Current through Register Vol. 35, No. 18, September 24, 2024
A. Under the direction of a medical director
or his or her designated physician, the MHCP shall have a system-wide
continuous quality improvement program to monitor the quality and
appropriateness of care and services provided to covered persons. This program
shall be based on a written plan which is reviewed at least annually and
revised as necessary. The plan shall describe at least:
(1) the scope and purpose of the
program;
(2) the organizational
structure of quality improvement activities;
(3) duties and responsibilities of the
medical director and/or designated physician responsible for continuous quality
improvement activities;
(4)
contractual arrangements, where appropriate, for delegation of quality
improvement activities;
(5)
confidentiality policies and procedures;
(6) specification of standards of care,
criteria and procedures for the assessment of the quality of services provided
and the adequacy and appropriateness of health care resources
utilized;
(7) a system of ongoing
evaluation activities, including individual case reviews as well as pattern
analysis;
(8) a system of focused
evaluation activities, particularly for frequently performed and/or highly
specialized procedures;
(9) a
system for monitoring random covered person satisfaction and network provider's
response and feedback on MHCP operations;
(10) a system for verification of providers'
credentials, recertification, performance reviews and for obtaining information
about any disciplinary action against a provider available from any state
licensing board applicable to the provider;
(11) the procedures for conducting peer
review activities, which shall include providers within the same discipline and
area of clinical practice;
(12) a
system for evaluation of the effectiveness of the continuous quality
improvement program to include care coordination between utilization
management, case management and disease management services.
B. The board of directors or other
management body of the MHCP shall be kept apprised of continuous quality
improvement activities and be provided at least annually with regular written
reports from the program delineating quality improvements, performance measures
used and their results, and demonstrated improvements in clinical and service
quality.
C. There shall be a
multidisciplinary continuous quality improvement committee responsible for the
implementation and operations of the program. The structure of the committee
shall include representation from the medical, nursing and administrative
staff, with substantial involvement of the medical director of the
MHCP.
D. The program shall monitor
the availability, accessibility, continuity and quality of care on an ongoing
basis. Indicators for evaluating the quality of health care services provided
by all participating providers shall be identified and established and may
include:
(1) a mechanism for monitoring
patient appointment and triage procedures, discharge planning services, linkage
between all modes and levels of care and appropriateness of specific diagnostic
and therapeutic procedures, as selected by the continuous quality improvement
program;
(2) a mechanism for
evaluating all providers of care that is supplemental to each provider's
quality improvement system;
(3) a
system to monitor provider and covered person access to utilization management
services, including, at a minimum, waiting times to respond to phone requests
for service authorization, covered person urgent care inquiries, and other
services required by this rule.
E. The MHCP shall follow up on findings from
the program to assure that effective corrective actions have been taken,
including, at a minimum, policy revisions, procedural changes and
implementation of educational activities for covered persons and
providers.
F. Continuous quality
improvement activities shall be coordinated with other performance monitoring
activities including utilization management, risk management, and monitoring of
covered person and provider complaints.
G. The MHCP shall maintain documentation of
the quality improvement program in a confidential manner. This documentation
shall be available to the superintendent, shall be submitted as part of the
health care insurer's annual report to the superintendent, and shall include:
(1) minutes of quality improvement committee
meetings;
(2) records of evaluation
activities, performance measures, quality indicators and corrective plans and
their results or outcomes.
H.
External quality audit:
(1) Upon request by the superintendent, each
MHCP shall have an external quality audit conducted by an IQRO approved by the
division, and shall submit proof to the superintendent that such an audit and
report has been completed.
(2) The
report must describe in detail the MHCP's conformance to performance standards
established by the IQRO, other national standard-setting bodies for MHCPs, and
the standards set out in this rule. The report shall also describe in detail
any corrective actions proposed and/or undertaken and approved by the IQRO. The
report shall be submitted to the division within 60 days of its receipt in
final form by the MHCP.
(3) The
superintendent may grant a MHCP a deferral of the above requirement for an
external quality audit for a 12-month period if it is in the initial three
years of start-up operations.
I.
Performance and outcome
measures.
(1) The division may develop
a performance and outcome measurement system for monitoring the quality of care
provided to MHCP covered persons. The data collected through this system may be
used by the division to:
(a) assist MHCPs and
their providers in quality improvement efforts;
(b) provide the division with information on
the performance of MHCPs for regulatory oversight;
(c) support efforts to inform consumers about
MHCP performance;
(d) promote the
standardization of data reporting by MHCPs and providers; and for
(e) any other purpose consistent with the
policies and provisions of this rule and the Insurance Code.
(2) The performance and outcome
measures may include population-based and patient-centered indicators of
quality of care, appropriateness, access, utilization, and satisfaction. To
minimize costs to health care insurers, MHCPs, providers, and the division,
performance measures will incorporate, when possible, data routinely collected
or available to the division from other sources. Data for these performance
measures may include but not be limited to the following:
(a) indicator data collected by MHCPs from
chart reviews and administrative data bases;
(b) satisfaction surveys of covered
persons;
(c) provider
surveys;
(d) all reports submitted
by MHCPs to the superintendent as required by this rule;
(e) data collected by the division for
administrative, epidemiological and other purposes, such as the state cancer
registry, vital records, and hospital records.
(3) MHCPs shall submit such performance and
outcome data as the division may request from time to time.
(4) The division shall provide each MHCP an
opportunity to comment on the compilation and interpretation of the data before
its release to consumers.
(5) The
division may conduct or arrange for periodic satisfaction surveys of covered
persons. Upon request by the superintendent, the MHCP shall provide the
division with the mailing list of covered persons to be used to select samples
of the MHCP's membership for the surveys. Upon request by the superintendent,
the MHCP shall also provide the division with a mailing list of former covered
persons who are no longer covered by the MHCP, which the division may use to
select samples of the MHCP's former covered persons for surveys.
(6) The division shall ensure the
confidentiality of patient specific information.
(7) The division shall take all necessary
measures to reduce duplicative reporting of information to state agencies. Any
performance and outcome measurement system developed by the division shall not
be duplicative of the health information system created by the Health
Information System Act, Chapter 24, Article 14A NMSA 1978, and implemented by
the New Mexico health policy commission.
(8) In developing a performance and outcome
measurement system, the division shall take into consideration data reporting
standards of nationally recognized accrediting entities, such as, for example,
the health plan employer data and information set (HEDIS), and shall attempt to
avoid duplication of such reporting standards, so that a MHCP may, where
possible, submit the same data to the division that the MHCP submits to a
private accrediting entity.
J.
Accreditation by nationally
recognized accrediting entity: Nothing in this section shall prohibit a
MHCP from submitting accreditation by a nationally recognized accrediting
entity as evidence of compliance with the requirements of this section. In
those instances where a MHCP seeks to meet the requirements of this section
through accreditation by a private accrediting entity, the MHCP shall submit to
the division the following information:
1)
current standards of the private accrediting entity in order to demonstrate
that the entity's standards meet or exceed the requirements of this
rule;
2) documentation from the
private accrediting entity showing that the MHCP has been accredited by the
entity; and 3) a summary of the data and information that was presented to the
private accrediting entity by the MHCP and upon which accreditation of the MHCP
was based. A MHCP accredited by the private accrediting entity that has
submitted all of the requisite information to the division may then be deemed
by the superintendent to have met the requirements of the relevant provisions
of this section where comparable standards exist, provided that the private
accrediting entity from which the MHCP obtained accreditation is recognized and
approved by the superintendent.
