Ohio Medicaid Managed Care Program

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Ohio Medicaid Managed Care Program

  1. 1. Ohio’s Medicaid Managed Care Program
  2. 2. Why Managed Care? <ul><li>Access </li></ul><ul><li>Consumer satisfaction </li></ul><ul><li>Quality </li></ul><ul><li>Policy direction supported by various external commissions & reviews </li></ul>
  3. 3. History <ul><li>1978 – First established in Ohio </li></ul><ul><li>1980s-1990s – Approaches explored, lessons learned </li></ul><ul><li>2000-2006 – ~13 counties; improvements in approach continue </li></ul><ul><li>2007 – Statewide expansion completed for CFC & ABD </li></ul><ul><ul><li>8 regions </li></ul></ul><ul><ul><li>Approximately 1.5 million enrollees </li></ul></ul>
  4. 4. Managed Care - 2010 <ul><li>Current caseload (February data) </li></ul><ul><ul><li>CFC – 1,404,549 </li></ul></ul><ul><ul><li>ABD – 117,720 </li></ul></ul><ul><li>Expenditures YTD (March data) </li></ul><ul><ul><li>CFC – $2.73 billion </li></ul></ul><ul><ul><li>ABD – $1.20 billion </li></ul></ul>
  5. 5. Ohio Medicaid Managed Care: Value Added Benefits for Members <ul><li>Preventive health programs and care coordination services </li></ul><ul><li>Connect members to primary care providers </li></ul><ul><li>Advice and direction for medical issues via a toll free 24/7 nurse advice line </li></ul><ul><li>Assistance in accessing services with a dedicated call center and member handbook </li></ul><ul><li>Special services, like care management, for members with special health care needs </li></ul><ul><li>Grievance resolution system </li></ul><ul><li>Expanded provider networks </li></ul><ul><li>Transportation services, expanded coverage, and member incentives (may vary by plan) </li></ul>
  6. 6. Ohio Medicaid Managed Care Quality Strategy <ul><li>Statewide comprehensive plan that incorporates how ODJFS: </li></ul><ul><ul><li>Monitors managed care plan compliance with state and federal regulations </li></ul></ul><ul><ul><li>Evaluates and improves services delivered to consumers enrolled in a managed care plan </li></ul></ul><ul><li>Framework for communicating approach for ensuring timely access to high quality health care. </li></ul><ul><li>Federal requirement for the state Medicaid agency to have a Managed Care Quality Strategy. </li></ul>
  7. 7. MCP Accountability System <ul><li>Robust accountability system for assessing and improving quality of care to managed care consumers </li></ul><ul><li>Key program domains: </li></ul><ul><ul><li>Access </li></ul></ul><ul><ul><li>Administrative Capacity </li></ul></ul><ul><ul><li>Consumer Satisfaction </li></ul></ul><ul><ul><li>Quality </li></ul></ul><ul><li>Performance measures and minimum established standards </li></ul><ul><li>Incentives and disincentives are used for program compliance and continuous quality improvement </li></ul>
  8. 8. Ohio Medicaid Managed Care Quality Strategy - Summary Access Administrative Capacity Consumer Satisfaction Quality <ul><li>Provider Panel Requirements </li></ul><ul><li>Grievance and Appeal Monitoring </li></ul><ul><li>Consumer/Provider Complaints </li></ul><ul><li>MCP 24/7 Nurse Advice Line </li></ul><ul><li>Access Performance Measures and Standards </li></ul><ul><li>Compliance Assessment System </li></ul><ul><li>MCP Reporting Requirements </li></ul><ul><li>Program Integrity </li></ul><ul><li>Financial Performance Measures and Standards </li></ul><ul><li>Data quality </li></ul><ul><li>Annual Consumer Satisfaction Survey </li></ul><ul><li>Managed Care Enrollment Center </li></ul><ul><li>MCP Member Services Lines </li></ul><ul><li>Prior Approval of MCP Marketing and Member Materials </li></ul><ul><li>Quality Assessment and Performance Improvement Program </li></ul><ul><li>Care Management Programs </li></ul><ul><li>Clinical Performance Measures and Standards </li></ul><ul><li>Annual external quality review activities </li></ul><ul><li>Medicaid Medical Directors Meetings </li></ul>
  9. 9. Ohio Medicaid Managed Care Quality Strategy – Access Domain <ul><li>Provider Panel </li></ul><ul><ul><li>Searchable online directory </li></ul></ul><ul><ul><li>Monitoring of accuracy of information </li></ul></ul><ul><ul><li>Provider panel standards </li></ul></ul><ul><li>Grievance/Appeals </li></ul><ul><ul><li>Access related reviewed by state staff </li></ul></ul><ul><ul><li>Training on coding </li></ul></ul><ul><ul><li>Checked for proper coding </li></ul></ul>
  10. 10. Ohio Medicaid Managed Care Quality Strategy – Access Domain <ul><li>Consumer/Provider Complaint </li></ul><ul><ul><li>On-line provider complaint form </li></ul></ul><ul><li>MCP 24/7 Nurse Advice Line </li></ul><ul><li>Access Performance Measures & Standards </li></ul><ul><ul><li>Adults' Access to Preventive/Ambulatory Health Services (HEDIS) </li></ul></ul><ul><ul><li>Children's Access to Primary Care [CFC only] (HEDIS) </li></ul></ul><ul><ul><li>Members' Access to Designated PCP </li></ul></ul>
  11. 11. Ohio Medicaid Managed Care Quality Strategy Medicaid Managed Care: ABD Population Members’ Access to Preventive/Ambulatory Health Services (HEDIS)
  12. 12. Ohio Medicaid Managed Care Quality Strategy – Administrative Capacity Domain <ul><li>Compliance Assessment System </li></ul><ul><ul><li>0 – 100 point system </li></ul></ul><ul><ul><li>Fines increase as points increase </li></ul></ul><ul><ul><li>At 100 points ODJFS can terminate agreement </li></ul></ul><ul><ul><li>There are other enforcement tools </li></ul></ul><ul><li>MCP Reporting Requirements </li></ul><ul><li>Program Integrity </li></ul>
  13. 13. Ohio Medicaid Managed Care Quality Strategy – Administrative Capacity Domain <ul><li>Financial Performance Measures and Standards </li></ul><ul><ul><li>Prompt Payment </li></ul></ul><ul><ul><li>Net worth per Member </li></ul></ul><ul><ul><li>Administrative Expense Ratio </li></ul></ul><ul><ul><li>Days Cash on Hand </li></ul></ul><ul><ul><li>Ratio of Cash to Claims Payable </li></ul></ul><ul><ul><li>Reinsurance </li></ul></ul>
  14. 14. Ohio Medicaid Managed Care Quality Strategy – Administrative Capacity Domain <ul><li>Data Quality </li></ul><ul><ul><li>Encounter Data Volume (utilization measures) </li></ul></ul><ul><ul><li>Rejected Encounters </li></ul></ul><ul><ul><li>Acceptance Rate (encounters) </li></ul></ul><ul><ul><li>Encounter Data Accuracy Studies </li></ul></ul><ul><ul><li>Incomplete Outpatient Hospital Data </li></ul></ul><ul><ul><li>Incomplete Data For Last Menstrual Period (CFC) </li></ul></ul><ul><ul><li>Generic Provider Number Usage </li></ul></ul><ul><ul><li>Designated PCP for newly enrolled members </li></ul></ul><ul><ul><li>Timeliness (monthly) </li></ul></ul>
  15. 15. Ohio Medicaid Managed Care Quality Strategy – Consumer Satisfaction Domain <ul><li>Annual consumer satisfaction survey </li></ul><ul><li>Managed care enrollment center </li></ul><ul><li>MCP Member Services Lines </li></ul><ul><li>Prior approval of MCP marketing and member materials </li></ul>
  16. 16. Ohio Medicaid Managed Care Quality Strategy – Quality Domain <ul><li>Quality and care management programs </li></ul><ul><ul><li>Submitted annually by MCPs </li></ul></ul><ul><ul><li>Reviewed internally by clinical staff </li></ul></ul><ul><ul><li>Subjected to evidence based review by the external quality review organization </li></ul></ul><ul><li>Performance Improvement Projects </li></ul><ul><ul><li>Topics: Members with special health care needs, Dental care, and EPSDT Statewide Collaborative </li></ul></ul><ul><ul><li>Validated by external quality review organization to ensure compliance with CMS protocols </li></ul></ul>
  17. 17. Ohio Medicaid Managed Care Quality Strategy – Quality Domain <ul><li>External Quality Review Activities </li></ul><ul><li>Federal regulations require the state Medicaid agency to contract with an external quality review organization to: </li></ul><ul><ul><li>Evaluate quality and accessibility of services provided to managed care plan members. </li></ul></ul><ul><ul><li>Provide information to the state to design appropriate, effective interventions to improve health care quality and access over time. </li></ul></ul><ul><li>ODJFS contracts with Health Services Advisory Group </li></ul>
  18. 18. External Quality Review Activities (cont.) <ul><li>Overview of EQR activities: </li></ul><ul><ul><li>Evaluation of managed care plan administrative compliance </li></ul></ul><ul><ul><li>Validation of MCP performance improvement projects </li></ul></ul><ul><ul><li>Validation of clinical performance measures </li></ul></ul><ul><ul><li>Encounter data validation/accuracy studies </li></ul></ul><ul><ul><li>Consumer satisfaction surveys </li></ul></ul><ul><ul><li>Quality of life surveys </li></ul></ul><ul><ul><li>MCP Information systems reviews </li></ul></ul><ul><ul><li>Program evaluations </li></ul></ul><ul><ul><li>Statewide quality improvement initiatives </li></ul></ul>
  19. 19. Ohio Medicaid Managed Care Quality Strategy – Quality Domain <ul><li>Performance Measures </li></ul><ul><li>CFC Population </li></ul><ul><li>Care Management </li></ul><ul><ul><li>Care Management of High Risk Members </li></ul></ul><ul><ul><li>Care Management of Members </li></ul></ul><ul><li>Clinical Performance (HEDIS measures) </li></ul><ul><ul><li>Comprehensive Diabetes Care (CDC)/Eye exam </li></ul></ul><ul><ul><li>Use of Appropriate Medications for People with Asthma </li></ul></ul><ul><ul><li>Perinatal care - Frequency of ongoing prenatal care, timeliness of prenatal care, postpartum care </li></ul></ul><ul><ul><li>Well-Child Visits – First 15 Mos of Life; 3-6 Years; 12-21 Years </li></ul></ul><ul><ul><li>Annual dental visits </li></ul></ul><ul><ul><li>Lead screening for 1 Year and 2 Year Olds </li></ul></ul>
  20. 20. Ohio Medicaid Managed Care Quality Strategy – Quality Domain <ul><li>ABD Population </li></ul><ul><li>Care Management </li></ul><ul><ul><li>Care Management of High Risk Members </li></ul></ul><ul><ul><li>Care Management of Members </li></ul></ul><ul><li>Clinical Performance (HEDIS) </li></ul><ul><ul><li>Persistence of Beta-Blocker Treatment after Heart Attack </li></ul></ul><ul><ul><li>Cholesterol Management for Patients with Cardiovascular Conditions/LDL-C screening performed </li></ul></ul><ul><ul><li>Comprehensive Diabetes Care (CDC)/Eye exam </li></ul></ul><ul><ul><li>Use of Appropriate Medications for People with Asthma </li></ul></ul><ul><ul><li>Follow-up After Hospitalization for Mental Illness </li></ul></ul><ul><ul><li>Condition-specific measures: Congestive heart failure, Coronary arterial disease, Non-mild hypertension, Diabetes, Chronic obstructive pulmonary disease, Asthma, Mental Health, Alcohol and Drug </li></ul></ul><ul><ul><li>Inpatient Hospital discharge rate </li></ul></ul><ul><ul><li>Emergency Department utilization rate </li></ul></ul><ul><ul><li>Hospital Readmission </li></ul></ul>
  21. 21. Ohio Medicaid Managed Care Quality Strategy – Quality Domain Medicaid Managed Care: CFC Population Frequency of Ongoing Prenatal Care- Percent Who Received 81% of More of Expected Visits (HEDIS)
  22. 22. Overview: Ohio’s Managed Care Program Evaluation <ul><li>Evaluation conducted by Health Services Advisory Group </li></ul><ul><li>Purpose of Program Evaluation: </li></ul><ul><ul><li>To evaluate the current design of key managed care program areas </li></ul></ul><ul><ul><ul><li>Performance measures </li></ul></ul></ul><ul><ul><ul><li>Pay-for-performance </li></ul></ul></ul><ul><ul><ul><li>Access-monitoring strategies </li></ul></ul></ul><ul><ul><ul><li>Data quality strategies </li></ul></ul></ul><ul><ul><li>To assess the extent of regulations in comparison with other state Medicaid managed care programs </li></ul></ul><ul><ul><li>To make recommendations with the potential to improve program effectiveness, and strengthen the quality strategy. </li></ul></ul><ul><li>Results and Follow-Up </li></ul><ul><ul><ul><li>Ohio’s monitoring strategies are robust and align with other state Medicaid managed care programs </li></ul></ul></ul><ul><ul><ul><li>Implementation of strategies to enhance the above 4 key program areas </li></ul></ul></ul>

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