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Medical Assistance Program Oversight Council October 11, 2013.

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Presentation on theme: "Medical Assistance Program Oversight Council October 11, 2013."— Presentation transcript:

1 Medical Assistance Program Oversight Council October 11, 2013

2 HUSKY Health Program and Charter Oak Health Plan Medical ASO Program Dashboard Highlights 2

3 Determining a Primary Care Provider’s Panel: PCP Attribution MCO Assignment  Process used by the MCOs prior to 2012  Based on a member’s zip code and geographic location to a provider  Could be determined by the member’s choice or the MCO’s algorithm for assignment of Members  Member may have never seen the provider ASO Attribution  Process effective 2012 and going forward  Based on who the member has visited and provider’s billed services  Member may self select a provider or the ASO will attribute based on a member’s claim history  Member had a service with the provider Under the ASO Model, members are now linked to a PCP based on their usual source of care. The attribution process is utilized to reflect a member’s choice of PCP. 3

4 Attribution Statistics 66 % 65% 66% 61% The attribution process reviews procedure codes submitted by PCPs for preventive services and other office visits.

5 CMAP Provider Network Growth January 2012 – June 2013 June 2013 Statistics Instate and Border Providers only # of PCPs3,111 # of Specialists 12, % +7.3%+1.4%

6 Person Centered Medical Homes (PCMH) July 1, 2012 – June 30, 2013

7 Call Center Statistics July 1, 2012 – June 30, nd Q 2013 Call Center Performance MeasureStandardResults % of Calls Answered within 60 Seconds 90%98.6% Crisis Line: % of Calls Answered within 15 Seconds 90%100% % of Calls Abandoned <5%0% Average Talk Time N/A 5.53 Min

8 Access for Members with Cultural & Linguistic Needs July 1, 2012 – June 30, 2013

9 Grievance Statistics July 1, 2012 – June 30, nd Q 2013 Resolution Timeliness (Metric: 90% within 30 Days) Same Day17% 2-7 Days41% 8-30 Days37% Days5% More than 45 Days0% **A grievance is any expression of dissatisfaction

10 Intensive Care Management Outreach July 1, 2012 – June 30, 2013 # Members Outreached for ICM 43,074 # Members Who Agreed to/ Enrolled in ICM16,836 Member Age # in ICM 0-18 years old2, and older14,609 Diabetes Cardiac BH Sensitive Gastrointestinal Respiratory Perinatal Cancers, Auto-Immune and Sickle Cell Disorders Autism and Developmental Delays Neuromuscular and Degenerative Renal Injuries and Infections Top Driving Conditions that Identified Members for ICM:

11 ICM: Addressing Immediate Needs July 1, 2012 – June 30, 2013 Members are assessed for adequacy of basic human needs (food, housing, safety, utilities, etc.). The Intensive Care Manager will immediately address those unmet needs. From July 1, 2012 through June 30, 2013, staff assisted: Members who indicated they were hungry and without food4,376 Members who indicated they had concerns about safe housing 5,682 Members who were screened as positive for behavioral health needs and received interventions to effectively manage it 3,657 Members who were receptive to engaging in smoking cessation behaviors 2,512

12 HUSKY A, C and D Member Authorizations and Appeals July 1, 2012 – June 30, 2013 Service Type Prior AuthorizationsMember AppealsAdministrative Hearings Total Requested Approved Denied/ NOAs Total Appeals Outcome Total Requested Outcome Admissions58,54758, Overturn 3 Upheld 2 Withdrawn 5 4 Withdrawn 1 Upheld Professional/ Surgical Services 4,4374, Overturn 12 Upheld 2 Withdrawn 9 6 Withdrawn 2 Upheld 1 Overturn Outpatient Therapies 19,67419, Overturn 2 Upheld 4 Withdrawn 7 5 Withdrawn 2 Overturn Radiology 61,65158,8252, Overturn 18 Upheld 23 Withdrawn 1 Untimely Filing Withdrawn 1 Upheld 2 Dismissed Upheld: Service denial remains. Overturn: Service request approved. Withdrawn: Member withdrew appeal/ hearing request. Dismissed: Hearing Officer dismissed the hearing.

13 HUSKY A, C and D Member Authorizations & Appeals (cont) July 1, 2012 – June 30, 2013 Service Type Prior AuthorizationsMember AppealsAdministrative Hearings Total Requested Approved Denied/ NOAs Total AppealsOutcome Total Requested Outcome DME22,59619,8652, Overturn 15 Upheld 17 Withdrawn 3 Untimely filing Withdrawn 2 Upheld 1 Overturn 2 Dismissed Home Health 11,69211, Overturn 18 Upheld 2 Withdrawn Withdrawn 4 Upheld 7 Dismissed 1 Overturn Hospice Pharmacy (Synagis) Overturn 1 Upheld 22 Withdrawn Vision Care GRAND TOTAL 179,346172,0387, Upheld: Service denial remains. Overturn: Service request approved. Withdrawn: Member withdrew appeal/ hearing request. Dismissed: Hearing Officer dismissed the hearing.

14 HUSKY B Member Authorizations and Appeals July 1, 2012 – June 30, 2013 Prior AuthorizationsMember Appeals Service TypeTotal RequestedApprovedDeniedTotal AppealsOutcome Admissions Professional/ Surgical Services Outpatient Therapies Overturn 11 Upheld 4 Withdrawn Radiology DME Upheld 1 Withdrawn Home Health Upheld Hospice00000 Pharmacy (Synagis) Upheld Vision Care11000 GRAND TOTAL1,6561, Upheld: Service denial remains. Overturn: Service request approved. Withdrawn: Member withdrew appeal.

15 HUSKY Health and Charter Oak Health Utilization & Cost Statistics Medical & Behavioral Health (BH) 15

16 Hospital Inpatient - Medical & BH Combined Dates of Service January 2012 – March 2013 Note: All HUSKY Health & Charter Oak members except Dual members (i.e., members who are eligible for both Medicare and Medicaid) are included. Data includes claims paid through 08/31/13. Utilization and PMPM cost statistics for Q4 12 & Q1 13 contain a factor for incurred but not reported (IBNR) claims payment. From Q to Q1 2013: Admissions per 100 MMs decreased by 3.2%. Days per 100 MMs decreased by 8.1%. The average length of stay decreased by 5.0%.

17 Hospital Inpatient - Medical & BH Combined Dates of Service January 2012 – March 2013 From Q to Q1 2013: Inpatient PMPM decreased by 1.8%. Cost per admission decreased by 2.7% or $200 per admission. Note: All HUSKY Health & Charter Oak members except Dual members are included. Data includes claims paid through 08/31/13. Utilization and PMPM cost statistics for Q4 12 & Q1 13 contain a factor for incurred but not reported (IBNR) claims payment.

18 Inpatient Users - CY 2012 Inpatient Admissions – Top Major Diagnosis Categories CY 2012 Note: All HUSKY Health & Charter Oak members except Dual members are included. Inpatient Utilization Strategies Intensive Care Management (ICM) /collaboration with providers and CTBHP. ICM visits while inpatient. Discharge planning. Transitional Care outreach within 7 days of discharge. Medication adherence mgmt.

19 Hospital Emergency Dept (ED) - Medical & BH Dates of Service January 2012 – March 2013 Note: All HUSKY Health & Charter Oak members except Dual members are included. Data includes claims paid through 8/31/13. Utilization and PMPM cost statistics for Q4 12 & Q1 13 contain a factor for incurred but not reported (IBNR) claims payment. The charts below represent total ED visits. ED visits per 100 MMs decreased by 3.2% from Q to Q HUSKY D has the highest ED utilization. The cost per ED visit increased by 8.5% from Q to Q HUSKY C ($429) and HUSKY D ($383) have the highest cost per ED visit.

20 Hospital Emergency Dept (ED) - Medical & BH Dates of Service January 2012 – March 2013 The charts below represent hospital ED visit PMPM cost billed as emergent versus non-emergent. The PMPM cost for emergent visits increased by 6.3% from Q to Q The PMPM cost for non-emergent visits decreased by 11.7% from Q to Q Note: All HUSKY Health & Charter Oak members except Dual members are included. Data includes claims paid through 8/31/13. Utilization and PMPM cost statistics for Q4 12 & Q1 13 contain a factor for incurred but not reported (IBNR) claims payment.

21 Hospital Emergency Dept (ED) - Medical & BH Calendar Year 2012 Note: All HUSKY Health & Charter Oak members except Dual members are included. Total ED Users =269,205 (41% of all members) ED Utilization Strategies Focused member outreach to link members with a PCP and coordinate care Educate members on use of 24/7 Nurse Advice line Intensive Care Management Refer BH ED users to CTBHP

22 Hospital ED – Top Primary Diagnoses CY 2012 Adult Note: All HUSKY Health & Charter Oak members except Dual members are included. Child

23 Maternal & Child Birth – CY

24 Obstetric P4P program 24 Performance Measures  Timely completion (within 14 days) of online obstetrics prenatal and post-partum notification forms  A first obstetric visit within 14 days after confirmation of pregnancy  At least one postpartum visit within days after delivery  Full-term, vaginal delivery after spontaneous labor whenever medically possible  Appropriate use of 17-alpha hydroxyprogestron Care provided on dates of services 7/1/2013 through 6/30/2014 will be eligible for the P4P payment Providers began using the on- line obstetric notification form August 1 Eligible providers include: providers currently enrolled as family medicine physicians, obstetrician/gynecologists, obstetric nurse practitioners, family medicine nurse practitioners, physician assistants and certified nurse midwives

25 Questions?


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