Prevention/Care Management, 2009
State of Wyoming
Wyoming's Office of Healthcare Financing refined measures used for program evaluation as a result of participating in the Medicaid Care Management Learning Network, an AHRQ Knowledge Transfer program. The Learning Network serves State Medicaid agencies that operate care management programs for chronically ill beneficiaries in fee-for-service plans or primary care case management programs. Wyoming is one of 17 States participating in the Learning Network.
The Learning Network provides expertise to participating States in four key areas critical to ensuring a quality-driven care management program:
- Helping patients become active in their care.
- Encouraging provider participation in care management programs.
- Creating program interventions aligned with the State's measurement strategy that will impact patient care.
- Designing valid and reliable evaluations to determine program success.
Wyoming provides care management services to Medicaid beneficiaries through a contract with APS Healthcare that began in 2004. This care management service, known as the Health Management program, is available to all Medicaid beneficiaries in the State. The Health Management program serves approximately 82,000 members through three program components: disease management; complex case management; and prevention and education.
Teri Green, Wyoming Medicaid Director, states, "AHRQ's valuable assistance and expertise with program evaluation provided us with the impetus to continue to build and improve our program."
AHRQ provided technical assistance on program measurement during several calls with Wyoming officials and the Learning Network workshops. Wyoming staff received an overview of the importance of measurement through the Learning Network workshops.
Workshop sessions focused on aligning measures with interventions and reviewing evaluation methods (e.g., random control trials versus pre/post tests). Using the measurement expertise of AHRQ staff and AHRQ's publications, Designing and Implementing Disease and Care Management Programs: A User's Guide, and Monitoring and Evaluating Medicaid Fee-For-Service Care Management Programs: A User's Guide, the Agency provided recommendations on the following:
- Defining the numerator and denominator of each measure: This is important because State staff need to determine the appropriate claims system codes specific to the measure (numerator) and the eligible population of the care management program (denominator).
- Involving physicians in the selection of goals: Physician support and buy-in are critical for the success of a care management program. By involving physicians in the selection of measurement goals, States can earn their support and trust.
- Setting appropriate measurement goals: To create a successful measurement strategy, a State must choose goals for its measures. As part of this process, AHRQ staff suggested that Wyoming distinguish between absolute and relative improvements (e.g., a 10 percent increase from 60 percent means that the vendor must increase the rate by 10 percent instead of six percent).
- Measuring medication adherence and use: AHRQ staff recommended possible measures for understanding how many Medicaid care management program members are using prescribed medications appropriately.
With AHRQ's assistance, Wyoming staff refined measures used for evaluating the third year of its vendor contract with APS Healthcare. The measures included setting forth certain financial and quality goals. If APS fails to achieve the specified goals, a percentage of the fees the State paid are returned.
In order to encourage APS to focus on improving performance in targeted areas, State staff reduced the number of measures the vendor was financially responsible for achieving from 20 to 10 measures. To provide additional incentive for meeting goals, Wyoming officials increased the percentage of fees the vendor risks losing if it does not meet the specified goals.
For more information on the Learning Network, go to: http://www.ahrq.gov/qual/medicaidmgmt/
Impact Case Study Identifier: KT-OCKT-19
AHRQ-Sponsored Activity: Medicaid Care Management Learning Network
Topic(s): Policy, Chronic Disease Management
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Current as of November 2009
Impact Case Studies and Knowledge Transfer Case Studies: Prevention/Care Management, 2009. November 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/casestudies/pcm/pcm2009.htm