Commonwealth Pennsylvania Department of Human Services ...• validation of performance improvement...

Commonwealth Pennsylvania Department of Human Services Office of Medical Assistance Programs

2016 External Quality Review Report Gateway Health

Final Report April 2017

Table of Contents

INTRODUCTION .............................................................................................................................................. 4

I: STRUCTURE AND OPERATIONS STANDARDS ................................................................................................ 5

II: PERFORMANCE IMPROVEMENT PROJECTS ............................................................................................... 10

III: PERFORMANCE MEASURES AND CAHPS SURVEY ..................................................................................... 15 PA-SPECIFIC PERFORMANCE MEASURE SELECTION AND DESCRIPTIONS ............................................................................. 17 HEDIS PERFORMANCE MEASURE SELECTION AND DESCRIPTIONS .................................................................................... 21 CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (CAHPS) SURVEY ...................................................... 36

IV: 2015 OPPORTUNITIES FOR IMPROVEMENT MCO RESPONSE ................................................................... 37 CURRENT AND PROPOSED INTERVENTIONS .................................................................................................................. 37 ROOT CAUSE ANALYSIS AND ACTION PLAN .................................................................................................................. 69

V: 2016 STRENGTHS AND OPPORTUNITIES FOR IMPROVEMENT ................................................................... 80

VI: SUMMARY OF ACTIVITIES ........................................................................................................................ 86

2016 External Quality Review Report: Gateway Health of 86

List of Tables and Figures

Table 1.1: SMART Items Count Per Regulation....................................................................................................................... 5

Table 1.2: GH Compliance with Enrollee Rights and Protections Regulations ....................................................................... 7

Table 1.3: GH Compliance with Quality Assessment and Performance Improvement Regulations ...................................... 7

Table 1.4: GH Compliance with Federal and State Grievance System Standards................................................................... 9

Table 3.1: Performance Measure Groupings ........................................................................................................................ 15

Table 3.2: Access to Care ...................................................................................................................................................... 28

Table 3.3: Well-Care Visits and Immunizations .................................................................................................................... 28

Table 3.4: EPSDT: Screenings and Follow-up ........................................................................................................................ 29

Table 3.5: EPSDT: Dental Care for Children and Adults ........................................................................................................ 30

Table 3.6: Women’s Health................................................................................................................................................... 31

Table 3.7: Obstetric and Neonatal Care................................................................................................................................ 32

Table 3.8: Respiratory Conditions......................................................................................................................................... 33

Table 3.9: Comprehensive Diabetes Care ............................................................................................................................. 33

Table 3.10: Cardiovascular Care............................................................................................................................................ 34

Table 3.11: Utilization ........................................................................................................................................................... 35

Table 4.1: CAHPS 2016 Adult Survey Results ........................................................................................................................ 36

Table 4.2: CAHPS 2016 Child Survey Results......................................................................................................................... 36

Table 5.1: Current and Proposed Interventions ................................................................................................................... 37

Table 5.2: RCA and Action Plan – Annual Dental Visits......................................................................................................... 69

Table 5.3: RCA and Action Plan – Comprehensive Diabetes Care – HbA1c Poor Control .................................................... 73

Table 5.4: RCA and Action Plan – Frequency of Ongoing Prenatal Care: ≥ 81% of Expected Prenatal Care Visits Received76

Figure 1 - P4P Measure Matrix – GH..................................................................................................................................... 84

Figure 2 - Emergency Department Utilization Comparison .................................................................................................. 84

Figure 3 - P4P Measure Rates – GH ...................................................................................................................................... 85


Introduction

Purpose and Background The final rule of the Balanced Budget Act (BBA) of 1997 requires that State agencies contract with an External Quality Review Organization (EQRO) to conduct an annual external quality review (EQR) of the services provided by contracted Medicaid Managed Care Organizations (MCOs). This EQR must include an analysis and evaluation of aggregated information on quality, timeliness and access to the health care services that a MCO furnishes to Medicaid Managed Care recipients.

The EQR-related activities that must be included in detailed technical reports are as follows: • review to determine MCO compliance with structure and operations standards established by the State (42 CFR

§438.358), • validation of performance improvement projects, and • validation of MCO performance measures.

HealthChoices Physical Health (PH) is the mandatory managed care program that provides Medical Assistance recipients with physical health services in the Commonwealth of Pennsylvania (PA). The PA Department of Human Services (DHS) Office of Medical Assistance Programs (OMAP) contracted with IPRO as its EQRO to conduct the 2016 EQRs for the HealthChoices PH MCOs and to prepare the technical reports. This technical report includes six core sections:

I. Structure and Operations Standards II. Performance Improvement Projects

III. Performance Measures and Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey IV. 2015 Opportunities for Improvement – MCO Response V. 2016 Strengths and Opportunities for Improvement

VI. Summary of Activities

For the PH Medicaid MCOs, the information for the compliance with Structure and Operations Standards section of the report is derived from the commonwealth’s monitoring of the MCOs against the Systematic Monitoring, Access and Retrieval Technology (SMART) standards, from the HealthChoices Agreement, and from National Committee for Quality Assurance (NCQA™) accreditation results for each MCO.

Information for Section II of this report is derived from activities conducted with and on behalf of DHS to research, select, and define Performance Improvement Projects (PIPs) for a new validation cycle. Information for Section III of this report is derived from IPRO’s validation of each PH MCO’s performance measure submissions. Performance measure validation as conducted by IPRO includes both Pennsylvania specific performance measures as well as Healthcare Effectiveness Data and Information Set (HEDIS®1) measures for each Medicaid PH MCO. Within Section III, CAHPS Survey results follow the performance measures.

Section IV, 2015 Opportunities for Improvement – MCO Response, includes the MCO’s responses to the 2015 EQR Technical Report’s opportunities for improvement and presents the degree to which the MCO addressed each opportunity for improvement.

Section V has a summary of the MCO’s strengths and opportunities for improvement for this review period as determined by IPRO and a “report card” of the MCO’s performance as related to selected HEDIS measures. Section VI provides a summary of EQR activities for the PH MCO for this review period.

1 HEDIS is a registered trademark of the National Committee for Quality Assurance. 2016 External Quality Review Report: Gateway Health of 86

I: Structure and Operations Standards This section of the EQR report presents a review by IPRO of Gateway Health’s (GH’s) compliance with structure and operations standards. The review is based on information derived from reviews of the MCO that were conducted within the past three years.

Methodology and Format The documents used by IPRO for the current review include the HealthChoices Agreement, the SMART database completed by PA DHS staff as of December 31, 2015, and the most recent NCQA Accreditation Survey for GH, effective December 2015.

The SMART items provided much of the information necessary for this review. The SMART items are a comprehensive set of monitoring items that PA DHS staff reviews on an ongoing basis for each Medicaid MCO. The SMART items and their associated review findings for each year are maintained in a database. The SMART database has been maintained internally at DHS since RY 2013. Upon discussion with the DHS regarding the data elements from each version of database, IPRO merged the RY 2015, 2014, and 2013 findings for use in the current review. IPRO reviewed the elements in the SMART item list and created a crosswalk to pertinent BBA regulations. A total of 126 items were identified that were relevant to evaluation of MCO compliance with the BBA regulations. These items vary in review periodicity as determined by DHS.

The crosswalk linked SMART Items to specific provisions of the regulations, where possible. Some items were relevant to more than one provision. It should be noted that one or more provisions apply to each of the categories in Table 1.1. Table 1.1 provides a count of items linked to each category.

Table 1.1: SMART Items Count Per Regulation BBA Regulation SMART Items Subpart C: Enrollee Rights and Protections Enrollee Rights 7 Provider-Enrollee Communication 1 Marketing Activities 2 Liability for Payment 1 Cost Sharing 0 Emergency and Post-Stabilization Services – Definition 4 Emergency Services: Coverage and Payment 1 Solvency Standards 2 Subpart D: Quality Assessment and Performance Improvement Availability of Services 14 Coordination and Continuity of Care 13 Coverage and Authorization of Services 9 Provider Selection 4 Provider Discrimination Prohibited 1 Confidentiality 1 Enrollment and Disenrollment 2 Grievance Systems 1 Subcontractual Relationships and Delegations 3 Practice Guidelines 2 Health Information Systems 18 Subpart F: Federal and State Grievance Systems Standards General Requirements 8 Notice of Action 3


BBA Regulation SMART Items Handling of Grievances and Appeals 9 Resolution and Notification 7 Expedited Resolution 4 Information to Providers and Subcontractors 1 Recordkeeping and Recording 6 Continuation of Benefits Pending Appeal and State Fair Hearings 2 Effectuation of Reversed Resolutions 0

Two categories, Cost Sharing and Effectuation of Reversed Resolutions, were not directly addressed by any of the SMART Items reviewed by DHS. Cost Sharing is addressed in the HealthChoices Agreements. Effectuation of Reversed Resolutions is evaluated as part of the most recent NCQA Accreditation review under Utilization Management (UM) Standard 8: Policies for Appeals and UM 9: Appropriate Handling of Appeals.

Determination of Compliance To evaluate MCO compliance on individual provisions, IPRO grouped the monitoring standards by provision and evaluated the MCO’s compliance status with regard to the SMART Items. For example, all provisions relating to enrollee rights are summarized under Enrollee Rights 438.100. Each item was assigned a value of Compliant or non-Compliant in the Item Log submitted by DHS. If an item was not evaluated for a particular MCO, it was assigned a value of Not Determined. Compliance with the BBA requirements was then determined based on the aggregate results of the SMART Items linked to each provision within a requirement or category. If all items were Compliant, the MCO was evaluated as Compliant. If some were Compliant and some were non-Compliant, the MCO was evaluated as partially-Compliant. If all items were non-Compliant, the MCO was evaluated as non-Compliant. If no items were evaluated for a given category and no other source of information was available to determine compliance, a value of Not Determined was assigned for that category.

Format The format for this section of the report was developed to be consistent with the subparts prescribed by BBA regulations. This document groups the regulatory requirements under subject headings that are consistent with the three subparts set out in the BBA regulations and described in the MCO Monitoring Protocol. Under each subpart heading fall the individual regulatory categories appropriate to those headings. IPRO’s findings are presented in a manner consistent with the three subparts in the BBA regulations explained in the Protocol, i.e., Enrollee Rights and Protections; Quality Assessment and Performance Improvement (including access, structure and operation, and measurement and improvement standards); and Federal and State Grievance System Standards.

In addition to this analysis of DHS’s MCO compliance monitoring, IPRO reviewed and evaluated the most recent NCQA accreditation report for each MCO.

This format reflects the goal of the review, which is to gather sufficient foundation for IPRO’s required assessment of the MCO’s compliance with BBA regulations as an element of the analysis of the MCO’s strengths and weaknesses.

Findings Of the 126 SMART Items, 88 items were evaluated and 38 were not evaluated for the MCO in Review Year (RY) 2015, RY 2014, or RY 2013. For categories where items were not evaluated, under review, or received an approved waiver for RY 2015, results from reviews conducted within the two prior years (RY 2014 and RY 2013) were evaluated to determine compliance, if available.

Subpart C: Enrollee Rights and Protections The general purpose of the regulations included in this category is to ensure that each MCO had written policies regarding enrollee rights and complies with applicable Federal and State laws that pertain to enrollee rights, and that the MCO ensures that its staff and affiliated providers take into account those rights when furnishing services to enrollees. [42 C.F.R. §438.100 (a), (b)]


Table 1.2: GH Compliance with Enrollee Rights and Protections Regulations ENROLLEE RIGHTS AND PROTECTIONS REGULATIONS

Subpart C: Categories Compliance Comments

Enrollee Rights Compliant 7 items were crosswalked to this category.

The MCO was evaluated against 7 items and was compliant on 7 items based on RY 2015.

Provider-Enrollee Communication Compliant

1 item was crosswalked to this category.

The MCO was evaluated against 1 item and was compliant on this item based on RY 2015.

Marketing Activities Compliant

2 items were crosswalked to this category.


Liability for Payment Compliant



Cost Sharing Compliant Per HealthChoices Agreement

Emergency Services: Coverage and Payment Compliant



Emergency and Post Stabilization Services Compliant



Solvency Standards Compliant



GH was evaluated against 18 of the 18 SMART Items crosswalked to Enrollee Rights and Protections Regulations and was compliant on all 18. GH was found to be compliant on all eight of the categories of Enrollee Rights and Protections Regulations. GH was found to be compliant on the Cost Sharing provision, based on the HealthChoices agreement.

Subpart D: Quality Assessment and Performance Improvement Regualtions The general purpose of the regulations included under this heading is to ensure that all services available under the Commonwealth’s Medicaid managed care program are available and accessible to GH enrollees. [42 C.F.R. §438.206 (a)]

The SMART database includes an assessment of the MCO’s compliance with regulations found in Subpart D. Table 1.3 presents the findings by categories consistent with the regulations.

Table 1.3: GH Compliance with Quality Assessment and Performance Improvement Regulations QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT REGULATIONS

Subpart D: Categories Compliance Comments Access Standards

Availability of Services Compliant


The MCO was evaluated against 12 items and was compliant on 11 items and partially compliant on 1 item based on RY 2015.


QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT REGULATIONS Subpart D: Categories Compliance Comments

Coordination and Continuity of Care Compliant



Coverage and Authorization of Services Compliant



Structure and Operation Standards

Provider Selection Compliant



Provider Discrimination Prohibited Compliant



Confidentiality Compliant



Enrollment and Disenrollment Compliant



Grievance Systems Compliant



Subcontractual Relationships and Delegations Compliant



Measurement and Improvement Standards

Practice Guidelines Compliant



Health Information Systems Compliant


The MCO was evaluated against 14 items and was compliant on 13 items and partially compliant on 1 item based on RY 2015.

GH was evaluated against 57 of 68 SMART Items that were crosswalked to Quality Assessment and Performance Improvement Regulations and was compliant on 55 items and partially compliant on 2 items. Of the 11 categories in Quality Assessment and Performance Improvement Regulations, GH was found to be compliant on all 11 categories.

Subpart F: Federal and State Grievance System Standards The general purpose of the regulations included under this heading is to ensure that enrollees have the ability to pursue grievances. 2016 External Quality Review Report: Gateway Health of 86

The Commonwealth’s audit document information includes an assessment of the MCO’s compliance with regulations found in Subpart F. Table 1.4 presents the findings by categories consistent with the regulations.

Table 1.4: GH Compliance with Federal and State Grievance System Standards FEDERAL AND STATE GRIEVANCE SYSTEM STANDARDS

Subpart F: Categories Compliance Comments

General Requirements Compliant 8 items were crosswalked to this category.


Notice of Action Compliant 3 items was crosswalked to this category.


Handling of Grievances & Appeals Compliant 9 items were crosswalked to this category.


Resolution and Notification Compliant 7 items were crosswalked to this category.


Expedited Resolution Compliant 4 items were crosswalked to this category.


Information to Providers and Subcontractors Compliant



Recordkeeping and Recording Compliant 6 items were crosswalked to this category.


Continuation of Benefits Pending Appeal and State Fair Hearings Compliant



Effectuation of Reversed Resolutions Compliant Per NCQA Accreditation, 2015

GH was evaluated against 13 of the 40 SMART Items crosswalked to Federal and State Grievance System Standards and was compliant on 13 items. GH was found to be compliant for all 9 categories of Federal and State Grievance System Standards.

Accreditation Status GH underwent an NCQA Accreditation Survey effective through March 16, 2018 and was granted an Accreditation Status of Accredited.


II: Performance Improvement Projects

In accordance with current BBA regulations, IPRO undertook validation of Performance Improvement Projects (PIPs) for each Medicaid PH MCO. For the purposes of the EQR, PH MCOs were required to participate in studies selected by OMAP for validation by IPRO in 2016 for 2015 activities. Under the applicable HealthChoices Agreement with the DHS in effect during this review period, Medicaid PH MCOs are required to conduct focused studies each year. For all PH MCOs, two new PIPs were initiated as part of this requirement. For all PIPs, PH MCOs are required to implement improvement actions and to conduct follow-up in order to demonstrate initial and sustained improvement or the need for further action.

As part of the new EQR PIP cycle that was initiated for all PH MCOs in 2015, PH MCOs were required to implement two internal PIPs in priority topic areas chosen by DHS. For this PIP cycle, two topics were selected: “Improving Access to Pediatric Preventive Dental Care” and “Reducing Potentially Preventable Hospital Admissions and Readmissions and Emergency Department Visits”.

“Improving Access to Pediatric Preventive Dental Care” was selected because on a number of dental measures, the aggregate HealthChoices rates have consistently fallen short of established benchmarks, or have not improved across years. For one measure, the HEDIS Annual Dental Visit (ADV) measure, from HEDIS 2006 through HEDIS 2013, the Medicaid Managed Care (MMC) average was below the 50th percentile for three years. Further, CMS reporting of FFY 2011-2013 data from the CMS-416 indicates that while PA met its two-year goal for progress on preventive dental services, the percentage of PA children age 1-20 who received any preventive dental service for FFY 2013 (40.0%), was below the National rate of 46.0%. The Aim Statement for the topic is “Increase access to and utilization of routine dental care for pediatric Pennsylvania HealthChoices members.” Four common objectives for all PH MCOs were selected:

1. Increase dental evaluations for children between the ages of 6 months and 5 years. 2. Increase preventive dental visits for all pediatric HealthChoices members. 3. Increase appropriate topical application of fluoride varnish by non-oral health professionals. 4. Increase the appropriate application of dental sealants for children ages 6-9 (CMS Core Measure) and 12-14 years.

For this PIP, OMAP is requiring all PH MCOs to submit the following core measures on an annual basis: • Adapted from CMS form 416, the percentage of children ages 0-1 who received, in the last year:

any dental service, a preventive dental service, a dental diagnostic service, any oral health service, any dental or oral health service

• Total Eligibles Receiving Oral Health Services provided by a Non-Dentist Provider • Total Eligibles Receiving Preventive Dental Services • The percentages of children, stratified by age (<1, 1-2, 3-5, 6-9, 10-14, 15-18, and 19-20 years) who received at

least one topical application of fluoride.

Additionally, MCOs are encouraged to consider other performance measures such as: • Percentage of children with ECC who are disease free at one year. • Percentage of children with dental caries (ages 1-8 years of age). • Percentage of oral health patients that are caries free. • Percentage of all dental patients for whom the Phase I treatment plan is completed within a 12 month period.

“Reducing Potentially Preventable Hospital Admissions and Readmissions and Emergency Department Visits” was selected as the result of a number of observations. General findings and recommendations from the PA Rethinking Care Program (RCP) – Serious Mental Illness (SMI) Innovation Project (RCP-SMI) and Joint PH/BH Readmission projects, as well as overall Statewide readmission rates and results from several applicable Healthcare Effectiveness Data and Information Set (HEDIS) and PA Performance Measures across multiple years, have highlighted this topic as an area of concern to be addressed for improvement. The Aim Statement for the topic is “To reduce potentially avoidable ED visits


and hospitalizations, including admissions that are avoidable initial admissions and readmissions that are potentially preventable.” Five common objectives for all PH MCOs were selected:

1. Identify key drivers of avoidable hospitalizations, as specific to the MCO’s population (e.g., by specific diagnoses, procedures, comorbid conditions, and demographics that characterize high risk subpopulations for the MCO).

2. Decrease avoidable initial admissions (e.g., admissions related to chronic or worsening conditions, or identified health disparities).

3. Decrease potentially preventable readmissions (e.g., readmissions related to diagnosis, procedure, transition of care, or case management)

4. Decrease avoidable ED visits (e.g., resulting from poor ambulatory management of chronic conditions including BH/SA conditions or use of the ED for non-urgent care).

5. Demonstrate improvement for a number of indicators related to avoidable hospitalizations and preventable readmissions, specifically for Individuals with Serious Persistent Mental Illness (SPMI).

For this PIP, OMAP is requiring all PH MCOs to submit the following core measures on an annual basis: MCO-developed Performance Measures MCOS are required to develop their own indicators tailored to their specific PIP (i.e., customized to the key drivers of avoidable hospitalizations identified by each MCO for its specific population).

DHS-defined Performance Measures • Ambulatory Care (AMB): ED Utilization. The target goal is 72 per 1,000 member months. • Inpatient Utilization—General Hospital/Acute Care (IPU): Total Discharges. The target goal is 8.2 per 1,000

months. • Reducing Potentially Preventable Readmissions (RPR). The target for the indicator is 8.5. Please note that, as

discussed below, this measure replaced the originally designated measure – Plan All-Cause Readmissions (PCR): 30-day Inpatient Readmission.

• Each of the five (5) BH-PH Integrated Care Plan Program measures: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Adherence to Antipsychotic Medications for Individuals with Schizophrenia Emergency Room Utilization for Individuals with Serious Persistent Mental Illness (SPMI) Combined BH-PH Inpatient Admission Utilization for Individuals with Serious Persistent Mental Illness

(SPMI) Combined BH-PH Inpatient 30-Day Readmission Rate for Individuals with Serious Persistent Mental Illness

(SPMI).

The PIPs extend from January 2015 through December 2018; with research beginning in 2015, initial PIP proposals developed and submitted in first quarter 2016, and a final report due in June 2019. The non-intervention baseline period is January 2015 to December 2015. Following the formal PIP proposal, the timeline defined for the PIPs includes required interim reports in July 2016, June 2017 and June 2018, as well as a final report in June 2019. Based on validation findings in 2016, the timeline has undergone adjustments.

The 2016 EQR is the thirteenth year to include validation of PIPs. For each PIP, all PH MCOs share the same baseline period and timeline defined for that PIP. To introduce each PIP cycle, DHS provided specific guidelines that addressed the PIP submission schedule, the measurement period, documentation requirements, topic selection, study indicators, study design, baseline measurement, interventions, re-measurement, and sustained improvement. Direction was given with regard to expectations for PIP relevance, quality, completeness, resubmissions and timeliness.

All PH MCOs are required to submit their projects using a standardized PIP template form, which is consistent with the CMS protocol for Conducting Performance Improvement Projects. These protocols follow a longitudinal format and capture information relating to:

• Activity Selection and Methodology • Data/Results • Analysis Cycle


• Interventions

Validation Methodology IPRO’s protocol for evaluation of PIPs is consistent with the protocol issued by the Centers for Medicare & Medicaid Services (CMS) (Validating Performance Improvement Projects, Final Protocol, Version 1.0, May 1, 2002) and meets the requirements of the final rule on EQR of Medicaid MCOs issued on January 24, 2003. IPRO’s review evaluates each project against ten review elements:

1. Project Topic And Topic Relevance 2. Study Question (Aim Statement) 3. Study Variables (Performance Indicators) 4. Identified Study Population 5. Sampling Methods 6. Data Collection Procedures 7. Improvement Strategies (Interventions) 8. Interpretation Of Study Results (Demonstrable Improvement) 9. Validity Of Reported Improvement 10. Sustainability Of Documented Improvement

The first nine elements relate to the baseline and demonstrable improvement phases of the project. The last element relates to sustaining improvement from the baseline measurement.

Review Element Designation/Weighting This section describes the scoring elements and methodology that will occur during the intervention and sustainability periods. MY 2015 is the baseline year, and during the 2016 review year, due to the several levels of feedback required, elements were reviewed and scored at multiple points during the year to provide guidance to the MCOs towards improving their proposals. However, no formal scoring was provided.

For each review element, the assessment of compliance is determined through the weighted responses to each review item. Each element carries a separate weight. Scoring for each element is based on full, partial and non-compliance. Points are awarded for the two phases of the project noted above and combined to arrive at an overall score. The overall score is expressed in terms of levels of compliance.

Table 2.1 presents the terminologies used in the scoring process, their respective definitions, and their weight percentage.

Table 2.1: Element Designation

Element Designation

Full Partial

Non-compliant

Element Designation

Definition

Met or exceeded the element requirements Met essential requirements but is deficient in some areas

Has not met the essential requirements of the element

Weight

100% 50% 0%

Overall Project Performance Score The total points earned for each review element are weighted to determine the MCO’s overall performance score for a PIP. For the EQR PIPs, the review elements for demonstrable improvement have a total weight of 80%. The highest achievable score for all demonstrable improvement elements is 80 points (80% x 100 points for Full Compliance; Table 2.2).

PIPs also are reviewed for the achievement of sustained improvement. For the EQR PIPs, this has a weight of 20%, for a possible maximum total of 20 points (Table 2.2). The MCO must sustain improvement relative to baseline after achieving demonstrable improvement. The evaluation of the sustained improvement area has two review elements.


Scoring Matrix When the PIPs are reviewed, all projects are evaluated for the same elements. The scoring matrix is completed for those review elements where activities have during the review year. At the time of the review, a project can be reviewed for only a subset of elements. It will then be evaluated for other elements at a later date, according to the PIP submission schedule. At the time each element is reviewed, a finding is given of “Met”, “Partially Met”, or “Not Met”. Elements receiving a “Met” will receive 100% of the points assigned to the element, “Partially Met” elements will receive 50% of the assigned points, and “Not Met” elements will receive 0%.

Table 2.2: Review Element Scoring Weights Review Scoring Element Standard Weight

1 Project Topic and Topic Relevance 5% 2 Study Question (Aim Statement) 5% 3 Study Variables (Performance Indicators) 15%

4/5 Identified Study Population and Sampling Methods 10% 6 Data Collection Procedures 10% 7 Improvement Strategies (Interventions) 15%

8/9 Interpretation of Study Results (DemonstrableImprovement

Improvement) and Validity of Reported 20%

Total Demonstrable Improvement Score 80% 10 Sustainability of Documented Improvement 20%

Total Sustained Improvement Score 20% Overall Project Performance Score 100%

Findings As noted previously, no formal scoring occurred for the current PIPs for this review year. However, the multiple levels of activity and collaboration that occurred between DHS, the PH MCOs, and IPRO beginning in 2014 continued and progressed throughout the review year.

At a 2014 MCO Quality Summit, DHS introduced its value-based program and two key performance goals: 1. Reduce Unnecessary Hospitalizations, and 2. Improve Use of Pediatric Preventive Dental Services. DHS asked IPRO to develop PIP topics related to these goals. Following multiple discussions between DHS and IPRO, the two PIP topics were developed and further refined throughout 2015.

Regarding the Dental topic, information related to the CMS Oral Health Initiative (OHI) was incorporated into the PIP, including examination of data from the CMS preventive dental measure, and inclusion of the measure as a core performance measure for the PIP. Through quarterly calls with MCOs and following additional review of the research and the PIP topic, initiatives that appeared to have potential value for improving access to and delivery of quality oral healthcare services were included in the PIP proposal as areas in which PH MCOs could seek to focus their efforts and develop specific interventions for their PIP. The PIP topic was introduced at a PH MCO Medical Directors’ meeting in Fall 2015.

Regarding the Readmission topic, initial discussions resulted in a proposal that focused primarily on the research indicating ambulatory care sensitive conditions which, if left unmanaged, could result in admissions and are related to readmissions, focusing on particular conditions. Throughout 2015, DHS refined its focus for this topic. In Fall 2015, DHS introduced two new pay-for-performance programs for the MCOs: the PH MCO and BH MCO Integrated Care Plan (ICP) Program Pay for Performance Program to address the needs of individuals with SPMI, and the Community Based Care Management (CBCM) Program. DHS requested the topic to be enhanced to incorporate elements of the new programs, including initiatives outlined for both programs that were provided as examples of activities that may be applicable for use in the PIP. MCOs are to consider and collect measures related to these programs; however, they were instructed that the focus of the PIP remains on each MCO’s entire population, and each MCO is required to analyze and identify indicators relevant to its specific population.


PH MCOs will continue to be asked to participate in multi-plan PIP update calls through the duration of the PIP to report on their progress or barriers to progress. Frequent collaboration between DHS and PH MCOs is also expected to continue. The PIP Submission Form that included instructions for each section for the proposal submissions was distributed to PH MCOs in February 2016, with a submission deadline for March 2016. Throughout 2016, subsequent to MCO proposal submissions, there were several levels of feedback provided to MCOs. In July, an overall summary document outlining common issues that were observed across most of the PIP proposal submissions was distributed to all PH MCOs. MCOs were asked to review the document and begin to discuss internally with appropriate staff for each of the topics. In July and August, each MCO received its MCO-specific review findings for each PIP and a request for a conference call to discuss, as well as an Update form to be completed following the calls. Throughout July and August, two conference calls were held with each MCO, to discuss the PIP proposal review findings with key MCO staff assigned to each PIP topic. MCOs were asked to complete the PIP Update form following the calls, in preparation for and to be submitted prior to, the MCO PIP Interactive Workshop scheduled by DHS. The Interactive Workshop was held with the MCOs at the end of August. MCOs were requested to come to the workshop with PIP project summaries that they were to present, which were later submitted to IPRO and distributed to all PH MCOs.

Following the workshop, in September, MCOs were given additional information to assist in preparing their next full PIP submission for the Project Year 1 Update. For the Readmission PIP, this included advising that DHS decided to replace the Plan All-Cause Readmissions (PCR) measure with the PAPM Reducing Potentially Preventable Readmissions (RPR) measure, particularly given that it is not reported for HEDIS by the Medicaid MCOs, as it is a HEDIS measure for commercial and Medicare products only. For the Dental PIP, MCOs were given the the CMS instructions for State submission of the five core performance measures from the 416 form.

During October and November, additional information was provided to MCOs. For Dental, they were given instructions regarding the core performance measures that are related to the 416 form, and the corresponding line item reporting element to be used from the form. Also, given that there are no established benchmarks for the CMS-416, DHS provided three years of CMS-416 Reports with PA state aggregate data and the excerpt on oral health from the 2015 CMS Secretary’s report with CMS OHI all-state data from FFY 2014, for the MCOs to calculate some appropriate benchmarks. For Readmission, MCOS were given the data for four of the five ICP measures. Adherence to Antipsychotic Medications for Individuals with Schizophrenia measure data were not included, as they were not finalized. Data for this measure was sent to MCOs in December, subsequent to to their Project Year 1 Update submission. Review of the Project Year 1 Update continued throughout December.


Source Measures

Access/Availability to Care HEDIS Children and Adolescents’ Access to PCPs (Age 12 - 24 months) HEDIS Children and Adolescents’ Access to PCPs (Age 25 months - 6 years) HEDIS Children and Adolescents’ Access to PCPs (Age 7-11 years) HEDIS Children and Adolescents’ Access to PCPs (Age 12-19 years) HEDIS Adults’ Access to Preventive/Ambulatory Health Services (Age 20-44 years) HEDIS Adults’ Access to Preventive/Ambulatory Health Services (Age 45-64 years) HEDIS Adults’ Access to Preventive/Ambulatory Health Services (Age 65+)

HEDIS Adult Body Mass Index Assessment Well-Care Visits and Immunizations

HEDIS Well-Child Visits in the First 15 Months of Life (6+ Visits) HEDIS Well-Child Visits (Age 3 to 6 years) HEDIS Childhood Immunizations by Age 2 (Combination 2) HEDIS Childhood Immunizations by Age 2 (Combination 3) HEDIS Adolescent Well-Care Visits (Age 12 to 21 years) HEDIS Immunizations for Adolescents HEDIS WCC Body Mass Index: Percentile (Age 3-11 years)

III: Performance Measures and CAHPS Survey

Methodology

IPRO validated PA specific performance measures and HEDIS data for each of the Medicaid PH MCOs.

The MCOs were provided with final specifications for the PA Performance Measures in February and March 2016. Source code, raw data and rate sheets were submitted by the MCOs to IPRO for review in 2016. A staggered submission was implemented for the performance measures. IPRO conducted an initial validation of each measure, including source code review and provided each MCO with formal written feedback. The MCOs were then given the opportunity for resubmission, if necessary. Source code was reviewed by IPRO. Raw data were also reviewed for reasonability and IPRO ran code against these data to validate that the final reported rates were accurate. Additionally, continuing as began in 2015, MCOs were provided with comparisons to the previous year’s rates and were requested to provide explanations for highlighted differences. For measures reported as percentages, differences were highlighted for rates that were statistically significant and displayed at least a 3-percentage point difference in observed rates. For the adult admission measures, which are not reported as percentages, differences were highlighted based only on statistical significance, with no minimum threshold.

For three PA performance Birth-related measures: Cesarean Rate for Nulliparous Singleton Vertex (CRS), Live Births Weighing Less Than 2,500 Grams (PLB), and Elective Delivery, rates for each of the measures were produced utilizing MCO Birth files in addition to the 2015 Department of Health Birth File. IPRO requested, from each MCO, information on members with a live birth within the measurement year. Similar to the methodology used in 2015, IPRO then utilized the MCO file in addition to the most recent applicable PA Department of Health Birth File to identify the denominator, numerator and rate for the three measures.

HEDIS 2016 measures were validated through a standard HEDIS compliance audit of each PH MCO. This audit includes pre-onsite review of the HEDIS Roadmap, onsite interviews with staff and a review of systems, and post-onsite validation of the Interactive Data Submission System (IDSS). A Final Audit Report was submitted to NCQA for each MCO. Because the PA-specific performance measures rely on the same systems and staff, no separate onsite review was necessary for validation of the PA-specific measures. IPRO conducts a thorough review and validation of source code, data and submitted rates for the PA-specific measures.

Evaluation of MCO performance is based on both PA-specific performance measures and selected HEDIS measures for the EQR. The following is a list of the performance measures included in this year’s EQR report.

Table 3.1: Performance Measure Groupings


Source Measures HEDIS WCC Body Mass Index: Percentile (Age 12-17 years) HEDIS WCC Body Mass Index: Percentile (Total) HEDIS WCC Counseling for Nutrition (Age 3-11 years) HEDIS WCC Counseling for Nutrition (Age 12-17 years) HEDIS WCC Counseling for Nutrition (Total) HEDIS WCC Counseling for Physical Activity (Age 3-11 years) HEDIS WCC Counseling for Physical Activity (Age 12-17 years) HEDIS WCC Counseling for Physical Activity (Total) EPSDT: Screenings and Follow-up HEDIS Lead Screening in Children (Age 2 years) HEDIS Follow-up Care for Children Prescribed Attention Deficit Hyperactivity Disorder (ADHD) Medication

PA EQR Follow-up Care for Children Prescribed Attention Deficit Hyperactivity Disorder (ADHD) Medication (BH Enhanced)

PA EQR Developmental Screening in the First Three Years of Life Dental Care for Children and Adults HEDIS Annual Dental Visits (Age 2-20 years) PA EQR Supplemental Annual Dental Visit (Age 2-21 years) PA EQR Dental Sealants for 6-9 Year Old Children at Elevated Caries Risk PA EQR Annual Dental Visits for Members with Developmental Disabilities (Age 2-21 years) Women’s Health HEDIS Breast Cancer Screening (Age 52–74 years) HEDIS Cervical Cancer Screening (Age 21-64 years) HEDIS Chlamydia Screening in Women (Total Rate) HEDIS Chlamydia Screening in Women (Age 16-20 years) HEDIS Chlamydia Screening in Women (Age 21-24 years) HEDIS Human Papillomavirus Vaccine for Female Adolescents HEDIS Non-Recommended Cervical Cancer Screening in Adolescent Females Obstetric and Neonatal Care HEDIS Frequency of Ongoing Prenatal Care – Greater than or Equal to 61% of Expected Prenatal Care Visits Received HEDIS Frequency of Ongoing Prenatal Care – Greater than or Equal to 81% of Expected Prenatal Care Visits Received HEDIS Prenatal and Postpartum Care - Timeliness of Prenatal Care HEDIS Prenatal and Postpartum Care - Postpartum Care PA EQR Prenatal Screening for Smoking PA EQR Prenatal Screening for Smoking during one of the first two visits (CHIPRA indicator) PA EQR Prenatal Screening for Environmental Tobacco Smoke Exposure (ETS) PA EQR Prenatal Counseling for Smoking PA EQR Prenatal Counseling for Environmental Tobacco Smoke Exposure (ETS) PA EQR Prenatal Smoking Cessation PA EQR Perinatal Depression Screening: Prenatal Screening for Depression

PA EQR Perinatal Depression Screening: Prenatal Screening for Depression during one of the first two visits (CHIPRA indicator)

PA EQR Perinatal Depression Screening: Prenatal Screening Positive for Depression PA EQR Perinatal Depression Screening: Prenatal Counseling for Depression PA EQR Perinatal Depression Screening: Postpartum Screening for Depression PA EQR Perinatal Depression Screening: Postpartum Screening Positive for Depression PA EQR Perinatal Depression Screening: Postpartum Counseling for Depression PA EQR Maternity Risk Factor Assessment: Prenatal Screening for Alcohol use PA EQR Maternity Risk Factor Assessment: Prenatal Screening for Illicit drug use PA EQR Maternity Risk Factor Assessment: Prenatal Screening for Prescribed or over-the-counter drug use PA EQR Maternity Risk Factor Assessment: Prenatal Screening for Intimate partner violence PA EQR Behavioral Health Risk Assessment PA EQR Cesarean Rate for Nulliparous Singleton Vertex PA EQR Percent of Live Births Weighing Less than 2,500 Grams PA EQR Elective Delivery Respiratory Conditions


Source Measures HEDIS Appropriate Testing for Children with Pharyngitis HEDIS Appropriate Treatment for Children with Upper Respiratory Infection HEDIS Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis HEDIS Use of Spirometry Testing in the Assessment and Diagnosis of COPD HEDIS Pharmacotherapy Management of COPD Exacerbation (Systemic Corticosteroid and Bronchodilator) HEDIS Medication Management for People with Asthma - 75% Compliance (Age 5-11 years, Age 12-18 years, Age 19-50

years, Age 51-64 years, and Total rate) PA EQR Asthma in Younger Adults Admission Rate (Age 18-39 years) PA EQR Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (40+ years) Comprehensive Diabetes Care HEDIS Hemoglobin A1c (HbA1c) Testing HEDIS HbA1c Poor Control (>9.0%) HEDIS HbA1c Control (<8.0%) HEDIS HbA1c Good Control (<7.0%) HEDIS Retinal Eye Exam HEDIS Medical Attention for Nephropathy HEDIS Blood Pressure Controlled <140/90 mm Hg PA EQR Diabetes Short-Term Complications Admission Rate (Age 18-64 years, Age 65+ years, and Total Rate) HEDIS Statin Therapy for Patients With Diabetes: Received Statin Therapy HEDIS Statin Therapy for Patients With Diabetes: Statin Adherence 80% Cardiovascular Care HEDIS Persistence of Beta Blocker Treatment After Heart Attack HEDIS Controlling High Blood Pressure PA EQR Heart Failure Admission Rate (Age 18-64 years, Age 65+ years, and Total Rate) HEDIS Statin Therapy for Patients With Cardiovascular Disease: Received Statin Therapy 21-75 years (Male) HEDIS Statin Therapy for Patients With Cardiovascular Disease: Received Statin Therapy 40-75 years (Female) HEDIS Statin Therapy for Patients With Cardiovascular Disease: Received Statin Therapy Total Rate HEDIS Statin Therapy for Patients With Cardiovascular Disease: Statin Adherence 80% - 21-75 years (Male) HEDIS Statin Therapy for Patients With Cardiovascular Disease: Statin Adherence 80% - 40-75 years (Female) HEDIS Statin Therapy for Patients With Cardiovascular Disease: Statin Adherence 80% - Total Rate HEDIS Cardiovascular Monitoring For People With Cardiovascular Disease and Schizophrenia Utilization PA EQR Reducing Potentially Preventable Readmissions HEDIS Adherence to Antipsychotic Medications for Individuals with Schizophrenia PA EQR Adherence to Antipsychotic Medications for Individuals with Schizophrenia (BH Enhanced) HEDIS Use of Multiple Concurrent Antipsychotics in Children and Adolescents (Ages 1 - 5 years, Ages 6 - 11 years, Ages

12 - 17 years, and Total Rate) HEDIS Metabolic Monitoring for Children and Adolescents on Antipsychotics (Ages 1 - 5 years, Ages 6 - 11 years, Ages

12 - 17 years, and Total Rate)

PA-Specific Performance Measure Selection and Descriptions Several PA-specific performance measures were calculated by each MCO and validated by IPRO. In accordance with DHS direction, IPRO created the indicator specifications to resemble HEDIS specifications. Measures previously developed and added as mandated by CMS for children in accordance with the Children’s Health Insurance Program Reauthorization Act (CHIPRA) and for adults in accordance with the Affordable Care Act (ACA) were continued as applicable to revised CMS specifications. Additionally, new measures were developed and added in 2016 as mandated in accordance with the ACA. For each indicator, the criteria that were specified to identify the eligible population were product line, age, enrollment, anchor date, and event/diagnosis. To identify the administrative numerator positives, date of service and diagnosis/procedure code criteria were outlined, as well as other specifications, as needed. Indicator rates were calculated through one of two methods: (1) administrative, which uses only the MCO’s data systems to identify numerator positives and (2) hybrid, which uses a combination of administrative data and medical record review (MRR) to identify numerator “hits” for rate calculation.


PA Specific Administrative Measures

1) Annual Dental Visits For Enrollees with Developmental Disabilities

This performance measure assesses the percentage of enrollees with a developmental disability age two through twenty-one years of age, who were continuously enrolled during calendar year 2015 that had at least one dental visit during the measurement year. This indicator utilized the HEDIS 2016 measure Annual Dental Visit (ADV) measure specifications.

2) Cesarean Rate for Nulliparous Singleton Vertex – CHIPRA Core Set

This performance measure assesses Cesarean Rate for low-risk first birth women [aka NSV CS rate: nulliparous, term, singleton, vertex].

3) Percent of Live Births Weighing Less than 2,500 Grams – CHIPRA Core Set

This performance measure is event-driven and identifies all live births during the measurement year in order to assess the number of live births that weighed less than 2,500 grams as a percent of the number of live births.

4) Elective Delivery – Adult Core Set

This performance measure assesses the percentage of enrolled women with elective vaginal deliveries or elective cesarean sections at ≥ 37 and < 39 weeks of gestation completed.

5) Follow-up Care for Children Prescribed Attention Deficit Hyperactivity Disorder (ADHD) Medication – CHIPRA Core Set

DHS enhanced this measure using Behavioral Health (BH) encounter data contained in IPRO’s encounter data warehouse. IPRO evaluated this measure using HEDIS 2016 Medicaid member level data submitted by the PH MCO.

This performance measure assesses the percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication that had at least three follow-up care visits within a 10-month period, one of which was within 30 days from the time the first ADHD medication was dispensed. Two rates are reported:

Initiation Phase: The percentage of children ages 6 to 12 as of the Index Prescription Start Date (IPSD) with an ambulatory prescription dispensed for ADHD medication that had one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase.

Continuation and Maintenance (C&M) Phase: The percentage of children 6 to 12 years old as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

6) Reducing Potentially Preventable Readmissions

This performance measure assesses the percentage of inpatient acute care discharges with subsequent readmission to inpatient acute care within 30 days of the initial inpatient acute discharge. This measure utilized the 2016 HEDIS Inpatient Utilization – General Hospital/Acute Care measure methodology to identify inpatient acute care discharges.

For the Reducing Potentially Preventable Readmissions measure, lower rates indicate better performance.


7) Asthma in Younger Adults Admission Rate – Adult Core Set

This performance measure assesses the number of discharges for asthma in adults ages 18 to 39 years per 100,000 Medicaid member months.

8) Diabetes Short-Term Complications Admission Rate – Adult Core Set

This performance measure assesses the number of discharges for diabetes short-term complications per 100,000 Medicaid member months. Two age groups will be reported: ages 18-64 years and age 65 years and older.

9) Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate – Adult Core Set

This performance measure assesses the number of discharges for chronic obstructive pulmonary disease (COPD) or asthma in adults aged 40 years and older per 100,000 Medicaid member months.

10) Heart Failure Admission Rate – Adult Core Set

This performance measure assesses the number of discharges for Heart Failure in adults aged 18 and older per 100,000 Medicaid member months. Two age groups will be reported: ages 18-64 years and age 65 years and older.

11) Adherence to Antipsychotic Medications for Individuals with Schizophrenia – Adult Core Set

DHS enhanced this measure using Behavioral Health (BH) encounter data contained in IPRO’s encounter data warehouse. IPRO evaluated this measure using HEDIS 2016 Medicaid member level data submitted by the PH MCO.

This performance measure assesses the percentage of members 19-64 years of age during the measurement year with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period.

12) Developmental Screening in the First Three Years of Life– CHIPRA Core Set

This performance measure assesses the percentage of children screened for risk of developmental, behavioral, and social delays using a standardized screening tool in the 12 months preceding their first, second, or third birthday. Four rates, one for each group and a combined rate, are to be calculated and reported for each numerator.

13) Dental Sealants for 6-9 Year Old Children at Elevated Caries Risk (New for 2016) – CHIPRA Core Set

This performance measure assesses the percentage of enrolled children ages 6-9 years at elevated risk of dental caries who received a sealant on a permanent first molar tooth within the measurement year. MCO rates are reported as identified by the MCO. Additionally, to be more closely aligned to the CHIPRA Core Set Measure specifications, this measure is enhanced for the state with additional available dental data.

14) Supplemental Annual Dental Visit (New for 2016)

This performance measure enhances the HEDIS 2016 Annual Dental Visit (ADV) measure for 2-20 year-olds with supplemental data for 21-year-olds, to assess the percentage of enrolled children under 21. Seven rates, one for each group and a combined rate, are to be calculated and reported for each numerator.


PA Specific Hybrid Measures

15) Prenatal Screening for Smoking and Treatment Discussion During a Prenatal Visit

This performance measure assesses the percentage of pregnant enrollees who were: 1. Screened for smoking during the time frame of one of their first two prenatal visits or during the time frame of

their first two visits following initiation of eligibility with the MCO. 2. Screened for smoking during the time frame of one of their first two prenatal visits (CHIPRA indicator). 3. Screened for environmental tobacco smoke exposure during the time from of one of their first two prenatal

visits or during the time frame of their first two visits following initiation of eligibility with the MCO. 4. Screened for smoking in one of their first two prenatal visits who smoke (i.e., a smoker during the pregnancy),

that were given counseling/advice or a referral during the time frame of any prenatal visit during pregnancy. 5. Screened for environmental tobacco smoke exposure in one of their first two prenatal visits and found to be

exposed, that were given counseling/advice or a referral during the time frame of any prenatal visit during pregnancy.

6. Screened for smoking in one of their first two prenatal visits and found to be current smokers that stopped smoking during their pregnancy.

This performance measure uses components of the HEDIS 2016 Prenatal and Postpartum Care Measure.

16) Perinatal Depression Screening

This performance measure assesses the percentage of enrollees who were: 1. Screened for depression during a prenatal care visit. 2. Screened for depression during a prenatal care visits using a validated depression screening tool. 3. Screened for depression during the time frame of the first two prenatal care visits (CHIPRA indicator). 4. Screened positive for depression during a prenatal care visit. 5. Screened positive for depression during a prenatal care visits and had evidence of further evaluation or

treatment or referral for further treatment. 6. Screened for depression during a postpartum care visit. 7. Screened for depression during a postpartum care visit using a validated depression screening tool. 8. Screened positive for depression during a postpartum care visit. 9. Screened positive for depression during a postpartum care visit and had evidence of further evaluation or

treatment or referral for further treatment.


17) Maternity Risk Factor Assessment

This performance measure assesses, for each of the following risk categories, the percentage of pregnant enrollees who were:

1. Screened for alcohol use during the time frame of one of their first two prenatal visits (CHIPRA indicator). 2. Screened for illicit drug use during the time frame of one of their first two prenatal visits (CHIPRA indicator). 3. Screened for prescribed or over-the-counter drug use during the time frame of one of their first two prenatal

visits (CHIPRA indicator). 4. Screened for intimate partner violence during the time frame of one of their first two prenatal visits (CHIPRA

indicator).



18) Behavioral Health Risk Assessment– CHIPRA Core Set

This performance measure is a combination of the screening assessments for all risk factors identified by each of the CHIPRA indicators in the Perinatal Depression Screening (PDS), Prenatal Screening for Smoking and Treatment Discussion During a Prenatal Visit (PSS), and Maternity Risk Factor Assessment (MRFA) measures.

This performance measure assesses the percentage of enrollees who were screened during the time frame of one of their first two prenatal visits for all of the following risk factors:

1. depression screening, 2. tobacco use screening, 3. alcohol use screening, 4. drug use screening (illicit and prescription, over the counter), and 5. intimate partner violence screening.

HEDIS Performance Measure Selection and Descriptions

Each MCO underwent a full HEDIS compliance audit in 2016. As indicated previously, performance on selected HEDIS measures is included in this year’s EQR report. Development of HEDIS measures and the clinical rationale for their inclusion in the HEDIS measurement set can be found in HEDIS 2016, Volume 2 Narrative. The measurement year for HEDIS 2016 measures is 2015, as well as prior years for selected measures. Each year, DHS updates its requirements for the MCOs to be consistent with NCQA’s requirement for the reporting year. MCOs are required to report the complete set of Medicaid measures, excluding behavioral health and chemical dependency measures, as specified in the HEDIS Technical Specifications, Volume 2. In addition, DHS does not require the MCOs to produce the Chronic Conditions component of the CAHPS 5.0 – Child Survey.

Children and Adolescents’ Access to Primary Care Practitioners

This measure assessed the percentage of members 12 to 24 months and 25 months to 6 years of age who had a visit with a PCP who were continuously enrolled during the measurement year. For children ages 7 to 11 years of age and adolescents 12 to 19 years of age, the measure assessed the percentage of children and adolescents who were continuously enrolled during the measurement year and the year prior to the measurement year who had a visit with a PCP during the measurement year or the year prior to the measurement year.

Adults’ Access to Preventive/Ambulatory Health Services

This measure assessed the percentage of enrollees aged 20 to 44 years of age, 45 to 64 years of age, and 65 years of age and older who had an ambulatory or preventive care visit during the measurement year.

Adult Body Mass Index (BMI) Assessment

This measure assessed the percentage of enrollees 18-74 years of age who had an outpatient visit and who had their BMI documented during the measurement year or the year prior to the measurement year.

Well-Child Visits in the First 15 Months of Life

This measure assessed the percentage of enrollees who turned 15 months old during the measurement year, who were continuously enrolled from 31 days of age through 15 months of age who received six or more well-child visits with a PCP during their first 15 months of life.


Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life

This measure assessed the percentage of enrollees who were 3, 4, 5, or 6 years of age during the measurement year, who were continuously enrolled during the measurement year and received one or more well-child visits with a PCP during the measurement year.

Adolescent Well-Care Visits

This measure assessed the percentage of enrollees between 12 and 21 years of age, who were continuously enrolled during the measurement year and who received one or more well-care visits with a PCP or Obstetrician/Gynecologist (OG/GYN) during the measurement year. Immunizations for Adolescents

This measure assessed the percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular Pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday. The measure calculates a rate for each vaccine and one combination rate.

Human Papillomavirus Vaccine for Female Adolescents

This measure assessed the percentage of female adolescents 13 years of age who had three doses of human papillomavirus (HPV) vaccine by their 13th birthday.

Childhood Immunization Status

This measure assessed the percentage of children who turned two years of age in the measurement year who were continuously enrolled for the 12 months preceding their second birthday and who received one or both of two immunization combinations on or before their second birthday. Separate rate were calculated for each Combination. Combination 2 and 3 consists of the following immunizations:

(4) Diphtheria and Tetanus, and Pertussis Vaccine/Diphtheria and Tetanus (DTaP/DT) (3) Injectable Polio Vaccine (IPV) (1) Measles, Mumps, and Rubella (MMR) (3) Haemophilius Influenza Type B (HiB) (3) Hepatitis B (HepB) (1) Chicken Pox (VZV) (4) Pneumococcal Conjugate Vaccine – Combination 3 only

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

This measure assessed the percentage of children 3 to 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year. Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value.

Lead Screening in Children

This measure assessed 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.

Annual Dental Visit

This measure assessed the percentage of children and adolescents between the ages of 2 and 20 years of age who were continuously enrolled in the MCO for the measurement year who had a dental visit during the measurement year.


Breast Cancer Screening

This measure assessed the percentage of women ages 52 to 74 years who were continuously enrolled in the measurement year and the year prior to the measurement year that had a mammogram in either of those years.

Cervical Cancer Screening

This measure assessed the percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: • Women age 21-64 who had cervical cytology performed every 3 years. • Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.

Chlamydia Screening in Women

This measure assessed the percentage of women 16 to 24 years of age, who were continuously enrolled in the measurement year, who had at least one test for Chlamydia during the measurement year. Two age stratifications (1620 years and 21-24 years) and a total rate are reported.

Prenatal and Postpartum Care

This measure assessed the percentage of women who delivered a live birth between November 6 of the year prior to the measurement year and November 5 of the measurement year, who were enrolled for at least 43 days prior to delivery and 56 days after delivery who received timely prenatal care and who had a postpartum visit between 21 and 56 days after their delivery. Timely prenatal care is defined as care initiated in the first trimester or within 42 days of enrollment in the MCO.

Frequency of Ongoing Prenatal Care

This measure assessed the percentage of women who delivered a live birth between November 6 of the year prior to the measurement year and November 5 of the measurement year, who were enrolled for at least 43 days prior to delivery and 56 days after delivery who had ≥61% or ≥81% of the expected prenatal visits during their pregnancy. Expected visits are defined with reference to the month of pregnancy at the time of enrollment and the gestational age at time of delivery. This measure uses the same denominator and deliveries as the Prenatal and Postpartum Care measure.

Appropriate Testing for Children with Pharyngitis

This measure assessed the percentage of children 2 to 18 years of age who were diagnosed with Pharyngitis, dispensed an antibiotic, and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing).

Appropriate Treatment for Children with Upper Respiratory Infection

This measure assessed the percentage of children three months to 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. A higher rate indicates appropriate treatment of children with URI (i.e., the proportion for whom antibiotics were not prescribed).

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

This measure assessed the percentage of adults 18 to 64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. A higher rate indicates appropriate treatment of adults with acute bronchitis (i.e., the proportion for whom antibiotics were not prescribed).


Use of Spirometry Testing in the Assessment and Diagnosis of Chronic Obstructive Pulmonary Disease (COPD)

This measure assessed the percentage of members 40 years of age and older with a new diagnosis or newly active COPD who received appropriate spirometry testing to confirm the diagnosis.

Pharmacotherapy Management of COPD Exacerbation

This measure assessed the percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter between January 1 through November 30 of the measurement year and who were dispensed appropriate medications. Two rates are reported: 1) Dispensed a systemic corticosteroid within 14 days of the event, and 2) dispensed a bronchodilator within 30 days of the event.

Follow-up Care for Children Prescribed Attention Deficit Hyperactivity Disorder (ADHD) Medication

This measure assessed the percentage of children newly prescribed attention deficit/hyperactivity disorder (ADHD) medication that had at least three follow-up care visits within a 10-month period, one of which was within 30 days from the time the first ADHD medication was dispensed. Two rates are reported.

Initiation Phase: The percentage of children 6 to 12 years of age as of the Index Prescription Start Date (IPSD) with an ambulatory prescription dispensed for ADHD medication that had one follow-up visit with a practitioner with prescribing authority during the 30-day Initiation Phase.

Continuation and Maintenance (C&M) Phase: The percentage of children 6 to 12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, that remained on the medication for at least 210 days and, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner with prescribing authority within 270 days (9 months) after the Initiation Phase ended.

Use of Appropriate Medications for People with Asthma

This measure assessed the percentage of members age 5 to 64 years during the measurement year continuously enrolled in the measurement year and the year prior to the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year.

Comprehensive Diabetes Care

This measure assessed the percentage of members 18 to 75 years of age who were diagnosed prior to or during the measurement year with diabetes type 1 and type 2, who were continuously enrolled during the measurement year and who had each of the following: • Hemoglobin A1c (HbA1c) tested • HbA1c Poor Control (<9.0%) • HbA1c Control (<8.0%) • HbA1c Good Control (<7.0%) • Retinal eye exam performed • Medical attention for Nephropathy • Blood pressure control (<140/90 mm Hg)

For the HbA1c Poor Control (>9.0%) measure, lower rates indicate better performance.

Controlling High Blood Pressure

This measure assessed the percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria: • Members 18-59 years of age whose BP was <140/90 mm Hg.


• Members 60-85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg. • Members 60-85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg.

For this measure, a single rate, the sum of all three groups, is reported.

Persistence of Beta-Blocker Treatment After a Heart Attack

This measure assessed the percentage of enrollees 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment. MCOs report the percentage of enrollees who receive treatment with beta-blockers for six months (180 days) after discharge.

Adherence to Antipsychotic Medications for Individuals with Schizophrenia

This measure assessed the percentage of members 19-64 years of age during the measurement year with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period.

Non-Recommended Cervical Cancer Screening in Adolescent Females

This measure assessed the percentage of adolescent females 16-20 years to age who were screened unnecessarily for cervical cancer. For this measure, a lower rate indicates better performance.

Medication Management for People with Asthma - 75% Compliance

This measure assessed the percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period and remained on an asthma controller medication for at least 75% of their treatment period.

Cardiovascular Monitoring For People With Cardiovascular Disease and Schizophrenia

This measure assessed the percentage of members 18–64 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test during the measurement year.

Statin Therapy for Patients With Diabetes (New for 2016)

This measure assessed the percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met either of the following criteria: • Received Statin Therapy. Members who were dispensed at least one statin medication of any intensity during

the measurement year. • Statin Adherence 80%. Members who remained on a statin medication of any intensity for at least 80% of the

treatment period.

Statin Therapy for Patients With Cardiovascular Disease (New for 2016)

This measure assessed the percentage of males 21–75 years of age and females 40–75 years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met either of the following criteria: • Received Statin Therapy. Members who were dispensed at least one high or moderate-intensity statin

medication during the measurement year. • Statin Adherence 80%. Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period.


Use of Multiple Concurrent Antipsychotics in Children and Adolescents (New for 2016)

This measure assessed the percentage of children and adolescents 1–17 years of age who were on two or more concurrent antipsychotic medications.

For the Use of Multiple Concurrent Antipsychotics in Children and Adolescents measure, lower rates indicate better performance.

Metabolic Monitoring for Children and Adolescents on Antipsychotics (New for 2016)

This measure assessed the percentage of children and adolescents 1–17 years of age who had two or more antipsychotic prescriptions and had metabolic testing.

CAHPS® Survey

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is overseen by the Agency of Healthcare Research and Quality (AHRQ) and includes many survey products designed to capture consumer and patient perspectives on health care quality. NCQA uses the adult and child versions of the CAHPS Health Plan Surveys for HEDIS.

Implementation of PA-Specific Performance Measures and HEDIS Audit

The MCO successfully implemented all of the PA-specific measures for 2016 that were reported with MCO-submitted data. The MCO submitted all required source code and data for review. IPRO reviewed the source code and validated raw data submitted by the MCO. All rates submitted by the MCO were reportable. Rate calculations were collected via rate sheets and reviewed for all of the PA-specific measures. As previously indicated, for three PA Birth-related performance measures IPRO utilized the MCO Birth files in addition to the 2015 Department of Health Birth File to identify the denominator, numerator and rate for the Birth-related measures.

IPRO validated the medical record abstraction of the three PA-specific hybrid measures consistent with the protocol used for a HEDIS audit. The validation process includes a MRR process evaluation and review of the MCO’s MRR tools and instruction materials. This review ensures that the MCO’s MRR process was executed as planned and the abstraction results are accurate. A random sample of 16 records from each selected indicator across the three measures was evaluated. The indicators were selected for validation based on preliminary rates observed upon the MCO’s completion of abstraction. The MCO passed MRR Validation for the Prenatal Screening for Smoking and Treatment Discussion during a Prenatal Visit, the Perinatal Depression Screening, and the Maternity Risk Factor Assessment measures.

The Dental Sealants for 6-9 Year Old Children at Elevated Caries Risk (SEAL-CH) measure was new in 2016, and several issues were discovered during the validation process for the 2016 PA-specific Performance measures . IPRO held several meetings with each MCO to address their issues and answer questions regarding the data requirements. A number of the MCOs initially indicated that they did not capture particular dental data elements (tooth number and provider taxonomy codes). However, IPRO observed these elements were typically populated in the Medicaid PROMISe dental encounter data that IPRO received from DHS for the MCOs, and noted that it appears that the MCOs typically receive these data elements along with other dental data from their dental vendors, as they may be required for claims. IPRO advised the MCOs that they may need additional steps to pull the provider taxonomy data elements from the data repository used for encounter data, because the provider taxonomy codes may not be pulled and included on the data repository used to calculate the measures. IPRO requested that the MCOs provide documentation regarding this process, and quality check procedures along with source code for the measure for validation. Additionally, a number of MCOs appeared to have notably fewer numerator hits (application of the sealant on the correct tooth number by the CMS-defined provider). Upon inquiry, many MCOs indicated that in addition to some difficulty with identifying or mapping the correct taxonomy code, they were observing that sealants were being applied by providers other than those identified by the CMS-defined taxonomy codes (e.g., by a PCP). MCOs were reminded to follow the specifications for the measure, but that implementation issues would be noted. All MCOs that had the issue of missing data elements


successfully submitted the requested documentation and passed validation for the measure. Feedback received from MCOs regarding the 2016 implementation has been highlighted for discussion of potential modifications to the measure specifications for the 2017 validation process.

For the 2016 Reducing Potentially Preventable Readmissions (RPR) measure, the validation process was enhanced to include comparative analyses of RPR and IPU for all MCOs. As noted in 2015, there were additional data validation issues for a number of MCOs, which required additional analysis of their data to achieve resolution and produce reportable rates. As this measure uses components of the HEDIS Inpatient Utilization (IPU) measure, IPU is a useful comparative measure to evaluate internal consistency of reporting at the MCO, allowing for some differences in criteria. As was done in 2015 to resolve issues for a subset of MCOs, IPRO conducted comparative analyses of RPR and IPU for all MCOs in 2016.

During the timeframe to collect records for the 2016 PA-specific Performance measures, following the MCO’s confirmation of Race/Ethnicity values, it was discovered that the Ethnicity value for Hispanic in their submitted files was incorrect. GH advised that they identified a mapping issue and were working to resolve the issue. To resolve the issue, IPRO advised GH to resubmit all HEDIS 2016 Member Level Data Files with corrected Ethnicity value, and correct the Ethnicity field for the data files for PA Performance Measures that already have been validated and finalized at the time. For PA Performance Measures that had not been finalized or submitted yet, GH was instructed to correct the Ethnicity issue as part of running/re-running the file and submit as applicable for validation. GH provided the requested files with correct Ethnicity value to pass the validation.

The MCO successfully completed the HEDIS audit. The MCO received an Audit Designation of Report for all applicable measures.

Findings

MCO results are presented in Tables 3.2 through 3.11. For each measure, the denominator, numerator, and measurement year rates with 95% upper and lower confidence intervals (95% CI) are presented. Confidence intervals are ranges of values that can be used to illustrate the variability associated with a given calculation. For any rate, a 95% confidence interval indicates that there is a 95% probability that the calculated rate, if it were measured repeatedly, would fall within the range of values presented for that rate. All other things being equal, if any given rate were calculated 100 times, the calculated rate would fall within the confidence interval 95 times, or 95% of the time.

Rates for both the measurement year and the previous year are presented, as available [i.e., 2016 (MY 2015) and 2015 (MY 2014)]. In addition, statistical comparisons are made between the 2016 and 2015 rates. For these year-to-year comparisons, the significance of the difference between two independent proportions was determined by calculating the z-ratio. A z-ratio is a statistical measure that quantifies the difference between two percentages when they come from two separate populations. For comparison of 2016 rates to 2015 rates, statistically significant increases are indicated by “+”, statistically significant decreases by “–” and no statistically significant change by “n.s.”.

In addition to each individual MCO’s rate, the MMC average for 2016 (MY 2015) is presented. The MMC average is a weighted average, which is an average that takes into account the proportional relevance of each MCO. Each table also presents the significance of difference between the plan’s measurement year rate and the MMC average for the same year. For comparison of 2016 rates to MMC rates, the “+” symbol denotes that the plan rate exceeds the MMC rate; the “–” symbol denotes that the MMC rate exceeds the plan rate and “n.s.” denotes no statistically significant difference between the two rates. Rates for the HEDIS measures were compared to corresponding Medicaid percentiles; comparison results are provided in the tables. The 90th percentile is the benchmark for the HEDIS measures.

Note that the large denominator sizes for many of the analyses led to increased statistical power, and thus contributed to detecting statistical differences that are not clinically meaningful. For example, even a 1-percentage point difference between two rates was statistically significant in many cases, although not meaningful. Hence, results corresponding to each table highlight only differences that are both statistically significant, and display at least a 3-percentage point difference in observed rates. It should also be mentioned that when the denominator sizes are small, even relatively


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Table 3.2: Access to Care 2016 (MY 2015) 2016 (MY 2015) Rate Comparison

Indicator Source Indicator Denom Num Rate

Lower 95% Confidence

Limit

Upper 95% Confidence

Limit

2015 (MY2014)

Rate

2016 Rate Compared

to 2015 MMC

2016 Rate Compared

to MMC

HEDIS 2016 Percentile

HEDIS Children and Adolescents Access to PCPs (Age 12 24 Months) 8,280 8,056 97.3% 96.9% 97.7% 96.3% + 96.8% + ≥ 75th and <

90th percentile

HEDIS Children and Adolescents Access to PCPs (Age 25 Months 6 Years) 36,993 32,531 87.9% 87.6% 88.3% 88.5% - 89.0% - ≥ 50th and <

75th percentile

HEDIS Children and Adolescents Access to PCPs (Age 7 11 Years) 31,318 28,726 91.7% 91.4% 92.0% 91.9% n.s. 92.8% - ≥ 50th and <

75th percentile

HEDIS Children and Adolescents Access to PCPs (Age 12 19 Years) 42,768 38,551 90.1% 89.9% 90.4% 90.4% n.s. 91.4% - ≥ 50th and <

75th percentile

HEDIS Adults Access to Preventive/ Ambulatory Health Services (Age 20 44 Years) 57,441 47,218 82.2% 81.9% 82.5% 83.7% - 81.8% + ≥ 50th and <

75th percentile

HEDIS Adults’ Access to Preventive/ Ambulatory Health Services (Age 45 64 Years) 25,787 23,302 90.4% 90.0% 90.7% 91.5% - 90.4% n.s. ≥ 75th and <

90th percentile

HEDIS Adults Access to Preventive/ Ambulatory Health Services (Age 65+ Years) 588 514 87.4% 84.6% 90.2% 91.7% - 85.7% n.s. ≥ 50th and <

75th percentile

HEDIS Adult BMI Assessment (Ages 18 74 Years) 432 309 71.5% 67.2% 75.9% 83.2% - 86.1% - ≥ 10th and < 25th percentile

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Table 3.3: Well-Care Visits and Immunizations 2016 (MY 2015) 2016 (MY 2015) Rate Comparison



Limit


Limit

2015 (MY2014)

Rate

2016 Rate Compared

to 2015 MMC

2016 Rate Compared

to MMC


HEDIS Well Child Visits in the First 15 Months of Life (≥ 6 Visits) 432 308 71.3% 66.9% 75.7% NA NA 69.5% n.s. ≥ 75th and <

90th percentile

HEDIS Well Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (Age 3 to 6 Years)

432 320 74.1% 69.8% 78.3% NA NA 75.8% n.s. ≥ 50th and < 75th percentile

large differences in rates may not yield statistical significance due to reduced power; if statistical significance is not achieved, results will not be highlighted in the report. Differences are also not discussed if the denominator was less than 30 for a particular rate, in which case, “NA” (Not Applicable) appears in the corresponding cells. However, “NA” (Not Available) also appears in the cells under the HEDIS 2016 percentile column for PA-specific measures that do not have HEDIS percentiles to compare.

The tables below show rates up to one decimal place. Calculations to determine differences between rates are based upon unrounded rates. Due to rounding, differences in rates that are reported in the narrative may differ slightly from the difference between the rates as presented in the table.

Access to/Availability of Care

There were no strengths identified for the 2016 (MY 2015) Access/Availability of Care performance measures.

One opportunity for improvement was identified for the 2016 (MY 2015) Access/Availability of Care performance measures: • GH’s 2016 rate for the Adult BMI Assessment (Age 18-74 years) measure was statistically significantly below the

2016 MMC weighted average by 14.5 percentage points.

Well-Care Visits and Immunizations

There were no strengths identified for the 2016 (MY 2015) Well-Care Visits and Immunizations performance measures.

The following 2016 Well-Care Visits and Immunizations performance measure opportunities for improvement were identified: • In 2016, six rates for GH were statistically significantly below the respective 2016 MMC weighted averages.

o Childhood Immunizations Status (Combination 2) – 6.9 percentage points o Childhood Immunizations Status (Combination 3) – 6.6 percentage points o Body Mass Index: Percentile (Age 3 - 11 years) – 10.1 percentage points o Body Mass Index: Percentile (Age 12-17 years) – 11.3 percentage points o Body Mass Index: Percentile (Total) – 10.6 percentage points o Counseling for Nutrition (Total) – 5.4 percentage points


2016 (MY 2015) 2016 (MY 2015) Rate Comparison Lower 95% Upper 95% 2015 2016 Rate 2016 Rate Indicator HEDIS 2016 Indicator Denom Num Rate Confidence Confidence (MY2014) Compared MMC Compared Source Percentile Limit Limit Rate to 2015 to MMC

≥ 50th and < HEDIS Lead Screening in Children 432 336 77.8% 73.7% 81.8% 77.9% n.s. 81.0% n.s. 75th percentile -Follow up Care for Children Prescribed HEDIS 2,649 656 24.8% 23.1% 26.4% 23.8% n.s. 30.8% - <10th percentile ADHD Medication – Initiation Phase -Follow up Care for Children Prescribed

HEDIS ADHD Medication – Continuation 858 227 26.5% 23.4% 29.5% 20.8% + 37.4% - <10th percentile Phase -Follow up Care for Children Prescribed

PA EQR ADHD Medication (BH Enhanced) – 2,649 697 26.3% 24.6% 28.0% 25.4% n.s. 31.9% - NA Initiation Phase

-Follow up Care for Children Prescribed PA EQR ADHD Medication (BH Enhanced) – 814 246 30.2% 27.0% 33.4% 26.1% n.s. 41.8% - NA

Continuation Phase Developmental Screening in the First PA EQR 20,238 9,451 46.7% 46.0% 47.4% 47.2% n.s. 51.1% - NA Three Years of Life – Total


Childhood Immunization Status ≥ 25th and < HEDIS 432 306 70.8% 66.4% 75.2% 73.5% n.s. 77.8% - (Combination 2) 50th percentile Childhood Immunization Status ≥ 25th and < HEDIS 432 296 68.5% 64.0% 73.0% 70.8% n.s. 75.1% - (Combination 3) 50th percentile

- Adolescent Well Care Visits ≥ 50th and < HEDIS 432 244 56.5% 51.7% 61.3% 58.2% n.s. 55.7% n.s. (Age 12 to 21 Years) 75th percentile WCC Body Mass Index: Percentile ≥ 25th and < HEDIS 281 169 60.1% 54.2% 66.0% 62.6% n.s. 70.3% --(Age 3 11 Years) 50th percentile WCC Body Mass Index: Percentile ≥ 25th and < HEDIS 151 90 59.6% 51.4% 67.8% 64.9% n.s. 70.9% -- (Age 12 17 Years) 50th percentile WCC Body Mass Index: Percentile ≥ 25th and < HEDIS 432 259 60.0% 55.2% 64.7% 63.5% n.s. 70.5% - (Total) 50th percentile

WCC Counseling for Nutrition ≥ 50th and < HEDIS 281 187 66.5% 60.9% 72.2% 71.2% n.s. 70.7% n.s. -(Age 3 11 Years) 75th percentile WCC Counseling for Nutrition ≥ 25th and < HEDIS 151 86 57.0% 48.7% 65.2% 65.6% n.s. 64.2% n.s. - (Age 12 17 Years) 50th percentile WCC Counseling for Nutrition ≥ 50th and < HEDIS 432 273 63.2% 58.5% 67.9% 69.1% n.s. 68.6% - (Total) 75th percentile

WCC Counseling for Physical Activity ≥ 50th and < HEDIS 281 166 59.1% 53.1% 65.0% 64.6% n.s. 61.0% n.s. -(Age 3 11 Years) 75th percentile WCC Counseling for Physical Activity ≥ 50th and < HEDIS 151 86 57.0% 48.7% 65.2% 66.2% n.s. 62.4% n.s. - (Age 12 17 Years) 75th percentile

WCC Counseling for Physical Activity ≥ 50th and < HEDIS 432 252 58.3% 53.6% 63.1% 65.2% - 61.6% n.s. (Total) 75th percentile Immunizations for Adolescents ≥ 75th and < HEDIS 432 360 83.3% 79.7% 87.0% 83.0% n.s. 84.3% n.s. (Combination 1) 90th percentile

EPSDT: Screenings and Follow-up

There were no strengths noted for EPSDT: Screenings and Follow-up performance measures for 2016 (MY 2015).

The following opportunities for improvement were identified for 2016 (MY 2015) for EPSDT: Screenings and Follow-up performance measures: • GH’s rates for the following seven EPSDT Screenings and Follow-up measures were statistically significantly

below the 2016 MMC weighted averages: o Follow-up Care for Children Prescribed ADHD Medication (Initiation Phase) – 6.1 percentage points o Follow-up Care for Children Prescribed ADHD Medication (Continuation Phase) – 11.0 percentage points o Follow-up Care for Children Prescribed ADHD Medication - BH Enhanced (Initiation Phase) – 5.6 percentage

points o Follow-up Care for Children Prescribed ADHD Medication - BH Enhanced (Continuation Phase) – 11.6

percentage points o Developmental Screening in the First Three Years of Life (Total) – 4.4 percentage points o Developmental Screening in the First Three Years of Life (1 year) – 5.5 percentage points o Developmental Screening in the First Three Years of Life (2 years) – 5.4 percentage points

Table 3.4: EPSDT: Screenings and Follow-up

Developmental Screening in the First PA EQR 6,660 2,741 41.2% 40.0% 42.3% 42.8% - 46.6% - NA Three Years of Life - 1 year Developmental Screening in the First PA EQR 6,761 3,310 49.0% 47.8% 50.2% 50.3% n.s. 54.4% - NA Three Years of Life - 2 years Developmental Screening in the First PA EQR 6,817 3,400 49.9% 48.7% 51.1% 50.1% n.s. 52.4% - NA Three Years of Life - 3 years

Table 3.5: EPSDT: Dental Care for Children and Adults 2016 (MY 2015) 2016 (MY 2015) Rate Comparison

Indicator Source

HEDIS

Indicator Denom Num Rate Lower 95%

Confidence Limit

Upper 95% onfidence C

Limit

2015 (MY2014)

Rate

2016 Rate Compared

to 2015 MMC

2016 Rate ompared C

to MMC


–Annual Dental Visit (Age 2 20 years) 131,977 73,589 55.8% 55.5% 56.0% NA NA 59.9% - ≥ 50th and < i75th percent le

PA EQR

PA EQR

PA EQR

PA EQR

PA EQR

PA EQR

PA EQR

PA EQR

PA EQR

PA EQR

PA EQR

Supplemental Annual Dental Visit -(Age 2 3 years)1 14,883 5,984 40.2% 39.4% 41.0% 30.6% + 45.0% - NA

Supplemental Annual Dental Visit -(Age 4 6 years)1 22,719 14,431 63.5% 62.9% 64.1% 60.9% + 67.8% - NA

Supplemental Annual Dental Visit - (Age 7 10 years)1 30,429 19,074 62.7% 62.1% 63.2% 62.1% n.s. 68.0% - NA

Supplemental Annual Dental Visit - (Age 11 14 years)1 28,802 16,837 58.5% 57.9% 59.0% 58.5% n.s. 63.5% - NA

Supplemental Annual Dental Visit - (Age 15 18 years)1 25,806 13,668 53.0% 52.4% 53.6% 51.9% + 55.4% - NA

Supplemental Annual Dental Visit - (Age 19 20 years)1 9,338 3,595 38.5% 37.5% 39.5% NA NA 40.0% - NA

Supplemental Annual Dental Visit - (Age 20 21 years)1 3,553 1,268 35.7% 34.1% 37.3% NA NA 38.5% - NA

Supplemental Annual Dental Visit -(Total Age 2 21 years)1 135,530 74,857 55.2% 55.0% 55.5% 53.7% + 59.4% - NA

Annual Dental Visits for Members with Developmental Disabilities

-(Age 2 21 years) 11,514 5,544 48.2% 47.2% 49.1% 47.8% n.s. 55.7% - NA

-Dental Sealants for 6 9 Year Of Children At Elevated Caries Risk 16,562 3,959 23.9% 23.3% 24.6% NA NA 24.7% - NA

-Dental Sealants for 6 9 Year Of Children At Elevated Caries Risk (BH

Enhanced) 17,356 3,966 22.9% 22.2% 23.5% NA NA 19.3% + NA

Dental Care for Children and Adults

One strength was noted for Dental Care for Children and Adults performance measures for 2016 (MY 2015). • GH’s 2016 rate for the Dental Sealants for 6-9 Year Of Children At Elevated Caries Risk (BH Enhanced) measure

was statistically significantly above the 2016 MMC weighted average by 3.5 percentage points.

The following opportunities for improvement were identified for 2016 (MY 2015) for the 2016 Dental Care for Children and Adults performance measures: • GH’s rates for the following seven Dental Care for Children and Adults measures were statistically significantly

below the 2016 MMC weighted averages: o Annual Dental Visit (Age 2–20 years) – 4.1 percentage points o Supplemental Annual Dental Visit (Age 2-3 years) – 4.7 percentage points o Supplemental Annual Dental Visit (Age 4-6 years) – 4.3 percentage points o Supplemental Annual Dental Visit (Age 7-10 years) – 5.3 percentage points o Supplemental Annual Dental Visit (Age 11-14 years) – 5.0 percentage points o Supplemental Annual Dental Visit (Total Age 2-21 years) – 4.1 percentage points o Annual Dental Visits for Members with Developmental Disabilities (Age 2-21 years) – 7.6 percentage points

1 Supplemental Annual Dental Visit is the enhancement of the HEDIS 2016 Annual Dental Visit (ADV) measure. In 2015 NCQA revised the upper age limit from 21 years of age to 20 years of age. DHS enhanced the ADV measure and requested the MCOs to submit the measure for age cohort 2-21 years as of December of the measurement year 2015.

Women’s Health

There were no strengths identified for the 2016 (MY 2015) Women’s Health performance measures.


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Table 3.6: Women’s Health 2016 (MY 2015) 2016 (MY 2015) Rate Comparison



Limit


Limit

2015 (MY2014)

Rate

2016 Rate Compared

to 2015 MMC

2016 Rate Compared

to MMC


HEDIS Breast Cancer Screening (Age 52 74 Years) 6,757 3,637 53.8% 52.6% 55.0% 55.2% n.s. 60.8% - ≥ 25th and <

50th percentile

HEDIS Cervical Cancer Screening 427 247 57.8% 53.0% 62.6% 63.5% n.s. 62.8% - ≥ 50th and < 75th percentile

HEDIS Chlamydia Screening in Women (Total) 13,402 7,098 53.0% 52.1% 53.8% 54.7% - 58.6% - ≥ 25th and < 50th percentile

HEDIS Chlamydia Screening in Women (Age 16 20 Years) 7,875 3,868 49.1% 48.0% 50.2% 50.8% - 55.2% - ≥ 25th and <

50th percentile

HEDIS Chlamydia Screening in Women (Age 21 24 Years) 5,527 3,230 58.4% 57.1% 59.7% 61.5% - 63.2% - ≥ 25th and <

50th percentile

HEDIS Human Papillomavirus Vaccine for Female Adolescents 432 112 25.9% 21.7% 30.2% 31.6% n.s. 27.3% n.s. ≥ 50th and <

75th percentile

HEDIS Non Recommended Cervical Cancer Screening in Adolescent Females1 13,946 250 1.8% 1.6% 2.0% 2.7% - 1.7% n.s. ≥ 50th and <

75th percentile

The following opportunities for improvement were identified for the Women’s Health performance measures for 2016 (MY 2015): • In 2016, GH’s rates were statistically significantly below the 2016 MMC weighted averages for the following five

measures: o Breast Cancer Screening (Age 52-74 years) – 7.0 percentage points o Cervical Cancer Screening – 5.0 percentage points o Chlamydia Screening in Women (Total) – 5.7 percentage points o Chlamydia Screening in Women (Age 16-20 years) – 6.1 percentage points o Chlamydia Screening in Women (Age 21-24 years) – 4.8 percentage points

1 For the Non-Recommended Cervical Cancer Screening in Adolescent Females measure, lower rate indicates better performance

Obstetric and Neonatal Care

One strength was identified for Obstetric and Neonatal Care performance measures for 2016 (MY 2015). • GH’s 2016 rate for the Prenatal Screening Positive for Depression measure was statistically significantly above

the 2016 MMC weighted average by 10.5 percentage points.

The following opportunities for improvement for GH were identified among the 2016 Obstetric and Neonatal Care performance measures: • In 2016, GH’s rates were statistically significantly lower than the respective 2016 MMC weighted averages for

the following fifteen measures: o ≥ 61% of Expected Prenatal Care Visits Received – 6.0 percentage points o ≥ 81% of Expected Prenatal Care Visits Received – 6.5 percentage points o Prenatal and Postpartum Care – Timeliness of Prenatal Care – 8.4 percentage points o Prenatal and Postpartum Care – Postpartum Care – 15.9 percentage points o Prenatal Screening for Smoking – 24.6 percentage points o Prenatal Screening for Smoking during one of the first two visits (CHIPRA indicator) – 24.1 percentage points o Prenatal Screening for Environmental Tobacco Smoke Exposure – 14.3 percentage points o Prenatal Screening for Depression – 39.7 percentage points o Prenatal Screening for Depression during one of the first two visits (CHIPRA indicator) – 39.4 percentage

points o Postpartum Screening for Depression – 22.6 percentage points o Prenatal Screening for Alcohol use – 25.9 percentage points o Prenatal Screening for Illicit drug use – 28.6 percentage points o Prenatal Screening for Prescribed or over-the-counter drug use – 30.5 percentage points o Prenatal Screening for Intimate partner violence – 26.1 percentage points o Prenatal Screening for Behavioral Health Risk Assessment – 28.7 percentage points


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Table 3.7: Obstetric and Neonatal Care 2016 (MY 2015) 2016 (MY 2015) Rate Comparison



Limit


Limit

2015 (MY2014)

Rate

2016 Rate Compared

to 2015 MMC

2016 Rate Compared

to MMC


HEDIS ≥61% of Expected Prenatal Care Visits Received 432 340 78.7% 74.7% 82.7% 76.2% n.s. 84.7% - NA

HEDIS ≥81% of Expected Prenatal Care Visits Received 432 281 65.0% 60.4% 69.7% 55.2% + 71.5% - ≥ 50th and <

75th percentile

HEDIS Prenatal and Postpartum Care Timeliness of Prenatal Care 432 339 78.5% 74.5% 82.5% 80.0% n.s. 86.9% - ≥ 25th and <

50th percentile

HEDIS Prenatal and Postpartum Care Postpartum Care 432 208 48.1% 43.3% 53.0% 52.3% n.s. 64.1% - < 10th

percentile PA EQR Prenatal Screening for Smoking 383 220 57.4% 52.4% 62.5% 87.5% - 82.1% - NA

PA EQR Prenatal Screening for Smoking during one of the first two visits (CHIPRA indicator)

383 215 56.1% 51.0% 61.2% 87.5% - 80.2% - NA

PA EQR Prenatal Screening for Environmental Tobacco Smoke Exposure 383 79 20.6% 16.4% 24.8% 21.1% n.s. 34.9% - NA

PA EQR Prenatal Counseling for Smoking 68 58 85.3% 76.1% 94.4% 75.7% n.s. 83.0% n.s. NA

PA EQR Prenatal Counseling for Environmental Tobacco Smoke Exposure 30 14 46.7% 27.1% 66.2% NA NA 64.1% n.s. NA

PA EQR Prenatal Smoking Cessation 67 12 17.9% 8.0% 27.8% 6.1% + 13.6% n.s. NA

PA EQR Prenatal Screening for Depression 383 104 27.2% 22.6% 31.7% 52.4% - 66.8% - NA

PA EQR Prenatal Screening for Depression during one of the first two visits (CHIPRA indicator)

383 81 21.1% 16.9% 25.4% 40.2% - 60.6% - NA

PA EQR Prenatal Screening Positive for Depression 104 29 27.9% 18.8% 37.0% 17.0% + 17.4% + NA

PA EQR Prenatal Counseling for Depression 29 24 NA NA NA 66.7% NA 79.9% NA NA

PA EQR Postpartum Screening for Depression 252 115 45.6% 39.3% 52.0% 78.1% - 68.3% - NA

PA EQR Postpartum Screening Positive for Depression 115 18 15.7% 8.6% 22.7% 15.2% n.s. 14.1% n.s. NA

PA EQR Postpartum Counseling for Depression 18 13 NA NA NA NA NA 86.2% NA NA

PA EQR Cesarean Rate for Nulliparous Singleton Vertex1 1,671 401 24.0% 21.9% 26.1% 22.4% n.s. 22.8% n.s. NA

PA EQR Percent of Live Births Weighing Less than 2,500 Grams (Positive)1 7,410 704 9.5% 8.8% 10.2% 9.5% n.s. 9.2% n.s. NA

PA EQR Prenatal Screening for Alcohol use 383 203 53.0% 47.9% 58.1% 77.4% - 78.9% - NA

PA EQR Prenatal Screening for Illicit drug use 383 191 49.9% 44.7% 55.0% 74.7% - 78.5% - NA

PA EQR Prenatal Screening for Prescribed or over the counter drug use 383 186 48.6% 43.4% 53.7% 72.6% - 79.1% - NA

PA EQR Prenatal Screening for Intimate partner violence 383 93 24.3% 19.9% 28.7% 53.0% - 50.4% - NA

PA EQR Prenatal Screening for Behavioral Health Risk Assessment 383 29 7.6% 4.8% 10.4% 25.9% - 36.2% - NA

PA EQR Elective Delivery1 1,774 292 16.5% 14.7% 18.2% 11.7% + 15.1% n.s. NA

1 Lower rate indicates better performance for three measures that are related to live births: Cesarean Rate for Nulliparous Singleton Vertex, Percent of Live Births Weighing Less than 2,500 Grams (Positive), and Elective Delivery.

Respiratory Conditions

One strength was noted for the 2016 (MY 2015) Respiratory Conditions performance measures: • GH’s rate for the Asthma in Younger Adults Admission Rate (Age 18-39 years) measure was statistically

significantly below (better than) the MMC weighted average by 2.36 admissions per 100,000 member months.

One opportunity for improvement was identified for the 2016 (MY 2015) Respiratory Conditions performance measures: • GH’s 2016 rate for the Chronic Obstructive Pulmonary Disease or Asthma in Older Adults Admission Rate (Age

40+ years) measure was statistically significantly above (worse than) the 2016 MMC weighted average by 4.39 admissions per 100,000 member months.


2016 (MY 2015) 2016 (MY 2015) Rate Comparison

Lower 95% Upper 95% 2015 2016 Rate 2016 Rate Indicator HEDIS 2016 Indicator Denom Num Rate Confidence Confidence (MY2014) Compared MMC Compared Source Percentile Limit Limit Rate to 2015 to MMC Appropriate Testing for Children ≥ 25th and < 50th HEDIS 5,542 3,934 71.0% 69.8% 72.2% 70.1% n.s. 71.9% n.s. with Pharyngitis percentile Appropriate Treatment for Children ≥ 50th and < 75th HEDIS 1 12,996 1,288 90.1% 89.6% 90.6% 89.1% + 90.6% n.s.

with Upper Respiratory Inection percentile Avoidance of Antibiotic Treatment in ≥ 50th and < 75th HEDIS 2 2,124 1,559 26.6% 24.7% 28.5% 26.4% n.s. 25.5% n.s.

Adults with Acute Bronchitis percentile Use of Spirometry Testing in the ≥ 50th and < 75th HEDIS 821 260 31.7% 28.4% 34.9% 28.1% n.s. 31.8% n.s. Assessment and Diagnosis of COPD percentile

Pharmacotherapy Management of ≥ 50th and < 75th HEDIS COPD Exacerbation – Systemic 1,037 768 74.1% 71.3% 76.8% 74.2% n.s. 76.6% n.s. percentile Corticosteroid

Pharmacotherapy Management of ≥ 50th and < 75th HEDIS 1,037 893 86.1% 84.0% 88.3% 84.5% n.s. 87.5% n.s. COPD Exacerbation – Bronchodilator percentile Medication Management for People ≥ 75th and < 90th HEDIS with Asthma – 75% Compliance (Age 1,577 543 34.4% 32.1% 36.8% 31.6% n.s. 36.6% n.s. percentile

- 5 11 Years) Medication Management for People ≥ 75th and < 90th HEDIS with Asthma – 75% Compliance 1,238 423 34.2% 31.5% 36.9% 33.1% n.s. 35.9% n.s. percentile

- (Age 12 18 Years) Medication Management for People ≥ 75th and < 90th HEDIS with Asthma – 75% Compliance 1,217 527 43.3% 40.5% 46.1% 40.2% n.s. 45.2% n.s. percentile

- (Age 19 50 Years) Medication Management for People ≥ 75th and < 90th HEDIS with Asthma – 75% Compliance 386 218 56.5% 51.4% 61.6% 53.2% n.s. 57.2% n.s. percentile

- (Age 51 64 Years) Medication Management for People ≥ 75th and < 90th HEDIS with Asthma – 75% Compliance (Age 4,418 1,711 38.7% 37.3% 40.2% 36.1% + 40.7% - percentile

- 5 64 Years) Asthma in Younger Adults Admission

PA EQR - Rate (Age 18 39 years)3 per 100,000 1,098,345 113 10.29 8.39 12.19 10.17 n.s. 12.65 - NA member months

Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older

PA EQR 604,191 634 104.93 96.77 113.10 131.43 - 100.55 + NA Adults Admission Rate (40+ years)3

per 100,000 member months 1

2016 (MY 2015) 2016 (MY 2015) Rate Comparison

Lower 95% Upper 95% 2015 2016 Rate 2016 Rate Indicator HEDIS 2016 Indicator Denom Num Rate Confidence Confidence (MY2014) Compared MMC Compared Source Percentile Limit Limit Rate to 2015 to MMC ≥ 25th and < HEDIS Hemoglobin A1c (HbA1c) Testing 658 557 84.7% 81.8% 87.5% 85.6% n.s. 86.2% n.s. 50th percentile

≥ 25th and < HEDIS HbA1c Poor Control (>9.0%)1 658 322 48.9% 45.0% 52.8% 42.5% + 37.5% + 50th percentile

Table 3.8: Respiratory Conditions

Per NCQA, a higher rate indicates appropriate treatment of children with URI (i.e., the proportion for whom antibiotics were not prescribed). 2 Per NCQA, a higher rate indicates appropriate treatment of adults with acute bronchitis (i.e., the proportion for whom antibiotics were not prescribed).3 For the Adult Admission Rate measures, lower rates indicate better performance.

Comprehensive Diabetes Care

No strength was noted for the 2016 (MY 2015) Comprehensive Diabetes Care performance measures.

The following 2016 Comprehensive Diabetes Care performance measure opportunities for improvement were identified: • In 2016, GH’s rates were statistically significantly lower than the MMC weighted averages for the following three

measures: o HbA1c Control (<8.0%) – 10.2 percentage points o HbA1c Good Control (<7.0%) – 6.3 percentage points o Blood Pressure Controlled <140/90 mm Hg – 9.3 percentage points

• GH’s 2016 rate for the HbA1c Poor Control (>9.0%) measure was statistically significantly above (worse than) the 2016 MMC weighted average by 11.5 percentage points.

Table 3.9: Comprehensive Diabetes Care


≥ 25th and < HEDIS HbA1c Control (<8.0%) 658 269 40.9% 37.0% 44.7% 45.6% n.s. 51.1% - 50th percentile ≥ 25th and < HEDIS HbA1c Good Control (<7.0%) 444 139 31.3% 26.9% 35.7% 32.4% n.s. 37.6% - 50th percentile ≥ 50th and < HEDIS Retinal Eye Exam 658 393 59.7% 55.9% 63.5% 54.7% n.s. 59.2% n.s. 75th percentile ≥ 25th and < HEDIS Medical Attention for Nephropathy 658 593 90.1% 87.8% 92.5% 82.1% + 90.0% n.s. 50th percentile

Blood Pressure Controlled <140/90 mm ≥ 25th and < HEDIS 658 380 57.8% 53.9% 61.6% 66.4% - 67.1% -Hg 50th percentile - Diabetes Short Term Complications 2 PA EQR Admission Rate - (Age 18 64 Years) 1,692,813 394 23.27 20.98 25.57 28.79 - 22.63 n.s. NA

per 100,000 member months - Diabetes Short Term Complications 2 PA EQR Admission Rate (Age 65+ Years) per 9,723 1 10.28 0.00 30.44 0.00 n.s. 8.18 n.s. NA

100,000 member months - Diabetes Short Term Complications 2 PA EQR Admission Rate (Total Age 18+ 1,702,536 395 23.20 20.91 25.49 28.55 - 22.52 n.s. NA

Years) per 100,000 member months Statin Therapy for Patients With HEDIS 4,103 2,576 62.8% 61.3% 64.3% NA NA 62.8% n.s. NA Diabetes: Received Statin Therapy Statin Therapy for Patients With HEDIS 2,576 1,693 65.7% 63.9% 67.6% NA NA 67.7% - NA Diabetes: Statin Adherence 80%

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Table 3.10: Cardiovascular Care 2016 (MY 2015) 2016 (MY 2015) Rate Comparison



Limit


Limit

2015 (MY2014)

Rate

2016 Rate Compared

to 2015 MMC

2016 Rate Compared

to MMC


HEDIS Persistence of Beta Blocker Treatment After Heart Attack 123 109 88.6% 82.6% 94.6% 89.92% n.s. 90.9% n.s. ≥ 75th and <

90th percentile

HEDIS Controlling High Blood Pressure (Total Rate) 411 140 34.1% 29.4% 38.8% 50.12% - 61.0% - < 10th percentile

PA EQR Heart Failure Admission Rate1 (Age 18 64 Years) per 100,000 member months

1,692,813 258 15.24 13.38 17.10 20.18 - 18.53 - NA

PA EQR Heart Failure Admission Rate1 (Age 65+ Years) per 100,000 member months

9,723 10 102.85 39.10 166.60 136.80 n.s. 77.15 n.s. NA

PA EQR Heart Failure Admission Rate1 (Total Age 18+ Years) per 100,000 member months

1,702,536 268 15.74 13.86 17.63 21.14 - 18.99 - NA

HEDIS Statin Therapy for Patients With Cardiovascular Disease: Received Statin Therapy 21 75 years (Male)

697 528 75.8% 72.5% 79.0% NA NA 76.1% n.s. NA

1 For HbA1c Poor Control, lower rates indicate better performance. 2 For the Adult Admission Rate measures, lower rates indicate better performance

Cardiovascular Care

Two strengths were identified for Cardiovascular Care performance measures for 2016 (MY 2015). • In 2016, GH’s rates were statistically significantly below (better than) the MMC weighted averages for the

following measures: o Heart Failure Admission Rate (Age 18-64 years) – 3.29 admissions per 100,000 member months o Heart Failure Admission Rate (Total Age 18+ years) – 3.25 admissions per 100,000 member months

The following 2016 Cardiovascular Care performance measure opportunities for improvement were identified: • In 2016, GH’s rates were statistically significantly lower than the MMC weighted averages for the following four

measures: o Controlling High Blood Pressure (Total Rate) – 27.0 percentage points o Statin Therapy for Patients With Cardiovascular Disease: Statin Adherence 80% (Male 21-75 years) – 6.3

percentage points o Statin Therapy for Patients With Cardiovascular Disease: Statin Adherence 80% (Female 40-75 years) – 8.8

percentage points o Statin Therapy for Patients With Cardiovascular Disease: Statin Adherence 80% (Total Rate) – 7.3 percentage

points


Statin Therapy for Patients With HEDIS Cardiovascular Disease: Received 539 408 75.7% 72.0% 79.4% NA NA 74.4% n.s. NA

- Statin Therapy 40 75 years (Female) Statin Therapy for Patients With

HEDIS Cardiovascular Disease: Received 1,236 936 75.7% 73.3% 78.2% NA NA 75.3% n.s. NA Statin Therapy Total Rate

Statin Therapy for Patients With HEDIS Cardiovascular Disease: Statin 528 381 72.2% 68.2% 76.1% NA NA 78.5% - NA

Adherence 80% - - 21 75 years (Male) Statin Therapy for Patients With

HEDIS Cardiovascular Disease: Statin 408 273 66.9% 62.2% 71.6% NA NA 75.7% - NA Adherence 80% - - 40 75 years (Female)

Statin Therapy for Patients With HEDIS Cardiovascular Disease: Statin 936 654 69.9% 66.9% 72.9% NA NA 77.2% - NA

Adherence 80% - Total Rate Cardiovascular Monitoring For People

HEDIS With Cardiovascular Disease and 39 34 87.2% 75.4% 99.0% 75.00% n.s. 78.2% n.s. NA Schizophrenia

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Table 3.11: Utilization 2016 (MY 2015) 2016 (MY 2015) Rate Comparison



Limit


Limit

2015 (MY2014)

Rate

2016 Rate Compared

to 2015 MMC

2016 Rate Compared

to MMC


PA EQR Reducing Potentially Preventable Readmissions1 20,301 2,009 9.9% 9.5% 10.3% 8.34% + 10.17% n.s. NA

HEDIS Adherence to Antipsychotic Medications for Individuals with Schizophrenia 772 516 66.8% 63.5% 70.2% 67.98% n.s. 70.46% - ≥ 75th and <

90th percentile

PA EQR Adherence to Antipsychotic Medications for Individuals with Schizophrenia (BH Enhanced)

2,182 1,556 71.3% 69.4% 73.2% 72.31% n.s. 69.43% n.s. NA

HEDIS Use of Multiple Concurrent Antipsychotics in Children and Adolescents2: Ages 1 5 years

17 0 NA NA NA NA NA 1.49% NA NA


1,109 8 0.7% 0.2% 1.3% NA NA 0.85% n.s. ≥ 50th and < 75th percentile



HEDIS Use of Multiple Concurrent Antipsychotics in Children and Adolescents2: Total Rate


HEDIS Metabolic Monitoring for Children and Adolescents on Antipsychotics: Ages 1

5 years 31 7 22.6% 6.2% 38.9% NA NA 29.76% n.s. ≥ 75th and <

90th percentile

HEDIS Metabolic Monitoring for Children and Adolescents on Antipsychotics: Ages 6

11 years 1,311 473 36.1% 33.4% 38.7% NA NA 37.52% n.s. ≥ 75th and <

90th percentile

HEDIS Metabolic Monitoring for Children and Adolescents on Antipsychotics: Ages 12 17 years


HEDIS Metabolic Monitoring for Children and Adolescents on Antipsychotics: Total Rate

3,719 1,395 37.5% 35.9% 39.1% NA NA 38.96% n.s. ≥ 75th and < 90th percentile

1 For the Adult Admission Rate measures, lower rates indicate better performance

Utilization

There were no strengths noted for GH’s 2016 (MY 2015) Utilization performance measures.

One opportunity for improvement was identified for the 2016 (MY 2015) Utilization performance measures: • GH’s 2016 rate for the Adherence to Antipsychotic Medications for Individuals with Schizophrenia measure was

statistically significantly below the 2016 MMC weighted average by 3.6 percentage points.

1 For the Reducing Potentially Preventable Readmissions measure, lower rates indicate better performance. 2 For the Use of Multiple Concurrent Antipsychotics in Children and Adolescents measure, lower rates indicate better performance.


Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey

Satisfaction with the Experience of Care

The following tables provide the survey results of four composite questions by two specific categories for GH across the last three measurement years, as available. The composite questions will target the MCOs performance strengths as well as opportunities for improvement.

Due to differences in the CAHPS submissions from year to year, direct comparisons of results are not always available. Questions that are not included in the most recent survey version are not presented in the tables.

2016 Adult CAHPS 5.0H Survey Results

Table 4.1: CAHPS 2016 Adult Survey Results Survey Section/Measure 2016 Rate 2015 Rate 2016 MMC 2016 2015 2014 Compared to Compared to Weighted (MY 2015) (MY 2014) (MY 2013) 2015 2014 Your Health Plan Average

77.46% 73.91% Satisfaction with Adult’s Health Plan (Rating of 8 to 10) ▲ 76.83% ▲ 78.31%

Getting Needed Information (Usually or Always) 88.15% ▲ 80.34% ▼ 81.82% 84.26%

Your Healthcare in the Last Six Months Satisfaction with Health Care (Rating of 810) 73.67% ▲ 73.52% ▲ 71.15% 74.95%

Appointment for Routine Care When Needed (Usually or Always) 83.02% ▲ 81.45% ▼ 81.67% 79.45%

▲▼ = Performance compared to prior years’ rate Shaded boxes reflect rates above the 2016 MMC Weighted Average.

2016 Child CAHPS 5.0H Survey Results

Table 4.2: CAHPS 2016 Child Survey Results CAHPS Items 2016 Rate 2015 Rate 2016 MMC 2016 2015 2014 Compared Compared to Weighted (MY 2015) (MY 2014) (MY 2013) to 2015 2014 Your Child’s Health Plan Average

84.13% 83.33% Satisfaction with Child’s Health Plan (Rating of 8 to 10) ▼ 86.32% ▲ 85.88%

Getting Needed Information (Usually or Always) 76.79% ▼ 79.87% ▼ 82.09% 81.53%

Your Healthcare in the Last Six Months Satisfaction with Health Care (Rating of 810) 87.18% ▲ 86.64% ▲ 84.33% 85.60%

Appointment for Routine Care When Needed (Usually or Always) 91.22% ▲ 91.15% ▼ 93.64% 88.72%

▲▼ = Performance compared to prior years’ rate Shaded boxes reflect rates above the 2016 MMC Weighted Average.


IV: 2015 Opportunities for Improvement MCO Response

Current and Proposed Interventions The general purpose of this section is to assess the degree to which each PH MCO has addressed the opportunities for improvement made by IPRO in the 2015 EQR Technical Reports, which were distributed in April 2016. The 2016 EQR is the eighth to include descriptions of current and proposed interventions from each PH MCO that address the 2015 recommendations.

DHS requested the MCOs to submit descriptions of current and proposed interventions using the Opportunities for Improvement form developed by IPRO to ensure that responses are reported consistently across the MCOs. These activities follow a longitudinal format, and are designed to capture information relating to: • Follow-up actions that the MCO has taken through June 30, 2016 to address each recommendation; • Future actions that are planned to address each recommendation; • When and how future actions will be accomplished; • The expected outcome or goals of the actions that were taken or will be taken; and • The MCO’s process(es) for monitoring the action to determine the effectiveness of the actions taken.

The documents informing the current report include the responses submitted to IPRO as of August 2016, as well as any additional relevant documentation provided by GH.

Table 5.1 presents GH’s responses to opportunities for improvement cited by IPRO in the 2015 EQR Technical Report, detailing current and proposed interventions.

Table 5.1: Current and Proposed Interventions Reference Number: GH 2015.01: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Well-Child Visits in the First 15 Months of Life (≥ 6 Visits) measure. Follow Up Actions Taken Through 06/30/16:

Gateway to Practitioner Excellence (GPE®) 2016 Program (January 2016 – ongoing). Well-Child Visits in the First Fifteen Months ((≥ 6 visits) is a component of Gateway’s provider pay-for-performance program. The 2016 program structure offers incentives to PCPs who complete 6 or more visits with pediatric members in their first 15 months of life. The GPE® program is augmented by a comprehensive PCP Dashboard that provides participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and incentive earning potential.

Practice Reference Guide (January 2016 - Ongoing). HEDIS Well-Child Visits in the First Fifteen Months (W15) Tip Sheet refreshed to be included in a Practice Reference Guide made available to all providers and promoted at onsite practice visits by the GPE® Provider Engagement Team as well as the Provider Relations Representatives.

Brochure and Visit Reminder Magnet for Well-Baby Visits in First 15 Months (February 2016 - ongoing). The brochure describes well-baby visits and recommended schedule for visits in the first 15 months, including Gateway resources for members. A magnet with the recommended schedule is also included so that members can record and remember all their scheduled visits. Brochure/magnet included in the postpartum letter sent to new moms.

Well-Baby Maintenance Model (February 2016 - ongoing). A tool that indicates members in the W15 population and how many visits they have completed YTD compared to what would be expected. The goal of the maintenance model is to identify members who need visits and intervene in the most time-efficient and meaningful ways with provider and other domains to improve visit timeliness. The model is being used to:

• Pilot activities with embedded CM at CHP (described below) • Identify low performing practices to be outreached to by the GPE® Provider Engagement Team • Evaluate visit completion patterns by PCP practice, geographic region, and race and ethnicity

Well-Child Visits in the First 15 Months Provider Newsletter Article (March 2016). Newsletter article educating providers on the recommended schedule and importance of well-baby visits included in the Provider Newsletter.

Embedded Care Manager (CM) Outreach Pilot (March 2016 - ongoing). Embedded CM at Children’s Primary Care Center conducting live outreach for appointment scheduling assistance to members behind on well-baby visits. The CM also uses the


well-baby brochure/magnet during face to face meetings with parents/guardians.

Well-Baby Call Campaign (April 2016). Gateway Health Outreach Navigators called Heads of Household to remind them their baby was overdue for a visit. The Navigators assisted in scheduling PCP appointments for members, as needed.

Omnichannel Well-Baby Education Program (May 2016 - ongoing). Program consists of a blend of outbound telephone calls, email and/or SMS messages (for members who opt in). The Target Population is Heads of Household for members ages 0-15 months. The purpose is to encourage new parents to take their baby to the recommended number of well visits in the baby’s first 15 months. Program educates on needed immunizations & lead screening, too. Outreach occurs at 2, 4, 6, 9, 12, and 14 months. Live agent assistance available to schedule appointment and resolve barriers/SDoH impediments to care.

Monitoring Effectiveness via Monthly HEDIS Surveillance Report (May 2015 – Ongoing). The HEDIS surveillance report monitors monthly administrative data for all HEDIS measures to identify trends. The report utilizes rolling year data and includes a one-year lookback to provide the most accurate picture of current HEDIS measure performance. Report includes the total number of gaps needed to reach 75th and 90th percentile Quality Compass thresholds. This report enables the assigned Gateway Health Operational Lead to monitor monthly rate changes/trends, assess impact of activities released into the market, and to plan future intervention activities. A multi-disciplinary group of Gateway Health staff also meet monthly to review rates and problem solve around barriers and opportunities. This method applies both to actions implemented previously and those planned in the future.

The expected outcome/goal of these collective actions is to meet or exceed the 2015 NCQA Quality Compass 90th percentile benchmark of 74.47%. Future Actions Planned: Gateway Health plans to continue all of its current activities targeting well-child visits in the first 15 months. Gateway Health will monitor performance of the measure as well as the success of these activities through internal meetings, such as the monthly Pediatric Workgroup. New actions will be developed as needed based on ongoing evaluation. Reference Number: GH 2015.02: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Body Mass Index: Percentile (Age 3 - 11 years) and (Total) measure. Follow Up Actions Taken Through 06/30/16:

Practice Reference Guide (January 2016 - ongoing). HEDIS Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) Tip Sheet refreshed to be included into a Practice Reference Guide made available to all providers and promoted at onsite practice visits by the GPE® Provider Engagement Team as well as the Provider Relations Representatives.

Clinical Obesity Assessment Provider Newsletter Article (December 2015). Newsletter article included provider recommendations for completing an annual weight assessment based on clinical best practice. Coding guidance for BMI assessment, nutrition counseling, and physical activity counseling also included.

Wellness Coach/Dietician (March 2016 - ongoing). Gateway Health hired a Wellness Coach/Registered Dietician that provides wellness coaching and dietitian services for pediatric members and families that are looking to make positive lifestyle changes through nutrition and exercise. Members are referred to these services through their Case Manager, as needed.

Pediatric Obesity Prevention & Treatment Toolkit (April 2016). A toolkit was developed to promote awareness of the pediatric provider’s role in both prevention and treatment of childhood obesity and to provide tools for providers that enhance their assessment and treatment of pediatric obesity The Pediatric Obesity Toolkit includes: • Primary Care Provider Cover Letter: Letter from Gateway Health’s Medical Director describing the problem of

childhood obesity in Pennsylvania, and the need for physicians to not only treat obesity, but to also play an active role in prevention. The letter describes the PA Chapter, American Academy of Pediatrics’ program, EPIC® - Pediatric Obesity: Evaluation, Treatment and Prevention in Community Settings, and strongly encourages provider participation.

• EPIC® - Pediatric Obesity: Evaluation, Treatment and Prevention in Community Settings Brochure: Program funded by the PA Department of Health and administered by the PA Chapter, American Academy of Pediatrics. It is an on-site, free, 1-1.5 hour, CME/CEU program on pediatric obesity presented by a Physician and a Registered Dietitian from the physician office’s community. The program is available to all providers throughout the state of Pennsylvania.

• Childhood Nutrition and Weight Management Services Billing Guide: Guide describes covered services for nutrition and weight management, including billable codes and required ICD-10 diagnosis codes for services rendered.


• Participating Hospitals for Nutrition Services: List of participating hospitals by county providing outpatient nutrition services that providers may refer patients to for obesity-related nutrition services. The PCP must make a referral for the member to receive these services.

The toolkits have been delivered to GPE® Pediatric and Family Practice offices by the Provider Engagement Team and Provider Relations Representatives at office visits occurring during Quarter 2 and 3 of 2016.


The expected outcome/goal of these collective actions is to meet or exceed the HEDIS 50th percentile benchmarks for the Total, and Ages 3-11 measures, at 67.23% and 66.86% respectively. Gateway Health’s goal is to achieve the 75th percentile or higher for all components of the WCC measure, 77.98% for WCC BMI Total Percentile, and 77.48% for WCC BMI Ages 3-11 Percentile.

Future Actions Planned: In addition to ongoing activities listed above, Gateway Health has the following future actions planned:

CME/CEU Program Collaboration (July 2016). Gateway partnered with the PA Chapter, American Academy of Pediatrics to promote the on-site, free, 1-1.5 hour, CME/CEU program on pediatric obesity. “EPIC® - Pediatric Obesity: Evaluation, Treatment and Prevention in Community Settings”, an interactive program presented by a Physician and a Registered Dietitian from your community. The partnership includes Gateway Health outreach to targeted providers using memos and presentations at provider visits, as well as direct outreach from the PA Chapter, American Academy of Pediatrics to encourage participation. Reference Number: GH 2015.03: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Follow-up Care for Children Prescribed ADHD Medication: Continuation Phase measure. Follow Up Actions Taken Through 06/30/16: Clinical Practice Guidelines (January 2016 – ongoing). Clinical Practice Guidelines are published on Gateway Health’s website for providers to access and review. The Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention Deficit/ Hyperactivity Disorder in Children and Adolescents from the American Academy of Pediatrics is included. In addition the clinical indicators support that the child will receive the recommended follow up visits at regular intervals.

Practice Reference Guide (January 2016 - Ongoing). The Follow-Up Care for Children Prescribed ADHD Medication measure was included in a Practice Reference Guide made available to all providers and promoted at onsite practice visits by the GPE®

Provider Engagement Team as well as the Provider Relations Representatives.

Inter-Agency Collaboration. Collaboration with the BH-MCOs (Value Behavioral Health, Community Care Behavioral Health, and Magellan) quality departments to identify opportunities for joint interventions to address measures impacting both Physical Health and Behavioral Health.


The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Follow-up Care for Children Prescribed ADHD Medication: Continuation Phase measure in 2017.



Implementation of the Telephonic Psychiatric Consultation Service (TiPS) program (July 2016). TiPS is a new HealthChoices program designed to increase the availability of child psychiatry consultation teams regionally and telephonically to PCPs and other prescribers of psychotropic medications. The program provides real time peer-to-peer resources to the PCP who desires immediate consultative advice for children with behavioral health concerns. Gateway will be providing education to providers about the option to access these services.

Member Outreach & Education (4th Quarter 2016). When members are newly prescribed an ADHD medication, they will receive an educational letter and materials that support the importance of timely and routine follow-up. The information will contain information encouraging parents to contact Gateway’s Care Management department if they are in need of assistance in scheduling the follow up appointments or need assistance in accessing behavioral health services. Gateway Care Managers will assist the member in being linked to services through their respective BH-MCO. Reference Number: GH 2015.04: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Follow-up Care for Children Prescribed ADHD Medication (BH Enhanced): Continuation Phase measure. Follow Up Actions Taken Through 06/30/16:

Clinical Practice Guidelines (January 2016 – ongoing). Clinical Practice Guidelines are published on Gateway Health’s website for providers to access and review. The Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention Deficit/ Hyperactivity Disorder in Children and Adolescents from the American Academy of Pediatrics is included. In addition the clinical indicators support that the child will receive the recommended follow up visits at regular intervals.

Practice Reference Guide (January 2016 - Ongoing). The Follow-Up Care for Children Prescribed ADHD Medication measure was included in a Practice Reference Guide made available to all providers and promoted at onsite practice visits by the GPE®

Provider Engagement Team as well as the Provider Relations Representatives.

Inter-Agency Collaboration. Collaboration with the BH-MCOs (Value Behavioral Health, Community Care Behavioral Health, and Magellan) quality departments to identify opportunities for joint interventions to address measures impacting both Physical Health and Behavioral Health.


The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Follow-up Care for Children Prescribed ADHD Medication (BH Enhanced): Continuation Phase measure in 2017.


Implementation of the Telephonic Psychiatric Consultation Service (TiPS) program (July 2016). TiPS is a new HealthChoices program designed to increase the availability of child psychiatry consultation teams regionally and telephonically to PCPs and other prescribers of psychotropic medications. The program provides real time peer-to-peer resources to the PCP who desires immediate consultative advice for children with behavioral health concerns. Gateway will be providing education to providers about the option to access these services for

Member Outreach & Education (4th Quarter 2016). When members are newly prescribed an ADHD medication, they will receive an educational letter and materials that support the importance of timely and routine follow-up. The information will contain information encouraging parents to contact Gateway’s Care Management department if they are in need of assistance in scheduling the follow up appointments or need assistance in accessing behavioral health services. Gateway Care Managers will assist the member in being linked to services through their respective BH-MCO. Reference Number: GH 2015.05: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Annual Dental Visit (Age 2–21 years) measure. Follow Up Actions Taken Through 06/30/16:


Member Education via Gateway Health Website (January 2014 – ongoing). Gateway Health continues to supply educational materials on its member-facing website. This includes links to information about proper oral hygiene techniques, such as brushing and flossing. These materials are reviewed annually by the Dental Operational Lead and updated as necessary.

Secondary Claims Review (January 2014 – ongoing). The Dental Operational Lead works with the Health Services Analytics team and Gateway Health’s dental benefit manager, United Concordia, to investigate situations where Gateway Health may be the member’s secondary insurance for a dental claim. These claims are pulled into Gateway Health’s system as appropriate.

Public Health Dental Hygiene Practitioner (PHDHP) Program (January 2015 – ongoing). Gateway Health employs dental hygienists with a public health certification that allows them to practice in certain community settings. These PHDHPs are allocated to each of the 3 HealthChoices zones that Gateway serves and are familiar with the dental landscape in those areas. Members and heads of households of eligible members are contacted by telephone to discuss the importance of oral healthcare and assist with finding the member a dental home. PHDHPs also attend events in the community, such as health fairs, to educate large numbers of members on the importance of caring for their teeth. The PHDHPs focus on members ages 05 years to form good habits early and assist with establishing a dental home.

Collaboration with Head Start Programs (September 2015 – ongoing). The PHDHPs in the New West and Southwest zones attend Head Start and Early Head Start programs to educate students on the importance of proper oral hygiene and nutrition. They also attend events associated with the Head Start programs where parents/ guardians are present to educate them alongside their children. This is an opportunity to provide face to face instruction to these students and respond to any questions that are asked.

Educational Booklet for Dental Providers (September 2015 – ongoing). In-network dentists were sent booklets with information about the importance of seeing children under the age of 3 years. The booklet includes the recommendation from the American Dental Association, suggestions for examining these children, and the appropriate codes for billing the exam. The booklet is meant to simplify the process of seeing young children for dentists who may be reluctant due to inexperience.

No Contact Postcards (November 2015 - ongoing) Members who live in households where the PHDHPs have trouble making contact by telephone are sent a postcard. These postcards contain a reminder that the member is due for a dental appointment and a call back number to reach the PHDHP who sent the postcard to them. The majority of postcards will be mailed to households with members ages 0-5 years as part of Gateway Health’s effort to establish dental homes for members at a young age.

Gateway to Practitioner Excellence (GPE®) 2016 Program (January 2016 – ongoing). Annual Dental Visits is a component of Gateway’s provider pay-for-performance program. The 2016 program structure offers incentives to dentists for rendering dental care and to PCPs to strengthen the formation of Pediatric Dental Homes for members age 8 years and younger. The GPE®

program is augmented by a comprehensive PCP Dashboard that provides participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and incentive earning potential.

Practice Reference Guide (January 2016 - Ongoing). The Annual Dental Visits Tip Sheet refreshed to be included in a Practice Reference Guide made available to all providers and promoted at onsite practice visits by the GPE® Provider Engagement Team as well as the Provider Relations Representatives.

Collaboration with High Volume Practices (January 2016 - Ongoing). Practices with a high volume of Gateway Health members, whether they perform well or not, often have large numbers of members who still need to visit a dentist. Gateway Health collaborates with these practices to assist with improving the rates through ideas like dental events or targeted interventions.

Dental Education Booklets (March 2016 – ongoing). Booklets were created for parents/guardians of infants and toddlers to educate them about the importance of seeing a dentist upon the eruption of the first tooth or first birthday, proper snacks for a healthy smile, and appropriate brushing techniques. These booklets are handed out by the PHDHPs at community events and when they are at medical practices for mobile dental events.

Special Needs Indicator for Providers on the Gateway Health Website (May 2016 – ongoing). A change to provider information on Gateway Health’s website to add an indicator if the provider accepts special needs children went live. This indicator will help parents/ guardians with special needs children find a dentist that will accept those children as patients.


Omnichannel Dental Education Program (May 2016 - ongoing). Program consists of a blend of outbound telephone calls, email and/or SMS messages (for members who opt in). The Target Population is parents/guardians of children ages 6-18 and member ages 18-20). The purpose is to encourage good oral hygiene and at least annual dental visits. Live agent assistance available to schedule appointment and resolve barriers/SDoH impediments to care.

Pre Queue Member Messaging (June – July 2016). When members/ heads of household call into the Medicaid Customer Service line they hear a message regarding dental visits. The message is in regards to the school year ending and children having more time to go see the dentist. Customer Service representatives received talking points for additional conversation with the heads of households about how often children should go to the dentist and to offer assistance with finding a dentist if they do not already have one.

2016 Community Dental Days (June – August 2016). Replicating Gateway’s 2015 summer community dental days, dental events are scheduled at medical practices for members who attend those practices using area dentists who have mobile equipment. These medical practices tend to be in areas with less access to dentists and as a result have lower dental rates for members. Gateway Health PHDHPs are present to counsel members individually and provide face to face education about the need to continue good oral health habits, as well as assist with finding a permanent dental home. There are currently 22 events planned at 12 practices in all 3 of the HealthChoices zones that Gateway Health is present.


The expected outcome/goal of these collective actions is to meet or exceed the 2015 NCQA Quality Compass 75th percentile benchmark of 60.31%. Future Actions Planned: In addition to ongoing activities listed above, Gateway Health has the following future actions planned:

Member Newsletter Notification (July 2016). Members receive a postcard in the mail notifying them that the quarterly newsletter is available. The July Medicaid newsletter notification also contains a call to action for members to use the summer break from school to schedule an appointment with a dentist. This notification will go out to all Medicaid households.

Provider Newsletter Article (July 2016). An article in the July provider newsletter contains information about how a provider can improve their dental rates. The article urges providers to speak to members and their parents/ guardians about scheduling an appointment with a dentist and suggests that they even have a list of area dentists to share with the members to give them options. The article also contains resources for the provider to become certified to apply topical fluoride varnish on members.

Member Educational Postcards (August 2016). Young adult members targeted for the omnichannel dental education program will be sent a postcard if they are unable to be reached. The postcard will have a simple reminder for the member or head of household that the member is due for a dental visit. The postcard will also provide information about dental being a covered benefit and a telephone number to reach Gateway Health’s Customer Service for assistance in finding a dentist.

PHDHPs in FQHCs (3rd Quarter 2016). To build on the reach of the PHDHPs, Gateway Health will partner with FQHCs to allow the PHDHPs to spend time at the practice to educate and counsel members and heads of households who are present for a visit with the medical provider. This will allow for the PHDHP to work through barriers to getting dental care and assist the member with establishing a dental home. Reference Number: GH 2015.06: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Breast Cancer Screening (Age 52-74 years) measure. Follow Up Actions Taken Through 06/30/16:

“Care Gap” Button (October /2014 – ongoing). All Gateway Health member-facing representatives utilize the “Care Gap” function made available in current software configuration. The function displays actionable open gaps, including breast cancer screening. Members may not be aware that they have specific gaps in care and this offers an opportunity for them to receive a reminder.


Barrier Discussion for Members with Intellectual or Physical Disabilities (3rd & 4th Quarter 2015). Gateway Health conducted phone interviews with women who had known intellectual or physical disabilities to better understand barriers to getting a mammogram and develop interventions that can impact the specific barriers mentioned. Gateway Health wants to better understand what its members’ needs are to develop more targeted interventions that will help to improve accessibility to and utilization of breast cancer screening. Phone interviews were conducted by telephone with 30 members and the results were analyzed to determine the most frequent barriers discussed. The results will impact interventions moving forward by helping to shape some of the focus.

Women’s Preventive Health Community Awareness Series (September 2015 – ongoing). The preventive health community awareness series targets the senior population in the city of Pittsburgh at 5 different senior centers. These events are meant to raise awareness and improve the knowledge of seniors in regards to guidelines for routine screening. Each presentation typically reaches 35 people and provides the participants with an opportunity to have questions answered.

Breast Cancer Awareness Month Information (October 2015). Gateway Health recognized Breast Cancer Awareness Month by running a social media campaign to promote the importance of getting routine mammograms, as well as to provide information about resources for cancer patients and survivors. An article was also included in the Q3 Member newsletters with an infographic showing members changes in breast health that should be discussed with their provider. Mammogram Reminder Postcard (November 2015). Members who have had a mammogram in the past and were due received a gentle reminder in the mail to inform them that they are due again. These postcards focused on members who most recently had a mammogram in the past 4 years. The purpose of the postcard was to inform the member that they are due, educate on the current guidelines for screening, and provide contact information if they want to reach out to Gateway Health for assistance with scheduling a PCP appointment.

Gap Closure IVR Campaign with Appointment Scheduling Assistance (4th Quarter 2015). Members who had not received a mammogram were called to remind them that they were due for a screening and offer assistance in scheduling a PCP appointment for additional discussion about getting screened. The phone calls served as a reminder to members that it is important to get routine mammograms and that our records show that they are due. Live agents assisted with scheduling members for appointments.

Gateway to Practitioner Excellence (GPE®) 2016 Program (January 2016 – ongoing). Breast Cancer Screening is a component of Gateway’s provider pay-for-performance program. The 2016 program structure offers incentives to PCPs whose members receive a mammogram. The GPE® program is augmented by a comprehensive PCP Dashboard that provides participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and incentive earning potential.

Practice Reference Guide (January 2016 - Ongoing). The Breast Cancer Screening Tip Sheet refreshed to be included in a Practice Reference Guide made available to all providers and promoted at onsite practice visits by the GPE® Provider Engagement Team as well as the Provider Relations Representatives.

Women’s Health Pre Queue Member Messaging (May 2016). Members who called into Gateway Health’s Customer Service line during the month of May heard a recorded message about the importance of preventive women’s health as part of Women’s Health Month. The message includes the current recommendation for breast cancer screening and why it is important to be screened regularly.

Omnichannel Women’s Prevention Program (May 2016 - ongoing). Program consists of a blend of outbound telephone calls, email and/or SMS messages (for members who opt in). The Target Population is adult females with one of more open gap included as part of women’s preventive health care. The purpose is to encourage mammograms. Live agent assistance available to schedule appointment and resolve barriers/SDoH impediments to care.



The expected outcome/goal of these collective actions is to meet or exceed the 2015 NCQA Quality Compass 50thth percentile benchmark of 53.37%. Future Actions Planned: In addition to ongoing activities listed above, Gateway Health has the following future actions planned:

Collaboration with the American Cancer Society (3rd Quarter 2016). Gateway Health is collaborating with the American Cancer Society to educate providers on ways to improve cancer screening rates through a webinar. The webinar will include some information on ways to utilize Electronic Health Records and engage members in a conversation about cancer screening. Information will be provided for follow-up, including ways to reach out to the American Cancer Society for additional training.

Breast Cancer Awareness Month Activities (3rd Quarter 2016). Gateway Health will utilize national Breast Cancer Awareness Month to increase the visibility of the topic of breast cancer amongst its members by including an article in the fall newsletter and using social media to reach large groups. The messages will support the push to increase screening rates and offer additional resources to cancer patients and survivors.

Provider Assisted Outreach (4th Quarter 2016). Gateway Health will explore forming collaborative efforts with high volume practices to send letters that are signed by the provider to members who are due for breast cancer screening. These letters will indicate that the provider is working with Gateway Health to share the recommended screening guidelines and that the provider would like to help them schedule a mammogram.

Breast Cancer Screening Focus Groups (4th Quarter 2016 – 1st Quarter 2017). Due to the challenges that Medicaid recipients face in getting needed care there is an opportunity to perform more in depth barrier analysis for intervention development. Gateway Health is exploring professionally conducted focus groups to better understand its population’s needs. Qualitative research can provide detailed data that may not be captured through other forms of member surveys and will allow for interventions that target specific barriers that are found to be most common. Reference Number: GH 2015.07: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Chlamydia Screening in Women (Age 16-20 years) and (Total) measure. Follow Up Actions Taken Through 06/30/16:

“Care Gap” Button (October /2014 – ongoing). All Gateway Health member-facing representatives utilize the “Care Gap” function made available in current software configuration. The function displays actionable open gaps, including chlamydia screening. Members may not be aware that they have specific gaps in care and this offers an opportunity for them to receive a reminder.

Provider Newsletter Article (4th Quarter 2015). An article was published in the autumn provider newsletter about chlamydia screening. The article was meant to educate providers who may be unfamiliar with the prevalence of chlamydia or how simple it is to screen for the disease. It contained chlamydia statistics, guidelines for screening, and a call to action for providers. The newsletter is made available to all providers on Gateway Health’s website and providers are sent notification that a new article has been published.

Online Member Education (November 2015 – ongoing). The member section of Gateway Health’s website includes a piece on teen and youth health and wellness. This page supplies members and heads of households with information about the importance of sexually transmitted disease (STD) testing for any members who are sexually active, which includes chlamydia. There is also a link to additional resources for education about chlamydia and screening for the disease.

Practice Reference Guide (January 2016 - Ongoing). The Chlamydia Screening in Women Tip Sheet refreshed to be included in a Practice Reference Guide made available to all providers and promoted at onsite practice visits by the GPE® Provider Engagement Team as well as the Provider Relations Representatives.

Women’s Health Pre-Queue Member Messaging (May 2016). Members who called into Gateway Health’s Customer Service line during the month of May heard a recorded message about the importance of preventive women’s health as part of Women’s Health Month. Customer Service representatives were given talking points for the message that included getting tested for sexually transmitted diseases, such as chlamydia, and to remind members that it is a covered benefit.

Omnichannel Women’s Prevention Program (May 2016 - ongoing). Program consists of a blend of outbound telephone calls, email and/or SMS messages (for members who opt in). The Target Population is adult females with one of more open gap included as part of women’s preventive health care. The purpose is to encourage chlamydia screenings. Live agent assistance


available to schedule appointment and resolve barriers/SDoH impediments to care.


The expected outcome/goal of these collective actions is to meet or exceed the 2015 NCQA Quality Compass 50thth percentile benchmark of 58.43%. Future Actions Planned: In addition to ongoing activities listed above, Gateway Health has the following future actions planned:

Member Educational Materials (4th Quarter 2016) Gateway Health will continue to develop educational materials regarding chlamydia screening, which will include newsletter articles and website updates. These materials will be part of the effort to increase sexual health awareness and inform members about the importance of being tested for STDs if they are sexually active. Materials will emphasize the risks of having multiple partners and the need to be screened even if the member is asymptomatic. Reference Number: GH 2015.08: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the ≥ 81% of Expected Prenatal Care Visits Received measure. Follow Up Actions Taken Through 06/30/16:

MOM Matters® Program (prior to 2014 – ongoing). MOM Matters® is a multidisciplinary, continuum-based holistic approach to health care delivery that proactively identifies pregnant members. MOM Matters® supports the practitioner-patient relationship and plan of care, and emphasizes the prevention of risk factors and complications by using evidence-based guidelines and patient empowerment strategies. Member Interventions (based on risk stratification levels) may include: • Prenatal welcome packet for all members that includes a welcome letter, prenatal rewards brochure, an educational

booklet related to pregnancy, and information related to alcohol and smoking cessation, domestic violence hotline, and resources around depression during pregnancy.

• Maternity-related education delivered through a variety of mechanisms (e.g., member handbook, newsletter articles, educational mailings, telephone on-hold messaging, Gateway Health website)

• Antepartum and/or postpartum home health visit, as indicated • Prenatal rewards program • Comprehensive telephonic and/or face-to-face assessment, ongoing care management, and treatment plans which

includes assessment of co-morbid medical/behavioral health conditions and psychosocial issues, depression screening and smoking status

• Pharmacy review of all medications • Reminder calls for postpartum visit • Postpartum Mailer sent two weeks after delivery to support telephonic postpartum outreach • Assistance with barriers to seeking care • Needs assessment and connection to community resources

MOM Matters ® materials are reviewed at least annually. In January 2016, the new member welcome letter was revised to include a clearer call to action.

Care Management Maternity Team Training (2014 – ongoing). Ongoing training is provided to Care Management and the Maternity team to assist in aligning Care Management outreach with prenatal quality indicators. Training includes encouraging a proactive approach to finding barriers that will keep members from seeking care, as well as:

- Timely prenatal care - Warm transfer to community partners - Assistance in scheduling prenatal appointments - Arranging transport to doctor visits - Referrals to Behavioral Health services - Promote Text4Baby and a no cost phone through Safelink. - HEDIS specifications PPC and FPC


This training is also provided as part of the onboarding process for new staff.

Quarterly Provider Newsletters (2014 – ongoing). These educational materials have been sent out quarterly since 2014 and include education on prenatal provider incentives, a MOM Matters® Program overview (including member incentive description), tips on completing a depression screening and an overview of MOM Matters® as a part of the Gateway to Lifestyle Management Program.

Provider Education (August 2015 - ongoing). Gateway Health began educating high-volume OB/GYN providers in August 2015 about timely and accurate claims/billing, and how they can earn incentive dollars by providing first trimester prenatal visits. Gateway Health is also identifying those providers who are untimely in billing or who are using incorrect codes, which are impeding the tracking of prenatal care visits. This ongoing education includes face-to-face visits with high volume offices; discussing coding issues and promotion, leave-behind tip sheet and contact phone for future questions, and blast fax tip sheet to all Providers.

Data Optimization (January 2016 – ongoing). Gateway developed a proprietary platform used to drive early identification of pregnant members. This platform forms the basis for all member outreach to pregnant members.

Gateway to Practitioner Excellence (GPE®) 2016 Program (January 2016 – ongoing). The Frequency of Prenatal Care (≥81%) measure is a component of Gateway Health’s provider pay-for-performance program. The 2016 program structure offers a $50 incentive to qualifying obstetrical care providers who perform greater than 81% of expected visits, adjusted for the gestational age and month of pregnancy in which care begins based on claims data. The incentive is paid for a maximum of one per program year per member. Gateway Health has designed an important performance measurement tool to support the 2016 GPE® program. Through our newly developed comprehensive PCP Dashboard, we are able to provide participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and earning potential. In 2016, these reports will be provided monthly as well as annually to providers. Reports are distributed through onsite provider office visits and through vendor-level mailings.

Focused Provider Education & Practice Reference Guide (January 2016 – ongoing). The Gateway Health Provider Engagement Team began visiting participating providers in July 2015 in an ongoing outreach effort. During the visits, the team educates providers about the importance of early and frequent prenatal care and current clinical practice guidelines. An overview of FPC & PPC measure components are included in the 2016 Practice Reference Guide used during on-site visits and distributed to providers. The Practice Reference Guide includes measure definition, information of HEDIS coding, and tips to improve HEDIS FPC & PPC scores.

Revised Provider Materials (May 2016). Gateway completed revisions to all provider-facing maternity documents to ensure alignment with HEDIS specifications. New content was approved for the Obstetrical Billing Guide and Medicaid Provider Manual.

Omnichannel Education Program (May 2016 - ongoing). Includes IVR Call/Email/SMS & Live agent assistance components to educate members about early and frequent prenatal care. The program runs the length of members’ pregnancies with contact occurring at least once per month. Provides reminders on frequency for prenatal visits as pregnancy progresses. Provides live agent assistance to schedule appointment and resolve barriers/SDoH impediments to care.


The expected outcome/goal of these collective actions is to meet or exceed the 2015 NCQA Quality Compass 75th percentile benchmark of 69.78%.



Medical Record Review Process Enhancements (3rd Quarter 2016). Gateway will be devoting resources to year-round medical record capture and review. In addition to directly impacting the HEDIS® hybrid project, these activities will enhance provider processes and documentation through a rigorous feedback loop of education and monitoring. For FPC, this initiative will enhance Gateway’s ability to track members who switch providers during the pregnancy.

Member Incentives (4th Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around prenatal care. Reference Number: GH 2015.09: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Prenatal and Postpartum Care – Timeliness of Prenatal Care measure. Follow Up Actions Taken Through 06/30/16:













Data Optimization (January 2016 – ongoing). Gateway developed a proprietary platform used to drive early identification of


pregnant members. This platform forms the basis for all member outreach to pregnant members.

Gateway to Practitioner Excellence (GPE®) 2016 Program (January 2016 – ongoing). The Prenatal & Postpartum Care -Timeliness of Prenatal Care measure is a component of Gateway Health’s provider pay-for-performance program. The 2016 program structure offers a $200 incentive to qualifying obstetrical care providers who perform a member’s first prenatal visit in the first trimester or within 42 days of enrollment. Gateway Health has designed an important performance measurement tool to support the 2016 GPE® program. Through our newly developed comprehensive PCP Dashboard, we are able to provide participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and earning potential. In 2016, these reports will be provided monthly as well as annually to providers. Reports are distributed through onsite provider office visits and through vendor-level mailings.

Focused Provider Education & Practice Reference Guide (January 2016 – ongoing). The Gateway Health Provider Engagement Team began visiting participating providers in July 2015 in an ongoing outreach effort. During the visits, the team educates providers about the importance of early and frequent prenatal care and current clinical practice guidelines. An overview of FPC & PPC measure components are included in the 2016 Practice Reference Guide used during on-site visits and distributed to providers. The Practice Reference Guide includes measure definition, information of HEDIS coding, and tips to improve HEDIS FPC & PPC scores.






Medical Record Review Process Enhancements (3rd Quarter 2016). Gateway will be devoting resources to year-round medical record capture and review. In addition to directly impacting the HEDIS® hybrid project, these activities will enhance provider processes and documentation through a rigorous feedback loop of education and monitoring. For PPC, this initiative will enhance Gateway’s ability to track members who switch providers during the pregnancy.

Member Incentives (4th Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around prenatal care. Reference Number: GH 2015.10: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Prenatal and Postpartum Care – Postpartum Care measure. Follow Up Actions Taken Through 06/30/16:








MOM Matters ® materials are reviewed at least annually. In January 2016, the new member welcome letter was revised to include a clearer call to action. During that time, the postpartum mailer was also revised to more clearly define the 21 - 56 days post-delivery window. The mailer promotes the benefits of working with the MOM Matters® team plus notification of the 24 hour nurse line and promotion of the member portal. The mailer also covers healthy habits in regard to diet, exercise and smoking cessation.







Gateway to Practitioner Excellence (GPE®) 2016 Program (January 2016 – ongoing). The Prenatal & Postpartum Care Timeliness of Prenatal Care measure is a component of Gateway Health’s provider pay-for-performance program. The 2016 program structure offers a $200 incentive to qualifying obstetrical care providers who perform a member’s first prenatal visit in the first trimester or within 42 days of enrollment. Gateway Health has designed an important performance measurement tool to support the 2016 GPE® program. Through our newly developed comprehensive PCP Dashboard, we are able to provide participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and earning potential. In 2016, these reports will be provided monthly as well as annually to providers. Reports are distributed through onsite provider office visits and through vendor-level mailings.

Focused Provider Education & Practice Reference Guide (January 2016 – ongoing). The Gateway Health Provider Engagement Team began visiting participating providers in July 2015 in an ongoing outreach effort. During the visits, the team educates


providers about the importance of early and frequent prenatal care and current clinical practice guidelines. An overview of FPC & PPC measure components are included in the 2016 Practice Reference Guide used during on-site visits and distributed to providers. The Practice Reference Guide includes measure definition, information of HEDIS coding, and tips to improve HEDIS FPC & PPC scores.







Member Incentives (4th Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around postpartum care. Reference Number: GH 2015.11: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Prenatal Screening for Environmental Tobacco Smoke Exposure measure. Follow Up Actions Taken Through 06/30/16:






• Pharmacy review of all medications • Reminder calls for postpartum visit • Postpartum Mailer sent two weeks after delivery to support telephonic postpartum outreach • Assistance with barriers to seeking care


• Needs assessment and connection to community resources MOM Matters ® materials are reviewed at least annually. In January 2016, the new member welcome letter was revised to include a clearer call to action.







The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Prenatal Screening for Environmental Tobacco Smoke Exposure measure in 2017.



Member Incentives (4th Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around prenatal care. Reference Number: GH 2015.12: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Prenatal Screening for Depression measure. Follow Up Actions Taken Through 06/30/16:















The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Prenatal Screening for Depression measure in 2017.



Member Incentives (4th Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around prenatal care. Reference Number: GH 2015.13: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Prenatal Screening for Depression during one of the first two visits (CHIPRA indicator) measure. Follow Up Actions Taken Through 06/30/16:


booklet related to pregnancy, and information related to alcohol and smoking cessation, domestic violence hotline,


and resources around depression during pregnancy. • Maternity-related education delivered through a variety of mechanisms (e.g., member handbook, newsletter articles,

educational mailings, telephone on-hold messaging, Gateway Health website) • Antepartum and/or postpartum home health visit, as indicated • Prenatal rewards program • Comprehensive telephonic and/or face-to-face assessment, ongoing care management, and treatment plans which










The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Prenatal Screening for Depression during one of the first two visits (CHIPRA indicator) measure in 2017. Future Actions Planned: In addition to ongoing activities listed above, Gateway Health has the following future actions planned:


Member Incentives (4th Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around prenatal care. Reference Number: GH 2015.14: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Prenatal Screening for Illicit Drug Use measure. Follow Up Actions Taken Through 06/30/16:

MOM Matters® Program (prior to 2014 – ongoing). MOM Matters® is a multidisciplinary, continuum-based holistic approach to 2016 External Quality Review Report: Gateway Health of 86

health care delivery that proactively identifies pregnant members. MOM Matters® supports the practitioner-patient relationship and plan of care, and emphasizes the prevention of risk factors and complications by using evidence-based guidelines and patient empowerment strategies. Member Interventions (based on risk stratification levels) may include: • Prenatal welcome packet for all members that includes a welcome letter, prenatal rewards brochure, an educational













The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Prenatal Screening for Illicit Drug Use measure in 2017. Future Actions Planned: In addition to ongoing activities listed above, Gateway Health has the following future actions planned:


Member Incentives (4th Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around prenatal care.


Reference Number: GH 2015.15: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Prenatal Screening for Prescribed or Over-the-Counter Drug Use measure. Follow Up Actions Taken Through 06/30/16:














The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Prenatal Screening for Prescribed or Over-the-Counter Drug Use measure in 2017. Future Actions Planned: In addition to ongoing activities listed above, Gateway Health has the following future actions planned:

Medical Record Review Process Enhancements (3rd Quarter 2016). Gateway will be devoting resources to year-round medical record capture and review. In addition to directly impacting the HEDIS® hybrid project, these activities will enhance provider


processes and documentation through a rigorous feedback loop of education and monitoring. For PPC, this initiative will enhance Gateway’s ability to track members who switch providers during the pregnancy.

Member Incentives (4th Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around prenatal care. Reference Number: GH 2015.16: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Prenatal Screening for Behavioral Health Risk Assessment measure. Follow Up Actions Taken Through 06/30/16:














The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Prenatal Screening for Behavioral Health Risk Assessment measure in 2017.




Member Incentives (4th Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around prenatal care. Reference Number: GH 2015.17: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Pharmacotherapy Management of COPD Exacerbation: Bronchodilator measure. Follow Up Actions Taken Through 06/30/16:

Transition Management Program (2014 - ongoing). Gateway Health’s Transition Management (TM) Program focuses on a subset of diagnoses, including COPD. Through daily admission reports, members without an open Care Management case are referred to the TM Team; members with an open case are referred to their existing Case Manager who completes the TM process to ensure continuity of care. The TM Care Coordinator initiates outreach during the inpatient stay at the earliest point when the member is able to engage and maintains contact with the member through a series of interactions.

Embedded Care Managers (November 2015 – ongoing). Gateway has embedded care managers located at a variety of high-volume PCP practices. Embedded CMs represent an additional point of contact for members post-discharge should the TM team not be able to engage the members.

Practice Reference Guide (January 2016 - Ongoing). The Pharmacotherapy Management of COPD Exacerbation: Bronchodilator measure was included in a Practice Reference Guide made available to all providers and promoted at onsite practice visits by the GPE® Provider Engagement Team as well as the Provider Relations Representatives.

Clinical Practice Guidelines (January 2016 – ongoing). Clinical Practice Guidelines are published on Gateway Health’s website for providers to access and review. The Clinical Practice Guideline for the “Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease” was formed through the collaborative efforts of the National Heart, Lung, and Blood Institute, National Institutes of Health, USA and the World’s Health Organization in 1998. Revision December 2015.

Care Management Staff Education (May 2016). Provided in conjunction with AstraZenica on the Pharmacological management of Asthma and COPD.



Care Management Learning Modules (3rd Quarter 2016). In conjunction with Pharmacy, develop an online learning module that will review the different types of medication used for the treatment of Asthma/COPD. Also provide CM with accessible trainings on the different types of inhalation devices.

COPD Discharge Packet. (3rd Quarter 2016). This packet would be for members recently discharged from the hospital with a diagnosis of COPD. The packet would contain information related to COPD exacerbations, COPD Action Plan, Symptom log,


COPD tips, Stickers to label controller vs rescue inhalers. The goal is to have this packet to the member within 3 days of discharge. Once the member has the packet the CM would follow up to provide reinforcement of the education and answer any questions that the member may have.

Embedded Staff COPD Packet (4th Quarter 2016). This packet would be for members recently discharged from the hospital with a diagnosis of COPD. The packet would contain information related to COPD exacerbations, COPD Action Plan, Symptom log, COPD tips, Stickers to label controller vs rescue inhalers. This packet would be provided to the member upon leaving the PCP’s office, with review of the material provided from the embedded CM.

Low-Performing Provider Engagement (4th Quarter 2016). Investigate high-volume practices with low rates ordering bronchodilators. Conduct provider education summarizing the GOLD standards related to bronchodilators. Reference Number: GH 2015.18: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Medication Management for People with Asthma - 75% Compliance (Age 19-50 years) and (Age 51-64 years) measure. Follow Up Actions Taken Through 06/30/16:

Embedded Care Managers (November 2015 – ongoing). Gateway has embedded care managers located at a variety of high-volume PCP practices. Embedded CMs work with members living with asthma to resolve barriers to medication compliance.

Clinical Practice Guidelines (January 2016 – ongoing). Clinical Practice Guidelines are published on Gateway Health’s website for providers to access and review. “Guidelines for the Diagnosis and Management of Asthma” is a National Guideline developed by the National Heart, Lung and Blood Institute as part of the National Asthma Education and Prevention Program.

Practice Reference Guide (January 2016 - Ongoing). The Medication Management for People with Asthma measure was included in a Practice Reference Guide made available to all providers and promoted at onsite practice visits by the GPE® Provider Engagement Team as well as the Provider Relations Representatives.

Omnichannel Asthma Medication Adherence Program (May 2016 - ongoing). Program consists of a blend of outbound telephone calls and email messages (for members who opt in). The purpose is to increase medication adherence of members with a medication possession ratio of >20% to <85%. Live agent assistance available to schedule appointment and resolve barriers/SDoH impediments to care is available.


Omnichannel Asthma Education Program (June 2016 - ongoing). Program consists of a blend of outbound telephone calls and email messages (for members who opt in). The purpose is to educate members with asthma about proper medication use and developing an Asthma Action Plan. Live agent assistance available to schedule appointment and resolve barriers/SDoH impediments to care is available.



Future Actions Planned:

Asthma Sticker Letter (3rd Quarter). A letter will be mailed to all new members enlisted in the asthma registry. This letter will explain the difference of controller vs rescue inhaler. The letter will also include 12 stickers for the member to place an identification sticker on the specific inhaler.



Asthma Kiosk initiative (4th Quarter 2016). This collaborative program with King of Prussia Pharmacy Services targets asthmatic members by combining an innovative educational concept with inhalers, spacers, masks and medications dispensed directly their provider’s office resulting in an immediate start for members’ pharmacological therapy.

Asthma Discharge Packet. (4th Quarter 2016). This packet would be for members recently discharged from the hospital with a diagnosis of asthma. The packet would contain information related to asthma exacerbations, Asthma Action Plan, Symptom log, asthma tips, Stickers to label controller vs rescue inhalers. The goal is to have this packet to the member within 3 days of discharge. Once the member has the packet the CM would follow up to provide reinforcement of the education and answer any questions that the member may have.

Embedded Staff Asthma Packet (4th Quarter 2016). This packet would be for members recently discharged from the hospital with a diagnosis of asthma. The packet would contain information related to asthma exacerbations, Asthma Action Plan, Symptom log, asthma tips, Stickers to label controller vs rescue inhalers. This packet would be provided to the member upon leaving the PCP’s office, with review of the material provided from the embedded CM.

Low-Performing Provider Engagement (4th Quarter 2016). Investigate High volume low performing practices for Medication Management for people with asthma with less than 75% compliance for the specific age groups. Provide a tip sheet for providers summarizing the NHLBI guidelines for the management of asthma. Reference Number: GH 2015.19: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Chronic Obstructive Pulmonary Disease or Asthma in Older Adults Admission Rate (Age 40+ years) measure. Follow Up Actions Taken Through 06/30/16:


Embedded Care Managers (November 2015 – ongoing). Gateway has embedded care managers located at a variety of high-volume PCP practices. Embedded CMs work with members living with asthma to resolve barriers to medication compliance and represent an additional point of contact for members post-discharge should the TM team not be able to engage the members following a hospitalization for COPD

Clinical Practice Guidelines (January 2016 – ongoing). Clinical Practice Guidelines are published on Gateway Health’s website for providers to access and review. The Clinical Practice Guideline for the “Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease” was formed through the collaborative efforts of the National Heart, Lung, and Blood Institute, National Institutes of Health, USA and the World’s Health Organization in 1998. Revision December 2015. Guidelines for the Diagnosis and Management of Asthma” is a National Guideline developed by the National Heart, Lung and Blood Institute as part of the National Asthma Education and Prevention Program.


Omnichannel Asthma Medication Adherence Program (May 2016 - ongoing). Program consists of a blend of outbound telephone calls and email messages (for members who opt in). The purpose is to increase medication adherence of members with a medication possession ratio of >20% to <85%. Live agent assistance available to schedule appointment and resolve barriers/SDoH impediments to care is available.

Omnichannel Asthma Education Program (June 2016 - ongoing). Program consists of a blend of outbound telephone calls and email messages (for members who opt in). The purpose is to educate members with asthma about proper medication use and developing an Asthma Action Plan. Live agent assistance available to schedule appointment and resolve barriers/SDoH impediments to care is available.


The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Chronic Obstructive Pulmonary Disease or Asthma in Older Adults Admission Rate (Age 40+ years) measure in 2017.


Asthma Sticker Letter (3rd Quarter). A letter will be mailed to all new members enlisted in the asthma registry. This letter will explain the difference of controller vs rescue inhaler. The letter will also include 12 stickers for the member to place an identification sticker on the specific inhaler.


Asthma & COPD Discharge Packets (3rd Quarter 2016). This packet would be for members recently discharged from the hospital with a diagnosis of COPD. The packet would contain information related to COPD exacerbations, COPD Action Plan, Symptom log, COPD tips, Stickers to label controller vs rescue inhalers. The goal is to have this packet to the member within 3 days of discharge. Once the member has the packet the CM would follow up to provide reinforcement of the education and answer any questions that the member may have.

Asthma Kiosk initiative (4th Quarter 2016). This collaborative program with King of Prussia Pharmacy Services targets asthmatic members by combining an innovative educational concept with inhalers, spacers, masks and medications dispensed directly their provider’s office resulting in an immediate start for members’ pharmacological therapy.

Embedded Staff Asthma & COPD Packets (4th Quarter 2016). This packet would be for members recently discharged from the hospital with a diagnosis of COPD. The packet would contain information related to COPD exacerbations, COPD Action Plan, Symptom log, COPD tips, Stickers to label controller vs rescue inhalers. This packet would be provided to the member upon leaving the PCP’s office, with review of the material provided from the embedded CM.

Low-Performing Provider Engagement (4th Quarter 2016). Investigate high-volume practices with low rates ordering bronchodilators and/or with low asthma medication compliance. Conduct provider education summarizing the GOLD standards related to bronchodilator and the NHLBI guidelines for the management of asthma. Reference Number: GH 2015.20: The MCO’s rate was statistically significantly worse than the 2015 (MY 2014) MMC average for the HbA1c Poor Control (>9.0%) measure. Follow Up Actions Taken Through 06/30/16:

Gateway to Lifestyle Management® (GTLM) Diabetes program (prior to 2014 – present). GTLM is a multidisciplinary, continuum-based holistic approach to health care delivery that proactively identifies populations with chronic medical conditions, including diabetes. GTLM supports the practitioner-patient relationship and plan of care, and emphasizes the prevention of exacerbations and complications by using evidence- based guidelines and patient empowerment strategies. Member-facing activities include a welcome packet for all newly identified members; relevant member newsletter articles at least twice a year; educational information available on the website and member portal; periodic member education focusing on self-management delivered via IVR, newsletter, outbound calls, and/or pre-queue messaging; comprehensive telephonic assessment, written self-management plan, and care management which includes assessment of co-morbid conditions and gaps in care

Care Management Staff Training (ongoing). Staff received in-services on diabetes disease process and protocols, new medications, and changes to clinical practice guidelines.

o Diabetes Complications - March 2016 o Diabetes In-service - February 2016 o Smoking Cessation Training - February 2016 o Diabetes Medication Training - November 2015

Care4Life Texting Program (2014 – Ongoing). Participants receive personalized diabetes education, set and track blood glucose, weight, and exercise goals. Participants can also set reminders to take medications, log blood glucose, and make appointments. Provided at no cost to those members, who opt-in.

Gateway to Practitioner Excellence (GPE®) 2016 Program (January 2016 – ongoing). The HbA1c poor control measure is a


component of Gateway Health’s provider pay-for-performance program. The 2016 program structure offers a $10 incentive to qualifying PCPs for each member whose HbA1c level is ≤ 9% via evidence of submission of CPT II codes on the encounter claim. The incentive is paid for a maximum of one new date of service in each quarter of 2016 with a maximum payout of four times per program year per member. Gateway Health has designed an important performance measurement tool to support the 2016 GPE® program. Through our newly developed comprehensive PCP Dashboard, we are able to provide participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and earning potential. In 2016, these reports will be provided monthly as well as annually to providers. Reports are distributed through onsite provider office visits and through vendor-level mailings.

Focused Provider Education & Practice Reference Guide (January 2016 – ongoing). The Gateway Health Provider Engagement Team began visiting participating providers in July 2015 in an ongoing outreach effort. During the visits, the team educates providers about the importance of HbA1c control and current clinical practice guidelines. An overview of CDC measure components is included in the 2016 Practice Reference Guide used during on-site visits and distributed to providers. The Practice Reference Guide includes measure definition, information on HEDIS coding, and tips to improve HEDIS CDC scores.

Diabetes Care Plan (May 2016). The care plan is a mailing which provides members with the dates and/or results of diabetes-related exams and refill dates for medication. It includes education on HbA1c screenings and the most recent lab/test result known to Gateway Health via claims. Providers were also made aware of this effort via a fax blast to all PCPs, family practices, and endocrinologists.

Diabetes Health Awareness Series (June 2016). Provided at a variety of community centers throughout Allegheny County on diabetes education and importance of diet. Dates of the series included: June 7, 8, 14, and 16, 2016.

Omnichannel Condition Management Education Program (May 2016 - ongoing). Includes IVR Call/Email/SMS & Live agent assistance components to educate members about diabetes screenings, including HbA1c and favorable values, as well as on the importance of regular screenings. Provides reminders to get screened. Provides live agent assistance to schedule appointment and resolve barriers/SDoH impediments to care



Medical Record Review Process Enhancements (3rd Quarter 2016). Gateway will be devoting resources to year-round medical record capture and review. In addition to directly impacting the HEDIS® hybrid project, these activities will enhance provider processes and documentation through a rigorous feedback loop of education and monitoring. For CDC, this initiative will enhance Gateway’s ability to track members who with HbA1c >9 closer to real time.

In-Home HbA1c Testing Kits (3rd Quarter 2016). Gateway is planning to offer an in-home testing option for certain diabetic members.

EHR Data (3rd Quarter 2016). Gateway is engaged in an initiative to enhance our capture of member-level detail directly from EHRs. Data will include labs, transition of care documentation, and continuity of care documentation.

Member Incentives (3rd Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around HbA1c control. In 2016, the focus will be on testing gaps. In 2017, the program will wrap together health education activities, medication adherence, and regular provider visits to enhance members’ compliance with evidence-based clinical practice guidelines.


Reference Number: GH 2015.21: The MCO’s rate was statistically significantly worse than the 2015 (MY 2014) MMC average for the HbA1c Control (<8.0%) measure. Follow Up Actions Taken Through 06/30/16:





Gateway to Practitioner Excellence (GPE®) 2016 Program (January 2016 – ongoing). The HbA1c poor control measure is a component of Gateway Health’s provider pay-for-performance program. The 2016 program structure offers a $10 incentive to qualifying PCPs for each member whose HbA1c level is ≤ 9% via evidence of submission of CPT II codes on the encounter claim. The incentive is paid for a maximum of one new date of service in each quarter of 2016 with a maximum payout of four times per program year per member. Gateway Health has designed an important performance measurement tool to support the 2016 GPE® program. Through our newly developed comprehensive PCP Dashboard, we are able to provide participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and earning potential. In 2016, these reports will be provided monthly as well as annually to providers. Reports are distributed through onsite provider office visits and through vendor-level mailings.





Monitoring Effectiveness via Monthly HEDIS Surveillance Report (May 2015 – Ongoing). The HEDIS surveillance report monitors monthly administrative data for all HEDIS measures to identify trends. The report utilizes rolling year data and includes a one-year lookback to provide the most accurate picture of current HEDIS measure performance. Report includes the


total number of gaps needed to reach 75th and 90th percentile Quality Compass thresholds. This report enables the assigned Gateway Health Operational Lead to monitor monthly rate changes/trends, assess impact of activities released into the market, and to plan future intervention activities. A multi-disciplinary group of Gateway Health staff also meet monthly to review rates and problem solve around barriers and opportunities. This method applies both to actions implemented previously and those planned in the future.

The expected outcome/goal of these collective actions is to meet or exceed the 2015 NCQA Quality Compass 50th percentile benchmark of 47.91% . Future Actions Planned: In addition to ongoing activities listed above, Gateway Health has the following future actions planned:

Medical Record Review Process Enhancements (3rd Quarter 2016). Gateway will be devoting resources to year-round medical record capture and review. In addition to directly impacting the HEDIS® hybrid project, these activities will enhance provider processes and documentation through a rigorous feedback loop of education and monitoring. For CDC, this initiative will enhance Gateway’s ability to track members who with HbA1c <8.0 closer to real time.



Member Incentives (3rd Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around HbA1c control. In 2016, the focus will be on testing gaps. In 2017, the program will wrap together health education activities, medication adherence, and regular provider visits to enhance members’ compliance with evidence-based clinical practice guidelines. Reference Number: GH 2015.22: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Diabetes Short-Term Complications Admission Rate (Age 18-64 years) and (Total Age 18+ years) measure. Follow Up Actions Taken Through 06/30/16:


Transition Management Program (2014 - ongoing). Gateway Health’s Transition Management (TM) Program focuses on a subset of diagnoses, including diabetes. Through daily admission reports, members without an open Care Management case are referred to the TM Team; members with an open case are referred to their existing Case Manager who completes the TM process to ensure continuity of care. The TM Care Coordinator initiates outreach during the inpatient stay at the earliest point when the member is able to engage and maintains contact with the member through a series of interactions.





Gateway to Practitioner Excellence (GPE®) 2016 Program (January 2016 – ongoing). The HbA1c poor control measure is a component of Gateway Health’s provider pay-for-performance program. The 2016 program structure offers a $10 incentive to qualifying PCPs for each member whose HbA1c level is ≤ 9% via evidence of submission of CPT II codes on the encounter claim. The incentive is paid for a maximum of one new date of service in each quarter of 2016 with a maximum payout of four times per program year per member. Gateway Health has designed an important performance measurement tool to support the 2016 GPE® program. Through our newly developed comprehensive PCP Dashboard, we are able to provide participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and earning potential. In 2016, these reports will be provided monthly as well as annually to providers. Reports are distributed through onsite provider office visits and through vendor-level mailings.





The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Diabetes Short-Term Complications Admission Rate measure in 2017.


Medical Record Review Process Enhancements (3rd Quarter 2016). Gateway will be devoting resources to year-round medical record capture and review. In addition to directly impacting the HEDIS® hybrid project, these activities will enhance provider processes and documentation through a rigorous feedback loop of education and monitoring. For CDC, this initiative will enhance Gateway’s ability to track members who with HbA1c >9 closer to real time.



Member Incentives (3rd Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around HbA1c control. In 2016, the focus will be on testing gaps. In 2017, the program will wrap together health education activities, medication adherence, and regular provider visits to enhance members’ compliance with evidence-based clinical practice guidelines. Reference Number: GH 2015.23: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for the Controlling High Blood Pressure (Total Rate) measure. Follow Up Actions Taken Through 06/30/16:

Gateway to Lifestyle Management® (GTLM) Cardiac program (prior to 2014 – ongoing). GTLM is a multidisciplinary, continuum-based holistic approach to health care delivery that proactively identifies populations with chronic medical conditions, including cardiovascular disease. GTLM supports the practitioner-patient relationship and plan of care, and


emphasizes the prevention of exacerbations and complications by using evidence- based guidelines and patient empowerment strategies. Member-facing activities include a welcome packet for all newly identified members; relevant member newsletter articles at least twice a year; educational information available on the website and member portal; periodic member education focusing on self-management delivered via IVR, newsletter, outbound calls, and/or pre-queue messaging; comprehensive telephonic assessment, written self-management plan, and care management which includes assessment of co-morbid conditions, smoking status and gaps in care

Provision of Blood Pressure Cuffs (Prior to January 2016 – Ongoing). Gateway makes blood pressure cuffs available to members. Availability is promoted through our GTLM Cardiac program and Care Management teams.

Quarterly Member Newsletter Articles (2016). Articles that highlight the importance of cardiac care, treatment plan and medication adherence

o Q1 2015- Keeping Up the Beat :Six Tips for a Healthier Heart o Q2 2015- Blood Pressure & Exercise o Q3 2015- Understanding Blood Pressure o Q4 2015- Managing High Cholesterol

Care Management Staff Training (January 2016). Staff received in-services on cardiovascular disease process and protocols, new medications, and changes to clinical practice guidelines.

Gateway to Practitioner Excellence (GPE®) 2016 Program (January 2016 – ongoing). The blood pressure control measure is a component of Gateway Health’s provider pay-for-performance program. The 2016 program structure offers a $10 incentive to qualifying PCPs for each member whose blood pressure reading is <140/90. The incentive is paid for a maximum of one new date of service in each quarter of 2016 via of submission of CPT II codes on the encounter claim. The maximum payout is four times per program year per member. Gateway Health has designed an important performance measurement tool to support the 2016 GPE® program. Through our newly developed comprehensive PCP Dashboard, we are able to provide participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and earning potential. In 2016, these reports will be provided monthly as well as annually to providers. Reports are distributed through onsite provider office visits and through vendor-level mailings.

Focused Provider Education & Practice Reference Guide (January 2016 – ongoing). The Gateway Health Provider Engagement Team began visiting participating providers in July 2015 in an ongoing outreach effort. During the visits, the team educates providers about the importance of blood pressure control and current clinical practice guidelines. An overview of CBP measure components is included in the 2016 Practice Reference Guide used during on-site visits and distributed to providers. The Practice Reference Guide includes measure definition, information of HEDIS coding, and tips to improve HEDIS CBP scores.

Omnichannel Education Program (May 2016 – Ongoing). Includes IVR Call/Email/SMS & Live agent assistance components to educate members about blood pressure reading limits and the importance of regular screenings. Provides reminders to get screened. Provides live agent assistance to schedule appointment and resolve barriers/SDoH impediments to care.


Medical Record Review Process Enhancements (3rd Quarter 2016). Gateway will be devoting resources to year-round medical record capture and review. In addition to directly impacting the HEDIS® hybrid project, these activities will enhance provider processes and documentation through a rigorous feedback loop of education and monitoring. For CBP, this initiative will enhance Gateway’s ability to track members who with elevated blood pressure closer to real time.


Member Incentives (3rd Quarter 2016). Gateway Health will be combining the omnichannel education program with innovative member incentives around blood pressure. In 2016, the focus will be on testing gaps. In 2017, the program will wrap together health education activities, medication adherence, and regular provider visits to enhance members’ compliance with evidence-based clinical practice guidelines. Reference Number: GH 2015.24: The MCO’s rate was statistically significantly below the 2015 (MY 2014) MMC average for


the Heart Failure Admission Rate (Age 65+ years) measure. Follow Up Actions Taken Through 06/30/16:

Gateway to Lifestyle Management® (GTLM) Cardiac program (prior to 2014 – ongoing). GTLM is a multidisciplinary, continuum-based holistic approach to health care delivery that proactively identifies populations with chronic medical conditions, including cardiovascular disease. GTLM supports the practitioner-patient relationship and plan of care, and emphasizes the prevention of exacerbations and complications by using evidence- based guidelines and patient empowerment strategies. Member-facing activities include a welcome packet for all newly identified members; relevant member newsletter articles at least twice a year; educational information available on the website and member portal; periodic member education focusing on self-management delivered via IVR, newsletter, outbound calls, and/or pre-queue messaging; comprehensive telephonic assessment, written self-management plan, and care management which includes assessment of co-morbid conditions, smoking status and gaps in care


Wellbridge Program (2015 – ongoing) - Gateway Health partners with Wellbridge Health to support members with complex chronic conditions, including heart failure. The member receives a tablet that integrates with monitoring devices such as scales and glucometers. Equally important, the device provides the member with access to mobile and web-based applications such as Lumosity (memory and cognition), carbohydrate counters, and other valuable healthcare information. Through daily monitoring, frequent video-chats, personal interactions with a social worker, and setting prioritized member-specific goals, participating members are able to increase their knowledge of their chronic condition and increase their healthy behaviors.

Provision of Blood Pressure Cuffs (Prior to January 2016 – Ongoing). Gateway makes blood pressure cuffs available to members. Availability is promoted through our GTLM Cardiac program and Care Management teams.

Omnichannel Education Program (May 2016 – Ongoing). Includes IVR Call/Email/SMS & Live agent assistance components to educate members about blood pressure reading limits and the importance of regular screenings. Provides reminders to get screened. Provides live agent assistance to schedule appointment and resolve barriers/SDoH impediments to care.

The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for the Heart Failure Admission Rate measure in 2017.

Future Actions Planned: Gateway Health plans to continue all of its current activities targeting Heart Failure Admission Rates. Gateway Health will monitor performance of the measure as well as the success of these activities through internal meetings, such as the monthly ED and Readmission Workgroups. New actions will be developed as needed based on ongoing evaluation. Reference Number: GH 2015.25: For the Adult CAHPS survey, two of the four Adult CAHPS composite survey items decreased between 2015 (MY 2014) and 2014 (MY 2013). Three composite survey items evaluated fell below the 2015 (MY 2014) MMC weighted averages. Follow Up Actions Taken Through 06/30/16:

Dedicated Personnel (Ongoing). Starting in September 2014, Gateway Health created the role of Member Perception Operational Lead to focus on improving member satisfaction by developing targeted interventions that address specific barriers.

Sensitivity Training Modules (Ongoing). Member-facing employees complete education modules, including a sensitivity training module every December. This training is specific to interactions with a unique membership that has wide ranging concerns and allows Gateway Health employees to act in a professional manner and assist our members in the best way possible.

Member Services Quality Audits &Training (Ongoing). Gateway Health conducts monthly audits to assess Member Services staff performance when speaking with both members and providers, allowing supervisors to share regular feedback on call performance and support the goal of performance excellence. Gateway Health also cross-trains a number of representatives so they are able to answer questions from multiple lines of business, which contributes to shorter wait times when members call into the Service Center.


Quality Recognition Program (2nd Quarter 2015 - ongoing). In order to promote positive member interaction, Gateway Health monitors and rewards member-facing employees who score highly on audited calls. We highlight these individuals in our Employee Newsletter to encourage all staff members to provide top quality service for our members.

IVR Off-Cycle Member Satisfaction Survey (4th Quarter 2015). Gateway Health conducted an off-cycle member satisfaction survey, via IVR, to glean specific perception information from the Medicaid membership. We aimed to ascertain patterns and trends in member satisfaction and identify opportunities to intervene in areas where members expressed dissatisfaction. In order to effectively achieve this goal, data was returned at the member level, thus allowing for geographic analysis and/or other demographic influences.

Member Newsletter Articles (July 2015, November 2015, March 2016). In order to increase awareness of Gateway Health services, preventive health best practices, and available community resources, articles were included in the Member Newsletters published in July 2015, November 2015, and March 2016. These articles were kept at a sixth grade reading level to ensure the majority of our membership would understand the material. Additionally the newsletter notification mailing included a message about selecting a doctor and making appointments.

Dedicated Provider Engagement (April 2015 - ongoing). Gateway Health created the Provider Engagement Team to interact with providers on a regular basis. The building of this relationship helps to circumvent any misconceptions and misunderstandings that may occur as it relates to our membership and our business operations. The engagement team also works to encourage extended hours and participation in our Gateway to Practitioner Excellence programs. Having a dedicated Gatewarepresentative in the office sends a message of support for the same goal of quality care for members.

Gateway to care Welcome Calls (4th Quarter 2015 - ongoing). Gateway Health initiated a new Gateway to Care Welcome Call for all Medicaid members that joined our plan within 60 days of enrollment. As part of the welcome call, Member Services representatives helped each new member get oriented with the plan and answer any questions they may have.

The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for all Adult CAHPS composite measures in 2017.

y


Member Handbook (July 2016). In order to better communicate needed information, including coverage and benefit detail, Gateway Health redesigned the Medicaid Member Handbook, condensing material to remove duplicate statements, improving the page layout, and placing simple visuals throughout the handbook. We expect this new handbook to be well-received and help our members better understand and navigate their health care needs.

New Member Welcome Letter (July 2016). In order to better communicate needed information, including coverage and benefit detail, Gateway Health redesigned the new member welcome letter, sharing information in a concise manner, improving the page layout, and placing simple visuals throughout the letter. We expect this new member welcome letter to be well-received and help our members better understand and navigate their health care needs.

Hold Messages in Que (3rd Quarter 2016) In an effort to share information with members, Gateway Health is developing a new set of short messages to play on the phone as members wait to speak with a Member Services Representative. These messages range in subject from reminders about vaccinations to making appointments with a doctor. Members are welcome to speak more about these topics when they reach a Member Services Representative, in addition to any other items they wish to discuss.

Enhanced Community Affairs Team (3rd Quarter 2016). Starting in Q3 2016, Gateway Health’s new Director of Community Affairs will start to build out and implement their plan for member outreach and retention. To assist in this effort, additional Community Affairs staff will be hired to work directly in the communities we serve, thus enhancing our ability to interact with members on a personal level. Through this enhanced team, we aim to achieve greater member satisfaction and improved communication.

IVR Flu Shot Survey (3rd Quarter 2016). Gateway Health will conduct a flu shot survey to ask members if they have received (or intend to receive) a flu shot this year. Our goal is to share needed information about getting vaccinated so that members feeinformed and better prepared to protect themselves and their family against the flu. Reference Number: GH 2015.26: For the Child CAHPS survey, two of the four comparable items evaluated in 2015 (MY 2014)

l

decreased from 2014 (MY 2013). One composite survey item evaluated fell below the 2015 (MY 2014) MMC weighted


average. Follow Up Actions Taken Through 06/30/16:

Dedicated Personnel (Ongoing). Starting in September 2014, Gateway Health created the role of Member Perception Operational Lead to focus on improving member satisfaction by developing targeted interventions that address specific barriers.

Sensitivity Training Modules (Ongoing). Member-facing employees complete education modules, including a sensitivity training module every December. This training is specific to interactions with a unique membership that has wide ranging concerns and allows Gateway Health employees to act in a professional manner and assist our members in the best way possible.

Member Services Quality Audits &Training (Ongoing). Gateway Health conducts monthly audits to assess Member Services staff performance when speaking with both members and providers, allowing supervisors to share regular feedback on call performance and support the goal of performance excellence. Gateway Health also cross-trains a number of representatives so they are able to answer questions from multiple lines of business, which contributes to shorter wait times when members call into the Service Center.

Quality Recognition Program (2nd Quarter 2015 - ongoing). In order to promote positive member interaction, Gateway Health monitors and rewards member-facing employees who score highly on audited calls. We highlight these individuals in our Employee Newsletter to encourage all staff members to provide top quality service for our members.

IVR Off-Cycle Member Satisfaction Survey (4th Quarter 2015). Gateway Health conducted an off-cycle member satisfaction survey, via IVR, to glean specific perception information from the Medicaid membership. We aimed to ascertain patterns and trends in member satisfaction and identify opportunities to intervene in areas where members expressed dissatisfaction. In order to effectively achieve this goal, data was returned at the member level, thus allowing for geographic analysis and/or other demographic influences.

Member Newsletter Articles (July 2015, November 2015, March 2016). In order to increase awareness of Gateway Health services, preventive health best practices, and available community resources, articles were included in the Member Newsletters published in July 2015, November 2015, and March 2016. These articles were kept at a sixth grade reading level to ensure the majority of our membership would understand the material. Additionally the newsletter notification mailing included a message about selecting a doctor and making appointments.

Dedicated Provider Engagement (April 2015 - ongoing). Gateway Health created the Provider Engagement Team to interact with providers on a regular basis. The building of this relationship helps to circumvent any misconceptions and misunderstandings that may occur as it relates to our membership and our business operations. The engagement team also works to encourage extended hours and participation in our Gateway to Practitioner Excellence programs. Having a dedicated Gateway representative in the office sends a message of support for the same goal of quality care for members.

Gateway to care Welcome Calls (4th Quarter 2015 - ongoing). Gateway Health initiated a new Gateway to Care Welcome Call for all Medicaid members that joined our plan within 60 days of enrollment. As part of the welcome call, Member Services representatives helped each new member get oriented with the plan and answer any questions they may have.

The expected outcome/goals of these collective actions is to meet or exceed the 2016 MMC weighted average for all Child CAHPS composite measures in 2017.


Member Handbook (July 2016). In order to better communicate needed information, including coverage and benefit detail, Gateway Health redesigned the Medicaid Member Handbook, condensing material to remove duplicate statements, improving the page layout, and placing simple visuals throughout the handbook. We expect this new handbook to be well-received and help our members better understand and navigate their health care needs.

New Member Welcome Letter (July 2016). In order to better communicate needed information, including coverage and benefit detail, Gateway Health redesigned the new member welcome letter, sharing information in a concise manner, improving the page layout, and placing simple visuals throughout the letter. We expect this new member welcome letter to be well-received and help our members better understand and navigate their health care needs.


Hold Messages in Que (3rd Quarter 2016) In an effort to share information with members, Gateway Health is developing a new set of short messages to play on the phone as members wait to speak with a Member Services Representative. These messages range in subject from reminders about vaccinations to making appointments with a doctor. Members are welcome to speak more about these topics when they reach a Member Services Representative, in addition to any other items they wish to discuss.

Enhanced Community Affairs Team (3rd Quarter 2016). Starting in Q3 2016, Gateway Health’s new Director of Community Affairs will start to build out and implement their plan for member outreach and retention. To assist in this effort, additional Community Affairs staff will be hired to work directly in the communities we serve, thus enhancing our ability to interact with members on a personal level. Through this enhanced team, we aim to achieve greater member satisfaction and improved communication.

IVR Flu Shot Survey (3rd Quarter 2016). Gateway Health will conduct a flu shot survey to ask members if they have received (or intend to receive) a flu shot this year. Our goal is to share needed information about getting vaccinated so that members feel informed and better prepared to protect themselves and their family against the flu.

IVR Off-Cycle Member Satisfaction Survey (4th Quarter 2016). Gateway Health will conduct off-cycle member satisfaction surveys, via IVR, to glean specific perception information from each Medicaid membership group. We aim to ascertain patterns and trends in member satisfaction and identify opportunities to intervene in areas where each membership grouping expresses dissatisfaction. In order to effectively achieve this goal, data will be returned at the member level, thus allowing for geographic analysis and/or other demographic influences.

Root Cause Analysis and Action Plan The 2016 EQR is the seventh year MCOs were required to prepare a Root Cause Analysis and Action Plan for measures on the HEDIS 2015 P4P Measure Matrix receiving either “D” or “F” ratings. Each P4P measure in categories “D” and “F” required that the MCO submit: • A goal statement; • Root cause analysis and analysis findings; • Action plan to address findings; • Implementation dates; and • A monitoring plan to assure action is effective and to address what will be measured and how often that

measurement will occur.

For the 2016 EQR, GH was required to prepare a Root Cause Analysis and Action Plan for the following performance measures:

1. Controlling High Blood Pressure 2. Comprehensive Diabetes Care – HbA1c Poor Control2

3. Frequency of Ongoing Prenatal Care: ≥ 81% of Expected Prenatal Care Visits Received

GH submitted an initial Root Cause Analysis and Action Plan in August 2016.

Table 5.2: RCA and Action Plan – Annual Dental Visits Instructions: For each measure in grade categories D and F, complete this form identifying factors contributing to poor performance and your internal goal for improvement. Some or all of the areas below may apply to each measure. Managed Care Organization (MCO): Gateway Health

Measure: Controlling High Blood Pressure

Response Date: August 05, 2016

Goal Statement: Please specify goal(s) Gateway will meet or exceed the 2015 NCQA Quality Compass 50th percentile benchmark

Comprehensive Diabetes Care – HbA1c Poor Control is an inverted measure. Lower rates are preferable, indicating better performance.


2

for measure. of 57.53%.

Analysis: What factors contributed to poor performance? Please enter "N/A" if a category of factors does not apply.

Findings: Gateway Health did not demonstrate improvement in the Controlling High Blood Pressure measure from HEDIS 2015 (50.12%) to HEDIS 2016 (34.06%).

Policies (e.g., data systems, delivery systems, provider facilities)

- Lack of an internal database to store blood pressure results - Deficient success rates in chart retrieval during HEDIS medical record review process

capture. - Difficult to track members trending toward readings outside of normal limits - Inaccurate member demographics negatively impacts member outreach

Procedures (e.g., payment/reimbursement, credentialing/collaboration)

- Insufficient rate of CPT II code submission that indicate blood pressure readings - No current mechanism to extract blood pressure readings from EHRs - Dependency on member self-report

People (e.g., personnel, provider network, patients)

- Member may not understand normal blood pressures readings, the importance of regular screenings/self-monitoring, lifestyle management techniques, and medication adherence

- Members may not be aware clinical guideline recommendations regarding blood pressure reading limits.

- Members may not report untoward side effects from hypertension medication to providers resulting in non-adherence with medication

- Members may receive sample medications from providers making it difficult to assess hypertension medication adherence

- Members can be difficult to reach due to nonworking phone numbers and/or outdated addresses

Provisions (e.g., screening tools, medical record forms, provider and enrollee educational materials)

- Providers may lack hypertension educational materials that are consistent with health literacy best practice standards

- Providers may lack adequate resources for member support and education

Other (specify) - Members seek care in the emergency department for hypertensive episodes which may result in a lack of coordination between ED and PCP and impede blood pressure control

- SDoH factors and other barriers may negatively impact management of condition, access to care, and access to resources.

MCO: Gateway Health

Measure: Controlling High Blood Pressure

Action Include those planned as well as already implemented. Add rows if needed.

Implementation Date Indicate start date (month, year) duration and frequency (e.g., Ongoing, Quarterly)

Monitoring Plan How will you know if this action is working? What will you measure and how often? Include what measurements will be used, as applicable.

Gateway to Lifestyle Management® Prior to 2014 - ongoing Effectiveness is monitored via participation (GTLM) Cardiac program - GTLM is a rates. An analysis will be completed at year-multidisciplinary, continuum-based end year to determine if members included in holistic approach to health care the HEDIS sample and engaged with GTLM delivery that proactively identifies were more often seen to have favorable blood populations with chronic medical pressure readings as compared to those conditions, including cardiovascular members in the HEDIS sample who chose not disease. GTLM supports the to engage with GTLM.


practitioner-patient relationship and plan of care, and emphasizes the prevention of exacerbations and complications by using evidence- based guidelines and patient empowerment strategies. Member-facing activities include a welcome packet for all newly identified members; relevant member newsletter articles at least twice a year; educational information available on the website and member portal; periodic member education focusing on self-management delivered via IVR, newsletter, outbound calls, and/or prequeue messaging; comprehensive telephonic assessment, written self-management plan, and care management which includes assessment of co-morbid conditions, smoking status and gaps in care Provision of Blood Pressure Cuffs – Gateway makes blood pressure cuffs available to members. Availability is promoted through our GTLM Cardiac program and Care Management teams.

Prior to January 2016 Ongoing

Effectiveness of this action is monitored via a “Better Living Now” contract with a DME vendor on a quarterly basis. Invoices will be compared to provider data to evaluate those members who need additional follow-up due to uncontrolled blood pressure.

Improvement will be determined through the analysis of the number of enrollments in the cardiac GTLM program and a review of blood pressure results which show an increase in controlled rates less than 140/90 on a quarterly basis.

Care Management Staff Training – Prior to January 2016 Effectiveness of the action is monitored via Staff received in-services on Ongoing attendance rosters to specific trainings and cardiovascular disease process and application of new material as assessed protocols, new medications, and during routine call audits. changes to clinical practice guidelines. Gateway to Practitioner Excellence (GPE®) 2016 Program – The blood pressure control measure is a component of Gateway Health’s provider pay-for-performance program. The 2016 program structure offers a $10 incentive to qualifying PCPs for each member whose blood pressure reading is <140/90. The incentive is paid for a maximum of one new date of service in each quarter of 2016 via of submission of CPT II codes on the encounter claim. The maximum payout is four times per program year per member.

January 2016 - ongoing Effectiveness is measured by monthly provider dashboard reports. Individual practices will be reviewed quarterly to assess performance improvements and to identify/resolve barriers to improvement.

Gateway Health has designed an important performance measurement tool to support the 2016 GPE® program. Through our newly developed


comprehensive PCP Dashboard, we are able to provide participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and earning potential. In 2016, these reports will be provided monthly as well as annually to providers. Reports are distributed through onsite provider office visits and through vendor-level mailings. Focused Provider Education & Practice Reference Guide - The Gateway Health Provider Engagement Team began visiting participating providers in July 2015 in an ongoing outreach effort. During the visits, the team educates providers about the importance of blood pressure control and current clinical practice guidelines. An overview of CBP measure components is included in the 2016 Practice Reference Guide used during on-site visits and distributed to providers. The Practice Reference Guide includes measure definition, information of HEDIS coding, and tips to improve HEDIS CBP scores.

January 2016 - ongoing Effectiveness is measured by monthly provider dashboard reports. Individual practices will be reviewed quarterly to assess performance improvements and to identify/resolve barriers to improvement.

Effectiveness is also monitored via review of monthly surveillance reporting of administrative HEDIS data with month-overmonth comparisons and final HEDIS measure rates year-over-year.

Omnichannel Education Program – Includes IVR Call/Email/SMS & Live agent assistance components to educate members about blood pressure reading limits and the importance of regular screenings. Provides reminders to get screened. Provides live agent assistance to schedule appointment and resolve barriers/SDoH impediments to care.

May 2016 Ongoing

Effectiveness is monitored on a monthly basis through key performance metrics including reach rates, expression of intent to get screened, rate of transfer to live agents for assistance, and proportion of members who have a PCP visit within 90 days of the outreach.

Medical Record Review Process Enhancements – Gateway will be devoting resources to year-round medical record capture and review. In addition to directly impacting the HEDIS® hybrid project, these activities will enhance provider processes and documentation through a rigorous feedback loop of education and monitoring. For CBP, this initiative will enhance Gateway’s ability to track members who with abnormal blood pressure readings closer to real time.

Planned for 3rd Quarter 2016 Effectiveness will monitored through key performance indicators that are currently under development, as well as through metrics related to the hybrid medical record review process.

EHR Data – Gateway is engaged in an initiative to enhance our capture of member-level detail directly from EHRs. Data will include labs, transition of care documentation, and continuity of care documentation.

Planned for 3rd Quarter 2016 Effectiveness will monitored through key performance indicators that are currently under development.


Member Incentives – Gateway Health Planned for 2017 Effectiveness will be monitored through key will be combining the omnichannel performance indicators that are currently education program with innovative under development. To include participation member incentives around blood rates and overall HEDIS improvement. pressure control. Incentives will wrap together health education activities, medication adherence, and regular provider visits to enhance members’ compliance with evidence-based clinical practice guidelines

Table 5.3: RCA and Action Plan – Comprehensive Diabetes Care – HbA1c Poor Control3

/Managed Care Organization (MCO): Gateway Health

Measure: Comprehensive Diabetes Care – HbA1c Poor Control4


Goal Statement: Please specify goal(s) for measure.

Gateway will meet or exceed the 2015 NCQA Quality Compass 50th percentile benchmark of 42.22%

Analysis: Findings: What factors contributed to poor Gateway Health did not demonstrate improvement in the Comprehensive performance? Diabetes Care – HbA1c Poor Control measure from HEDIS 2015 (42.52%) to Please enter "N/A" if a category of factors HEDIS 2016 (48.94%). does not apply. Policies • Deficient success rates in chart retrieval during HEDIS medical record (e.g., data systems, delivery systems, review process capture. provider facilities) • Vendor for lab data currently captures values from a specific set of labs

resulting in less than 100% of reported lab values • Inaccurate member demographics negatively impacts member outreach

Procedures • Most recent lab values not always available to Care Management staff (e.g., payment/reimbursement, when speaking with members credentialing/collaboration) • Providers may not offer in-office HbA1c tests which would require

members to make a separate lab visit


• Limited use of CPT II codes by providers • Member knowledge deficit regarding: the diabetes disease process,

complications, and (ADA) American Diabetes Association guideline recommendations

• Members do not understand proper glucometer use and best practices for tracking of blood glucose levels

• Members are not compliant with ADA guidelines recommendations for self-management

• Members may not understand diabetes disease process and self-management as well as available resource

• Member may not return within calendar year for follow-up on a lab of >9.0%

• Members can be difficult to reach due to nonworking phone numbers and/or outdated addresses

• Provider may not personalize treatment options in a manner than promotes adherence for members

3 Comprehensive Diabetes Care – HbA1c Poor Control is an inverted measure. Lower rates are preferable, indicating better performance.

4 Comprehensive Diabetes Care – HbA1c Poor Control is an inverted measure. Lower rates are preferable, indicating better performance.


Provisions (e.g., screening tools, medical record forms, provider and enrollee educational materials)

• Poor coordination between endocrinologists and PCPs • Providers may lack diabetes educational materials that are consistent

with health literacy best practice standards • Providers may lack adequate resources for member support and

education Other (specify) • SDoH factors and other barriers may negatively impact management of

condition, access to care, and access to resources. MCO: Gateway Health

Measure: Comprehensive Diabetes Care – HbA1c Poor Control5




Gateway to Lifestyle Management® (GTLM) Diabetes program - GTLM is a multidisciplinary, continuum-based holistic approach to health care delivery that proactively identifies populations with chronic medical conditions, including diabetes. GTLM supports the practitioner-patient relationship and plan of care, and emphasizes the prevention of exacerbations and complications by using evidence- based guidelines and patient empowerment strategies. Member-facing activities include a welcome packet for all newly identified members; relevant member newsletter articles at least twice a year; educational information available on the website and member portal; periodic member education focusing on self-management delivered via IVR, newsletter, outbound calls, and/or pre-queue messaging; comprehensive telephonic assessment, written self-management plan, and care management which includes assessment of co-morbid conditions and gaps in care

Prior to 2014 -ongoing

Effectiveness is monitored at via participation rates. An analysis will be completed at year-end year to determine if members included in the HEDIS sample and engaged with GTLM were more often seen to have HbA1c values of less than 8.0 as compared to those members in the HEDIS sample who chose not to engage with GTLM.

Effectiveness is also monitored via review of monthly surveillance reporting of administrative HEDIS data with month-over-month comparisons and final HEDIS measure rates year-over-year.

Care Management Staff Training – Staff Prior to January 2016 Effectiveness of the action is monitored via received in-services on diabetes disease - attendance rosters to specific trainings and process and protocols, new medications, Ongoing application of new material as assessed during and changes to clinical practice guidelines. routine call audits. Gateway to Practitioner Excellence (GPE®) January 2016 Effectiveness is measured by monthly provider 2016 Program – The HbA1c poor control ongoing dashboard reports. Individual practices will be measure is a component of Gateway reviewed quarterly to assess performance Health’s provider pay-for-performance improvements and to identify/resolve barriers to program. The 2016 program structure offers improvement. a $10 incentive to qualifying PCPs for each member whose HbA1c level is ≤ 9% via Effectiveness is also monitored via review of monthly evidence of submission of CPT II codes on surveillance reporting of administrative HEDIS data

Comprehensive Diabetes Care – HbA1c Poor Control is an inverted measure. Lower rates are preferable, indicating better performance.


5

the encounter claim. The incentive is paid for a maximum of one new date of service in each quarter of 2016 with a maximum payout of four times per program year per member.

with month-over-month comparisons and final HEDIS measure rates year-over-year.

Gateway Health has designed an important performance measurement tool to support the 2016 GPE® program. Through our newly developed comprehensive PCP Dashboard, we are able to provide participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and earning potential. In 2016, these reports will be provided monthly as well as annually to providers. Reports are distributed through onsite provider office visits and through vendor-level mailings. Focused Provider Education & Practice Reference Guide - The Gateway Health Provider Engagement Team began visiting participating providers in July 2015 in an ongoing outreach effort. During the visits, the team educates providers about the importance of HbA1c control and current clinical practice guidelines. An overview of CDC measure components is included in the 2016 Practice Reference Guide used during on-site visits and distributed to providers. The Practice Reference Guide includes measure definition, information on HEDIS coding, and tips to improve HEDIS CDC scores.

January 2016 ongoing

Effectiveness is measured by monthly provider dashboard reports. Individual practices will be reviewed quarterly to assess performance improvements and to identify/resolve barriers to improvement.


Diabetes Care Plan – The care plan is a mailing which provides members with the dates and/or results of diabetes-related exams and refill dates for medication. It includes education on HbA1c screenings and the most recent lab/test result known to Gateway Health via claims. Providers were also made aware of this effort via a fax blast to all PCPs, family practices, and endocrinologists.

May 2016 Analysis of the number of diabetic care gap closures, confirmed via claims, for control of HbA1c and other CDC measure components is used to monitor the effectiveness of this action. This analysis occurs after each mailing.


Omnichannel Education Program – May 2016 Effectiveness is monitored on a monthly basis Includes IVR Call/Email/SMS & Live agent Ongoing through key performance metrics including reach assistance components to educate rates, expression of intent to get screened, rate of members about diabetes screenings, transfer to live agents for assistance, proportion of including HbA1c and favorable values, as members who have a PCP visit within 90 days of well as on the importance of regular the outreach, and proportion of members who screenings. Provides reminders to get have an HbA1c test within 90 days of the outreach. screened. Provides live agent assistance to schedule appointment and resolve Effectiveness is also monitored via review of barriers/SDoH impediments to care. monthly surveillance reporting of administrative

HEDIS data with month-over-month comparisons and final HEDIS measure rates year-over-year.


Medical Record Review Process Enhancements – Gateway will be devoting resources to year-round medical record capture and review. In addition to directly impacting the HEDIS® hybrid project, these activities will enhance provider processes and documentation through a rigorous feedback loop of education and monitoring. For CDC, this initiative will enhance Gateway’s ability to track members who with HbA1c >9 closer to real time.

Planned for 3rd

Quarter 2016 Effectiveness will monitored through key performance indicators that are currently under development, as well as through metrics related to the hybrid medical record review process.


EHR Data – Gateway is engaged in an initiative to enhance our capture of member-level detail directly from EHRs. Data will include labs, transition of care documentation, and continuity of care documentation.

Planned for 3rd

Quarter 2016 Effectiveness will monitored through key performance indicators that are currently under development.


Member Incentives – Gateway Health will be combining the omnichannel education program with innovative member incentives around HbA1c control. In 2016, the focus will be on testing gaps. In 2017, the program will wrap together health education activities, medication adherence, and regular provider visits to enhance members’ compliance with evidence-based clinical practice guidelines.

Planned for 3rd

Quarter 2016 Effectiveness will be monitored through key performance indicators that are currently under development. To include participation rates and overall HEDIS improvement.


Table 5.4: RCA and Action Plan – Frequency of Ongoing Prenatal Care: ≥ 81% of Expected Prenatal Care Visits Received Managed Care Organization (MCO): Gateway Health

Measure: Frequency of Ongoing Prenatal Care: ≥ 81% of Expected Prenatal Care Visits Received


Goal Statement: Please specify goal(s) for measure.

Gateway will meet or exceed the 2015 NCQA Quality Compass 75th percentile benchmark of 69.78%

Analysis: What factors contributed to poor performance? Please enter "N/A" if a category of factors does not apply.

Findings: Gateway Health demonstrated improvement in the Frequency of Ongoing Prenatal Care: ≥ 81% of Expected Prenatal Care Visits Received measure from HEDIS 2015 (55.23%) to HEDIS 2016 (65.05%).

Policies (e.g., data systems, delivery systems, provider facilities)

• Unsuccessful in accessing EHRs for several key OB/GYN practices during hybrid medical record review process

Procedures (e.g., payment/reimbursement, credentialing/collaboration)

• Providers submit ONAFs late in the pregnancy or is not filled out completely

• Members lack an easy mechanism to self-identify as pregnant • Providers submit claims late or as bundled claims post-delivery. This

impedes Gateway’s ability to identify pregnant members via claims data • Providers billing practices are inconsistent with HEDIS value set



• Providers send in ONAFs late, incomplete, or with inaccuracies • Provider offices struggle to keep up with cancellations and rescheduling

of no-show appointments for Medicaid members • Members have competing demands/barriers/SDoH that impede receipt

of prenatal care • Members switch prenatal care providers during pregnancy • Members can be difficult to reach due to nonworking phone numbers

and/or outdated addresses Provisions (e.g., screening tools, medical record forms, provider and enrollee educational materials)

• Provider billing guides were promoting codes that do not indicate a prenatal appointment per the HEDIS Value Set.

• Member mailings and web content lacked a call to action in regard to early and regular prenatal care.

Other (specify) N/A

MCO: Gateway Health

Measure: Frequency of Ongoing Prenatal Care: ≥ 81% of Expected Prenatal Care Visits Received




MOM Matters® Program - MOM Matters® is a multidisciplinary, continuum-based holistic approach to health care delivery that proactively identifies pregnant members. MOM Matters® supports the practitioner-patient relationship and plan of care, and emphasizes the prevention of risk factors and complications by using evidence-based guidelines and patient empowerment strategies. Member Interventions (based on risk stratification levels) may include: -Prenatal welcome packet for all members that includes a welcome letter, prenatal rewards brochure, an educational booklet related to pregnancy, and information related to alcohol and smoking cessation, domestic violence hotline, and resources around depression during pregnancy. - Maternity-related education delivered through a variety of mechanisms (e.g., member handbook, newsletter articles, educational mailings, telephone on-hold messaging, Gateway Health website) - Antepartum and/or postpartum home health visit, as indicated - Prenatal rewards program - Comprehensive telephonic and/or face-toface assessment, ongoing care management, and treatment plans which includes assessment of co-morbid medical/behavioral health conditions and psychosocial issues, depression screening

Prior to 2014 – ongoing

Effectiveness is monitored via participation rates. An analysis will be completed at year-end year to determine if members who engaged with MOM Matters® completed more prenatal visits as compared to those members who chose not to engage with MOM Matters® .


and smoking status - Pharmacy review of all medications -Reminder calls for postpartum visit -Postpartum Mailer sent two weeks after delivery to support telephonic postpartum outreach - Assistance with barriers to seeking care – Needs assessment and connection to community resources

MOM Matters ® materials are reviewed at least annually. In January 2016, the new member welcome letter was revised to include a clearer call to action. Data Optimization – Gateway developed a January 2016 The platform undergoes regular data validation, as per proprietary platform used to drive early ongoing Gateway protocols. Effectiveness is monitored via review of identification of pregnant members. This monthly surveillance reporting of administrative HEDIS data platform forms the basis for all member with month-over-month comparisons and final HEDIS outreach to pregnant members. measure rates year-over-year. Gateway to Practitioner Excellence (GPE®) 2016 Program – The Frequency of Prenatal Care (≥81%) measure is a component of Gateway Health’s provider pay-forperformance program. The 2016 program structure offers a $50 incentive to qualifying obstetrical care providers who perform greater than 81% of expected visits, adjusted for the gestational age and month of pregnancy in which care begins based on claims data. The incentive is paid for a maximum of one per program year per member.




Gateway Health has designed an important performance measurement tool to support the 2016 GPE® program. Through our newly developed comprehensive PCP Dashboard, we are able to provide participating providers with a snapshot of their members’ current preventive health status including service counts, open gaps, incentives earned, and earning potential. In 2016, these reports will be provided monthly as well as annually to providers. Reports are distributed through onsite provider office visits and through vendor-level mailings. Focused Provider Education & Practice Reference Guide - The Gateway Health Provider Engagement Team began visiting participating providers in July 2015 in an ongoing outreach effort. During the visits, the team educates providers about the importance of early and frequent prenatal care and current clinical practice guidelines. These visits are augmented by visits to high-volume obstetrical providers completed by Gateway’s maternity HEDIS SME. An





overview of FPC & PPC measure components are included in the 2016 Practice Reference Guide used during on-site visits and distributed to providers. The Practice Reference Guide includes measure definition, information of HEDIS coding, and tips to improve HEDIS FPC & PPC scores. Revised Provider Materials - Gateway completed revisions to all provider-facing maternity documents to ensure alignment with HEDIS specifications. New content was approved for the Obstetrical Billing Guide and Medicaid Provider Manual.

May 2016 Effectiveness is also monitored via review of monthly surveillance reporting of administrative HEDIS data with month-over-month comparisons and final HEDIS measure rates year-over-year.

Omnichannel Education Program – Includes IVR Call/Email/SMS & Live agent assistance components to educate members about early and frequent prenatal care. The program runs the length of members’ pregnancies with contact occurring at least once per month. Provides reminders on frequency for prenatal visits as pregnancy progresses. Provides live agent assistance to schedule appointment and resolve barriers/SDoH impediments to care.

May 2016 Ongoing

Effectiveness is monitored on a monthly basis through key performance metrics including reach rates, expression of intent to get screened, rate of transfer to live agents for assistance, proportion of members who achieve FPC compliance.


Medical Record Review Process Enhancements – Gateway will be devoting resources to year-round medical record capture and review. In addition to directly impacting the HEDIS® hybrid project, these activities will enhance provider processes and documentation through a rigorous feedback loop of education and monitoring. For FPC, this initiative will enhance Gateway’s ability to track members who switch providers during the pregnancy.

Planned for 3rd

Quarter 2016 Effectiveness will be monitored through key performance indicators that are currently under development, as well as through metrics related to the hybrid medical record review process.


Member Incentives – Gateway Health will Planned for 3rd Effectiveness will monitored through key performance be combining the omnichannel education Quarter 2016 indicators that are currently under development. To include program with innovative member participation rates and overall HEDIS improvement. incentives around prenatal care



V: 2016 Strengths and Opportunities for Improvement The review of MCO’s 2016 performance against structure and operations standards, performance improvement projects and performance measures identified strengths and opportunities for improvement in the quality outcomes, timeliness of, and access to services for Medicaid members served by this MCO.

Strengths • GH was found to be fully compliant on Subparts C, D, and F of the structure and operations standards.

• The MCO’s performance was statistically significantly above/better than the MMC weighted average in 2016 (MY 2015) on the following measures: o Dental Sealants for 6-9 Year Of Children At Elevated Caries Risk (BH Enhanced) o Prenatal Screening Positive for Depression o Asthma in Younger Adults Admission Rate (Age 18-39 years) o Heart Failure Admission Rate (Age 18-64 years) o Heart Failure Admission Rate (Total Age 18+ years)

• The following strengths were noted in 2016 for Adult and Child CAHPS survey items: o Of the four Adult CAHPS composite survey items reviewed, GH showed an increase for all four items in 2016

(MY 2015) as compared to 2015 (MY 2014). In addition, two items were higher than the 2016 MMC weighted averages.

o For GH’s Child CAHPS, two composite survey items increased in 2016 (MY 2015) as compared to 2015 (MY 2014). Two survey items evaluated in 2016 (MY 2015) were above the 2016 MMC weighted averages.

Opportunities for Improvement • For more than 40 percent of the measures under study, the MCO’s performance was statistically significantly

below/worse than the MMC rate in 2016 (MY 2015) as indicated by the following measures: o Adult BMI Assessment (Age 18-74 years) o Childhood Immunizations Status (Combination 2, and Combination 3) o Body Mass Index: Percentile (Age 3 - 11 years, Age 12-17 years, and Total) o Counseling for Nutrition (Total) o Follow-up Care for Children Prescribed ADHD Medication (Initiation Phase, and Continuation Phase) o Follow-up Care for Children Prescribed ADHD Medication - BH Enhanced (Initiation Phase, and Continuation

Phase) o Developmental Screening in the First Three Years of Life (1 year, 2 years, and Total) o Annual Dental Visit (Age 2–20 years) o Supplemental Annual Dental Visit (Age 2-3 years, Age 4-6 years, Age 7-10 years, Age 11-14 years, and Total

Age 2-21 years) o Annual Dental Visits for Members with Developmental Disabilities (Age 2-21 years) o Breast Cancer Screening (Age 52-74 years) o Cervical Cancer Screening o Chlamydia Screening in Women (Age 16-20 years, Age 21-24 years, and Total) o ≥ 61% of Expected Prenatal Care Visits Received o ≥ 81% of Expected Prenatal Care Visits Received o Prenatal and Postpartum Care – Timeliness of Prenatal Care o Prenatal and Postpartum Care – Postpartum Care o Prenatal Screening for Smoking o Prenatal Screening for Smoking during one of the first two visits (CHIPRA indicator) o Prenatal Screening for Environmental Tobacco Smoke Exposure o Prenatal Screening for Depression o Prenatal Screening for Depression during one of the first two visits (CHIPRA indicator) o Postpartum Screening for Depression o Prenatal Screening for Alcohol use


o Prenatal Screening for Illicit drug use o Prenatal Screening for Prescribed or over-the-counter drug use o Prenatal Screening for Intimate partner violence o Prenatal Screening for Behavioral Health Risk Assessment o Chronic Obstructive Pulmonary Disease or Asthma in Older Adults Admission Rate (Age 40+ years) o HbA1c Poor Control (>9.0%) o HbA1c Control (<8.0%) o HbA1c Good Control (<7.0%) o Blood Pressure Controlled <140/90 mm Hg o Controlling High Blood Pressure (Total Rate) o Statin Therapy for Patients With Cardiovascular Disease: Statin Adherence 80% (Male 21-75 years, Female

40-75 years, and Total Rate) o Adherence to Antipsychotic Medications for Individuals with Schizophrenia

• The following opportunities were noted in 2016 (MY 2015) for Adult and Child CAHPS survey items: o For GH’s Adult CAHPS, two of the four composite survey items evaluated in 2016 (MY 2015) were below the

2016 MMC weighted averages. o For GH’s Child CAHPS, two composite survey items decreased in 2016 (MY 2015) as compared to 2015 (MY

2014). The rate for two composite survey items evaluated in 2016 (MY 2015) fell below the 2016 MMC weighted average.

Additional targeted opportunities for improvement are found in the MCO-specific HEDIS 2016 P4P Measure Matrix that follows.


2016

Gateway Health (GH) P4P Measure Matrix Report Card

The Pay-for-Performance (P4P) Matrix Report Card provides a comparative look at 9 of the 10 measures included in the Quality Performance Measures component of the “HealthChoices MCO Pay for Performance Program.” Nine measures are Healthcare Effectiveness Data Information Set (HEDIS®) measures, and the remaining one is a PA specific measure. The matrix:

1. Compares the Managed Care Organization’s (MCO’s) own P4P measure performance over the two most recent reporting years (2016 and 2015); and

2. Compares the MCO’s 2015 P4P measure rates to the 2016 Medicaid Managed Care (MMC) Weighted Average.

The table is a three by three matrix. The horizontal comparison represents the MCO’s current performance as compared to the most recent MMC weighted average. When comparing a MCO’s rate to the MMC weighted average for each respective measure, the MCO rate can be either above average, average or below average. Whether or not a MCO performed above or below average is determined by whether or not that MCO’s 95% confidence interval for the rate included the MMC Weighted Average for the specific indicator. When noted, the MCO comparative differences represent statistically significant differences from the MMC weighted average.

The vertical comparison represents the MCO’s performance for each measure in relation to its prior year’s rates for the same measure. The MCO’s rate can trend up (), have no change, or trend down (). For these year-to-year comparisons, the significance of the difference between two independent proportions was determined by calculating the z-ratio. A z-ratio is a statistical measure that quantifies the difference between two percentages when they come from two separate study populations.

The matrix is color-coded to indicate when a MCO’s performance rates for these P4P measures are notable or whether there is cause for action:

The green box (A) indicates that performance is notable. The MCO’s 2016 rate is statistically significantly above the 2016 MMC weighted average and trends up from 2015.

The light green boxes (B) indicate either that the MCO’s 2016 rate is not different than the 2016 MC weighted average and trends up from 2015 or that the MCO’s 2016 rate is statistically significantly above the 2016 MMC weighted average but there is no change from 2015.

The yellow boxes (C) indicate that the MCO’s 2016 rate is statistically significantly below the 2016 MMC weighted average and trends up from 2015 or that the MCO’s 2016 rate not different than the 2016 MMC weighted average and there is no change from 2015 or that the MCO’s 2016 rate is statistically significantly above the 2016 MMC weighted average but trends down from 2015. No action is required although MCOs should identify continued opportunities for improvement.

The orange boxes (D) indicate either that the MCO’s 2016 rate is statistically significantly below the 2016 MMC weighted average and there is no change from 2015 or that the MCO’s 2016 rate is not different than the 2016 MMC weighted average and trends down from 2015. A root cause analysis and plan of action is therefore required.

The red box (F) indicates that the MCO’s 2016 rate is statistically significantly below the 2016 MMC weighted average and trends down from 2015. A root cause analysis and plan of action is therefore required.

Emergency Department utilization comparisons are presented in a separate table. Statistical comparisons are not made for the Emergency Department Utilization measure. Arithmetic comparisons as noted for this measure represent arithmetic differences only.


GH Key Points

A - Performance is notable. No action required. MCOs may have internal goals to improve

• No GH P4P measures fell into this comparison category.

B - No action required. MCOs may identify continued opportunities for improvement

Measure that statistically significantly improved from 2015 to 2016 and was not statistically significantly different from the 2016 MMC weighted average is: • Well-Child Visits in the First 15 Months of Life, 6 or more6

C - No action required although MCOs should identify continued opportunities for improvement

Measures that statistically significantly improved from 2015 to 2016 but were statistically significantly below/worse than the 2016 MMC weighted average are: • Frequency of Ongoing Prenatal Care: ≥ 81% of Expected Prenatal Care Visits • Annual Dental Visit (Ages 2 – 20 years)

Measure that did not statistically significantly change from 2015 to 2016 and was not statistically significantly different from the 2016 MMC weighted averages is: • Adolescent Well-Care Visits

D - Root cause analysis and plan of action required

Measures that did not statistically significantly change from 2015 to 2016 but were statistically significantly below/worse than the 2016 MMC weighted average are: • Prenatal Care in the First Trimester • Postpartum Care7

Measure that statistically significantly decreased/worsened from 2015 to 2016 but was not statistically significantly different from the 2016 MMC weighted averages is: • Reducing Potentially Preventable Readmissions8

F - Root cause analysis and plan of action required

Measures that statistically significantly decreased/worsened from 2015 to 2016 and were statistically significantly below/worse than the 2016 MMC weighted average are: • Comprehensive Diabetes Care: HbA1c Poor Control9

• Controlling High Blood Pressure

GH’s Emergency Department Utilization10 increased from 2015 to 2016 and is higher (worse) than the 2016 MMC average.

6 Well-Child Visits in the First 15 Months of Life, 6 or more was added as a P4P measure in 2016 (MY 2015). 7 Postpartum Care was added as a P4P measure in 2016 (MY 2015). 8 Reducing Potentially Preventable Readmissions was a first year PA specific performance measure in 2012 (MY 2011). Lower rates are preferable, indicating better performance. This measure was added as a P4P measure in 2013 (MY 2012).9 Comprehensive Diabetes Care – HbA1c Poor Control is an inverted measure. Lower rates are preferable, indicating better performance.

A lower rate, indicating better performance, is preferable for Emergency Department Utilization.


10

f

Figure 1 - P4P Measure Matrix – GH Medicaid Managed Care Weighted Average Statistical Significance Comparison

Year

to Y

ear S

tatis

tical

Sig

nific

ance

Com

paris

on

Trend Below Average Average Above Average C Frequency of Ongoing Prenatal Care: ≥ 81% of Expected Prenatal Care Visits

Annual Dental Visit (Ages 2 – 20 years)

B Well-Child Visits in the First 15 Months of Life, 6 or more11

A

No Change

D Prenatal Care in the First Trimester

Postpartum Care12

C Adolescent Well-Care Visits

B

F Comprehensive Diabetes Care: HbA1c Poor Control13

Controlling High Blood Pressure

D Reducing Potentially Preventable Readmissions14

C

Figure 2 - Emergency Department Utilization Comparison Medicaid Managed Care Average Comparison

Trend Below/Poorer than Average Average Above/Better than

Average

Year

to

Year

F D C Emergency Department Utilization15

Key to the P4P Measure Matrix and Emergency Department Utilization Comparison

A: Performance is notable. No action required. MCOs may have internal goals to improve. B: No action required. MCOs may identify continued opportunities for improvement. C: No action required although MCOs should identify continued opportunities for improvement. D: Root cause analysis and plan of action required. F: Root cause analysis and plan of action required.

11 Well-Child Visits in the First 15 Months of Life, 6 or more was added as a P4P measure in 2016 (MY 2015). 12 Postpartum Care was added as a P4P measure in 2016 (MY 2015). 13 Comprehensive Diabetes Care – HbA1c Poor Control is an inverted measure. Lower rates are preferable, indicating better performance. 14 Reducing Potentially Preventable Readmissions was a first year PA specific performance measure in 2012 (MY 2011). Lower rates are preferable, indicating better performance. This measure was added as a P4P measure in 2013 (MY 2012).15 A lower rate, indicating better performance, is preferable for Emergency Department Utilization


- -

- 16

-

Quality Performance Measure HEDIS 2012 Rate

HEDIS 2013 Rate

HEDIS 2014 Rate

HEDIS 2015 Rate

HEDIS 2016 Rate

HEDIS 2016 MMC WA

Adolescent Well Care Visits (Age 12 21 Years) 61.3% ═ 59.6% = 59.4% = 58.2% = 56.5% = 55.7%

Comprehensive Diabetes Care HbA1c Poor Control 32.7% ═ 40.8% ▲ 45.3% = 42.5% = 48.9% ▲ 37.5%

Controlling High Blood Pressure 63.5% ═ 55.2% ▼ 51.6% = 50.1% = 34.1% ▼ 61.0%

Frequency of Ongoing Prenatal Care: ≥ 81% of Expected Prenatal Care Visits Received 85.2% ═ 69.1% ▼ 71.3% = 55.2% ▼ 65.0% ▲ 71.5%

Prenatal Care in the First Trimester 91.7% ═ 85.4% ▼ 81.8% ▲ 80.0% = 78.5% = 86.9%

Postpartum Care17 48.1% = 64.1%

Annual Dental Visits 50.4% ═ 53.3% ▲ 52.7% ▼ 53.7% ▲ 55.8% ▲ 59.9%

Well Child Visits in the First 15 Months of Life, 6 or more18 71.3% ▲ 69.5%

Quality Performance Measure HEDIS 2012 Rate

HEDIS 2013 Rate

HEDIS 2014 Rate

HEDIS 2015 Rate

HEDIS 2016 Rate

HEDIS 2016 MMC WA

Emergency Department Utilization (Visits/1,000 MM)19 80.4 84.4 83.2 81.9 82.0 74.0

Quality Performance Measure PA 2012 Rate

PA 2013 Rate

PA 2014 Rate

PA 2015 Rate

PA 2016 Rate

PA 2016 MMC WA

Reducing Potentially Preventable Readmissions20 6.9% NA 6.1% ═ 8.9% ▲ 8.3% = 9.9% ▲ 10.2%

P4P performance measure rates for 2012, 2013, 2014, 2015, and 2016 as applicable are displayed in Figure 3. Whether or not a statistically significant difference was indicated between reporting years is shown using the following symbols:

▲ Statistically significantly higher than the prior year, ▼ Statistically significantly lower than the prior year or ═ No change from the prior year.

Figure 3 - P4P Measure Rates – GH

16 Comprehensive Diabetes Care - HbA1c Poor Control is an inverted measure. Lower rates are preferable, indicating better performance. 17 Postpartum Care was added as a P4P measure in 2016 (MY 2015). 18 Well-Child Visits in the First 15 Months of Life, 6 or more was added as a P4P measure in 2016 (MY 2015). 19 A lower rate, indicating better performance, is preferable for Emergency Department Utilization. 20 Reducing Potentially Preventable Readmissions was a first year PA specific performance measure in 2012 (MY 2011). Lower rates are preferable, indicating better performance. This measure was added as a P4P measure in 2013 (MY 2012).


VI: Summary of Activities

Structure and Operations Standards • GH was found to be fully compliant on Subparts C, D, and F. Compliance review findings for GH from RY 2015, RY

2014 and RY 2013 were used to make the determinations.

Performance Improvement Projects • As previously noted, GH’s Dental and Readmission PIP proposal submissions were validated. The MCO received

feedback and subsequent information related to these activities from IPRO and DHS in 2016.

Performance Measures • GH reported all HEDIS, PA-Specific and CAHPS Survey performance measures in 2016 for which the MCO had a

sufficient denominator.

2015 Opportunities for Improvement MCO Response • GH provided a response to the opportunities for improvement issued in the 2016 annual technical report and a root

cause analysis and action plan for those measures on the HEDIS 2015 P4P Measure Matrix receiving either “D” or “F” ratings

2016 Strengths and Opportunities for Improvement • Both strengths and opportunities for improvement have been noted for GH in 2016. A response will be required by

the MCO for the noted opportunities for improvement in 2017.


Commonwealth Pennsylvania Department of Human Services ...• validation of performance improvement...

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