Fostering Quality Improvement in the SC Medicaid Program
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- Lorena McDowell
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1 Fostering Quality Improvement in the SC Medicaid Program
2 Medicaid Matching Expenditures as a Percent of Total State General Fund Revenue Medicaid is approximately 1/ $0 $2,000,000, 000 $4,000,000, 000 $6,000,000, 000 $8,000,000, 000 $10,000,000,000 General Fund Revenue Medicaid Match Source: South Carolina Budget and Control Board, Office of Research and Statistics
3 Medicaid Total Expenditures 1,500,000 $4,750 1,400,000 1,300,000 $4,250 1,200,000 $3,750 1,100,000 $3,250 People 1,000, ,000 $2,750 Millions 800, , , , ,000 Recent Events Impacting Costs Preferred Drug List timplemented Implementation of Medicare Part D Delay in GAPS billings/utilization Active Eligibility Review Effect of coordinated care $2,250 $1,750 $1,250 $750 Enrollees Exp. W/O DSH
4
5 Eligibility Diagram by Poverty Level
6 SC Medicaid Healthcare Delivery Systems Institutions Hospitals Nursing Homes Intermediate Care Facility-MR (ICF-MR) Psychiatric Residential Treatment Facility (PRTF) Waivers MR/RD Community Choices Head & Spinal Cord HIV/AIDS Autism Ventilator-dependent PRTF Waiver Complex Children (coming) DDSN Habilitation (coming) Mental Health Habilitation (coming)
7 SC Medicaid Healthcare Delivery Systems Fee for Service (FFS) Managed Care Organization (MCO) Medical Homes Network (MHN) Health Opportunity Account (HOA)
8 Medicaid Quality CMS defines quality as the right care for every person every time. CMS partners with the state so that efforts will most likely achieve safe, effective, efficient, patient-centered, timely and equitable care. On April 25, 2007 CMS issued a State Medicaid Directors (SMD) letter to announce a national Value-Driven Health Care (VHC) initiative. The VHC consists of four "cornerstones": Interoperable Health Information Technology Transparency of Quality Transparency of Price Incentives for High-Value Health Care.
9 Quality in SC Medicaid - Need for Change Contracts for healthcare delivery contain quality expectations in the scope of work Readiness to perform Annual external reviews Ongoing quality monitoring i some outcome based Advocates tell you about quality problems Respond to unusual practices emerging in FFS data Collect HEDIS measures for internal use on FFS and Health Plans in existence Heavily focused on claims payment
10 Top Dental Codes for Children Top Five Dental Procedures by Cost for Ages 0 to 3 in SFY 08 Code Procedure Net Cost Top Five Dental Procedures by Cost for Ages 4 to 7 in SFY 08 Code Procedure Net Cost D2930 Prefab Stainless Steel Crown $1,653,665 D2930 Prefab Stainless Steel Crown $3,779,133 D1120 Prophylaxis-CHILD $1,284,439 D1120 Prophylaxis-CHILD $2,973,001 D3220 Endodontics, Vital $722,285 Pulpotomy D0150 D1203 Comprehensive Oral Eval-New/Establish Top Application of Fluoride Prophy NT $720,595 D1203 Top Application of $1,552,205 Fluoride Prophy NT D3220 Endodontics, Vital Pulpotomy $1,503,386 $666,589 D0120 Periodic Oral Evaluation $1,462,878
11 Top Chiropractor Claims for Children Top Five Procedures by Cost for Ages 1 and Under in SFY 08 Code Procedure Net Cost Patients t Top Five Procedures by Cost for Ages 2 to 5 in SFY 08 Code Procedure Net Cost Patients t Chiro Manipulative Treat (CMT) $18, Chiro Manipulative Treat (CMT) $27, Chiro Manipulative Treat (CMT) S $8, Chiro Manipulative Treat (CMT) SP $15, Chiro Manipulative Treat (CMT) SP $8, Chiro Manipulative Treat (CMT) S $8, Radiolog Exam Spine Lumbosacra $ Radiolog Exam Spine Cerv; 2 O $ Radiolog Exam Spine Thorcic $ Radiolog Exam Spine Lumbosacra $772 26
12 Coordination of Pharmaceutical Usage Too many medications can cause serious health problems DHHS is working with the SC College of Pharmacy to help educate doctors on the latest research Our goal is to ensure decisions are based on the latest clinical evidence Number of Atypical Drugs Patients 4 Atypicals 2 3Atypicals 34 2 Atypicals 662 1At Atypical 7,933 Total Patients 8,631
13 Coordination of Pharmaceutical Usage Problem: Review of utilization data within a six- month window in 2008 revealed over 135 recipients i met the following criteria: Using 4 or more Pharmacies Have 5 or more Prescribers Have at least 1 Schedule II Drug g( (Narcotic) The person with the highest number of prescribers was 17 within the six-month window and the person with the highest drug cost was over $15,000 Solution: Pharmacy Lock-In Program
14 SC Healthy Connections is our Medicaid Transformation Plan Many South Carolinians are generally of poor health 20% of the Medicaid recipients account for 80% of costs Lack of overall coordinating i force that demands & rewards value from the system Greatest capacity for effective changes is where the relationship of payer, provider and beneficiary intersect
15 South Carolina Healthy Connections
16 SC Healthy Connections Medicaid beneficiaries can voluntarily select the health delivery system that works best for them Choices include Managed Care Organizations Medical Home Network Fee for Service Health Opportunity Account (Richland County) Every day is open enrollment for new beneficiaries & annual recertification of beneficiaries Enrollment broker provides outreach calls and mailings Contracted with eight health h care plans
17 SC Healthy Connections Roll-Out January 2008 October 2007 May 2008 March 2008
18 Healthy Connections Enrollment Mail
19 Shift to Healthy Connections Managed Care Enrollment Me embers 450, , , , , , , ,000 50, Managed Care Projected Total Managed Enrollment Activities Eligibles that have Care Members State Fiscal Year Enrolled Prior to Enrollment Process in October , % As of October 1, , % 281,169 lives enrolled in either a MCO or MHN (43.5% of the eligible Medicaid population)
20 Health Plans Rapidly Emerge: 2004 In 2004, before the launch of SC Healthy Connections, the state had two Medicaid health plans About 80,000 recipients were in the plans
21 Health Plans Rapidly Emerge: 2008 Eight health h plans total One plan has statewide presence Eight counties have eight plan choices 39 counties have at least 4 plans
22 Available Plans as of October 1, 2008 Network Participation as of October 1, 2008 Counties Present Number of Enrollees SC Healthy Connections Choices Amerigroup (MCO) 26 10, Blue Choice Health Plan (MCO) 32 7,166 Carolina Cresent Health Plan (MCO) 33 12,775 CHC Cares (MCO) 18 3,125 First Choice (MCO) ,170 South Carolina Solutions (MHN) 38 64,247 Total Carolina Care (MCO) 39 28,196 Unison Health Plan (MCO) 32 32,322 Subtotal for HCC 281,169 SC Healthy Connections Kids Amerigroup (MCO) 25 1, Carolina Cresent Health Plan (MCO) 28 1,268 First Choice (MCO) 46 4,245 Unison Health Plan (MCO) Subtotal for HCK 6,849 Fee for Service* ,153 Grand Total Enrollment as of Oct 1, ,171 *Figures are based on Preliminary August 2008 eligibility reports and excludes limited services eligibles. Fee for Service eligibles include members that are not eligible for Manged Care enrollment.
23 HEDIS Measures Show Delivery System Value Well Visits and Dental Care for Children Increase from FY2006 to FY2007 Under Expanded MCO Care Based on HEDIS Measures Rate (visits pe er 1,000 member mo onths) FFS MCO 10 0 Annual Dental Visits Infants with 6+ Well Visits in Well Visits 3-6 Year Olds Adolescent Well Care Visits First 15 Months
24 HEDIS Measures Show Delivery System Value Adult Well Visits Increase While Adult ER Visits Decline from FY2007 to FY2008, Based on HEDIS Measures ths) 1,000 member mont FFS MCO Rate (visits per Adult ER Visits Adult Well Visits Cervical Cancer Screening Breast Cancer Screening Appropriate Asthma Drug Usage
25 HEDIS Measures Show Delivery System Value Comprehensive Diabetes Care Comparison SFY 2007 and FFS MCO Percent HbA1c Testing Eye Exam (Retinal) Performed LDL-C Screening Performed Medical Attention to Nephropathy
26 Value Driven Health Care - Emerging Coordinated care contracts require value Care management outreach to beneficiaries provide instruction Value of medical home to beneficiary How to use the health care system HEDIS Measures/National Certification Quality Studies Internal DHHS quality review programs for FFS and Waiver beneficiaries are under review Update waiver contracts requirements to require outcomes based programs Standard review of clinical programs
27 Value Driven Health Care Mature SC Medicaid will be purchaser of value-driven healthcare h Pay for performance indicators will be part of all our major contracts More members will be monitored by HEDIS measures Targeted studies to help shape care delivery to address chronic disease & health status Report card measures to guide beneficiary choice
28 Medicaid Summary in South Carolina SFY 08 claims payments were approximately $4.5 billion Medicaid pays for 50% of all births in South Carolina and 85% of all teen births 30% of all children in South Carolina are on Medicaid Over 50% of Medicaid members are ages 0 to 18 Medicaid pays for three-fourths of the nursing home beds in SC By focusing on quality, we can improve outcomes and achieve a higher, more effective return on our investment.
29 Conclusion
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