed tracking form data is available for
performance monitoring.
Wisconsin's
New Quality Performance Measure System for Medicaid
Managed Care Wisconsin has implemented MEDDIC-MS,
a new system of performance measures that addresses
many of the most difficult issues not adequately
addressed by current quality assurance / performance
monitoring systems. It is perhaps the first
automated, rapid-cycle quality performance measure
system to be successfully implemented in a large,
state-wide, publicly funded healthcare system.
Delivery of EPSDT (known as HealthCheck in Wisconsin)
services for children between birth and age
two years are a priority in the Medicaid/BadgerCare
program because they facilitate the delivery
of vital early childhood preventive health services
and offer opportunities for screening, diagnosis,
and intervention for potentially serious conditions,
thereby improving quality of life and preventing
future complications. MEDDIC-MS measures are:
percent of children who receive seven or more,
six, and five comprehensive HealthCheck examinations
by the age of two years (MEDDIC-MS).
One
study of “Quality
Oversight In Medicaid Primary Care Case Management
Programs” (Schneider et al.) found
that the Medicaid PCCM programs had different
partterns of performance monitoring and quality
management. Some State Medicaid Agencies were
aiming to boost performance by paying incentives.
In PCCM programs, the clinical areas most commonly
targeted for quality improvement were childhood
immunizations, diabetes, and asthma, followed
by satisfaction with care. Five state PCCM programs
(20 percent) reported that they were able to
demonstrate improvements in satisfaction with
care, and another five reported improvement
in childhood immunizations. Of twenty-five PCCM
programs, five states (20 percent) reported
bonus payments for EPSDT.
The
Iowa Quality Assurance Technical Assistance
(TA) effort was sponsored through CompCare,
a joint initiative of Health Resources and Services
Administration (HRSA) and the Center for Medicare
and Medicaid Services (CMS). A State-level workgroup
comprised of representatives from the Iowa’s
Department of Human Services and the Department
of Public Health identified a need for better
coordination of quality assurance (QA) efforts
in child health. The aim was to shift from individual-
and program-level quality assurance efforts
toward a more comprehensive child health quality
improvement system.
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