SFY 2018–2019 External Quality Review ...

SFY 2018?2019 External Quality Review Technical Report

for Medicaid Health Plans

April 2020

Table of Contents

1. Executive Summary........................................................................................................................ 1-1 Purpose and Overview of Report ..................................................................................................... 1-1 Scope of External Quality Review (EQR) Activities ....................................................................... 1-1 High-Level Findings and Conclusions ............................................................................................. 1-2 Michigan Department of Health and Human Services............................................................... 1-2 Aetna Better Health of Michigan ............................................................................................... 1-5 Blue Cross Complete of Michigan ............................................................................................. 1-6 HAP Empowered........................................................................................................................ 1-7 McLaren Health Plan.................................................................................................................. 1-8 Meridian Health Plan of Michigan ............................................................................................. 1-9 Molina Healthcare of Michigan ............................................................................................... 1-10 Priority Health Choice, Inc....................................................................................................... 1-11 Total Health Care, Inc. ............................................................................................................. 1-13 Trusted Health Plan .................................................................................................................. 1-14 UnitedHealthcare Community Plan.......................................................................................... 1-15 Upper Peninsula Health Plan.................................................................................................... 1-16

2. Introduction to the Annual Technical Report ............................................................................. 2-1 Purpose of Report ............................................................................................................................. 2-1 Organizational Structure of Report .................................................................................................. 2-1 Section 1--Executive Summary ................................................................................................ 2-2 Section 2--Introduction to the Annual Technical Report .......................................................... 2-2 Section 3--Overview of Michigan Medicaid Managed Care Program ..................................... 2-2 Section 4--External Quality Review Activities......................................................................... 2-2 Section 5--Assessment of MHP Performance........................................................................... 2-2 Section 6--MHP Comparative Information With Recommendations for MDHHS.................. 2-2

3. Overview of Michigan Medicaid Managed Care Program ........................................................ 3-1 Managed Care in Michigan and Overview of MHPs ....................................................................... 3-1 Overview of MHPs..................................................................................................................... 3-1 Quality Strategy................................................................................................................................ 3-2

4. External Quality Review Activities ............................................................................................... 4-1 Compliance Monitoring ................................................................................................................... 4-1 Activity Objectives..................................................................................................................... 4-1 Technical Methods of Data Collection and Analysis ................................................................. 4-1 Description of Data Obtained and Related Time Period ............................................................ 4-2 Validation of Performance Measures ............................................................................................... 4-3 Activity Objectives..................................................................................................................... 4-3 Technical Methods of Data Collection and Analysis ................................................................. 4-4 Description of Data Obtained and Related Time Period ............................................................ 4-5 Validation of Performance Improvement Projects ........................................................................... 4-6 Activity Objectives..................................................................................................................... 4-6

2018?2019 MHP External Quality Review Technical Report State of Michigan

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Technical Methods of Data Collection and Analysis ................................................................. 4-7 Description of Data Obtained and Related Time Period ............................................................ 4-9

5. Assessment of MHP Performance................................................................................................. 5-1 Methodology .................................................................................................................................... 5-1 Aetna Better Health of Michigan (AET) .......................................................................................... 5-1 EQR Activity Results ................................................................................................................. 5-1 Strengths, Weaknesses, and Overall Conclusions.................................................................... 5-11 Follow-Up on Prior EQR Recommendations........................................................................... 5-13 Recommendations for Program Improvement ......................................................................... 5-22 Blue Cross Complete of Michigan (BCC) ..................................................................................... 5-25 EQR Activity Results ............................................................................................................... 5-25 Strengths, Weaknesses, and Overall Conclusions.................................................................... 5-33 Follow-Up on Prior EQR Recommendations........................................................................... 5-36 Recommendations for Program Improvement ......................................................................... 5-42 HAP Empowered (HAP) ................................................................................................................ 5-45 EQR Activity Results ............................................................................................................... 5-45 Strengths, Weaknesses, and Overall Conclusions.................................................................... 5-53 Follow-Up on Prior EQR Recommendations........................................................................... 5-57 Recommendations for Program Improvement ......................................................................... 5-63 McLaren Health Plan (MCL) ......................................................................................................... 5-66 EQR Activity Results ............................................................................................................... 5-66 Strengths, Weaknesses, and Overall Conclusions.................................................................... 5-74 Follow-Up on Prior EQR Recommendations........................................................................... 5-77 Recommendations for Program Improvement ......................................................................... 5-83 Meridian Health Plan of Michigan (MER)..................................................................................... 5-86 EQR Activity Results ............................................................................................................... 5-86 Strengths, Weaknesses, and Overall Conclusions.................................................................... 5-94 Follow-Up on Prior EQR Recommendations........................................................................... 5-97 Recommendations for Program Improvement ....................................................................... 5-102 Molina Healthcare of Michigan (MOL) ....................................................................................... 5-104 EQR Activity Results ............................................................................................................. 5-104 Strengths, Weaknesses, and Overall Conclusions.................................................................. 5-113 Follow-Up on Prior EQR Recommendations......................................................................... 5-116 Recommendations for Program Improvement ....................................................................... 5-123 Priority Health Choice, Inc. (PRI)................................................................................................ 5-125 EQR Activity Results ............................................................................................................. 5-125 Strengths, Weaknesses, and Overall Conclusions.................................................................. 5-133 Follow-Up on Prior EQR Recommendations......................................................................... 5-136 Recommendations for Program Improvement ....................................................................... 5-140 Total Health Care, Inc. (THC)...................................................................................................... 5-143 EQR Activity Results ............................................................................................................. 5-143 Strengths, Weaknesses, and Overall Conclusions.................................................................. 5-151 Follow-Up on Prior EQR Recommendations......................................................................... 5-154

2018?2019 MHP External Quality Review Technical Report State of Michigan

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Recommendations for Program Improvement ....................................................................... 5-160 Trusted Health Plan (TRU) .......................................................................................................... 5-163

EQR Activity Results ............................................................................................................. 5-163 Strengths, Weaknesses, and Overall Conclusions.................................................................. 5-172 Follow-Up on Prior EQR Recommendations......................................................................... 5-175 Recommendations for Program Improvement ....................................................................... 5-185 UnitedHealthcare Community Plan (UNI) ................................................................................... 5-188 EQR Activity Results ............................................................................................................. 5-188 Strengths, Weaknesses, and Overall Conclusions.................................................................. 5-196 Follow-Up on Prior EQR Recommendations......................................................................... 5-199 Recommendations for Program Improvement ....................................................................... 5-206 Upper Peninsula Health Plan (UPP)............................................................................................. 5-209 EQR Activity Results ............................................................................................................. 5-209 Strengths, Weaknesses, and Overall Conclusions.................................................................. 5-217 Follow-Up on Prior EQR Recommendations......................................................................... 5-221 Recommendations for Program Improvement ....................................................................... 5-224

6. MHP Comparative Information With Recommendations for MDHHS ................................... 6-1 EQR Activity Results ....................................................................................................................... 6-1 Compliance Monitoring ............................................................................................................. 6-1 Performance Measures ............................................................................................................... 6-3 Performance Improvement Project........................................................................................... 6-15 Summary, Conclusions, and Recommendations ............................................................................ 6-16 Strengths and Associated Conclusions..................................................................................... 6-16 Weaknesses and Associated Conclusions ................................................................................ 6-18 Quality Strategy Recommendations for Michigan ................................................................... 6-20

2018?2019 MHP External Quality Review Technical Report State of Michigan

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1. Executive Summary

Purpose and Overview of Report

States with Medicaid managed care delivery systems are required to annually provide an assessment of managed care entities' performance related to the quality of, timeliness of, and access to care and services they provide, as mandated by 42 Code of Federal Regulations (CFR) ?438.364. To meet this requirement, the Michigan Department of Health and Human Services (MDHHS) has contracted with Health Services Advisory Group, Inc. (HSAG) to perform the assessment and produce this annual report.

MDHHS administers and oversees the Michigan Medicaid managed care program. The Michigan Medicaid managed care program's managed care entities include 11 Medicaid Health Plans (MHPs) contracted with MDHHS to provide medical services to Medicaid recipients in Michigan. The MHPs include:

? Aetna Better Health of Michigan ? Blue Cross Complete of Michigan ? HAP Empowered ? McLaren Health Plan ? Meridian Health Plan of Michigan ? Molina Healthcare of Michigan ? Priority Health Choice, Inc. ? Total Health Care, Inc. ? Trusted Health Plan ? UnitedHealthcare Community Plan ? Upper Peninsula Health Plan

Scope of External Quality Review (EQR) Activities

To conduct this assessment, HSAG used the results of mandatory external quality review (EQR) activities, as described in 42 CFR ?438.358. The purpose of these activities, in general, is to provide valid and reliable data and information about the MHPs' performance. For the state fiscal year (SFY) 2018?2019 assessment, HSAG used findings from the following mandatory EQR activities to derive conclusions and make recommendations about the quality of, timeliness of, and access to care and services provided by each MHP. More detailed information about each activity is provided in Section 4 of this report.

2018?2019 MHP External Quality Review Technical Report State of Michigan

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