HealthChoices Medicaid Managed Care
Pennsylvania; Data Collection and Rate Setting
Christine Bowser (Director, Bureau of Managed
Care Operations, Pennsylvania Department of Public Welfare)
April 17, 2002
Pennsylvania at a Glance (D-Link)
- Budget = $45.5 Billion in State and Federal Funds
- Pennsylvania has 1.4 million Medical Assistance (MA) Eligibles
Pennsylvania - Rural/Urban Map
(D-Link)
HealthChoices Medicaid Managed Care
- Implemented in 1997 in first zone with full state implementation by 2005
- Currently have seven MCOs providing services in three zones
- 938,000 MA recipients are served in these three zones
HealthChoices Zones (D-link)
HealthChoices More Inclusive Than Exclusive...
(D-link)
| Covered Services |
Eligibility
Groups |
- Medical Services
- Pharmaceuticals (Physical and Behavioral Health)
- Dental Benefits
- Behavioral Health
|
- Temporary Assistance for Needy Families
- General Assistance
- Supplemental Security Income
- HIV/AIDS
- Children in Substitute Care
- Intermediate Care Facility for the Mentally Retarded
- Home & Community Based Waivers
|
HealthChoices- Who is NOT Included?
- New Eligibles (first 4-6 weeks)
- Persons in Nursing Facilities (after first 30 days)
HealthChoices- Behavioral Health
- Comes under "umbrella" of HealthChoices
- Contract directly with County Government (Right of First Opportunity)
- County Based Contractor manages care
- Formal Letters of Agreement with Physical Health MCOs
Key Structures of HealthChoices
- Core Teams (Contract Monitoring)
- Independent Enrollment Contractor
- Open Enrollment
- Special Needs Units
Special Needs Definition:
- Non-categorical
- Inclusive, not diagnosis-driven
- Circumstances and needs
- Anyone at anytime
- Short term or long term
- Self-identified or MCO-identified
Special Needs Units (SNUs)
- Assist with access
- Care coordination
- Access community resources
- Navigate managed care and related service systems
Top 5 Identifiers for Consumers with
One Special Need (D-Link)
Top 5 Identifiers for Consumers UNDER
AGE 21 with One Special Need (D-Link)
External Support Agency Referrals for Consumers UNDER 21 with Special Needs
(D-Link)
External Support Agency Referrals for
Consumers 21 AND OVER with Special Needs (D-Link)
Activities Reported by SNUs (D-Link)
| Activity |
SNU Activity Level |
| TTY Interventions |
More than 400 members |
| Language Line Interventions |
More than 400 requests from members
More than 70 SNU initiated contacts |
| Transportation |
MATP: 1,021 requests from 627 members
OTHER: 3,041 requests from 1,477 members |
| SNU Case Management |
Approximately 25,000 Consumers |
| Training, Education, and Outreach |
More than 500 activites that reached approximately 44,200 persons |
Net Result for Special Needs Population
- Included in mainstream medicine
- Provided incentives for MCOs to serve
- Getting better access to care
- Getting better quality care
- Managing the dollars available
How Do We Measure Success?
- Data, Data, Data
- HEDIS, EQR, and CAHPS
- Performance Profile
- Quality Improvement Plans
Performance Profile
- Shows how MCOs are performing on 28 measures
- Compares MCOs to each other and to national benchmarks
- Given to each new enrollee
- Available on website, English and Spanish hard copy, Braille, large print,
and audio tape
How Is HealthChoices Doing with
Quality Improvement?
- 47 individual measures met or exceeded 75th percentile for HEDIS/CAHPS benchmarking
- 59% of average program measures showed improvement from previous year
- 17 individual measures exceeded the 90th percentile benchmark
- Member satisfaction exceeds 75th percentile for:
Seeing a specialist
Satisfaction with MCO
Satisfaction with specialist
- Steady increases in:
Pap tests
Childhood immunizations
- For “Care for Pregnant Women” measure, all 6 MCOs exceeded
national average with 3 MCOs exceeding 75th percentile
- Preventative services show sustained, positive trend
- Access among 12-24 months old is very high
- Screens for cervical cancer increased
Focused Activities - Clinical Guideline
for HIV/AIDS
Next Step: Risk Adjusted Rates
Risk Adjusted Rates (RAR)- Why?
- HealthChoices has significant risk adjustment
- Category of aid
- Dual eligibles
- Geography
- HIV-AIDS Risk Pools
- Maternity Care Payments
- Limited risk sharing for SSI and home nursing costs
- Next Step - More closely link capitation to health diagnoses of MCO’s
members
Steps to Risk Adjusted Rates
- Two Year preparation time – Implementation January 2003
- Met with experts and developers of various RAR Grouper Tools
- Selected CDPS (Chronic Illness and Disability Payment System)
- Met with all stakeholder groups
- Involved MCOs in decisions and provided technical assistance
- Independent contractor to evaluate accuracy and completeness of encounter
data
- MCO corrective action plans and sanctions
- Two “Dry Runs” shared with MCOs
Key Concept:
To risk adjust MCO capitation payments, you need good encounter data.
Here's why...
How Encounter Data Fits In (D-Link)
To risk adjust MCO capitation payments, you need good encounter data.
Here's why...
Key Concept:
If encounter data is incomplete or incorrect, you won't get the right numbers
of each diagnosis.
Once you have good encounter data, you need a grouper...
How A Grouper Works: (D-Link)
Building a Case Mix: (D-Link)
Key Concept:
The Case Mix tells you how sick the members of each plan are. Case Mixes over
1.0 show sicker members, Case Mixes less than 1.0 show healthier members.
You now use the Case Mix to adjust the capitation up or down....
How Risk Adjustment Works (D-Link)
How Risk Adjustment Could Be Used to
Pay Providers (D-Link)
Timeline for Initial RAR (D-Link)
Timeline for First Update to MCO Plan
Factors (D-Link)
Future of HealthChoices:
- Expansion statewide
- More linkage of quality indicators to reimbursement
- More partnerships on clinical issues
- Technology Assessment Groups
- Home Nursing Clinical Guidelines
For More Information:
Ms. Chrstine Bowser - Director, Bureau of Managed Care Operations
chbowser@state.pa.us
(717) 772 - 6300
HealthChoices Website:
http://www.dpw.state.pa.us/omap/hcmc/omaphcmci.asp
Go to: Final Summary | Disability
Conference | Provider Reimbursement | HRSA
| HHS