Medica: A Health Plan Case Study


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Presented by Ken Bence, M.H.A., M.B.A.
Director of Public Health, Medica, at the 2013 National Chlamydia Coalition meeting

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  • At Medica 12 years, first 4 with responsibility for HEDIS reportingDeveloped strong ties with public health community
  • Mission: includes health improvementVision: includes innovation
  • Several grants over the years have supported STD screening and treatment
  • State Public Programs = MedicaidMedica serves 46 counties, just over halfBulk of our counties include all state public programs, others carve out specific programsMA & MinnesotaCare (and to an extent SNBC) include the age groups pertinent to Chlamydia
  • Hospitals & Health Systems are the bigger players, most are based in the Metro with service areas extending to different parts of the stateMedica & Allina used to be combinedHealthPartners & Sanford straddle the line, include both provider and payerPark Nicollet and HealthPartners just combinedHealthPartners and Essentia just received NCQA accreditation as an ACO, among the first 6PreferredOne commercial only, Ucare and MHP government programs only
  • This helped to set up Minnesota’s collaborative environment
  • Rates not acceptable, below national benchmarks
  • Importance of partnerships
  • Packaged into a Performance Improvement Project (PIP) as specified in contract with DHS 2006-8Partnership
  • Initiatives added between 2004-2010
  • Starting in 2008, exceeded national average for Medicaid, still behind the national 90th %ileMinnesota statewide average around 50% (claims)
  • Young adults can now stay on parents’ plan up to age 26
  • Medica: A Health Plan Case Study

    1. 1. Perspectives on Performance in HealthPlans: Planning of Measures, Health PlanPractice, and Possibilities for IncreasingChlamydia Screening Rates A Health Plan Case Study Ken Bence, M.H.A., M.B.A. Director of Public Health Presentation to the National Chlamydia Coalition February 20, 2013 1
    2. 2. About Me 2
    3. 3. Minneapolis, MNFebruary 23, 2013Accenture Tower 3
    4. 4. Overview for Today• Brief introduction to Medica• Minnesota Medicaid Managed Care• Why Chlamydia?• Programs & Interventions• Ideas to Adopt/Adapt 4
    5. 5. Medica Health PlansStarted as a physician-owned plan in 1975Part of Allina (integrated health system) 1994-2001A full service insurer  Commercial group, Medicare, Medicaid, TPA Medica Service Area (MSA) and Individual plans and services  Open access, PPO, HMO, tiered and care system networksA regional plan + national reach  96% of area physicians  Nearly 27,000 regional physicians and healthcare professionals, >615,000 nationally  More than 240 regional hospitals, >5,000 nationally UnitedHealth Group National Network Coverage 5
    6. 6. MissionVision We do much more than finance care and process claimsWe encourage prevention, fitness and wellnessWe encourage members to get needed tests and careWe work with providers to improve outcomes, safety and efficiency 6
    7. 7. Medica Today 2nd largest Minnesota health insurer  Primary business is in MN, ND, SD and WI  National coverage alliance with other insurers More than 1.6 million members  Employer-based group coverage  Leased networks and services  Individual-Family  Medicare  Medicaid  Health Management Nonprofit  $3.8 billion annual premium adjusted revenue in 2011  90% of premiums go to care 7
    8. 8. Corporate Giving• Mission is to fund community-based initiatives and programs that support the needs of Medica’s customers and the greater community by improving their health and removing barriers to health care services• Grants awarded to 501(c)(3) or governmental organizations throughout Medica’s service area• Awarded over 600 grants totaling more than $12 million since 2003• Annual funding priorities posted each March 1st• 2012 Funding Priorities:  Behavioral Health - Filling the Gaps  Reducing Inappropriate Emergency Room Utilization, Hospital Admissions & Readmissions  Primary Care and Preventive Health Services for People with Disabilities  Early Childhood Health  Organizational Core Mission Support• 8
    9. 9. State Public ProgramsMedica is ranked 14th best Medicaidhealth plan nationally by NCQA#1 in Minnesota 9
    10. 10. Minnesota’s Healthcare Landscape• A system of NON-PROFIT providers & payers, BY LAW• All licensed health plans MUST participate in state healthcare programs, BY LAW• All Medica providers MUST participate in all product lines, BY CONTRACT  Hospitals & Health Systems  Health Plans 10
    11. 11. Minnesota’s Medicaid Managed Care ModelMedical Assistance (MA) • Minnesota’s version of traditional Medicaid, based on income • State/federal funding, administered by Department of Human Services (DHS) • Covers kids < 21, pregnant women • May also cover qualifying adults with kids, disabledMinnesotaCare • For families and children above the Medicaid income limits, even if they have access to insurance (“working poor”) • State subsidized, sliding-scale premiumsMinnesota’s Medicaid Expansion • Brings adults without kids into MA, federally funded 11
    12. 12. Collaboration Plans• Mandated in statute since 1995• All HMOs shall file a plan every five years with the Commissioner of Health• Describes the actions the plan intends to take to contribute to achieving one or more high-priority public health goals• Must be jointly developed with LPH and other community organizations providing health services within the same service area as the plan• All HMOs shall file reports updating progress on their plan• Current plan (2010-2014) was done collaboratively with all plans together, through agreement with the Department of Health 12
    13. 13. So…. Why Medica’s interest in Chlamydia? 13
    14. 14. New HEDIS Measure in 2001 Commercial Medicaid80%70%60%50%40%30%20%10%0% 2001 2002 2003 14
    15. 15. Environmental Factors • Infections on the rise in Minnesota, especially urban/suburban • Growing awareness of disparities • Priority for Metro local public health • Collaboration plans • Emerging privacy considerations • Urine test available • Later, Expedited Partner Therapy (2008) • Became one of the State’s quality metrics for preventionProvider Factors • Inconsistencies among providers, despite clear preventive health guidelines • MN Community Measurement • Patients may be going elsewhere to avoid insurance claims • Discomfort taking sexual histories 15
    16. 16. So…. What did we do? 16
    17. 17. First, we studied the problem! • Chart audits • Literature review • Physician consultations • Department of Human Services studyOur Findings: • The problem is multi-faceted • A comprehensive solution is needed • Our leverage points: • Providers • Enrollees/patients • General • Targeted 17
    18. 18. So we made a plan….Provider-directed Initiatives Financial incentive for primary care providers, added to existing program (PIP) Tool kits for clinics • Chlamydia screening & treatment guidelines • Chlamydia statistics & coding recommendations • Fact sheets, forms, wallet cards & posters • Chlamydia care path(s) • “Diagnosis and Treatment of Chlamydia in Pregnancy” • Comparison of Chlamydia Testing Technologies • Guide to Sexual History Taking • Online Chlamydia Course (California STD/HIV Prevention Center) with CMEs • Journal articles • MN Family Planning and STD Hotline information Clinic-level data Newsletter articles Consultation 18
    19. 19. Member-directed Initiatives • Clinical case managers provided with scripting for appropriate members • Medica CallLink® 24/7 nurse line reminders for appropriate callers • Referral resources provided to customer service representatives • Information included in preventive health mailings • Chlamydia screenings added to The Way to Better HealthSM member incentive program – for males too! • Targeted mailings to males & females, including vouchers • Newsletter articles – “It’s Your Health” 19
    20. 20. So…. What happened? 20
    21. 21. Medicaid Commercial80%70%60%50%40%30%20%10%0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 HEDIS Year 21
    22. 22. So…. What’s next? 22
    23. 23. Healthcare Reform!• More people insured• First dollar preventive care coverage• Reproductive health care debates• Confusion 23
    24. 24. And more of the same….Working through partnerships • A new PIP: • Collaborative, 4 health plans working together • Will work with clinics to support their efforts • Developed a new provider tool kit • Will support the MN Chlamydia Partnership to promote the State strategy • Total Cost of Care arrangements with key healthcare systems • Aligned with State Health Care Home and other alternative payer arrangements • Promotes relationships with primary care • Encourages provider organizations to innovate • Primary Care Designation project in State Public Programs • Enhanced community outreach • “Triple Aim” 24
    25. 25. Thank you!Questions? 25