Plugging The Quality Holes in Medicaid: Quality Measurement in PA as it applies

to Managed Care

Carol SmolijVice President, Quality, Healthcare ManagementHealth Partners of Philadelphia

Association for Community Affiliated Plans

About Health Partners

Now in our 25th year, Health Partners continues to be a community force, helping historically underserved residents lead healthier lives through equal access to care. We are a not-for-profit health plan owned by seven hospitals that provides healthcare coverage to residents of the five counties of Southeastern Pennsylvania (including Philadelphia). Our plan has been recognized as a national model for Medicaid managed care.

•Albert Einstein Medical Center

•Aria Health

•Episcopal Hospital

•Hahnemann University Hospital

•Hospital of the University of Pennsylvania

•St. Christopher’s Hospital for Children

•Temple University Hospital

Owner Hospitals

Our Mission• To manage our

business to exceed expectations.

• To operate with respect and dignity in all relationships.

• To continually improve the health outcomes of our Members.

Making a Difference Every Day

• More than 450 employees

• More than 150,000 members

• Ranked #1 in member satisfaction in our market for six years

•Churning Effect

•Member Centric Barriers

•Reporting Inequity

•Continuous Enrollment

Challenges

•HEDIS

•Monthly YTD

•Member Level Detail

•Quarterly Focused Rates

•State Specific Measures

Current PA MCO Quality Reporting

•Diabetes

•Pregnancy

•Hypertension

•Lead / EPSDT

PA Focused Areas

•BMI

•Pregnancy - Depression

•Pregnancy – Smoking / ETS

•High Lead Levels - referral

PA EQR Measures

•Improved Care Across Delivery Systems

•Same to same measures

•Analysis of membership

•Study of demographics

Quality Measurement in PA

•Continued – Improved Care Across Delivery Systems

•Identification of commonalities statewide – i.e. dental care

•Convergence of ideas

•Shared decision making

•Quarterly meetings / shared agenda items

Quality Measurement in PA

•Comparison

•Changes over time

•Collaboration

Access Plus (FFS) & Primary Care Case Management (PCCM)

•Data Sharing

•Member Transfers

•Plan Collaboration

•Reporting Equity

•Better Benchmarking

Looking Ahead

•Medicaid Accreditation Advisory Committee (MAAC)

•Medicaid Health Plans of America (MHPA)

•Reporting differences between Commercial & Medicaid

•Negative Impact of Enrollment Churn

•Role of States in Determining COC

NCQA MAAC

Questions

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Thank you!