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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

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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

  • 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 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

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 MedicaidPartners 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 MedicaidOveruse 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 InitiativesTo Control Health Care Costs

  • Patient-centered Medical Homes

  • Chronic Care Management

  • Advanced Care Planning

  • Accountable Care Organizations

  • Knowledge Management


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