Medical Assistance Program Oversight CouncilOctober 11, 2013

HUSKY Health Program and

Charter Oak Health Plan

Medical ASOProgram Dashboard Highlights

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Determining a Primary Care Provider’s Panel: PCP Attribution

MCO Assignment Process used by the MCOs

prior to 2012 Based on a member’s zip

code and geographic location to a provider

Could be determined by the member’s choice or the MCO’s algorithm for assignment of Members

Member may have never seen the provider

ASO Attribution Process effective 2012 and

going forward Based on who the member has

visited and provider’s billed services

Member may self select a provider or the ASO will attribute based on a member’s claim history

Member had a service with the provider

Under the ASO Model, members are now linked to a PCP based on their usual source of care. The attribution process is utilized to reflect a member’s choice of PCP.

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Attribution Statistics

66% 65% 66% 61%

The attribution process reviews procedure codes submitted by PCPs for preventive services and other office visits.

CMAP Provider Network GrowthJanuary 2012 – June 2013

June 2013 Statistics

Instate and BorderProviders only

# of PCPs 3,111

# of Specialists 12,350

+20.9%+7.3% +1.4%

Person Centered Medical Homes (PCMH)July 1, 2012 – June 30, 2013

Call Center StatisticsJuly 1, 2012 – June 30, 2013

2nd Q 2013 Call Center Performance

Measure Standard Results% of Calls Answered within 60 Seconds 90% 98.6%

Crisis Line: % of Calls Answered within 15 Seconds

90% 100%

% of Calls Abandoned <5% 0%

Average Talk Time N/A 5.53

Min

36,515

24,33028,751 25,398

9,764

8,748

13,744 17,620

9,828

8,164

7,281 6,407

6,364

5,218

6,404 6,4958,930

9,424 12,7616,888

8,329

7,0525,836

5,000

15,000

25,000

35,000

45,000

55,000

65,000

75,000

Q3 2012 Q4 2012 Q1 2013 Q2 2013

Total Member Calls by Call Reason

Provider Access Eligibility Check

Info on ASO Services Covered Services

Other ASO/Vendor/Broker Miscellaneous

Access for Members with Cultural & Linguistic NeedsJuly 1, 2012 – June 30, 2013

Grievance StatisticsJuly 1, 2012 – June 30, 2013

52 63 38 40

165204

168207

26

26

16

1519

43

39

3681

96

9380

0

50

100

150

200

250

300

350

400

450

500

Q3 2012 Q4 2012 Q1 2013 Q2 2013

Access Quality - Provider Quality - ASO Financial Other

2nd Q 2013 Resolution Timeliness (Metric: 90%

within 30 Days)Same Day 17%

2-7 Days 41%

8-30 Days 37%

31-45 Days 5%

More than 45 Days 0%

**A grievance is any expression of dissatisfaction

Intensive Care Management Outreach July 1, 2012 – June 30, 2013

# Members Outreached for ICM 43,074

# Members Who Agreed to/ Enrolled in ICM 16,836

Member Age # in ICM 0-18 years old 2,227 19 and older 14,609

• Diabetes• Cardiac• BH Sensitive • Gastrointestinal• Respiratory• Perinatal

• Cancers, Auto-Immune and Sickle Cell Disorders• Autism and Developmental Delays• Neuromuscular and Degenerative• Renal• Injuries and Infections

Top Driving Conditions that Identified Members for ICM:

ICM: Addressing Immediate Needs July 1, 2012 – June 30, 2013

Members are assessed for adequacy of basic human needs (food, housing, safety, utilities, etc.). The Intensive Care Manager will immediately address those unmet needs. From July 1, 2012 through June 30, 2013, staff assisted:

Members who indicated they were hungry and without food 4,376

Members who indicated they had concerns about safe housing

5,682

Members who were screened as positive for behavioral health needs and received interventions to effectively manage it

3,657

Members who were receptive to engaging in smoking cessation behaviors

2,512

HUSKY A, C and D Member Authorizations and AppealsJuly 1, 2012 – June 30, 2013

Service TypePrior Authorizations Member Appeals Administrative Hearings

Total Requested

Approved Denied/ NOAs

Total Appeals

Outcome Total Requested

Outcome

Admissions 58,547 58,299 248 61 Overturn3 Upheld

2 Withdrawn 5

4 Withdrawn1 Upheld

Professional/ Surgical Services

4,437 4,096 341 162 Overturn12 Upheld

2 Withdrawn9

6 Withdrawn2 Upheld

1 Overturn

Outpatient Therapies

19,674 19,204 470 115 Overturn2 Upheld

4 Withdrawn7

5 Withdrawn2 Overturn

Radiology61,651 58,825 2,826 83

41 Overturn18 Upheld

23 Withdrawn1 Untimely Filing

4643 Withdrawn

1 Upheld2 Dismissed

•Upheld: Service denial remains. •Overturn: Service request approved.

•Withdrawn: Member withdrew appeal/ hearing request.•Dismissed: Hearing Officer dismissed the hearing.

HUSKY A, C and D Member Authorizations & Appeals (cont)July 1, 2012 – June 30, 2013

Service Type

Prior Authorizations Member Appeals Administrative HearingsTotal

RequestedApproved Denied/

NOAsTotal Appeals Outcome Total

RequestedOutcome

DME 22,596 19,865 2,731 95

60 Overturn15 Upheld

17 Withdrawn3 Untimely filing

52

47 Withdrawn2 Upheld

1 Overturn2 Dismissed

Home Health

11,692 11,224 468 3212 Overturn18 Upheld

2 Withdrawn28

16 Withdrawn4 Upheld

7 Dismissed1 Overturn

Hospice 199 199 0 0 0 0 0

Pharmacy (Synagis)

484 260 224 21 Overturn1 Upheld

2 2 Withdrawn

Vision Care 66 66 0 0 0 0 0

GRAND TOTAL

179,346 172,038 7,308 245 245 149 149

•Upheld: Service denial remains. •Overturn: Service request approved.

•Withdrawn: Member withdrew appeal/ hearing request.•Dismissed: Hearing Officer dismissed the hearing.

HUSKY B Member Authorizations and AppealsJuly 1, 2012 – June 30, 2013

Prior Authorizations Member Appeals

Service Type Total Requested Approved Denied Total Appeals Outcome

Admissions 265 264 1 0 0Professional/

Surgical Services43 33 10 0 0

Outpatient Therapies

692 470 222 161 Overturn11 Upheld

4 Withdrawn

Radiology 424 412 12 0 0

DME 203 138 65 32 Upheld

1 Withdrawn

Home Health 23 18 5 1 1 Upheld

Hospice 0 0 0 0 0

Pharmacy (Synagis)

5 2 3 1 1 Upheld

Vision Care 1 1 0 0 0GRAND TOTAL 1,656 1,338 318 21 21

•Upheld: Service denial remains.

•Overturn: Service request approved.

•Withdrawn: Member withdrew appeal.

HUSKY Health and

Charter Oak Health

Utilization & Cost StatisticsMedical & Behavioral Health (BH)

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Hospital Inpatient - Medical & BH CombinedDates of Service January 2012 – March 2013

Note: All HUSKY Health & Charter Oak members except Dual members (i.e., members who are eligible for both Medicare and Medicaid) are included. Data includes claims paid through 08/31/13. Utilization and PMPM cost statistics for Q4 12 & Q1 13 contain a factor for incurred but not reported (IBNR) claims payment.

From Q1 2012 to Q1 2013:• Admissions per 100 MMs decreased by 3.2%.• Days per 100 MMs decreased by 8.1%.• The average length of stay decreased by 5.0%.

Hospital Inpatient - Medical & BH CombinedDates of Service January 2012 – March 2013

From Q1 2012 to Q1 2013:• Inpatient PMPM decreased by 1.8%.

• Cost per admission decreased by 2.7% or $200 per admission.

Note: All HUSKY Health & Charter Oak members except Dual members are included. Data includes claims paid through 08/31/13. Utilization and PMPM cost statistics for Q4 12 & Q1 13 contain a factor for incurred but not reported (IBNR) claims payment.

Inpatient Users - CY 2012 Inpatient Admissions – Top MajorDiagnosis Categories CY 2012

Note: All HUSKY Health & Charter Oak members except Dual members are included.

Inpatient Utilization Strategies• Intensive Care Management (ICM) /collaboration with providers and CTBHP.• ICM visits while inpatient.• Discharge planning.• Transitional Care outreach within 7 days of discharge.• Medication adherence mgmt.

Hospital Emergency Dept (ED) - Medical & BHDates of Service January 2012 – March 2013

Note: All HUSKY Health & Charter Oak members except Dual members are included. Data includes claims paid through 8/31/13. Utilization and PMPM cost statistics for Q4 12 & Q1 13 contain a factor for incurred but not reported (IBNR) claims payment.

The charts below represent total ED visits.

• ED visits per 100 MMs decreased by 3.2% from Q1 2012 to Q1 2013.

• HUSKY D has the highest ED utilization.

• The cost per ED visit increased by 8.5% from Q1 2012 to Q1 2013.

• HUSKY C ($429) and HUSKY D ($383) have the highest cost per ED visit.

Hospital Emergency Dept (ED) - Medical & BHDates of Service January 2012 – March 2013

The charts below represent hospital ED visit PMPM cost billed as emergent versus non-emergent.

• The PMPM cost for emergent visits increased by 6.3% from Q1 2012 to Q1 2013.

• The PMPM cost for non-emergent visits decreased by 11.7% from Q1 2012 to Q1 2013.

Note: All HUSKY Health & Charter Oak members except Dual members are included. Data includes claims paid through 8/31/13. Utilization and PMPM cost statistics for Q4 12 & Q1 13 contain a factor for incurred but not reported (IBNR) claims payment.

Hospital Emergency Dept (ED) - Medical & BHCalendar Year 2012

Note: All HUSKY Health & Charter Oak members except Dual members are included .

Total ED Users =269,205 (41% of all members)

ED Utilization Strategies•Focused member outreach to link members with a PCP and coordinate care

•Educate members on use of 24/7 Nurse Advice line

•Intensive Care Management

•Refer BH ED users to CTBHP

Hospital ED – Top Primary DiagnosesCY 2012

Adult

Note: All HUSKY Health & Charter Oak members except Dual members are included.

Child

Maternal & Child Birth – CY 2012

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Obstetric P4P program

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• Performance Measures

Timely completion (within 14 days) of online obstetrics prenatal and post-partum notification forms

A first obstetric visit within 14 days after confirmation of pregnancy At least one postpartum visit within 21-56 days after delivery Full-term, vaginal delivery after spontaneous labor whenever medically possible Appropriate use of 17-alpha hydroxyprogestron

• Care provided on dates of services 7/1/2013 through 6/30/2014 will be eligible for the P4P payment

• Providers began using the on-line obstetric notification form August 1

• Eligible providers include: providers currently enrolled as family medicine physicians, obstetrician/gynecologists, obstetric nurse practitioners, family medicine nurse practitioners, physician assistants and certified nurse midwives

Questions?