South Carolina Department of Health and Human Services Birth Outcomes Initiative Bryan Amick Director of Pharmacy
� Medicaid Update Agenda � Managed Care � BOI � LARCs � SBIRT � Centering � Proviso 33.34 E(2) � Next Phase
Quick Facts about Medicaid in South Carolina in SFY12 • More than $11,000 is spent each minute for South Carolina Medicaid services • Medicaid covers 40% of all children in our State • About 55% of the South Carolina Medicaid population are children • Medicaid pays for more than 50% of all births and 85% of all teen births in SC
SC Medicaid Total Expenditures South Carolina Medicaid expenditures have grown 38.21% from FY2007 to FY2014. This is a 4.8% annual growth. SFY 2014 spending would be $1.2 billion (64%) higher without agency actions to control costs and improve outcomes since 2011. This would have been a 7.3% annual growth.
SC Medicaid: Expenditures by Eligibility Category
DHHS Fundamental Analysis • Social determinants are 80 ‐ 90% of health • IOM: Health care spending rising faster than GDP is – Creating a health care bubble – Depressing economic growth – State Medicaid spending could go to other needed areas such as Transportation and Education
DHHS Fundamental Analysis cont. Excess Spending: • One ‐ third of all health care spending is wasteful Unnecessary services • Administrative waste • • $750 billion nationally in 2009 Inefficient services • High prices • • If applied to 2010 Medicaid expenditures the waste would Fraud and abuse • equal $1.8 billion Missed prevention • opportunities Source: Institute of Medicine 2010
South Carolina’s Challenge and Strategy • Among those insured by Medicaid, there are great disparities in health status • Socio-economic factors are among the determinants that primarily influence health status • Targeting health investments sends more money into counties that need it, that are relatively unhealthy
South Carolina Strategic Pillars Payment Reform • MCO Incentives & Withholds � Purchasing Quality • Payor ‐ Provider Partnerships • Catalyst for Payment Reform Health Outcomes • Value Based Insurance Design Clinical Integration • Dual Eligible Project (SCDuE) � Pushing Out Excess • Patient Centered Medical Homes Costs • Telemedicine/Monitoring Hotspots & Disparities • Birth Outcomes Initiative � Providing Value to • Rural Hospital Transformation • Express Lane Eligibility the Taxpayer • Foster Care Coordination • Health Access/Right Time (HeART)
Managed Care
Managed Care Conversion Managed Care Organization Select Health 268,256 United Health Care 49,568 Absolute Total Care 89,223 BlueChoice 60,680 Medical Home Networks South Carolina Solutions 150,404 Carolina Medical Homes 16,307 Palmetto Physicians 20,604 Connection
Managed Care Conversion Managed Care Conversion MHN to MCO Transition All MHN’s are converting to MCO’s. January 1, 2014 all Medicaid managed care plans will be fully capitated Current MCOs include Blue Choice, Select Health, Absolute Total Care, Wellcare (Oct 1st) > Carolina Medical Homes membership will convert to WellCare January 1, 2014 > South Carolina Solution membership will convert to Molina Health Care January 1, 2014 > Palmetto Physician Connections membership will convert to Advicare January 1, 2014
Managed Care Conversion What Happens to Current MHN Members? All members have a choice: Some MHN members will not be eligible for the January 1, 2014 transition to a MCO � Dual Medicare/Medicaid Members � Individuals currently residing in long term care waiver programs These members will move back to fee for service Medicaid • Dual eligible members, those enrolled in waivers, and/or certain other Recipient Special Programs (RSP) were sent letters regarding their conversion back to Fee For Service Medicaid • Dual eligible demonstration project for managed care coverage enrollment may begin as early as July 2014
Managed Care Conversion What Happens to Current MHN Members? (cont.) • Those MHN’s that are converting to MCO’s will be allowed to retain current members if the plans provider networks are in place • All MHN members will be notified of their enrollment options no less than 30 days prior to go ‐ live
Managed Care Conversion What Happens to Current MHN Members? (cont.) MHN members in the new Managed Care health plans who have developed adequate networks will be transferred to that new Managed Care plan Current MHN members that are not in counties with an adequate provider network for the managed care plan conversion will be given a choice for enrollment and transferred to other Managed Care plans
Birth Outcomes Initiative
BOI � Launched in 2011, improve health of moms and babies in South Carolina and to save money � Over 100 stakeholders meeting monthly � Elimination of elective inductions for non ‐ medically indicated deliveries prior to 39 weeks gestation � Reducing the number of admissions and the average length of stay in neonatal intensive care units � Making 17P, a compound that helps prevent pre ‐ term births, available to all at ‐ risk pregnant women with a no “hassle factor” � Implementing a universal screening and referral tool (SBIRT) in the physicians office to screen pregnant women and 12 months post ‐ delivery � Promote Baby Friendly Certified Hospitals and Breast Feeding
BOI � Non ‐ Payment Policy for non ‐ medically necessary deliveries prior to 39 weeks gestation effective January 1, 2013 � First state in the nation for both Medicaid and private insurance payer (BCBSSC) to partner and to have the same no payment policy � February 2013 – introduced Phase 2 of BOI with new objectives for the 6 work groups: Behavioral Health Data Capacity Baby Friendly Care Coordination Health Disparities Patient Safety & Quality
BOI Quality Improvement Run Chart: SC Rates for Documented Elective Inductions as a Subset of the =>37 to <39 Weeks Delivery 14.00% 12.00% 11.92% 10.12% 9.83% 9.62% 10.00% 10.08% 8.31% 9.36% 8.00% Rate 7.85% State rate 6.57% 6.00% Median 9.49% 4.66% 4.00% 2.00% 0.00% Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Rate=The number of SC cases with documented inductions as a subset of the >=37 and <39 weeks delivery/ The number of SC deliveries between >=37 and <39 weeks that did not have documented medical indications
Run Chart: Medicaid Rates with Documented Elective Inductions as a Subset of the =>37 to <39 Weeks Delivery 14.00% 12.00% 12.11% 10.00% 8.69% 8.45% 8.99% 8.31% 8.89% 8.57% 8.00% 7.33% 6.00% MEDICAID rate 5.84% Median 8.51% 4.00% 3.80% 2.00% 0.00% Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Rate=The number of Medicaid cases with documented inductions as a subset of the >=37 and <39 weeks delivery. The number of Medicaid deliveries between >=37 and <39 weeks that did not have documented medical indications
LARCs – Long Acting Reversible Contraceptives • Providers rely on the patient coming to the outpatient clinic/office after discharge for the contraceptive. • This practice proved to be challenging due to the fact Medicaid beneficiaries often missed their post ‐ partum appointment which resulted in unplanned pregnancies soon after.
LARCs – Long Acting Reversible Contraceptives • Prior to March 1, 2012, LARCs were not reimbursed outside of the DRG when inserted inpatient • Providers relied on mother coming to the outpatient clinic/office after discharge for contraceptive
LARCs – Long Acting Reversible Contraceptives • SC is the only state where Medicaid covers the cost of insertion and the device immediately post delivery. • Allows providers to bill for the insertion procedure, and the cost of the device • This allows costs associated with LARC to be reimbursed, promoting preventative health practice and potential Medicaid Savings.
Medicaid Reimbursement for Immediate Post ‐ Partum LARC This policy is likely to reduce the number of repeat and unintended births as it is more convenient and less time ‐ consuming for the patient to receive a LARC. Opportunity to eliminate policy restrictions that may burden our providers Improve health outcomes for patients by removing barriers to appropriate care. Makes sense for providers and hospitals financially because it limits the number unplanned births and allows for the costs associated with LARC to be reimbursed.
SBIRT Screening Brief Intervention and Referral to Treatment An evidenced based, integrated and comprehensive approach to the Identification, Intervention and Treatment of Substance (Drug and Alcohol) Usage, Domestic Violence, Depression, and Tobacco Usage *SBIRT program in South Carolina is specific to pregnant women to include 12 months postpartum
SBIRT
SBIRT • Pregnant member is identified by health plan, Primary Care provider, or OB/GYN • Screening completed on every pregnant member: – Completed screening tool faxed to health plan and maintained in patient’s medical record – Positive screen: • Brief Intervention is performed • Patient willing to seek treatment: – Patient referred to county agency or private provider and health plan notified of referral
Screening, Brief Intervention and Referral to Treatment (SBIRT))
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