Making Medicaid Work for You

1
Making Medicaid Work for You Presented by Marsha
Morris, Commissioner Bureau of Medical
Services West Virginia Department of Health and
Human Resources November 5, 2007
2
Mountain Health Choices The First Step Toward a
New Medicaid

• West Virginia is taking steps to improve the
  health of Medicaid members.
• Mountain Health Choices (MHC) represents the
  first phase in West Virginias effort to redesign
  Medicaid.

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Medicaid Redesign
Medicaid Redesign Implementation Plan
PHASE I Children and Adults with Children
(TANF Population)
PHASE II Pregnant Women
PHASE III Elderly
PHASE IV All Other Populations
4
DEMOGRAPHICS West Virginia Beneficiaries By
Expenditures
WEST VIRGINIA MEDICAID BENEFICIARIES AND
EXPENDITURES BY ENROLLMENT GROUP
100
Elderly (31,144)
90
Blind Disabled (91,190)
80
Adults (60,233)
70
Children (191,316)
60
50
40
30
Note Beneficiaries are
20
enrollees who received
a Medicaid service.
10
Blind Disabled
0
includes adults,
children, and elderly
who qualify based on a
disability.
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Deficit Reduction Act of 2005
Deficit Reduction Act of 2005

• The DRA changes the face of Medicaid.
• Rx
• LTC Transfer of Assets
• Fraud and Abuse
• Benefits and Cost Sharing
• Financing
• Grants
• West Virginia is poised to move Medicaid to a
  model that emphasizes preventive care,
  partnership, personal empowerment and
  responsibility.

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Improving Childrens Health in West Virginia

• Cause
• Unhealthy Diet
• High Smoking Rate
• Lack of health education

• Effect
• 21 childhood obesity rate
• 12 of WV children have at some point been
  diagnosed with asthma

• Solution
• Care Management
• Preventative Health Care
• Health Education
• Healthy Rewards

7
Healthy Adults
Improving Parents Health in West Virginia

• State of Poor Health
• 10 of WV adults have been told by a physician
  that they have diabetes
• 285 in 100,000 WV adults have chronic heart
  disease
• 13 of WV adults have asthma
• WV adults rank 41st in physical activity
  participation
• 64 of WV adults are obese, ranking next to last
  in the country

• Solutions
• Care Management
• Personal Responsibility
• Preventative Health

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Goals of West Virginia Medicaid Redesign
Mountain Health Choices An Overview

• Goals of MHC
• Establishment of a Medical Home
• Tailor benefits to needs of a specific population
  
• Coordinate care, especially for members with
  chronic conditions
• Provide members with the opportunity and
  incentives to maintain and improve their health

• Hallmarks for Members
• Prevention
• Personal Responsibility
• Establishment of a Medical Home
• Care Management

9
Mountain Health Choices Implementation

• Implementation Dates
• 1. March 1, 2007 Began in three pilot counties
• 2. September 1, 2007 Phase 1 of Statewide
  expansion- 16 counties
• 3. October 1, 2007 Phase 2 of Statewide
  expansion- 21 counties
• November 1, 2007 Phase 3 of Statewide Expansion-
  9 counties
• Six counties are currently in the process of
  contracting with HMOs

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Basic Benefit Package

• Basic Coverage
• The Basic Plan covers all mandatory services and
  some optional services, but with limits
  including
• Four prescriptions per month
• Five NEMT round trips per year
• Maximum of 25 home health visits annually

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Enhanced Benefit Package

• Member
• Agreement
• Signature required for enrollment in Enhanced
  Plan
• Outlines responsibilities of members
• Encourages appropriate use of the health care
  system
• Signature required for enrollment in Enhanced
  Plan

• Health
• Improvement Plan
• Member and physician develop health plan for the
  next year
• Health Improvement Plan includes
• preventive screenings
• immunizations
• laboratory tests
• number of well / sick visits
• health education classes
• Reflects EPSDT standards for children

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Enhanced
Enhanced Benefits Package

• Enhanced
• Education Classes
• Weight Management Programs
• Nutritional Education
• Diabetes Education
• Smoking Cessation

• Enhanced
• Health Care Coverage
• Cardiac Rehabilitation Services
• More non-emergency medical transportation
• No limits on the number of prescriptions
• Contact lenses for children
• Clinic and rehab services

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Healthy Rewards
Healthy Rewards Concept

• Guiding Principles
• Provide strong incentives to promote healthy
  behaviors and personal responsibility
• HRs should be simple for member to understand and
  access
• HRs should not impose additional work on
  providers

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Advanced Medical Home
Medicaid Transformation Grants

• Pharmacy
• Medicaid
• E Health

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Advanced Medical Home
MTG - Pharmacy

• Automated Prior-Authorization System
• POS Enhanced Coordination of Care System
• Clinical Web Portal

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Advanced Medical Home
MTG - Improved Medicaid

• Project Management
• Advanced Medical Homes
• Health Improvement Institute
• Healthy Reward Accounts
• Education and Outreach

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WV HEALTH IMPROVEMENT INSTITUTE
ADOPTION OF ELECTRONIC HEALTH RECORDS Develop
proposed mechanisms to accelerate adoption of
electronic health records in West Virginia
EDUCATION OF THE PROVIDER COMMUNITY To develop
a system of provider engagement to accelerate
Medicaid Transformation and assist physician
practices with migration to AMH
MEASUREMENT Create a forum of alignment of
measures across stakeholders to facilitate
reporting
SELF MANAGEMENT SUPPORT To align and improve
access to resources and best practices to improve
the self-activation capacity of all patients
PAY FOR PERFORMANCE To provide guidance on the
deployment of a P4P program as a model for the
State
QUALITY COLLABORATIONS To support a focused
collaboration of key stakeholders on improving
quality, building on past initiatives
Advanced Medical Homes Pay 4 Performance Evidenced
Based Medicine Health Information Systems
Member Education Healthy Rewards Advanced Medical
Homes
Electronic Health Information Provider Technology
Incentives
OTHER RELEVANT INITIATIVES WV HIN WVMI - OTHERS
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Electronic Health Records
Advanced Medical Home

• A team approach to careutilizing advanced
  information systems (including a standardized
  electronic health record) redesigned, more
  functional offices, and a whole-person
  orientation that focuses on quality, safety and
  care provided in a community context.

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Advanced Medical Home
MTG e-Health

• Electronic Medical Records
• Electronic Prescribing
• Provider Portals
• Benefit Management
• Care Coordination

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HIE requires common interests and TRUST among
participants

• Health Information Exchange projects must
  develop a community vision and a strong business
  value to secure vested community interest and
  develop TRUST among the many stakeholder
  entities.
• Evolution of State Health Information Exchange/ A
  Study of Vision, Strategy, and Progress

21
West Virginia Perspective

• An early effort at Health Information Exchange in
  West Virginia SHINE- failed because of a lack
  of common interest and trust among health care
  providers.
• In 2006, the West Virginia Health Information
  Network (WVHIN) was established to design a
  statewide, interoperable health information
  technology network within 5 years.
• Governor Manchins Health Action Plan The
  ultimate purpose of West Virginias health system
  should be to ensure the best possible health
  outcomes for all West Virginians. Both physical
  and mental health are essential components of
  overall health. Prevention and health promotion
  must be cornerstones of West Virginias health
  policy. E-health, or health information
  technology, is a cornerstone of a high-value
  health care system.

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HIT and HIE to support West Virginia Medicaid
Redesign

• Electronic Health Systems need to
• support enhanced access to preventive and disease
  management services, defined personal health
  management goals and responsibilities and rewards
  for healthy behavior
• meet needs of Advanced Medical Home
• provide integration with telehealth applications
  and
• facilitate advanced planned care with strong
  self-management components.

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Coordinating health care delivery the
opportunity for health information exchange

• 52 acute care community hospitals, 18 critical
  access hospitals, 6 rehab, 4 VA, with a total of
  70 hospitals
• Seven state-operated facilities, 2 behavioral
  health facilities, four long-term care, one
  community hospital (all implementing a version of
  the VAs Vista EHR)
• 14 behavioral health centers, and 65 certified
  intermediate care facilities
• 34 nonprofit primary care centers, with 139
  primary care service sites (including 41
  school-based health centers), providing services
  in or to 47 counties
• 54 local health departments, 73 home health
  agencies and 20 hospice organizations
• 3,743 MDs and 507 DOs active and practicing in
  West Virginia according to the respective
  licensing boards. Approximately one-third of West
  Virginias physicians are self-employed in a solo
  practice. More than one-third of West Virginias
  physicians provide primary care.

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Harnessing the Power of HIT for Health Improvement

• Studies indicate that 20 to 40 of diagnostic
  tests are duplicated due to lack of results being
  readily available and the potential benefit of
  full HIT integration as producing a reduction in
  laboratory and radiology test ordering by 9 to
  14, lowering ancillary test charges by up to 8,
  reducing hospital admissions, costing an average
  of 17,000 each, by 2 to 3, and reducing excess
  medication usage by 11.
• Studies predict a gain of as much as 30 in
  efficiency from EHR use and HIE, mostly through
  reducing unnecessary tests and prescriptions,
  paperwork and medical mistakes. In West
  Virginia, this amounts to a potential 3 billion
  savings of total health spending of 10 billion
  (the total state general revenue budget for 2007
  was 3.629 billion) and nearly 1 billion for
  West Virginia Medicaid.

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Lessons Learned - Early Stages

• Community health centers can be leaders in health
  improvement and EHR adoption
• Leverage health improvement, EHR alone is not a
  silver bullet to improve outcomes and contain
  cost without system improvements
• Data warehouse and HIE require ability to capture
  and report information electronically at the
  point of care (paper to bytes)
• Exploring ways to coordinate with MITA to build
  and finance infrastructure (90 match)
• Focus EHR acceleration and financing support at
  the primary care and community health level for
  greatest ROI.

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Mountain Health Choices Additional Information

http//www.wvdhhr.org/bms/
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Contact

• Marsha Morris, Commissioner
• West Virginia
• Department of Health and Human Resources
• Bureau for Medical Services
• [phone]