Health Outcomes Quality Management
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Medicaid Quality Strategy
Requirements as outlined under Code of Federal Regulation 42 CFR 438.200 - 204 delineate State responsibilities for adoption of a Quality Strategy. 42 CFR 438.202(a) states that States will have a written strategy for assessing and improving the quality of managed care services offered by all [Managed Care Organizations] MCOs and [Prepaid Inpatient Health Plans] PIHPs. The 2007 State of Colorado Quality Strategy was adopted January 2007 after commentary was obtained from stakeholders and the public. |
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HEDIS 1 Reports
HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. The performance measures in HEDIS are related to many significant public health issues such as cancer, heart disease, smoking, asthma and diabetes. HEDIS also includes a standardized survey of consumers' experiences that evaluates plan performance in areas such as customer service, access to care and claims possessing.
Legislative Report on Status of Pediatric Health Care Quality Performance Measures
Behavioral Health Organization Performance Measure Validation
Health Services Advisory Group (HSAG), the Department of Health Care Policy and Financing's External Quality Review Organization (EQRO), conducts validation activities outlined in the CMS Performance Measure Validation Protocol for each of the Behavioral Health Organizations (BHOs). The performance measures are calculated on an annual basis. Each BHO is subject to the same measures making it possible to compare performance measures for each health plan. |
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Encounter Data Validation
The Department contracted Health Services Advisory Group, Inc. (HSAG) to conduct the 2008 Behavioral Health Encounter Data Validation (EDV) study. The purpose of the EDV study was to evaluate the extent to which administrative encounters for behavioral health services are accurate and complete.
Focused Studies
On an annual basis, the Department of Health Care Policy & Financing collaborates with its contracted managed care organizations (MCOs), prepaid inpatient health plans (PIHPs) and the external quality review organization, Health Service Advisory Group, Inc. (HSAG), to examine a specific aspect of health care for a defined point in time. The intended purpose of these studies is to identify opportunities and meaningful interventions that will promote quality care. These projects are usually based on information extracted from medical records or MCO/PHP administrative data such as enrollment files and encounter/claims data. |
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Site Reviews
Reviews performed on-site at the MCO/PIHP health care delivery system sites to assess the physical resources and operational practices in place to deliver health care. There are various components of a site review, such as desk audits, emergency site visits, profiling, compliance reporting requirements and other quality and program integrity review activities. The Final Report is reviewed by the Department in order to make recommendations for contract changes and for future audit process improvement. |
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Physical Health Plan Site Reviews
Colorado Access 2009 Denver Health 2009, 2008, 2007 Rocky Mountain Health Plan 2009, 2008, 2007
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Behavioral Health Plan Site Reviews
Access Behavioral Care 2009, 2008, 2007 Behavioral HealthCare, Inc. 2009, 2008, 2007 Colorado Health Partnerships 2009, 2008, 2007 |
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Performance Improvement Projects (PIPS)
Performance Improvement Projects (PIPs), are the method health plans use to improve clinical and non-clinical services. PIPs provide a structured approach to measuring performance, implementing change to improve performance, and measuring the resulting outcomes. Changes that lead to favorable sustained results become permanent standards, practices, or procedures. Changes that are not successful should be revised and re-measured so that improvements are made. MCO/BHO requirements under the Code of Federal Regulations (42 CFR 423.240) state that PIPs be designed to achieve significant improvement, sustained over time, in clinical and nonclinical areas that are expected to have a favorable effect on health outcomes and/or member satisfaction.
Behavioral Health PIPS
Access Behavioral Care
Behavioral HealthCare, Inc.
Colorado Health Partnerships
Foothills Behavioral Health Partners
Northeast Behavioral Health Partnership
Managed Care PIPS
Colorado Access
Denver Health
Rocky Mountain Health Plan |
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Client Satisfaction Surveys CAHPS 2 (Consumer Assessment of Health Plans Study)
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program develops and supports the use of a comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care. These surveys cover topics that are important to consumers, such as the communication skills of providers and the accessibility of services. |
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Annual Technical Reports
The Balanced Budget Act of 1997, Public Law 105-33, requires states to prepare an annual technical report that describes the manner in which data from activities conducted in accordance with 42 CFR 438.358 was aggregated and analyzed. The report must describe how conclusions were drawn as to the quality and timeliness of, and access to, care furnished by the states' managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs). The report of results must also contain an assessment of the strengths and weaknesses of the plans with regard to health care quality, timeliness, and access, make recommendations for improvement, and assess the degree to which any previous recommendations were addressed by the MCOs and PIHPs. |
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Interventions
Interventions are developed based on recommendations from the Focused Studies. The intervention audience includes Medicaid members and providers. Most interventions are available in English and Spanish. |
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1 HEDIS is a registered trademark of the National Committee for Quality Assurance 2 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality
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