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The Face of Alabama Medicaid December 5, 2006

The Face of Alabama Medicaid December 5, 2006. Demographics FY 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)

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The Face of Alabama Medicaid December 5, 2006

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  1. The Face of Alabama Medicaid December 5, 2006

  2. Demographics FY 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

  3. Children in Working Families As of September 2005 Source: Obtained for MLIF and SOBRA populations based on information from Medicaid applications as filed.

  4. Eligibles Percent Distribution by Race FY 2005

  5. Aids For Physicians

  6. 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

  7. Agency Website 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

  8. 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

  9. Alabama’s Primary Care Case Management Waiver Program

  10. Goal Improve health care outcomes for Medicaid recipients through creation of a Medical Home while containing the escalating cost of quality health care.

  11. 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

  12. 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

  13. 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

  14. 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 andadmits own patients

  15. 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

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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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)

  23. 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

  24. 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.

  25. Every noble work is at first impossible. Thomas Carlyle

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