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High Risk Medical Workgroup
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Charge
DHS Core Team Work Group develops a viable integrated Fee-For-Service and managed care wellness strategy for those individuals and populations most at risk for years of life lost. A strategy is adopted, implemented, and evaluated.
Key design elements and contraints
- Legislatively approved 09/11 budget.
- Outcome driven
- Consumer/patient-centered
- Medical home model
- Evidenced based
- Population based
- 80% plus FCHP enrollment
- 90% plus MHO enrollment
- 90% plus DCO enrollment
- DMAP FFS Disease Management/Medical Management Program (DM-MCM) design
Key due dates
- Present initial report to Core Team by end of July 2009
- Present interim report by end of October 2009
- Begin Implementation by January 1, 2010
Participants, including but not limited to:
- Consumer
- SPD
- CAF
- FCHP member
- MHO member
- DCO member
- Safety Net Provider
- AMHD managed care/FFS expertise
- DMAP managed care/FFS expertise
- Public Health
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Potential Discussion "Starter" Options
Recommendations may include these options, modification of these options, and/or new options and may include pilot, regional, phased, or statewide approaches:
Step 1 - Determine basic foundation for FFS and managed care
- Criteria for eligible population determined
- Population outcomes identified and agreed to
- Qualified services identified
- Qualified providers identified
Managed care discussion - Option 1
- Names shared between MHO and FCHP and/or DCO
- MHO provides service and bills FCHP and/or DCO
- FCHP and/or DCO pays if qualified services provided by qualified providers
- Evaluation at year intervals
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Managed care discussion - Option 2
- MHO, FCHP, DCO “early adopter” partners agree to Performance Improvement Project (PIP) either in addition to an existing PIP or as an additional PIP
- Link partnership to performance outcomes for defined population
- Agree on payment model
- Names shared between MHO and FCHP and/or DCO
- Agreement reached on which plan type provides to which client/patient
- Lead plan shares service plan
- Non-lead plan identifies any supporting action or service
- Progress reports shared and drive continuous quality improvement
- FCHP and/or DCO pays for MHO provided services
- State and plans consider broader managed care policy implications based on outcomes
Fee-for-service Discussion - Option 1
- MHO provides wellness services to populations not eligible for the Disease Management Program (DM-MCM)
- MHO coordinates provision of wellness services with primary care practitioner
- MHO coordinates with DM-MCM regarding D-MCM eligible populations
- Best “mix” of MHO/DMP-MCM services is determined
- MHO bills for services as appropriate or is paid case rate
- Approach is assessed and evaluated against desired outcomes annually
Links
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