SAMHSA's National Mental Health Information Center

This Web site is a component of the SAMHSA Health Information Network

About the Program

Mental Health Parity

Resources

Journal Articles

Featured Publications

In the News

Organization & Financing

SAMHSA Managed Care Initiative Training Sessions

May 1998

Dates: May 19 1998-American Psychiatric Association, Washington, D.C.
May 20, 1998-Parklawn Conference Center, Rockville, Maryland

Title: The the Centers for Medicare and Medicaid Services's Quality Improvement System for Managed Care (QISMC)

Speakers: May 19: Stephen F. Jencks, M.D., Director
Priority Management Group
Office of Clinical Standards and Quality Health
the Centers for Medicare and Medicaid Services

May 20: Patricia MacTaggart, MBA, Director,
Quality and Performance Management Group
Center for Medicaid and State Operations
the Centers for Medicare and Medicaid Services

Summary Background

To fully understand the Quality Improvement System for Managed Care (QISMC), some contextual definition of the current government-purchased managed care environment is required. Medicaid, Medicare, as well as Mental Health Grants are moving towards "value-based purchasing" (The complete term used to define this new paradigm is "value-based, beneficiary-centered, quality-focused, medical purchasing strategies.") This means that the government, as a purchaser of medical services, must know what it is buying and hold itself, as well as providers, accountable for the quality of those medical services, which includes mental health and substance abuse. In addition, the government also must validate (document) what is done, in terms of medical services-simply saying that "we do good" is no longer enough. In short, value-based, beneficiary-centered, quality-focused strategies require that the focus of medical purchasing be on the consumer. It also demands that quality be the number one concern.

Product Outcome Tools

CMS is working with the states to develop tools that can be used to meet these new standards. Product outcome tools (of which QISMC is one) can be used to achieve quality medical services. They include the following:

Performance measurement. QISMC requires that managed care organizations measure the level of medical services across the board-including baseline data. Baseline data provides the information necessary to determine the progress of an organization. (The current weakness found in performance measurements tools used in mental health and substance abuse have resulted in a lack an agreement on community standards and data definition in these areas.)
Request for Proposal (RFP)/Contract Specifications. The first step toward holding the contractor accountable for delivering quality services is ensuring the areas of responsibility are stated in the RFP. Including specifications, such as network capacity, culture competence, and geographic access, will help to ensure the quality of the product outcome.
Grievances and Complaints. There must be a process within the state that allows a consumer, who is unhappy with services, access to a fair hearing. Analyses of these areas will point out trends, telling states where there are issues-not, however, if they are valid.
Enrollment Parameters. The first step toward quality is determining if the consumer has been given sufficient information in order to make an intelligent decision concerning what health plan to choose. Of additional importance in determining quality is the accuracy and cultural appropriateness of the ongoing information provided by the health plan in the form of Consumer Information Models and Consumer Guides
Data Information Systems and Validation Tools. There is a lot of information available, but little of it is built from data that has been validated. It is impossible to manage anything without good information. The requirement for validated data has a great impact on small, community-based providers. Information systems are very costly-beyond the means of most small health plans. CMS is trying to facilitate partnerships with large managed care organizations that would enable smaller entities to interface with the information systems of large health organizations.
QISMC. The Quality Improvement System for Managed Care, which will be discussed in detail.

What is QISMC?

The Quality Improvement System for Managed Care (QISMC) is one of several tools that can be used to ensure quality and can serve as the framework which brings the other tools together. It is intended to establish a relationship between the purchaser (e.g., the state for Medicaid; CMS for Medicare) and their contractors (the delivery networks). QISMC does this in the following way:

Establishes performance standards for managed care plans. QISMC does not deal with areas that are the primary responsibility of the state (Medicaid) or CMS (Medicare), such as oversight or fixed term review. QISMC can be defined as "the daughter of the Quality Assurance Review Initiative." Like that program, QISMC includes structured quality indicators. The difference, however, is that QISMC not only is concerned with having the proper structure in place to deliver quality healthcare, but it also demands that the delivery system actually improve the quality of health care to the clientele. This also can and does include the concept that the maintenance of health is, indeed, improving health care. The important message is that having the processes in place is not sufficient, you must deliver quality service.
Represents a common ground for Medicaid and Medicare-it brings them together. The goal for both is to collect the necessary information, without wasting money on duplicative administrative mechanisms to get it done. QISMC now has both programs asking the same providers for the same information in the same way and stratifies the data received. The benefit is that Medicaid and Medicare collect their data, without requiring the provider to complete numerous different forms with similar questions that are asked numerous ways.
Balances the best of both of purchasing and regulatory strategies. It sets uniform, minimum standards that must be met, while allowing the purchaser (the state) to move way beyond, if desired. QISMC sets the goals at a reasonable standard, that both the marketplace and the managed care organizations (MCOs) can meet. The QISMC document is a tool for states to use. For example, in terms of access, it states that the care delivery system must meet the standards as established by CMS for Medicare and as established by the state for Medicaid, but it also must deal with linguistics, handicap accessibility, cultural competency, and other areas. The regulatory aspect simply sets the minimum requirement, although the state is free to set the standard as high it desires.
Moves from Quality Assurance (QA) to Quality Assessment and Performance Improvement (QAPI). Unlike other approaches, QISMC requires an analysis of the delivery system and a plan and measurements for improvement.

Domains of QISMC

There are four domains in QISMC; some are new; others were already established. The established domains include:

�Member Rights. The QISMC document (in its current form) incorporates the Consumer Bill of Rights to the degree that CMS has the legal authority to do in Medicare.

�Health Service Management This concerns the structure of the managed care plan and includes, for example, their oversight, the relationship of their Quality Medical Director to the Chief Executive Officer, and the collection and tracking of the data information. It is, essentially, the structure that accreditation agencies use as well.

New domains include:

�Delegation This area incorporates much in the area of mental health and substance abuse. CMS has found that state contracts with a comprehensive managed care plan often subcontract these services to a managed behavioral care organization. Carve-In or Carve-Out, QISMC, stipulates that the responsibility for the delivery of that health care service remains with the state.

�QAPI. Quality Assessment and Performance Improvement deals with two things: (1) minimum performance levels must be established in all areas of service delivery in the contract, and (2) both clinical and non-clinical areas must include demonstratable and measurable improvement. Within this framework, there is the need to establish a balance between encouraging health plans take risks to improve quality, and, at the same time, provide sufficient (but not an overwhelming) amount of information to the consumer so that they can make an intelligent choice of health care coverage. This "pushes the envelope" of traditional quality standards, as it is not found in accreditation criteria or in the commercial arena. With this, Medicaid and Medicare are far ahead of anyone else.

Quality Assessment and Performance Improvement (QAPI)

QAPI is divided into non-clinical and clinical focus areas. While QISMC places new emphasis on one non-clinical focus area, several have traditionally been monitored by Managed Care Organizations. Non Clinical Focus Areas include:

(1) availability, (2) convenience, (3) timeliness: MCOs generally concentrate on these areas themselves as they represent general good business practices.

(4) appeals (payments, coverage, benefits), and (5) complaints or grievances: MCOs also are attuned to these areas, because of the potential for bad publicity.

(6) cultural competency: this has become extremely important and very topical. QAPI has spotlighted this area, emphasizing that MCOs are obligated to know the needs of their consumers, based on the consumers' own cultural background. There is a need, however, to develop a universal definition of the term "cultural competency."

Clinical Focus Areas include: (1) preventive, (2) maintenance, (3) chronic, (4) acute, and (5) continuity.

CMS believes that any clinical area of concern to a low-income or Medicaid recipient can be found in the categories listing above-although it may not be readily apparent to each advocacy group. The question is how quickly are the categories phased-in, how many does the MCO have to review each year, and how many must be improved each year? What is desired is that the MCOs prioritize the clinical areas, do one very well, and not omit any area, over time. How many per year or the exact timing of review is something that has yet to be determined. The effects of quality improvement are generally not seen for several years after implementation, so there is a certain amount of logic to some type of rotation. This, however, can be a difficult concept for policy experts to understand, as well as the consumers.

There is, however, a challenge to moving this agenda forward without losing every contractor. Medicaid, in reality, is not the best payer. There is a need for the commercial market to serve Medicaid and Medicare clientele. If the bar is raised too high, the easy answer will be that local state and county officials just won't have the option of being an excellent managed care provider.

A few current topics associated with this process also were discussed. Special Needs Populations is one such area. The issue, for them, is are they are part of this process? CMS feels they are and has developed key approaches to encourage and ensure they are included, such as:

the engagement of key stakeholders in the design, implementation, and monitoring of QISMC. To ensure success, however, it is important that all the stakeholders listen to each other.
the targeting of special needs populations in the marketing strategies of MCOs as well and their enrollment practices.
the appropriate application of the term "medical necessity." Many groups are hoping that, following managed care, HFCA will provide a "Medicaid" definition of "medical necessity." That will not happen; medical necessity is medical necessity. What needs to be addressed is the broadness of the definition applied to the term "medical necessity" in the state Medicaid programs. In the commercial market, "medical necessity," particularly in mental health and substance abuse, is very narrowly defined. In reality, a Medicaid consumer, being evaluated for medical necessity or medical appropriateness, should be treated the same, regardless of whether they are a fee-for-service or managed care plan patient. CMS, however, has neither the funding nor the authority to redesign "Medicaid's" definition of "medical necessity."
the recognition of the importance coordination of services-how referrals and made and the linkages in place to receive other social services. This is particularly true in terms of what is and is not written in the contract.
the financing of risk adjustment (probably more significant for the physically disabled) to ensure there is sufficient money is the system to receive the proper care.
the review of databases. Are the systems in place to collect the necessary data the accurately and in a timely manner?
quality management. Are the MCOs actually doing what they said they would do?

The final part of QISMC is the technical assistance that CMS can offer to the states to fully implement the program. CMS realizes that states and providers need help with the transition phase of QISMC. CMS wants ensure that, through mutual efforts, the technical assistance provided truly meets the needs of the states, the purchasers, and those directly affected by QISMC.

Question/Comment and Answer Session
MHLG Presentation, May 19, 1998

Stephen F. Jencks, M.D.,

17: Can you clarify what you mean by "improvement" in areas? Is that all areas? Will there be a phase-in period?

1: Over an initial period of three years, there is a process to get to the requirement for improvement in clinical and non-clinical areas-although it differs slightly for Medicaid vs. Medicare.

17: Are these actually regulations, or can alternatives be suggested?

1: The regulations will create a framework which could support a number of alternatives. For example, the regulations would allow us to specify clinical areas in National Projects or to leave that to the health plans. The regulations do not say we are going to require one a year or two a year; they say, "there will be projects with the following characteristics." Understand that the level of effort that will be required is not yet absolute. This is partially because we are still trying to determine what the level of effort is for different types of health plans. For those who have never done this before, the level of effort required to implement a plan-wide improvement program is very high. As they get to understand what is required and have processes in place, the required level of effort will decrease.

17: Is there a concern in CMS about mental health and substance abuse issues "falling off the edge?"

1: There is real concern about the inclusion of mental health and substance abuse issues as an active integral part of performance improvement. The reason for the concern is attributed to the lack of agreed upon measurements that measure quality improvement in mental health and substance abuse. As measurements begin to emerge, the progress of inclusion will accelerate.

17: The NCQA already requires that every managed care plan involve itself in quality improvement in clinical and preventive areas. Everyone claims that managed behavioral health care must be held to the same standards as medical care. What are your views from a Federal level?

1: One of the problems repeatedly faced is a concern that we are giving mental health and substance abuse issues more prominence than we can support, in terms of advocacy. This is a genuine problem-balancing the portfolio. It is important not to overplay the issue. With the proper type of presentation, a defensible position on mental health and substance abuse issues can be offered.

3: That's why it is important to have a solid conceptualization of mental health and substance abuse issues. For example, we need to establish some quality assurance for Medicare and Medicaid, as it relates to special populations. Given the risk of undertreatment for this population in a managed care/capitated situation, we may want to set separate standards for this highly vulnerable population.

1: This is outside my expertise, but I know there are some Medicaid experts that are looking at this issue.

17: I have questions about the data collection and National Programs. You are not mandating any specific data requirements or data systems-there are a lot of different data systems in the country. Is that correct?

1: We are requiring that plans report encounter data, but as far as quality improvement, data systems can be run any way, as long as they can produce the ability to measure the kinds of data required in the regulations. What is needed is to have the quality improvement and quality assessment needs run the data system, rather than a set of specifications about type and number of fields.

3: It seems, in terms of total quality management, that one thing I found missing was making use of data that already exists. In other words, asking plans to look at their appeals and grievance data and in order to identify areas for improvement.

1: Actually there is language that requires plans to examine evidence that they have in order to develop the topics for improvement projects. It may not be exact, but it requires a review of responses to existing services.

17: I continue to be concerned about the barriers that prevent a more open flow of information between Medicaid and Medicare. There is such a patchwork of state Medicaid plans-partnerships that are only on paper, databases that don't "talk" to one another, missing files, blank pages, and wrong payments. How do we ever get back on an even keel?

1: There are two separate issues here. One is, that there is a need to be very smart (and tolerant) when you're analyzing 50 different state plans. The second issue is that, once you've got an overview view, you need to determine exactly how CMS can best assist in solving the various problems. Our sense is that, while regulation is important, providing technical assistance and training is equally important.

17: My question is about the actual selection of the topics within the clinical areas. The standards give overarching examples of how they are to be selected. What other kinds of support does CMS propose in terms of making relevant selections?

1: We will have an external review process that will determine if the contractor did what was asked in the contract. The exact details of how this will occur are still being discussed. This will require considerable technical skill, in terms of oversight, which, up to now, has not been required. Keep in mind, this all will not happen within the first year!

17: If each state can decide to measure different areas in mental health, with different measurement, how can valid comparisons be made?

1: We understand this will happen-for two reasons. One, is that different people will have different ideas. The second is that, although comparisons between states is not a top priority at this point, there is considerable anxiety about this. We are just beginning to work through the state's concerns. One solution is to have technically satisfactory answers-that is-measurements that make sense, and not just a ranking of the states.

17: There is a mental health statistics program at SAMHSA that puts out a consumer-oriented report card. To get the states to support it, they offered small demonstration programs that states could use a funding foundation. Is there any consideration to provide such incentives in this program?

1: Although there are Federally sponsored matching funds under Medicaid, they are very tightly restricted. I haven't heard any discussion in this area.

17: There are a lot of other quality improvement programs in progress. How does this compare or fit in? Is there any overlap?

1: Although the issues may be related and all generally are going in the same direction, demonstratable and measurable improvement is a hallmark of QISMC.

Question/Comment and Answer Session
Federal Presentation, May 20, 1998

Patricia MacTaggart

17: How is CMS dealing with problem that many states encounter who have contracted with a proprietary firm to provide clinical services and have overlooked including a provision in the contract that gives them access to that data? Access is denied, and therefore no collection of data takes place.

1: Ideally, it is imperative to write data access into the contract-or to say to the firm that, unless they provide the data, they will be responsible for the reporting. One of the biggest data issues in mental health and substance abuse, however, is confidentiality versus the reality of a health care delivery service. Health care cannot be properly managed without the proper information. States do, however, carve-out mental health and substance abuse services. What they sometimes have neglected to address is that it is often difficult to get individuals to work together and share information when they are under the same contract-and required to do so-and it becomes significantly more difficult when there are two entities that are not under the same contract. There also is the question of the technical abilities of separate systems to "talk to each other," with the carve out of mental health, substance abuse, pharmaceuticals, and everything else. This is a real problem, with both the confidentiality issues and technical capabilities to consider. I don't have an answer for the confidentiality issue; I think it will get bigger every day. The states, however, who chose for whatever reason to carve-out segments of their delivery, have a responsibility to ensure they have the linkage to obtain information from all sources.

17: Is your enrollment in managed care voluntary or mandatory?

1: In most states, the enrollment is mandatory. The BBA requirement says a state can mandatorily enroll anyone in a health plan, except the dually-eligible for Medicare/Medicaid, and certain other categories such as children eligible for special needs care. The interesting issue has been in carve-outs, because for all others, except for those in a carve-out, CMS typically requires choice. So, if you are going to demand mandatory enrollment, the state must offer more than one health plan. For mental health/substance abuse, and other carve-outs, we have allowed sole source-often times they're county governments or local entities working in mental health.

17: The delegation domain of QISMC works in the large proportion of states that integrate mental health and substance abuse services with primary care. How applicable is QISMC when the state carves it out and contracts separately or when a county, as in California, contracts out separately, through MediCal? Will they be held to the same quality improvement standards?

1: There has been a large debate over the last two years concerning how far QISMC can be pushed forward in a Prepaid Health Plan (PHP) Medicaid world, which is really the legal authority for the carve-outs to exist. In reality, they are not a part of the Congressional Act; they are a regulation-based entity. The real question is how much can CMS require? If you really believe quality is quality, it shouldn't matter if it's carve-in or carve-out. The approach we are taking is that QISMC is for managed care plans. In CMS, we are debating the relationship of the BBA regulations to QISMC. Should quality be affected by the fact that you are a PHP or an MCO? The regulations, however, are not final. The principle we are working with is that the consumer doesn't care how it's paid for; all they know is that they have an issue and that the quality should be the same.

17: What do you mean when you say, in terms of QAPI, Medicare and Medicaid are far beyond accreditation?

1: Accreditation, up until now, has absolutely not required quality improvement. The National Committee for Quality Assurance (NCQA), for next year, is working on their HEIDIS measures in concert with their structure accreditation, in a effort to move in this direction. Only in the last several years has the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) looked at improvement-but they only do it facility by facility, and only in some areas, not ambulatory care.

17: Is there some "spill-over" for evaluation with state-run (and lesser budgeted) substance abuse agencies?

1: The good news for the states or the counties is that as the Federal government pushes this agenda, they won't use different approaches for agencies, based on budget constraints. The other good news is that states, even under substance abuse grants is that QISMC is a tool they can use. They are not prohibited from using it. From my perspective, the more we move in the same direction, the more likely we will move forward. The biggest issue now, however, is explaining to some grant providers that capitation does not equate to a grant-that when the money runs out, the responsibility to serve the clientele remains. There is the added responsibility of capitation.

17: Could you talk a bit more on how Medicaid defines "medical necessity?" How does Medicare define it?

1: For Medicaid, each state must define "medical necessity" in their State Medicaid Plan. In the Federal Register, Congress placed a very limited definition on it-very appropriately, as medical necessity should be individually specific. Medicare is very careful not to define it, because it is illogical to try to apply an individually specific definition for people at large. There is a big fear that CMS will default to the commercial approach, which has been limiting for mental health and substance abuse, and define it in terms of limitations, such as 13 visits.

One of the things some states have done is said that the "more acute" mental health services belongs in the managed care plan, but the "wraparound' services belong on the county or local entity. CMS is working with states to ensure they have a mandatory information piece which informs their consumers that they may receive additional visits or services at the local level, and make the appropriate referrals. This correlates to continuity with the same provider issues for wraparound services-how can the state ensure they do not have to change providers?

17: Do you help states write RFPs?

1: Only to a certain level, depending on the state law. We give "pieces" and "ideas" or "best practice advice." States report they are getting very worried and tired about having to address each clinical area-access standards for HIV, for immunization. That is not the case-there are access standards that should apply across all the disciplines of service. What we don't want to do is get contracts to be regulatory, which means they become 50 pages of weight, where everything is put in them and then nothing is really accomplished.

17: At the Indian Health Service (IHS), many of our patients are being mandatorily assigned to managed care organizations, except on the reservation. This creates a problem, as many will still go to the Indian Health Service, but we are not always reimbursed for these services.

1: This may not be a popular view, but my job is to buy the best health care for the consumers that I purchase for, that's what Medicaid is about. But Medicaid has been used as a funding stream for many services. What I did with the Indian Health Services when I was in Minnesota, when I was talking about the tribal population, I met with the tribal chief and council at the reservation. When I was talking about providers, I talked to IHS, because, as a provider, I was concerned with their issues. Those provider needs are different than the needs of the consumers. Special protections are needed for safety net providers and we are trying to balance that, but it is difficult, as Medicaid is many different things to different people. If I believe in value-based purchasing, my issue should not be whether the IHS provider gets paid or not, but making sure that they are not being "dumped on." That is, IHS is doing all the work because the network is not providing for the patients. The best way to do this is to get the network to contract with the IHS to provide services. That's not a CMS perspective-it's a former Medicaid Director's. CMS's perspective is that every effort will be made to work with the states to make it work with IHS and everyone else. But there is an inherent conflict here between value-based purchasing, getting the best quality and the best network for my consumers, with, as a Medicaid buyers, having certain responsibilities to certain provider-call them safety net providers. Medicaid has much to learn about the IHS, and CMS is putting a lot of effort into this. There are, however, no really rationale answers and very few "off the shelf" answers.

17: As we go through this transition, there is a lack of staff expertise to provide the required oversight to a quality improvement system. How do you see CMS providing technical assistance in this area during the transition, particularly for government people, CMS regional office staff, state mental health, substance abuse, and Medicaid personnel for whom this is a very different way of assuring that care gets delivered to their populations?

1: The first step is how do we get the document out? There is talk of using satellite broadcasts and getting the message out through that method, so that everyone can hear the same thing at the same time. But the real issue isn't the document, but how we get the players to actually do it. Some states are way ahead of us, they have already had discussions along these lines. I don't really have the answer. Although we can give a Federal perspective, the real answers must come from the states and from the maximum use of technical assistance and whatever travel money we have. We know the "scripts" must be the same, we need to use the best person to present the information, and, also, we must target our audiences and determine who is the right person to present the information to.

17: In a follow-up to the statement you made about some states are dividing up levels of care-acute vs. wraparound, managed care vs. county. In mental health, consistency of care/provider is essential. Is there some way that CMS could build into the next level of care reimbursement to the MCO by the county so this could be ensured?

1: That is one of the "hot" issues that I doubt you will get CMS to come down on one side or the other, as it is a state issue. There are cadres of experts on this issue and they have various opinions. The bottom line is that, political realities impact on this issue. States will work within the confines of what state legislatures will allow.