Working together to provide quality care for MDwise members Show me the Money Working together to provide quality care for MDwise members P0607

Indiana Health Coverage Programs FSSA Traditional Medicaid OMPP Hoosier Healthwise Risk-Based Managed Care MDwise MHS Anthem MAXIMUS MDwise (Care Select) ADVANTAGE (Care Select) HP 590 Program Healthy Indiana Plan Anthem Blue Cross Blue Shield Enhanced Services Plan (ESP) Care Select Cenpatico Behavioral Health Magellan Health Services Managed Behavioral Health Organizations FSSA= Family & Social Services Administration OMPP= Office of Medicaid Policy and Planning Maximus= Enrollment Broker P0607

Who is MDwise? MDwise is a local, not-for-profit company serving Hoosier Healthwise, Care Select and Healthy Indiana Plan (HIP) members. MDwise believes that everyone deserves to have health coverage. MDwise Hoosier Healthwise covers 270,000 children, pregnant women, and eligible families. P0607

Who is MDwise? P0607

What is Risk-Based Medicaid? MCE’s are paid a per member per month fee; this is called a capitated rate  The capitated premium covers the cost of the care for all covered services for the patients. The MCE’s assume financial risk for services of members; thus the name “Risk-Based” does not mean the patients are “high risk”. P0607

Benefit Package Coverage Package A – Standard Plan Full coverage for children, low-income families. Package B – Pregnancy Coverage Only Pregnancy-related, postpartum care, family planning, pharmacy, transportation, urgent care services for some pregnant women. Package C – Children’s Health Plan Preventive, primary, and acute care services for some children under 19 years old. Package P – Presumptive Eligibility Presumptive eligibility for pregnant women. (RID # starts with 550) Package E – Emergency Only Limited to treatment for medical emergency conditions. P0607

NCQA National Committee for Quality Assurance is the organization that accredits Managed Care Organizations (MCO’s). Mission To improve the quality of health care. Vision To transform health care quality through measurement, transparency and accountability. Values Our passion is improving the quality of health care. We stand for accountability throughout the health care system. P0607

NCQA created HEDIS Effectiveness Data & Information Set Healthcare Effectiveness Data & Information Set A set of standardized performance measures Ensures that consumers have reliable information on the performance of MCO’s. >90% of health plans use HEDIS to measure performance on important dimensions of care and service. P0607

Pay for Performance or P4P are Incentivized HEDIS Measures A contractual activity of MCO’s P4P is an incentive to meet quality measures for providers in the commercial, Medicaid and Medicare insured populations. 1.0% of the MDwise capitated payment is withheld, and paid to the MCO when quality goals are met. P0607 9

Pay for Performance – P4P Supplemental payment based on measured performance against a target Incent high quality care by shifting greatest reimbursement to highest quality providers and plans Incent provider offices to increase visits or improve processes. Site contests or office contests to improve quality of care. P0607

Pay for Performance – P4P Provider incentives based on claims submissions. Provider incentives based on meeting targeted measures. Site contests by increasing a measure or bringing in the most members requiring services in a given measure. Provider incentives adding provider staff or equipment that can help increase a quality measure or quality of care to members. P0607

HEDIS contains 71 Quality Measures:            Asthma Medication Use Persistence of Beta-Blocker Treatment after Heart Attack Controlling High Blood Pressure Comprehensive Diabetes Care Breast Cancer Screening Antidepressant Medication Management Childhood and Adolescent Immunization Status Advising Smokers to Quit & offering assistance to quit….and others P0607

OMPP Incentivized HEDIS Measures Adolescent well-care Well-care for children ages 3-6 years Well-care for children, 0 – 15 months Timeliness of prenatal care Frequency of prenatal care Timeliness of postpartum care 7 day follow-up of a behavioral health stay LDL-C screenings for diabetic members Cervical cancer screenings Follow – up care for children prescribed ADHD meds P0607

How do we Compare? MDwise NCQA 90th%tile Cervical Cancer Screening 74.45% 79.5% LDL-C (Diabetes Care) 68.61% 82.5% Follow-Up after Hospitalization for Mental Illness (7 Days) 48.22% 64.2% P0607

How do we Compare? MDwise NCQA 90th%tile Timeliness of Prenatal Care 89.54% 92.2% Timeliness of Postpartum Care 75.67% 72.7% Frequency of Prenatal Care 82.73% 81.0% P0607

How do we Compare? MDwise NCQA 90th%tile Six or More Well-Care Visits in the First 15 Months of Life 60.83% 73.9% Annual Well-Child Visit Ages 3-6 72.99% 80.3% Annual Well-Child Visit Adolescents 53.28% 56.7% P0607

How we Promote Quality Care Provider and staff education Network Improvement Program (NIP) Team Billing and process audits ManagedCare.com Member education Reminder Calls about appointments to members Member incentives: Well Child (3 – 6 and 12 – 21) Provider incentives Disease/Health management services for members with diabetes Disease/Health management for members with asthma P0607

How NIPT Can Help….. The Network Improvement Programs Team assists MDwise departments in the outreach and education of its providers and delivery systems. NIP Team Responsibilities: Created to take improvement efforts to a higher level Educating providers on HEDIS and ROQ standards. Providing physicians information about their quality performance Diagnose office practices that may result in missed opportunities to provide care or cause services to not be billed correctly Creating and distributing reference/educational materials and tools P0607

NIP Reports P0607

NIP Reports P0607

NIP Reports P0607

Disease/Health Management RN’s identify & evaluate members with unique healthcare needs Develop individualized plan of care Assist in overcoming barriers to care Risk assessment Maintains contact with PMP and member Implements interventions for identified needs. P0607

Disease Management Goals • Empower member with self-management tools, education and awareness • Promote the Asthma/Diabetes action plan in the home, school, and provider office • Encourage adherence to the physician’s treatment plan • Reinforce self-management goals: problem-solving techniques, overcoming barriers, and establishing goals • Provide physicians with member specific utilization information including pharmacy, emergency room, and outpatient visits • Promote relationship between the member and his/her physician(s) • Promote healthy lifestyle choices P0607

Opportunities for Improvement Maximize every member interaction to provide preventive and well-care. Well care visits for children when they are in for acute care Schedule the 15th month EPSDT (Early Periodic Screening, Diagnosis, and Treatment) visit prior to the 15th month of life LDL-C screens for diabetics when in for acute care Document all components of prenatal and postpartum care and submit for well-care visits. Staff who does scheduling can identify members who need services to schedule in a timely fashion Ensure proper billing for services rendered. Be sure that the documentation is complete P0607

Converting Acute Visits to Well Visits P0607

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Documentation for Well Child Visits Developmental milestones Review diet and nutrition Previous problems addressed? Address obesity and other chronic problems Ask about smoking, starting at age 10 yrs. Mental and physical assessment BMI – record & discuss Unclothed exam Provide anticipatory guidance & counseling Do routine testing (lead, vision, hearing) P0607

HealthWatch/EPSDT/Bright Futures Preventive healthcare program Emphasis is given to early detection For members from birth to 21 years old Required care for Medicaid members Assures availability and accessibility of required health care resources These components of care are a required part of the well-child assessment P0607

Opportunities If a member contacts the primary medical provider’s (PMP’s) office for a sore throat (sick visit) the office should take the opportunity to provide preventive care and schedule a well child visit if the member is due for services. If the PMP office receives a list of non – compliant members, the office should reach out to the members and schedule preventive services. P0607

Opportunities A PMP office could take the opportunity to convert a sick visit into a well – child visit when the member is in the office for acute care. If the PMP office has electronic medical records (EMR), implement alerts to reflect the non – complaint members in the quality measures. P0607

Opportunities If a member is being seen for an initial prenatal visit or post partum visit, all the components of a preventive well – child exam are provided. The appropriate V20.2 or V70.0 can be submitted as a secondary diagnosis code and count towards the AWC measure. If all components of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services were provided, remember to submit the appropriate 99381 – 99385 or 99391 – 99395 with the V20.2. P0607

Opportunities If all components of EPSDT were not provided, remember to submit the appropriate E&M code along with V20.2, V70.0, or V70.3 to ensure the services count towards the HEDIS measure. If EPSDT services were provided along with acute care, be sure to submit the appropriate EPSDT code along with the E&M code and the 25 modifier to ensure the services are counted towards the HEDIS measure. P0607

Quiz…….. If the PMP office provides immunizations and well care at the same visit, can I bill for both? How do I bill for both services and how do they count towards the HEDIS measure? When can I bill for the following combination 99381 and V20.2 as primary? If a pregnant adolescent member is seen for prenatal care, how is the claim coded to count towards the HEDIS measure? Can a sick visit and a preventive visit be billed and reimbursed n the same date of service (DOS)? P0607

Quiz…….. Is MDwise currently at the NCQA 90th percentile for the well – child 3 – 6 measure? Name 2 examples of provider incentives? Name 2 examples to promote quality of care within the MDwise network. Give an example of a disease management goal? Give an example for an opportunity for improvement? What is a goal of the EPSDT program? P0607

Resources MDwise website : www.MDwise.org My Wellness Zone: http://mdws.staywellsolutionsonline.com/ American Academy of Pediatrics http://www.aap.org/ P0607

American Academy of Pediatrics

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Thanks for your hard work! Questions? P0607

Handouts HEDIS poster Well – Child Mini Poster Quality PDF http://www.mdwise.org/about/mdwisequalityprogram09.pdf EPSDT grid Network Improvement Program Charts P0607