Ohio’s Medicaid ManagedOhio’s Medicaid ManagedCare ProgramCare Program

Why Managed Care?Why Managed Care?

AccessAccess Consumer satisfactionConsumer satisfaction QualityQuality

Policy direction supported by various Policy direction supported by various external commissions & reviewsexternal commissions & reviews

HistoryHistory

1978 – First established in Ohio1978 – First established in Ohio 1980s-1990s – Approaches explored, 1980s-1990s – Approaches explored,

lessons learnedlessons learned 2000-2006 – ~13 counties; 2000-2006 – ~13 counties;

improvements in approach continueimprovements in approach continue 2007 – Statewide expansion 2007 – Statewide expansion

completed for CFC & ABDcompleted for CFC & ABD 8 regions8 regions Approximately 1.5 million enrolleesApproximately 1.5 million enrollees

Managed Care - 2010Managed Care - 2010

Current caseload Current caseload (February data)(February data) CFC – 1,404,549CFC – 1,404,549 ABD – 117,720ABD – 117,720

Expenditures YTD Expenditures YTD (March data)(March data) CFC – $2.73 billionCFC – $2.73 billion ABD – $1.20 billionABD – $1.20 billion

Ohio Medicaid Managed Care:Value Added Benefits for Members

• Preventive health programs and care coordination services • Connect members to primary care providers • Advice and direction for medical issues via a toll free 24/7 nurse

advice line• Assistance in accessing services with a dedicated call center

and member handbook• Special services, like care management, for members with

special health care needs• Grievance resolution system• Expanded provider networks• Transportation services, expanded coverage, and member

incentives (may vary by plan)

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Ohio Medicaid Managed Care Quality Strategy

• Statewide comprehensive plan that incorporates how ODJFS:– Monitors managed care plan compliance with state and

federal regulations– Evaluates and improves services delivered to consumers

enrolled in a managed care plan

• Framework for communicating approach for ensuring timely access to high quality health care.

• Federal requirement for the state Medicaid agency to have a Managed Care Quality Strategy.

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MCP Accountability System

• Robust accountability system for assessing and improving quality of care to managed care consumers

• Key program domains: – Access – Administrative Capacity– Consumer Satisfaction – Quality

• Performance measures and minimum established standards

• Incentives and disincentives are used for program compliance and continuous quality improvement

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Ohio Medicaid Managed Care Quality Strategy - Summary

Access Administrative Capacity

Consumer Satisfaction

Quality

• Provider Panel Requirements•Grievance and Appeal Monitoring•Consumer/Provider Complaints•MCP 24/7 Nurse Advice Line•Access Performance Measures and Standards

•Compliance Assessment System•MCP Reporting Requirements•Program Integrity•Financial Performance Measures and Standards •Data quality

•Annual Consumer Satisfaction Survey•Managed Care Enrollment Center•MCP Member Services Lines•Prior Approval of MCP Marketing and Member Materials

•Quality Assessment and Performance Improvement Program• Care Management Programs•Clinical Performance Measures and Standards•Annual external quality review activities•Medicaid Medical Directors Meetings

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Ohio Medicaid Managed Care Quality Strategy – Access Domain

• Provider Panel– Searchable online directory– Monitoring of accuracy of information– Provider panel standards

• Grievance/Appeals – Access related reviewed by state staff– Training on coding– Checked for proper coding

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Ohio Medicaid Managed Care Quality Strategy – Access Domain

• Consumer/Provider Complaint– On-line provider complaint form

• MCP 24/7 Nurse Advice Line• Access Performance Measures & Standards

– Adults' Access to Preventive/Ambulatory Health Services (HEDIS)

– Children's Access to Primary Care [CFC only] (HEDIS)

– Members' Access to Designated PCP

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Ohio Medicaid Managed CareQuality Strategy

Medicaid Managed Care: ABD Population Members’ Access to Preventive/Ambulatory Health Services (HEDIS)

80.0%84.0% 88.0%

0%10%20%30%40%50%60%70%80%90%

100%

NCQA 2008 Mean (weighted by age of population)Ohio MC CY 2007Ohio MC CY 2008

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Ohio Medicaid Managed Care Quality Strategy – Administrative Capacity

Domain

• Compliance Assessment System– 0 – 100 point system– Fines increase as points increase– At 100 points ODJFS can terminate

agreement– There are other enforcement tools

• MCP Reporting Requirements

• Program Integrity

13

Ohio Medicaid Managed Care Quality Strategy – Administrative Capacity

Domain

• Financial Performance Measures and Standards– Prompt Payment– Net worth per Member– Administrative Expense Ratio– Days Cash on Hand– Ratio of Cash to Claims Payable– Reinsurance

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Ohio Medicaid Managed Care Quality Strategy – Administrative Capacity

Domain

Data Quality – Encounter Data Volume (utilization measures)– Rejected Encounters – Acceptance Rate (encounters)– Encounter Data Accuracy Studies – Incomplete Outpatient Hospital Data– Incomplete Data For Last Menstrual Period (CFC)– Generic Provider Number Usage– Designated PCP for newly enrolled members– Timeliness (monthly)

Ohio Medicaid Managed Care Quality Strategy – Consumer Satisfaction Domain

• Annual consumer satisfaction survey

• Managed care enrollment center

• MCP Member Services Lines

• Prior approval of MCP marketing and member materials

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Ohio Medicaid Managed Care Quality Strategy – Quality Domain

• Quality and care management programs– Submitted annually by MCPs– Reviewed internally by clinical staff – Subjected to evidence based review by the external quality

review organization

• Performance Improvement Projects– Topics: Members with special health care needs, Dental

care, and EPSDT Statewide Collaborative – Validated by external quality review organization to ensure

compliance with CMS protocols

16

17

Ohio Medicaid Managed Care Quality Strategy – Quality Domain

External Quality Review Activities• Federal regulations require the state Medicaid agency

to contract with an external quality review organization to:– Evaluate quality and accessibility of services

provided to managed care plan members.– Provide information to the state to design

appropriate, effective interventions to improve health care quality and access over time.

• ODJFS contracts with Health Services Advisory Group

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External Quality Review Activities (cont.)

• Overview of EQR activities:– Evaluation of managed care plan administrative compliance– Validation of MCP performance improvement projects– Validation of clinical performance measures– Encounter data validation/accuracy studies– Consumer satisfaction surveys– Quality of life surveys– MCP Information systems reviews– Program evaluations– Statewide quality improvement initiatives

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Ohio Medicaid Managed Care Quality Strategy – Quality Domain

Performance MeasuresCFC Population

Care Management– Care Management of High Risk Members– Care Management of Members

Clinical Performance (HEDIS measures)– Comprehensive Diabetes Care (CDC)/Eye exam – Use of Appropriate Medications for People with Asthma– Perinatal care - Frequency of ongoing prenatal care, timeliness of prenatal

care, postpartum care– Well-Child Visits – First 15 Mos of Life; 3-6 Years; 12-21 Years– Annual dental visits – Lead screening for 1 Year and 2 Year Olds

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Ohio Medicaid Managed Care Quality Strategy – Quality Domain

ABD PopulationCare Management

– Care Management of High Risk Members– Care Management of Members

Clinical Performance (HEDIS)– Persistence of Beta-Blocker Treatment after Heart Attack – Cholesterol Management for Patients with Cardiovascular Conditions/LDL-C screening

performed – Comprehensive Diabetes Care (CDC)/Eye exam – Use of Appropriate Medications for People with Asthma – Follow-up After Hospitalization for Mental Illness– Condition-specific measures: Congestive heart failure, Coronary arterial disease, Non-

mild hypertension, Diabetes, Chronic obstructive pulmonary disease, Asthma, Mental Health, Alcohol and Drug

– Inpatient Hospital discharge rate – Emergency Department utilization rate – Hospital Readmission

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Ohio Medicaid Managed Care Quality Strategy – Quality Domain

59.0%67.0% 70.0%

0%10%20%30%40%50%60%70%80%90%

100%

NCQA 2008 Mean Ohio MC CY 2007Ohio MC CY 2008

Medicaid Managed Care: CFC Population Frequency of Ongoing Prenatal Care- Percent Who Received 81% of More of Expected

Visits (HEDIS)

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Overview: Ohio’s Managed Care Program Evaluation

• Evaluation conducted by Health Services Advisory Group • Purpose of Program Evaluation:

– To evaluate the current design of key managed care program areas • Performance measures• Pay-for-performance • Access-monitoring strategies• Data quality strategies

– To assess the extent of regulations in comparison with other state Medicaid managed care programs

– To make recommendations with the potential to improve program effectiveness, and strengthen the quality strategy.

• Results and Follow-Up• Ohio’s monitoring strategies are robust and align with other state Medicaid

managed care programs• Implementation of strategies to enhance the above 4 key program areas