the face of alabama medicaid december 5, 2006. demographics fy 2005 medicaid covers: 20.7% of...

The Face of Alabama MedicaidDecember 5, 2006

DemographicsFY 2005

Medicaid covers:

• 20.7% of Alabama’s total population (includes all eligibility categories)

• 46% of all deliveries in Alabama

• 37.9% of Alabama’s children (under 19)

• 19.7% of Alabama’s elderly (65 and above)

• 74% of nursing home days in Alabama

Children in Working Families As of September 2005

Source: Obtained for MLIF and SOBRA populations based on information from Medicaid applications as filed.

Eligibles Percent Distribution by Race FY 2005

Aids For Physicians

External Communications

• Expanded Agency Website

• ListServs

• General Stakeholders, Pharmacy, Hospice, DME, LTC, PCCM Physicians, Transformation Stakeholders

• Online Publications

• Shopping Cart For Patient Education Materials

• Town Hall Meetings

www.medicaid.alabama.gov • Changes based on input from 2004 Town Hall

meetings

• Searchable fee schedules, databases

• Agency forms, manuals and brochures

• Link to EDS secure website

• Emergency and Disaster Information - Katrina

• Average 62,000 individual visits/month

Agency Website

Other Activities

• Online newsletter, Medicaid Matters

• CD ROM Education for Physicians• Asthma

• Medical Home and Health Literacy

• Electronic Distribution of Manuals

• Policy Advisory Task Forces• Physicians

• DME

• PCCM

• LTC

• P&T

• DUR

Alabama’s Primary Care Case Management Waiver Program

Goal

Improve health care outcomes for Medicaid recipients

through creation of a Medical Home while containing the escalating cost of quality

health care.

Program Redesign . . .

This time around …

• A cost effective model

– More program accountability

– Have ability to demonstrate success

• More focus on affecting outcomes

– Effective patient management tools through program enhancements

– Patient information

Show Me The Money

• Changes . . . – PMP determines case mgt fee – Based on contractual components– PMP will share in any savings– Performance Measures

• And the Money is . . .– $1.60 average case management fee– 22 PMPS receiving $2.60– $625,536 in case mgmt fees/

March 06

PMP Decides Case Management Fee

EPSDT Provider $0.45

VFC Participant $0.10

Medical Home CME $0.10

24/7 Coverage $0.85

Hospital Admitting Privileges $0.30

In-Home Monitoring (Disease Mgmt) $0.10

InfoSolutions Participant $0.50

Electronic Notices $0.05

Electronic Educational Materials $0.15

$2.60

Case Management Fee Components

• EPSDT– PMP performs own screenings

• Vaccines for Children– Enrolled as VFC provider

• Medical Home Project– Completes training regarding establishing and

maintaining medical home for patients

• 24/7 Arrangements– Provides direct after hour coverage as specified– Does not automatically refer to Emergency

Department

• Hospital Admitting– Has hospital admitting privileges and

admits own patients

Case Management Fee Components

• In-Home Monitoring

– Agrees to work with Agency/partners to place in-home monitoring services for select patients

• InfoSolutions– Agrees to work with BC/BS and utilize the

InfoSolutions/e-Prescribing pharmacy data

• Electronic Notices– Agrees to receive notices from Medicaid/EDS

via e-mail or fax

• Electronic Educational Materials– Agrees to receive educational items via

electronic means/reproduce for assigned Patient 1st patients

Moving Into the 21st CenturyTools to Help the PMP Manage the Patient

In-Home Monitoring

InfoSolutions

ePrescribing

In-Home Monitoringaka Disease Management

• Partnership with USA Medical School and the Alabama Department of Public Health (ADPH)

• Telemetry concept

• Targets chronic diseases through claims utilization

• Diabetics initial phase

• Monitor blood sugars, weight and blood pressure

• Coordination with Primary Physician

• Supported with case management

• Web based with real-time reporting available

InfoSolutions

•Purpose is to inform providers of patient activity based on Medicaid paid claims data.

• Desktop or PDA tool for physicians

• Download patient information

•Access prescription and medical claims history

• Utilization

• Diagnoses

• Lab results

e-PrescribingComponent of InfoSolutions

• Download prescription history

• Automatically alerted to potential drug-to-drug interactions

• Prescribe/refill multiple medications

• Electronic submission of prescriptions

• Establish “favorites” list of frequently prescribed medications

• View both Blue Cross/Medicaid formulary

Successful …

• 18,458* InfoSolutions hits• 6,323* e-Prescribing hits • 213** PMPs contracted

• Additional Case Management monies paid (50¢ per patient per month)

• Not so successful– Termination of fees if no utilization– Reviewed quarterly

*1st quarter of CY 06** as of April 20th

Patient Interventionaka Case Management

• Health Department case managers work with patient to resolve issues identified– Direct referral from physician (no form required)

• Targeted to:– Frequent use of ED

– Non-compliant patients

• Available for:– Interaction with In-Home Monitoring

– Persons identified by Agency and PMP

Everything You Need To Know About Your Patients

• Periodic Re-screen List – EPSDT (monthly)– Identification of children due a screening

• Referral Report (aka I Did Not Refer Report) (monthly)– Identification of instances in which the provider’s number

was used without permission

– Keep in mind “cascading referrals”

• Emergency Room Management Report (quarterly)– Identification of who is going to the ER and why

• Profiler (quarterly)

The Profiler

• Provider Report Card

• Bigger is Better

• Overall Patient and Cost Comparison

• Pharmacy Information– Including costs and utilization

• Performance Measures– Basis for Shared Savings Distribution

– Process Measures Now

– Outcomes Measures In Future

• Generic Dispensing Rate: – The percentage of generic prescriptions ordered for the

PMPs panel as compared to the peer group.

• Visits Per Unique Member: – Average number of visits per recipient seen by the PMP as

compared to the peer group. This measure is annualized.

• Number of Non-Certified Emergency Room Visits: – Average number of recipients that are utilizing the

emergency room as compared to the peer group. This measure is annualized.

Measures of Success

Every noble work is at first impossible.

Thomas Carlyle