State of Wisconsin: MEDDIC-MS and MEDDIC-MS SSI Medicaid Managed Care Performance Measures

The Institute of Medicine has found that one of the most confounding problems with healthcare quality improvement is the need for accurate, automated, cost-effective quality performance measurement. This need is particularly acute in large, publicly funded programs such as Medicaid, which deliver healthcare services using a managed care delivery system. Wisconsin's MEDDIC-MS and MEDDIC-MS SSI automated performance measure systems have successfully addressed this problem.

Situation

The Institute of Medicine has recognized that one of the most confounding problems with healthcare quality improvement is the fundamental need for accurate, real-time, cost-effective quality performance measurement. States with Medicaid, SCHIP and SSI-eligible populations enrolled in managed care delivery systems need accurate, valid quality measures to facilitate comprehensive program quality improvement, transparency and accountability. But, they also need to keep non-care administrative costs to an absolute minimum. Existing privately-controlled performance measure systems designed to be operated by individual health plans are costly, inflexible and cumbersome. They use out-moded approaches to data acquisition and are poorly designed for operation in very large health systems such as state-wide Medicaid programs. Wisconsin has successfully implemented a system that addresses these problems.

Solution

Wisconsin’s Department of Health and Family Services has developed and implemented the MEDDIC-MS and MEDDIC-MS SSI Rapid-cycle automated Medicaid managed care quality performance measure and quality improvement system. MEDDIC-MS stands for “Medicaid Encounter Data Driven Improvement Core Measure Set.” MEDDIC-MS SSI is a companion system of performance measures developed for Wisconsin’s supplemental security income (SSI) managed care program.

The MEDDIC-MS and MEDDIC-MS SSI automated rapid-cycle performance measures leverage existing technology, merged existing data streams and targeted measure denominator design to produce valid, accurate performance data without medical record review, without duplicative (and often inaccurate) measure calculation by each HMO and with the flexibility and speed necessary to meet changing program needs.

Automated performance measurement is essential in modern healthcare. The Institute Medicine (IOM) underscores its importance in the 2002 book, "Leadership by Example: Coordinating Government Roles in Improving Health Care Quality."

According to the IOM, healthcare performance monitoring systems should have three essential qualities:

1. Measures "derived from computerized data and public reporting of comparative quality information."
   
2. "Providers should not be burdened with reporting the same patient-specific performance data more than once to the same government agency."
3. "Finally, effective performance measurement demands real-time access to sufficient clinical detail and accurate data. By the time retrospective performance measures reach decision-makers, it is too late for them to be useful. The current health information environment is far too fragmented, technologically primitive, and overly dependent on paper medical records."
   

The IOM noted that these qualities are of particular importance to publicly funded healthcare delivery systems such as state Medicaid programs. The MEDDIC-MS and MEDDIC-MS SSI meet the IOM’s criteria to a greater extent than old, HMO-based measures.

In addition, automated measures facilitate state Medicaid program compliance with the requirements of the new Medicaid Managed Care Final Rule. MEDDIC-MS and MEDDIC-MS SSI provide a cost-effective way to comply with the federal requirements, while meeting the state’s need for accurate performance data for decision support.

Better Health and Lower Costs

1. According to a recent survey by the DHFS, Wisconsin publicly reports a more robust set of performance measures than any other state Medicaid managed care program with 59 indicators, including MCO accreditation status for its Medicaid/BadgerCare HMO program and 34 measures for its SSI managed care program serving disabled individuals. Many more data points are actually calculated, but not all are included in public reporting for brevity’s sake.

2. Despite the greater number of measures reported by Wisconsin, the state’s costs are a small fraction of what old-style HMO-based systems cost. A recent IOM report showed per-measure administrative cost of $17,833 for data acquisition alone using typical old-style HMO-based measures and record review. This does not include added costs for software, which in one case in the IOM reported was over $30,000. It does not include full or part time help costs added solely for the purpose of managing the data gathering, analysis and reporting functions. In 2006, Wisconsin’s cost for data extraction and calculation of all the measures, totaled only $22,355. The actual average per-measure cost in the Medicaid and SCHIP program was $450.00 and for the SSI measures was $235.16.

3. All performance measure calculation costs formerly borne by the program’s HMOs have been eliminated, since the calculation of the measures is done by an independent third party. This allows MCO resources formerly consumed by performance measurement activities to be redirected to performance improvement.

4. “Gaming” performance measure results by MCOs is impossible because results are calculated by an independent third-party. This assures data integrity necessary for pay-for-performance incentives. It also eliminates the need for very expensive “compliance audits” used with old HMO-based systems.

5. Duplicative auditing and validation of HMO measure reporting formerly conducted by the State has been eliminated. Annual HMO encounter data validity audits are conducted by the state, streamlining the data validation process.

6. Costs associated with validation of performance measures requirements in the new federal External Quality Review Final Rule have been reduced due to the elimination of the HMO’s role in calculation of the measures. This reduced the need for data validation and measure calculation review by the state’s EQRO of all 13 HMOs to a single entity—the independent third party that does the measure calculation.

7. According to a CMS report published in 2006:

• “Other States may benefit from Wisconsin’s creation of a comprehensive set of State-specific Medicaid measures, its design, and publication of Medicaid consumer report cards (and related performance categorization methodology) and its development of statewide databases that integrate managed care encounters with other available data sources affording rapid-cycle quality measurement.”
  
• And, “In many cases, MEDDIC-MS measures assess clinical quality in a manner similar to HEDIS; however, the State’s measures generally go beyond HEDIS measures to incorporate deeper clinical measurement or additional age/demographic groups.”
  

8. The old axiom in quality improvement goes, “that which is measured, improves.” MCO performance on a variety of clinical performance measures has, indeed, improved since the MEDDIC-MS measures were implemented and public reporting began. Examples include:

Between 2000 and 2005:

• In Medicaid/SCHIP, prevalence of asthma remained unchanged, but the need for emergency department services for asthma declined from 25.9 to 21.6 percent and the need for inpatient care declined from 7.6 to 5.8 percent. In SSI, asthma prevalence also remained stable, but the need for inpatient care decreased from 14.2 percent to 10.5 percent and the need for ED care decreased from 30.1 percent to 29.4 percent. Each of these improvements result in improved quality of life and reduced costs.
  
• Blood lead toxicity screening: rates have improved--increasing from 59.9 to 67 percent for 1 year olds and from 47.7 percent to 49.3 percent for 2 year olds.
  
• In Medicaid/SCHIP, hemoglobin A1c (HbA1c) testing rates improved from 70.7 to 82.8 percent and lipid profile testing rate improved from 45.7 to 67.2 percent for adult diabetics. In SSI, hemoglobin A1c (HbA1c) testing rates improved from 50.9 to 85.4 percent and lipid profile testing rate improved from 39 to 66.1 percent for adult diabetics.
  
• The rate at which 7 or more EPSDT exams for children birth to age 1 year were provided increased from 45.5 to 69.2 percent.
  

Read more about HMO quality improvement performance and other aspects of Wisconsin’s Medicaid and BadgerCare HMO program online at: http://www.dhfs.state.wi.us/medicaid7/providers/index.htm (scroll down to “Quality Reports.”)

9. In August 2003, the federal Centers for Medicare and Medicaid Services reviewed Wisconsin’s comprehensive quality assessment and performance improvement (QAPI) strategy, including the MEDDIC-MS performance measure system and found it to be in substantial compliance with all applicable requirements.

10. MEDDIC-MS and MEDDIC-MS SSI are the first and, at present, the only state-specified Medicaid, SCHIP and SSI managed care performance measures that have been evaluated and accepted by the Agency for Healthcare Research and Quality (AHRQ) for inclusion on the National Quality Measures Clearinghouse (NQMC®). To view the measure summaries on the NQMC, go to: http://www.qualitymeasures.ahrq.gov/resources/measureindex.aspx and scroll down to "State of Wisconsin."

11. In June 2005, MEDDIC-MS and MEDDIC-MS SSI were selected as finalists for the 2005 Innovations Award by the Council of State Governments. Final selection of winners of this international award (CSG includes both states in the U.S. and the provinces of the Dominion of Canada) will be made in August, 2005.

12. URAC® a nationally recognized health care accreditation body has evaluated and accepted MEDDIC-MS and MEDDIC-MS SSI for its health plan accreditation program.

13. MEDDIC-MS and MEDDIC-MS SSI include an integrated performance goal-setting system, creating a direct link between performance measurement and performance improvement. Based on HHS QISMC “performance gap” system, allows realistic, data-driven performance improvement goal-setting by setting incremental goals on selected targets for each individual HMO. It makes Wisconsin’s MEDDIC-MS and MEDDIC-MS SSI performance measure systems the first to include systematic performance improvement mechanisms.

14. MEDDIC-MS and MEDDIC-MS SSI are in the public domain. States or other entities wishing to adapt or adopt them for their own program needs may do so without purchasing costly manuals, software or concern about copyright infringement. This allows rapid, low-cost implementation across states. Since the measures are user-defined, the state gains the flexibility to add, delete and revise measures as program needs dictate, instead of being forced to wait for the developer of proprietary measures to make necessary changes.