Driving Quality Improvement in Medicaid Managed Care

1. Driving Quality Improvementin Medicaid Managed Care Marc Leib, M.D., J.D. Chief Medical Officer Arizona Health Care Cost Containment System June 15, 2007

2. AHCCCS ABCs • Arizona was the last state in the country to adopt Medicaid--began in 1982 • Essentially 100% Medicaid Managed Care • Only Native Americans and individuals covered under the Federal Emergency Services Program (FESP) in fee-for-service • Long term care members in managed care

3. AHCCCS ABCs (cont) • AHCCCS has over 1 million members • ~950,000 are in Managed Care Organizations (MCOs) • AHCCCS contracts with 8 acute care health plans, 8 long term care plans and 3 specialty plans (BHS,CRS and DDD) • AZ is the only state with all long term care members in MCOs

4. AHCCCS Successes • AHCCCS has lowest pmpm cost for drugs and third lowest overall costs among all programs • Does not participate in Drug Rebate Program • Open formulary at State level • No limits on the number of prescriptions • Mandatory generic use, when available • MCOs may require step therapy • Brand name drugs provided whenever needed

5. BUT, . . . Can managed care drive quality improvement in Medicaid while running a cost-effective program? Yes—when quality is of primary importance, not an afterthought

6. Quality Improvement Activities • Performance Measures (PMs) • Performance Improvement Projects (PIPs) • Contractual Obligations • MCO competition • Annual EQRO Report of Each Contractor • Public-Private Partnerships with Commercial/Other Health Insurers

7. Performance Measures • Determine baseline rate from encounter and/or claims data • Establish Minimum Performance Standards (MPS), Benchmarks and Goals • MPS based on historical data with percentage improvements expected • Benchmarks based on national reported data, such as public health goals (National Immunization Survey, NCQA HEDIS published data, etc.)

8. Performance Measures (cont.) • Goals based on Healthy People 2010 or other sources • MPS, Benchmarks and Goals included in MCO contracts including technical specifications (methodology) • Periodically evaluate new PMs, discuss with MCOs and add to contract

9. Performance Improvement Projects • Plans undertake two PIPs per year: • AHCCCS mandated • Self-selected • Four year projects (minimum) • Year 1—baseline measurements • Year 2—institute measures intended to improve outcomes • Year 3—demonstrate initial improvement • Year 4—demonstrate sustained improvement

10. PMs and PIPs May Be Integrated: Immunization Targets • Establish PMs: MPS, Benchmarks and Goals for vaccination rates • Develop and mandate use of State Immunization Registry—electronic data base accessible to MCOs, providers and state regulators • Share AHCCCS data with Registry • Establish a PIP: Require MCOs to increase provider reporting to registry • Identify provider non-reporters and encourage MCO intervention (partner with medical societies such as ArMA and AAP)

11. Contract Requirements • PMs and PIPs are contractually required • Failure to attain PM MPS may result in penalties--Corrective Action Plans (CAPs), Monetary Penalties or Closed Enrollment • Although never implemented, could result in contract termination

12. MCO Competition • “Friendly” competition among MCOs fosters increased quality improvement • PM and PIP results shared among MCOs • External Quality Review Organization (EQRO) reports shared and posted on public website • Plan CEOs and Medical Directors strive to be “best” among all plans

13. Monitoring Managed Care Organizations • Monitor provider network • Operational and financial reviews (OFRs) • Education and technical assistance • Corrective action plans, notice to cure, sanctions (financial and enrollment limits) • Monitor MCO QA and Peer Review actions • Annual EQRO reports assess MCOs

14. Public-Private Partnerships • AHCCCS and its Contractors occasionally partner with Medicare or commercial plans • Example: Partnered with commercial plans to improve asthma medication prescribing patterns of providers • Results: Significant improvement in ratio of maintenance meds to rescue meds • Results noted across all plans

15. Partnering With MCOs • Provide incentives for Contractors/providers to continually improve quality of care • Support collaborative processes between Contractors, the medical community and members • Establish benchmarks that will lead to continued quality improvement in health care • Monitor Contractors to establish standards

16. Medicaid Managed Care Ultimately, the goal of the AHCCCS managed care program is to provide each patient: The right care, At the right time Every time

17. QUESTIONS?

18. THANK YOU Marc Leib, M.D. (602) 417-4240 Marc.Leib@azahcccs.gov