MEDICAID MANAGED CARE PROGRAM MANAGEMENT: THE NEXT GENERATION ANNE JACOBS, MANAGING DIRECTOR NAVIGANT HEALTHCARE

Transcription

1 MEDICAID MANAGED CARE PROGRAM MANAGEMENT: THE NEXT GENERATION ANNE JACOBS, MANAGING DIRECTOR NAVIGANT HEALTHCARE Page 1

2 WHAT S EXPECTED OF MEDICAID HEALTH PLANS? Some might ask, if the delivery system embraces better coordination, patient management and integration, why do we need health plans? How do health plans add value if physicians and hospitals deliver better care? National Committee for Quality Assurance The State of Health Care Quality 2011 Page 2

3 HOW SOPHISTICATED IS MEDICAID AS A PURCHASER? FINDINGS FROM A NAVIGANT -ADMINSTERED PLAN SURVEY» The state needs to develop/implement tools that actually monitor. Today s process is a huge dump of documents that receive little to no actual review until a provider or member expresses a complaint.» Need more collaboration in choosing measures, metrics and performance targets with a longer term view.» Move to increasing focus on quality improvement and less on process monitoring for compliance. Page 3

4 HOW SOPHISTICATED IS MEDICAID AS A PURCHASER? FINDINGS FROM A NAVIGANT -ADMINSTERED SURVEY OF HEALTH PLANS» Reporting [is] not meaningful or used in oversight; requirements [are imposed] for costly, low impact interventions.» There are burdensome reporting requirements, administrative requirements that do nothing to promote health. Page 4

5 THE MEDICAID ENVIRONMENT: TODAY'S APPROACH IS NOT SUSTAINABLE» State budget deficits» Anticipated growth in Medicaid enrollment» Increased use of managed care for high risk populations» Emergence of delivery and payment reforms (e.g., ACO, etc.)» Challenges about the value generated by health plans» Emerging information technologies for data exchange and decision support» Increased focus on integration, prevention, quality and outcomes Page 5

6 VALUE BASED PURCHASING: AN ORGANIZING PRINCIPLE FOR THE NEXT GENERATION OF MEDICAID MANAGED CARE Medicaid agencies must transform from compliance officers to value generators. Medicaid health plans must transform from being compliant to generating value. Page 6

7 VALUE BASED PURCHASING: AN ORGANIZING PRINCIPLE FOR THE NEXT GENERATION OF MEDICAID MANAGED CARE People are realizing that we can t keep paying for care the way we do and expect to get anything other than the high cost and low quality care that we get. Meredith B Rosenthal, Professor of Health Economics and Policy, Harvard School of Public Health Page 7

8 VALUE BASED PURCHASING: AN ORGANIZING PRINCIPLE FOR THE NEXT GENERATION OF MEDICAID MANAGED CARE» State purchasers and MCOs must develop new ways to partner to transform the system to achieve increased quality for lower costs» States have increasing purchasing power to influence changes in healthcare system delivery and payment and with that increased responsibility to demonstrate value» MCOs must leverage their role as a change agent to demonstrate value But must demonstrate their value as a private enterprise that generates value for public benefit while also substantiating administrative costs and profits Page 8

9 VALUE BASED PURCHASING IS NOT SIMPLY» Consumer report cards and public reporting OR» Pay for performance and incentive payments OR» Goal setting OR» Continuous quality improvement OR» Bundling payments Rather, it is all of these elements and more, executed as part of a cohesive strategy that aligns incentives for consumers, providers, health plans and the state to achieve the program s goals

10 VALUE-BASED PURCHASING DEFINITION: MICHAEL PORTER» A demand side strategy, involving the actions of coalitions, employer purchasers, public sector purchasers, health plan payers and individual consumers to reward excellence in healthcare delivery.» Rewards can take three dominant forms: Enhanced reputation Enhanced payment Enhanced market share» A critical external motivator in establishing a business case for why providers of care should embrace, lead and implement the reengineering of healthcare delivery.» A transformational strategy for the healthcare delivery system. Page 10

11 VALUE BASED PURCHASING DEFINITION: NATIONAL BUSINESS COALITION ON HEALTH Value-based purchasing is a strategy used by employers, and increasingly the Federal government, to use their market power as a force to promote quality and value of health care services. The overarching goal of VBP is a health care system, built on value, with a clear return for every dollar spent. Page 11

12 VALUE-BASED PURCHASING DEFINITION: AHRQ buyers should hold providers of healthcare accountable for both cost and quality of care brings together information on the quality of healthcare, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the healthcare system to reduce inappropriate care and to identify and reward the bestperforming providers. Page 12

13 VALUE-BASED PURCHASING DEFINITION: AHRQ keep in mind that this is a process in development and there will be many changes to the concept before we are through. Page 13

14 PROPOSED VALUE BASED PURCHASING MODEL STRATEGIC MEASURES AND TOOLS» Limited Number of Priorities» Metrics Linked to Priorities» Leading and Outcomes Metrics» Data Analytics & Dashboard STRONG LEADERSHIP AND MANAGEMENT PROCESS» Clear and Publicly Committed Vision» Applied Accountability» Shared Objectives and Incentives» Ongoing Monitoring and Action JOINT PLANNING AND COLLABORATION» Joint Planning: States, Vendors, Providers, Members» Vendor Annual Plans» Continuous Improvement FINANCIAL DRIVERS ALIGNED INCENTIVES Foundational Elements Transparency and Informed Decision-making Standards and Simplification Information Technology

15 STATES HAVE IMPLEMENTED PIECES OF VBP State A Joint Planning and Collaboration Strong Leadership and Management Strategic Measures and Tools B Aligned Incentives C D E F Page 15

16 ALIGNED INCENTIVES State Health Plan Provider Consumer Page 16

17 THE VALUE BASED PURCHASING PROCESS Remeasure Pay incentives Identify performance gaps Conduct root cause analysis Measure and adapt Collaborate & Communicate Find potential solutions and ROI Implement interventions Design incentives Set goals Page 17

18 HAVING MORE GOALS DOES NOT MEAN YOU ACHIEVE MORE GOALS Number of Goals Achieved with Excellence Number of Goals Established Source: FranklinCovey Page 18

19 NEXT STEPS FOR HEALTH PLANS IN STATES MOVING AHEAD WITH VBP» Elevate this change within your organization VBP should transform the way your health plan operates Make it a priority led by plan executives Involve everyone administration, providers, members and build infrastructure Show the benefits potential and realized» Carefully examine the VBP program design Identify enhancement opportunities Be creative» Identify opportunities for savings and quality improvement Determine which areas offer greatest potential return on investment» Pursue every opportunity to collaborate With other payers With key providers Page 19

20 NEXT STEPS FOR HEALTH PLANS IN STATES NOT YET MOVING AHEAD WITH VBP» Approach state agency and fellow health plans and other purchasers Be prepared to make the case» Form coalitions to drive change even without state agency Identify leader Engage partners (other health plans, key providers, other purchasers) Define a structured process and timelines» Agree upon goals Select goals where you can have the greatest impact (i.e., ROI) Focus on 1-3 goals» Assess contracts and regulations: What aspects of VBP can be achieved now What changes will be required in the future Page 20

21 MEDICAID MANAGED CARE PROGRAM MANAGEMENT: THE NEXT GENERATION ANNE JACOBS, MANAGING DIRECTOR NAVIGANT HEALTHCARE Page 21