Connecticut
Medicaid Managed Care Council
Quality Assurance Subcommittee
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:  October 17, 2002

Chair: Paula Armbruster

Department of Public Health Obesity/CVD Grant Update

Sharon Mierzwa provided an update:

• Two training sessions for over 200 practitioners were held in September & October for pediatric and adult management of obesity by DPH/HSC.  Management guidelines are being developed.  There is support for programs for morbidly obese adults to include behavioral health, nutrition and physical activity interventions.
• Two obesity pilots have been funded from the CDC grant in a CT urban area (East Hartford) and rural area (Ledyard).  The pilots will guide CT in future obesity intervention programs.
• DPH is developing a strategic obesity prevention plan that will be on the DPH web site in January.  The plan will be used as a tool to build consensus.
• The Dept. of Education and DPH are collaborating to disseminate the Governor’s CT at Play physical activity challenge program to CT elementary schools.
• DPH is working with health plans and Qualidigm on defining the codes for general Medicaid obesity-related service reimbursement.  The department has also met with health plans, providers and the Office of the Managed Care Ombudsman to address obesity interventions/reimbursement.

Sharon Mierzwa and Patricia Henrickson (obesity project coordinator) provided information on several conferences:

• Tools for Schools; Promoting Healthy Eating & Physical Activity in Schools, by the State Dept of Education in Middletown on Wednesday October 30, 8:30-4 PM. Contact (860) 486-1787.
• Breaking the Nutrition Barriers USDA, FNS Northeast Regional Conference in Boston, MA on December 5.  contact pa-nero@fns.usda.gov or call (617) 565-6395.
• Marketing Prevention for Societal Health  sponsored by NECOM on 10/22 in Marlborough, MA. Contact NECON for post conference mailings at www.NECONinfo.org.

HUSKY Nutritional Services Matrix

FirstChoice/Preferred One, Health Net and Anthem have submitted a completed matrix.  Anthem BCFP discussed their matrix. Service prior authorization is required for special dietary supplements and IV therapy and non-PCP referrals for nutritional services. 

Amanda Learner, CT CHP, noted that only 2% of encounters for one year for HUSKY A members <21 years were based on obesity and obesity-related diagnoses.  At this time, obesity prevalence cannot be determined from encounter data.  The percentage of obesity-related claims data is less than national obesity prevalence rates (13% of children 6-11 years and 14% aged 12-19 years) and 40% prevalence reported in a New Haven middle school obesity intervention pilot, reported by Dr. Margaret Grey.

Obesity issues are broad, involving lifestyles & nutrition influenced by culture and ethnicity, school & community access to physical activity and nutritional foods and marketing targeting schools with associated financial incentives.  The QA subcommittee is committed to working with DPH and others on these broader areas; however it is also important to identify HUSKY members’ access to nutritional services related to obesity, deemed medically necessary by their health provider.  If health providers are unable to obtain authorization and reimbursement for interventions, members may often not receive these services.  There was agreement that clarification is needed for obesity services in HUSKY by more clearly defining how providers obtain these services for their patients and reimbursable billing codes.  At this time, “obesity” codes are not reimbursable.  Clarification can be done either in the Subcommittee meetings or in a time-limited work group of providers, advocates, DSS and health plan medical directors.

Qualidigm Mystery Shopper Project

Jack Hubner presented the results from the 2001 project, which assessed primary care providers’ well-care appointment scheduling compliance, and practitioner office staff conduct related to patient courtesy, knowledge of the HUSKY A program and accommodation of Spanish-speaking members and also compared the PCP database with another state database of sanctioned & deceased practitioners.

A random sample of 480 PCP providers from HUSKY MCO networks, including pediatricians, family practice and general practice physicians, were chosen for appointment calls for a fictitious HUSKY A member.

Results:

• 346 (74%) of 470 calls made resulted in a connected call to a provider.  Three main reasons were cited for the 124 unconnected calls: busy signal (47%). Incorrect or out-of-service provider # (30%) and no answer (14%).  Three call attempts were made.
• 187 (54%) of the 346 connected calls resulted in scheduled appointments, of which 92% (172) met the 6 week well care scheduling standard in the DSS/MCO contracts.  Reasons for no appointments for 159 calls were attributed to providers: not accepting new patients (25%), no longer accepting new Medicaid patients (5%), no longer with the health plan (14%), not longer with the medical practice (12%), needed to have the child’s medical record before an appointment could be made (7%), or provider does not treat children (8%). 
• Overall results:  slightly more than half (54%) of the 346 connected calls resulted in appointments, 40% of the total N (n=470).  Approximately 39% (172) of the study N (n=470) calls resulted in an appointment within the contract standard time period of 6 weeks.
• One half of provider offices receiving calls were asked whether Spanish translation services were available; 23% of the connected calls resulted in appointments with Spanish translation services available.
• There were 17 provider matches indicating provider number error-inactive status.
• There was no provider match between the MMC plan’s provider lists and the DPH database for deceased or sanctioned providers.
• Accuracy of office staff in answering questions: close to 100% knew if the provider was in the member’s health plan and off-hour appointment availability in the office, only 82% knew the HUSKY A policy of no client payments and 87% could tell the ‘member’ if there was a bus stop near the office.

Discussion noted that the calls were made at a busy time for school physicals (August); however it is worrisome that only 54% of connected calls resulted in any scheduled appointment.

The QA Subcommittee will meet on Thursday November 21 at 10:30 AM in LOB RM 2600.  The Teen EPSDT work group will meet Tuesday October 29 at 4:30 PM in LOB RM 2600.