florida healthy kids program annual evaluation summary

Florida Healthy Kids Program Annual Evaluation Summary

Reporting on Calendar Year 2011

Prepared for the Florida Healthy Kids Corporation

Prepared by the Institute for Child Health Policy

University of Florida

October 2012

CONTRIBUTORS AND ACKNOWLEDGEMENTS Jill Boylston Herndon, Ph.D. Principal Investigator of the Florida Healthy Kids Program Evaluation Associate Professor, Institute for Child Health Policy and Department of Health Outcomes and Policy Affiliate Associate Professor, Department of Pediatrics University of Florida Elizabeth A. Shenkman, Ph.D. Co-Principal Investigator of the Florida Healthy Kids Program Evaluation Director, Institute for Child Health Policy Professor and Chair, Department of Health Outcomes and Policy Professor, Department of Pediatrics University of Florida Briony Tatem, M.S. Research Coordinator Institute for Child Health Policy Department of Health Outcomes and Policy University of Florida Vartika Bhardwaj, B.S. Research Assistant Institute for Child Health Policy Department of Health Outcomes and Policy University of Florida Alex Craen Research Assistant Institute for Child Health Policy Department of Health Outcomes and Policy University of Florida

Annual Evaluation Summary, Reporting on Calendar Year 2011 Institute for Child Health Policy, of 29

I. INTRODUCTION The Florida Healthy Kids Program (FHKP) provides health and dental coverage for children ages 5 through 18 years who are at or below 200% of the federal poverty level (FPL) and eligible for premium assistance under Title XXI of the Social Security Act, the Children’s Health Insurance Program (CHIP). The FHKP health insurance program became available statewide in September 2000, and the dental program became available statewide in 2002. For each county, the Florida Healthy Kids Corporation selects commercially licensed health plans through a competitive bid process. As of January 1, 2011, there is health plan choice in every county. The dental plans, each of which provides dental benefits statewide, are also selected through a competitive bid process. The monthly premium amount for Title XXI enrollees is $15 for families with incomes between 101% and 150% of the FPL and $20 for families with incomes between 151% and 200% of the FPL. In addition, families pay copayments for certain services. The dental benefit package is the same as Medicaid’s benefit package and requires no additional cost sharing or copayments. Families whose children are not eligible for premium assistance may obtain health and dental coverage for their children through the FHKP at the full premium amount. The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requires that states have a system-wide quality program for their CHIP-contracting managed care organizations (MCOs), including an annual external review of the quality of care provided by the MCOs.1 Pursuant to the FHKP Quality Plan and following Centers for Medicaid and Medicare Services (CMS) external quality review protocols where appropriate, the Institute for Child Health Policy (ICHP) conducted the following external quality review activities for the reporting period calendar year 2011:

• calculated plan-level quality of care indicators, including HEDIS® measures and additional CHIPRA recommended measures;

• conducted in-depth administrative interviews with each of the health and dental plans, using a web-based questionnaire that allows for interactive follow up and includes a database repository with customized query reporting capability;

• validated health and dental plan performance improvement projects (PIPs); and • conducted data quality certification of health and dental plan claims and encounter data.

In calendar year 2011, there were nine health plans that participated in the FHKP: Amerigroup, Blue Cross and Blue Shield of Florida – BlueCare, Blue Cross and Blue Shield of Florida - BlueOptions, Coventry (Vista), Florida Health Care Plans, United Healthcare, WellCare – HealthEase, and WellCare – Staywell. Two statewide dental plans also participated in the FHKP: DentaQuest and MCNA Dental Plans. This report summarizes the key evaluation activities and provides performance summaries for each of the participating health and dental plans. More detailed information can be found in the individual reports associated with each of the main evaluation activities.


II. SUMMARY OF MAJOR EVALUATION ACTIVITIES A. Calculate Quality of Care Measures Overview. The Children’s Health Insurance Program Reauthorization Act (CHIPRA) places increased emphasis on measuring and monitoring the quality of care in states’ Children’s Health Insurance Programs (CHIP). The Institute for Child Health Policy (ICHP) assessed plan-level quality of care using HEDIS® and non-HEDIS® CHIPRA measures that can be reliably calculated from administrative data for measurement year 2011 and prepared a detailed report on the methods and findings.2 The HEDIS® measurement system evaluates important dimensions of health care through a set of standardized health plan performance measures produced by the National Committee for Quality Assurance (NCQA) and are featured prominently in the CHIPRA Initial Core Set of Children’s Health Care Quality Measures (CHIPRA Quality Measures).3 Methods. Three data sources with child-level information were used to calculate the quality of care indicators: (1) enrollment data, (2) health and dental plan claims and encounter data, and (3) pharmacy data. The enrollment files contain information about the child’s age and sex, the plan in which the child is enrolled, and the number of months of enrollment. The claims and encounter data contain Current Procedural Terminology codes and Current Dental Terminology codes, International Classification of Diseases, 9th Revision codes, place of service codes, rendering provider taxonomy, and other information necessary to calculate the quality of care indicators. The pharmacy data contain information about filled prescriptions, including the drug name, dose, date filled, and refill information. A minimum 3-month lag was used for the claims and encounter data. The measurement year for most of the HEDIS® measures corresponds to calendar year 2011. The non-HEDIS® dental measures were calculated for the federal fiscal year October 1, 2010 through September 30, 2011, to be consistent with the Centers for Medicare and Medicaid Services (CMS) Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Report – Form CMS-416 reporting guidelines and CHIPRA technical specifications.4,5 For the HEDIS® measures, the ICHP successfully completed an NCQA-Certified HEDIS® Compliance Audit, and NCQA-certified software was used to calculate the measures using HEDIS® 2012 specifications.6 Following the specifications, rates were not reported when the measure denominator was less than 30. However, eligible individuals in plans with low denominators were included in the calculations of the overall program rates. Non-HEDIS® CHIPRA measures were calculated using the technical specifications in the Initial Core Set of Children’s Health Care Quality Measures: Technical Specifications and Resource Manual for Federal Fiscal Year 2011 Reporting with the exception of applying the EPSDT eligibility requirement, which is not applicable to FHKP members.4 Key Findings. The FHKP performed above the national Medicaid HEDIS® average by more than five percentage points for the following quality measures: Adolescent Well-Care Visits; Immunizations for Adolescents; and Annual Dental Visit, 11-14 Years of Age and 15-18 Years of Age. The FHKP was within five percentage points of the national Medicaid HEDIS® average for the following quality measures: Children and Adolescents’ Access to Primary Care Practitioners; Appropriate Testing for Children with Pharyngitis; Appropriate Treatment for Children with Upper Respiratory Infection; Use of Appropriate Medications for People with Asthma; Follow-Up Care for Children Prescribed ADHD Medication, Initiation Phase; 30-Day Follow-Up after Hospitalization for Mental Illness; and Annual Dental Visit, 4-6 Years of Age and 7-10 Years of Age. The FHKP performed below the national Medicaid HEDIS® average by more than five percentage points for the following quality measures: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment; Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life; Chlamydia Screening in Women 16-20 Years; Follow-Up Care for Children Prescribed ADHD Medication, Continuation and Maintenance Phase; and 7-Day Follow-Up after Hospitalization for Mental Illness. There was significant variation in plan performance both within and across measures.


B. Conduct In-Depth Interviews with Health and Dental Plan Administrators Overview. How managed care plans organize care for their members may impact enrollees’ receipt of recommended and necessary services, the quality of care provided, and member satisfaction. The Centers for Medicare and Medicaid Services (CMS) recommends that Medicaid managed care external quality reviews include in-depth interviews with managed care organization (MCO) administrators to obtain a thorough understanding of how they provide care to their membership and how they monitor the quality of care their members receive.7 The ICHP conducted in-depth administrative interviews with health and dental plans, using an interactive web-based tool.8,9 The responses provided are used in other external quality review activities, such as evaluating whether plans are meeting program performance standards, compliance with federal and state regulations, and conducting focused studies. Methods. A web-based interview and data collection tool was implemented in 2011 for the reporting period calendar year 2010. The goals of the web-based tool were to facilitate plan responses, ICHP review of submitted information, follow-up processes, and longitudinal tracking. Plan responses are automatically stored in an electronic database. The tool includes a reporting feature that allows for customized queries of the database. The core aspect of the administrative interview tool is a detailed questionnaire that the ICHP developed for use in interviewing health and dental plan administrators as part of external quality review activities. The questionnaire includes recommended topic areas in CMS external quality review protocols.7 It also includes questions that relate to health and dental plan contract requirements and additional topics of interest to the FHKP. The Administrative Interview questionnaire contains the following sections: (1) Organizational Structure; (2) Member Enrollment and Disenrollment; (3) Children’s Programs and Preventive Care; (4) Care Coordination and Disease Management Programs for Children with Chronic Conditions or Special Health Care Needs; (5) Clinical Guidelines, Performance Measures, and Quality Assessment and Performance Improvement (QAPI); (6) Member Materials, Enrollee Rights, and Member Services; (7) Provider Network; (8) Provider Reimbursement and Incentives; (9) Utilization and Referral Management; (10) Grievance Procedures; (11) Delegation; (12) Health Information Systems; and (13) Data Acquisition. Collectively, these sections contain more than 300 questions about the plans’ structure and process characteristics as they pertain to providing services to FHKP enrollees. The responses to these questions are supported by supplementary documentation such as plan operating policies and procedures and member materials. The ICHP contacted the administrators responsible for administering the FHKP benefits via e-mail with a link to the online tool and instructions. Each plan administrator assigned the appropriate personnel within the plan to complete specific sections of the questionnaire. After reviewing the completed questions, the administrator submitted the questions to the ICHP for review. After reviewing the responses, the ICHP requested additional information or clarification as needed using the follow-up processes built into the online tool. ICHP compiled a detailed summary of each plan’s responses. Each plan is easily able to see the completion status of the interview overall, each section, and each question. Each plan administrator can also review all of the plan’s responses using the Questionnaire Review feature. Results. The ICHP conducted interviews with the nine health plans and two dental plans that were participating in the FHKP as of December 2011. Detailed information about each plan’s organizational structures and processes for delivering care to FHKP enrollees were collected. These results were summarized in separate reports for the health plans and for the dental plans.8,9 In addition, the reporting tool allows for ongoing queries of the plans’ responses that can be customized to specific plans and questions.


C. Validation of Performance Improvement Projects

Overview. Performance improvement projects (PIP) are central to quality improvement, and validation of performance improvement projects is one of three required external quality review activities.10 The overall aim of a PIP is to improve health care outcomes and processes. PIPs should target improvement in relevant areas of clinical care and non-clinical services. Topics selected for study should reflect the plan’s FHKP enrollment in terms of demographic characteristics, prevalence of disease, and the potential consequences (risks) of the disease. The study topic for the PIP should address a significant portion of enrollees or target high-risk conditions or populations with the potential to significantly affect enrollee health, functioning, or satisfaction. States can allow plans to select the study topic, or the state may select the study topic. PIPs were implemented for the first time in the FHKP during the 2011-2012 evaluation period.

Topics and Performance Goals. The FHKP Board of Directors selected the PIP topics in January 2011 based on areas that were identified as needing improvement and essential to promoting the well-being of FHKP enrollees. The topic selected for the health plans was Well-Child Visits, and the performance indicator is the HEDIS® measure Well-Child Visits in the 3rd, 5th, 5th and 6th Years of Life, where only ages 5-6 years applies to the FHKP. The performance goals set by the FHKP Board of Directors were as follows:

• plans performing 10 or more percentage points below the FHKP mean: improve performance to the FHKP mean;

• plans performing within 10 percentage points of the FHKP mean but 10 or more percentage points below the national Medicaid HEDIS® mean: improve performance to the national mean; and

• plans performing within 10 percentage points of the national Medicaid HEDIS® mean: improve performance to the national mean or to 110% of current rate, whichever is greater.

The topic selected for the dental plans was preventive dental services, and the performance indicator is the percentage of children receiving preventive dental services. The performance goals set by the FHKP Board of Directors were as follows:

• improve the percentage of children receiving preventive dental services as measured by CDT codes D1000-D1999 by at least 6 percentage points for children enrolled (a) any length of time, (b) at least 6 months continuously, and (c) at least 12 months continuously;

• identify baseline measures for the percentage of children who received age-appropriate preventive dental services based on established clinical guidelines (e.g., AAPD Guidelines); and

• increase the percentage of children in each age category receiving age-appropriate preventive services by at least six percentage points.

Process and Methods. In February 2011, the plans submitted their PIP proposals to the FHKP. The ICHP EQR team reviewed the proposals and provided feedback to the FHKP in March 2011, which then provided feedback to the plans in April 2011. Plans were to revise their PIPs based on the feedback and begin implementation in May 2011. The period May 2011 through April 2012 represented the first year of PIP implementation. Plans submitted a comprehensive Year 1 report in July 2012, which the ICHP EQR team reviewed following detailed protocols for validating PIPs developed by the Centers for Medicare and Medicaid Services (CMS).10 Plans were evaluated on their performance on each of ten steps for validating PIPs identified by CMS as having Met, Partially Met, or Not Met the standards for that step. Each plan was provided with a detailed written evaluation of its strengths and opportunities for improvement for each of the ten activities. ICHP and FHKP staff held individual onsite meetings with each plan to review the feedback. In addition, a report summarizing the main findings for the program overall was provided to the FHKP.11

Key Findings. For the program overall, there was no statistically significant improvement in well-child visit rates, and only one individual plan demonstrated improvement between the baseline measurement and re-measurement. This is not surprising given that interventions were in place less than one year at the time of the first re-measurement. For the program overall and the individual dental plans, there was improvement in the percentage of children who received preventive dental services. However, given the increasing trend in rates over time and the limited scope of the interventions implemented, the EQR team did not have high confidence that the increase was attributable to the interventions. More detailed findings for each plan are provided in the plan profiles in Section III below.


D. Conduct Data Quality Certification of Claims and Encounter Data Overview. Claims and encounter data are increasingly being used in Medicaid and CHIP programs to evaluate program and plan performance and to establish performance-based incentive programs. In addition, claims and encounter data are frequently used to meet federal and state reporting requirements. The CMS has noted that completeness of and accuracy of encounter data vary across plans. Consequently, the CMS strongly encourages external quality review efforts to include assessments of the completeness and accuracy of encounter data. The CMS notes that improving encounter data quality is an iterative process and requires “continuous quality improvement processes implemented year after year.” Quality Assessment Processes. Detailed data submission layouts that describe the requirements for data submissions, including the data fields, critical thresholds, and how to handle adjustments, were developed by the ICHP and approved by the FHKP. There are 30 critical fields in the health plan encounter data, 22 critical fields in the dental encounter data, 13 critical fields in the pharmacy data, and 14 critical fields in the provider data. Most critical fields have an error threshold of 0.01%. The health and dental plans submit claims and encounter data files to the ICHP on a quarterly basis. Upon receipt of the data, the ICHP: (1) conducts a volume analysis, which includes examining the number of records and total paid amounts to determine if the values are within the expected range; (2) verifies that each critical field contains non-missing values in the correct format (type and size), the values are valid and reasonable, and the percentage of unexpected or missing values is within the established critical error threshold; (3) evaluates whether adjustment and voided claims follow the processes outlined in the data submission guidelines and the mother internal control number (ICN) can be traced back in historical files; (4) evaluates for duplicate submissions; and (5) verifies that providers in the encounter file can be matched to the provider file. After this review, the ICHP sends a message to each plan summarizing the findings of the data quality analysis and noting any “critical” issues that must be addressed. Data submissions that do not meet all critical reporting requirements are considered to be “noncompliant”, and plans must address any issues identified and resubmit their data files until they achieve a “compliant” status. Conference calls are held between the plan, ICHP and the FHKP to discuss critical issues and identify remediation and resubmission processes. The ICHP submit quarterly logbooks to the FHKP that document the files received, the date received, whether quality assurance checks were passed, critical issues identified, and corrective actions. Key Findings. For CY 2011, there were a total of 2,804,006 paid claims lines for 333,828 unique enrollees for the medical encounter data and 1,009,357 paid claims lines for 331,898 unique enrollees for the dental encounter data. Table 1 summarizes the number of plans whose data files were noncompliant in each quarter of 2011. As the CMS notes, improving encounter data quality is an iterative process. The ICHP works with plans that have noncompliant files until they successfully remediate identified issues. The plans are typically very responsive and successfully address critical issues in a timely manner. Table 1: Number of Plans in Each Quarter with Noncompliant First Submissions Quarter 2011Q1 2011Q2 2011Q3 2011Q4 # of Plans with Noncompliant Files on First Submission 4 3 5 5

Table 2 summarizes the percentage of missing and invalid values for some of the core data elements for the health plans. The percentage of missing values is less than 1%, exceeding the performance standards within the CMS protocols which allow for a greater percentage of missing or invalid values.

Table 2: Percentage of Missing and Invalid Values for Selected Data Fields – Health Plans Data Field % Missing/Invalid

Values Applicable

Claims Data Field % Missing/Invalid

Values Applicable

Claims Admission Date 0.00% Inpatient Provider NPI 0.14% All Amount Paid 0.00% All Provider Taxonomy 0.51% All Claim Status 0.00% All Place of Service 0.00% Professional Discharge Date 0.97% Inpatient Procedure Code 0.48% Professional Member ID 0.01% All Revenue Code 0.00% Facility Principal Diagnosis 0.23% All Type of Bill 0.02% Facility


III. Plan Profiles


Amerigroup Active in Florida Healthy Kids since 2003

Performance Measures

Plan Overview

Amerigroup was founded in 1994 as Americaid Community Care, which focused on serving Medicaid recipients. As the company’s publicly insured populations grew to include CHIP and Medicare, it changed its name to Amerigroup. Amerigroup currently serves approximately 1.9 million people in 11 states, including Florida.

Preventive Care, 2011

Measure Plan FHKP Overall

National Medicaid

Mean Well-Child Visits, 3-6 Years 65.0% 62.8% 71.9%

Adolescent Well-Care Visits 57.0% 53.8% 48.1%

Adolescent Immunizations, Tdap/TD

87.0% 86.1% 67.8%

Adolescent Immunizations, Meningococcal

66.9% 64.2% 56.3%

Plan Organizational Characteristics

Total FHKP Members, December 2011 74,435

Plan Type HMO – Mixed Model

For-Profit Yes

Publicly Traded Yes

Effective Care Respiratory Conditions, 2011


National Medicaid

Mean Appropriate Testing, Pharyngitis

69.2% 67.1% 64.9%

Appropriate Asthma Medication, 5-11 y

95.1% 94.0% 91.8%

Appropriate Asthma Medication, 12-18y

87.9% 87.1% 85.8%

Effective Care Behavioral Health, 2011


National Medicaid

Mean 7-Day Follow-Up After MH Hospitalization

42.5% 39.0% 44.6%

30-Day Follow-Up After MH Hospitalization

63.4% 60.7% 63.8%



65.1% 65.1% 65.0%

59.7% 63.1% 62.8%

69.7% 71.6% 71.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009-2010 MY 2010 MY 2011Amerigroup FHKP Overall HEDIS mean

Amerigroup – PIP Summary

Members

Total Members, December 2011

5-6 Year Olds Eligible for HEDIS

Well-Child Visit

74,435 2,129

PIP Component Rating

1. Appropriate Study Topic Met

2. Clear, Measureable Study Question Met

3. Objective, Measureable Indicators Partially Met

4. Appropriately Identified Population Met

5. Valid and Reliable Sampling (if applicable)

N/A- No Sampling

6. Valid and Reliable Data Collection Met

7. Intervention Strategies Likely to Induce Permanent Change Partially Met

8. Appropriate Data Analysis & Interpretation of Results Met

9. “Real” Improvement Documented Not Rated

10. “Real” Improvement Sustained Not Rated

Strengths Opportunities for Improvement

Inter-departmental workgroup that identified member, provider and

systems barriers

Provide more detail about the process for identifying

barriers and which are most significant and

actionable

Reasonable and appropriate interventions

targeting members, providers and systems

More clearly identify the performance goal

Clear data analysis plan and good interpretation of

data findings

Develop additional interventions with potential

for high impact and provide more detail about

interventions

Clear presentation of information

Provide more detail about how data findings feed

back into quality improvement processes

Summary of Interventions Type Interventions

Member Level • Live calls to members without WCV

Provider Level

• Quality Incentive Program

• List of members without WCV delivered by plan staff to providers

• Educational material

Systems • Evaluate completeness of encounters submitted by providers

Well-Child Visits


BCBS- BlueCare Active in Florida Healthy Kids since 1996

PerformanceMeasures



National Medicaid




85.2% 86.1% 67.8%


39.0% 64.2% 56.3%

Plan Overview

Blue Cross and Blue Shield of Florida (BCBS) was formed by the merger of two organizations: Blue Cross of Florida, Inc. (formerly Florida Hospital Service Corporation, which began in 1944) and Blue Shield of Florida, Inc. (formerly Florida Medical Services Corporation, which began in 1946). The merger occurred in 1980 to form the consolidated entity Blue Cross and Blue Shield of Florida. Health Options, Inc., which offers the BlueCare product, is a wholly owned and operated for-profit subsidiary of BCBS of Florida that was purchased in 1983 as South Florida Group Health.



Plan Type HMO (Network)

For-Profit Yes

Publicly Traded No



National Medicaid


53.9% 67.1% 64.9%


LD 94.0% 91.8%


LD 87.1% 85.8%



National Medicaid


LD 39.0% 44.6%


LD 60.7% 63.8%



BCBS- BlueOptions Active in Florida Healthy Kids since 1996

PerformanceMeasures



National Medicaid




88.8% 86.1% 67.8%


50.9% 64.2% 56.3%

Plan Overview

Blue Cross and Blue Shield of Florida (BCBS) was formed by the merger of two organizations: Blue Cross of Florida, Inc. (formerly Florida Hospital Service Corporation, which began in 1944) and Blue Shield of Florida, Inc. (formerly Florida Medical Services Corporation, which began in 1946). The merger occurred in 1980 to form the consolidated entity Blue Cross and Blue Shield of Florida. BlueOptions is an exclusive provider organization (EPO).



National Medicaid


43.7% 67.1% 64.9%


LD 94.0% 91.8%


LD 87.1% 85.8%



Plan Type EPO

For-Profit No

Publicly Traded No



National Medicaid


LD 39.0% 44.6%


LD 60.7% 63.8%



BCBS – PIP Summary


Thoughtful identification of member/provider barriers

Clarify measurement of study indicators and performance goals

Interventions address identified barriers; well-

designed materials

Clarify identification and analysis of test and

control groups

Identified and acted on ways to improve member

materials and processes

Provide a more detailed data analysis plan to

evaluate performance

Thoughtful identification of barriers to implementing

interventions and strategies to overcome those barriers

Strengthen approaches for analyzing and

reporting performance over time

Members



Well-Child Visit BlueCare 4,194 110

BlueOptions 2,605 78


Member Level

• Revised Welcome Brochure to highlight WCVs and educate families that no co-pay is required

• Added FHKP dedicated page on plan website with benefit information and preventive care resources

• Reminder mailings and calls to parents of members without a WCV

Provider Level

• Phone outreach to providers with higher numbers of members without WCV

• List of members without WCV mailed to providers

• Provider newsletters and fax blasts with care guidelines and highlighting no member co-pay for wellness visits


1. Appropriate Study Topic Partially Met



4. Appropriately Identified Population Not Met

5. Valid and Reliable Sampling (if applicable) Not Met

6. Valid and Reliable Data Collection Partially Met


8. Appropriate Data Analysis & Interpretation of Results Partially Met



44.9% 43.6%

38.5%41.4% 42.3%

59.7% 63.1% 62.8%

69.7% 71.6% 71.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009-2010 MY 2010 MY 2011

BCBS - BlueCare BCBS - BlueOptions

FHKP Overall HEDIS mean

Well-Child Visits


Coventry Active in Florida Healthy Kids since 1996


Plan Overview Coventry Health Care of Florida, Inc., formerly known as Vista Healthplan, Inc. (Coventry/Vista) is a Florida-based MCO with corporate offices located in Broward County. Vista was originally licensed under HIP Health Plan of Florida, Inc., which was founded in 1985 as HIP Network of Florida, Inc. In 2000, Florida Healthplan Holdings, LLC, purchased HIP Health Plan. In 2001, HIP Health Plan was renamed Vista Healthplan, Inc. Beacon Health Plans, Inc., and Healthplan Southeast, Inc., were merged into Vista Healthplan Inc. at the end of 2001. In 2007, Coventry Health Care, Inc. purchased Vista’s parent company. Vista is a wholly-owned subsidiary of Coventry, which is a publicly traded Fortune 500 company. In 2010, Vista changed its name to Coventry Health Care of Florida, Inc. to reflect the affiliation with its parent entity.



National Medicaid




85.0% 86.1% 67.8%


64.0% 64.2% 56.3%



Plan Type HMO (IPA)

For-Profit Yes

Publicly Traded No



National Medicaid


LD 39.0% 44.6%


LD 60.7% 63.8%



National Medicaid


72.2% 67.1% 64.9%


97.5% 94.0% 91.8%


90.2% 87.1% 85.8%



Coventry – PIP Summary


Member Level

• Members due for WCV accessible to customer service staff to address during inbound calls

• Letters and automated calls to members without WCV

• Website links to preventive care information and resources

• Community outreach events

Provider Level

• Face-to-face visits with targeted providers: HEDIS education and review members due for WCV

• List of members without WCV sent to all providers

• Provider portal with information about members needing WCV

Systems • HEDIS training for plan staff to

improve member outreach efforts • Evaluate completeness/accuracy of

encounters submitted by providers


Clear identification of study indicators and

results Increase specificity of

performance goal

Strong interventions that are multifaceted and

address identified member, provider, and

plan barriers

Incorporate greater provider/member

engagement in developing and evaluating interventions

Significant improvement in ICHP-reported rate

Prioritize interventions that have greater potential for

impact




3. Objective, Measureable Indicators Met



N/A- No Sampling






Members



Well-Child Visit 23,615 713

Well-Child Visits

55.3%51.9%

63.4%59.7% 63.1% 62.8%

69.7% 71.6% 71.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009-2010 MY 2010 MY 2011

Conventry FHKP Overall HEDIS mean


Florida Health Care Plans Active in Florida Healthy Kids since 1992




National Medicaid




86.8% 86.1% 67.8%


61.8% 64.2% 56.3%

Plan Overview

Florida Health Care Plans, Inc. (FHCP) was incorporated as a not-for-profit entity on June 2, 1971, and began operations on July 1, 1974. FHCP became the first federally qualified HMO in Florida in 1976. In 1994, FHCP became a not-for-profit controlled affiliate of Halifax Community Health Center. Recently, in 2009, FHCP was acquired by BCBS of Florida, transitioning from a not-for-profit to a for-profit entity. FHCP was the original health plan that served the FHKP when it began as a pilot program in 1992 in Volusia County. FHCP served FHKP members in Collier and Volusia counties during calendar year 2011.



Plan Type HMO (Mixed Type)

For-Profit Yes

Publicly Traded No



National Medicaid


61.7% 67.1% 64.9%


LD 94.0% 91.8%


LD 87.1% 85.8%



National Medicaid


LD 39.0% 44.6%


LD 60.7% 63.8%



FHCP – PIP Summary


Member surveys used to assess barriers and

intervention effectiveness

Provide a more detailed barrier analysis; refine survey instrument and

methodology

Interventions target members and providers and are well described

Identify methods to evaluate statistically

significant changes in performance

Detailed feedback sought from providers regarding provider follow-up with members due for WCV

Consider more intensive interventions and involving

providers in developing interventions

Members



Well-Child Visit 5,142 144


Member Level

• Birthday reminder letters for annual WCV

• Surveys to assess barriers to getting WCV

• Newsletters with educational information about well visits

Provider Level

• List of members without WCV given to providers and feedback solicited from provider offices about members scheduled or unable to contact

• Educational resources on wellness/prevention







N/A- No Sampling






Well-Child Visits

54.3%

66.2% 64.6%59.7%63.1% 62.8%

69.7% 71.6% 71.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009-2010 MY 2010 MY 2011

FHCP FHKP Overall HEDIS mean


Simply Health Care Plans, Inc. Active in Florida Healthy Kids since 2010




National Medicaid




LD 86.1% 67.8%


LD 64.2% 56.3%

Plan Overview

Simply Healthcare Plans, Inc. (Simply) is a Florida-based HMO that is focused on government programs. It received its certificate of authority to operate in Florida in December 2009. In 2010, Simply acquired Total Health Choice, Inc.’s assets related to the Florida Medicaid and FHKP lines of business.



Plan Type HMO (Network)

For-Profit Yes

Publicly Traded No



National Medicaid


74.3% 67.1% 64.9%


LD 94.0% 91.8%


LD 87.1% 85.8%



National Medicaid


LD 39.0% 44.6%


LD 60.7% 63.8%



Simply – PIP Summary

Members


5-6 Year Olds Eligible for HEDIS Well-Child Visit

1,900 45


Clear data analysis plan Provide a more detailed barrier analysis

Member outreach to assess reasons why

members do not have well-child visits

Provide more information about data quality, data collection, and internal HEDIS measurement

Interventions target both members and providers

Identify additional and more intensive interventions


Member Level

• Outreach calls to members without WCV to provide education about well-child check-ups, assess reasons for not scheduling appointments, and assist with scheduling appointments

• Remind parents of upcoming appointments

Provider Level

• Notify providers of patients due for WCV







N/A-No Sampling



8. Appropriate Data Analysis & Interpretation of Results Not Rated



Well-Child Visits

64.4%59.7%

63.1%

62.8%

69.7%71.6% 71.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009-2010 MY 2010 MY 2011Simply FHKP Overall HEDIS mean


United Health Care Active in Florida Healthy Kids since 1998




National Medicaid




87.2% 86.1% 67.8%


57.2% 64.2% 56.3%

Plan Overview

United Healthcare of Florida, Inc. (UHC) was incorporated as a for-profit HMO in 1970. In 1973, it received its certificate of authority to operate as an HMO in Florida. UHC of Florida is a wholly owned subsidiary of United Healthcare, Inc., which in turn is a wholly owned subsidiary of United HealthCare Services, Inc., which in turn is a wholly owned subsidiary of UnitedHealth Group, Inc.



Plan Type HMO (Group and IPA)

For-Profit Yes

Publicly Traded Yes



National Medicaid


64.7% 67.1% 64.9%


92.9% 94.0% 91.8%


86.6% 87.1% 85.8%



National Medicaid


41.5% 39.0% 44.6%


63.8% 60.7% 63.8%



United Health Care – PIP Summary

Members



Well-Child Visit 51,266 1,294

Summary of Interventions Type Intervention

Member Level

• Birthday postcard reminders • Live & automated reminder calls to

members due for WCV; welcome calls • Incentive program in development • Newsletter education

Provider Level

• Clinical Practice Consultant visits to large-panel provider offices: HEDIS education, review members due for WCV, share best practices

• Print and online preventive care guidelines and resources

• Pre-printed postcards provided to PCPs to send to members due for WCV

Systems • Database updates to track members due

for WCV & generate provider reports • Evaluate completeness/accuracy of

encounters submitted by providers







N/A- No Sampling


7. Intervention Strategies Likely to Induce Permanent Change Met

8. Appropriate Data Analysis & Interpretation of Results Met




Careful and thorough barrier analysis with barriers prioritized

Monitor ICHP-calculated rates as well as plan-

calculated rates

Multifaceted and creative interventions that address

barriers at member, provider, and plan levels

Quantify intervention activities where possible

Ongoing process of quality assessment and

improvement

Consider placing greater emphasis on more

innovative aspects of PIP such as incentive program

and Clinical Practice Consultants

Well-Child Visits

54.1%

64.8% 65.5%59.7%

63.1% 62.8%

69.7% 71.6% 71.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009-2010 MY 2010 MY 2011

UHC FHKP Overall HEDIS mean


WellCare-HealthEase Active in Florida Healthy Kids since 2003

Plan Overview WellCare Health Plans, Inc. is the parent company of WellCare of Florida and HealthEase of Florida. WellCare of Florida was formed in 1985 as Well Care HMO by a group of physicians located in Tampa, Florida. HealthEase of Florida, Inc., was formed in 2000 to acquire Tampa General Health Plan, Inc., which was licensed as a Florida HMO in 1997. In 2002, WellCare Health Plans, Inc. (WHP) was formed to acquire various WellCare subsidiaries that operate health plans focused on government programs. Included in these acquisitions were WellCare of Florida and HealthEase of Florida, which are indirectly wholly-owned subsidiaries of WHP. WHP is a publicly traded company that specializes in providing managed care services for public insurance programs. The WellCare companies offer two product lines for the FHKP, Staywell and HealthEase, which have served FHKP members since 2003.

Plan Organizational Characteristics Total FHKP Members, December 2011 10,439

Plan Type HMO (IPA)

For-Profit Yes

Publicly Traded Yes



National Medicaid


36.2% 39.0% 44.6%


55.2% 60.7% 63.8%



National Medicaid




82.3% 86.1% 67.8%


55.5% 64.2% 56.3%



National Medicaid


69.9% 67.1% 64.9%


100% 94.0% 91.8%


77.8% 87.1% 85.8%



WellCare-Staywell Performance Measures

Active in Florida Healthy Kids since 2003



National Medicaid


29.3% 39.0% 44.6%


51.8% 60.7% 63.8%



National Medicaid




85.9% 86.1% 67.8%


68.6% 64.2% 56.3%

Plan Overview WellCare Health Plans, Inc. is the parent company of WellCare of Florida and HealthEase of Florida. WellCare of Florida was formed in 1985 as Well Care HMO by a group of physicians located in Tampa, Florida. HealthEase of Florida, Inc., was formed in 2000 to acquire Tampa General Health Plan, Inc., which was licensed as a Florida HMO in 1997. In 2002, WellCare Health Plans, Inc. (WHP) was formed to acquire various WellCare subsidiaries that operate health plans focused on government programs. Included in these acquisitions were WellCare of Florida and HealthEase of Florida, which are indirectly wholly-owned subsidiaries of WHP. WHP is a publicly traded company that specializes in providing managed care services for public insurance programs. The WellCare companies offer two product lines for the FHKP, Staywell and HealthEase.



National Medicaid


66.3% 67.1% 64.9%


90.9% 94.0% 91.8%


88.1% 87.1% 85.8%



Plan Type HMO (IPA)

For-Profit Yes

Publicly Traded Yes



WellCare – PIP Summary

Members



Well-Child Visit HealthEase 10,439 301

StayWell 49,125 1,379


Member Level

• Letters encouraging retaining coverage • Incentive program - gift card for

scheduling and keeping WCV appointment

• Outreach calls with education about WCV and scheduling assistance

• Members due for WCV accessible to customer service staff to address during inbound calls

• Reminder birthday letters

Provider Level

• Office visits with providers with higher rates of members due for WCV

• Pay for Performance program based on meeting specific performance thresholds

• Lists of members due for WCV delivered to providers

• Newsletter with preventive care guidelines

• Provider portal with information about members needing WCV

Systems • Evaluate completeness/accuracy of encounters submitted by providers






5. Valid and Reliable Sampling (if applicable) Met

6. Valid and Reliable Data Collection Met






WCV compliance evaluated by county and

language

Provide more detail about the barrier analysis

process and findings

Clear data analysis and appropriate interpretation

of findings

Provide more detail about each intervention

Broad range of interventions, including

innovative strategies such as member and provider

incentives

Consider a greater focus on a more limited set of

interventions with the greatest potential for

impact

Well-Child Visits

46.3%

63.9%

57.5%

62.4%66.2%

59.6%59.7% 63.1%

62.8%

69.7% 71.6% 71.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2009-2010 MY 2010 MY 2011

Wellcare- HealthEase Wellcare- Staywell

FHKP Overall HEDIS mean


DentaQuest Active in Florida Healthy Kids since 2002

Annual Dental Visit, 2011


National Medicaid

Mean

4-6 Years Old 57.6% 57.6% 54.3%

7-10 Years Old 62.2% 63.1% 58.5%

11-14 Years Old 57.6% 58.3% 53.2%

15-18 Years Old 51.4% 52.2% 44.9%

Children Receiving Dental Preventative Services

Enrollment Length Plan FHKP

Overall

Any 35.6% 36.5%

At least 3 Months 40.6% 41.5%


11-12 Months 51.2% 52.1%

Plan Overview

DentaQuest, Inc. was formerly known in Florida as Atlantic Dental, Inc. (ADI). ADI was established and incorporated in Florida in 1997, specializing in dental benefits administration. ADI was acquired by Doral Dental USA in 2008. The ultimate parent company is Dental Service of Massachusetts, Inc., a non-profit dental service corporation. All business conducted outside of Massachusetts is under the DentaQuest brand. In 2010, ADI changed its name to DentaQuest of Florida, Inc.



Plan Type HMO (Group & IPA)

For-Profit Yes

Publicly Traded No



DentaQuest – PIP Summary

Members


Number Members Enrolled 11-12 Months

119,404 75,392


Plan provided thoughtful narrative about the

relevance of preventive dental care to child oral health and overall health

Provide rationale for selection of pilot county;

identify appropriate comparison county

Selection of dental

sealants as study topic for age-appropriate

preventive services – strong evidence base

More precisely define study indicators and

performance goals and develop a more detailed

data analysis plan

Plan examined rates over several years to place

overall results in a larger context

Conduct a careful barrier analysis that forms the

basis for interventions at member, provider and

plan levels


Member Level

• Reminder mailings to members due

for visits

• Phone calls to members due for visits





4. Appropriately Identified Population Not Met

5. Valid and Reliable Sampling (if applicable) N/A

6. Valid and Reliable Data Collection Not Met





48% 49% 52%

46% 48%

51%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FFY 2008-2009 FFY 2009-2010 FFY 2010-2011

FHKP Overall DentaQuest

Preventive Visits Enrolled 11-12 Months


MCNA Dental Plans

Performance Measures Active in Florida Healthy Kids since 2005

Annual Dental Visit, 2011


National Medicaid

Mean

4-6 Years Old 56.8% 57.6% 54.3%

7-10 Years Old 63.2% 63.1% 58.5%

11-14 Years Old 58.3% 58.3% 53.2%

15-18 Years Old 52.9% 52.2% 44.9%

Plan Overview

Managed Care of North America Inc., (MCNA) is a Florida-based dental managed care company that administers dental benefits for Medicaid, CHIP, and Medicare programs in 22 states.

Children Receiving Dental Preventative Services

Enrollment Length Plan FHKP

Overall

Any 35.8% 36.5%



11-12 Months 52.3% 52.1%



Plan Type HMO (Group)

For-Profit Yes

Publicly Traded No



MCNA – PIP Summary

Members


Number Members Enrolled 11-12 Months

101,348 60,086





4. Appropriately Identified Population Partially Met


N/A – No Sampling







Member Level

• Community outreach in Broward, Duval, Miami-Dade and Polk counties promoting good oral health behaviors and stressing importance of dental check-ups

Provider Level

• Provider outreach to selected provider offices in Miami-Dade and Palm Beach counties with education about: preventive services, caregiver counseling, AAPD guidelines, effective recall systems, dental records, and referring members who repeatedly break appointments to Case Management for follow-up


Thoughtful narrative about importance of preventive dental services and low use among low-income

populations

Refine and clarify data analysis plan and

measurement approaches

Selection of dental sealants as study topic for age-appropriate preventive services – strong evidence

base

Develop more targeted and more intensive

interventions based on a careful barrier analysis

Plan solicits information from providers about

members who repeatedly miss scheduled

appointments so case management can provide

assistance

Address identified inconsistencies in study

indicators and measurement

48% 49%49% 51% 52%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FFY 2008-2009 FFY 2009-2010 FFY 2010-2011

FHKP Overall MCNA

Preventive Visits Enrolled 11-12 Months


End Notes 1Children’s Health Insurance Program Reauthorization Act of 2009. Public Law 111-3. Available at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_public_laws&docid=f:publ003.111. 2 Herndon et al. “Quality of Care: Health and Dental Plan Performance Measures for Measurement Year 2011.” Prepared for the Florida Healthy Kids Corporation. August 2012. 93 Pages.

3Department of Health and Human Services. Federal Register Notice 2474-NC-CMS: Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs - Background Report. 2009. 4 U.S. Department of Health & Human Services. Centers for Medicare & Medicaid Services, Medicaid Early & Periodic Screening & Diagnostic Treatment Benefit, State Agency Responsibilities. https://www.cms.gov/MedicaidEarlyPeriodicScrn/03_StateAgencyResponsibilities.asp. Accessed July 23, 2011. 5Centers for Medicare & Medicaid Services. CHIPRA Initial Core Set Technical Specifications Manual 2011: Washington DC; February 2011. 6National Committee for Quality Assurance. HEDIS 2011: Volume 2 Technical Specifications: Washington DC: National Committee for Quality Assurance; 2010. 7 Centers for Medicare and Medicaid Services. 2003. Monitoring Medicaid Managed Care Organizations (MCOs) and Prepaid Inpatient Health Plans (PIHPs): A Protocol for Determining Compliance with Medicaid Managed Care Proposed Regulations at 42 CFR Parts 400, 430, et al., Final Protocol, Version 1.0, February 11, 2003 8Herndon et al. “Florida Healthy Kids Program Interviews with Plan Administrators: Health Plan Organizational Structure and Processes for Calendar Year 2011.” Prepared for the Florida Healthy Kids Corporation. September 2012. 18 Pages. 9Herndon et al. “Florida Healthy Kids Program Interviews with Plan Administrators: Dental Plan Organizational Structure and Processes for Calendar Year 2011.” Prepared for the Florida Healthy Kids Corporation. September 2012. 13 Pages. 10Centers for Medicare and Medicaid Services. 2002. Validating Performance Improvement Projects. Final Protocol Version 1.0. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Quality-of-Care-External-Quality-Review.html. 11Herndon et al. “Florida Healthy Kids Program Performance Improvement Project Validation: Reporting on PIPs Implemented During the 2011-2012 Evaluation Period.” Prepared for the Florida Healthy Kids Corporation. September 2012. 30 Pages.


florida healthy kids program annual evaluation summary

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