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The emergence of Managed Care has produced many challenges and opportunities for state Medical Assistance agencies across the nation. There has been a great deal of attention directed at the “quality” of health care provided to Medical Assistance recipients who fall under Managed Care requirements. Along with concerns about the quality of services provided, there are also concerns over the availability of health care for these recipients.
The Division of Medical Services has accepted the challenges Managed Care has presented. Not only are we committed to providing our recipients with the highest quality of care available when and where they need it, we are also assuming a leadership role in the promotion of healthy and responsible lifestyles for our recipients. To the extent possible, we have also developed and implemented Quality Improvement projects in areas we feel are important to the health and well being of our participants.
Our division utilizes many different avenues when evaluating the quality and availability of care provided to recipients of Medical Assistance.
Examples are:
These studies are conducted to examine issues of particular interest or concern within the populations that we serve. For the most part, our office utilizes the HEDIS measurements produced by the National
Committee for Quality Assurance (NCQA).
Data is obtained primarily from paid claims or by audits of individual medical records. Once the data has been assembled we are able to determine our baseline (where we are at) and compare that to our standard (where we would like to be).
The findings of our studies are compared to benchmarks (predetermined standards/goals) such as Healthy People 2010. Once issues have been identified, we use the results of these studies to formulate outreach campaigns to bring about our desired results. After a period of time, we do another analysis of our data to determine any measurable improvement (how far we have come).
Recipient Satisfaction Surveys and Specific Service Surveys:
We send out monthly Recipient Satisfaction Surveys to a random sample of our recipients receiving Medical Assistance. This survey asks questions regarding the quality of services the recipient receives, how they are treated, their ease in accessing medical care, satisfaction with their PCP, the availability of referrals, etc.
We also send out a monthly Specific Service survey. This survey is sent to recipients who have recently received medical treatment. The survey specifically asks questions regarding the recipients satisfaction with the particular service/treatment they received.
Both of these surveys are completed on a monthly basis and give the recipient the opportunity to provide us with feedback on their experiences with the Medical Assistance Managed Care Program.
Many times these reviews are the result of a recipient complaint. These reviews are completed as complaints are received and consist of a review of billing and medical records to assure appropriate payment, compliance with rules and regulations and to detect fraud and abuse of the Medical Assistance Program.
We monitor 24 hour accessibility of our PCP’s by conducting random after-hours phone audits. Our Managed Care staff call PCP’s during non-business hours to determine if the PCP has an adequate process in place to allow recipients access to care and referrals.
When it is determined a PCP’s 24 hour access process is sub-par, we work directly with the PCP to come up with a workable solution to meet everyone’s needs.
These are completed on a quarterly basis. Every quarter a different area of the state is targeted with the entire state being completed on a yearly basis.
We monitor our PCP’s caseload on a monthly basis to ensure our PCP’s are not accepting any more than the maximum 750 recipients allowed.
We monitor our recipient’s request for change from one PCP to another on an on-going basis.
When a recipient wishes to change their PCP they are asked to provide the reason for their desire to change. These change reasons are tracked and evaluated to determine if problems exist in certain areas or with certain PCP’s.
We have the capability of conducting provider profiles to compare one PCP’s performance in a certain area to the performance of his/her counterparts in the same geographic area or to other areas of the state on a periodic basis.
These profiles might compare one PCP’s rate of age appropriately immunized children under age 2 who are enrolled in Medical Assistance to the rate for the same thing of another PCP. This gives the PCP feedback on how he/she is performing in relationship to their colleagues.