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A Case for Quality The Value of Medicaid Managed Care Working to Improve Health Every Day May 10, 2011. Optima Health Plans Serving 440,000 Virginia Members. Virginia-based; Not-for-Profit Health Plan Service of Sentara Healthcare 25-year history Statewide presence

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A Case for Quality

The Value of Medicaid Managed Care

Working to Improve Health Every Day May 10, 2011


Optima health plans serving 440 000 virginia members
Optima Health Plans Serving 440,000 Virginia Members

  • Virginia-based; Not-for-Profit Health Plan

    • Service of Sentara Healthcare

    • 25-year history

    • Statewide presence

  • Diversified Membership

    • Commercial – 277,000

    • Medicaid – 153,000

    • Medicare – 14,000

  • Strong Provider Network

    • 14,000 Physicians

    • 69 Hospitals

  • Performance Excellence

    • Fiscally sound; A+ rating

      Excellent accreditation by NCQA for 11th consecutive year


Optima family care medicaid managed care plan
Optima Family CareMedicaid Managed Care Plan

  • 147,000 Members

  • High Touch for Members

    • Reach 72% valid new households in 90 days; touch 20% of new members

  • Retain 85% of Newborns

  • Clinical Outreach

    • Automated health assessments

    • Outreach to frequent ER users

  • Invest $250,000 Value Yearly with Community Partners

    • Girls basketball league

    • CHCS grant with CHIP of VA & DMAS

    • Commitment to Community


Virginia Medicaid and CHIP Health Plans Provide Better Access to Well Child Visits 2007 Compared to FFS

58%

46%

Source: “Virginia Medicaid Managed Care Performance Report, 2007-2008”, Virginia Department of Medical Assistance Services.

December 2008.

4


Virginia medicaid health plans outperform ffs and pccm in lowering the rate of low weight births
Virginia Medicaid Health Plans Outperform FFS and PCCM in Lowering the Rate of Low-Weight Births

11.8

11.9

11.9

10.7

10.0

9.9

8.7

8.3

8.5

Source: Improving Birth Outcomes Through Adequate Prenatal Care Study, Commonwealth of Virginia Department of

Medical Services, December 2010

5


Managing medicaid partners in pregnancy program
Managing Medicaid Lowering the Rate of Low-Weight BirthsPartners in Pregnancy Program

  • OB HEDIS Outcomes

  • 2007 2008 & 2009

  • Prenatal Care 88.2% 84.6%

  • Postpartum 67.5% 68.2%

  • Actions

    • Redesigned High Risk OB Model with Community Outreach Partner

    • NICU Dollars Saved

      • Saved > $300 PMPM / intervention baby

    • Birth Weight Improvement

      • From 07-09, # Infants >2500 grams grew 10%

    • High Patient Satisfaction


Managing medicaid overuse of emergency services
Managing Medicaid Lowering the Rate of Low-Weight BirthsOveruse of Emergency Services

  • The Problem

  • # ER visits per month increasing. Over 6 months

  • 22,500 went to ER 3-10 times & of that, 6,100

  • did not have corresponding PCP visit

  • Actions

    • Targeted home education visits for the frequent flyers without PCP claims. At 3-mos:

      • 50-100 visits / month

      • 53% did not return ER (17% more than group not visited)

      • 36% went to their PCP (5% higher than group not visited)

      • Cost avoidance of $252,000

    • Called every member after every ER visit. At 3 mos:

      • 3,300 calls / month

      • 25% listened to call & left message 40% of time

    • At 6-mos, PCP appointment compliance increased to 48%


Transformation of Care Initiatives Lowering the Rate of Low-Weight BirthsTo Control Health Care Costs

  • Patient-centered Medical Homes

  • Chronic Care Management

  • Advanced Care Planning

  • Accountable Care Organizations

  • Knowledge Management


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