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Healthcare Reform

Using Medicaid Data to Make Managed Care Better

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Data rules day two of the Medicaid Enterprise Systems Conference.

You can learn a lot about a state from its Medicaid encounter data. At least, that’s what Mark Pitcock of the New Mexico Human Services Department thinks when it comes to Managed Care Organizations.

With the onset of the Affordable Care Act, the general trend in the U.S. has been to move from a fee-for-service style of healthcare to managed care, in which the Managed Care Organization (MCO) contracts with a network of providers to administer care to members at reduced cost.

It’s a rapidly changing environment churning out a wealth of patient data. Being on the vanguard, New Mexico has had to find out from trial and error the best way to use all of that data.

Most MCOs are “capitated,” which means they pay their network of providers a set amount based on the number of members, or patients, regardless of how much care is given out. That “bulk” payment method can make it difficult to track individual patient data, services, payment and outcomes, but Pitcock says that tracking is essential to improving the programs.

“My advice is to make it as easy for MCOs to produce data as possible, by using standardized filing systems, then hold them to it,” he said.

The New Mexico  Model

New Mexico was one of the first states to embark on the transition in it’s Medicaid system, starting in 1997 with the SALUD program. Over the years, more MCOs have come on board in the state, some for physical health and others for behavioral health, and on January 1, 2014, the Centennial Care program will integrate all care. This means that whereas some Medicaid patients in New Mexico currently have 4 MCOs, each patient will now choose one, which will provide physical and behavioral health services.

All MCOs are required to operate statewide.

Used correctly, [data] can reveal the quality of healthcare delivered cross the state, reduce benefit costs, and predict what is going to happen… 

It’s a rapidly changing environment churning out a wealth of patient data. Being on the vanguard, New Mexico has had to find out from trial and error the best way to use all of that data.

“Include encounter related contract requirements ‘with teeth’,” Pitcock said. In New Mexico, MCOs are required to submit at least 90 percent of claims data within 30 days of the patient visit to the provider, whether that be a primary care doctor, dentist, or ER physician.

Though it was tough to wrangle some of their MCOs to give up that much data in a timely manner, it paid off.

Put the Data to Work

“Managed care has been around for quite some time, and continues to steadily increase each year,” said Todd Marker, vice president of Business Development for Xerox Government Healthcare Solutions who has worked with the New Mexico data.

“Once you bring in all that data, what are you going to do with it?” Marker asked. Used correctly, it can reveal the quality of healthcare delivered cross the state, reduce benefit costs, and predict what is going to happen based on the data in house, he said.

“How do you really know what the  difference in effectiveness between two different MCOs? Are health outcomes on a risk-adjusted basis comparable or not?

Is one MCO doing better? How do they compare to fee for service?” Marker asked.

He described the “dreaming sessions” Xerox used with New Mexico to determine the types of reporting and analytics most important to the state. One of the things that state wanted to do was look at emergency room utilization.

Looking into their own Medicaid Management Information Services data, Pitcock and Marker discovered the number of ER visits, number of avoidable visits, and the specific individuals who used the ER most frequently.

…states can use data for “managing managed care.”

Between 2009 and 2012, the average ER visit charge was $1,750, of which $700 was actually paid. The smallest MCO actually had the highest normalized ER visit rate, when total visits were divided by total members. That MCO averaged 47 ER visits per 1,000 member months, which was still lower than the national average of 63, encouraging news for Pitcock.

Displayed graphically, those visits spiked in October of 2009, which was likely due to a bad flu season at that time, Marker said.

Stratified by user, they found that one individual visited the ER 33 times between 2009 and 2012, and could then alert that MCO to check in to what is going on with that individual.

In this way, states can use data for “managing managed care.”

“To me, the most important thing is getting encounter data in a timely, accurate way so you have visibility into your members’ experience,” Pitcock said. “Data needs to be high quality if you’re going to use it.”

Sound advice for the many states still lacking resources to actively manage their MCOs, Marker said.