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A Case for Quality The Value of Medicaid Managed Care Working to Improve Health Every Day May 10, 2011

A Case for Quality The Value of Medicaid Managed Care Working to Improve Health Every Day May 10, 2011. Optima Health Plans Serving 440,000 Virginia Members. Virginia-based; Not-for-Profit Health Plan Service of Sentara Healthcare 25-year history Statewide presence

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A Case for Quality The Value of Medicaid Managed Care Working to Improve Health Every Day May 10, 2011

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  1. A Case for Quality The Value of Medicaid Managed Care Working to Improve Health Every Day May 10, 2011

  2. Optima Health Plans Serving 440,000 Virginia Members • Virginia-based; Not-for-Profit Health Plan • Service of Sentara Healthcare • 25-year history • Statewide presence • Diversified Membership • Commercial – 277,000 • Medicaid – 153,000 • Medicare – 14,000 • Strong Provider Network • 14,000 Physicians • 69 Hospitals • Performance Excellence • Fiscally sound; A+ rating Excellent accreditation by NCQA for 11th consecutive year

  3. Optima Family CareMedicaid Managed Care Plan • 147,000 Members • High Touch for Members • Reach 72% valid new households in 90 days; touch 20% of new members • Retain 85% of Newborns • Clinical Outreach • Automated health assessments • Outreach to frequent ER users • Invest $250,000 Value Yearly with Community Partners • Girls basketball league • CHCS grant with CHIP of VA & DMAS • Commitment to Community

  4. Virginia Medicaid and CHIP Health Plans Provide Better Access to Well Child Visits 2007 Compared to FFS 58% 46% Source: “Virginia Medicaid Managed Care Performance Report, 2007-2008”, Virginia Department of Medical Assistance Services. December 2008. 4

  5. Virginia Medicaid Health Plans Outperform FFS and PCCM in Lowering the Rate of Low-Weight Births 11.8 11.9 11.9 10.7 10.0 9.9 8.7 8.3 8.5 Source: Improving Birth Outcomes Through Adequate Prenatal Care Study, Commonwealth of Virginia Department of Medical Services, December 2010 5

  6. Managing MedicaidPartners in Pregnancy Program • OB HEDIS Outcomes • 2007 2008 & 2009 • Prenatal Care 88.2% 84.6% • Postpartum 67.5% 68.2% • Actions • Redesigned High Risk OB Model with Community Outreach Partner • NICU Dollars Saved • Saved > $300 PMPM / intervention baby • Birth Weight Improvement • From 07-09, # Infants >2500 grams grew 10% • High Patient Satisfaction

  7. Managing MedicaidOveruse of Emergency Services • The Problem • # ER visits per month increasing. Over 6 months • 22,500 went to ER 3-10 times & of that, 6,100 • did not have corresponding PCP visit • Actions • Targeted home education visits for the frequent flyers without PCP claims. At 3-mos: • 50-100 visits / month • 53% did not return ER (17% more than group not visited) • 36% went to their PCP (5% higher than group not visited) • Cost avoidance of $252,000 • Called every member after every ER visit. At 3 mos: • 3,300 calls / month • 25% listened to call & left message 40% of time • At 6-mos, PCP appointment compliance increased to 48%

  8. Transformation of Care InitiativesTo Control Health Care Costs • Patient-centered Medical Homes • Chronic Care Management • Advanced Care Planning • Accountable Care Organizations • Knowledge Management

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