State role in quality monitoring. TennCare's Division of Quality Oversight seeks to ensure that TennCare members have access to timely, appropriate, and high quality health care services and experience optimal health outcomes. The MCOs are monitored through rigorous reporting, site visits, conference calls, and meetings (Bureau of TennCare 2013a). Tennessee requires MCOs to report on quality measures, and the MCO contracts require hundreds of deliverables related to quality reporting. Quality measures include the following:
Health care effectiveness. In 2006, Tennessee became the first state in the nation to require its MCOs to be NCQA-certified. The state also began requiring that all MCOs report annually on the full set of Healthcare Effectiveness Data and Information Set (HEDIS) measures. HEDIS allows the MCOs to be measured on standardized, evidence-based performance measures; the HEDIS scores are compared to national averages and published. With the implementation of behavioral health integration, Tennessee began reporting on behavioral health measures in HEDIS in 2009. The state was not able to do this when health services were divided between MCOs and BHOs, because HEDIS is specific to MCOs. The HEDIS measures related to behavioral health include antidepressant and attention deficit hyperactivity disorder (ADHD) medication compliance and follow-up after hospitalization for mental illness. The MCOs are required to contract with an NCQA-certified HEDIS auditor to validate their processes in accordance with NCQA requirements.
Consumer experience. Tennessee MCOs are required to contract with an NCQA-certified vendor to conduct annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. The MCOs must submit both their HEDIS and CAHPS results to TennCare, NCQA, and the state's EQRO (described further below).
Inpatient stays and readmissions. To monitor inpatient stays, TennCare has separate reporting requirements that mirror HEDIS; these focus on the length and number of inpatient psychiatric hospital stays. To monitor readmissions, the state looks at initial appointment timeliness and whether/when patients receive treatment after a hospital discharge.
Patient access. The state imposes standards for the numbers and types of providers participating in the MCOs' networks. An MCO cannot participate in TennCare unless its network is of a certain size. As required by their contracts, the MCOs must demonstrate their ability to provide all contracted services on a timely basis and ensure accessibility to services. The Bureau of TennCare routinely evaluates provider networks and requests a corrective action plan when it identifies non-compliance (Bureau of TennCare 2013a).
Performance-improvement. MCOs are contractually obliged to conduct two clinical and three non-clinical PIPs relevant to the enrollee population. One of the two clinical PIPs must be relevant to one of the behavioral health disease management programs for bipolar disorder, major depression, or schizophrenia. Two of the three non-clinical PIPs must be in the area of long-term care.
Table V.1 describes goals for some of the performance measures outlined above and the progress the state has made toward reaching those objectives.
|TABLE V.1. Progress Toward Selected TennCare Performance Measure Goals, 2010-2012|
|Goal||Objective||Progress To Date|
|Improve health care for program enrollees||By 2013, the statewide weighted HEDIS rate for follow-up after hospitalization for mental illness will be maintained at 51% for follow-up within 7 days of discharge and 72% for follow-up within 30 days of discharge.||2010 baseline: 7-day rate was 37.93%; 30-day rate was 61.24%.
2012: 7-day rate was 45.7%; 30-day rate was 66.8%.
|By 2013, the statewide HEDIS rate for antidepressant medication management will be maintained at 63% for acute phase and 48% for continuation phase.||2010 baseline: Rate was 50.11% for acute phase and 32.03% for continuation phase.
2012: Rate was 47.1% for acute phase and 28.5% for continuation phase.
|By 2013, the statewide weighted HEDIS rate for follow-up care for children prescribed ADHD medication will be maintained at 36% for initiation and 46% for continuation and maintenance.||2010 baseline: Rate was 34.3% for acute phase and 44.2% for continuation phase.
2012: Rate was 38.2% for acute phase and 47.2% for continuation phase.
|Ensure appropriate access to care for enrollees||By 2013, 97% of TennCare heads of household and 98% or greater of TennCare children will go to a doctor or clinic when they are first seeking care rather than a hospital (emergency room).||2007 baseline: Rate was 94% for heads of household and 97% for children.
2010: Rate was 92% for heads of household and 97% for children.
2012: Rate was same as baseline.
|Ensure enrollees' satisfaction with services||By 2013, 95% of TennCare enrollees will be satisfied with TennCare.||2007 baseline: Rate was 90%.
2010: Rate was 94%.
2012: Rate was 95%
|SOURCES: Bureau of TennCare 2012a; Hamblen and Fox 2011; Gordon, Long, and Dungan 2013.|
Federal role in quality monitoring. In addition to the requirements imposed by the state, there are federal requirements for quality monitoring. The Balanced Budget Act of 1997 requires that an EQRO independently review TennCare's health plans. The EQRO conducts federally mandated activities such as performance measure and PIP validation and also administers specific requests by the Bureau of TennCare, including an annual HEDIS/CAHPS report, impact analysis report, and provider data validation. The EQRO reviews each health plan individually. Recent EQRO reports related to behavioral health services included the 2010 PIP Validation Report, which evaluated a PIP on follow-up for children prescribed ADHD medication, conducted by Amerigroup; a PIP on behavioral health postpartum depression screening, conducted by Volunteer State Health Plan; and a PIP on improving compliance with continuing treatment for MDDs, conducted by UnitedHealthcare (Bureau of TennCare 2012b).
Pay-for-performance quality incentive payments. Since 2006, TennCare has offered pay-for-performance quality incentive payments to its MCOs. In 2010, TennCare began offering quality incentive payments for three behavioral health HEDIS measures. MCOs are eligible for incentive payments if they demonstrate significant improvement from the baseline for the specified measures, or if they meet a specific goal. Significant improvement is determined by using NCQA's minimum effect size change methodology. In 2010, Amerigroup met the criteria for four quality incentive payments, and Volunteer State Health Plan met the criteria for nine quality incentive payments (Bureau of TennCare 2012c).
Tennessee's MCOs also have incentive programs for providers such as pay-for-performance programs customized to the provider. Providers' raises are tied to specific performance metrics. For behavioral health providers, measures that monitor outcomes are included in their contracts with the MCOs. Providers that do not meet the required metrics are paid less, and those with negative or unsafe outcomes have their contract terminated.