Workshop/Breakout Title Workshop/Breakout Speaker(s)

1. Financing Early Childhood Systems: Lessons from the Past and Challenges for the Future - The Medicaid Perspective March 7, 2006 Anne Marie Murphy, Ph.D. Illinois Medicaid Director Workshop/Breakout Title Workshop/Breakout Speaker(s)

2. About Illinois Today • 5th in the nation in population – 12.4 million • > 850,000 children under age 5 • > 550 children under age 3 • 102 counties – 77 considered rural • 66% of population resides in Chicago and six counties surrounding Cook County • Illinois Healthcare and Family Services (HFS) is the agency responsible for Medicaid and SCHIP • Medicaid and SCHIP covers about one-third of children; about 40% of the children under age 3 • Medicaid covers about 45% of the State’s 185,000 births • Eligibility Standards: 200% - children up to age 19; 185% for their parents/caretaker relatives • Primarily Fee-for-Service; Voluntary Managed Care in Cook County and five counties downstate

3. Role of Medicaid To impact the health care delivery system, improve health outcomes and address the health care needs of the highest risk population: Medicaid is a good place to start…

4. Access to healthcare for All Children • Currently, Illinois covers 1.2 million children through Medicaid and SCHIP • Medicaid and SCHIP are virtually identical and we call it all KidCare • There are still 250,000 uninsured children in Illinois • Lack of insurance drives up everyone’s costs due to cost shifting to private insurance • Lack of insurance affects children’s academic performance

5. All Kids • Just as we as a nation recognize the right of every child to a public education, Governor Blagojevich has championed the right of all children to have access to affordable health care. • All uninsured children irrespective of income or immigration status are eligible • Built on Medicaid’s comprehensive services • Not free care, but rather affordable care • Remove stigma of Medicaid – all children will be in the All Kids Program

6. An Insurance Card is not Enough! • Transforming the Medicaid program into a coordinated health care program that promotes medical homes (PCCM) • Expanding the network of providers: expedited payment, adequate preventive reimbursement rates • Collecting information for providers so they know what care their new patients have had • Provider profiling – strong emphasis on maternal and child health indicators

7. Primary Care Case Management • Implement for 1.2 million participants – July 1, 2006 • Provide a “medical home” • Focus on preventive and primary care services • Facilitate access to specialty care • Expand provider network – PCCM fees • Ensure access to appropriate health care services (outreach to children “miss” EPSDT screenings) • Monitor on key performance measures • Perform ongoing provider feedback Anticipated Results: Coordinated health care delivery system; “medical home” concept realized; improved health outcomes and reduction in unnecessary health expenditures

8. States’ Opportunities • With so many children in one healthcare delivery system, states really can provide leadership with respect to healthcare • Can reduce the number of uninsured children • Can enhance private/public partnerships: • Title V, advocates, providers, foundations • Can really impact the content and quality of health care delivered • Can pilot and “test” new strategies for improving health outcomes For Positive Change: The time is right – now!

9. Medicaid – A broad menu with innovation possible! • EPSDT: Comprehensive package of services, including well child screenings, based on a periodicity schedule, with a broad preventive focus: • Developmental Screening, (federal req.) including mental development, anticipatory guidance and referral, as needed • ObjectiveDevelopmental Screening (Illinois) – separate CPT code and reimbursement rate – unbundled from preventive office visit for reimbursement, irrespective of billing private insurance • Recognition of Perinatal Depression as a “risk assessment” for infants (up to a year)

10. What we have learned:Provider Involvement - Key • Physician Training: ICAAP, IAFP, Others (MCH advocates and partners) – in-office, web-based, grand rounds, residency programs – ABCD II • Provider Education on: • Screening Tools • Reimbursement Policies and Claims Submission • Anticipatory Guidance and Referral Resources • Pilot New Strategies and Models for identification, referral and treatment = improve health outcomes

11. What we have learned:Partnerships - Key • Early Intervention System • Family Case Management and WIC • Advocate Groups, Private Foundations, Public Health Sector • Technical Assistance through EDOPC (Healthy Steps model) • Collaboration with Other Partners • UIC Perinatal Depression Consultation Service (provider consultation)

12. How we have paid for it: • Medicaid federal match for: • Local foundation monies for provider training (Michael Reese Health Trust, Commonwealth) • Local health department (governmental entities) for outreach to young children not accessing services (determined through data matching efforts) • State Plan Amendment for local governmental entities to recoup their costs for services, over and above EPSDT reimbursement • Covered Services (flexibility through EPSDT to recognize services)

13. Perinatal Depression: Medicaid Reimbursement Why: • Prevalence of perinatal depression – 7-20%, higher with low socio-economic populations • Maternal depression adversely impacts a child’s development How: • Comprehensive Prenatal and Postpartum Care – Medicaid covered • EPSDT requires health screening, including mental/developmental assessment – Medicaid covered Priority Goal: Improve Health Outcomes • Risk Assessment – component of prenatal care • Risk Assessment – component of EPSDT/well child screenings • Reimbursement for Covered Services is allowed

14. Reimbursement Methodology:Risk Assessment Risk Assessment: • Prenatal Risk Assessment H1000 • Postpartum Risk Assessment 99420 HD • Infant Risk Assessment 99420 HD Medical Record Documentation: Record “risk assessment” in the infant’s medical record. Provide anticipatory guidance and referral, as needed. Screening tool – give to mother.

15. Reimbursement Methodology:Developmental Screening • Developmental Screening CPT 96110 • Developmental Assessment CPT 96111 Medical Record Documentation: • Screening/Assessment findings in the child’s medical record • Document anticipatory guidance and referrals

16. Opportunities in Managed Care • Specify content of care requirements – in contract • Engage in Performance Improvement Project (PIP) on EPSDT and Perinatal Care • Measure baseline data – provide feedback, report outcomes • Implement Quality Improvement (collaborative) • Re-measure – require improvement and provide feedback

17. Challenges Encounter Rate Clinics: • Need for detail in administrative data (to document content of EPSDT services) – unbundling rates • Use of data for assessing content of care through CPT Codes • Findings: FQHCs and other Encounter Clinics not providing sufficient detail – only enough to get reimbursement for the office visit • Resolution: Involvement of Provider Associations; Stakeholders; Presentation of Findings; Future Training and Ongoing Provider-Specific Feedback • Managed Care Organizations: encounter data

18. Early Results • Increase in the number of Women Screened (Risk Assessment) SFY 2004 5,968 unduplicated women SFY 2005 22,830 unduplicated women • Increase in the number of Developmental Screenings for Children (under age 3) SFY 2004 76,000 screenings SFY 2005 88,000 screenings

19. Medicaid Makes a Difference Illinois Medicaid is positively impacting: • Provider Practice - to ensure developmentally oriented care, including screening and referral through reimbursement and provider training • Managed Care Organizations’ Practice – to include monitoring in its Quality Assurance Program • Encounter Rate Clinics (FQHCs) and other providers – to promote identification of all services provided for evaluating content of care • Fee-for-Service System – by implementing the PCCM model with accountability and provider feedback

20. Lessons Learned • Investing in child health and development early – positively impacts the future • Medicaid has a large role • This is an ongoing process; in constant need of improvement • Partnerships are vital to success • There are tough choices – a close look may lead to changes • Resources must be available and feasible • Sustainability only when providers “buy-in” • Feedback is vital • Positive change through strategic planning and implementation takes time

21. Questions? Questions?

22. Questions? Thank you!