Quality and Innovation Incentive Programs. » Print This Page

Gjerset & Lorenz works with the state Medicaid agencies, hospitals, managed care organizations (MCOs), and other stakeholders to design and implement state-specific Medicaid quality improvement programs. Our services include all stages of quality program design, operations, and audits. In essence, Gjerset & Lorenz works as an intermediary between the state’s Medicaid agency, the MCOs, and the participating hospitals to coordinate collaboration and create the necessary synergy between all parties.  

Program Design & Approval

Gjerset & Lorenz brings invaluable experience from its work in multiple states to design Medicaid quality programs and can provide a turnkey solution to program development. To do so, Gjerset & Lorenz:  

  • Identifies opportunities or deficiencies within a state’s existing delivery system to develop various program initiatives designed to improve health care outcomes for a particular state’s Medicaid population.
  • Assists the state agency in obtaining federal approval of the Medicaid quality program.
  • Identifies funding for the non-federal share of Medicaid quality payments.
  • Builds networks of hospitals and providers sufficient to effectuate the healthcare outcomes improvements necessary to achieve the program’s goals.
  • Assists the state in all aspects of program development, including identification of funding sources, providing legal analysis of proposed initiatives, helping with program proposal submissions to CMS for approval, and drafting responses to budget inquiries from CMS and state leadership.
  • Educates providers in calculating risks of loss resulting from provider tax funded programs.

Program Operations

Gjerset & Lorenz provides program administration services that allow hospitals and MCOs to meaningfully improve health outcomes and significantly mitigates administrative burden on the state Medicaid agencies and MCOs of the administrative duties. Some examples of Gjerset & Lorenz’s services in this area include:

  • Works with the hospitals, MCOs, and state Medicaid agency to develop meaningful and attainable outcome goals related to health improvements.
  • Designs pathways to achieve outcome goals:
  • To ensure that all stakeholder knowledge is leveraged to the maximum extent possible, Gjerset & Lorenz works to increase coordination among MCOs and hospitals. Gjerset & Lorenz facilitates regular symposiums between hospitals and MCOs for all relevant stakeholders to share ideas and information regarding suggested program improvements, lessons learned, and program successes. Additionally, Gjerset & Lorenz holds regular provider-specific meetings for providers to discuss ideas about how to continuously improve the program.
  • Because healthcare outcomes rely heavily on community healthcare safety nets, Gjerset & Lorenz works with hospitals to form relationships with additional community resources to address access to care issues and social determinants of health.
  • Gjerset & Lorenz helps providers identify solutions that address barriers to outcome improvement, including transportation issues, limited office hours or appointment scheduling, and health equity issues.
  • Gjerset & Lorenz develops continuous quality improvement plans to ensure that providers are working toward continuous outcome improvements in the program.
  • Gjerset & Lorenz helps with all aspects of reporting data related to the program, including preparation of materials for measuring quality improvement and maintaining proper documentation to support future program audits. To do so, Gjerset & Lorenz works directly with providers on the collection, analysis, and consolidation of participant data. This step requires an understanding of the various ways that hospitals report data in order to provide accurate consolidation services among several different types of EHR systems.

Audits

Gjerset & Lorenz provides full-service support with third party audits regarding the quality incentive programs. Some examples of Gjerset & Lorenz’s services in this area include:

  • Works with hospitals to ensure that all patient level data is obtained, analyzed, consolidated and submitted in a format acceptable to third-party auditors.
  • Works with hospitals to draft all narrative responses requested from third-party auditors regarding data collection, performance calculations, and other audit inquiries.
  • Maintains data from all previous reporting periods to ensure that accurate recordkeeping procedures are followed.
  • Works with hospitals and third-party auditors to ensure that the rates ultimately determined by the auditors are the most favorable rates possible under program rules.
  • Advocates for hospitals and MCOs to ensure that the third-party auditors follow LDH guidance and quality program rules in determining achievement under quality program goals.

Outcome Achievements

Gjerset and Lorenz is proud to report that its quality incentive programs have helped improve outcomes for Medicaid patients. Please see below for some examples of healthcare outcome improvement achieved through quality improvement programs that Gjerset & Lorenz helps to administer:

  • Increased the number of members receiving quality services and interventions by over 60% in 12 months
  • Provided services to over one fourth of the state’s Medicaid members
  • 62% of Medicaid participants in the program controlled their diabetes, more than double from the previous year
  • 67% of Medicaid participants in the program controlled their blood pressure, a 17% improvement over 12 months
  • 64% improvement in the number of Medicaid participants who over-utilize the ED receiving one-on-one navigation services (including assistance scheduling primary care visits, appointment reminders, and education)
  • Increased the number of children and adolescents with well-child or well-care visits by over 22% in 12 months
  • Addressed social determinants of health through educating providers on culturally effective care, partnering with local food banks and community health centers, opening community health centers in areas with decreased medical and social services, and through van purchases to help with transportation issues. 
  • Improved coordination of care among providers, MCOs, and community resources, reducing the costs and resources associated with duplicative care.
  • Offered new services to Medicaid members and improved existing services, including diet and physical activity counseling, closer patient follow up, outreach to members due for care, appointment reminders, and digital medicine services (allowing for monitoring and adjusting treatment without an office visit).
  • Identified opportunities to bring additional services to Medicaid members through co-locating services, offering primary care services during specialty visits, telehealth, transportation, increased office hours, and navigation services.