Childhood Immunization and Managed Care Organizations

1
Childhood Immunization and Managed Care
Organizations

• Olusegun Ishmael, MD, MBA
• Vice President Medical Affairs
• Managed Health Services (MHS)

2
Managed Care Organizations (MCO)

• Payment structure
• Capitation rate (PMPM)
• Goals
• Reduce Healthcare Costs
• Medical necessity
• Prior authorization for procedures
• Inpatient Length of Stay
• Improve Quality and Outcomes
• Provider and Member Incentives
• Data to identify individuals not receiving
  preventative care
• Preventative care vs. Episodic care
• EPSDT, Immunizations, etc. vs. ER and acute visits

3
Managed Care Organization (MCO) - HEDIS

• NCQA - National Committee for Quality Assurance
• The Healthcare Effectiveness Data and Information
  Set (HEDIS) is a tool used by more than 90
  percent of America's health plans to measure
  performance on important dimensions of care and
  service.
• Data

4
2006 HEDIS
5
Childhood Immunizations Barriers

• Members
• Continuous eligibility
• Members residence patterns
• Education
• Societal
• Culture of our nation
• Provider
• Payment structure Primary care vs. specialists
• Providers educating members time factor
• Provider administrative burden, EMRs, CHIRP

6
Childhood Immunizations MCO Initiatives

• Providers
• Access and Availability
• Education of providers
• Pay-4-Performance
• Provide physicians their data from claims

7
Childhood Immunizations MCO Initiatives

• Members
• Transportation
• Member Education
• Pay-4-Action
• Member advisory group
• Community events health fairs, meet your
  provider
• Home Health Visits
• Community Partnerships e.g. PBS station

8
Childhood Immunizations MCO Initiatives

• Health Plan
• Quality Improvement Department
• Data, Data, Data
• State Contract
• Pay-4-Performance/Negative incentives