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Medical Assistance Program Oversight Council October 11, 2013

Medical Assistance Program Oversight Council October 11, 2013. HUSKY Health Program and Charter Oak Health Plan. Medical ASO Program Dashboard Highlights. Determining a Primary Care Provider’s Panel: PCP Attribution.

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Medical Assistance Program Oversight Council October 11, 2013

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  1. Medical Assistance Program Oversight CouncilOctober 11, 2013

  2. HUSKY Health Program and Charter Oak Health Plan Medical ASOProgram Dashboard Highlights

  3. Determining a Primary Care Provider’s Panel: PCP Attribution 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. • 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

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

  5. CMAP Provider Network GrowthJanuary 2012 – June 2013 +7.3% +1.4% +20.9%

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

  7. Call Center StatisticsJuly 1, 2012 – June 30, 2013

  8. Access for Members with Cultural & Linguistic NeedsJuly 1, 2012 – June 30, 2013

  9. Grievance StatisticsJuly 1, 2012 – June 30, 2013 **A grievance is any expression of dissatisfaction

  10. Intensive Care Management Outreach July 1, 2012 – June 30, 2013 Top Driving Conditions that Identified Members for ICM: • 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

  11. ICM: Addressing Immediate NeedsJuly 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:

  12. HUSKY A, C and D Member Authorizations and AppealsJuly 1, 2012 – June 30, 2013 • 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 • 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 AppealsJuly 1, 2012 – June 30, 2013 • 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 CombinedDates of Service January 2012 – March 2013 • From Q1 2012 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%. 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.

  17. Hospital Inpatient - Medical & BH CombinedDates of Service January 2012 – March 2013 • From Q1 2012 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 MajorDiagnosis Categories CY 2012 • 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. Note: All HUSKY Health & Charter Oak members except Dual members are included.

  19. Hospital Emergency Dept (ED) - Medical & BHDates of Service January 2012 – March 2013 The charts below represent total ED visits. • The cost per ED visit increased by 8.5% from Q1 2012 to Q1 2013. • HUSKY C ($429) and HUSKY D ($383) have the highest cost per ED visit. • ED visits per 100 MMs decreased by 3.2% from Q1 2012 to Q1 2013. • HUSKY D has the highest ED utilization. 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.

  20. Hospital Emergency Dept (ED) - Medical & BHDates 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 Q1 2012 to Q1 2013. • The PMPM cost for non-emergent visits decreased by 11.7% from Q1 2012 to Q1 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.

  21. Hospital Emergency Dept (ED) - Medical & BHCalendar Year 2012 • 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 Total ED Users =269,205 (41% of all members) Note: All HUSKY Health & Charter Oak members except Dual members are included.

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

  23. Maternal & Child Birth – CY 2012 23

  24. Obstetric P4P program • 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 24

  25. Questions?

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