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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

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Together for quality1
Together For Quality


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)


  • 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)


  • 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


Case management fee components
Case Management Fee Components


    • 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



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


  • 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


  • 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