Pennsylvania Early Warning Monitoring Program

1
Pennsylvania Early Warning Monitoring Program

• Mary Jeanne Serafin, MA

2
Pennsylvania Goals

• Statewide Mandatory MA Managed Care
• To Improve Access to Care
• To Improve Quality of Care
• To Stabilize MA Spending
• Created HealthChoices Program

3
HealthChoices Components
Independent Enrollment Assistance Program (IEAP)

HealthChoices
Physical Health Program
Behavioral Health Program
4
Behavioral Health Component

• Only one BH-MCO in each County
• Enrollees assigned to BH-MCO in County
• Enrollees offered choice of providers

• Carved out from Physical Health
• County Right of First Opportunity to Bid
• Managed by Co. Gov. or Private BH-MCO

5
HealthChoices Implementation

• Start date 2/1/97
• All categories of Medicaid
• Counties or State contracts with MCO

• 895,907 lives
• Three Zones
• Southeast, Southwest, Lehigh/Capital
• 25 Counties includes both urban and rural

6
Early Warning Program

• Performance Based Measures
• Access
• Quality Appropriateness
• Outcomes
• MCO Functions
• Stakeholder Feedback

• Joint SAMHSA, State, CMS Pilot
• Monitoring Program
• Limited Set Indicators
• Real Time

7
Early Warning Program Purpose

• Enhance public accountability
• Improve healthcare safety net
• Direct oversight to problems
• Identify systemic stress
• Minimize burden

8
Early Warning Process

• County and BH-MCO involvement from the onset
• Included QM IS staff
• Consensus on indicators

9
Public Accountability

• Stakeholders
• Current Information
• Participate
• Indicator development
• Evaluation of findings
• Corrective activities
• New forums for communication and
  problem solving
• Enhanced stakeholder input confidence

10
Special Needs Populations

• Children
• Serious and Persistently Mentally Ill
• Involuntarily committed
• Homeless
• Minorities
• Substance Abusers

11
Measurement

• Specific indicators - event driven
• Outcomes
• Benchmarks
• Broad indicators - open ended

• Rapid
• Practical, reliable, valid
• Lead indicators
• Multiple redundant
• Measures
• Sources

12
EWP Indicators Access

• Provider surveys
• Change in MCO policy
• Stakeholder feedback

• Authorizations
• Denials
• Consumer complaints
• Provider grievances

13
EWP Indicators Quality

• Grievances
• Stakeholder feedback

• Rehospitalization
• Involuntary commitment
• Provider survey
• Consumer complaints

14
EWP Indicators MCO Operations

• Change in MCO policy
• Telephone
• Stakeholder feedback

• Claims paid
• Consumer complaints
• Provider survey
• Grievances

15
EWP Benefits

• Medicaid recipients
• Assure access
• General services
• Special services
• MCO
• Monitor quality
• Complaints addressed

• State,federal, local governments
• Real-time, reliable data
• Problems identified
• Improved efficiency
• Stakeholder collaboration support

16
EWP Benefits

• Providers
• Direct feedback to state
• Assured prompt payment
• Improved treatment network

• Advocates
• Real-time performance information
• Participation in problem identification and
  resolution

17
EWP Report Access

• Mary Jeanne Serafin, MA
• Director, Quality Management Program
• Office of Mental Health and Substance Abuse
  Services
• 300 Liberty Avenue, Room 413
• Pittsburgh, Pennsylvania 15222
• Phone [phone] E-mail mserafin.state.pa.us
  
• Reports available on Department of Public Welfare
  website
• www.dpw.state.pa.us/general/guides.asp