Quality in Managed Long-Term Services and Supports Programs. Appendix G. Texas's Star+plus Program

11/01/2013

  Element     Description  
MLTSS Program Texas STAR+PLUS Program
Lead Agency Texas Health and Human Services Commission (HHSC)
Medicaid Authority 1115 Research and Demonstration Waiver
Inception 1998
Year LTSS Added Since Inception.
Groups Enrolled Medicaid beneficiaries who receive SSI and/or qualify for certain waiver services. Includes dual eligibles.
# Enrolled 400,790 (June 2012)
Subset using LTSS is 71,239.
  1. State Quality Oversight Infrastructure
Texas HHSC employs 5 FTEs who oversee STAR+PLUS program quality and 3 FTEs who oversee quality for the 5 health plans that serve STAR+PLUS members.

In addition, Texas HHSC reports there are 13 area HHSC Medicaid/CHIP Regional Advisory Committees who meet quarterly to discuss and provide recommendations related to Medicaid and CHIP including quality strategy issues. Membership may include representation from the following:

  • Medicaid/CHIP PCPs;
  • Specialty providers (including pediatricians);
  • Rural health providers;
  • Long-term care providers;
  • Hospitals;
  • Consumer advocates;
  • Members who use or have used Medicaid/CHIP services;
  • Medicaid/CHIP MCOs;
  • Political subdivisions with a constitutional or statutory obligation to provide health care to indigent patients;
  • School districts;
  • Faith-based organizations.

These groups review program data and policies and make recommendations.

Recommendations from this group are shared with health plan management staff as a QI process. There is also a STAR+PLUS workgroup that meets on a quarterly basis as well as a state level quality committee that inform the QI process.

  1. State IT Infrastructure for Supporting Quality Oversight
In Texas, the state and MCOs have benefitted from using encounter data to track quality. The state reports they have been able to use encounter data effectively by having consistent staff that have been working in the encounter data system for a long while. Over time, they have increased the number of edits and encounter data is cleaner.

The state, in collaboration with the EQRO has and the University of Florida School of Engineering developed the ThLC. ThLC is a web portal that allows the MCOs and HHSC staff to view quality of care results by program (e.g., STAR, STAR+PLUS), health plan, service area, gender, race/ethnicity, and other key variables. The portal is interactive and allows MCOs to interact and share documents. The portal also contains results for HEDIS measures and PPE measures for admissions, readmissions, and emergency department visits. The portal currently contains Medicaid data but there are plans to populate it with Medicare data in the future. The portal allows MCOs to conduct trending as it currently contains 3 years worth of data. There are future plans to provide this portal at the provider level.

ThLC has a great deal of flexibility in reporting. It can focus on specific geographic areas; however, it cannot report on areas with fewer than 20 individuals. The portal can also sort by provider and has some registry information. The portal can post the registry information on an HHSC location and the health plan can access it. MCOs can see doctor and patient information and use it to follow up on specific issues such as flu shots. The STAR+PLUS MCOs are regularly using the registries.

The state also works with the EQRO to maintain a data repository with linked health care claims and encounter data, enrollment files, HEDIS, PPE, and CAHPS survey results. As the EQRO's responsibilities have evolved so has the information provided. HHSC provides the necessary information to them, in the form of data extracts, that provides the state with the basis for calculating HEDIS measures, CDPS risk scores, certified data sets for Managed Care capitation rate-setting, Potentially Preventable Readmissions, Potentially Preventable Complications, Encounter Data Quality Logs and other ad hoc information.

Texas is currently planning for a new data enterprise system with the hopes that this system will be able to provide line managers and program coordinators with the ability to pull and manage data for QI efforts.

  1. MCO Quality Oversight Responsibilities
MCOs must conduct PCP and other provider profiling activities at least annually. Provider profiling activities must include, but not be limited to:
  • Developing PCP and provider-specific reports that include a multi-dimensional assessment of a PCP or provider's performance using clinical, administrative, and member satisfaction indicators of care that are accurate, measurable, and relevant to the enrolled population.
  • Establishing PCP, provider, group, service area or regional benchmarks.
  • Providing feedback to individual PCPs and providers regarding the results of their performance and the overall performance of the provider Network.

MCOs are also required to ensure network adequacy by verifying that covered services furnished by providers are available and accessible to members in compliance with established appointment wait time standards and within established geographical standard for covered services furnished by PCPs. The MCO must enforce access and other network standards required by the contract and take appropriate action with providers whose performance is determined by the MCO to be out-of-compliance.

  1. State Audits of MLTSS Program
A process used to evaluate MCOs is the AIT. This is an administrative questionnaire, developed and administered by the EQRO that is sent to the MCOs on an annual basis that covers policies, procedures and other administrative items related to QA. Based on MCO responses and other items such as MCO tenure or performance, the EQRO will follow-up with conference calls or site visits if needed.
  1. Performance Measures and Quality-Related Reports
Texas HHSC works with the EQRO to collect all applicable HEDIS measures on the STAR+PLUS program population. In addition ICHP calculates the CDPS risk scores, and PPEs for STAR+PLUS members.

Additional measures specific to LTSS include the following:

  • Percent STAR+PLUS members with good access to Service Coordination not collected not collected.
  • Percent increases in STAR+PLUS members that receive personal attendant and/or respite services through the consumer-directed services delivery model.
  • Number of STAR+PLUS members entering NF.
  • Number of STAR+PLUS 1915(c) waiver clients returning to community services.

Texas HHSC noted that they are currently facing challenges as they perceive there are not a lot of good standardized LTSS measures. They are considering developing their own LTSS measures with ICHP.

  1. LTSS-Focused PIPs
The EQRO provides technical assistance and works with the MCOs in developing PIPs based on identified areas where improvement is needed and based on the state's overarching goals for the STAR+PLUS Program. The EQRO submits a summary report to HHSC on each MCO's PIP in terms of appropriateness, adequacy of design and other factors necessary to conduct a strong PIP.

The EQRO reports that Texas has just started collaborative PIPS this year. The EQRO also reports that there have also been PIPs in the past around reducing nursing home admission rates. They identified that the SP was important. Some literature suggests that if you comply with antidepressant medication it can reduce nursing home admissions. One MCO focused on depression screening and found it helpful in reducing nursing home admissions.

Another focus for PIPS for STAR+PLUS health plans is diabetes care. They are trying to improve compliance with testing. They would also like to shift the current focus of test compliance and collect actual data (lab results) as a part of PIPs.

  1. Care Coordination
Presently, MCOs are required to provide a service coordinator (care coordinator) to all STAR+PLUS members who request one. The MCO must also provide a service coordinator to STAR+PLUS member when the MCO determines one is required through an assessment of the member's health and support needs. The MCO is required to contact each STAR+PLUS member a minimum of 2 times per calendar year. This contact can be written, telephonic, or in-person, depending upon the member's level of need. The MCO must document the mechanisms, number and method of contacts, and outcomes.
  1. 24-Hour Back-Up
There is currently no requirement for a 24-hour back-up system.
  1. CI Reporting and Investigation
CI data is provided to the state by the MCO through the complaint system on a quarterly basis.

Additionally, HHSC reviews all investigation reports provided by Texas DFPS. Based on the content of the report, HHSC may conduct an on-site survey of the provider or require the provider to submit evidence of follow-up action on the incident. The investigative findings and HHSC's follow-up on those findings is entered into the abuse, neglect, or exploitation database by HHSC staff. HHSC also records deaths in a database. Reports of CIs are compiled on a monthly basis for each program provider.

In preparation for annual and some intermittent reviews of providers, HHSC staff compiles data related to all CIs reported by or involving the program provider. HHSC may use this information in selecting the sample of individuals whose records will be reviewed and who may be interviewed to ensure appropriate follow-up was conducted by the provider.

All abuse, neglect and exploitation reported to the DFPS as required by licensure regulations are investigated. Investigation of some self-reported incidents may be completed without an on-site investigation. If further investigation is warranted to ensure compliance with federal, state, or local laws, an on-site investigation is scheduled.

Oversight activities occur on an ongoing basis. Information regarding validated instances of abuse, neglect or exploitation is monitored, tracked and trended for purposes of training HHSC staff and to prevent recurrence.

Providers are responsible for training their staff about reporting CIs and events.

  1. Mortality Review
Per MCO report, mortality cases are handled by the MCO Quality department and are investigated as a quality of care case. The Quality staff logs the case and requests the necessary information to conduct the review working in collaboration with other MCO departments as necessary. The case is presented to and discussed with the Medical Director. The Medical Director reviews the case and may request additional information or may speak with the provider. The findings of the case are presented to the Peer Review Committee for recommendations. The health plan carries out the recommendation of the Peer Review Committee. The Quality department tracks quality of care concerns related to providers to identify any trends. Trends identified are brought to the Peer Review Committee for discussion and recommendation. Data from this process is provided by the MCO to the state on a quarterly basis.
  1. EQRO Responsibilities
The EQRO, the ICHP at University of Florida, also plays a large role in evaluating the quality of the program as well as Texas CHIP and other Texas managed care programs.

Texas HHSC contracts with the EQRO to conduct an annual independent review and all mandatory EQRO activities: (1) determining MCO compliance with federal Medicaid managed care regulations; (2) Validation of performance measures produced by the MCO; and (3) Validation of PIPs undertaken by the MCO. They also conduct a number of additional tasks such as conducting the annual satisfaction survey, validating encounter data and conducting focused studies. The EQRO also conducts calculates and reports performance data for the MCOs in dashboards and MCO report cards.

ICHP has assisted Texas HHSC in developing several tools to assist in evaluating the quality of the STAR+PLUS program. ICHP has created a dashboard that management can use to view the performance of the STAR+PLUS MCOs. ICHP is also working with Texas HHSC to finalize a legislatively-mandated MCO report card. There are plans to publish this report card on the state website for public reporting purposes. In developing the format for this MCO report card, ICHP worked with University of Florida School of Journalism to conduct focus groups with Medicaid beneficiaries, including STAR+PLUS program participants, to determine what type of public reporting members wanted. Focus group findings reveal that beneficiaries wanted pictures, big print and diversity among the people featured in the pictures. Texas used this information in designing their MCO report cards. Texas HHSC staff noted that in working on the report card for STAR+PLUS difficulty was encountered in comparing members who are dually eligible for Medicaid and Medicare and those who are eligible for Medicaid only. They noted a need to take great pains to ensure that the encounter data is correct.

Another tool that is used to evaluate MCOs is the AIT. This is an administrative questionnaire, developed and administered by the EQRO that is sent to the MCOs on an annual basis that covers policies, procedures and other administrative items related to QA. Based on MCO responses and other items such as MCO tenure or performance, the EQRO will follow-up with conference calls or site visits if needed.

Texas HHSC has also worked with worked with their EQRO to track quality for over 10 years. In addition to conducting the activities required by CMS including validating PIPs, validating performance measures and conducting MCO reviews, the EQRO also validates encounter data and calculates performance measures for Texas HHSC.

  1. Ombudsman/ Function
Texas HHSC has an Office of the Ombudsman which operates "The Medicaid Managed Care Helpline." This helpline is designed to help Medicaid beneficiaries who need help accessing health care services. The office places a priority on individuals with urgent or complex health care needs. Help offered through the helpline includes:
  • Information about the client's coverage.
  • Guidance on how to access services.
  • Referrals to the right place to get help.
  • Direct assistance from staff to resolve a problem.

The Medicaid Managed Care Helpline also provides general information about managed care programs to providers, health plans, community-based organizations and other stakeholders. The ombudsman's function is to work together with Medicaid/CHIP Health Plan Management and the MCO to resolve the member's or provider's issue.

There is also a long-term care ombudsman at the state's Department of Aging and Disability Services. Texas HHSC staff report that the 2 ombudsman programs work closely together.

Additionally, the MCO is required by contract to provide Member Advocates to assist members. Member Advocates must be physically located within the service area and must inform members of their rights and responsibilities, the complaints and appeals process and the array of services that are available to them. Member Advocates must also assist members in writing complaints and are responsible for monitoring the complaint. Member Advocates are responsible for making recommendations to MCO management on any changes needed to improve either the care provided or the way care is delivered. Member Advocates are also responsible for helping or referring members to community resources available to meet member needs that are not available from the MCO as covered services.

  1. Experience of Care/ Satisfaction Surveys
The EQRO conducts the CAHPS Experience of Care Survey with STAR+PLUS program participants on an annual basis. The standard CAHPS questions are supplemented with some LTSS-focused questions about unmet service needs, and ADLs, etc. MCOs also conduct their own consumer satisfaction survey. The MCO that was interviewed reported that it has attempted to develop some LTSS-specific survey questions to supplement their consumer satisfaction survey; however, it has proved difficult to analyze results without having specific information on the LTSS services the program participants were receiving.
  1. Membership Oversight
Texas HHSC reports there are 13 area HHSC Medicaid/CHIP Regional Advisory Committees who meet quarterly to discuss and provide recommendations related to Medicaid and CHIP including quality strategy issues. Membership may include representation from the following:
  • Medicaid/CHIP PCPs;
  • Specialty providers (including pediatricians);
  • Rural health providers;
  • Long-term care providers;
  • Hospitals;
  • Consumer advocates;
  • Members who use or have used Medicaid/CHIP services;
  • Medicaid/CHIP MCOs;
  • Political subdivisions with a constitutional or statutory obligation to provide health care to indigent patients;
  • School districts;
  • Faith-based organizations.

These groups review program data and policies and make recommendations.

  1. State Technical Assistance to MCOs
The AIT, Performance Dashboards, routine reports and routine interactions with the state determine the need for technical assistance.
  1. MCO Report Cards on LTSS
The EQRO is working with Texas HHSC to finalize a legislatively-mandated MCO report card. This report card will be published on the state website. In developing the format for this MCO report card, ICHP worked with University of Florida School of Journalism to conduct focus groups with Medicaid beneficiaries, including STAR+PLUS program participants, to determine what type of public reporting members wanted. Focus group findings reveal that beneficiaries wanted pictures, big print and diversity among the people featured in the pictures. Texas used this information in designing their MCO report cards. Texas HHSC staff noted that in working on the report card for STAR+PLUS difficulty was encountered in comparing members who are dually eligible for Medicaid and Medicare and those who are eligible for Medicaid only. They noted a need to take great pains to ensure that the encounter data is correct.
  1. Financial Incentives, Penalties and Withholds
The state has established the following quality-related financial incentives:
  • 5% risk--The state will place each MCO at risk for 5% of the Capitation Payment(s). If the MCO meets the performance expectations they will receive up to 100% of the risk reserve.
  • Quality Challenge Award--If 1 or more MCOs are unable to earn the full amount of the performance-based at risk portion of the Capitation Rate, the state will reallocate all or part of the funds through the MCOs Program's Quality Challenge Award. The state will use these funds to reward MCOs that demonstrate superior clinical quality, service delivery, access to care, and/or member satisfaction. The state will determine the number of MCOs that will receive these funds annually based on the amount of the funds to be reallocated.
  • Additionally, there are programs based on inpatient and nursing home utilization. These MCOs must achieve a 22% reduction in projected FFS Hospital Inpatient Stay costs, for the Medicaid-only population, through the implementation of the STAR+PLUS model. MCOs achieving savings beyond 22% will be eligible for the STAR+PLUS Shared Savings Award and will be at risk for savings less than 22%.
  • NF Utilization Dis-incentive--The state is introducing a dis-incentive to prevent inappropriate admission to NFs. For the initial year the state will compare the MCOs annual rate of nursing home admissions for Medicaid-only STAR+PLUS enrollees to determine if there is a statistically significant increase in admissions from the prior state fiscal year. Those admitted and discharged within 120 days are excluded from the analysis. Upon gathering the data, the state will determine whether to include a NF utilization measure in either the Performance-Based Capitation Rate or the Quality Challenge Award for State Fiscal Years following 2012.
  • Additional Incentives and Dis-incentives--The state will evaluate all performance-based incentives and dis-incentive methodologies annually and in consultation with the MCOs. The state may then modify the methodologies as needed in an effort to motivate, recognize, and reward MCO for performance.

State staff report they are currently reviewing the 5% risk and quality challenge as it can sometimes incentivize contradictory practices. They hope to streamline the process and help incentivize MCOs to increase client-centered practices.

  1. Other Quality Management/ Improvement Activities
Texas has implemented STAR+PLUS in waves and the EQRO has taken advantage of this natural experiment in conducting studies. They have been able to construct focused studies with a pre-post program implementation design. They found that STAR+PLUS had a positive effect on treatment of COPD and receipt of beta-blockers; however, implementation of the STAR+PLUS program has had no effect on diabetes care.

The EQRO has been working with HHSC to develop many future studies on the STAR+PLUS program. The next study the EQRO plans to conduct with the STAR+PLUS program is a study on the receipt of behavioral health care. They also plan to conduct a study on preventable hospitalization and STAR+PLUS members. A final paper will focus on the effects of STAR+PLUS on preventative care. Previously, the EQRO had conducted a focus study on dual eligible in the STAR+PLUS program and how participants' define quality of care.

ADL = activity of daily living
AIT = Administrative Interview Tool
CAHPS = Consumer Assessment Health Care Providers and Systems
CDPS = Chronic Illness and Disability Payment System
CHIP = Children's Health Insurance Program

CI = critical incident
COPD = chronic obstructed pulmonary disease
DFPS = Texas Department of Family and Protective Services
EQRO = external quality review organization
FFS = fee-for-service

FTE = full-time equivalent
HEDIS = Health Effectiveness Data and Information Set
HHSC = Texas Health and Human Services Commission
ICHP = Texas Institute for Child Health Policy
IT = information technology

LTSS = long-term services and supports
MCO = managed care organization
MLTSS = managed long-term services and supports
NF = nursing facility
PCP = primary care provider

PIP = performance improvement project
PPE = potentially preventable event
QA = quality assurance
QI = quality improvement
SP = service plan

SSI = Supplemental Security Income
ThLC = Texas Healthcare Learning Collaborative

View full report

Preview
Download

"LTSSqual.pdf" (pdf, 1.03Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®