1. Driving Quality Improvement in Medicaid Managed Care
Marc Leib, M.D., J.D.
Chief Medical Officer
Arizona Health Care Cost Containment System
June 15, 2007

2. AHCCCS ABCs
Arizona was the last state in the country to adopt Medicaid--began in 1982
Essentially 100% Medicaid Managed Care
Only Native Americans and individuals covered under the Federal Emergency Services Program (FESP) in fee-for-service
Long term care members in managed care

3. AHCCCS ABCs (cont) AHCCCS has over 1 million members
~950,000 are in Managed Care Organizations (MCOs)
AHCCCS contracts with 8 acute care health plans, 8 long term care plans and 3 specialty plans (BHS,CRS and DDD)
AZ is the only state with all long term care members in MCOs

4. AHCCCS Successes
AHCCCS has lowest pmpm cost for drugs and third lowest overall costs among all programs
Does not participate in Drug Rebate Program
Open formulary at State level
No limits on the number of prescriptions
Mandatory generic use, when available
MCOs may require step therapy
Brand name drugs provided whenever needed

5. BUT, . . .
Can managed care drive quality improvement in Medicaid while running a cost-effective program?
Yes—when quality is of primary importance, not an afterthought

6. Quality Improvement Activities
Performance Measures (PMs)
Performance Improvement Projects (PIPs)
Contractual Obligations
MCO competition
Annual EQRO Report of Each Contractor
Public-Private Partnerships with Commercial/Other Health Insurers

7. Performance Measures
Determine baseline rate from encounter and/or claims data
Establish Minimum Performance Standards (MPS), Benchmarks and Goals
MPS based on historical data with percentage improvements expected
Benchmarks based on national reported data, such as public health goals (National Immunization Survey, NCQA HEDIS published data, etc.)

8. Performance Measures (cont.)
Goals based on Healthy People 2010 or other sources
MPS, Benchmarks and Goals included in MCO contracts including technical specifications (methodology)
Periodically evaluate new PMs, discuss with MCOs and add to contract

9. Performance Improvement Projects
Plans undertake two PIPs per year:
AHCCCS mandated
Self-selected
Four year projects (minimum)
Year 1—baseline measurements
Year 2—institute measures intended to improve outcomes
Year 3—demonstrate initial improvement
Year 4—demonstrate sustained improvement

10. PMs and PIPs May Be Integrated: Immunization Targets
Establish PMs: MPS, Benchmarks and Goals for vaccination rates
Develop and mandate use of State Immunization Registry—electronic data base accessible to MCOs, providers and state regulators
Share AHCCCS data with Registry
Establish a PIP: Require MCOs to increase provider reporting to registry
Identify provider non-reporters and encourage MCO intervention (partner with medical societies such as ArMA and AAP)

11. Contract Requirements
PMs and PIPs are contractually required
Failure to attain PM MPS may result in penalties--Corrective Action Plans (CAPs), Monetary Penalties or Closed Enrollment
Although never implemented, could result in contract termination

12. MCO Competition
“Friendly” competition among MCOs fosters increased quality improvement
PM and PIP results shared among MCOs
External Quality Review Organization (EQRO) reports shared and posted on public website
Plan CEOs and Medical Directors strive to be “best” among all plans

13. Monitoring Managed Care Organizations
Monitor provider network
Operational and financial reviews (OFRs)
Education and technical assistance
Corrective action plans, notice to cure, sanctions (financial and enrollment limits)
Monitor MCO QA and Peer Review actions
Annual EQRO reports assess MCOs

14. Public-Private Partnerships
AHCCCS and its Contractors occasionally partner with Medicare or commercial plans
Example: Partnered with commercial plans to improve asthma medication prescribing patterns of providers
Results: Significant improvement in ratio of maintenance meds to rescue meds
Results noted across all plans

15. Partnering With MCOs
Provide incentives for Contractors/providers to continually improve quality of care
Support collaborative processes between Contractors, the medical community and members
Establish benchmarks that will lead to continued quality improvement in health care
Monitor Contractors to establish standards

16. Medicaid Managed Care
Ultimately, the goal of the AHCCCS managed care program is to provide each patient:
The right care,
At the right time
Every time

17. QUESTIONS?

18. Marc Leib, M.D. (602) 417-4240 Marc.Leib@azahcccs.gov
THANK YOU
Marc Leib, M.D.
(602)