HealthChoice Quality Assurance Quality Strategy

Per 42 C.F.R 438.202(a), each state contracting with Managed Care Organizations must have a written strategy for assessing and improving the quality of managed care services. 

Maryland Quality Strategy Report    

 

Consumer MCO Report Card

2017 HealthChoice Consumer MCO Report Card English

2017 HealthChoice Consumer MCO Report Card Spanish

 

 

Purpose of the Consumer Report Card

The Department of Health and Mental Hygiene’s (the Department) Consumer Report Card was developed to assist HealthChoice enrollees in comparing and selecting a health plan.  It allows enrollees to see what other enrollees say about particular health plans and to see how health plans compare in key performance areas, so enrollees can easily make informed choices about their health care.  Since the Consumer Report Card is a comparison of health plans, the scores do not directly indicate whether a plan is providing good or poor services to enrollees.  It simply indicates how one plan performed relative to another.

The Consumer Report Card, which is provided to enrollees at the time of enrollment, is one source of information for enrollees.  Other information on the different health plans also is provided to enrollees at the time of enrollment, such as a comparison chart of the plans’ provider networks, service regions, and optional benefit offerings.

The Department conducted focus groups with members to understand what was important to them in selecting a health plan.  The results were six main categories:

  • Access to Care
  • Doctor Communication and Service
  • Keeping Kids Healthy
  • Care for Kids with Chronic Illness
  • Taking Care of Women
  • Care for Adults with Chronic Illness

 

    Research indicates that users of report cards and similar documents can usually only assimilate five to seven categories into their decision-making.  The results from the HealthChoice member focus groups corroborate these findings.

Each health plan’s performance scores are based on HealthChoice enrollee information that was collected from:

  • Patient medical charts.
  • Member answers to mail or phone surveys.
  • Records of the services provided to members.

While the Consumer Report Card shows six performance areas, each performance area consists of five to seven measures, which are rolled-up into an overall score.  The ratings in the Consumer Report Card, therefore, are based on 40+ quality and access measures.  The categories were chosen based on the importance to the majority of Medicaid members and the availability of health plan level data that have been validated by an independent organization.

All but four performance measures were constructed using the HEDIS® (Health Plan Employer Data and Information Set) and CAHPS® (Consumer Assessment of Health Plans Survey) quality performance systems.  The National Committee on Quality Assurance (NCQA), a national non-profit organization dedicated to improving the quality of managed health care, sponsors both HEDIS® and CAHPS®.  The other four measures are constructed by the Department using reported health plan information and closely modeled after the HEDIS methodology.  All performance measures are based on the services, care and experiences of members who were enrolled in HealthChoice throughout calendar year 2002.

The HEDIS® scores are based on randomly selected lists of members who are eligible to be included in a particular evaluation — such as children who have seen a primary care physician over the year.  The health plans supplies the information on whether or not the member received the particular service.  Health plans can gather this information from members’ medical charts or from administrative records or both.  The accuracy of this information is independently checked by an outside organization.

The CAHPS® measures are based on a randomly selected list of all children and adult members who were enrolled throughout 2002. These members are mailed a copy of the CAHPS survey and asked to report about their experiences with their health plan and its doctors.  Follow-up phone calls also are used to interview some members who do not respond by mail.  An independent research firm collects the survey responses and scores the answers. The research firm’s scoring methodology also is checked by an independent organization.

The Department hired Delmarva and NCQA to calculate the performance scores on the Consumer Report Card.  Plans whose scores were statistically different than the plan average either received an above average (three stars) or below average score (one star).  Plans whose scores were not statistically different than the plan average received an average score (two stars).

The "Not Rated By Researchers" term means that the health plan has too few members for the researchers to be able to report a meaningful score for the performance measure or category.

Consumer Report Card In Future Years

The Consumer Report Card will be updated each year with more current scores.  Performance categories and measures may change to reflect new enrollee informational needs.