- Evaluation Design
- Pay for Performance
- Performance Measures
- Quality Assessment and Performance Improvement (QAPI) Program
- Health Plan Accreditation
The KanCare contracts require high performance from each of the KanCare health plans, and the program as a whole. Below are some of the key quality measurement programs that are being used to ensure high quality of care in KanCare.
Under the terms of the KanCare Section 1115 demonstration, the State was to submit a proposed evaluation design for the demonstration to CMS within 120 days. The draft evaluation design, submitted April 26, 2013, incorporates measures from the KanCare contracts related directly to the goals of the KanCare program, which are to:
- Provide integration and coordination of care across the whole spectrum of health to include physical health, behavioral health, mental health, substance use disorders and LTSS;
- Improve the quality of care Kansas Medicaid beneficiaries receive through integrated care coordination and financial incentives paid for performance (quality and outcomes);
- Control Medicaid costs by emphasizing health, wellness, prevention and early detection, as well as integration and coordination of care; and
- Establish long-lasting reforms that sustain the improvements in quality of health and wellness for Kansas Medicaid beneficiaries and provide a model for other states for Medicaid payment and delivery system reforms as well.
After CMS and stakeholder feedback, the State submitted a final draft design for CMS review on Aug. 24. The evaluation design was updated in March of 2015 and is available here.
Pay for Performance
The pay for performance (P4P) program will allow the State to reward the KanCare health plans who perform well, while ensuring that significant penalties occur if a plan does not meet certain State requirements. The basis behind the P4P program is a payment withhold. The State will withhold a portion of the payments due to KanCare health plans each month. At the end of the year, the State will assess whether or not each health plan has met the required performance target. If they have, the health plan will receive the payments back. If they do not, the State will retain the withheld payments.
In the first year of the contracts, three (3) percent of the health plans’ payments will be withheld each month. In the following years, five (5) percent will be withheld. The percentage withhold is tied to six (6) performance measures in the first year, so each measure is worth approximately .5% of the withhold. Fifteen (15) performance measures will be tied to the five (5) percent withhold in later years, so each measure is worth 1/3rd of a percent. KanCare health plans who meet the State target on some, but not all, of the required measures can receive a portion of the withhold back.
For year one of the contract, the State chose six (6) performance measures related to operations, which will ensure that the health plans transition providers and beneficiaries smoothly into the KanCare program. The year one performance measures are tied to the following areas of each health plan’s operations:
- Timely claims processing
- Encounter data submission
- Credentialing process for providers
- Customer Service
In the following contract years, fifteen (15) quality of care measures will be utilized. Five measures each were chosen in the categories of physical health; behavioral health, long-term care, and HCBS waivers; and nursing facilities. A list of the 15 measures is below.
- Comprehensive Diabetes Care (HEDIS Measure)
- Well-child Visits in the First 15 Months of Life (HEDIS Measure)
- Preterm Births (Join Commission National Quality Measures)
- Annual Monitoring for Patients on Persistent Medications (HEDIS Measure)
- Follow-up After Hospitalization for Mental Illness (HEDIS Measure)
Behavioral Health, LTC, and HCBS Waivers
- Increased Competitive Employment: An increased number of people with developmental or physical disabilities, or with significant mental health treatment needs, will gain and maintain competitive employment.
- National Outcome Measures (NOMs):
- The NOMs for people receiving Substance Use Disorder services will meet or exceed the benchmark in at least 4 of these 5 areas: Living Arrangements; Number of Arrests; Drug and Alcohol Use; Attendance at Self-Help Meetings; and Employment Status.
- The NOMs for people with SPMI or SED receiving mental health services will meet or exceed the benchmark in at least 4 of these 5 areas: Adult Access to Services; Youth Access to Services; Homeless SPMI; Youth School Attendance; and Youth Living in a Family Home.
- Decreased Utilization of Inpatient Services: A decreased number of people with mental health treatment needs will utilize inpatient psychiatric services, including state psychiatric facilities and private inpatient mental health services.
- Improved Life Expectancy: The life expectancy for people with disabilities will improve.
- Increased Integration of Care: The rate of integration of physical, behavioral (both mental health and substance use disorder), long term care and HCBS waiver services will increase.
- Nursing Facility Claim Denials: The MCO will meet or exceed the benchmark for denial of nursing facility claims.
- Fall Risk Management: The number of people at risk of falling (i.e., who had a fall, had problems with balance and walking, or were identified as at risk for a fall) will be seen by a practitioner and receive fall risk intervention.
- Decreased Hospital Admission After Nursing Facility Discharge: The percentage of members discharged from a nursing facility who had a hospital admission within 30 days will decrease.
- Decreased Nursing Facility Days of Care: The number of nursing facility days used by eligible beneficiaries will decrease.
- Increased use of PEAK (Promoting Excellent Alternatives in Kansas)-Certified Days of Care: The percentage of nursing facility days paid for services in PEAK-certified person centered care homes will increase.
For the year one measures, the State has established performance targets for each measure that are above and beyond the required contract standard. This will provide an incentive for each health plan to perform at a higher level than what is generally required in other states.
For the measures in future years, the State will generally require five percent improvement for each measure every year. If a health plan fails to make the required improvement, or performs worse than they did in a previous year, the penalty will increase.
For additional information about the Pay for Performance (P4P) program, please see the latest update to the State Quality Strategy – Attachment J of the KanCare RFP.
In addition to the performance measures required for the P4P program, the State also requires dozens of additional measures be reported by the KanCare health plans. These measures include all of the measures currently reported for each of the Home and Community Based Services waivers, the current mental health and substance use disorder measures, a full set of HEDIS measures, and all required reporting for nursing facilities. For a full list of measures, please see the latest update to the State Quality Strategy – Attachment J of the KanCare RFP.
Quality Assessment and Performance Improvement (QAPI) Program
Each of the KanCare health plans was required to submit a written Quality Assessment and Performance Improvement (QAPI) program plan to the State for approval. The QAPI plan detailed how each health plan will meet the quality program requirements set forth in the KanCare contracts. The QAPI program will evaluate how care is provided in the KanCare program, identify outliers to specific quality indicators, determine what needs to be accomplished to ensure high-quality care, and detail how improvements will be identified and documented.
As part of the QAPI program, each health plan must have a QAPI governing body that oversees the program, and a QAPI committee that includes stakeholders such as providers and consumers.
The QAPI program must also include:
- Performance Improvement Projects;
- Submitting required performance measures;
- Detecting over- and under-utilization;
- Assessing the quality and appropriateness of care furnished to consumers; and
- Reporting on homelessness and employment.
Performance Improvement Projects
Each of the KanCare health plans is required to conduct at least two performance improvement projects (PIPs) every year. The PIPs are designed to achieve significant improvement in clinical and non-clinical areas that are important to health outcomes and consumer satisfaction with the health plan. The State must approve each PIP, and will review the results of PIPs each year to determine if additional PIPs are needed to improve the performance of the health plans.
Health Plan Accreditation
Each of the three KanCare health plans and their subcontractors is required to obtain accreditation by the National Committee for Quality Assurance (NCQA). The NCQA is an independent, 501 (c) (3) non-profit organization that assesses and scores the performance of health plans nationally. Plans are evaluated in the areas of quality management and improvement, utilization management, provider credentialing and consumers’ rights and responsibilities. By requiring the KanCare health plans to become NCQA accredited, we will ensure that each plan is deemed capable of providing the highest quality of care and service to Medicaid consumers. One component of the NCQA accreditation is completion of the annual Healthcare Effectiveness Data and Information Set (HEDIS) measurements. Additional information about HEDIS for the KanCare program is available in the HEDIS FAQs document available here.