1. HRSA HIV/AIDS Bureau1 HIV/AIDS BUREAU HEALTH RESOURCES AND SERVICES ADMINISTRATION FUNDAMENTALS OF MANAGED CARE

2. HRSA HIV/AIDS Bureau2 FUNDAMENTALS OF MANAGED CARE 1. Managed Care Elements 2. Organizational Models 3. Continuum of Managed Care 4. Functions of MCOs 5. Collaborative Organizations 6. Utilization and Quality Management 7. Information Requirements

3. HRSA HIV/AIDS Bureau3 HMOS PPO PHO ISN IPA TPA POS PCCM IDS IPO THE ALPHABET SOUP OF MANAGED CARE SSO MCO MCP MCE

4. HRSA HIV/AIDS Bureau4 MANAGED CARE ELEMENTS  Combines financing and delivery systems  Patients are enrolled in a managed care plan on a prepaid basis with a defined benefit package that includes preventive and primary care services  Patients select (or assigned) a primary care provider (PCP) who acts as a gatekeeper to coordinate specialty and hospital care  Utilization and clinical practice are reviewed to contain costs while improving health status  Providers typically paid on a capitation basis but can be paid fee-for-service (FFS )

5. HRSA HIV/AIDS Bureau5 ORGANIZATIONAL PERSPECTIVE State (or employer) Managed Care Organization (MCO) Managed Care Organization (MCO) Inpatient Providers Inpatient Providers Primary Care Providers Primary Care Providers Specialty/Other Providers Specialty/Other Providers Premium $$$$ $$$ $$$$ State (or employer) Managed Care Organization (MCO) Managed Care Organization (MCO) Inpatient Providers Inpatient Providers Primary Care Providers Primary Care Providers Specialty/Other Providers Specialty/Other Providers

6. HRSA HIV/AIDS Bureau6 Fee for ServiceCapitated More Freedom of ChoiceLess Choice More ExpensiveLess Expensive INDEMNITY HMOS Traditional Managed PPO POS IPA/Network Group Staff THE CONTINUUM OF MANAGED CARE

7. HRSA HIV/AIDS Bureau7 HMO MODELS  STAFF Physicians are employees of the HMO  GROUP Physicians are members of a multi-specialty or single specialty group practice which in turn contracts with the HMO  IPA Either the individual physician contracts directly with the HMO or the individual physician is part of a physician corporation which contracts with the HMO  NETWORK The HMO contracts with group practices, IPA- physician corporations and/or individual physicians

8. HRSA HIV/AIDS Bureau8 OTHER MANAGED CARE MODELS  POINT OF SERVICE (POS)  HMO offers members option to receive services from non- network providers at a reduced level of coverage  PREFERRED PROVIDER ORGANIZATION (PPO)  A system which contracts with providers at discounted fees  Members may seek care from non-participating providers but at higher copays or deductibles  MANAGED INDEMNITY  Fee for service insurance plan  Members receive services from any provider with some restrictions on utilization and cost e.g. pre-authorization; maximum fee schedule

9. HRSA HIV/AIDS Bureau9 FUNCTIONS OF MCOs  MARKETING  Private (small, large, federal groups), Individual, Medicaid, Medicare  MEMBERSHIP ACCOUNTING  Group billing and contracts  Enrollment & disenrollment; pcp assignment  NETWORK OPERATIONS  Provider credentialing and contracting, provider services  MEMBERSHIP SERVICES  Inquiries, education, grievances

10. HRSA HIV/AIDS Bureau10 FUNCTIONS CONTINUED  CLAIMS ADMINISTRATION  In vs Out of Network; physician vs institution  Incurred But Not Reported (IBNR) Claims  MANAGEMENT INFORMATION SYSTEMS  Reports for all departments  FINANCE  budget projections, premium calculations, capitation rates  UTILIZATION MANAGEMENT and QUALITY ASSURANCE

11. HRSA HIV/AIDS Bureau11 COLLABORATIVE ORGANIZATIONS  INTEGRATED SERVICE NETWORK (ISN) - a collaboration of either primary care providers (horizontal) or primary, specialty and inpatient providers (vertical) for managed care purposes  PHYSICIAN HOSPITAL ORGANIZATION (PHO) - legal entity between hospital & MDs to contract with MCOs  SHARED SERVICES ORGANIZATION (SSO) - a collaboration between several organizations, such as community health centers, to share administrative, MIS, medical management and other services in order to participate in managed care (also TPA -third party administrators )

12. HRSA HIV/AIDS Bureau12 UTILIZATION MANAGEMENT  GOALS  plan members receive medically necessary & cost effective care;  utilization and cost patterns of participating providers are within defined limits;  plan meets its utilization and cost projections.  COMPONENTS  Referral Process  Prior or Pre-authorization:  Concurrent Review  Formulary  Medical Claims Review  Physician Selection/Physician Profiling

13. HRSA HIV/AIDS Bureau13 QUALITY MANAGEMENT  GOALS  Healthcare services are available, accessible & acceptable and meet defined standards for medically appropriate care  Participating providers meet credential criteria  Health outcomes monitored & meet established criteria  QUALITY STUDIES  Chart Reviews/audits  Incident or complaint investigation  Specific disease or condition investigation  Population wide studies  PROVIDER AND STAFF EDUCATION  PATIENT SATISFACTION SURVEYS  ACCESS STANDARDS REVIEW

14. HRSA HIV/AIDS Bureau14 NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA)  Private, not for profit organization; goal is to assess & report on quality of MCP  Two Major Activities: Accreditation and HEDIS  Accreditation:  Evaluates how well a MCP manages its delivery system  Reviews quality improvement, physician credentialing, member’s rights & responsibilities; preventive health services; utilization management and medical records  Becoming a Standard - many plans are seeking NCQA credentialling and growing list of employers require it

15. HRSA HIV/AIDS Bureau15 HEDIS  Health Plan Employer Data & Information Set  Current version is 3.0 which includes commercial Medicaid & Medicare sectors  Key Performance Measures - clinical quality, access, member satisfaction, utilization and plan financial performance  Quality of Care Measures - include immunization rates; cervical cancer screening; asthma inpatient admission rate;  Only I AIDS measure in testing phase - PCP prophylaxis

16. HRSA HIV/AIDS Bureau16 INFORMATION REQUIREMENTS  Three key areas of data:  Enrollment, utilization, and cost  Accurate and timely information is crucial  Data helps staff to manage utilization and risk  Information provides the foundation for future planning

17. HRSA HIV/AIDS Bureau17 TYPES OF REPORTS  MEMBERSHIP  Accurate and timely membership report of enrolled and disenrolled members  CAPITATION  Compare capitation revenue to cost of providing service  AGGREGATE UTILIZATION AND COST  Compare projected versus actual utilization and cost  INDIVIDUAL PROVIDER UTILIZATION AND COST  Utilization and cost patterns for each primary care provider

18. HRSA HIV/AIDS Bureau18 SELECTED DATA ELEMENTS Data Element You ProvideManaged Care Plan Provides  Member Months X  Capitation Revenue PMPM X  Primary Care Visits PMPM X  Cost of Primary Care PMPM X  Specialty Visits PMPM X  Ancillary Tests PMPMX  # of Primary Care Visits Per Provider X  # of Referrals per Provider X  # of Hosp/ital Admissions per ProviderX

19. HRSA HIV/AIDS Bureau19 RYAN WHITE PROGRAMS VERSUS MCOs RYAN WHITE PROGRAMS  public health mission  population driven  enabling services  medically and culturally appropriate providers  provide care to uninsured  accessible sites  experience with vulnerable populations MCOs  for profit mission  market driven  mandated benefits only  cost efficient contracted providers  care only to members  “commercial” sites  experience with middle class