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

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“Guide to Michigan Medicaid Health Plans – Quality Checkup” 19 compares Medicaid MCOs on theirperformance on six measures: doctor’s communication and service, getting care, keeping kids healthy,taking care of women, living with illness, and accreditation. California translates selected HEDIS© andCAHPS© results into ratings of “below average,” “average,” and “above average.” The consumer guidecontaining these ratings is included in Medicaid enrollment packets to help beneficiaries choose a healthplan and it is also available online. DC’s guide rates plans based on two survey questions that askpatients how they rate their health care and their health plan. North Carolina is the only PCCM-onlystate that prepares a guide that compares its PCCM program with traditional fee-for-service.Most states plan to report on some or all of the CHIPRA core child health quality measures. Thirtystates indicated that they planned to report in Medicaid and CHIP on some or all of the children’s healthquality measures included in the core being developed by HHS. Five states indicated that they did notplan to use these measures, and 16 states did not know or did not respond to the question.State “performance improvement projects” (PIPs) indicate the breadth of state priorities and activity.Federal regulations require all states with MCOs to contract with an External Quality ReviewOrganization (EQRO) to provide an independent assessment of the quality performance of plansparticipating in Medicaid. All states reported contracting with an EQRO (except Mississippi, with its newmanaged care program, reported it did not have a contract as of October 2010.) Four PCCM-only states– Alabama, North Carolina, Oklahoma, and Vermont – also reported contracting with EQROs.In addition to assessing plan compliance with standards for access to care and other requirements,EQROs conduct clinical studies and validate the required “Performance Improvement Projects” (PIPs).States reported a wide range of PIPs, reflecting many health priorities across the states, including amongothers: improving birth outcomes (DC and Virginia); access to pediatric subspecialists (South Carolina);emergency room use (Oklahoma); use of clinical risk groups to identify candidates for case management(New York); smoking cessation (Alabama); improving coordination between behavioral health andmedical providers (Arizona); and improving outcomes for specified chronic diseases (several states.)19 http://www.michigan.gov/documents/QualityCheckupJan03_59423_7.pdf38 00
Special initiatives to improve quality and care coordinationKey Section Findings:Medicaid programs have undertaken a range of strategies to improve care, including initiativesto reduce inappropriate use of ERs. Most states also have initiatives to reduce obesity, withMedicaid MCOs often playing a leading role.About half the states have Medicaid initiatives designed to reduce racial and ethnic disparitiesin care and outcomes, including participation in broader state efforts.States report a broad spectrum of other special managed care quality initiatives.Large numbers of states report initiatives to improve primary care and to better coordinatecare for Medicaid beneficiaries with more complex needs.Managed care has raised expectations regarding the quality and appropriateness of care delivered toMedicaid beneficiaries, and it has provided state Medicaid programs with structural mechanisms forexamining and potentially driving improvements in care. The survey asked states about their initiativesin three national priority areas – reducing inappropriate emergency room use, improving obesity rates,and reducing racial and ethnic disparities. It also asked about their adoption of strategies to promotemore coordinated care. State responses indicate many kinds of activity on many fronts.Initiatives to improve qualityAll but a small number of states have initiatives toreduce the use of emergency rooms (ER) for nonemergentneeds. Initiatives to reduce inappropriate useof ERs were reported by 43 states. States’ focus on thisissue was fueled by $50 million in CMS grants to states in2008 for ER diversion projects. State approaches toreducing non-emergency use of ERs vary, depending inpart on their managed care arrangements.States with MCOs often include a focus on ER use in theircontracts. For example, some state contracts specify thatplans must monitor ER use as part of their broadermonitoring of over- and under-utilization. Some statesreported ER use as a factor in their P4P systems. Statesalso reported that plans identify high ER users and targetthem for case management or care coordination, or usedata on high ER users to profile providers and work withplan medical directors to improve utilization patterns.Through its statewide collaborative,“Implement Medicaid Programs for theReduction of Avoidable Visits to theEmergency Department (IMPROVE),” Ohiocoordinated key stakeholders in five regionsof high ED utilization. Regional participantsinclude hospitals, community providers,managed care plans, advocacy organizationsand their respective associations, andMedicaid consumers. The IMPROVECollaborative adopted a rapid-cycle qualityimprovement approach, developed by theInstitute for Healthcare Improvement, that ispopulation-based and patient-centered. Fiveregional groups, including executive/clinicalleaders of health care systems, partner withOhio Medicaid and managed care plans toidentify priority populations for the reductionof avoidable ED visits.In states with PCCM programs, ER diversion can involve a data system that notifies primary care doctorswhen their patients use the ER. Also, ER use is often included among the data used to profile PCPs. Somestates have established 24-hour nurse consultation lines and/or other approaches to educatebeneficiaries on when it is appropriate to use the ER. States also have used information technology toidentify high users of ERs and established case management programs for those with ER use exceeding aspecified threshold, such as five or more visits in a 90-day period.39
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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 and 38: States with non-comprehensive PHPsK
Page 39 and 40: Measuring, monitoring, and improvin
Page 41 and 42: seven states required 10 measures o
Page 43: CAHPS© surveys. North Carolina is
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:
1330 G S T R E E T NW, W A S H I N
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Kaiser Family Foundation Survey on State Medicaid Managed Care ...

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