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Plugging The Quality Holes in Medicaid: Quality Measurement in PA as it applies to Managed Care

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Association for Community Affiliated Plans. Plugging The Quality Holes in Medicaid: Quality Measurement in PA as it applies to Managed Care Carol Smolij Vice President, Quality, Healthcare Management Health Partners of Philadelphia. About Health Partners.

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slide1

Association for Community Affiliated Plans

Plugging The Quality Holes in Medicaid: Quality Measurement in PA as it applies to Managed Care

Carol Smolij

Vice President, Quality, Healthcare Management

Health Partners of Philadelphia

slide2

About Health Partners

Now in our 25th year, Health Partners continues to be a community force, helping historically underserved residents lead healthier lives through equal access to care. We are a not-for-profit health plan owned by seven hospitals that provides healthcare coverage to residents of the five counties of Southeastern Pennsylvania (including Philadelphia). Our plan has been recognized as a national model for Medicaid managed care.

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Owner Hospitals

  • Albert Einstein Medical Center
  • Aria Health
  • Episcopal Hospital
  • Hahnemann University Hospital
  • Hospital of the University of Pennsylvania
  • St. Christopher’s Hospital for Children
  • Temple University Hospital
slide4

Our Mission

  • To manage our business to exceed expectations.
  • To operate with respect and dignity in all relationships.
  • To continually improve the health outcomes of our Members.
slide5

Making a Difference Every Day

  • More than 450 employees
  • More than 150,000 members
  • Ranked #1 in member satisfaction in our market for six years
slide6

Challenges

  • Churning Effect
  • Member Centric Barriers
  • Reporting Inequity
  • Continuous Enrollment
slide7

Current PA MCO Quality Reporting

  • HEDIS
  • Monthly YTD
  • Member Level Detail
  • Quarterly Focused Rates
  • State Specific Measures
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PA Focused Areas

  • Diabetes
  • Pregnancy
  • Hypertension
  • Lead / EPSDT
slide9

PA EQR Measures

  • BMI
  • Pregnancy - Depression
  • Pregnancy – Smoking / ETS
  • High Lead Levels - referral
slide10

Quality Measurement in PA

  • Improved Care Across Delivery Systems
    • Same to same measures
    • Analysis of membership
    • Study of demographics
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Quality Measurement in PA

  • Continued – Improved Care Across Delivery Systems
    • Identification of commonalities statewide – i.e. dental care
    • Convergence of ideas
    • Shared decision making
    • Quarterly meetings / shared agenda items
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Access Plus (FFS) & Primary Care Case Management (PCCM)

  • Comparison
  • Changes over time
  • Collaboration
slide13

Looking Ahead

  • Data Sharing
  • Member Transfers
  • Plan Collaboration
  • Reporting Equity
  • Better Benchmarking
slide14

NCQA MAAC

  • Medicaid Accreditation Advisory Committee (MAAC)
  • Medicaid Health Plans of America (MHPA)
  • Reporting differences between Commercial & Medicaid
  • Negative Impact of Enrollment Churn
  • Role of States in Determining COC
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Questions

???

Thank you!

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