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Louisiana's Medicaid Managed Care Quality Strategy

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Louisiana's Medicaid Managed Care Quality Strategy Louisiana’s Medicaid Managed Care Quality Strategy Prepared by: The Bureau of Health Services Financing Louisiana Medicaid March 2019 Louisiana Medicaid Managed Care Quality Strategy Table of Contents 1. Introduction – Managed Care Goals, Objectives and Overview ............................................ 1 1.1 History of Managed Care in Louisiana ............................................................... 1 1.2 Quality Management Structure .......................................................................... 4 1.3 Quality Strategy Aims, Goals, and Objectives ..................................................... 2 2. DRIVING IMPROVEMENT AND MONITORING PROGRESS ......................................... 5 2.1 Goals and Objectives for Continuous Quality Improvement ................................ 5 2.2 MCO Performance Measures ............................................................................. 5 2.3 Performance Measures and Performance Improvement Projects (PIPs) .............. 5 2.4 Other Medicaid Quality Interventions ................................................................ 7 2.5 Annual External Independent Reviews ............................................................... 8 2.6 Procedures for Identifying, Evaluating, and Reducing Health Disparities .......... 10 2.7 Use of Sanctions .............................................................................................. 11 3. State Standards for Access and Clinical Policies and Guidelines ......................................... 14 3.1 Provider Network Adequacy Standards and Availability of Services ................. 14 3.2 Adoption & Dissemination of Evidence-Based Clinical Practice Guidelines ........ 25 3.3 Transition of Care Policy ................................................................................. 25 3.4 Mechanisms Used to Identify Persons with Special Health Care Needs (SHCN) . 26 3.5 Non-Duplication Strategy ................................................................................ 27 4. EVALUATING, UPDATING, AND DISSEMINATING THE QUALITY STRATEGY ....... 28 4.1 Quality Strategy Development and Public Comment ......................................... 28 4.2 Quality Strategy Review, Update, and Evaluation ............................................. 28 5. APPENDIX A: Louisiana Medicaid MCO Performance Measures (2020 HEDIS Reporting Year /2019 Measurement Year) ......................................................................................... 30 i i Louisiana Medicaid Managed Care Quality Strategy 1 Introduction – Managed Care Goals, Objectives and Overview 1.1 History of Managed Care in Louisiana Louisiana’s Medicaid managed care program is responsible for providing high-quality, innovative, and cost-effective health care to Medicaid enrollees. Guided by the Triple Aim, the Louisiana Department of Health (LDH) partners with enrollees, providers, and health plans to continue building a Medicaid managed care delivery system that improves the health of populations (better health), enhances the experience of care for individuals (better care) and effectively manages costs of care (lower costs). More specifically, the Department’s Medicaid managed care objectives include: advancing evidence-based practices, high-value care and service excellence; supporting innovation and a culture of continuous quality improvement (CQI) in Louisiana; ensuring enrollees ready access to care, including through innovative means such as medical homes and telehealth; improving enrollee health; decreasing fragmentation and increasing integration across providers and care settings, particularly for enrollees with behavioral health needs; using a population health approach, supported by health information technology, to advance health equity and address social determinants of health; reducing complexity and administrative burden for providers and enrollees; aligning financial incentives and building shared capacity to improve health care quality through data and collaboration; and, minimizing wasteful spending, unnecessary utilization, and fraud. Today, Louisiana Medicaid serves nearly 1.7 million Louisianans, approximately 35 percent of the state’s population. Five (5) statewide Managed Care Organizations (MCOs), one (1) Behavioral Health Prepaid Inpatient Health Plan (PIHP) and one (1) Dental Prepaid Ambulatory Health Plan (PAHP) pay for healthcare services for more than 90 percent of the Louisiana Medicaid population, including more than 481,000 new adults since Medicaid expansion took effect in July 2016. These managed care entities (MCEs) pay for Medicaid benefits and services included in the Louisiana Medicaid state Plan, state statutes and administrative rules, Medicaid policy and procedure manuals. In addition, these MCEs also provide specified value-added Medicaid benefits and services. On February 1, 2012, the Louisiana Department of Health (LDH) transitioned nearly 900,000 Medicaid enrollees from the state’s 45-year-old fee-for-service (FFS) program to a Medicaid managed care model. Rollout occurred in phases based upon designated geographic service areas, with the statewide rollout completed on June 1, 2012. In transitioning from fee-for-service to a Medicaid managed care model, Louisiana sought to: Improve access to care Improve care coordination Increase emphasis on disease prevention and the early diagnosis and management of chronic conditions 1 1 Louisiana Medicaid Managed Care Quality Strategy Improve health outcomes and quality of care Provide for a more financially stable Medicaid program In 2014, LDH issued a request for proposal (RFP) for its second-generation, full-risk Medicaid managed care contracts, with a start date of February 1, 2015. The RFP provided for an initial three-year contract term and the option to extend the contracts up to 24 months. Subsequently, the Louisiana Legislature approved a 23-month extension to these contracts, from February 1, 2018 through the contract expiration date of December 31, 2019. In December 2015, LDH integrated specialized behavioral health services into the managed care program in an effort to improve care coordination for enrollees and facilitate provision of whole-person health care. Louisiana also continues to administer the Coordinated System of Care (CSoC), a single behavioral health PIHP to help children with behavioral health challenges that are at risk for out of home placement. Wraparound support and other services are provided to assist children with staying in or returning to their home. In 2019, LDH has initiated procurement for its third-generation, full-risk Medicaid managed care contracts, with an operational start date of January 1, 2020. 1.2 Quality Strategy Aims, Goals, and Objectives This Quality Strategy establishes clear aims, goals, and objectives to drive improvements in care delivery and health outcomes as well as metrics by which progress will be measured. It articulates priority interventions, and details the standards and mechanisms for holding MCEs accountable for desired outcomes. The Quality Strategy is a roadmap by which LDH will use the managed care infrastructure to facilitate improvement in health and health care through programmatic interventions. Guided by the Triple Aim and the broad aims of the National Quality Strategy – Better Care, Healthy People, Healthy Communities, and Affordable Care – Louisiana’s Quality Strategy framework defines and drives the overall vision for advancing health outcomes and quality of care provided to Louisiana Medicaid enrollees. Described in Table 1, these broad aims link to Louisiana specific goals and objectives, intended to highlight key areas of quality focus for the Louisiana Medicaid managed care program. Table 1: Louisiana Quality Strategy Aims, Goals, and Objectives Aims Goals Objectives Better Care. Make Ensure access to care to Ensure timely and approximate access to primary health care more meet enrollee needs and specialty care person-centered, coordinated, and Improve coordination Ensure appropriate follow-up after emergency accessible so it occurs and transitions of care department visits and hospitalizations through at the “Right care, right effective care coordination and case management time, right place.” Facilitate patient- Engage and partner with enrollees to improve centered, whole-person enrollee experience and outcomes care Integrate behavioral and physical health 2 Louisiana Medicaid Managed Care Quality Strategy Aims Goals Objectives Healthier People, Promote wellness and Ensure maternal safety and appropriate care during Healthier prevention childbirth and postpartum Communities. Improve Prevent prematurity and reduce infant mortality the health of Promote healthy development and wellness in Louisianans through children and adolescents better prevention and treatment and proven Promote oral health in children interventions that Improve immunization rates address physical, Prevent obesity and address physical activity and behavioral, and social nutrition in children and adults needs. Prevent prematurity and reduce infant mortality Improve cancer screening Improve HIV and Hepatitis C virus infection screening Promote healthy development and wellness in children and adolescents Promote use of evidence-based tobacco cessation treatments Improve hypertension, diabetes, and cardiovascular disease management and control Improve chronic Improve respiratory disease management and disease management control and control Improve HIV control Improve quality of mental
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