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Texas Health Steps (THSteps) Program
 Draft Process Improvement Plan
January 2002

Background

During recent years, stakeholders composed of numerous work groups, state agency staff, advocates, advisory groups, professional associations and external reviewers have identified THSteps concerns and recommended solutions. Some of these concerns have been reflected in the THSteps Subcommittee of the State Managed Care Advisory Committee (SMCAC) recommendations document and the SMCAC issue log; the STAR Program member complaint logs; and a report by the Texas Nurses Association: THSteps Research Report, Provider Survey of 2001.

The stakeholders have expressed the following concerns:

  • Providers perceive certain program requirements as administrative hassles (e.g., lead screen requirements, requirements to participate in Vaccines for Children, paperwork, documentation requirements of completed checkups, time intensity of exam).
  • THSteps provider enrollment is required in addition to Medicaid enrollment.
  • CMS-required standards for a comprehensive preventive health visit are inconsistent with prevailing provider practices, especially those of physicians.
  • In Medicaid managed care (MMC), providers perceive a lack of coordination between the medical home and other THSteps providers who may serve the client (there is disagreement among medical providers as to whether THSteps should be provided exclusively in the medical home)
  • THSteps Medical Case Management coordination with MMC health plans is a concern.
  • Members need additional education and information about appropriate and timely services.
  • Providers have stated a need for program-related administrative and clinical training.
  • Member education is needed regarding the importance of scheduling and keeping appointments.
  • Better coordination is needed with the various entities conducting outreach.
  • Better information about the Medical Transportation Program (MTP) is needed for members and providers.
  • Materials and information that indicate which providers perform THSteps are needed.
  • Complications with data and coding issues result in uncertainty about program performance and accountability.
  • Medicaid Identification Form 3087 doesn't always reflect accurate information. For example, THSteps participation status may not be up-to-date.
  • THSteps can be performed in various provider locations outside the medical home, thus creating information and data collection issues.
  • The Compass 21 (C21) encounter data subsystem is not currently operating optimally.
  • Outreach and overdue notices are frequently out of date or inaccurate due to incomplete data in SAVERR.
  • There is a lack of comparability or standardization between CPT codes and THSteps codes.
  • The HCFA 416 report to CMS is incomplete.
  • Modifier codes are problematic for HMOs; claims with these codes are sometimes not included on encounter submissions.
  • MMC providers can report encounters with either Preventive Medicine Services CPT codes, or THSteps local codes. The clinical elements, periodicity and documentation requirements of THSteps local codes closely match those of American Academy of Pediatrics (AAP) recommendations. There is no explicitly defined correlation between the THSteps/AAP system and corresponding elements needed to satisfy service descriptors in the CPT reporting system.
  • A need exists to develop a system that can use CPT codes to perform the same program functions as THSteps local codes.
  • There are shortages of providers willing to provide THSteps in many areas.
  • There are gaps in MTP availability, particularly in rural areas.
  • MTP policies were created for a fee for service (FFS) environment. These policies may be problematic for managed care members needing transportation assistance.
  • Policies and procedures for out of area and Value Added services transport by MTP need to be clarified.
  • Primary Care Providers (PCPs) are not always available to families in a manner that accommodates the needs of families.
  • MTP transport of siblings is not allowed under Federal regulations.
  • Policy development and planning for THSteps and related Medicaid funded programs (e.g. FFS & MMC) are not always coordinated.
  • There seem to be differing perceptions about what is considered THSteps services, in relation to the Medicaid "parent" program.
  • THSteps, MTP and Medical Case Management programs appear to function autonomously.
  • Structures and processes are not in place to accomplish strategic planning and significant quality improvement among THSteps and related Medicaid funded programs.

Response to Stakeholder Concerns

A work group of Texas Department of Health (TDH), Department of Human Services (DHS) and Health and Human Services Commission (HHSC) staff convened in December 2001 to evaluate the identified concerns and to collaboratively formulate a plan for THSteps process improvement activities.

The charge to the work group was to develop a high-level process improvement plan by December 21, 2001. The plan was to contain a list of goals and strategies to address stakeholder concerns.

The work group participated in the following process:

Step 1. Re-wrote the above concerns, translating them from "problem statement" language into "strategy" language.

Step 2. Clustered strategies that identified similar concerns, and identified the larger goals the clustered strategies addressed. Please notice that all listed items are addressed in the plan, with the exception of the following:

  • Complications with data and coding issues result in uncertainty about program performance and accountability. The group decided that this bullet states the result of the problem, rather than identifying the problem, and thus should not be included in a work plan. All the concerns that lead to this outcome are identified in the work plan.
  • MTP transport of siblings is not allowed under federal regulations. The group decided that some concerns are beyond the scope of this project. Any relief would have to result from a change in federal law.

Step 3. Clustered the strategies under the following four major goals:

  1. Simplify administrative requirements for providers and health plans.
    1. Assess perceived provider administrative hassles and "onerous" program requirements and determine whether any or all of these requirements should be reduced or eliminated without compromising patient health care.
    2. Continue to streamline THSteps provider enrollment in relation to Medicaid enrollment.
    3. Research and confirm that CMS-required standards for documentation of a comprehensive preventive health visit are inconsistent with prevailing provider practices, especially that of physicians.
    4. In Medicaid managed care (MMC), continue to improve coordination between the medical home and other THSteps providers who may serve the client. (There is disagreement among medical providers as to whether THSteps should be provided exclusively in the medical home.)
    5. Continue to improve THSteps Medical Case Management coordination with MMC health plans.
    6. Eliminate THSteps local codes and use only CPT codes. Assess the requirement for modifier codes (these codes are problematic for HMOs and claims with these codes are sometimes not included on encounter submissions).
    7. Periodicity - modify when a child over age 2 is considered overdue.
  2. Resolve and simplify data issues in order to improve program performance evaluation and accountability.
    1. Enhance the timeliness of Medicaid Identification Form 3087 information and the timeliness of outreach and overdue notices caused by incomplete data in SAVERR.
    2. Improve the collection of MCO encounter data and fee-for-service claims processing reporting at NHIC to generate an accurate and complete HCFA 416 report to CMS.
  3. Improve access to care for THSteps clients, and strengthen provider and member outreach and education.
    1. Continue to make efforts to increase the number of providers willing to provide THSteps in areas where providers are available, but unwilling to participate.
    2. Continue to increase MTP availability, particularly in rural areas.
    3. Clarify MTP policies to ensure consistency in application.
    4. Encourage and provide incentives to Primary Care Providers (PCP) to be available to families in a manner that accommodates their needs.
    5. Continue to improve recipient education and information about appropriate and timely services; the importance of scheduling and keeping appointments; and about the Medical Transportation Program.
    6. Continue to improve program-related administrative and clinical training for providers.
    7. Continue to improve coordination among various entities conducting outreach.
    8. Continue the development of materials and information that indicates which providers perform THSteps, and expand efforts in providing this information to recipients.
  4. Establish a process for coordination and planning among THSteps, Medicaid, DHS, et al.
    1. Integrate the THSteps policy development group with planning coordination with related Medicaid funded programs (e.g. FFS & MMC).
    2. Clarify how the THSteps program functions in relation to the Medicaid "parent" program at HHSC.
    3. Continue to improve the organizational functionality among THSteps, MTP and Medical Case Management.
    4. Continue strategic planning and quality improvement among THSteps and related Medicaid funded programs.

Next Steps

HHSC and TDH are inviting associations and interested individuals to review and comment on the strategies described above. Individual work groups will be formed to begin working on each of the goals and strategies. HHSC has established a web page on the HHSC website for comments and to provide updates about the progress of the work groups. The address for the Web page is: http://www.hhsc.state.tx.us/Medicaid/index.html.

External stakeholder meetings will be held at appropriate intervals. Progress reports will be provided to the Medicaid Managed Care Regional Advisory Committees (RACs), to the Medical Care Advisory Committee (MCAC), to the Statewide Managed Care Advisory Committee (SMCAC) and to participants in the regular Medicaid HMO CEO meetings.

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