Brochure. Medicaid managed care. Tackle the challenges of managed care with one partner

Transcription

1 Brochure Tackle the challenges of managed care with one partner

2 Truven Health Analytics was acquired by IBM in 2016 to help form a new business, Watson Health. Watson Health aspires to improve lives and give hope by delivering innovation to address the world s most pressing health challenges through data and cognitive insights. Truven Health Analytics, part of the Watson Health business, understands Medicaid leaders need to know that their investments in managed care are delivering value lower costs, higher quality and better outcomes. We also know you need to provide stakeholders with reliable, comprehensive and timely insights. And you need to accomplish all of that while evolving beyond traditional models to make continuous improvements. Tackle the challenges with one partner Truven Health provides a suite of solutions designed to help states integrate encounter data into the decision-making process, increase Managed Care Organization (MCO) performance and thrive in the managed care environment. Truven Health has helped more than 15 state Medicaid agencies with encounter data validation. Encounter data management Truven Health works with you and your MCOs to help you: Identify areas for improvement so that encounter data submitted to the state accurately reflects the care provided to Medicaid beneficiaries Minimize instances where data is rejected for quality deficiencies Prepare reports and quality measures that can be compared across all plans Our data validation process includes a robust assessment of data quality, completeness and timeliness. We examine field quality, data submission volume trends, utilization rates compared to benchmarks, reasonability of values for key data elements and handling of financial adjustments. We consider the findings in light of MCO data capabilities and statistics reported by the MCO to the state. This approach provides both you and your MCOs with a view of their data strengths and weaknesses, and a roadmap for improvement. Page 2

3 Data warehousing and decision support system As part of our managed care support, our experts can design, implement and help you manage a user-friendly enterprise data warehouse solution for your encounter data and relevant fee-for-service data. As part of this process, we: Collect, standardize, monitor and report on encounter data submissions Enhance the data for advanced analytics by adding groupings and applying adjustment methodologies, such as episodes of care and predictive health risk scores Integrate enrollment and provider data, as well as MCO capitation amounts We help you improve and simplify the various aspects of managed care Achieve high-quality data for plan oversight and decision-making Strengthen MCO contract performance Partner with MCOs to realize quality and savings targets Fight the unique risks of fraud, waste, and abuse in managed care Expand MCOs and Managed Long-Term Services and Supports (MLTSS) Plan management Truven Health can help your Medicaid agency add or expand managed care programs: You receive the data you need to support program initiatives Federal waiver requirements and state regulations are addressed Contractually enforceable standards are prepared The encounter data collection program is welldocumented Our team has special expertise working with states to design and implement Managed Long-Term Services & Supports (MLTSS) and integrated delivery programs for high-need populations, such as Medicare-Medicaid dual eligibles. We support integrated program planning, stakeholder engagement and communications, data analysis, procurement strategy, quality management, incentives strategy, evaluation planning and project management. Truven Health can also help your agency evaluate MCO performance and quality, and improve plan oversight. Our analytic and benchmarking solutions provide insights into cost-savings, quality of care, access, enrollment accuracy, member and provider satisfaction, utilization and more. Performance management/program integrity We believe improved managed care program performance begins with good data management and strong policy and contract provisions, combined with advanced analytics all working together to maintain a high level of program integrity. Our proven analytics, systems and expertise can help you address the current and emerging fraud, waste and abuse concerns that can be unique to managed care. We focus on helping you identify and improve performance and program integrity issues at multiple levels: Contract review: Verifying MCOs have the information, processes, and tools needed for effective program integrity work, and governments have the oversight needed to help ensure beneficiary service delivery and MCO performance in accordance with requirements Provider enrollment screening: Reviewing healthcare providers enrolling with MCOs to identify and remove potentially ineligible or problematic providers Program integrity operational reviews: Systematic reviews of structures, policies, procedures and other operations to identify improvement opportunities for managed care special investigation units Financial auditing: Reconciling encounter data to financial information to ensure data and reporting accuracy by MCOs Advanced analytics: Designed to identify traditional feefor-service provider issues, as well as potential risks to managed care, including: Unbundling and upcoding of claims Identifying beneficiaries enrolled in, but ineligible for, managed care Providers or MCOs submitting potentially falsely elevated cost or level-of-care data to justify higher capitation rates Billing similar services to multiple plans or to managed care and fee-for-service Helping avoid service caps, such as denying or restricting patient access to needed and allowable services Page 3

4 Financial management stakeholders from elected officials, to program managers, to taxpayers all want reliable and accurate financial management of public resources. And our solutions help you accomplish that. Put us to work to help you: Identify opportunities for cost-containment Produce risk scores, estimate future costs and risk-adjust MCO rates Compare managed care models to fee-for-service delivery Monitor budgets Care management Our solutions can help you combine and analyze your valuable data to take care management to new levels. With the right data and analytics, you can measure condition prevalence, track rates of preventive screens, and identify gaps in care and medication management. Those analytics can be honed down to even an individual patient level, which can then be used to target high-risk candidates for intervention. We believe with this type of detailed information in your hands, you can make the move to true population health management, with all of the benefits for both patients and the agency s bottom line. Facets of managed care performance improvement With data management at the core of improvement opportunities, our expertise and analytics and technology can deliver actionable information. We believe that information is essential for driving the financial and care management of a plan. It s also critical to the adjustment of policy and contract provisions, so that you can improve managed care service delivery and cost-effectiveness. Page 4

5 Managed care questions, answered Monitor performance How does enrollment and disenrollment vary by plan? Are my enrollees accessing needed services? Is complete, valid MCO encounter data being received in a timely way? Are my MCOs meeting contract performance standards? Are utilization metrics trending as expected? Measure ROI and outcomes Are we meeting the goals set in our quality strategy? Are there disparities in quality that we need to address? What cost-savings have been realized? What is our ROI? Have there been measurable improvements in health status? How well are MCOs managing chronic conditions and our sickest patients? Enhance and expand Do we need to refine our rate-setting process? How can we improve the quality of our encounter data? What should our new quality goals and improvement projects be? Should we expand managed care to new populations? Do we need to contract with more/different MCOs? Why choose Truven Health? For more than 20 years, Truven Health has assisted Medicaid agencies with encounter data at all points of the managed care contracting cycle, and we currently manage encounter data for more than 400 MCOs. We are a national leader in state Medicaid decision support, with more state customers than any other decision support contractor. Performance Care Data Plan Financial We also have contracts with several federal healthcare agency, along with 40+ years of experience exclusively in healthcare data and analytics. Get connected Please us at stategov@truvenhealth.com or visit truvenhealth.com/medicaid About IBM Watson Health business Truven Health Analytics, part of the IBM Watson Health business, provides market-leading performance improvement solutions built on data integrity, advanced analytics and domain expertise. For more than 40 years, our insights and solutions have been providing hospitals and clinicians, employers and health plans, state and federal government agencies, life sciences companies and policymakers, the facts they need to make confident decisions that directly affect the health and well-being of people and organizations in the US and around the world. The company was acquired by IBM in 2016 to help form a new business, Watson Health. Watson Health aspires to improve lives and give hope by delivering innovation to address the world s most pressing health challenges through data and cognitive insights. Truven Health Analytics owns some of the most trusted brands in healthcare, such as MarketScan, 100 Top Hospitals, Advantage Suite, Micromedex, Simpler and ActionOI. Truven Health has its principal offices in Ann Arbor, MI, Chicago, IL and Denver, CO. For more information, please visit truvenhealth.com Page 5

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