Childhood Immunization and Childhood Immunization and

Managed Care OrganizationsManaged Care Organizations

Olusegun Ishmael, MD, MBAOlusegun Ishmael, MD, MBAVice President Medical AffairsVice President Medical AffairsManaged Health Services (MHS)Managed Health Services (MHS)

Managed Care Organizations (MCO)Managed Care Organizations (MCO)

– Payment structure Payment structure Capitation rate (PMPM)Capitation rate (PMPM)

– GoalsGoals Reduce Healthcare CostsReduce Healthcare Costs

– Medical necessityMedical necessity– Prior authorization for proceduresPrior authorization for procedures– Inpatient Length of StayInpatient Length of Stay

Improve Quality and OutcomesImprove Quality and Outcomes– Provider and Member IncentivesProvider and Member Incentives– Data to identify individuals not receiving preventative careData to identify individuals not receiving preventative care

– Preventative care vs. Episodic carePreventative care vs. Episodic care EPSDT, Immunizations, etc. vs. ER and acute visitsEPSDT, Immunizations, etc. vs. ER and acute visits

Managed Care Organization (MCO) - Managed Care Organization (MCO) - HEDISHEDIS

– NCQA - National Committee for Quality NCQA - National Committee for Quality Assurance Assurance

– The Healthcare Effectiveness Data and The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to than 90 percent of America's health plans to measure performance on important dimensions of measure performance on important dimensions of care and service.care and service.

– DataData

2006 HEDIS2006 HEDIS

Childhood Immunization Status - Combo 2

55.47%

73.85%80.05%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

MHS IN East North CentralMedicaid HMO Avg

NCQA Medicaid 75thPercentile

HE

DIS

Rat

e

Childhood Immunizations BarriersChildhood Immunizations Barriers

– MembersMembers Continuous eligibilityContinuous eligibility Members residence patternsMembers residence patterns EducationEducation

– SocietalSocietal Culture of our nationCulture of our nation

– Provider Provider Payment structure – Primary care vs. specialistsPayment structure – Primary care vs. specialists Providers educating members – time factorProviders educating members – time factor Provider administrative burden, EMRs, CHIRPProvider administrative burden, EMRs, CHIRP

Childhood Immunizations MCO InitiativesChildhood Immunizations MCO Initiatives

– Providers Providers Access and AvailabilityAccess and Availability Education of providersEducation of providers Pay-4-PerformancePay-4-Performance Provide physicians their data from claimsProvide physicians their data from claims

Childhood Immunizations MCO InitiativesChildhood Immunizations MCO Initiatives

– Members Members TransportationTransportation Member EducationMember Education Pay-4-ActionPay-4-Action Member advisory groupMember advisory group Community events – health fairs, meet your providerCommunity events – health fairs, meet your provider Home Health VisitsHome Health Visits Community Partnerships e.g. PBS stationCommunity Partnerships e.g. PBS station

Childhood Immunizations MCO InitiativesChildhood Immunizations MCO Initiatives

– Health Plan Health Plan Quality Improvement DepartmentQuality Improvement Department

– Data, Data, DataData, Data, Data

– State ContractState Contract Pay-4-Performance/Negative incentivesPay-4-Performance/Negative incentives