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

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