This project studied two features of the Massachusetts Medicaid plan, “MassHealth”: Quality Improvement Plan and the Insurance Reimbursement Program. The Quality Improvement Plan report described and evaluated quality improvement (QI) activities conducted under the Commonwealth’s Medicaid Section 1115 waiver. This report described specific activities in Massachusetts’ primary care case management program with managed care organizations (MCOs); including the organizational structure supporting these activities. In addition, an evaluation of aspects of the QI activities directed to the primary care case management program was conducted. Massachusetts actively incorporated managed care practices in a primary care case management program, and required MCOs contracting with MassHealth to pursue QI activities. The state invested heavily in these activities, dedicating staff time to set goals, develop the initiatives, generate data and educational materials, and work directly with the MCOs and the network management vendor for the Primary Care Clinician (PCC) Plan activities. Many MassHealth beneficiaries who were not directly affected by these activities – those who remained in fee-for-service, and those who enrolled with a PCC Plan provider - were not included in the QI activities due to having fewer than 200 PCC Plan enrollees on their panels. Some strengths of the program included: (1) use of process measures that were credible to providers; (2) a well-developed system of working with individual medical practices and tailoring QI plans to each practice; (3) developed action plans consistent with QI principles including creating an open, safe environment, encouraging diverse viewpoints, and negotiating agreements; and (4) understanding the limitations of the profile data and using these data as a starting point for dialog with individual medical practices, not as the basis for rewards or sanctions.
PIC ID: 8090; Agency Sponsor: CMS-ORDI, Office of Research, Development, and Information; Federal Contact: Magee, Carol, 410-786-6611; Performer: Research Triangle Institute, Waltham, MA