perinatal services in medi-cal managed care: strategies to better serve our members 11/5/14...
TRANSCRIPT
Perinatal services in Medi-Cal Managed Care: strategies to better serve our members
11/5/14 Perinatal Services Coordinator Annual Meeting
Maternal, Child and Adolescent Health (MCAH) Branch
California Department of Public Health
Sarah Royce, MD, MPH, Chief, Medical Policy Section
Medi-Cal Managed Care Division, DHCS
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– Medi-Cal Managed Care Plans• Models• Requirements for obstetric care
– How are Plans doing in assuring women have timely prenatal and postpartum care?
– What we need to do to close the performance gaps?
• Medi-Cal Managed Care Quality Strategy, 2014-5
Overview
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• Commercial + local initiative 12 Plans in 14 counties
• Two commercial Plans– 3 Plans in 19 counties
• County organized health system (COHS)– Single Plan in each county– 6 Plans in 22 counties
• Geographic managed care– 6 commercial plans in
Sacramento and San Diego
• San Benito– Single commercial plan (only
county where enrollment optional)
Medi-Cal managed care models
http://www.dhcs.ca.gov/individuals/Pages/MMCDHealthPlanDir.aspx
Hatch marks show2013 expansion
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• cover and ensure provision of all medically necessary services for pregnant women
• ensure that ACOG guidelines are used• implement a risk assessment tool that is
– comparable to ACOG, CPSP standards, including: medical, OB, nutritional, psychosocial, health education
– administered at initial prenatal visit, once each trimester, and at postpartum visit
• Develop individualized care plans• Follow up identified risks with
appropriate interventions
DHCS contracts require Plans to
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• Apply provider credentialing standards to all prenatal care providers. Ensure they are – trained on standards of providing
comprehensive perinatal services per ACOG standards
– Demonstrate professional
competence• Execute an MOU (or subcontract)
for services provided by local
health department MCAH programs
DHCS contracts require Plans to:
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• Plans review medical records of primary care providers (including obstetrics)– When OB joins network and every 3 years – Chart review tool– Results reported to DHCS every 6 months
• Two perinatal performance measures included in set that Plans report each year
– Validated by external quality review organization– DHCS contracts require Plans to perform at least as
well as the lowest 25% of Medicaid plans in the US (Minimum Performance Level, MPL)
Oversight of obstetric care
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Prenatal and postpartum caremeasures• Healthy mother• Healthy birth, newborn
~82,000 women in Medi-Cal managed care denominator in 2013 because they:• had a live birth, and • enrolled continuously in same Plan from 43 days prior through 56 days after delivery
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83.8%81.4%
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Served in 2013
Left to do**
81% of women who gave birth had had timely prenatal care*
15,000 pregnant women without timely prenatal care
* no improvement compared to 2012** among 6 million members as of 12/2013
Our task at hand
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Timely postpartum visit
• Preconception health• Family planning• Breastfeeding• Depression screening
• Follow-up of conditions Example: diabetes in 11.9% of women with live births in 2012*• Preconception diabetes in 3.9%• Gestational diabetes in 8%
*DHCS FPACT/UCSF analysis of encounter data in DHCS data warehouse (reported by Plans)
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Statistically significant decline in Medi-Cal average, 2011-13 (4000 fewer women with timely postpartum care)
61.7%
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• Disparities– Significantly lower proportion of Black mothers had timely
postpartum care than other race-ethnic groups– For ensuring timely postpartum visits among Black
mothers, the Plans with the best success had double the postpartum visit rates compared to the lowest performing Plans*
• For all women, Plans report it is difficult to:– Promptly identify women who recently gave birth, needed
for outreach efforts– Collect visit info from providers using global billing or
capitation*among Plan-counties with > 200 Black women who gave birth in 2012
Challenges in timely postpartum care
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5% improvement in timely post partum care– Statewide Medi-Cal average– # Plan-counties > minimum performance level– Black women who gave birth
Re-visit statewide targets in light of:– Plan-specific commitments– Effort DHCS, Plans, partners
can mobilize– What is ambitious yet feasible
Preliminary targets: Medi-Cal Managed Care Quality Strategy, 2014-5
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1. Speed up, intensify DHCS response – Rapid cycle quality improvement (QI)
2. QI Learning Collaborative
Postpartum subgroup – Understand, address causes of
low performance– Optimize provider education,
feedback, incentives– Optimize member engagement
3. Improve data quality and use
4. Enhance collaboration
DHCS interventions
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Share resources, improve the community systems of care by:
• Providing Plans a cross walk of available MCAH programs so they can refer members
• Provide to Plans CDPH training opportunities and materials for managed care providers and mothers
• Promote partnerships between Plans and local MCH programs via MOUs or other mechanisms
Collaboration with CDPH/MCAH