What are Medicare managed care plans doing to measure and improve quality of care? While results of the present study suggest that provider incentives were not substantial enough to be worth the additional burden, strategies focusing on education and incentives for beneficiaries may be a valuable way to influence quality of care and population health in Medicaid managed care plans. This study included 25 key informant interviews with stakeholders in the Medicaid program in one Northeastern state. Consistent with prior research, and despite managed care plans describing significant efforts to influence care quality, providers in our study indicated that they were often unaware of these efforts (Cukor et al., 2002; Fairbrother et al., 2000). People really like it. Other research, however, has reported that providers find quality management strategies that focus on education and peer influence to be more productive than those that are regulatory or financial incentive based (Williams et al., 1999). Then, within the care management process, they have to do an initial health risk assessment with folks. I would say they do some education in person, face to face. Things that in the hierarchy of quality improvement methodologies would tend to be at the lower rungs. States influences on Medicaid investments to address patients social needs, Medicaid enrollment in managed care by plan type. All other trademarks and copyrights are the property of their respective owners. SUMMARY: This final rule advances CMS' efforts to streamline the Medicaid and Children's Health Insurance Program (CHIP) managed care regulatory framework and reflects a broader strategy to relieve regulatory burdens; support state flexibility and . This cobranded initiative also used plan staff called clinical practice consultants, who another plan representative further described, I think probably one of the most effective interventions that we have is our clinical practice consultants. Two providers reported practicing in patient-centered medical home settings. It is available to individuals in three common formats: preferred provider organizations, health maintenance organizations, or point-of-sale care. Providers were eligible to participate if they cared for Medicaid enrollees. Medicaid reforms to expand coverage, control costs and improve care: Results from a 50-state Medicaid budget survey for state fiscal years 2015 and 2016. Plans and the state Medicaid program described focusing their quality measurement efforts on collecting HEDIS measures, and although providers generally acknowledged the importance of these measures, they described them as minimally sufficient in characterizing quality of care among Medicaid beneficiaries. Across participants, a few strategies emerged as best practices, with most participants in agreement that they were effective. Managed care was initially welcomed by a. employers b. workers c. private insurance d. the government A 2. Future research would also be improved by examining if and how beneficiaries are able to access and participate in plan quality management strategies. Some studies have found that although managed care plans describe significant efforts to manage and improve care quality, knowledge of these efforts largely fails to reach providers and result in improved quality of care for patients (Cukor et al., 2002; Fairbrother et al., 2000). The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ("managed care techniques"). I mean, basically the incentives would get spent on Saturday clinics to get em through. Another provider described an incentive that was problematic due to poor communication between the plan and the practice: Unbeknownst to us, we had agreed that we would take part in a small pay for performance program. And in October, [the plan] approached us with lists of patients that supposedly not had their three-year-old visits and adolescents who had not had their chlamydia screening this was the first we ever heard that this was even a performance measure for us. So we went through their list and about three quarters of them actually had had whatever the thing was. Quality management by state Medicaid agencies converting to managed care: Plans and current practice, JAMA Journal of the American Medical Association. One provider said. Many managed care plans offer . As a prominent model of health care reform that has been supported and promoted by the Affordable Care Act (Davis, Abrams, & Stremikis, 2011), care coordination is a primary function of patient-centered medical homes (Agency for Healthcare Research and Quality, n.d.). and transmitted securely. Under managed care, the state pays a managed care plan a capitation ratea fixed dollar amount per member per monthto cover a defined set of services for each person enrolled in the plan. The resulting themes and example quotes follow, separated by type of participant and by whether strategies to manage care quality target providers or beneficiaries. Do they offer it to patients? The present research aims to address this gap in the literature by presenting stakeholder perspectives regarding quality management in Medicaid managed care from Medicaid officials, managed care plan representatives, and providers. This could be an area for future research. Although previous research has suggested that the provision of performance feedback to providers may be a key strategy to manage quality of care (Williams et al., 1999), this did not emerge as a best practice in the present study. I havent heard about it. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government. - Definition & Shortage Quiz, What Is a Standing Order? As discussed by the study participants, the lack of awareness of managed care plans efforts among providers not only seriously hinders the efficacy of these strategies but also causes frustration and significant administrative burden that may harm care quality. They are nurses who have really good analytic heads also, and they go into provider offices to collect data, but what they also do is they get to know the staff in the office and they begin to talk with them about how their office works, what they do, and then they are able to share with that office, heres what your results show, and then drill down to the with the office to say, how can we improve.. And so then they reach out to their patient. 5 . With 81% of Medicaid beneficiaries enrolled in managed Medicaid (Kaiser Family Foundation, 2016b) and most Medicaid expansion states enrolling all newly eligible beneficiaries in managed care plans (Smith et al., 2015), it is important to understand Medicaid plans efforts to manage and improve quality of care for this vulnerable population as well as providers level of awareness and perceptions of these strategies. Interview participants described attempts to manage and improve quality of care for Medicaid managed care beneficiaries. Provider interview participants were frequently unaware of strategies managed care plans used that targeted beneficiaries. Despite the common focus on HEDIS measures, providers voiced skepticism about the validity of performance data as applied to their own patient population (including problems with identifying and properly attributing patients to practices). In recruiting provider participants, we informed potential participants that we were interested in learning about perceptions of how Medicaid managed care plans may influence quality of care. The site is secure. HMOs, and their close cousins, preferred provider organizations (PPOs), share the goal of reducing healthcare costs by focusing on preventative care and implementing utilization management controls. Today, capitated managed care is the dominant way in which states deliver . In other words, the administrative cost- I dont see the actual benefit of the programs. A DRG is best described as: Once analysis of the first interviews was completed, the process was streamlined by dividing into two subteams of two or three members each, with each team member coding the transcripts independently, then meeting in the subteam to reconcile the codes and discuss potential themes. 1. 4.5 points. Enrolling in a course lets you earn progress by passing quizzes and exams. These included outreach and reminders, incentives, a combination of outreach plus incentives, and more active engagement through beneficiary advisory boards. Such representatives commonly described both monetary and non-monetary incentives. Their ideas for improvement centered on improved communication between plans and providers. Coordinating care for adults with complex care needs in the patient-centered medical home: Challenges and solutions (AHRQ Publication No. It is important to consider the underlying policy context of this study. Other efforts were more specifically focused on noncompliant members: If people are not looking compliant, we will send a targeted letter to those people who we dont have claims demonstrating that theyre meeting what we would like or what the standards are. This is a claims-based thing. Once again, the issues of other things that impact patients such as housing and not having a correct address, or not having a correct phone number affect the effectiveness of that. I think they certainly can [improve care quality]. 8600 Rockville Pike See the types of managed care plans and details of managed care. False Managed Care is a health care delivery system organized to manage cost, utilization, and quality. So things like posters and letters, and primary care provider reminders, those are all helpful. the contents by NLM or the National Institutes of Health. This qualitative study found that Medicaid health plans described robust efforts to measure and improve quality through performance feedback, beneficiary outreach, and provider-focused incentives, often targeting widely reported HEDIS measures. When a managed care organization is known for being the best in a specific service field, the number of cases using that service increases. Managed care has two key components: utilization review and healthcare provider networks/ arrangements. These perspectives ranged from a lack of awareness of any programs, to feeling that the programs were not effective, to believing that they were very helpful. Qualitative perspectives of primary care providers who treat Medicaid managed care patients. Weston C, Gandell T, Beauchamp J, McAlpine L, Wiseman C, & Beauchamp C (2001). You can assess your knowledge of this care and its history by completing the quiz and worksheet. 1. We use the same kind of HEDIS standards and if they are adherent, they dont get the letter. If you talk to a care manager, and you start talking about what your issues are and theyre able to help you, every time you spend twenty minutes on the phone with a care manager. Heres a $25 gift card for engaging with care management to help you get your health on track. Supplemental material for this article is available online. managed care is best described as: a. an insurance company that provides healthcare services b. a broad and constantly changing array of health plans, employers and purchasers to attempt to manage costs and quality. Managed care plan representatives also described strategies to manage care quality that target beneficiaries. In turn, the plan pays providers for all of the Medicaid services an enrollee may require that are included in the plan's contract with the state. These plans work in place of your original Medicare coverage. Federal and private health insurance that offers reduced costs to its members, Federal and private health insurance that offers both reduced costs to its members and unlimited providers to choose from, Health insurance that was developed twenty years ago, Health insurance that is designed to reduce the costs of services to its members by contracting with specific providers. Physician experiences with, and ratings of, managed care organizations in Massachusetts. A Medicaid official described the benefit of holding managed care plans responsible for quality management: . These include provider networks, provider oversight, prescription drug tiers, and more. - Definition, History & Systems Quiz, What Is Medicare? Medicaid officials were asked how managed care plans are identified and contracted with, how they deal with plans that exit the Medicaid market, which measures are important in measuring quality of care and outcomes, how quality data are generated and used, and what strategies the plans use to improve quality. Managed care organizations are integrated entities in the healthcare system, which endeavor to reduce healthcare expenditures costs. We sent them documentation. These possibilities indicate gaps in communication among plans, providers, and beneficiaries. Part of her new role is to explain the goal of managed care, in order to educate staff on its purpose and how . Coded data were entered into the qualitative software package NVivo to allow for data management. Its not us telling them what they need to do per se, its about creating shared goals. I think thats why we have a lot of success in sort of helping people turn corners and we have a whole network of staff who are dedicated to helping them get housing or transportation or food. Detailed definitions of managed care terms follow. Smith VK, Gifford K, Ellis E, Rudowitz R, Snyder L, & Hinton E (2015). The majority of these beneficiaries (approximately 55 million) are enrolled in risk-based managed care plans (Kaiser Family Foundation, 2016a). O An insurance company that provides health services. The primary strategy that providers described plans using was provider feedback on important, almost exclusively HEDIS-based, measures. this means - Definition, Eligibility & Coverage, What Is Medicare? One provider discussed problems associated with lists of noncompliant patients: The quality of the list has been our issue. Whether its going to change our rates, thatll be a while before we can tell that. Each of the aforementioned populations must enroll in a managed care plan (i.e., mandatory managed care enrollment). HHS Vulnerability Disclosure, Help Under Medicaid managed care, private health insurance plans receive capitated payments from state Medicaid programs to finance health services for Medicaid beneficiaries. All interviews were audio recorded (with participants consent) and transcribed for data analysis. Little is known, however, about how plans structure quality management efforts, how they are perceived by providers and policy-makers, and whether these individuals consider that such efforts result in improved quality of care for Medicaid beneficiaries. official website and that any information you provide is encrypted Thats one place where Medicaid has actually some dollars on the table for the providers to fill out the assessment forms on pregnancy, and be able to manage them accordingly. Any time we have a new pregnant woman, were supposed to do a risk assessment form that is sent to [the plan]. In subsequent meetings, the team refined the coding scheme and associated code definitions according to their fit to the transcript data; the team also discussed preliminary patterns (or themes) emerging from the data and reconciled coding of the first transcripts. The present research builds upon Landon, Wilson, et al.s (1998) framework to consider the roles of three stakeholder groups in Medicaid managed care and how they may affect efforts to manage and improve quality of care. They dont like to be looked at. I think if they were to work cooperatively, to meet with providers to set common goals, to open lines of communication, all of which are absent. One of these two plans is a national, for-profit plan that serves both Medicaid and commercial populations. Managed care plan representatives described how they attempt to manage care quality by targeting providers. The concept can best be described as a broad spectrum of cost controlling options designed to coordinate the financing and provision of healthcare to produce high-quality healthcare for the lowest possible cost. If we had known, Day 1, that we were part of that contract, we couldve paid attention to it, run reports, figured out how we were doing and kind of tracked it throughout the whole year. State Medicaid offices that contract with managed care plans are responsible for monitoring the quality of care and outcomes of Medicaid beneficiaries enrolled in these plans, and many states either encourage or require managed care organizations to participate and invest in quality improvement or management (Centers for Medicare & Medicaid Services, n.d.). This is problematic given enormous changes to health care following implementation of the Affordable Care Act and intensive efforts by the Centers for Medicare & Medicaid Services to increase federal and state oversight of Medicaid managed care.