PL
Manage Performance Measures
Health Plan Management
Description
The Manage Performance Measures business process involves the design, implementation, and maintenance of mechanisms and measures the State Medicaid Agency (SMA) uses to monitor the business activities and performance of the State Medicaid Enterprise’s business processes and programs. This includes the steps involved in defining the criteria by which the SMA measures activities and programs (e.g., Consumer Assessment of Healthcare Providers and Systems (CAPHS) and Healthcare Effectiveness Data and Information Set (HEDIS) measures). This business process develops the reports and other mechanisms that it uses to track activity and effectiveness at all levels of monitoring. Business Intelligence analysis (i.e., historical, current and predictive views of business operations) occurs within this process. Examples of performance measures and associated reports may be things such as: Goal: The SMA makes prompt and accurate payments to providers. Measurement: Pay or deny 95% of all clean claims within 30 days of receipt. Mechanism: The SMA generates weekly report on claims processing timelines. Goal: Accurately and efficiently, draw and report funds in accordance with the federal Cash Management Improvement Act (CMIA) and general cash management principles and timeframes to maximize non-general fund recovery. Measurement: Draw 98% of funds with the minimum time allowed under CMIA. Mechanism: The SMA generates monthly report on funds drawn. Goal: Improve health care outcomes for Medicaid members. Measurement: Reduce emergency room visits by ten percent by assigning a primary care case manager. Mechanism: The SMA generates monthly report comparing emergency room usage by member for the period prior to and after Primary Care Case Managers (PCCM) assignment.
Business Process Template
Trigger events
Environment-based
- Receive request to revise or develop new performance measures and/or reporting.
- Notification of a periodic review of measures and/or reporting is due.
- Receive notification for executing a periodic monitoring activity.
- Receive notice describing an incident requiring monitoring.
Interaction-based
None published
Results
- Update to the criteria, mechanisms, and/or reports utilized to monitor performance measures.
- Produce reporting related to the incident analysis or periodic monitoring results.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Receive request or reach scheduled review time.
- 2. Review existing performance measures and reports.
- 3. Revise, delete or add to existing measures and reports.
- 4. Produce updated definition of performance measures.
- 5. Monitor business activity against established performance measures.
- 6. Assess resulting information with business intelligence methods (i.e., historical, current and predictive views of business operations).
- 7. Produce reporting.
- 8. END: Disseminate information to designated members (e.g., individuals or business processes).
Predecessor processes
- NOTE: Any MITA business process could be a predecessor to any performance monitoring activity depending on the performance measures.
- Develop Agency Goals and Objectives
- Maintain Program Policy
- Maintain State Plan
- Manage Health Plan Information
- Identify Utilization Anomalies
- Manage Compliance Incident Information
Successor processes
Shared data
- Business Activity data store including performance information (e.g., CAPHS and HEDIS measures)
Constraints
The SMA will comply with federal and state regulations. Business intelligence tools have different abilities depending on the tool utilized and technical configuration.
Failures
- Inability to access relevant information.
Performance measures
- Time to complete the process = within __ hours, ___ minutes
- Accuracy with which State Medicaid Enterprise applies updates
- Consistency with which State Medicaid Enterprise applies updates
- Error rate = __%
- Effectiveness of performance measures
- Ease of implementation of performance measures
Source: CMS MITA 3.0 Business Process Template, Plan Management BPT.pdf, pages 8-10.
Business Capability Model (12 questions)
Each capability question defines five maturity levels, from Level 1 through Level 5.
Business Capability Descriptions
Is the process primarily manual or automatic?
- LEVEL 1The process consists primarily of manual paper-based activity to accomplish tasks. The process is manual and duplicated in multiple areas within the organization.
- LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks.
- LEVEL 3SMA automates process to the full extent possible within the intrastate.
- LEVEL 4SMA automates process to the full extent possible across the interstate.
- LEVEL 5SMA automates process to the full extent possible across the nation.
Does the State Medicaid Agency use standards in the process?
- LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific performance standards.
- LEVEL 2A mix of nationally recognized and state-specific performance standards is applied.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized performance standards for monitoring intrastate business activity.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized performance standards for monitoring interstate business activity.
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized performance standards for monitoring national business activity.
Does the State Medicaid Agency use Plan of Action with Milestones (POAM)?
- LEVEL 1SMA does not have a Service Level Agreement (SLA) or Key Performance Indicator (KPI).
- LEVEL 2SMA has put in place a SLA and some KPI are established, collected, and monitored.
- LEVEL 3SMA periodically evaluates operational business processes against an established intrastate SLA and KPI. When SMA does not meet targets, creates and executes a Plan of Action with Milestones (POAM).
- LEVEL 4SMA periodically evaluates operational business processes against an established interstate SLA and KPI. When SMA does not meet targets, creates and executes a POAM.
- LEVEL 5SMA periodically evaluates operational business processes against an established national SLA and KPI. When SMA does not meet targets, creates and executes a POAM.
How does the State Medicaid Agency publish performance measures?
- LEVEL 1SMA manually produces and distributes performance measures and outcomes to other parties responsible for the activity.
- LEVEL 2SMA electronically publishes performance measures and outcomes.
- LEVEL 3SMA fully publishes performance measures and outcomes within the intrastate. Based on use of MITA Framework, industry standards, and information definitions States may share outcome measures with other States and federal agencies.
- LEVEL 4SMA fully publishes performance measures and outcomes across the interstate.
- LEVEL 5SMA fully publishes performance measures and outcomes across the nation.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
- LEVEL 1Very little collaboration occurs with other agencies to standardize performance measures or business tasks.
- LEVEL 2SMA collaborates with other agencies and entities to adopt nationally recognized performance measures.
- LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national performance measures as well as develop and share reusable business services.
- LEVEL 4SMA collaborates with other interstate agencies and entities to adopt national performance measures as well as develop and share reusable processes including clinical information.
- LEVEL 5SMA collaborates with agencies and entities for national (and international) interoperability improvements that maximize automation of routine operations.
Business Capability Quality: Timeliness of Process
How timely is the end-to-end process?
- LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation).
- LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements.
- LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Timeliness exceeds Level 2.
- LEVEL 4Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. SMA has interstate interoperability, which further improves timeliness over Level 3.
- LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and with federal agencies. Most processes execute at the point of service. Results are almost immediate.
Business Capability Quality: Data Access and Accuracy
How accurate is the information in the process?
- LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making.
- LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
- LEVEL 3Automation of information collection increases the reliability of SMA’s internal information. External sources of information use MITA Framework and industry standards for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy rating is at 99% or higher.
- LEVEL 4Automation of information collection increases the reliability of SMA’s internal and external sources of information. SMA adopts MITA Framework and industry standards for information exchange with interstate agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
- LEVEL 5SMA adopts MITA Framework and industry standards for information exchange with national agencies. Decision-making is automatic using national standardized business rules definitions. Accuracy rating is at 99% or higher.
How accessible is the information in the process?
- LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually. SMA limits communications to paper, email, Compact Disc (CD) or publications.
- LEVEL 2SMA stores information in disparate systems, but automation and nationally recognized standards increase accessibility over Level 1. Communication occurs through email, Compact Disc (CD) or publication on state’s website.
- LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. Accessibility is greater than Level 2.
- LEVEL 4SMA obtains information easily and exchanges with interstate agencies and entities. Accessibility is greater than Level 3.
- LEVEL 5SMA obtains information easily and exchanges with national agencies and entities. Accessibility is greater than Level 4.
Business Capability Quality: Cost Effectiveness
What is the cost of the process compared to the benefits of its results?
- LEVEL 1High relative cost due to low number of automatic, standardized tasks.
- LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for interstate information exchange. SMA increases cost effectiveness ratio over Level 3.
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national (and international) information exchange. SMA increases cost effectiveness ratio over level 4.
Business Capability Quality: Effort to Perform; Efficiency
How efficient is the process?
- LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and SMA performance standards. Efficiency is low.
- LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving efficiency to 95% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving efficiency to 98% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving efficiency to 98% or higher.
Business Capability Quality: Accuracy of Process Results
How accurate are the results of the process?
- LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low. SMA conducts manual review and verification of accuracy of calculations prior to publication.
- LEVEL 2Automation and standardized business rules definitions reduce error. Less manual review and verification of accuracy of calculations is needed prior to publication. SMA improves accuracy above Level 1.
- LEVEL 3SMA adopts nationally recognized performance measures by intrastate agencies and entities improving accuracy to 90% or higher.
- LEVEL 4SMA adopts nationally recognized performance measures by interstate agencies and entities improving accuracy to 98% or higher.
- LEVEL 5SMA adopts nationally recognized performance measures by national agencies and entities improving accuracy to 98% or higher.
Business Capability Quality: Utility or Value to Stakeholders
Does the business process satisfy stakeholders?
- LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
- LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving stakeholder satisfaction to 95% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving stakeholder satisfaction to 98% or higher.
Source: CMS MITA 3.0 Business Capability Model, Plan Management BCM.pdf, pages 27-34.