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CASE STUDIES
INFORMATICS
Managed Care Encounter Data Concerns
THE CHALLENGE: The state has six health plans running on different systems. The current data vendor was not able to collect all the required data, process the information, and upload it to the state’s data warehouse in time for rate-setting activities. We developed master data requests and liaised with multiple contractors to identify the data elements that satisfied the required efficiency analyses. Mercer worked directly with the state's MCOs to ensure that data submission was consistent and accurate.
CHILD BEHAVIORAL HEALTH
Moving to Managed Care
THE CHALLENGE: The state was tasked with restructuring the Medicaid program to achieve improvement in outcomes, sustain cost and build a more efficient administrative structure. Key features included moving behavioral health services from fee-for-service into managed care and incorporating the ability to manage specialty behavioral health services. MCOs would now be responsible for managing integrated physical health, behavioral health and home and community based services.
ACTION TAKEN AND RESULTSSUD SERVICES AND MEDICAID
Providing SUD Services
THE CHALLENGE: The state wanted to expand capacity for an array of ASAM levels of care and support adoption of medication-assisted treatment while supporting providers and managed care organizations in this transition by helping them fully understand service definitions, provider qualifications and billing expectations. It was necessary to gather current SUD program and staffing information from providers in order to assist in provider reimbursement and capitation rate development.
PHARMACY PROGRAM EFFICIENCIES
Enhancing MCO Capitation Rate Setting
THE CHALLENGE: Faced with rising medical trends and a shrinking state budget, the state engaged us to identify and quantify inappropriate use of medications within their capitated MCO pharmacy programs. Confidence in the credibility of a pharmacy-specific rate-adjustment process that identified program inefficiencies was required. The development of an actuarially sound algorithm and analytical tool producing defendable results required the integration of clinical, pharmaceutical, and actuarial expertise.
ACTIONS TAKEN AND RESULTSLET'S GET SOCIAL
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