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The Truven Health Blog


The latest healthcare topics from a trusted, proven, and unbiased source.


Managing Medicaid Managed Care and Encounter Data


By David Nelson/Monday, May 19, 2014
David Nelson imageMedicaid agencies have increasingly turned to managed care organizations (MCOs) to deal with the tremendous increase in enrollment driven by the Affordable Care Act (ACA). The Centers for Medicare and Medicaid Services (CMS) released an Encounter Data Toolkit in November of 2013 to assist states with the operational task of managing the data streams from their MCO contractors. 

While most states are collecting encounter data, many face challenges in assessing the quality of data, and some still lack the confidence in their data to use it for rate setting, quality improvement, or public reporting. Over the past 15 years, Truven Health has helped nearly 20 states with their managed care programs and encounter data quality and completeness. We have assisted agencies with encounter data and managed care at all points of the encounter data process, including plan selection and evaluation, data collection, edit revisions, data quality improvement, and using data for plan management.

Most states choose to collect and process managed care data using their Medicaid management information systems (MMIS), for reasons that include the following:
  • The state can leverage the electronic data collection and translation processes already used for fee-for-service (FFS) claims.
  • The MMIS transaction system allows the state to process managed care data on a record-by-record basis, performing such tasks as editing and shadow pricing using procedures/protocols that are familiar because they are also used for FFS data.  
  • All data are maintained in the same system of record. The managed care data are housed with the FFS service data, which allows the Medicaid agency to incorporate all of the data, as needed and appropriate, in federal and state reports.
However, processing managed care data through the MMIS can also have drawbacks. Other states have experienced such issues as:
  • Delays in implementing new processes for managed care data because of the competing demands from FFS claims processing and associated system change orders.
  • Over-rejection of managed care encounters when edits designed for FFS claims processing are inappropriately applied to managed care records, which have already been adjudicated by the health plan.
  • Delays in the ongoing processing of managed care encounter data because persistent data quality issues cause repeated edit failures. This problem can be exacerbated if processes for resubmitting rejected records aren’t well designed and/or well understood and followed by the plans.
  • Inaccurate use or interpretation of managed care data in reporting and analysis because the nuances of encounter data are not accounted for in standard reports or communicated to users performing ad hoc analysis.
To avoid the above problems, states can either make appropriate adjustments to their MMIS systems and processes to fully accommodate encounter data, or consider other system options. States that are planning to re-procure their MMIS systems in the near future have the additional consideration of how much to invest in the existing MMIS system. This is particularly true for states that are moving to statewide, capitated managed care.

Some states have recently asked Truven Health about collecting encounter data directly from their managed care organizations. States could use their data warehouse decision support system (DW/DSS) to collect and process encounter data as either an interim approach or as a longer term process independent of the MMIS. Factors in support of loading the data directly into the DW/DSS include:
  • The DW/DSS is designed to incorporate managed care data – the data model and analytic reporting applications already anticipate the inclusion of managed care data. The DW/DSS provides a single, integrated repository for FFS and managed care data, capable of supporting transformed Medicaid statistical information systems (T-MSIS) and other federal reporting, as well as state-specific reporting needs.
  • By outsourcing this specialized function to a vendor like Truven Health that is highly experienced with encounter data, a state might help speed the availability of the quality data needed for performance monitoring, rate-setting, and public accountability. 
  • Our experience with the validation of managed care data will also help speed improvements in data integrity and increase credibility of the information.
Specifically, Truven Health’s managed care encounter data services, using the DW/DSS would include:
  • Receiving, processing, and translating managed care encounter data
  • Editing encounter data and providing feedback reports to managed care plans for resubmission
  • Storing encounter data and making it accessible for analysis alone or with FFS data
  • Incorporating encounter data into select federal reports
  • Validating and improving encounter data accuracy and completeness
  • An annual in-depth study of the quality of encounter data and development of a Data Quality Improvement Plan with each managed care organization
As Medicaid agencies turn to MCOs to deal with the tremendous increase in enrollment driven by the ACA, they have a partner in their DW/DSS contractors to implement the best practices outlined in the Encounter Data Toolkit. For more information you can contact me at david.nelson@truvenhealth.com.

David Nelson
Vice President, Market Planning & Strategy

Comparing the Quality of Care in Medicare Options and All Plans: A Difficult Task Worth Doing


By Ray Fabius/Thursday, January 24, 2013
Ray Fabius imageAs Dr. Reinhardt has mentioned there is a dearth of evidence in the literature to clearly demonstrate that managed care models are consistently out-performing traditional Medicare models.  Differences in model type (HMO, PPO, POS), in network access (broad versus narrow), and in regional influences and illness burden greatly complicate this effort.  However, from a theoretical standpoint managed care should be superior to unmanaged care.

The pursuit of patient satisfaction surveys and quality and efficiency metrics should be encouraged and required for all health plans regardless of model type.  Those that outperform should be recognized with additional compensation – as noted by my colleague Dr Bithoney, happily this is happening today albeit on a limited basis – and promoted broadly to expand their membership. 

AHRQ, NQF, NCQA and others have worked diligently over a few decades to create measures that can be calculated with administrative data.  With the growing availability of real-time lab and pharmacy data newer metrics are being enhanced.  And as physicians convert from paper records to electronic platforms the task of evaluating the health status of populations over time and against predicted trends will be possible and should be encouraged – particularly by Medicare.  Through the greater use of data including that from diverse and non-traditional sources or ‘big data’ we should be able to determine the best health plans and optimal delivery models, and secure the financial future of this most important program. 

Ray Fabius MD
Chief Medical Officer

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