CYE 2014 Performance Measure FAQ

As of September 20, 2013

1.   For the Inpatient Utilization and Ambulatory Care measures for adults, is the age range supposed to be ages 21+ vs. 20+?

No.  The age range for the adult Inpatient Utilization and Ambulatory Care measures is ages 20+. This aligns with the age brackets described in the methodology.  For consistency purposes, AHCCCS is striving to align as closely as possible with national methodologies; therefore, the adult age group for these measures will begin at age 20.

2.   Will performance measures be based on authorization data or claims (encounter) data?

Measures will be calculated using encounter data.

3.   Some lines of business (CMDP and DDD) have specific performance measures listed related to behavioral health. What are the responsibilities associated with those measures?

In regards to the Behavioral Health measures, AHCCCS will now be responsible for running all of the DBHS performance measures, similar to how measures are run for Acute-care and ALTCS contractors (historically DBHS has run their own measures with EQRO validation).  AHCCCS will provide an aggregate rate as well as rates specific to the CMDP and DDD populations.  We will share the data with the Contractors as well as DBHS and AHCCCS will generate a report similar to what is published for the Acute-care measures.  In the interim, CMDP and DDD should be receiving quarterly status updates on each measure from DBHS.  AHCCCS have provided extensive guidance on how DBHS should achieve ongoing monitoring and reporting; starting in October, DBHS will have to submit quarterly reports on their PMs (aggregate and specialized populations-specific) in order to ensure they are on track.  AHCCCS believes that this will help all parties involved to better manage member health.

4.   Regarding the various admissions rates (Diabetes Short-Term Complications, COPD, Asthma, and CHF) does the “transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)” exclusion, mean that members residing in these setting are excluded?

Yes.

5.   How will the Follow-Up After Hospitalization measures work for physical health since the methodology is only for mental health?

Basically, this measure will measuring office visits within the specified timeframes following a discharge from a hospital.  Any hospital discharge (with the exception of deliveries for the 7-day measure) should be followed by a follow-up visit with a PCP or specialist.  The belief is that follow-up care will lower the hospital readmission rate, promote better member health, and potentially lower long-term costs.

6.   For  the  Follow-Up  After  Hospitalization  measures,  will  they  encompass  behavioral  health conditions also or will those be attributed to ADHS?

All diagnoses will be included in the measure; however, the hospitalization and related follow-up care will be attributed to the payer of the hospitalization.   For an Acute-care member, if the hospitalization is paid for by an Acute-care contractor, the contractor is also responsible for ensuring the follow-up care.  If the hospitalization is paid for by DBHS, they would be responsible for ensuring follow-up care.

7.   Could additional definition regarding members included in the measures be provided, specially related to dual members?

At this time, only aligned dual members will be included in the performance measure rates.  The population may be expanded if AHCCCS can reach a data sharing agreement with CMS for dual members and/or AHCCCS develops a mechanism for accepting Medicare claim data for Medicaid members, regardless of with health plan provides the member’s Medicare coverage.  Should one of those developments occur, AHCCCS will notify Contractors of the change; however, for CYE 2014 only aligned members will be included in the measures.

8.   How does the Readmission measure differ from the Readmission PIP?

The Readmission PIP evaluates all hospital discharges and related readmissions within 30 days. There are limited exclusions for the PIP and it is generally broader than the Performance Measure. The performance measure will more closely align with national methodologies (CMS Adult Core and HEDIS) and will focus on a count of readmissions within 30 days as well as the probability of readmissions, based on a series of risk adjustments related to the population served.

9.   How will the Readmission performance measure work?

The Readmission performance measure will focus on a count of readmissions within 30 days as well as the probability of readmissions, based on a series of risk adjustments related to the population served.  Contractors should use the commercial risk tables outlined in the HEDIS specifications.  The only exception to this is ALTCS E/PD contractors, who should use the Medicare risk tables outlined in the HEDIS methodology.  The measure is all-cause, so it is possible that the initial discharge and readmission diagnoses will not be the same.

10. For the Flu measures, please verify that there are no longer SNF vs. HCBS rates but rather the rates are based on age.

Yes, the Flu measures are now based on age.  Placement will no longer be a factor for the measures. The exclusions for this measure will remain the same.

11.  For the admissions measures, are the rates based purely on admissions or on interventions post admit?

The rates for these measures will be calculated using discharge diagnoses.  If the primary diagnoses align with one of the measures, the hospital admission will count towards that measure rate.

12.  Is the rate for ED utilization based on member months or member years? (NEW)

The ED measure should be reflective of member years.  When the measure information was initially published, member months were indicated.  However, such was not correct.  All MPS and Goal rates were based on member years data.