Making Medicaid Better Newsletter 12.06.2011
First enrollment opening nears for BAYOU HEALTH: A Message from Secretary Greenstein
Years of research, public discourse, hard work and late nights will soon culminate in the most significant transformation of Louisiana's Medicaid program in its more than 40 years of existence. In just one week, eligible enrollees in the New Orleans and Northshore regions will have an opportunity, for the first time, to make a choice about the way their health care is delivered. On Dec. 15, enrollment into BAYOU HEALTH begins, and the people we serve will choose which of five different Health plans best meets their needs and the needs of their family. As we near that hallmark date, I have been reflecting on the tremendous work that has occurred to get us here.
Doing nothing was not an option. Louisiana has long been on a predictable path toward failure. Just this week, the United Health Foundation once again ranked Louisiana as the second least healthy state in the nation. I believe our potential is more than 49th place. We have great providers and passionate leaders, but moving the dial on generations of poor health outcomes is no easy task. It requires a fundamental change in the way we do business. For the last four years, scores of dedicated individuals have been researching, designing, building and implementing an entirely new approach to care for Louisiana Medicaid and LaCHIP recipients. While we've had significant public discussion throughout this process, I understand it is only too easy to lose sight of the forest through trees. Therefore, it occurs to me that not everyone may fully understand the strength of the program we are launching.
A recent article in The Economist talked about how states are continuing to expand or (as in our case) introduce Medicaid managed care as means to bring smarter management and better coordination to their soon-to-be expanded Medicaid programs. At the very end was the following statement, "If states do not draft their contracts properly, or fail to be vigilant in monitoring patients' health, their experiment in managed care could be a disaster. On the other hand, if states are careful they could provide an answer to the question that has vexed America for years: how to provide good, cheap health care."
And here we find Louisiana's great advantage. I understand fully, from first-hand experience in other states, what the first part of that statement references. As with many programs, the early days of Medicaid managed care had their challenges. States made mistakes, and health plans took advantage of them. There were surely successes, but it's the failures that remain firmly planted in the forefront of many people's minds. Louisiana is one of the last states with a large Medicaid population to implement Medicaid managed care, and we have built BAYOU HEALTH to be the standard-bearer of how to do it right and meet The Economist's challenge to find the answer.
Careful. Collaborative. Cautious. These are the words I'd choose to describe the process used to build BAYOU HEALTH. We learned from other states' mistakes, incorporated best practices and, in some cases, designed promising practices that you don't see elsewhere. From day one, our focus has first and foremost been on improving health; everything we have built into BAYOU HEALTH keeps that goal front and center.
As we finally move into the implementation and execution phase of this years-long endeavor, I felt it was important to reassure and remind our providers, partners and stakeholders of the strength of the foundation we are laying. What we are building together is the groundwork of Louisiana's health renaissance-the chance to make impactful change that will last for generations. So, below are 13 points I believe are the differentiators that will make BAYOU HEALTH the model that other states look to emulate. They underscore our intense focus on health outcomes, quality measures and consumer engagement. I am proud of our work together, and these are just the top-line highlights that make BAYOU HEALTH stand above all other Medicaid Managed Care programs.
- 1. Quality Focus. With Health Plans reporting on 37 clinical quality measures, additional administrative quality measures and a portion of the capitation payment and shared savings contingent on meeting quality benchmarks, the focus on quality is obvious. We already have an External Quality Review Organization contract in place with national quality review organization IPRO. They have provided the framework for completion of the operational Readiness Reviews for each of the five Plans to assure that all contract requirements are addressed and met.
- 2. Encounter Data. We have made it very clear from the start (based on lessons learned from other states) that Plans must submit timely and accurate encounter dataon a monthly basis to our Fiscal Intermediary. We have builtstiff monetary penalties for failure to do so into the contracts.Some states are still not getting valid encounter data from their Medicaid managed care plans, in some cases many years after implementation.
- 3. Risk Adjusted Premiums. We are using the Johns Hopkins Adjusted Clinical Groupings (ACG) Case-Mix Model for our Risk Adjusted Premiums - something many other states don't yet have incorporated into their Medicaid Managed Care programs at all and something we learned right away must be included to prevent "cherry picking" and "lemon dropping." Plans that cover sicker individuals or those with chronic disease will be paid a higher per-member per-month for those individuals. This prevents health plans from having any advantage from cherry-picking their enrollees, and gives plans the resources they need to truly manage those conditions. The majority of state Medicaid Programs who do have full Risk Adjustmentuse a less sophisticated grouper that is not usedbycommercial insurance, that is static and not updated and relies on pharmacy data only.
- 4. Medical Loss Ratio (MLR) of 85 percent. A considerable number of state Medicaid managed care programs have no MLR requirementwhatsoever, or if they have one, there is no requirement for the Plan to refund the state the difference between the established MLR threshold and the actual MLR. BAYOU HEALTH Plans' Annual MLR statements will be independently audited and results released to the public so everyone can know fully where tax dollars are going.
- 5. Robust Financial Reporting Requirements.The BAYOU HEALTH quarterly financial reporting requirements are extremely detailed and robust. You can click here to see the extensive financial reporting we require - most of which will be published online. I have seen Financial Reporting forms for other state Medicaid managed care programs that pale in comparison.
- 6. Emphasis on Member Choice and Engagement.We have placed significant resourcesin outreach and education of members, promoting their awareness of BAYOU HEALTH and empowering them to engage in their own health care and that of their children.Great care has gone into every word contained in the written materials that will be mailed to enrollees: Readiness Brochure, Postcards and the Enrollment Packet, as well as ads, public relations pieces, posters, flyers and brochures. DHH-sponsored community enrollment events are planned in every parish (41 in the first Geographic Service Area alone over a five-week period). Medicaid eligibility staff is fully integrated into the education, outreach and assistance with Plan selection(a resource not even available to 90 to 95 percent of states since they contract with their social services agency to determine Medicaideligibility). We have built incentives (and penalties) in the contract for our Enrollment Broker to reach certain thresholds of pro-active selection rather than having people auto-enrolled. The reality is we could have sat back and done nothing on this front and just assigned everyone to a Plan (some other states do Medicaid managed care like this). But we knew that for BAYOU HEALTH to have the impact we desire, recipients needed to engage in their health care in ways they have never done before. That's why we have also included an aggressive outreach and education program for health care providers. Recent feedback we received from an individual who had seen our Provider Resource Guide said:"I appreciate your direction on creating such a consumer friendly process for the Medicaid clients."
- 7. Monitoring Prior Authorization Denials & Appeals. Health Plans must reportand DHH will closely monitor monthly reports of all claims denied for reasons including 1) not meeting medical necessity, 2) not eligible on date of service, and 3) needs additional data. We will quickly detect and address any indications of inappropriate denials by a Plan. We will also compare plans, and the contracts include financial sanctions each time the Division of Administrative Law reverses a Health Plan appeal decision when the rate of reversals exceeds those of Medicaid fee-for-service.
- 8. Provider Network Adequacy. The BAYOU HEALTH staff will conduct ongoing monitoring to assure that prepaid Health Plans have continuous adequate provider networks including specialists. The Enrollment Broker will conduct monthly "secret shopper" surveys to confirm that physician appointments are available within the time and distance requirements outlined in the contracts.
- 9. Actuarially Sound Rate. DHH contracted with a leading national actuary with Medicaid expertise to establish actuarially sound rates for Health Plans. Our rates are realistic and sufficient to assure access and provider participation. Rates will be reviewed annually and adjusted upward or downward to assure Health Plans are not being paid "too much" or "too little"
- 10. Single System for Complaint Tracking. Our Enrollment Broker contract includes a requirement to develop and maintain a web-based application that will be used to record, track and analyze complaints related to BAYOU HEALTH in a single location.
- 11. Dual Models. Louisiana has not shown preference for either the MCO (prepaid) or PCCM (shared savings) model of managed care as both models are being implemented simultaneously with the benefit of first market entry in all 64 parishes. Providers and Medicaid/LaCHIP recipients have a choice of health plan models. This is unprecedented and for the first time provides the opportunity to truly compare costs and outcomes within the two models.
- 12. Medicaid Administrative Realignment. Louisiana Civil Service has signed off on a complete reorganization of our Medicaid staff to provide the necessary ongoing monitoring of the Health Plans, assess outcomes, organize data for public reporting and recommend modifications to the program if necessary. This is critical, as we have refocused our entire staff to manage and monitor BAYOU HEALTH while still providing core services under the remaining fee-for-service program.
Transparency. DHH will voluntarily publish and share BAYOU HEALTH metrics in ways that no other state has done. The list of all the reports is extensive.
DHH schedules BAYOU HEALTH provider Q & A calls
The Department of Health & Hospitals will host a series of conference calls Monday, Dec. 19, Tuesday, Dec. 20 and Wednesday, Dec. 21, to answer provider questions about the implementation of BAYOU HEALTH. Medicaid staff directly involved in the development of BAYOU HEALTH will be on the call to answer your questions. A brief introduction and update of the implementation will be provided by Medicaid staff, but the bulk of the conference call will be devoted to provider questions and answers.
DHH is asking that providers call in based on provider type, as noted below, to accommodate the limited number of call-in lines and ensure the most efficient use of call time. The conference call schedule is as follows:
- Monday, Dec. 19, Noon to 1 p.m. - Hospitals (Statewide)
- Tuesday, Dec. 20, Noon to 1 p.m. - Physicians (Statewide)
- Wednesday, Dec. 21, Noon to 1 p.m. - Other Providers (Statewide)
If you are unable to participate on your assigned date, you may call in on another date. The call-in information is as follows:
- Call-in line - #1-888-278-0296
- Access Code - #7299088
To participate in a conference call please register by close of business, Friday, Dec. 16. During the registration you will have the opportunity to submit questions you would like answered during the conference call.
Systems issues are also addressed in DHH's recently released 834 Companion Guide, which addresses the file exchange requirements of the Enrollment Broker (Maximus) in conjunction with the CCNs, DHH and the DHH Fiscal Intermediary (Molina).
Plan Comparison Chart Posted
The official BAYOU HEALTH Enrollment website has been launched with many great features to help Medicaid and LaCHIP enrollees choose a health plan for themselves and their families.
One key feature that many people have been looking forward to seeing is the Health Plan Comparison Chart.
If you have questions about Coordinated Care Networks, contact DHH's Coordinated Care Network staff at firstname.lastname@example.org. Learn more at MakingMedicaidBetter.com.