Medicaid Contract Purchasing Specifications

Part 8 Quality Measurement and Improvement

Reflected in this Part are provisions from the Balanced Budget Act of 1997 (BBA), P.L. 105-33 under §1932(c) of the Social Security Act, 42 U.S.C. §1396u-2(c). relating to the measurement and improvement of quality in Medicaid MCOs. In particular, this provision requires States that contract with Medicaid MCOs on a risk basis to (1) develop and implement a "quality assessment and improvement strategy" and (2) provide for the conduct of an annual external independent review of the quality outcomes and timeliness of, and access to, covered items and services under each Medicaid MCO contract.

HCFA has published a letter to State Medicaid Directors dated January 20, 1998 providing initial guidance to states regarding external independent review, see www.hcfa.gov/medicaid/bbaeqr2.htm.

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on quality measurement and improvement is for your consideration. Purchasers may also find it useful to review Negotiating the New Health System (3^rd Ed.) which provides other options relating to quality measurement and improvement used by state agency purchasers in contracting with Medicaid MCOs. These options may be found at Table 5.1, Vol. 2, Part 4, pages 5-14 through 5-215 (www.gwu.edu/~chsrp).

Table of Contents

§801. In General
§802. Quality Measurement and Improvement Program
§803. Clinical Studies
§804. Drug Formulary Assessment
§805. Utilization Review
§806. External Quality Review
§807. Periodic Medical Audits
§808. Confidentiality
§809. Data Collection and Reporting

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language is for your consideration.

^K§801. In General¹

(a) Internal Quality Assurance — Contractor² shall establish and maintain an internal quality measurement and improvement program that complies with the requirements of 42 C.F.R. §434.34 and with the following:

(1) Program Elements — Contractor shall comply with the requirements of §802;

(2) Clinical Studies — Contractor shall conduct clinical studies in accordance with §803; and

(3) Drug Formulary Assessment —Contractor shall conduct the assessment required under §804.

(b) Utilization Review — Contractor shall comply with the requirements of §805.

(d) Medical Audit — Contractor shall comply with the requirements of §807.

(e) Reporting — Contractor shall comply with the requirements of §809 relating to reporting of quality data.

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on quality measurement and improvement programs is for your consideration.

^K§802. Quality Measurement and Improvement Program

(a) In General —Contractor shall establish and maintain an internal quality measurement and improvement program to:

(1) monitor and evaluate the quality and appropriateness of items and services covered under Part 1 furnished to enrolled children under [drafter insert name of purchasing document]; and

(2) identify and correct instances and patterns of inappropriate reduction or denial of items and services covered under Part 1 for enrolled children under [drafter insert name of purchasing document].

(b) Elements — The program described in subsection (a) shall contain the following elements:

(1) Standards — Contractor shall develop and apply the following standards:

(A) standards for measuring the quality, continuity, and appropriateness of items and services covered under Part 1 furnished to enrolled children;

(B) standards for access by enrolled children to items and services covered under Part 1 that are consistent with Part 6;

(C) standards for access by enrolled children with special health care needs (as defined in §1401(f)) to items and services covered under Part 1;

(D) standards for access by enrolled children whose family or caregivers do not use English as a primary language that are consistent with §506 of Part 5; and

(E) standards for access by enrolled children to items and services covered under Part 1 furnished in a culturally competent manner that are consistent with §501(d) of Part 5.

(2) Compliance Review — Contractor shall review its compliance (and the compliance of providers through which Contractor furnishes items and services covered under Part 1 to enrolled children) with:

(A) the requirements of §§101A - 103A of Part 1A relating to coverage determination standards, coverage determination procedures, and prior authorization;

(B) the requirement of §004(e) of the Overview for professional competence applicable to each provider participating in Contractor's provider network; and

(C) the requirement of §006(a)(1) of the Overview relating to the use of child health supervision guidelines reflecting generally accepted principles of professional pediatric practice.

(3) Satisfaction Surveys

(A) Duty to Survey — Contractor shall conduct, or arrange for the conduct of, a survey at least once every [ ] months to assess the satisfaction of enrolled children (and the children's families or caregivers) and providers participating in Contractor's provider network with respect to the accessibility and quality of items and services covered under Part 1.

(B) Prior Purchaser Approval — Contractor shall conduct the survey described in subparagraph (A) with an instrument that Purchaser has approved in advance of the administration of the survey.

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on clinical studies is for your consideration.

^K§803. Clinical Studies³

(a) Clinical Studies — Contractor shall conduct on an [ ] basis the following studies to assess the clinical quality of the items and services covered under Part 1 furnished to enrolled children under [drafter insert name of purchasing document]:

(1) the provision of appropriate immunization services covered under §102(b)(1)(C) of Part 1 to enrolled children whose immunization status is not current;

(2) the provision of mental and developmental evaluations covered under §102(b)(1)(A) of Part 1 to enrolled children under age 3;⁴

(3) the provision of preventive dental services covered under §102(b)(3) of Part 1 to enrolled children;

(4) the clinical management of enrolled children with elevated blood lead levels identified through assessments covered under §102(b)(1)(D) of Part 1;

(5) the clinical management of enrolled children diagnosed with tuberculosis covered under §108 of Part 1;

(6) the provision of case management services covered under §101(v) of Part 1 to enrolled children with special health care needs (as defined in §1401(f));

(7) the provision of family planning services covered under §101(g) and §104 of Part 1 to enrolled adolescents (as defined in §1401(a)); or

(8) the provision of EPSDT screening services covered under §102(b)(1) of Part 1 to enrolled adolescents.⁵

(b) Consultation — In conducting the clinical studies required under subsection (a), Contractor shall consult with [drafter insert names of experts in pediatric care and appropriate state agencies].

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on drug formulary assessments is for your consideration.

^K§804. Drug Formulary Assessment

(a) Assessment — In the event that Contractor uses a drug formulary as permitted under §103(c) of Part 1, Contractor shall perform on a [ ] basis an assessment of the sufficiency of the formulary for enrolled children which identifies:

(1) each drug in the formulary and its therapeutic equivalent;

(2) the process for substitution of a therapeutic equivalent; and

(3) the effect of the substitution of a therapeutic equivalent upon the quality of clinical care furnished to enrolled children.

(b) Consultation — In conducting the assessment described in subsection (a), Contractor shall consult with [drafter insert names of experts in pediatric care and appropriate state agencies].

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on utilization review is for your consideration.

^K§805. Utilization Review

(a) Compliance with Coverage Requirements —Contractor shall ensure that the utilization review policies and procedures in use by Contractor:

(1) comply with the requirements of §§101A - 103A of Part 1A relating to coverage determination standards, coverage determination procedures, and prior authorization; and

(2) are consistent with the child health supervision guidelines reflecting generally accepted principles of professional pediatric practice enumerated in §006(a)(1) of the Overview.⁶

(b) Detection of Under-Utilization — Contractor shall ensure that the utilization review policies and procedures in use by Contractor:

(1) effectively detect and correct instances and patterns of under-utilization of items and services covered under Part 1 by enrolled children; and

(2) provide for the periodic review of utilization patterns among enrolled children by pediatric specialists (as defined in §1401(s)).

(c) Personnel Qualified to Make Review Determinations — Contractor shall ensure that the personnel making utilization review or coverage determinations on the part of Contractor are qualified in accordance with §102A(f) of Part 1A.

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on external quality review is for your consideration.

§806. External Quality Review

^L(a) Cooperation with EQRO — Consistent with §905(d) of Part 9, Contractor shall ensure that Contractor and each provider participating in Contractor's provider network collects and reports the data and information required by an external quality review organization to carry out its responsibilities under §1902(a)(30)(C) and §1932(c)(2) of the Social Security Act, 42 U.S.C. §1396a(a)(30)(C) and 42 U.S.C. §1396u-2(c)(2).

^K(b) Access to External Quality Review Results — Consistent with §912(b) of Part 9, Contractor agrees that the results of each annual external independent quality review conducted by [drafter insert name of qualified independent entity (external quality review organization) conducting such review] shall be available to each:

(1) provider participating in Contractor's provider network;

(2) enrolled child (and the family or caregiver of such child); and

(3) potential enrolled child (and the family or caregiver of such child).

^L§807. Periodic Medical Audits — [RESERVED]

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on confidentiality is for your consideration.

^K§808. Confidentiality

The requirements of §1002 of Part 10 relating to confidentiality protections shall apply to Contractor's compliance with the quality measurement and improvement requirements under this Part.

If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on data collection and reporting is for your consideration.

^K§809. Data Collection and Reporting

Contractor shall ensure that Contractor and each provider participating in Contractor's provider network comply with the requirements of Part 9 relating to data collection and reporting.

^KCompliance measure: Contractor shall make available to Purchaser on request:

(1) copies of all standards for quality and access in use in Contractor's quality measurement and improvement program;

(2) copies of the protocols and procedures used by Contractor in carrying out clinical studies;

(3) copies of the protocols and procedures used by Contractor in conducting drug formulary assessments;

(4) copies of the protocols and practice guidelines used by Contractor in carrying out utilization review;

(5) the names and qualifications of the personnel conducting utilization review for Contractor; and

(6) copies of satisfaction surveys of enrolled children and participating providers.

Endnotes

An alternative option would be to require Contractor to comply with HCFAÀs Quality Improvement System for Managed Care (QISMC) for organizations contracting with Medicare and Medicaid. See Interim QISMC Standards, September 28, 1998, www.hcfa.gov/quality/docs/qismc-in.htm. QISMC Interim Standards and Guidelines are optional for Medicaid MCOs and mandatory for Medicare+Choice Organizations. See HCFA Operational Policy Letter #72, September 30, 1998, http://www.hcfa.gov/medicare/opl072.htm.
If Contractor also participates in the Medicare + Choice program, an alternative option would be to require Contractor to use the QISMC interim standards and guidelines for Medicaid that Contractor is otherwise required to use for Medicare.
An alternative option would to include the national quality assessment and performance improvement (QAPI) project of national interest that HCFA requires Medicare+ Choice organizations to conduct. In 1999, this project will focus on diabetes mellitus, using a standardized measurement set for diabetic processes of care and suggested interventions. See HCFA Operational Policy Letter #72, September 30, 1998, http://www.hcfa.gov/medicare/opl072.htm.
An alternative option would be to include enrolled children (including adolescents) in other age cohorts.
An alternative option would be to include enrolled children with chronic physical illnesses and conditions, behavioral, emotional, or mental disturbances, and substance use/abuse/dependence.
As discussed in footnote 1 to ï¿½002(a)(2) of the Overview, an alternative option would be to delete any requirement that Contractor use any of the child health supervision guidelines enumerated in ï¿½006(a)(1) of the Overview in any context, including utilization review. Another alternative option in the context of utilization review would be to require Contractor to develop (or adopt) and disseminate practice guidelines (other of the child health supervision guidelines enumerated in ï¿½006(a)(1) of the Overview) that are based on reasonable medical evidence or a consensus of health care professionals and to require that ContractorÀs utilization management is consistent with such guidelines.