ER utilization infection, or prevent (cont.) imminent tooth loss dental services (i.e. full & partial dentures, medically necessary, services that would be more cost-effective than alternative treatment for same condition) Long Term Coordinated, quality services for Maine’s most vulnerable citizens – Capitation for top N/A Aggressive case & $45.9M $17.2M Pros: Could be tied into Implementation Timeline: 20% disease Increased coordination HMO/MCO; Could be 18-24 mo. management Contracting strategies to improve a HMO/MCO-driven Savings Realization Timeline: Home & performance initiative 1-3 years community-based Prevent disease progression, Changes: Systems care hospitalization & institutionalization May have some Communication: Providers, Continually & Members able to stay in their challenges Members periodically home/community coordinating care Document: RFP process, clients to Cost savings with MCO/HMO (for Contract development, assure appropriate Ensure that members receiving Carve outs) HMO/MCO readiness level of care appropriate level of care review, Quality measures, Carve outs Specialty care provided by Determine (for Reduce waitlist experienced providers Performance bonus) Risk adjustment MCOs/HMOs will not be penalized for Performance bonus taking higher-risk members (for Risk for meeting quality adjustment) incentives Incentive for providers to provide Withhold to assure quality care (for Performance that process Cons: measures achieved State resources required for oversight
ER utilization (cont.) infection, or prevent imminent tooth loss dental services (i.e. full & partial dentures, medically necessary, services that would be more cost-effective than alternative treatment for same condition) Long Term – Coordinated, quality services for Maine’s most vulnerable citizens Capitation for top 20% N/A Aggressive case & disease management Home & community-based care Continually & periodically clients to assure appropriate level of care Carve outs Reduce waitlist Risk adjustment Performance bonus for meeting quality incentives Withhold to assure that process measures achieved $45.9M $17.2M Pros: Increased coordination Contracting strategies to improve performance Prevent disease progression, hospitalization & institutionalization Members able to stay in their home/community Cost savings Ensure that members receiving appropriate level of care Specialty care provided by experienced providers MCOs/HMOs will not be penalized for taking higher-risk members (for Risk adjustment) Incentive for providers to provide quality care (for Performance Cons: State resources required for oversight Could be tied into HMO/MCO; Could be a HMO/MCO-driven initiative May have some challenges coordinating care with MCO/HMO (for Carve outs) Implementation Timeline: 18-24 mo. Savings Realization Timeline: 1-3 years Changes: Systems Communication: Providers, Members Document: RFP process, Contract development, HMO/MCO readiness review, Quality measures, Determine (for Performance bonus)
recommendation-report12-15-2012.docx