a 15-year retrospective on medicaid hcbs quality the quality of home- and community-based services:...
TRANSCRIPT
A 15-YEAR RETROSPECTIVE ON
MEDICAID HCBS QUALITY
The Quality of Home- and Community-Based Services:
A Conversation about Strategic Directions for Research and Policy
Wednesday, February 11, 2015
Washington, D.C.
Beth Jackson, Ph.D., Truven Health Analytics
Anita Yuskauskas, Ph.D., Penn State University
A 15-YEAR RETROSPECTIVE ON MEDICAID HCBS QUALITY
1. Context of HCBS and federal policies in long term care
2. Introduction of quality expectations in the 1915c program
3. Movement toward standardization – automation of program design/application, evidence based approach
4. Healthcare landscape and where HCBS fits
1981
Sta
rt
of H
CBS
19
99
Ol
mst
ead
2002
GAO
Re
port
2004
TA &
Pr
oced
ural
gu
idan
ce
esta
blish
ed
2005
Au
tom
ated
W
aive
r App
&
star
t of
Asso
ciatio
n
2007
IPG
reva
mp
2001
Qua
lity
Prot
ocol Timeline of
important events.
HISTORY OF HCBS QUALITY
2008
IPG
ad
ded
perfo
rman
ces
mea
sure
s and
sa
mpl
ing
“Every system is perfectly designed to achieve exactly the results it gets.”
www.rbl.net
THE CENTRAL LAW OF IMPROVEMENT:
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OMNIBUS BUDGET AND RECONCILIATION ACT OF 1981
Authorized the provision of Home and Community Based Services (HCBS) as an alternative to institutional care.
The HCBS program was designed to be innovative, flexible, decentralized, and responsive to local need.
Consequently, the program lacked standardization in eligibility, design, services, provider types, rate structure and units, scope, and application…..and quality. …..and quality.
STANDARDIZATION V. FLEXIBILITY
EXPANSION OF HCBS MODELS AND AUTHORITIES: NEW INTERPRETATIONS
Multiple statutory references with different and sometimes competing guidance.– Quality varied by statutory or policy guidance, inconsistent approaches, design/implementation
– Dependent on State OR individual CMS assessor.
– Relied on a look-behind method of reports and anecdotal evidence.
New concepts and service delivery models: – Olmstead, person centered planning, Balancing LTC
– Self direction, managed LTC
– 1915c, 1915i, 1115, 1915b/c, 1915j, 1915a, and later Community First Choice, Balancing Incentives
Critical Federal legislation paralleled the growth and direction of HCBS
Court ordered deinstitutionalization – 14th Amendment Balanced Long Term Care Systems – ADA and Olmstead HCBS National Standard Measures - DRA Health Information Technology, Meaningful Use, Electronic
Health Records – ARRA
FEDERAL LEGISLATIVE ADVANCES
Flexibility and standardization were often at odds
Difficult to establish a national quality approach – differences by state in multiple aspects of multiple HCBS programs.– lack of consistent program parameters, – lack of common service definitions or units, – lack of research on evidence based practices
ORIGINAL DESIGN CONSQUENCES
Tower of Babel• People spoke
different languages
• Their work was diffused and sometimes at odds
• Collaboration and planning was difficult
© Truven Health Analytics Inc. All Rights Reserved. 12
February 11, 2015
Beth Jackson, Ph.D.
Movement Toward StandardizationIn
Medicaid HCBS Quality
© Truven Health Analytics Inc. All Rights Reserved. 13
CMS’ Two Avenues for Conveying Quality Expectations
Waiver Application Monitoring Reviews by CMS Staff
• What CMS requires• How states propose meeting
quality requirements
• Focus of CMS reviews• Whether states meet their
quality obligations
© Truven Health Analytics Inc. All Rights Reserved. 14
Pre-2000
1995 “Pre-print” Application• Check box approach• Very little description of waiver’s quality provisions
Guide for Conducting Reviews (pre-2000)• Voluntary for CMS Regional Office (RO) Staff• Focus on process, not content of reviews• Yielded little consistency across reviewers• RO staff took primary responsibility for quality
oversight, not states
© Truven Health Analytics Inc. All Rights Reserved. 15
2000-2001: CMS Develops the “Protocol”
States pushed for more consistency among CMS reviewers CMS sought increased and consistent oversight by reviewers CMS required reviewers to use the Protocol Protocol focused reviewers on the waiver “quality” assurances
Eligibility Determination (Level of Care) Service Planning Provider Qualifications Health & Welfare
Began to articulate notion of Continuous Quality Improvement (CQI) “Design, Design Implementation, Improvement” Encouraged reviewers to look for “evidence” of implementation (i.e., reports, minutes)
No uniformity in evidence provided by states Shift in primary responsibility for quality monitoring to the states Still substantial opportunity for reviewer inconsistency
© Truven Health Analytics Inc. All Rights Reserved. 16
2004 & 2007: Interim Procedural Guidance
“Interim” until CMS instituted a more formal procedure for states to report evidence
Response to 2002 GAO report
CMS reviewers required to use
Provided reviewers with guidance for assisting states in identifying evidence
Standardized format for CMS review reports, assurance-driven
No “evidence” reporting format required of states No uniformity in types of evidence provided by states
Many gaps in evidence for assurances
“IPG for Assessing HCBS Waiver Programs”
© Truven Health Analytics Inc. All Rights Reserved. 17
With Protocol & IPG, CMS had focused on asking states for evidence toward the end of a waiver cycle
Without first asking them in their applications what evidence they would be providing
“Cart-Before-Horse” phenomenon
© Truven Health Analytics Inc. All Rights Reserved. 18
2005: Automated Waiver Application
One large “box” where states were required to describe their quality improvement strategy
Application guidance stressed CQI – Discovery, Remediation, Improvement
States did not always fully articulate their “Discovery, Remediation, Improvement” approaches in their applications
States often did not specify what evidence they would produce under “Discovery”
CMS inconsistent in their approvals of the QI Strategies in state applications
Consequently, CMS found it difficult to hold states accountable in their “Evidence Packages” submitted under the IPG
© Truven Health Analytics Inc. All Rights Reserved. 19
2008: Automated Waiver Application, Version 3.5
For the first time, states required to specify Performance Measures for each assurance/sub-assurance (Discovery mechanism), including:
Metrics
Frequency of data collection & report generation
Sampling approach
Use of reports in QA/QI
Specific Performance Measures at the discretion of the state But CMS must approve them in the application
3.5 Application formed the basis for a more “evidence-based” approach to Quality in the waivers
© Truven Health Analytics Inc. All Rights Reserved. 20
Current Status
Review process not automated Submission of state’s evidence not supported by automation Still no standardization in how states report evidence
Poses challenges to CMS reviewers
States must craft their own Performance Measures
No ability to compare performance across programs/states
Most measures states track are process measures
States using experience/satisfaction surveys PES, Core Indicators, home-grown, etc. Cross-disability Experience of Care Survey under development
HCBS AND THE HEALTHCARE LANDSCAPE
WHERE IS HCBS IN RELATION TO THE REST OF THE HEALTHCARE SYSTEM?
QUALITY DRIVERS AND QUESTIONS…..
AFFORDABLE CARE ACT: THE THREE PART AIM
Improve the health of the population; Enhance the patient experience of care (including quality, access, and reliability); and Reduce, or at least control, the per capita cost of care.
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Quality:– National Strategy for Quality Improvement in Health Care– Adult Health Quality Measures– Interagency Work groups on Health Care Quality– MAP groups - Convene Multi-stakeholder Groups to provide input on
quality measures– Integration opportunities for Medicare-Medicaid
AFFORDABLE CARE ACT
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Changes to 1915(i) HCBS as a State Plan Benefit Extend Money Follows the Person demonstration Increased funding for ADRCs Community First Choice HCBS Balancing Incentives
ACA – FURTHERED THE NATIONAL FOCUS ON REBALANCING LTC AND EMPHASIZED QUALITY
SHARED CROSS SYSTEMS CONCEPTS
Person centered, integrated care models
Measures development and coordination across systems
Growth of managed care and self directed service delivery models
Integrated quality strategies and measures across all HCBS authorities
The role of HIT and EHRs in LTC: TEFT - Testing HCBS national measure sets & e-health
Coordinated research agenda - integration with policy
TENSIONS AND DISSONANCE
shannonkodonnell.blogspot.com
QUALITY IMPROVEMENT AND/OR QUALITY ASSURANCE –
Can they exist side by side? HCBS history shows there is often difficulty in meeting
basic assurances Process v Outcomes
– Lack of research on evidence based practices– What role does process play?
Oversight and Enforcement of minimum standards – who is responsible?
Federal role - guidance or compliance overseer ? This varies across programs. Is it CMS’ job to assure a minimum level of quality?
Is there a need for ongoing federal standards and reviews?
What are the roles of the states and MCOs? Do they differ?
THE ROLES IN HCBS QUALITY FEDERAL, STATE, MCOs, PROVIDERS
Is quality more than measures?
Design and oversight: building in quality up front in the design
Where is the focus on design in HCBS and what does it look like?
Is it necessary to measure process as well as outcomes?
THE PROCESSES OF HCBS QUALITY
What defines quality in HCBS?
What is the role of measures and what should be measured? Do individuals who receive services have good outcomes? Are they better off as a
result of receiving HCBS?
Are outcomes sufficient to tell the whole story?
How do we know about the quality of care and the fidelity of the providers/program? – Is the design of the program working as intended? – Are people getting what they are supposed to? – Is there good quality of care? Are providers doing what they are supposed to
meet the needs of individuals (evidence based practices)?
THE MEASURES OF HCBS QUALITY
