Quality Improvement and Patient Protection Committee Meeting. January 25, 2017
AGENDA Call to Order Approval of Minutes from the January 11, 2017 (VOTE) Updated Neonatal Abstinence Syndrome Trends Office of Patient Protection Annual Report Schedule of Next Committee Meeting (March 15, 2017)
AGENDA Call to Order Approval of Minutes from the January 11, 2017 (VOTE) Updated Neonatal Abstinence Syndrome Trends Office of Patient Protection Annual Report Schedule of Next Committee Meeting (March 15, 2017)
VOTE: Approving Minutes MOTION: That the Committee hereby approves the minutes of the QIPP meeting held on January 11, 2017, as presented. 4
AGENDA Call to Order Approval of Minutes from the January 11, 2017 (VOTE) Updated Neonatal Abstinence Syndrome Trends Office of Patient Protection Annual Report Schedule of Next Committee Meeting (March 15, 2017)
HPC’s Sept 2016 report identified care delivery and payment reform innovations that could contribute to the Commonwealth’s effort to address opioid use disorder Opioid Use Disorder in Massachusetts: an Analysis of its Impact on the Health Care System, Pharmacological Treatment, and Recommendations for Payment and Care Delivery Reform 1 2 3 Identify strategic policy Provide new research and opportunities to promote data analyses to support and innovative care delivery inform policy on the opioid and payment models for Draw on our experience epidemic in Massachusetts opioid use disorder with investment, treatment that are likely certification, and technical to result in reduced assistance programs to spending and improved inform scaling of emerging quality and/or access best practices 6
Updating HPC analyses for 2015 One recommendation in HPC’s report was that the Commonwealth continue to track the impact of opioid use disorder and related conditions on the health care system. HPC conducted the following analyses in 2014, and plans to update them annually: • Opioid-related hospital discharges (ED visits and inpatient admissions) • Impact on communities (discharges mapped by HPC region) • Impact on populations (admissions stratified by income, gender, and age) • Impact on exposed infants (Neonatal Abstinence Syndrome) 2015 update for today’s discussion See appendix for analyses methods 7
NAS increased significantly in Massachusetts between 2011 and 2015 1,400 20 1,197 1,190 1,162 17.0 18 17.2 16.6 Rate of NAS discharges per 1,000 live births 1,200 1,040 16 14.9 941 Volume of NAS discharges 1,000 13.2 14 12 800 10 600 27% increase 31% increase 8 in volume in rate 6 400 4 200 2 0 0 2011 2012 2013 2014 2015 2011 2012 2013 2014 2015 Source: HPC analysis of Center for Health Information and Analysis, Inpatient Discharge Database 2011-2015 Notes: NAS discharges were identified using ICD-9-CM diagnosis code 779.5 (drug withdrawal syndrome in a newborn). 8
NAS is increasing significantly throughout the nation but particularly rapidly in certain states 14 Massachusetts National Average 12 MA: 229% increase in Rate of NAS discharges per 1,000 live births rate 10 8 Nationally: 357% increase in rate 6 4 2 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD. Incidence of Neonatal Abstinence Syndrome — 28 States, 1999 – 2013. MMWR Morb Mortal Wkly Rep 2016;65:799 – 802. DOI: http://dx.doi.org/10.15585/mmwr.mm6531a2 9
Nationally, the rate of NAS is increasing most quickly in rural areas Rural and Urban Differences in Neonatal Abstinence Syndrome and Maternal Opioid Use, 2004 to 2013 JAMA Pediatr. Published online December 12, 2016. doi:10.1001/jamapediatrics.2016.3750 10
Rate of NAS discharges per 1,000 live births, by HPC region, in 2015 Source: HPC analysis of Center for Health Information and Analysis, Inpatient Discharge Database 2015 Notes: NAS discharges were identified using ICD-9-CM diagnosis code 779.5 (drug withdrawal syndrome in a newborn). 11
2015 NAS discharges by hospital volume See Appendix for hospital names Source: HPC analysis of Center for Health Information and Analysis, Inpatient Discharge Database 2015 Notes: NAS discharges were identified using ICD-9-CM diagnosis code 779.5 (drug withdrawal syndrome in a newborn). Only includes hospitals with 12 or more NAS discharges. 12
2015 NAS discharges by hospital volume, relative to total obstetric volume Total Births 300 6300 Total NAS Discharges 12 119 See appendix for hospital names 13
MA hospitals with highest rate of NAS in 2015 80 75.2 11 CHART Rate of NAS discharges per 1,000 live births 70 65.5 hospitals 60 9 non-CHART 53.8 50 hospitals 44.7 44.1 41.8 41.6 40 33.2 32.2 30.4 29.9 30 26.2 25.8 25.0 22.7 21.9 19.8 19.5 17.6 16.8 20 10 0 Source: HPC analysis of Center for Health Information and Analysis, Inpatient Discharge Database 2015 Notes: NAS discharges were identified using ICD-9-CM diagnosis code 779.5 (drug withdrawal syndrome in a newborn). Only includes 14 hospitals with 12 or more NAS discharges.
Due to rapidly increasing rates of NAS, the Commonwealth is focusing on quality and availability of treatment The FY2017 budget created an NAS taskforce (co-chaired by Secretary of EOHHS & the Office of the Attorney General) and advisory council , to develop recommendations to improve quality of and access to treatment. Recommended state plan of action , along with any proposed legislation or regulatory amendments , expected March 2017. State Plan of Action State plan of action: 1 State plan for the coordination of care and services for newborns with neonatal abstinence syndrome and substance exposed newborns including, but not limited to, those related to early intervention, substance use disorders and healthcare access issues; Include an inventory of the services and programs available in the Commonwealth to 2 serve newborns with neonatal abstinence syndrome and substance exposed newborns; 3 Identify gaps in available services and programs; Formulate a plan to address identified gaps; and, 4 Develop an interagency plan for collecting data, develop outcome goals and ensuring 5 quality service is delivered 15
AGENDA Call to Order Approval of Minutes from the January 11, 2017 (VOTE) Updated Neonatal Abstinence Syndrome Trends Office of Patient Protection Annual Report Schedule of Next Committee Meeting (March 15, 2017)
Office of Patient Protection Overview History of the Office of Patient Protection Core Responsibilities ▪ Created in 2000 to protect Massachusetts ▪ Regulating internal and external review for fully- managed care consumers (Ch. 141) insured plans ▪ OPP operated within the Department of Public ▪ Administering external review for fully-insured Health (DPH) plans – ▪ Consumer assistance and education Consumer rights to challenge health plan coverage denials ▪ Administering enrollment waivers to purchase – Massachusetts fully-insured plans only non-group health insurance ▪ Chapter 224 moved OPP from DPH to HPC ▪ Receiving and analyzing annual reports from health plans about appeals, disenrollment of ▪ OPP transfer took effect April 20, 2013 providers, other mandated information ▪ Developing and regulating an appeals process for patients in risk bearing provider organizations (RBPOs) and HPC-certified accountable care organizations (ACOs) 17
Internal review process Process for consumer with a fully-insured Mass. health plan 1. Consumer 2. Consumer 3. Carrier 4. Further receives denial appeals directly responds to appeal rights letter from carrier to carrier consumer ▪ Denial of prior ▪ May appeal in ▪ Written response ▪ Voluntary authorization or writing or over to consumer reconsideration if ▪ Carrier may denial of claim, the phone offered by carrier ▪ If denial based must be in writing (carrier puts in reverse, modify ▪ May be based on writing) or uphold original on medical ▪ Carrier responds medical decision necessity , may necessity or within 30 days seek external other reasons unless voluntary review through ▪ Consumer may extension OPP ▪ Carrier responds request expedited within two days if internal review expedited ▪ Consumer may request continuation of coverage 18
External review process Process for consumer with a fully-insured Mass. health plan, after pursuing internal review 1. Consumer 2. Consumer 3. Independent receives 2 nd denial requests 4. Next steps external review from carrier external review ▪ Consumer ▪ Deadline: 4 ▪ OPP reviews for ▪ ERA may uphold, receives written months from the eligibility overturn, or ▪ If eligible, OPP denial notice/final date the insured partially overturn ▪ ERA sends adverse receives the final sends to external determination adverse review agency written decision from carrier determination (ERA) to insured, ▪ External review if ▪ Submit ▪ ERA requests file representative, completed medical OPP, carrier from carrier ▪ Carrier must necessity external review ▪ ERA applies ▪ Consumer may form, copy of respond within 5 Mass. medical final adverse or request days, implement necessity adverse expedited without delay standard determination & ▪ Final and binding external review ▪ Standard: 45 $25 fee if ▪ Consumer may decision days applicable, any request ▪ Expedited: 72 supporting continuation of hours documents coverage 19
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