1. Childhood Immunization and Managed Care Organizations Olusegun Ishmael, MD, MBA Vice President Medical Affairs Managed Health Services (MHS)

2. Managed Care Organizations (MCO) –Payment structure Capitation rate (PMPM) Capitation rate (PMPM) –Goals Reduce Healthcare Costs Reduce Healthcare Costs –Medical necessity –Prior authorization for procedures –Inpatient Length of Stay Improve Quality and Outcomes Improve Quality and Outcomes –Provider and Member Incentives –Data to identify individuals not receiving preventative care –Preventative care vs. Episodic care EPSDT, Immunizations, etc. vs. ER and acute visits EPSDT, Immunizations, etc. vs. ER and acute visits

3. Managed Care Organization (MCO) - HEDIS –NCQA - National Committee for Quality Assurance –The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. –Data

4. 2006 HEDIS

5. Childhood Immunizations Barriers –Members Continuous eligibility Continuous eligibility Members residence patterns Members residence patterns Education Education –Societal Culture of our nation Culture of our nation –Provider Payment structure – Primary care vs. specialists Payment structure – Primary care vs. specialists Providers educating members – time factor Providers educating members – time factor Provider administrative burden, EMRs, CHIRP Provider administrative burden, EMRs, CHIRP

6. Childhood Immunizations MCO Initiatives –Providers Access and Availability Access and Availability Education of providers Education of providers Pay-4-Performance Pay-4-Performance Provide physicians their data from claims Provide physicians their data from claims

7. Childhood Immunizations MCO Initiatives –Members Transportation Transportation Member Education Member Education Pay-4-Action Pay-4-Action Member advisory group Member advisory group Community events – health fairs, meet your provider Community events – health fairs, meet your provider Home Health Visits Home Health Visits Community Partnerships e.g. PBS station Community Partnerships e.g. PBS station

8. Childhood Immunizations MCO Initiatives –Health Plan Quality Improvement Department Quality Improvement Department –Data, Data, Data –State Contract Pay-4-Performance/Negative incentives Pay-4-Performance/Negative incentives