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Basic Health Plan: Part 1

Basic Health Plan: Part 1. Preliminary Report Joint Legislative Audit and Review Committee Cynthia L. Forland Lisa Jeremiah November 30, 2005. Two-Part Study Mandated by 2005-07 Operating Budget.

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Basic Health Plan: Part 1

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  1. Basic Health Plan: Part 1 Preliminary Report Joint Legislative Audit and Review Committee Cynthia L. Forland Lisa Jeremiah November 30, 2005

  2. Two-Part Study Mandated by 2005-07 Operating Budget • Part 1: To what extent do BHP policies and procedures promote or discourage the provision of appropriate, high-quality, cost-effective care? • Part 2: What are the characteristics of individuals enrolled in BHP, and how are they utilizing services? Basic Health Plan: Part 1

  3. Presentation Outline • Background • Statutory and Contract Provisions • Monitoring and Measuring Performance of Health Plans • Other States • Findings and Recommendations Basic Health Plan: Part 1

  4. BHP to Make Health Care Services Available for Low-Income Residents • Established as a demonstration project in two counties in 1987 • Expanded statewide and merged with the Health Care Authority in 1993 • $500 million for benefits and $16 million for administrative costs for 2005-07 Basic Health Plan: Part 1

  5. Enrollment in Basic Health Plan • Eligibility: • Resident of Washington State • Not eligible for Medicare • Gross family income at or below 200% of the federal poverty level • Average monthly enrollment of 102,400 for 2005 • Served by 5 health plans Basic Health Plan: Part 1

  6. Health Care Authority Responsible for Administering Basic Health Plan • Define covered basic health care services • Establish enrollee premiums and cost-sharing • Contract with health plans • Monitor services provided by health plans Basic Health Plan: Part 1

  7. Key Findings • HCA-wide strategic planning and medical direction exist, but there is a lack of focus on Basic Health Plan • HCA requires quality health care, but provides limited specific guidelines and unclear expectations to health plans • Monitoring processes are in place, but they are insufficient to ensure quality health care Basic Health Plan: Part 1

  8. Study Questions • Does Basic Health Plan promote: • Appropriate, high-quality, cost-effective care? • Evidence-based treatment strategies? • Use of high-quality providers? • Treatment of chronic care and other high-cost conditions? • Use of preventive services? • Innovative health care service delivery methods? Basic Health Plan: Part 1

  9. How Is BHP Promoting Appropriate, High-Quality, Cost-Effective Care? • Statute: • HCA must assure access to good quality basic health care • Contract: • Health plans must have plan to improve quality, care delivery, satisfaction scores, and other standard measures • But: • Limited specific guidance • Most terms not defined Basic Health Plan: Part 1

  10. How Is BHP Promoting Evidence-Based Strategies? • Statute: • HCA must base policies on best available scientific and medical evidence • Contract: • Health plans must have a system to incorporate evidence-based medicine • But: • Limited specific guidance • Most terms not defined Basic Health Plan: Part 1

  11. How Does BHP Encourage Use of High-Quality Providers? • Statute: • Not specifically addressed • Contract: • Health plans must have an adequate network of providers who deliver high-quality health care services • Health plans provided guidance on initial and ongoing assessment of providers Basic Health Plan: Part 1

  12. How Does BHP Approach Chronic Conditions? • Statute: • HCA must explore disease management strategies • Contract: • Health plans must report top-five chronic conditions • Health plans must have disease management programs for two chronic conditions • But: • Limited guidance leads to inconsistent reporting • No link between top-five chronic conditions and disease management programs Basic Health Plan: Part 1

  13. How Does BHP Encourage Use of Preventive Services? • Statute: • HCA must develop program of proven preventive health measures • Contract: • Health plans must provide care recommended by U.S. Preventive Services Task Force guidelines • Health plans can not charge co-payments for preventive care Basic Health Plan: Part 1

  14. How Does BHP Use Innovative Health Care Service Delivery Methods? • Statute: • Not specifically addressed • Outside of scope and intent of the program • Contract: • Health plans are not required to use innovative health care service delivery methods Basic Health Plan: Part 1

  15. HCA’s Monitoring of Health Plans • Reviews based on Quality Improvement Standards • Focus is process and plans to ensure quality, not the actual quality of care • Interagency contract review team conducts annual reviews • Limited use of health care service utilization data Basic Health Plan: Part 1

  16. Performance Measures Do Not Focus on Health Care • Performance measures focus on administrative functions: • Example: How quickly health plans issue identification cards to enrollees • Example: What percent of customer service calls HCA answers within 5 minutes Basic Health Plan: Part 1

  17. Other States Provide Examples for Better Ensuring Quality Health Care • Massachusetts: Aligning quality improvement goals with evidence-based practice guidelines • Wisconsin: Comparing health-related performance across programs and health plans • Oregon: Guiding and monitoring care through contracts Basic Health Plan: Part 1

  18. Finding: Lack of Coordination and Planning for BHP • No strategic plan focused on the BHP • No strong integration of administrative and medical operations • Recommendation: HCA should develop goals and objectives for BHP focused on: • Assuring quality • Using evidence-based treatment • Exploring chronic disease management Basic Health Plan: Part 1

  19. Finding: Unclear Expectations and Limited Guidelines • Terms not defined and guidance is limited • Focus on process, not results • Quality Improvement Standards • Performance measures • Recommendation: HCA should develop specific guidelines and performance requirements for contracts with health plans Basic Health Plan: Part 1

  20. Finding: Insufficient Monitoring for Quality • Limited quality assessments • Limited use of health care service utilization data • Recommendation: HCA should improve its system of monitoring health plans • Application of quality assessment tools • Analysis and use of service utilization data • Analysis of health-related performance measures Basic Health Plan: Part 1

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