A Case for QualityA Case for QualityThe Value of Medicaid The Value of Medicaid

Managed CareManaged Care

Working to Improve Health Every Day

May 10, 2011May 10, 2011

• Virginia-based; Not-for-Profit Health PlanVirginia-based; Not-for-Profit Health Plan Service of Sentara HealthcareService of Sentara Healthcare 25-year history25-year history Statewide presenceStatewide presence

• Diversified MembershipDiversified Membership Commercial – 277,000Commercial – 277,000 Medicaid – 153,000Medicaid – 153,000 Medicare – 14,000Medicare – 14,000

• Strong Provider NetworkStrong Provider Network 14,000 Physicians14,000 Physicians 69 Hospitals69 Hospitals

• Performance ExcellencePerformance Excellence Fiscally sound; A+ rating Fiscally sound; A+ rating

Excellent accreditation by NCQA Excellent accreditation by NCQA for 11for 11thth consecutive year consecutive year

Optima Health Plans Optima Health Plans Serving 440,000 Virginia MembersServing 440,000 Virginia Members

Optima Family CareOptima Family CareMedicaid Managed Care PlanMedicaid Managed Care Plan

• 147,000 Members147,000 Members• High Touch for MembersHigh Touch for Members

– Reach 72% valid new Reach 72% valid new households in 90 days; touch households in 90 days; touch 20% of new members 20% of new members

• Retain 85% of Newborns Retain 85% of Newborns • Clinical Outreach Clinical Outreach

– Automated health assessmentsAutomated health assessments– Outreach to frequent ER users Outreach to frequent ER users

• Invest $250,000 Value Yearly Invest $250,000 Value Yearly with Community Partnerswith Community Partners– Girls basketball leagueGirls basketball league– CHCS grant with CHIP of VA & CHCS grant with CHIP of VA &

DMASDMAS– Commitment to CommunityCommitment to Community

Virginia Medicaid and CHIP Health Plans Provide Better Access to Well Child Visits

2007 Compared to FFS

4

58%

46%

Source: “Virginia Medicaid Managed Care Performance Report, 2007-2008”, Virginia Department of Medical Assistance Services. December 2008.

Virginia Medicaid Health Plans Outperform FFS and PCCM in Lowering the Rate of Low-Weight

Births

11.9

9.98.7

11.8

10.08.3

11.910.7

8.5

Source: Improving Birth Outcomes Through Adequate Prenatal Care Study, Commonwealth of Virginia Department of Medical Services, December 2010

5

Managing MedicaidManaging MedicaidPartners in Pregnancy ProgramPartners in Pregnancy Program

Deliveries During Reporting Period

656

916

1534

1415

0

500

1000

1500

2000

2500

Previous Year Current Year

Members Not Engaged w / HCT

Members Actively Engaged w ith Clinical Care Services

OB HEDIS OutcomesOB HEDIS Outcomes 2007 2008 & 2009

Prenatal Care 88.2% 84.6% Postpartum 67.5% 68.2%

ActionsActions• Redesigned High Risk OB Model Redesigned High Risk OB Model

with Community Outreach Partner with Community Outreach Partner • NICU Dollars Saved NICU Dollars Saved

– Saved > $300 PMPM / intervention babySaved > $300 PMPM / intervention baby• Birth Weight Improvement Birth Weight Improvement

– From 07-09, # Infants >2500 grams From 07-09, # Infants >2500 grams grew 10% grew 10%

• High Patient SatisfactionHigh Patient Satisfaction

Birthweight of Newborns

3619256

2020

# of Infants < 1000 gms

# Infants 1000 - 1499 gms

# Infants 1500 - 2499 gms

# Infants > 2500 gms

Managing MedicaidManaging MedicaidOveruse of Emergency ServicesOveruse of Emergency Services

The ProblemThe Problem # ER visits per month increasing. Over # ER visits per month increasing. Over 6 months 6 months 22,500 went to ER 3-10 times & of that, 22,500 went to ER 3-10 times & of that, 6,100 6,100 did not have corresponding PCP visitdid not have corresponding PCP visit

ActionsActions•Targeted home education visits for the Targeted home education visits for the

frequent flyers without PCP claims. At frequent flyers without PCP claims. At 3-mos:3-mos:– 50-100 visits / month50-100 visits / month– 53% did not return ER 53% did not return ER (17% more than group not (17% more than group not

visited)visited)

– 36% went to their PCP 36% went to their PCP (5% higher than group not (5% higher than group not visited)visited)

– Cost avoidance of $252,000Cost avoidance of $252,000

•Called every member after every ER Called every member after every ER visit. At 3 mos:visit. At 3 mos: – 3,300 calls / month3,300 calls / month– 25% listened to call & left message 40% of time25% listened to call & left message 40% of time

•At 6-mos, PCP appointment compliance At 6-mos, PCP appointment compliance increased to 48% increased to 48%

Transformation of Care InitiativesTransformation of Care Initiatives To Control Health Care CostsTo Control Health Care Costs

• Patient-centered Medical Patient-centered Medical HomesHomes

• Chronic Care ManagementChronic Care Management

• Advanced Care PlanningAdvanced Care Planning

• Accountable Care Accountable Care OrganizationsOrganizations

• Knowledge ManagementKnowledge Management