Case study 6 and 7 HIM310

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Ashford University *

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Dec 6, 2023

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1 Case Studies Six and Seven: Managed Care &Transfer Cases Ashton Henwood HIM310: Healthcare Reimbursement Instructor: Crystal Sayler November 27, 2023
2 Summary A study was performed to examine the access available for Medicaid-managed care programs as enrollment increases. The study is based on an availability assessment for Medicaid- managed care providers. The assessment includes calls to a stratified random sample of 1,800 primary care providers and specialists to examine enrollee appointment availability and timeliness. The study showed that over 50% of providers were notable in offering appointments to enrollees. Furthermore, 35% of the locations listed by the plan could not be found, and 8% were unavailable to accept new patients. The median wait time for a provider is two weeks, some ranging from one to two months or longer. Lastly, primary care providers were less likely to accept appointments than specialists despite having a longer waiting period (DHHS, 2014). Chapter Six Case Study: Managed Care Managed care is a system where Medicaid enrollees receive their health care services from a limited network of providers under contract to provide services to Medicaid beneficiaries at predetermined rates (MACPAC, 2022). The Patient Protection and Affordable Care Act (ACA) which was enacted in 2010, intends to make health insurance more affordable and accessible, expand Medicaid coverage to low-income adults, and support the innovation of healthcare delivery methods to lower the overall cost of healthcare (ACA, 2022). Under the ACA , states decide whether or not they wish to expand Medicaid eligibility. Most states provide numerous, or all, Medicaid services through managed care. Expanding Medicaid eligibility is optional rather than required under the Patient Protection and Affordable Care Act (MACPAC, 2022). Over time, there is a significant increase in enrollment needs. Following CMS's recommendations to
3 analyze enrollment access and quality data measurement are essential components for improvement in these areas. With increasing enrollment needs, Congress requested that the Office of Inspector General (OIG) assess the available access to managed care enrollees. The OIGs report OEI-02- 11-00320 found that the standards for access to care in Medicaid managed care programs vary drastically by state. Standards are not specific to provider type and area; states have various strategies to assess compliance with access standards and rather range from one primary care provider for every 100-2,500 enrollees. While various methods are used to examine access standard compliance, direct tests are uncommon (Murran, 2014). It is necessary to improve these standards to improve managed care access and address its quality. In regard to Medicaid managed care access to enrollees, several improvement actions can be taken. Initiating and enforcing a national standard for wait times for specific appointments may improve access. Validating and analyzing plan compliance and payment analysis can be executed by conducting surveys annually to independent auditors (secret shoppers) and enrollees. It is recommended that CMS improve oversight of state standards, methods, and efforts to improve standards are developed for key providers, assess compliance, ensure the conduction of direct tests, improve state efforts to identify and address violations, and provide technical assistance and share any effective practices (Murran, 2014). Establishing a National maximum standard for appointment wait times and improving state monitoring is essential to ensure standards are met. It would benefit states to provide data to CMS by reporting their Medicaid provider rates relating to Medicaid FFS and managed care. This proves beneficial as it would provide evidence on whether or not rate reductions harm access to care. Lastly, instilling a
4 framework for a quality rating system would act as an excellent resource for enrollees to compare managed care plans by state (CMS, 2023). All of these recommendations would positively affect access to managed care. Differences in an organization's case mix greatly affect a case study's findings. In addition, it affects the accuracy of findings when comparing organizational findings and the quality of care an organization provides. A case mix index, or CMI, is a standard measure for quality care within hospitals. Evaluating and identifying the level of illness severity in patients is the main measurement element. Hospitals with a higher CMI treat many ill patients, which factors into the hospital's overall clinical outcome. However, a higher CMI also means that the hospital has treated more intensive, complex, or medically needy patients. This higher CMI leads to a higher reimbursement rate for complex cases. An example of how different case mixes result in varied results would be conducting studies on specific patient populations. Results cannot be generalized to populations with different case mixes, and the outcome is difficult to compare. When analyzing case studies, case mixes must be across different organizations (SHC, 2023). Measuring quality data effectively and appropriately is important, as it identifies areas needing improvement to provide the best care for patients. Conclusion Managed care access standards vary drastically by state. Due to increasing enrollment needs, the current methods used to examine access standards and their compliance need significant improvement. Standard improvement actions include National standard initiation and enforcement, independent audits, enrollee and secret shopper surveying, direct testing, and providing a framework for quality rating systems. Lastly, conducting case studies for quality data
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