Kaiser Family Foundation Survey on State Medicaid Managed Care ...

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States were asked to indicate, for each non-comprehensive PHP, whether its enrollment was Medicaidonlyor mixed Medicaid and commercial, and also whether it was not-for-profit or for-profit, publiclytraded or not, and national or local. The profile of plans serving Medicaid beneficiaries varied by thetype of service provided.Nearly all Medicaid beneficiaries receivinginpatient or outpatient behavioral healthservices through a non-comprehensivePHP were in plans specializing inMedicaid, and not-for-profit, non-publiclytraded, and local plans were stronglydominant. Almost all (98 percent) of the7.9 million enrollees in PHPs providingbehavioral health were in plans thatprimarily or exclusively serve Medicaid(Figure 7). Only one in five beneficiaries(19 percent) received their care in forprofitPHPs, and smaller shares wereenrolled in plans affiliated with a publiclytraded company (10 percent) or with anational company (16 percent).By comparison, Medicaid enrolleesreceiving dental care through a noncomprehensivePHP were more likely tobe in plans with mixed Medicaid andcommercial enrollment, for-profit plans,and plans affiliated with a nationalcompany. Six states reported PHPcontracts limited to dental services, withdental PHP enrollment of a little over 2million in a total of 14 plans. Medicaidbeneficiaries receiving care in these planswere relatively evenly distributed betweendental PHPs with mixed enrollment (52percent) and Medicaid-only plans (48percent) (Table 8). For-profit plansaccounted for close to half (46 percent) ofFigure 7Distribution of Medicaid Enrollees in Behavioral Health PHPsby Selected PHP Characteristics(11 states)Medicaid enrollment in dental PHPs. Almost two-thirds (63 percent) of dental PHP enrollees wereenrolled in a plan affiliated with a national company.98%Mixed– 2%81% 90%84%19%For-profit16%NationalEnrollment composition For-profit status Publicly traded Local or nationalNote: 15 states contract with behavioral health PHPs.SOURCE: KCMU/HMA <strong>Survey</strong> of Medicaid Managed Care, September 2011.Figure 8Not publiclytradedPubliclytraded -10%LocalDistribution of Medicaid Enrollees in Dental PHPsby Selected PHP Characteristics(6 states)Medicaidonly52% 54%MixedNot-forprofit48% 46%MedicaidonlyNot-forprofitFor-profit10%90%Not publiclytraded37%Local63%NationalEnrollment composition For-profit status Publicly traded Local or nationalNote: Seven states contract with dental PHPs.SOURCE: KCMU/HMA <strong>Survey</strong> of Medicaid Managed Care, September 2011.Publiclytraded32 00
Measuring, monitoring, and improving quality in Medicaid managed careKey Section Findings:All states with MCOs and most states with PCCM programs require HEDIS© or other measuresof performance and CAHPS© or other surveys of patient experience. Required measures focusheavily on Medicaid priority areas such as prenatal and post-partum care, child health,preventive care, management of asthma, diabetes, and other chronic conditions, and access.Of the 48 states with MCOs and/or PCCM programs, over a quarter also measure and monitorquality in their fee-for-service delivery systems.Of the 36 states with MCOs, 16 require health plans to be accredited by a recognized nationalaccrediting organization, such as NCQA, to participate in Medicaid.Over three-fourths of states with MCOs publicly report on the quality of their MCOs, and half ofPCCM states publish quality reports on their PCCM programs. A smaller number of states alsopublicly report on PHP performance. Sixteen states with MCOs reported that they prepare aquality report card, using HEDIS©, CAHPS©, and state-specific measures, that Medicaidbeneficiaries can use to compare and choose health plans.Quality improvement projects in the states with MCOs reveal the breadth of state priorities,including, among others, improved birth outcomes, increased access to pediatric subspecialists,identification of high-risk individuals for case management, and coordination betweenbehavioral health and medical providers.Managed care provides a platform for states to ensure the quality of care for Medicaid beneficiaries.Federal regulations define requirements that both states and health plans must meet to measure,monitor, ensure, and improve the quality of care provided to Medicaid beneficiaries enrolled in riskbasedmanaged care, including both MCOs and non-comprehensive PHPs. Each state contracting withplans must have a written quality strategy that includes specified elements, including nationalperformance measures, and must, through its contracts, ensure plan compliance with standards set bythe state. Contracts with plans must require ongoing quality assessment and performance improvementprojects (PIP), and submission of performance data to the state; states must also arrange for annualexternal reviews of the quality, appropriateness, and timeliness of services furnished to Medicaidenrollees. Similar requirements do not exist for fee-for-service.With electronic data increasingly available on many aspects of utilization, clinical outcomes, and patientexperience, states have growing opportunities to examine health plan and health system performanceacross a broad spectrum of quality-related measures. Managed care offers a structure in whichperformance can be measured and enforced. Through managed care contracts, states can specifybenchmarks for acceptable performance and hold health plans accountable for their achievement, andstructure payment to reward (or penalize) good (or poor) performance. The survey asked states anumber of questions concerning the nature and breadth of current and planned activity aimed atmeasuring and improving quality in Medicaid.Appendix 12 provides a summary of states’ use of selected quality tools.Of the 36 states with MCOs, 16 require that risk-based plans be accredited to participate in Medicaid.One means by which states can assure quality in risk-based plans is to require that, as a condition ofparticipating in Medicaid, they obtain accreditation from a national accrediting body, such as the33
Page 1 and 2: kaisercommission onmedicaidand theu
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Page 5 and 6: Table of ContentsExecutive Summary
Page 7 and 8: EXECUTIVE SUMMARYMedicaid, the publ
Page 9 and 10: party enrollment brokers to provide
Page 11 and 12: HEDIS©, CAHPS©, and state-specifi
Page 13: ConclusionFor over 30 years, state
Page 16 and 17: from the recession and the slow rec
Page 18 and 19: A note on Medicaid managed care ter
Page 20 and 21: Managed caremodelTable 1: Medicaid
Page 23 and 24: States are increasingly mandating m
Page 25 and 26: States with Medicaid MCOsKey Sectio
Page 27 and 28: States have “auto-assignment” a
Page 29 and 30: excess of a specified threshold for
Page 31 and 32: Dental care and outpatient and inpa
Page 33 and 34: the second trimester, and within th
Page 35 and 36: eported that they limit PCP panel s
Page 37: States with non-comprehensive PHPsK
Page 41 and 42: seven states required 10 measures o
Page 43 and 44: CAHPS© surveys. North Carolina is
Page 45 and 46: Special initiatives to improve qual
Page 47 and 48: public health efforts to reduce dis
Page 49 and 50: Medicaid managed long-term care and
Page 51 and 52: (e.g., need to credential Adult <st
Page 53 and 54: In many states, broader efforts foc
Page 55 and 56: Looking ahead: Medicaid managed car
Page 57 and 58: ConclusionFor over 30 years, state
Page 59 and 60: APPENDIX 2: Summary of Medicaid Man
Page 61 and 62: Program Name(e.g., Popular Name, 19
Page 63 and 64: APPENDIX 3: MCO Contracts, Plan Cha
Page 65 and 66: State(No. ofcontracts)NameEnrollmen
Page 67 and 68: State(No. ofcontracts)NameEnrollmen
Page 69 and 70: APPENDIX 5: MCO Capitation Rate-Set
Page 71 and 72: APPENDIX 7: MCO Network Adequacy Re
Page 73 and 74: State Primary Care Obstetric Care S
Page 75 and 76: APPENDIX 9: Providers Recognized as
Page 77 and 78: APPENDIX 11: PCCM Administrative Se
Page 79 and 80: APPENDIX 13: Initiatives to Improve
Page 81 and 82: I. MANAGED CARE OVERVIEW1. Total Ma
Page 83 and 84: 4. Enrollment Requirements.a. We ar
Page 85 and 86: ii. Please indicate whether the fac
Page 87 and 88: c. Required Providers: We are inter
Page 89 and 90:
IV. NON-COMPREHENSIVE PREPAID HEALT
Page 91 and 92:
. Does your state use CAHPS© surve
Page 93 and 94:
VI. SPECIAL INITIATIVESAll states s
Page 95 and 96:
Appendix I: Managed Care Contracts1
Page 97:
Appendix II: Clinical Quality Perfo
Page 100:
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