BadgerCare Plus: Healthy Birth Outcomes Initiative

1. BadgerCare Plus: Healthy Birth Outcomes Initiative Infant Mortality Study Committee Jason Helgerson, Medicaid Director Department of Health Services November 16, 2010

2. History • Pay-for-Performance Workgroup established October 2007 • Diverse, multi-stakeholder group • Charge: Develop strategic plan for addressing disparities in birth outcomes

3. History (cont.) • Recommendations from P4P group • Develop and distribute registry identifying women at risk for a poor birth outcome • Strengthen PNCC requirements, including accountability • Require all HMOs to develop strategic plans for high risk women • Create incentives around birth outcomes

4. Results • All recommendations adopted • High-Risk Report implemented June 2009 • Revised PNCC guidelines and certification criteria—implementation in progress • 2009 State HMO contract required submission of detailed plan for addressing the needs of high-risk women

5. Results – SE WI BadgerCare Plus RFP • In 2008, ~ 40 percent (13,000) of Medicaid births were in six SE WI counties—Milwaukee, Kenosha, Ozaukee, Racine, Washington, and Waukesha. • Disparities in health outcomes are greatest in this part of the state. • RFP for BadgerCare Plus HMO Contract issued Fall 2009 for SE Wisconsin that includes:

6. Results – SE WI • Stricter requirements for provider network and access, including access to dental and specialty care providers • Specific criteria related to reduction of emergency department use • Contract encourages assignment to a primary care provider that can appropriately address their needs. • Special requirements related to healthy birth outcomes, including a new emphasis on inter-conception care

7. Results – SE WI • Separate contract awarded to four HMOs to provide services in the six counties: • Abri Health Plan • Children’s Community Health Plan • CommunityConnect Health Plan • United Healthcare • Contract effective September 2010; key requirements to improve birth outcomes effective January 2011.

8. SE WI HMO Contract Requirements • Medical home pilot for high-risk pregnant women • Poor birth outcome assessment • MOU with PNCC providers in their service area • Coordination with community-based agencies, especially those working on healthy birth outcome initiatives

9. Medical Homes for High Risk Pregnant Women • Target Population • Pregnant; and • On high-risk registry, provider-identified as eligible for registry, or <18; and • Live in high-risk areas of Milwaukee, Racine or Kenosha OR have a chronic condition

10. Medical Home Pilot (cont.) • Enrollment • 100 members/HMO (CY 2011); 200 (CY 2012); 300 (CY 2013) • Within first 20 weeks of pregnancy • Follow through 60-days post-partum • RFP HMO Contract includes specific requirements for pilot sites

11. Medical Home Pilot (cont.) • Incentive Payments • Enhanced payments beginning July 2011 • Additional $1,000/birth for every birth to an eligible member in the pilot • If positive birth outcome, an additional $1,000 • Payments to HMO must pass-through to provider/medical home site

12. Medical Home Pilot (cont.) • Implementation on January 1, 2011 • 12 pilot sites located throughout Milwaukee; one site in Kenosha • Semi-annual reports to DHS • Extensive evaluation • Qualitative and Quantitative

13. Poor Birth Outcome Assessment • Target Population • Women enrolled in HMO for 5 months prior to birth, and • On High Risk Report OR • Less than 18 years old • Financial penalty for poor birth outcome and unsatisfactory care

14. Poor Birth Outcome Assessment (cont.) • Poor birth outcomes— defined as any of the following • Baby born pre-term (< 37 weeks) • Baby born at low birth weight (<2500 grams) • Baby born at high birth weight (>4500 grams) • Baby dies within 28 days after birth

15. Poor Birth Outcome Assessment (cont.) • Satisfactory Care defined based on ACOG and other national guidelines • DHS EQRO will conduct chart review of all poor birth outcomes to determine whether woman received satisfactory care • Audits begin July 2011

16. Poor Birth Outcome Assessment (cont.) • Penalty • HMO assessed $2,000 per birth for each member who had a poor birth outcome and did not receive satisfactory care

17. Other Steps to Ensure Quality Care • Moving High-Risk Report to web-based portal • HMOs will report high-risk women previously unknown to Medicaid • Care coordination covered for women at high-risk for a poor birth outcome • Care coordinators primary role is to assist pregnant women in accessing both medical and non-medical care

18. Other Steps to Ensure Quality Care • Health and nutrition education covered under PNCC • Health care navigator in Kenosha – sole function is to assist pregnant women in accessing prenatal care • SE RFP HMOs are required to provide medically necessary, high-risk prenatal care within 3 weeks of member’s request.

19. Quality Care (cont.) • HMOs and care coordination providers required to have MOU establishing communication protocols • Covered Services • Targeted case management statewide • Mental health & substance abuse screening • Preventive mental health counseling & substance abuse brief intervention

20. Quality Care (cont.) • Covered services (cont.) • Over-the-counter tobacco cessation products, e.g., nicotine gum & patches • Brand & generic prescription drugs for tobacco cessation • Alpha hydroxyprogesterone (commonly referred to as 17-P) for women with history of pre-term labor • Transportation to and from covered services

21. Quality Care (cont.) • Reimbursement for elective and non-medically indicated C-sections the same as for vaginal delivery • No cost sharing (premiums or copayment) for pregnant women

22. Steps to Improve Early Enrollment • Express enrollment of pregnant women – same day eligibility through end of following month • Once ongoing eligibility determined, pregnant women retain their eligibility through 60 days post-partum. • Several points of entry for Medicaid and BadgerCare Plus, including face-to-face, telephone, internet and mail-in applications • Same system (ACCESS) used for applying for BadgerCare Plus, emergency food assistance, FoodShare and child care assistance

23. Early Enrollment (cont.) • More than 200 community partners trained to provide enrollment assistance via ACCESS • Automated process for documenting citizenship and identity (using SSN data exchange) • Electronic process for submitting verification documents (formerly mail-in only) • Significantly shortened period between Medicaid eligibility and HMO enrollment

24. HMO Enrollment • Enrollment specialists available to assist members in making informed choices about plan enrollment, disenrollment, exemptions, general questions • Members in SE have several options for choosing a HMO, including the option to choose at time of application

25. HMO Enrollment (cont.) • Once enrolled in a HMO, members have 90 days to switch to another HMO, then are locked in for 9 months. • Some members are eligible for exemptions from HMO enrollment, including continuity of care with established providers outside HMO networks (e.g. nurse midwives), or for women who are in their third trimester.

26. Summary • Significant progress made in addressing birth disparities between white and non-white births in SE Wisconsin • Initiation of high-risk registry for women at risk of having a poor birth outcome • Financial penalties and incentives around birth outcomes (e.g., $2,000 assessment) • Four southeast HMOs working together on improving birth outcomes

27. Summary (cont.) • HMOs more engaged with community partners and other local efforts to reduce disparities • Greater emphasis on the importance of outreach, member education and follow-up for missed appointments • Medical Home sites to place focus of care on member, including providing care in a culturally sensitive manner

28. Summary (cont.) • 2011 initiatives will continue this progress (i.e., medical home, financial assessment for poor birth outcomes) • Data from these initiatives, including an evaluation of the Medical Home Pilot, will inform future efforts to reduce racial and ethnic disparities, one of the most pressing challenges facing the State of Wisconsin

29. Summary (cont.) • Single point of entry for all BadgerCare Plus programs, FoodShare, and Child Care. • Potential to expand to include other programs • Open to idea of exploring the feasibility of adding an integrated data collection platform (similar to the Illinois Cornerstone System)

30. Questions