Together For Quality

1
Together For Quality

• What If?

2
Together For Quality
Goal

• Improve health care outcomes for Medicaid
  recipients through development and use of
  clinical support tools.

3
Electronic Clinical Support Tool (ECST)

• Why - Improve health care outcomes for Medicaid
  recipients
• How Utilize information from claims and
  laboratory results
• When If not now, when
• Who All providers with focus on Patient 1st
  Primary Medical Providers (PMPs)

4
Electronic Clinical Support Tool (ECST)
Components

• Database with a significant percentage of all
  medical and pharmacy claims
• Laboratory results from commercial and hospital
  laboratories
• Immunization database
• Formulary Information
• ePocrates
• InfoSolutions
• Patient input emergency medical information

5
Electronic Clinical Support Tool (ECST)
Results

• Interface linking all components
• Patient risk indexing
• Physician to peer risk indexing eg. HgbA1c rate
  of testing or test results compared to peers
• Access to information allowing physician to
  appropriately manage high risk patients
• Case management of high risk patients by Medicaid
  in concert with physician

6
Patient 1st

• Medical Home for eligible patients
• Constant source of primary care
• Less reliance on Emergency Room care
• Coordination of referrals
• Case management by physician
• Specialized case management available when needed
• Program accountability

7
Basic Program Concepts

• Providers enroll as a Primary Medical Provider
  (PMP)
• Patients are assigned to a PMP
• Services must be provided directly or through
  referral
• PMPs are paid a monthly case management fee based
  on signed contract

8
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

9
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 of hospital
• Hospital Admitting
• Has hospital admitting privileges andadmits own
  patients

10
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

11
Program Redesign . . .

• This time around
• A cost effective model
• More program accountability
• Have ability to demonstrate success
• More focus on affecting behavior
• Effective patient management tools through
  program enhancements
• Patient information

12
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

13

Measures of Success

• 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.

14
Real World Numbers

• 1,018 PMPs Enrolled
• 944 Physicians
• 74 Clinic Based
• 448,708 Total Enrollees
• 84,247 Over 21
• 364,461 Under 21
• As of 4/20/06

15
Shared Savings

• Medicaid will share 50 of documented savings
  with Medical Home providers.
• Distribution of savings based upon combination of
  efficiency and process outcomes
• 5.7m will be distributed to Medical Home
  providers from first year savings. Distribution
  pending CMS approval

16
Moving Into the 21st CenturyTools to Help the
PMP Manage the Patient
In-Home Monitoring InfoSolutions ePrescribing
17
In-Home Monitoring

• Partnership with USA Hospital and the Alabama
  Department of Public Health (ADPH)
• Telemetry concept
• Targets chronic diseases through claims
  utilization
• Diabetics initial phase
• Can monitor blood sugars, weight and blood
  pressure
• Coordination with Primary Physician
• Supported with case management
• Web based with real-time reporting available

18
Patient Intervention

• 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

19
InfoSolutions

• Database maintained by BCBSAL
• All BCBS of Alabama claims
• Medicaid pharmacy claims
• Laboratory results from commercial labs for BCBS
  patients
• Functions
• Preferred Drug information
• Formulary information
• Drug interactions and contraindications
• Wireless prescription
• Link to State Immunization Registry

20
Data Sources
21
Benefits

• Reduces likelihood of medical errors
• Fewer duplicated tests and procedures
• Limits unnecessary hospitalizations
• Up-to-date immunization records
• Prevents adverse drug events
• Promotes continuity of care

22
Why e-prescribing?
1994 AMA study

• Pharmacists report difficulty in reading 93 of
  all prescriptions.

23
e-Prescribing lets physicians

• View medication history

• Automatically review drug interactions

• View BC and AL Medicaid formularies

• Set up favorites medications list

• Transmit prescriptions direct-to- pharmacy

24
Obstacles are those frightful things you see when
you take your eyes off your goals Henry Ford