Or. Admin. Code § 410-141-3525 - Outcome and Quality Measures
(1)
Managed Care Entities (MCEs) shall report to the Authority its health promotion
and disease prevention activities, national accreditation organization results,
and Healthcare Effectiveness Data and Information Set (HEDIS) measures as
required by DCBS in OAR
836-053-1000. A copy of the
reports may be provided to the Authority's Performance Improvement Coordinator
concurrent with any submission to DCBS.
(2) The MCE shall inform the Authority if it
has been accredited by a private independent accrediting entity. If the MCE has
been so accredited, the MCE shall authorize the private independent accrediting
entity to provide the Authority a copy of its most recent accreditation review
in accordance with CFR 42
CFR §
438.332.
(3) As required by health system
transformation, MCEs shall be accountable for performance on outcomes, quality,
and efficiency measures incorporated into the MCE's contract with the
Authority. Measures are selected by the Authority with the incentive measures
specifically adopted by the Metrics and Scoring Committee using a public
process. Information can be requested from the Authority or viewed online at
the Metrics and Scoring Committee website located at
https://www.oregon.gov/oha/HPA/ANALYTICS/Pages/CCO-Metrics.aspx.
(4) MCEs shall address objective outcomes,
quality measures, and benchmarks for ambulatory care, inpatient care,
behavioral health care, dental services, HRSN Services and all other health
services provided by or under the responsibility of the MCE as specified in the
MCE's contract with the Authority and federal external quality review
requirements in CFR 42 §438.350, §438.358, and
§438.364.
(5) MCEs shall
implement an ongoing comprehensive quality assessment and performance
improvement program (QAPI) for monitoring, evaluating, and improving the
access, quality, and appropriateness of services provided to members consistent
with the needs and priorities identified in the MCE's community health
assessment, community health improvement plan, and the standards in the MCE's
contract. This process shall include an internal Quality Improvement (QI)
program with written criteria based on written policies, evidenced-based
practice guidelines, standards and procedures that are in accordance with the
requirements set forth in 42
CFR §
438.330, relevant law and the
community standards for care, or in accordance with accepted medical practice,
whichever is applicable, and with accepted professional standards. MCEs shall
have in effect mechanisms to:
(a) Detect both
underutilization and overutilization of services;
(b) Evaluate performance and customer
satisfaction consistent with MCE contractual requirements, relevant Oregon
Administrative Rules, and provide documentation of implementation of
interventions to achieve improvement in the access to and quality of care to
the Authority and the Authority contracted External Quality Review Organization
(EQRO);
(c) Evaluate grievance,
appeals, and contested case hearings consistent with OAR
410-141-3890 through
410-141-3915;
(d) Assess the quality and appropriateness of
coordinated care services provided to all members with identified special
health care needs including those who are aged, blind, or disabled or who have
high health care needs, multiple chronic conditions, behavioral health
disorders; who receive Medicaid funded long-term care or long-term services and
supports benefits; or who are children receiving Child Welfare services or OYA
services; and
(e) Report on the
diversity and capacity of the workforce in their service area including
capacity to provide services in a culturally responsive and trauma informed
manner, appropriately relying on workforce data provided by the
Authority;
(f) Undertake
performance improvement projects that are designed to improve the access,
quality and utilization of services. Projects must be designed to achieve
significant improvement in health outcomes and member satisfaction.
(6) MCEs shall implement policies
and procedures that assure the timely collection of data including health
disparities and other data required by rule or contract (or both) that allows
the MCE to conduct and report on its outcome and quality measures and report
its performance. MCEs shall submit to the Authority the MCE's annual written
evaluation of outcome and quality measures established for the MCE or other
reports as the Authority may require in response to the measures adopted by the
Metrics and Scoring Committee; including but not limited to output from
Electronic Health Records, Chart Reviews, Claim validation reports and other
materials required for final assessment of relevant measures and within
established deadlines.
(7) MCEs
shall adopt practice guidelines consistent with
42 CFR §
438.236 and the MCE contract that addresses
assigned contractual responsibilities for physical health care, behavioral
health care, and/or dental services; goals to increase care coordination with
other MCEs, the state, or other providers as outlined in OAR
410-141-0160 and
410-141-3860; and concerns
identified by members or their representatives and to implement changes that
have a favorable impact on health outcomes and member satisfaction in
consultation with its community advisory council or clinical review
panel.
(8) MCEs shall be
accountable for both core and transformational measures of quality and
outcomes:
(a) Core measures shall be
triple-aim oriented measures that gauge MCE performance against key
expectations for care coordination, consumer satisfaction, quality, and
outcomes. The measures shall be uniform across MCEs and shall encompass the
range of services included in MCE global budgets (e.g., behavioral health,
hospital care, women's health). Core measures may be defined as typical
standardized medical-centric measures such as The National Committee of for
Quality Assurance's (NCQAs) Electronic Clinical Quality Measures (eCQM) and
Healthcare Effectiveness Data and Information Set (HEDIS) that have state or
national normative statistics;
(b)
Transformational metrics shall assess MCE progress toward the broad goals of
health system transformation. This subset may include newer kinds of indicators
(for which MCEs have less measurement experience) or indicators that entail
collaboration with other care partners, such as social service agencies or
other community support services. Additional areas of transformational measures
may include culturally informed care, health equity or health-related services
not typically associated with medical care. Transformational metrics shall also
require cooperation from MCEs for pilot or demonstration activities as these
newly formed measures are developed over time. Development of different
evaluation criteria for acceptance by the metrics selection committees for use
by MCEs may also be necessary for transformational metrics.
(9) MCEs shall provide the
required data to the All Payer All Claims data system established in ORS
442.372 and
442.373 and the MCE agreement in
the manner authorized by OAR
409-025-0130.
(10) The positions of Medical or Dental
Director and the QI Coordinator shall have the qualifications, responsibility,
experience, authority, and accountability necessary to assure compliance with
this rule. MCEs shall designate a QI Coordinator who shall develop and
coordinate systems to facilitate the work of the QI Committee. The QI
Coordinator is generally responsible for the operations of the QI program and
must have the management authority to implement changes to the QI program as
directed by the QI Committee. The QI Coordinator shall be qualified to assess
the care of Authority members including those who are eligible for intensive
care coordination (ICC) services under OAR
410-141-3870 or shall be able to
retain consultation from individuals who are qualified.
(11) MCEs shall establish a QI Committee that
shall meet at least every two months. The Committee shall retain authority and
accountability to the Board of Directors for the assurance of quality of care.
Committee membership shall include, but is not limited to, the Medical or
Dental Director, the QI Coordinator, and other health professionals who are
representative of the scope of the services delivered. If any QI functions are
delegated, the QI Committee shall maintain oversight and accountability for
those delegated functions. The QI Committee shall:
(a) Approve the MCE annual quality strategy
and retain oversight and accountability of quality efforts and activities
performed by other MCE committees including the following: implementation of
the annual quality strategy, a work plan that incorporates implementation of
system improvements, and an internal utilization review oversight committee
that monitors utilization against practice guidelines and Treatment Planning
protocols and policies;
(b) Record
and produce dated minutes of Committee deliberations. Document recommendations
regarding corrective actions to address issues identified through the QI
Committee review process, and review of results, progress, and effectiveness of
corrective actions recommended at previous meetings. These records and minutes
shall be made available to relevant Authority quality staff, upon
request;
(c) MCEs shall conduct and
submit to the Authority an annual written evaluation of the QI Program and of
member care as measured against the written procedures and protocols of member
care. The evaluation of the QAPI program and member care is to include an
assessment of annual activities conducted which includes background and
rationale, a plan of ongoing improvement activities to address gaps which shall
ensure quality of care for MCE members and overall effectiveness of the QI
program. MCEs shall submit their evaluations to the Authority contracted
External Quality Review Organization (EQRO). The MCEs shall follow the
Transformation and Quality Strategy as outlined in the MCE contract for the
QAPI and transformational care annual evaluation criteria;
(d) Conduct a quarterly review and analysis
of all complaints and appeals received including a focused review of any
persistent and significant member complaints and appeals as required in OAR
410-141-3915;
(e) Review written procedures, protocols and
criteria for member care no less than every two (2) years, or more frequently
as needed to maintain currency with clinical guidelines and administrative
principles.
Notes
Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610 - 414.685
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