Basic Health Plan: Part 1 Preliminary Report Joint Legislative Audit and Review Committee Cynthia L. Forland Lisa Jeremiah November 30, 2005

Basic Health Plan: Part 12 Two-Part Study Mandated by Operating Budget Part 1: To what extent do BHP policies and procedures promote or discourage the provision of appropriate, high-quality, cost- effective care? Part 2: What are the characteristics of individuals enrolled in BHP, and how are they utilizing services?

Report pages 21-22Basic Health Plan: Part 13 Presentation Outline Background Statutory and Contract Provisions Monitoring and Measuring Performance of Health Plans Other States Findings and Recommendations

Report pages 1 and 3Basic Health Plan: Part 14 BHP to Make Health Care Services Available for Low-Income Residents Established as a demonstration project in two counties in 1987 Expanded statewide and merged with the Health Care Authority in 1993 $500 million for benefits and $16 million for administrative costs for

Report pages 1 and 3Basic Health Plan: Part 15 Enrollment in Basic Health Plan Eligibility: –Resident of Washington State –Not eligible for Medicare –Gross family income at or below 200% of the federal poverty level Average monthly enrollment of 102,400 for 2005 Served by 5 health plans

Report pages 3-5Basic Health Plan: Part 16 Health Care Authority Responsible for Administering Basic Health Plan Define covered basic health care services Establish enrollee premiums and cost- sharing Contract with health plans Monitor services provided by health plans

Basic Health Plan: Part 17 Key Findings HCA-wide strategic planning and medical direction exist, but there is a lack of focus on Basic Health Plan HCA requires quality health care, but provides limited specific guidelines and unclear expectations to health plans Monitoring processes are in place, but they are insufficient to ensure quality health care

Basic Health Plan: Part 18 Study Questions Does Basic Health Plan promote: –Appropriate, high-quality, cost-effective care? –Evidence-based treatment strategies? –Use of high-quality providers? –Treatment of chronic care and other high-cost conditions? –Use of preventive services? –Innovative health care service delivery methods?

Report pages 11-12Basic Health Plan: Part 19 How Is BHP Promoting Appropriate, High-Quality, Cost-Effective Care? Statute: –HCA must assure access to good quality basic health care Contract: –Health plans must have plan to improve quality, care delivery, satisfaction scores, and other standard measures But: –Limited specific guidance –Most terms not defined

Report page 13Basic Health Plan: Part 110 How Is BHP Promoting Evidence- Based Strategies? Statute: –HCA must base policies on best available scientific and medical evidence Contract: –Health plans must have a system to incorporate evidence-based medicine But: –Limited specific guidance –Most terms not defined

Report pages 13-14Basic Health Plan: Part 111 How Does BHP Encourage Use of High-Quality Providers? Statute: –Not specifically addressed Contract: –Health plans must have an adequate network of providers who deliver high-quality health care services –Health plans provided guidance on initial and ongoing assessment of providers

Report page 15-16Basic Health Plan: Part 112 How Does BHP Approach Chronic Conditions? Statute: –HCA must explore disease management strategies Contract: –Health plans must report top-five chronic conditions –Health plans must have disease management programs for two chronic conditions But: –Limited guidance leads to inconsistent reporting –No link between top-five chronic conditions and disease management programs

Report page 16Basic Health Plan: Part 113 How Does BHP Encourage Use of Preventive Services? Statute: –HCA must develop program of proven preventive health measures Contract: –Health plans must provide care recommended by U.S. Preventive Services Task Force guidelines –Health plans can not charge co-payments for preventive care

Report pages 16-17Basic Health Plan: Part 114 How Does BHP Use Innovative Health Care Service Delivery Methods? Statute: –Not specifically addressed –Outside of scope and intent of the program Contract: –Health plans are not required to use innovative health care service delivery methods

Report pages 4-6Basic Health Plan: Part 115 HCA’s Monitoring of Health Plans Reviews based on Quality Improvement Standards –Focus is process and plans to ensure quality, not the actual quality of care –Interagency contract review team conducts annual reviews Limited use of health care service utilization data

Report pages 5-7Basic Health Plan: Part 116 Performance Measures Do Not Focus on Health Care Performance measures focus on administrative functions: –Example: How quickly health plans issue identification cards to enrollees –Example: What percent of customer service calls HCA answers within 5 minutes

Report pages 19-20Basic Health Plan: Part 117 Other States Provide Examples for Better Ensuring Quality Health Care Massachusetts: Aligning quality improvement goals with evidence-based practice guidelines Wisconsin: Comparing health-related performance across programs and health plans Oregon: Guiding and monitoring care through contracts

Report pages 21-22Basic Health Plan: Part 118 Finding: Lack of Coordination and Planning for BHP No strategic plan focused on the BHP No strong integration of administrative and medical operations Recommendation: HCA should develop goals and objectives for BHP focused on: –Assuring quality –Using evidence-based treatment –Exploring chronic disease management

Report pages 21 and 23Basic Health Plan: Part 119 Finding: Unclear Expectations and Limited Guidelines Terms not defined and guidance is limited Focus on process, not results –Quality Improvement Standards –Performance measures Recommendation: HCA should develop specific guidelines and performance requirements for contracts with health plans

Report pages 22-23Basic Health Plan: Part 120 Finding: Insufficient Monitoring for Quality Limited quality assessments Limited use of health care service utilization data Recommendation: HCA should improve its system of monitoring health plans –Application of quality assessment tools –Analysis and use of service utilization data –Analysis of health-related performance measures