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MetaStar’s Role in MCO Quality Reviews

Jun 19, 2024

“Do not regret growing older,” said Mark Twain. “It is a privilege denied to many.” While we’re not entirely sure Mark Twain is the author of this adage, the truth in the statement still rings clear: aging is not a disease to be fought, but a stage of life to appreciate and possibly even enjoy. However, aging can also bring health issues, loss of ability, financial struggles, and lack of a support system. By 2040, the number of Americans age 65 and older will reach 21.6%, according to the Administration for Community Living (ACL), up from 16% in 2000. Additionally, people who are disabled—who make up almost 27% of the population according to the United States Centers for Disease Control and Prevention—experience similar challenges.

These groups of people often face challenges caring for themselves. While some lucky people can self-fund care in aging years or disability, many others lack the financial resources for these situations. While Medicare and private insurance can alleviate medical costs and replace lost wages, medical care isn’t the only need to arise when a person becomes unable to care for themself.

Medicaid enrollees receive medical care, but they also require support in their homes and communities for various tasks, including at-home medical tasks, personal care, home care, pet care, errands, and much more. However, most health insurances won’t cover these services outside of a medical setting. Older adults or people with a disability are then caught in a web of problems: Can they self-pay for care? Is there a friend or relative who can help them? Should they move to a nursing home or assisted living facility? Depending on the extent of needs, some of these options aren’t possible. Fortunately, Wisconsin offers various ways to meet the long-term care needs of older adults and people with disabilities while allowing them to stay in their own homes.

The Wisconsin Way of Meeting Long-Term Care (LTC) Needs

Wisconsin provides LTC services through Medicaid Managed Care programs, including Home- and Community-Based Services (HCBS), through the following programs: Family Care (FC), Family Care Partnership (FCP), and the Program of All-Inclusive Care for the Elderly (PACE). FC is offered statewide while FCP and PACE are only offered in certain counties. These programs, operated by managed care organizations (MCOs), provide a variety of healthcare and other services that allow people to remain in their homes. When a person enrolls in one of the HCBS programs, they need to choose an MCO to work with as care is coordinated through the enrollee’s team at the MCO.

Wisconsin has four MCOs. When an MCO plays such an important part in a person’s life, choosing the right one becomes essential. How can anyone compare such large and varied organizations? MetaStar helps maintain program standards and contributes data to user-friendly scorecards for each MCO. Potential enrollees can easily compare options and select the most suitable one based on impartial data that has been collected and reviewed by MetaStar.

MCO Scorecards—MetaStar Makes the Difference with Data

MetaStar’s Quality Compliance Review team conducts reviews annually to gather data for the MCO scorecards. The team reviews each MCO in the state. “It’s a comprehensive system-level evaluation to determine that they are meeting requirements and hopefully exceeding them,” said Alicia Stensberg, project manager for the External Quality Review Department at MetaStar. Data for the scorecard comes from program enrollee surveys, an extensive document review, and employee interviews, with the latter two completed by MetaStar’s team.

The MetaStar team reviews documents such as policies and procedures, monitoring data, training information, contracts, correspondence, and much, much more to ensure these documents meet the metrics set by the state and federal governments. Employee interviews conducted over two or three days, involving various groups of staff members—everyone from information technology to care team members to leadership to support and supervision staff gets interviewed. The interviews are done to corroborate the findings from document review, but Stensberg finds them interesting for another reason: “It’s neat to hear [the staff] talk about their passions for supporting members and helping people live full and safe lives. I hear about the different initiatives that they have and the ways that they’re being collaborative with different organizations and different resources, all in the name of supporting members. It’s a cool experience.” She cites an example of another state’s Medicaid program addressing gun violence, highlighting the importance of caring for enrollees’ needs beyond direct medical care. Stensberg continues: “If you’re looking at caring for the whole patient, gun violence is very, very real for so many of the Medicaid recipients. The amount of impact Medicaid has amazes me.”

Data from the review process helps reviewers identify a requirement as “met” or “not met.” If something is found to be deficient, Stensberg explains, the Wisconsin Department of Health Services (WI DHS) can implement a corrective action plan for the organization to make improvements.

The hundreds of pages of MetaStar’s technical review are distilled into key areas for MCOs, such as such as satisfaction, responsiveness, communication, care delivery, quality standard, staff turnover and staff ratios. The WI DHS compiles this data into easy-to-compare scorecards.

Additionally, the review data is reported to the Centers for Medicare & Medicaid Services (CMS) as an Annual Technical Report, which is hundreds of pages long (and available online for anyone who is interested.)

The MetaStar Quality Review Team

The Quality Reviewers are part of the MetaStar External Quality Review Department. Stensberg calls them “some of the most amazing people I’ve ever worked with. All of them are such strong advocates for the individuals receiving services and really understand how the systems operate.” They all have 10 years or more of experience in LTC or a related field, such as nursing, counseling, social work; they’ve worked with children’s programs and family care organizations. Stensberg herself previously worked with adults with disabilities, and, like the rest of her team, she thinks it helps her in her current work. While she misses the job, “I’m glad to be here because I’m still part of the field. I think I’m having an impact on a broader scale.” This all-star team ensures regular assessment of the MCOs so participants can be assured that the scorecards are a carefully considered collaboration between WI DHS and caring, patient-focused MetaStar reviewers.

In addition to the MCO reviews and scorecards, the External Quality Review Department is involved with another HCBS-waiver program: Include, Respect, I Self-Direct (IRIS). This unique program allows enrollees to have more control over what care they receive, where they receive it, and when. Be sure to check in next month when we discuss the IRIS program and its formula for giving enrollees more influence in the direction of their healthcare as well as more choice and more independence.

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