HEALTH PLAN COLLABORATION IMPROVES QUALITY OF SERVICES FOR MEDICAID ENROLLEES

By Alison L. Croke, M.H.A. and Margaret L. Oehlmann, M.P.H., Center for Health Care Strategies, January 24, 2002

Center for
Health Care Strategies, Inc.

Managed Care Best Practices Series

Health Plan Collaboration Improves Quality of Services for Medicaid Enrollees

By Alison L. Croke, M.H.A. and
Margaret L. Oehlmann, M.P.H.,
Center for Health Care Strategies

Table of Contents

Introduction 2
Best Clinical and Administrative Practices Workgroups: A Collaborative Model 4
The Collaborative Approach: Why it Works 5
A Typology for Improvement 6
Identification 6
Stratification 6
Outreach 7
Intervention 7
Process Improvement: Measuring for Success 8
Case Studies from Participating Health Plans 11
Harmony Health Plan of Illinois: A Multi-Faceted Identification Approach 11
Neighborhood Health Plan: Encouraging Adolescents to Seek Preventive Care 12
Building a Quality Network for Medicaid Plans 14
For More Information 15








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Introduction

Medicaid health plans -- approximately 330 across the United States -- share similar enrollee populations, similar challenges in working with state counterparts, and similar obstacles in dealing with the unique complexities of an often transient, high-risk population. Yet, plans typically operate within silos, with little opportunity to learn from each other.
In response to the challenges faced by Medicaid health plans, the Center for Health Care Strategies (CHCS) developed the Best Clinical and Administrative Practices (BCAP) project to provide health plans serving Medicaid and State Children's Health Insurance Program (SCHIP) beneficiaries with a forum to share best practices and test new quality initiatives. BCAP is funded through The Robert Wood Johnson Foundation's Medicaid Managed Care Program.
To shape the BCAP initiative, CHCS interviewed medical directors from Medicaid health plans across the country to determine their clinical and administrative priorities. Common themes emerged around quality initiatives for high-risk pregnancy, immunizations, asthma, and special needs populations.
These interviews confirmed the major challenges facing Medicaid health plans:
· Medicaid recipients are more likely than commercial or Medicare recipients to lack reliable mailing addresses and telephone numbers, as well as a primary care provider, thus making standard communication challenging.
· There is significant variation across states in regulatory requirements.
· Many health plans serving low-income populations find that existing national forums have not addressed important Medicaid issues adequately or consistently.
· Competitive issues make it difficult to share information with other health plans in the same region, compounding the sense that each health plan is isolated in addressing barriers to serving Medicaid and SCHIP enrollees.

This white paper outlines how BCAP is convening Medicaid health plans to collaboratively identify and pilot best practices for targeted populations covered under Medicaid and the State Children's Health Insurance Program. Case studies of two plans participating in workgroups for improving birth outcomes and pediatric preventive services are highlighted.

About the Center for Health Care StrategiesThe Center for Health Care Strategies (CHCS) is a non-profit resource center that promotes high quality health care services for low-income populations and people with chronic illnesses and disabilities. CHCS works with states, health plans, and consumer organizations through its Medicaid Managed Care Program to promote quality improvement in publicly financed managed care. The program is funded through a grant from The Robert Wood Johnson Foundation.









BCAP Workgroups: A Collaborative Model
The BCAP initiative convenes workgroups of up to 15 health plans to develop and pilot best practices for their enrollee populations. Each workgroup focuses on a defined topic, including birth outcomes, pediatric preventive care, asthma, and adults and children with special needs. Table 1 lists the health plans that participated in the Toward Improving Birth Outcomes and Improving Preventive Care Services for Children workgroups.
Each BCAP workgroup meets three to four times over one year. The first meeting gathers medical directors to review current research, share successes and challenges in improving outcomes for Medicaid beneficiaries, and brainstorm ideas for improvement initiatives. Each plan commits to piloting a series of small-scale quality improvement projects, examples of which are highlighted in the case study section of this article. Conference calls between meetings provide workgroup members with technical assistance from CHCS staff and consultants.

Table 1: Health Plans Participating in BCAP Workgroups
Toward Improving Birth Outcomes Improving Preventive Care Services for Children
Affinity Health Plan, New York City AlohaCare of Hawaii
Arkansas Foundation for Medical Care Americaid Community Care, Chicago, IL
CareSource, Dayton, Ohio AmeriChoice of Pennsylvania
Colorado Access, Denver, Colorado Blue Cross of California
Coventry Health Care of Delaware Community Health Network of Connecticut
Harmony Health Plan of Illinois Neighborhood Health Plan of Massachusetts
Health Partners of Philadelphia Neighborhood Health Plan of Rhode Island
LA Care Health Plan, Los Angeles, California The Wellness Plan, Detroit, MI
Neighborhood Health Plan of Massachusetts
Monroe Plan for Medical Care, Rochester, NY
Sentara Healthcare, Virginia Beach, VA
Additional staff members attend the remaining meetings to work on the pilots for a team approach. Plans with similar pilot project initiatives work together to discuss common barriers and share strategies for overcoming these barriers.
Plans in the workgroup commit to continue their pilots and collect process and outcome measures for an additional 12 months after the last workgroup meeting. During this second phase of the workgroup, CHCS conducts quarterly conference calls with the workgroup plans and provides technical assistance to individual plans as needed.

The Collaborative Approach: Why it Works
There are several factors that contribute to open discussion and information sharing in BCAP. Workgroup participants are invested in both clinical quality improvement and improving public health and come to BCAP willing to share successes and challenges. Health plans that join BCAP workgroups generally are not from the same market and/or geographic area. Finally, guests from state and federal entities are only invited to attend meetings based on prior approval from workgroup members. The collaborative model for disseminating best practices works because medical directors are able to share ideas, challenges, and strategies for improvement with peers who are equally committed to delivering quality health care to the Medicaid population.
In evaluating the BCAP experience, participants cited many reasons their participation in BCAP was valued. These include:
· The opportunity to network and discuss issues with professional peers.
· The use of reliable measurement techniques to guide plan improvement efforts.
· The structure of a consistent, transferable framework to focus quality improvement projects.

A Typology for Improvement
To facilitate discussion among medical directors from health plans with varying structures (e.g., Medicaid-only vs. commercially-based, for profit vs. non-profit) CHCS developed a four-step process improvement model to unify health plans' experiences in approaching quality improvement activities. The “Typology for Improvement” classifies health plan quality activities within a common framework. The steps -- Identification, Stratification, Outreach, and Intervention -- are described below.

Identification
What method does a health plan use to identify members with a specific medical condition? Claims data, lab data, pharmacy data, health risk assessments, and member welcome call reports are all common sources of identification information on which health plans rely.

Stratification
Once a member has been identified, how does the health plan assign risk levels and determine where to most appropriately target its limited resources? A common method of stratification is the use of claims data showing high utilization. While claims data tends to be readily available, health risk assessments, given upon enrollment by an enrollment broker or member services staff, or submitted by providers, can be used to better identify specific conditions (e.g., asthma, diabetes, pregnancy) or specific risk factors (e.g., smoking, chemical dependency, homelessness), and provide more clinical detail. This stratification process and analysis of risk factors helps health plans determine which risk factors to target with outreach and intervention.

Outreach
Once the target population has been identified and stratified for risk factors, the health plan needs to determine the best way to contact these members. Standard health plan outreach methods, such as mailings, outbound calls and community health fairs, may only reach a small subset of the target population. If the target population has complex needs or is historically non-compliant, creative outreach strategies will need to be implemented.

Intervention
After a member has been identified, assessed for risk factors, located, and approached about receiving services, what are the most appropriate services or interventions to offer the member? In some clinical areas (e.g., asthma or immunizations), this is an easier question to answer than others (e.g., high-risk pregnancy with multiple co-morbidities). Under BCAP, workgroup members brainstorm about clinically appropriate interventions, and then discuss creative ways to address the barriers to providing these interventions to Medicaid and other low-income enrollees.
This typology helps plans position themselves to address the significant disparities in important clinical outcomes between the Medicaid and commercial populations (e.g., low birth weight rate in commercial managed care in New York state is 4.6 percent, while in Medicaid it is 9.0 percent).
BCAP participants have uniformly found this typology helpful for designing care improvements. A number of plans have designed subsequent (non-BCAP) efforts in their organizations using the framework of this typology.

Process Improvement: Measuring for Success
Sustained improvement requires fundamental change in the care-delivery system. Plans are encouraged to test changes within the four areas of the typology for long-term viability using a structured model for improvement. Such a model provides guidance and focus for health plans implementing change. It also creates a common language and approach that facilitates communication and shared learning within the health plan.
The Model for Improvement used by BCAP participants defines aims, measures, and changes. Aim statements set goals that are realistic, but also mark meaningful improvement. They should be measurable and quantifiable. Measures link directly to aims, and document progress on a regular basis. Measures provide short-term feedback as to which process changes are working, and which need to be revised. Changes specify the strategies being tested to reach the stated aims.

Applying the Model for Improvement to Health Plan InnovationAim: Improve risk stratification of pregnant members by 30 percent.Measure: = number of pregnant women who receive a risk assessment total number of women identified as pregnant by the planChanges to try:· Standardize health risk assessment tools across health plan departments.· Revise health plan’s main voicemail to include the greeting, “press one if you are pregnant.” Members who “press one” are routed to a pregnancy case management unit where the health risk assessment is performed over the phone.· Reevaluate provider incentives for completing and returning the health risk assessment form. · Work with other health plans in the area to develop a common health risk assessment form.

Health plans participating in each BCAP workgroup also collect a set of “shared” measures to reflect the progress of the initiative on a broader scale. Shared measures provide a common metric for health plans in each BCAP workgroup to track progress. Shared measures are not intended for comparisons of health plan performance, but rather to highlight improvement trends. Examples of shared measures from both the Toward Improving Birth Outcomes and Improving Preventive Care Services for Children workgroups are highlighted in Table 2. Each workgroup included certain HEDIS measures as part of their shared measures.


Table 2. Examples of Shared Measures from BCAP Workgroups
Toward Improving Birth Outcomes
Measure Formula
Health Risk Assessment Rate # of completed Health Risk Assessments# of women identified as pregnant
Contact Rate # of women contacted# of women for whom contact was attempted
Low Birth Weight Rate All live births below 2500 gramsAll live births in the plan
Maternity Bed Days Per 1,000 deliveries.
Check-Ups After Delivery (HEDIS) The percentage of enrolled women who delivered (a) live birth(s) during the measurement year who were continuously enrolled 56 days after delivery, with no breaks in enrollment, who had a postpartum visit on or between 21 days and 56 days after delivery.
Improving Preventive Care Services for Children
Measure Formula
Missed Opportunity Rate # of immunizations given# of visits in a given practice
Outreach Response Rate # of responses to an outreach activity # of outreach attempts
Adolescent Well-Care Visits (HEDIS) The percentage of enrolled members who were age 12 through 21 years during the measurement year, who were continuously enrolled during the measurement year, and who have had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.
Well-Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life (HEDIS) The percentage of members who were three, four, five, six years old during the measurement year, who were continuously enrolled during the measurement year, and who received one or more well-child visits with a primary care practitioner during the measurement year.



Case Studies from Participating Health Plans
Harmony Health Plan of Illinois: A Multi-Faceted Identification Approach to Improve Birth Outcomes

Harmony Health Plan, a non-profit plan based in Northeast Illinois with 40,000 Medicaid members, found that while its providers knew which members were pregnant, this information was either not shared with the health plan or the plan did not have a systematic way of evaluating sources of identification. Harmony’s aim was to increase identification by 25 percent over its current rate. The plan measured this change using the following formula:
# of pregnant women known to the plan prior to delivery
# of pregnancy delivery claims

In order to accomplish its goal, Harmony conducted the following activities:
1. Analyzed state’s claims data tapes for pregnancy codes â€" Identified members who either self-reported or reported pregnancy through their physician by supplying their “estimated date of confinement.”
2. Offered provider incentives â€" Offered a monetary incentive of $25 to office managers to complete obstetrical risk assessment forms.
3. Analyzed pharmacy data - Identified prenatal vitamin prescriptions and compared this list to women known to be pregnant through other sources. Those not known to be pregnant previously were contacted by telephone.
Through the changes implemented under BCAP, Harmony increased its identification rate from three percent in July 2000 to 76 percent in June 2001. (See Figure 1.)


Figure 1: Harmony Health Plan - Identification Success Over One Year



Neighborhood Health Plan of Rhode Island: Encouraging Adolescents to Seek Preventive Care

Neighborhood Health Plan of Rhode Island (NHPRI) is a network model health plan serving primarily Medicaid beneficiaries throughout the state of Rhode Island. The plan's current Medicaid membership is close to 70,000 enrollees. NHPRI participated in the Improving Preventive Care Services for Children workgroup. The health plan conducted a school-based health center (SBHC) initiative with enrollees whose medical home was at Thundermist Health Associates (THA), the local community health center in Woonsocket, Rhode Island. NHPRI’s goal was to reach 100 percent of all 13-16 year old plan members who were not enrolled in a SBHC. Subsequently, the plan wanted to increase enrollment in the SBHC by 50 percent and increase the number of 13-16 year olds receiving complete physical exams (CPE) by 50 percent (those previously enrolled and newly enrolled).
NHPRI mailed a letter to all students who were both enrolled in the SBHC and had not received a CPE and a letter to those students who were not enrolled in the SBHC. These letters offered students a gift incentive (music/movie store or pizza gift certificate) to enroll in the SBHC and/or receive a physical exam.
The plan measured success of both its outreach attempts and its efforts to increase the number of CPEs using the formulas in Table 3.

Table 3: Formulas to Measure Outreach to Adolescents
Outreach Effort Measurement Formula
Mailing to home address with incentive to enroll and have a complete physical. # of students who enroll and have a complete physical exam (CPE)# of mailings
Mailing to home address with incentive for having a complete physical exam. # of students coming in for a CPE# of mailings
Invite NHPRI/THA members to enroll in their SBHC. # of 13-16 year old NHPRI/THA members enrolled in a SBHCtotal # of 13-16 year olds in the project area
Schedule and see NHPRI/THA members who want to come into the SBHC for a physical. # of NHPRI/THA members (13-16) enrolled in SBHC who receive CPEtotal # of NHP/THA members enrolled in SBHC

The results as of June 2001 were:
1. Eighty percent of enrolled students received a complete physical examination.
2. The number of students newly enrolled in the SBHC increased by 24 percent.
3. The total number of students having a CPE increased by 40 percent â€" from 11 percent to 51 percent.
NHPRI plans to expand this pilot project to other school-based health centers around the state.

Building a Quality Network for Medicaid Plans
CHCS’ Best Clinical and Administrative Practices initiative is building a network of Medicaid health plans across the country. As of January 2002, CHCS has four BCAP workgroups actively collaborating on improving birth outcomes, pediatric preventive services, asthma care, and care for children with special needs. These four workgroups represent 37 health plans and more than 4.8 million Medicaid enrollees. BCAP is currently recruiting plans for a fifth workgroup, focusing on adults with disabilities and chronic illnesses, which will start meeting in May 2002.
After each workgroup concludes, CHCS hosts a workshop for additional Medicaid health plans to disseminate the best practices developed and lessons learned by the workgroup. These workshops are open to up to 30 health plans. The first workshop on Toward Improving Birth Outcomes was in October 2001 in San Antonio, Texas. Participants will receive follow-up technical assistance from CHCS.
The second workshop, Improving Preventive Care Services for Children, will be held March 6-8, 2002 in Scottsdale, Arizona. Participating plans will learn quality improvement strategies to improve the quality of pediatric and adolescent preventive care and will leave the workshop armed with a personalized action plan.
For each BCAP workgroup, CHCS also publishes a best practice toolkit available to Medicaid plans nationally. This practical toolkit offers step-by-step instructions on adopting health plan best practices, including detailed case studies.
A BCAP Quality Summit is planned for October 2002 to highlight the accomplishments of health plans from each workgroup and further engage health plans in a broader discussion of quality improvement beyond specific clinical topics. Additional resources include Network Exchange Conference Calls facilitated by experts in the field; an online Resource Center on Best Clinical and Administrative Practices (www.chcs.org); and Best Practices Grants of up to $100,000 for Medicaid health plans seeking to develop, test, or refine “best practice” programs.
We have learned from the BCAP initiative that collaborations among Medicaid health plans provide a strong stimulus for success. Not only are innovative best practices in the delivery of care to low-income Medicaid beneficiaries being achieved, but a sense of community and collaboration has been created for health plans that are now part of a larger network to improve health care for low-income populations.

For More Information
Visit www.chcs.org, for more information about the Best Clinical and Administrative Practices, and/or to register for the next BCAP workshop for Medicaid plans, Improving Preventive Care Services for Children.