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Physician Organizations Integrating Care – Solutions for the Future October 21, 2009

Michigan Association of Health Plans. Rick Murdock Executive Director Michigan Association of Health Plans. Physician Organizations Integrating Care – Solutions for the Future October 21, 2009. Who we are. Aetna Assurant CareSource Michigan Grand Valley Health Plan

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Physician Organizations Integrating Care – Solutions for the Future October 21, 2009

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  1. Michigan Association of Health Plans Rick Murdock Executive Director Michigan Association of Health Plans Physician Organizations Integrating Care – Solutions for the Future October 21, 2009

  2. Who we are Aetna Assurant CareSource Michigan Grand Valley Health Plan Great Lakes Health Plan/United Health Care Health Alliance Plan Health Plan of Michigan, Inc. HealthMarkets, Inc HealthPlus of Michigan McLaren Health Plan Midwest Health Plan Molina Healthcare of Michigan OmniCare Health Plan Paramount Care of Michigan Physicians Health Plan-Mid-Michigan Priority Health ProCare Health Plan Total Health Care, Inc. Upper Peninsula Health Plan Michigan Association of Health Plans

  3. Past Experience has been passive in such areas as: • Development of Guidelines • Work on Practice Protocols • Administrative functions with Health Plans • Lessons learn are that we need active partnership with providers to achieve best outcomes Physician and Health Plans: Partnering opportunities

  4. What Drives Health Plans: • Performance Expectations • Cost Pressures • Access for Beneficiaries • Management of Risk Physician and Health Plans: Partnering opportunities

  5. Clinical Guideline (MQIC & US Preventive Health Task Force) Measurement Tools (HEDIS/CAHPS) Performance Measures (HEDIS) Report Cards (NCQA & State Purchasing Pools Determination of variation of use, comparisons with state and National data, regional differences flow from this analysis performance expectations: tools and Measurement

  6. Physician tools to implement measures • http://www.mqic.org/phys.htm • Measurement reports (2005, 2006, 2007, 2008) • Power Point Slides • http://www.mqic.org/meas.htm MQIC Tools and Measurement

  7. The Task Force's pioneering efforts began with the 1989 Guide to Clinical Preventive Services. • 2nd edition of Guide published in 1996. • Current Guide to Clinical Preventive Services • Web http://www.ahrq.gov/clinic/pocketgd08/ • Electric access, http://epss.ahrq.gov/PDA/index.jsp • Task Force makes recommendations based on explicit criteria. • Recommendations issued by the USPSTF are intended for use in the primary care setting. U.S. Preventive Service Task Force

  8. Set of standardized performance measures • Designed to ensure purchasers and consumers can reliably compare the performance of managed care organizations (MCO) and preferred provider organizations (PPO) • A model for emerging systems of performance measurement in other areas of health care delivery • Maintained by NCQA • Not-for-profit organization • Evaluates, publicly reports on quality of MCOs and PPOs • HEDIS 2009: 70 measures across eight domains of care • Measures MCOs and PPOs report in June 2009 based on activity of 2008 measurement year HEDIS

  9. Chronic disease and behavioral health management Preventive health and wellness Pharmacy management Consumer engagement and support Provider measurement Health information technology PPO operations Health plans are evaluated on using HEDIS measurements

  10. Michigan Commercial Report Cards from NCQA • http://reportcard.ncqa.org/plan/external/PlanRatings.aspx • America’s Best Health Plans from NCQA and U.S. News and World Report • http://health.usnews.com/sections/health/health-plans/index.html NCQA Report Cards

  11. Administrative Simplification: • Credentialing • Common Application form • Common Credentialing cycle) • Referrals • Automation • Claims Processing • Eligibility Verfication • MAHP Connect Cost pressures: Partnership Opportunity

  12. Product line requirements: • Medicare • Commercial (Insured and Self-Insured) • Medicaid • Support efforts to develop products for uninsured and increase access and reduce uncompensated care. Access: Partnership Opportunity

  13. Support Medical Home Initiatives Identify and support candidates for disease management and care coordination Access to registries (MCIR, etc) Provide data on outcomes management of risk: Partnership Opportunity

  14. Michigan Association of Health Plans Physician Organizations Integrating Care – Solutions for the FutureQUESTIONS?

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