Together for quality
This presentation is the property of its rightful owner.
Sponsored Links
1 / 24

Together For Quality PowerPoint PPT Presentation


  • 67 Views
  • Uploaded on
  • Presentation posted in: General

Together For Quality. What If?. Together For Quality. Goal. Improve health care outcomes for Medicaid recipients through development and use of clinical support tools. Electronic Clinical Support Tool (ECST). Why - Improve health care outcomes for Medicaid recipients

Download Presentation

Together For Quality

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Together for quality

Together For Quality

What If?


Together for quality1

Together For Quality

Goal

Improve health care outcomes for Medicaid recipients through development and use of clinical support tools.


Electronic clinical support tool ecst

Electronic Clinical Support Tool (ECST)

  • Why - Improve health care outcomes for Medicaid recipients

  • How – Utilize information from claims and laboratory results

  • When – If not now, when

  • Who – All providers with focus on Patient 1st Primary Medical Providers (PMPs)


Electronic clinical support tool ecst1

Electronic Clinical Support Tool (ECST)

Components

  • Database with a significant percentage of all medical and pharmacy claims

  • Laboratory results from commercial and hospital laboratories

  • Immunization database

  • Formulary Information

    • ePocrates

    • InfoSolutions

  • Patient input emergency medical information


Electronic clinical support tool ecst2

Electronic Clinical Support Tool (ECST)

Results

  • Interface linking all components

  • Patient risk indexing

  • Physician to peer risk indexing eg. HgbA1c rate of testing or test results compared to peers

  • Access to information allowing physician to appropriately manage high risk patients

  • Case management of high risk patients by Medicaid in concert with physician


Together for quality

Patient 1st

  • Medical Home for eligible patients

    • Constant source of primary care

      • Less reliance on Emergency Room care

    • Coordination of referrals

    • Case management by physician

    • Specialized case management available when needed

  • Program accountability


Basic program concepts

Basic Program Concepts

  • Providers enroll as a Primary Medical Provider (PMP)

  • Patients are assigned to a PMP

  • Services must be provided directly or through referral

  • PMPs are paid a monthly case management fee based on signed contract


Pmp decides case management fee

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


Case management fee components

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 of hospital

  • Hospital Admitting

    • Has hospital admitting privileges andadmits own patients


Case management fee components1

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


Program redesign

Program Redesign . . .

This time around …

  • A cost effective model

    • More program accountability

    • Have ability to demonstrate success

  • More focus on affecting behavior

    • Effective patient management tools through program enhancements

    • Patient information


The profiler

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


Together for quality

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.


Real world numbers

Real World Numbers

  • 1,018 PMPs Enrolled

    • 944 Physicians

    • 74 Clinic Based

  • 448,708 Total Enrollees

    • 84,247 Over 21

    • 364,461 Under 21

      * As of 4/20/06


Shared savings

Shared Savings

  • Medicaid will share 50 % of documented savings with Medical Home providers.

  • Distribution of savings based upon combination of efficiency and process outcomes

  • $5.7m will be distributed to Medical Home providers from first year savings. Distribution pending CMS approval


Moving into the 21st century tools to help the pmp manage the patient

Moving Into the 21st CenturyTools to Help the PMP Manage the Patient

In-Home Monitoring

InfoSolutions

ePrescribing


In home monitoring

In-Home Monitoring

  • Partnership with USA Hospital and the Alabama Department of Public Health (ADPH)

  • Telemetry concept

  • Targets chronic diseases through claims utilization

  • Diabetics initial phase

  • Can monitor blood sugars, weight and blood pressure

  • Coordination with Primary Physician

  • Supported with case management

  • Web based with real-time reporting available


Patient intervention

Patient Intervention

  • 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


Infosolutions

InfoSolutions

  • Database maintained by BCBSAL

    • All BCBS of Alabama claims

    • Medicaid pharmacy claims

    • Laboratory results from commercial labs for BCBS patients

  • Functions

    • Preferred Drug information

    • Formulary information

    • Drug interactions and contraindications

    • Wireless prescription

    • Link to State Immunization Registry


Together for quality

Data Sources:


Benefits

Benefits:

  • Reduces likelihood of medical errors

  • Fewer duplicated tests and procedures

  • Limits unnecessary hospitalizations

  • Up-to-date immunization records

  • Prevents adverse drug events

  • Promotes continuity of care


Why e prescribing

Why e-prescribing?:

1994 AMA study:

  • Pharmacists report difficulty in reading 93% of all prescriptions.


Together for quality

e-Prescribing lets physicians:

  • View medication history

  • Automatically review drug interactions

  • View BC and AL Medicaid formularies

  • Set up “favorites” medications list

  • Transmit prescriptions direct-to-pharmacy


Together for quality

Obstacles are those frightful things you see when you take your eyes off your goals

Henry Ford


  • Login