Show me the MoneyWorking together to

provide quality care for MDwise members

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Indiana Health Coverage ProgramsFSSA

Traditional Medicaid

OMPP

Hoosier HealthwiseRisk-Based Managed Care

MDwise

MHS

Anthem

MAXIMUS

MDwise (Care Select)

ADVANTAGE (Care Select)

HP

590 Program

Healthy Indiana Plan

MDwise

Anthem Blue Cross

Blue Shield

Enhanced Services Plan(ESP)

Care Select

Cenpatico

Behavioral Health

Magellan Health

Services

MDwise

Managed Behavioral Health Organizations

FSSA= Family & Social Services AdministrationOMPP= Office of Medicaid Policy and PlanningMaximus= Enrollment Broker

MHS

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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.

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Who is MDwise?

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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”.

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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.

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NCQA National Committee for Quality Assurance is the organization that

accredits Managed Care Organizations (MCO’s).

MissionTo 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.

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NCQA created HEDIS

Healthcare Effectiveness Data & Information Set

A set of standardized performance measures

• Ensures that consumers have reliable information on the performance ofMCO’s.

• >90% of health plans use HEDIS to measure performance on important dimensions of care and service.

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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.

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• 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.

Pay for Performance – P4P

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• 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.

Pay for Performance – P4P

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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

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• 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

OMPP Incentivized HEDIS Measures

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How do we Compare?

MDwise NCQA 90th

%tile

Cervical Cancer Screening74.45% 79.5%

LDL-C(Diabetes Care) 68.61% 82.5%

Follow-Up after Hospitalization for Mental Illness (7 Days)

48.22% 64.2%

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How do we Compare?

MDwise NCQA 90th

%tile

Timeliness of Prenatal Care89.54% 92.2%

Timeliness of Postpartum Care 75.67% 72.7%

Frequency of Prenatal Care82.73% 81.0%

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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%

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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

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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

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NIP Reports

MeasureEligible

MembersCurrent

NumeratorCurrent %

Meets90th

PercentileVol. Mbrs.

Missed Opp.Potential %

MeetsVol. Needed

for 90th% of Opportunity

Needed

W34 2,996 1,380 46.1% 79% 1254 87.9% 987 79%

AWC 3,239 747 23.1% 57% 1308 63.4% 1099 84%

Note: Data is based on dates of service 1/1/09-12/31/09 with claims paid through 11/30/09 captured.

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NIP ReportsDenom Meet % Meet Meet Denom % Meet Meet Denom % Meet Meet Denom % Meet Meet Denom % Meet Meet Denom % Meetinator Criteria Criteria Criteria inator Criteria Criteria inator Criteria Criteria inator Criteria Criteria inator Criteria Criteria inator Criteria

0 0 100.0% 0 0 #DIV/0! 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 #DIV/0! 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 #DIV/0! 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 #DIV/0! 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 #DIV/0! 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 #DIV/0! 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 #DIV/0! 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 #DIV/0! 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 #DIV/0! 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 #DIV/0! 0 0 0% 0 0 0% 0 0 0% 0 0 0%

Denom Meet % Meet Meet Denom % Meet Meet Denom % Meet Meet Denom % Meet Meet Denom % Meet Meet Denom % Meetinator Criteria Criteria Criteria inator Criteria Criteria inator Criteria Criteria inator Criteria Criteria inator Criteria Criteria inator Criteria

0 0 100.0% 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 0% 0 0 0% 0 0 0% 0 0 0%

0 0 100.0% 0 0 0% 0 0 0% 0 0 0% 0 0 0%

Doc4Doc3Doc2

Follow-up After Hospitalization for Mental Il

Doc1PracticeDS

Initial Phase

LDL-C Screening

MeasureCervical Cancer Screening

F/U Care for Children Prescribed ADHD Meds

Doc5 Doc6

Follow-up Within 7 Days of Discharge

Timeliness of Prenatal Care

Doc8

Adolescent Well-Care Visits

DS

MeasureCervical Cancer Screening

F/U Care for Children Prescribed ADHD Meds

Follow-up After Hospitalization for Mental IlInitial Phase

Practice

Well-Child Visits in First 15 Mths of Life

Follow-up Within 7 Days of Discharge

Doc7

Well-Child Visits - Ages 3-6

Timeliness of Postpartum Care

Well-Child Visits - Ages 3-6

Adolescent Well-Care Visits

Well-Child Visits in First 15 Mths of LifeFrequency of Prenatal Care >81%

Six or More Visits

LDL-C Screening

Six or More Visits

Timeliness of Prenatal Care

Timeliness of Postpartum Care

Frequency of Prenatal Care >81%

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NIP Reports

0%

20%

40%

60%

80%

100%

120%

CCS CDC ADD FUH PPC PPC FPC W15 W34 AWC

OMPP Target

DS Totals

Practice Totals

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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.

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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

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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

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Converting Acute Visits to Well Visits

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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)

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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

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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.

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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.

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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.

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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.

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Quiz……..

1. If the PMP office provides immunizations and well care at the same visit, can I bill for both?

2. How do I bill for both services and how do they count towards the HEDIS measure?

3. When can I bill for the following combination 99381 and V20.2 as primary?

4. If a pregnant adolescent member is seen for prenatal care, how is the claim coded to count towards the HEDIS measure?

5. Can a sick visit and a preventive visit be billed and reimbursed n the same date of service (DOS)?

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Quiz……..

1. Is MDwise currently at the NCQA 90th percentile for the well – child 3 – 6 measure?

2. Name 2 examples of provider incentives?3. Name 2 examples to promote quality of care within the

MDwise network.4. Give an example of a disease management goal?5. Give an example for an opportunity for improvement?6. What is a goal of the EPSDT program?

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Resources

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

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American Academy of Pediatrics

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Thanks for your hard work!

Questions?

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Handouts

HEDIS posterWell – Child Mini PosterQuality PDF http://www.mdwise.org/about/mdwisequalityprogram09.pdf EPSDT gridNetwork Improvement Program Charts