Connecticut
Medicaid Managed Care Council
Legislative Office Building Room 3000, Hartford CT 06106
(860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-8307
www.cga.state.ct.us/ph/medicaid
 

MEETING SUMMARY

MARCH 10, 2000

Present: Sen. Toni Harp (Chair), Rep. Vickie Nardello, David Parrella and James Gaito (DSS), Marie Roberto (DPH), Steve Netkin (OPM), Robert Gribbon (Comptroller), Holly Miller Sullivan for Paul DiLeo (DMHAS), Dorian Long for Gary Blau (DCF), Dr. Wilfred Reguero, Dr. Edward Kamens, Janice Perkins, Pat Carolan, Jeffery Walter, Ellen Andrews, Rev. Bonita Grubbs, Phyllis Rotella, Lisa Sementilli-Dann.

Also present: James Linnane and Rose Ciarcia (DSS), Steve Sobran and Sarah Erlick (Mercer), Sheila Alan Bell (Benova), Debra Russo Bracket (Qualidigm), Paula Armbruster, Sylvia Kelly (CHNCT), Glenn Wright (Preferred One), Mariette McCourt (Council staff).

Department of Social Services

Quarterly Utilization Report

James Linnane reviewed the highlights of the report:

·_Dental participation for any dental service should approximate 50%. Overall HUSKY A dental utilization rates averaged 16. 6% this quarter (3^rd), 18. 7% the 2^nd 1999 quarter and 19. 2% the 1^st 1999 quarter. The following summarizes the 1^st and 2^nd quarter utilization percentages for 3-20 year old HUSKY A members for any dental service:

There have been significant variations within MCO quarterly utilization rates that may relate in part to the seasonal availability of SBHC dental clinics. Rep. Nardello asked if DSS could identify services provided by the SBHC. Pat Carolyn stated that plans could identify SBHC thru the tax ID #, which focuses on a health center. The Medicaid ID # identifies the individual provider, however the provider may practice at both SBHC and private settings. Rep. Nardello, Pat Carolan and DSS will work together to determine the best way to answer the question of the seasonal aspect of SBHC on the dental data.

·_Maternal Health data looks at the percentage of low birth weight (LBW) deliveries compared to the statewide population. There is no statistically significant difference among health plans but there is a statistically significant difference between the HUSKY A LBW rates compared to the general population. This difference is related to several factors; for example the largest cities have LBW >10% and women may enroll in the HUSKY program at the end of the 1^st trimester or in the 2^nd trimester. While there is not a strong correlation of prenatal care and LBW rates, according to DSS, Marie Roberto (DPH) observed that less than 50% of women are enrolled in a managed care plan during the first trimester {this has ranged from 38% to 48% over the past 8 quarters} and recommended DSS look at this. Mr. Linnane stated that for some women, eligibility is determined by pregnancy. Women may enter the HUSKY program through the Healthy Start program or other FFS eligibility categories late in the first trimester or in the second trimester or change their health plan, thus the data for that plan reflects prenatal care beginning when the women is enrolled in the plan. Rep. Nardello asked for clarification that prenatal care outside the managed care system, but within FSS, is not included in the rates in the quarterly reports. Mr. Linnane stated that only care received while enrolled in a managed care plan is included in the data.

·_Postpartum rates remain less than 60% (49. 7% for the 2^nd quarter of 1999) even though these women are within the eligibility range. Janice Perkins (PHS) stated that PHS calls every mother within 2 weeks of delivery to remind her of postpartum care importance. PHS will look into data and billing to see if there are explanations for unaccounted visits. Mr. Linnane stated that postpartum care is part of the global maternity fee. Data may be missing from the quarterly data if the visits are not reported separately. Mr. Linnane stated DSS needed to look into this.

MCO Risk adjustment: Mercer

Mercer, the State actuarial consultant presented an overview of the MCO risk adjustment allocation analysis and methodology as requested by the Council at the February meeting. Steve Schramm and Sara Erlick, Mercer consultants, reported on the capitation rate add-on process. The per member per month (PMPM) add-on was calculated based on four target populations: Healthy Start mothers (HSM), DCF children (DCF), special needs children (SNK), and new borns (NB). The PMPM allocation methodology was based on the pool of money ($ 7,656,500 of the quality incentive money), the estimated prevalence of the target population in HUSKY A and cost analysis associated with the target group. Four primary assumptions were made based on data from DSS, MCOs, other states' Medicaid populations and HUSKY data:

·_Enrollment projections of the total HUSKY population, based in part on data through December 1999.

·_Overall target group prevalence

·_Population distribution by rate cell

·_Average costs for each target population

The allocations were based on the prevalence and the average costs of the target groups. , allocating more dollars to higher cost groups. The size of the group would determine the PMPM dollar amount as dollars are spread over larger or smaller numbers within the group.

The following summarizes the allocation to the four target groups:

The target population by rate cell is shown in the following table:

Questions from the Council:

·_Could the target groups be further refined? For example adolescents and women have lower utilization patterns in the HUSKY program. Ms Erlick responded that the analysis did look at age/sex cohorts. Two of the groups, DCF and special needs kids do include adolescents. In the 15-39 year old males, 46% were identified as adolescents in one of these groups. The methodology identified the population and distributed the dollars without changing the actual rate structure of the rate cells.

·_How does this redistribution of money impact the Upper Payment Limit (UPL)? Ms. Erlick stated that the quality incentive money (1% of total program costs) was included in the pool of money in the initial cost effectiveness analysis. The program costs remain below the UPL; the dollars taken from the incentives have been reallocated to target populations. Mercer cannot disclose specifics about the % UPL because of rate negotiation issues with the MCO's.

·_Did the analysis look at the types of services rendered to the target groups or look at all managed care covered services? Ms Erlick stated that capitation rates are population based not service based. The rates address all covered services.

Encounter data change:

James Linnane described changes in the HUSKY A encounter data collection, use and vendor that will begin with test data submitted by MCOs June 1, 2000. The current data quality is variable, especially when subcontractors are involved, associated with constant doubts about the completeness of the data and admits of invalid data. The new editing system introduces a new more stringent standard. This may initially increase the risk of incomplete data, however the use of data for setting capitation rates (in place of relying on 1994 FFS experience) should encourage more completeness of data reporting. The following summarizes the differences between the data current collection process and Mercer:

Data elements will be expanded to include more diagnoses and procedure codes, the Medicaid provider number and client eligibility on the date of service. In addition, the `allowed' charges versus the amount paid based on the provider/MCO contract will be collected as well as third party liability (TPL) payments, since Medicaid is the payer of last resort and the MCO pays the remaining charges). Failure to submit a data element or incorrect gender/age appropriate service data will result in the data being returned to the MCO for correction.

The timetable for the implementation of the new system is as follows:

·_March 2000: notice of change sent to MCOS per contract, 90 days pre-notification of contractual changes.

·_June 1, 2000: MCO begin submission of test data to Mercer.

·_July 15,2000: encounter data in the Mercer format will be submitted to Mercer.

·_August 1, 2000: Mercer sends edited data to the Children's Health Council and Qualidigm. MEDSTAT will overlap in the change process as part of the contingency plan for the transition.

Mr. Linnane provided examples of the uses of the new data other than rate setting:

·_Identify special needs children

·_Tracking the TPL, in that if the MCO does not bill the third party within 6 months, DSS will do so.

·_Allows compliance with HCFA 2082 additional requirements of reporting Medicaid program expenditures by categories (i. e. eligibility, race, age, gender, etc. ) as well as claims rather than capitation payments to the MCOs as currently reported.

·_Compliance with the Health Insurance Portability Act that requires all payers to use the same format for paying the provider. All payers (public and private) will have two years to comply with the regulations when the regulations are final, probably in the summer.

·_Improved reporting of Family Planning services for the HCFA 64 report, which allows the State to recoup a 90% federal reimbursement that currently is not claimed in HUSKY because the claims are not known. Mercer will flag family planning services per MCO.

While there was strong support from the Council for the intent of the change there was a lengthy discussion about the application of the change process and impact on providers and care access:

·_Providers will have a Medicaid number that will track plan network capacity; the group or clinic will have a Medicaid #/tax ID # for service claims. A file number identifying the patient, used by the practice, will be used to more easily access the chart in quality chart reviews.

o Non-Medicaid providers who see a HUSKY patient will be given a Medicaid # for that patient.

o Health providers have concerns about the use of the data, as they have experienced past problems with the IRS regarding claim payment information. DSS does not share raw data with anyone, certainly not the IRS. The MCOs provide information to the IRS on 1099 forms. Individual provider payments are not put forward as in a FFS claims system.

o It is important that MCOs have adequate time for provider training of the system. More stringent editing, while laudable, may have an adverse impact on providers because of an increase in rejected claims, leading to health provider financial problems as well as discouraging provider participation in HUSKY. DSS stated that by the time Mercer receives the data for editing, the providers have been paid, if in a FFS contract with a MCO. The editing process is more detailed; however, currently, MEDSTAT edits data and returns the whole batch to the plan for corrections if there is 5% incorrect data rate. The Council recommended that the Department take the time in this change process to evaluate the impact of the change on the system.

·_The Mercer system should improve the quality measurement in the program in that:

o Data should be more complete as plans will have more of an incentive to obtain data from providers and subcontractors since it will be used for MCO capitation payments.

o Better able to obtain medical record for chart review through the practice file number.

o Able to identify individual providers in the group through the Medicaid number.

·_A tracking system within DSS is needed to identify the impact of the system change on the program, considering the effect on providers and access to services. Mr. Linnane stated there will be identifiers in place to track the impact of the change; one possibility maybe using the encounter data, and trending forward, setting standard deviation boundaries to identify data problems, under reporting as well as over reporting. The Department will present the tracking mechanisms at a future Council meeting and the MCOs will review what is learned from the June test data to the Council.

·_Sanctions will continue to be applied as outlined in the 1999 contract; however the contract will be amended to have sanctions be placed in an account within DSS to be used for quality monitoring of the program, rather than rolled into the incentive pool that has been re-allocated to PMPM rate adjustments.

Qualidigm Operations Audit Follow-up

Judy Bell presented the follow-up Qualidigm audit to review the corrections of MCO deficiencies cited in the 1999 contract compliance audit and the MCO grievance/fair hearing process that was made effective July 1, 1999. The following table summarizes the corrections audit:

Overall, the MCOs have corrected most of their deficiencies; DSS will diligently follow-up with the MCOs on the correction of the remaining deficiencies. Two deficiencies common to all plans that were not included in the audit because they require clarification through DSS/MCO contract amendments were:

·_Compliance with the Behavioral Health administrator function.

·_MCO monthly case management reporting.

A new audit cycle will begin in May of 2000 with a deficiencies correction audit performed before the end of 2000.

Benova Report

Sheila Allen Bell reported on the following:

·_Enrollment in HUSKY:

o HUSKY A: 231,766

o HUSKY A <19 years: 174,003

o Since 7/1/98 >15,384 children have been enrolled in HUSKY A.

o HUSKY B: 5006 children have been enrolled since 7/1/98

o HUSKY Plus physical: 69 children enrolled plus 2 pending (Yale - 28, CCMC - 41).

o HUSKY Plus Behavioral Health: 6 children enrolled with 1 pending.

·_Minority HUSKY Outreach

Ms. Bell reported that there is low minority enrollment in A and B relative to overall minority population representation.

 

Percentage of Enrollees by Race

{The Multicultural Report from DPH provided data on age and per capita income by race and ethnicity for CT that can provide some basis of comparison of these enrollment numbers, considering the age distribution in HUSKY and income.

Ms. Bell stated that minority HUSKY enrollment is low, especially among Black persons living in Hartford County. Benova staff are looking at the reasons for the under-representation of minority groups in both programs and have been working with the legislative Black and Hispanic caucuses, local minority social support clubs, SCCU cultural affairs department and St. Raphael's minority health program for suggestions for redesigning outreach to specific groups. Formal and informal community leaders are key to bringing the message to the community level in a manner that will be heard by the targeted group. Benova will continue to monitor minority enrollment to access the impact of these targeted outreach efforts.

Behavioral Health Outcomes Pre-Post Managed Care

Paula Armbruster, Director, Outpatient services, Yale Child Studies (YCSC) Outpatient Clinic, presented data comparing pre-post managed care demographic characteristics and functional outcomes on children seen in the YCSC. The following summarizes the demographics:

·_Caregivers: other includes relative/guardian, DCF guardianship

·_Medicaid includes Medicaid, no insurance, grant, no charge.

* Corrected data on ethnicity; the percentage of minority clients exceeds that of non- minority clients.

Pre-Managed Care Post-Managed Care

·_CGAS: lowest level of functioning scored 1-100.

·_GAF: highest level of functioning, with 70 and above indicating normal function.

·_*Statistical significance based on the Wilcox rank-sum test

Ms. Armbruster summarized the observations from the study:

·_There was a shift in caregivers, with more children in Other (DCF) category in the managed care period (post MC).

·_There was a decrease in the `unknown' insurance category, suggesting more children were insured in the Post MC period.

·_More children from New Haven were served in the Post MC period, reflecting the impact of school-based mental health programs. There was greater congruence in the referral diagnosis and evaluation diagnosis in the Post MC period, suggesting greater provider sensitivity to differential diagnoses.

·_There was no statistically significant difference in the functional ratings of children before and after treatment between the Pre and post MC periods, despite the significant reduction of average number of session per child.

·_The average functional level, both on evaluation and discharge, (GAF 54 - 58) revealed persistent moderate impairment that raised the following points of discussion:

o The mental health provider's task may be to maintain or prevent deterioration of the child's functional level, given the level of impairment at evaluation.

o The average impairment level seen at evaluation suggests the need for earlier identification of `at-risk' children and secondary preventive interventions that would prevent the level of functional impairment now seen in the outpatient setting.

o Alternative interventions need to be considered, as psychodynamic models do not seem to be associated with more than a flat improvement in functional level (10 points pre-post treatment).

Medicaid Council Subcommittee Recommendations

·_The Consumer Access subcommittee will continue to work with DSS regarding specific recommendations regarding the identification of special needs children in the HUSKY A and B program.

·_Women's Health subcommittee brought forward recommendations for two areas in the HUSKY program:

o Smoking cessation: includes a recommendation that DSS amend the state plan to cover smoking prevention education, counseling, and devices as prescribed by the health care provider. Funding should be appropriated for this beginning in July 2000.

DPH requested that the recommendation be separated into 1) policy and 2) funding for a Council vote. The Council vote on this recommendation:

1) Policy of covered smoking cessation education, counseling and devices: unanimous approval by voice vote. .

2) Funding of the recommendation: 3 abstentions, no nays, remainder voice approval.

o Lactation Recommendations: It was moved and seconded that the Council vote separately on recommendations 3 b and 4.

1) Consideration of recommendations 1,2 3 A and C, 5, 6,7,8 were moved and seconded, with 2 nays, 1 abstention and voice approval of these recommendations.

2) Consideration of recommendation 3 b (rental or purchase of electric breast pumps and double mild collection kits, breast shells, supplemental nutrition systems, finger and cup feeding devices should be available to women in HUSKY A) was voted on with the change of "medical necessity" included in the recommendation: 3 abstentions, no opposed, voice vote approval of the recommendations.

3) The Department of Public Health opposed recommendation 4 (women with Medicaid-enrolled children should be able to access donor milk with a physician prescription for medical necessity, in cases where a woman is unable to provide her own milk for her infant) because of the absence of federal/state donor milk standards and regulations. Marie Roberto reported that the federal WIC program will no longer allow the use of banked human breast milk for some infants with special needs because of

__The lack of federal health and safety standards,

__No provisions for mandatory pathogen, drug, toxin and allergen screening

__The pasteurization process may cause the banked milk to lose some of its intrinsic value.

Other Council members expressed concern about the lack of safety standards and the Council agreed to table this recommendation until adequate information is forthcoming. It was suggested that a donor agency or representative from the USDA address this issue at a future Council meeting.

The next meeting of the Medicaid Council is April 14, 2000 at 9: 30 am in LOB RM 1D.