Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 141 - OREGON HEALTH PLAN › Section 410-141-3525 - Outcome and Quality Measures

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Managed Care Entities (MCEs) shall report to the Authority its health promotion
			 and disease prevention activities, national accreditation organization results,
			 and Healthcare Effectiveness Data and Information Set (HEDIS) measures as
			 required by DCBS in OAR 836-053-1000. A copy of the reports may be provided to
			 the Authority's Performance Improvement Coordinator concurrent with any
			 submission to DCBS.
(2) The MCE
			 shall inform the Authority if it has been accredited by a private independent
			 accrediting entity. If the MCE has been so accredited, the MCE shall authorize
			 the private independent accrediting entity to provide the Authority a copy of
			 its most recent accreditation review in accordance with CFR
			 42 CFR §
									438.332.
(3) As required by health system
			 transformation, MCEs shall be accountable for performance on outcomes, quality,
			 and efficiency measures incorporated into the MCE's contract with the
			 Authority. Measures are selected by the Authority with the incentive measures
			 specifically adopted by the Metrics and Scoring Committee using a public
			 process. Information can be requested from the Authority or viewed online at
			 the Metrics and Scoring Committee website located at
https://www.oregon.gov/oha/HPA/ANALYTICS/Pages/CCO-Metrics.aspx
.
(4) MCEs shall address objective outcomes,
			 quality measures, and benchmarks for ambulatory care, inpatient care,
			 behavioral health care, dental services, HRSN Services and all other health
			 services provided by or under the responsibility of the MCE as specified in the
			 MCE's contract with the Authority and federal external quality review
			 requirements in CFR 42 §438.350, §438.358, and
			 §438.364.
(5) MCEs shall
			 implement an ongoing comprehensive quality assessment and performance
			 improvement program (QAPI) for monitoring, evaluating, and improving the
			 access, quality, and appropriateness of services provided to members consistent
			 with the needs and priorities identified in the MCE's community health
			 assessment, community health improvement plan, and the standards in the MCE's
			 contract. This process shall include an internal Quality Improvement (QI)
			 program with written criteria based on written policies, evidenced-based
			 practice guidelines, standards and procedures that are in accordance with the
			 requirements set forth in 42
			 CFR §
									438.330, relevant law and the
			 community standards for care, or in accordance with accepted medical practice,
			 whichever is applicable, and with accepted professional standards. MCEs shall
			 have in effect mechanisms to:
(a) Detect both
			 underutilization and overutilization of services;
(b) Evaluate performance and customer
			 satisfaction consistent with MCE contractual requirements, relevant Oregon
			 Administrative Rules, and provide documentation of implementation of
			 interventions to achieve improvement in the access to and quality of care to
			 the Authority and the Authority contracted External Quality Review Organization
			 (EQRO);
(c) Evaluate grievance,
			 appeals, and contested case hearings consistent with OAR 410-141-3890  through
			 410-141-3915;
(d) Assess the
			 quality and appropriateness of coordinated care services provided to all
			 members with identified special health care needs including those who are aged,
			 blind, or disabled or who have high health care needs, multiple chronic
			 conditions, behavioral health disorders; who receive Medicaid funded long-term
			 care or long-term services and supports benefits; or who are children receiving
			 Child Welfare services or OYA services; and
(e) Report on the diversity and capacity of
			 the workforce in their service area including capacity to provide services in a
			 culturally responsive and trauma informed manner, appropriately relying on
			 workforce data provided by the Authority;
(f) Undertake performance improvement
			 projects that are designed to improve the access, quality and utilization of
			 services. Projects must be designed to achieve significant improvement in
			 health outcomes and member satisfaction.