FUNDAMENTALS OF MANAGED CARE HIV/AIDS BUREAU HEALTH RESOURCES AND SERVICES ADMINISTRATION HRSA HIV/AIDS Bureau 1
FUNDAMENTALS OF MANAGED CARE 1. Managed Care Elements 2. Organizational Models 3. Continuum of Managed Care 4. Functions of MCOs 5. Collaborative Organizations 6. Utilization and Quality Management 7. Information Requirements HRSA HIV/AIDS Bureau 2
IPA PCCM MCE HMOS IDS MCO THE ALPHABET SOUP OF MANAGED CARE SSO MCP PPO PHO POS ISN IPO TPA HRSA HIV/AIDS Bureau 3
MANAGED CARE ELEMENTS! Combines financing and delivery systems! Patients are enrolled in a managed care plan on a prepaid basis with a defined benefit package that includes preventive and primary care services! Patients select (or assigned) a primary care provider (PCP) who acts as a gatekeeper to coordinate specialty and hospital care! Utilization and clinical practice are reviewed to contain costs while improving health status! Providers typically paid on a capitation basis but can be paid fee-for-service (FFS) HRSA HIV/AIDS Bureau 4
ORGANIZATIONAL PERSPECTIVE State State (or (or employer) employer) Premium $$$$ Managed Managed Care Care Organization Organization (MCO) (MCO) $$$ $$$$ $$$$ Inpatient Inpatient Providers Providers Primary Primary Care Care Providers Providers Specialty/Other Specialty/Other Providers Providers HRSA HIV/AIDS Bureau 5
THE CONTINUUM OF MANAGED CARE Fee for Service More Freedom of Choice More Expensive Capitated Less Choice Less Expensive INDEMNITY HMOS Traditional Managed PPO POS IPA/Network Group Staff HRSA HIV/AIDS Bureau 6
HMO MODELS! STAFF Physicians are employees of the HMO! GROUP Physicians are members of a multi-specialty or single specialty group practice which in turn contracts with the HMO! IPA Either the individual physician contracts directly with the HMO or the individual physician is part of a physician corporation which contracts with the HMO! NETWORK The HMO contracts with group practices, IPAphysician corporations and/or individual physicians HRSA HIV/AIDS Bureau 7
OTHER MANAGED CARE MODELS! POINT OF SERVICE (POS)! HMO offers members option to receive services from nonnetwork providers at a reduced level of coverage! PREFERRED PROVIDER ORGANIZATION (PPO)! A system which contracts with providers at discounted fees! Members may seek care from non-participating providers but at higher copays or deductibles! MANAGED INDEMNITY! Fee for service insurance plan! Members receive services from any provider with some restrictions on utilization and cost e.g. pre-authorization; maximum fee schedule HRSA HIV/AIDS Bureau 8
FUNCTIONS OF MCOs! MARKETING! Private (small, large, federal groups), Individual, Medicaid, Medicare! MEMBERSHIP ACCOUNTING! Group billing and contracts! Enrollment & disenrollment; pcp assignment! NETWORK OPERATIONS! Provider credentialing and contracting, provider services! MEMBERSHIP SERVICES! Inquiries, education, grievances HRSA HIV/AIDS Bureau 9
FUNCTIONS CONTINUED! CLAIMS ADMINISTRATION! In vs Out of Network; physician vs institution! Incurred But Not Reported (IBNR) Claims! MANAGEMENT INFORMATION SYSTEMS! Reports for all departments! FINANCE! budget projections, premium calculations, capitation rates! UTILIZATION MANAGEMENT and QUALITY ASSURANCE HRSA HIV/AIDS Bureau 10
COLLABORATIVE ORGANIZATIONS! INTEGRATED SERVICE NETWORK (ISN) - a collaboration of either primary care providers (horizontal) or primary, specialty and inpatient providers (vertical) for managed care purposes! PHYSICIAN HOSPITAL ORGANIZATION (PHO) - legal entity between hospital & MDs to contract with MCOs! SHARED SERVICES ORGANIZATION (SSO) - a collaboration between several organizations, such as community health centers, to share administrative, MIS, medical management and other services in order to participate in managed care (also TPA -third party administrators) HRSA HIV/AIDS Bureau 11
UTILIZATION MANAGEMENT! GOALS! plan members receive medically necessary & cost effective care;! utilization and cost patterns of participating providers are within defined limits;! plan meets its utilization and cost projections.! COMPONENTS! Referral Process! Prior or Pre-authorization:! Concurrent Review! Formulary! Medical Claims Review! Physician Selection/Physician Profiling HRSA HIV/AIDS Bureau 12
QUALITY MANAGEMENT! GOALS! Healthcare services are available, accessible & acceptable and meet defined standards for medically appropriate care! Participating providers meet credential criteria! Health outcomes monitored & meet established criteria! QUALITY STUDIES! Chart Reviews/audits! Incident or complaint investigation! Specific disease or condition investigation! Population wide studies! PROVIDER AND STAFF EDUCATION! PATIENT SATISFACTION SURVEYS! ACCESS STANDARDS REVIEW HRSA HIV/AIDS Bureau 13
NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA)! Private, not for profit organization; goal is to assess & report on quality of MCP! Two Major Activities: Accreditation and HEDIS! Accreditation:! Evaluates how well a MCP manages its delivery system! Reviews quality improvement, physician credentialing, member s rights & responsibilities; preventive health services; utilization management and medical records! Becoming a Standard - many plans are seeking NCQA credentialling and growing list of employers require it HRSA HIV/AIDS Bureau 14
HEDIS! Health Plan Employer Data & Information Set! Current version is 3.0 which includes commercial Medicaid & Medicare sectors! Key Performance Measures - clinical quality, access, member satisfaction, utilization and plan financial performance! Quality of Care Measures - include immunization rates; cervical cancer screening; asthma inpatient admission rate;! Only I AIDS measure in testing phase - PCP prophylaxis HRSA HIV/AIDS Bureau 15
INFORMATION REQUIREMENTS! Three key areas of data:! Enrollment, utilization, and cost! Accurate and timely information is crucial! Data helps staff to manage utilization and risk! Information provides the foundation for future planning HRSA HIV/AIDS Bureau 16
TYPES OF REPORTS! MEMBERSHIP! Accurate and timely membership report of enrolled and disenrolled members! CAPITATION! Compare capitation revenue to cost of providing service! AGGREGATE UTILIZATION AND COST! Compare projected versus actual utilization and cost! INDIVIDUAL PROVIDER UTILIZATION AND COST! Utilization and cost patterns for each primary care provider HRSA HIV/AIDS Bureau 17
SELECTED DATA ELEMENTS Data Element You Provide Managed Care Plan Provides! Member Months X! Capitation Revenue PMPM X! Primary Care Visits PMPM X! Cost of Primary Care PMPM X! Specialty Visits PMPM X! Ancillary Tests PMPM X! # of Primary Care Visits Per Provider X! # of Referrals per Provider X! # of Hosp/ital Admissions per Provider X HRSA HIV/AIDS Bureau 18
RYAN WHITE PROGRAMS VERSUS MCOs RYAN WHITE PROGRAMS! public health mission! population driven! enabling services! medically and culturally appropriate providers! provide care to uninsured! accessible sites! experience with vulnerable populations MCOs! for profit mission! market driven! mandated benefits only! cost efficient contracted providers! care only to members! commercial sites! experience with middle class HRSA HIV/AIDS Bureau 19