Birth Outcomes Initiative Bryan Amick Director of Pharmacy Medicaid - - PowerPoint PPT Presentation

Bryan Amick Director of Pharmacy

South Carolina Department of Health and Human Services

Birth Outcomes Initiative

Agenda

Medicaid Update 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.

• One‐third of all health care

spending is wasteful

• $750 billion nationally in 2009
• If applied to 2010 Medicaid

expenditures the waste would equal $1.8 billion

Source: Institute of Medicine 2010

Excess Spending:

• Unnecessary services
• Administrative waste
• Inefficient services
• High prices
• Fraud and abuse
• Missed prevention
• pportunities

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
• Payor‐Provider Partnerships
• Catalyst for Payment Reform
• Value Based Insurance Design

Clinical Integration

• Dual Eligible Project (SCDuE)
• Patient Centered Medical Homes
• Telemedicine/Monitoring

Hotspots & Disparities

• Birth Outcomes Initiative
• Rural Hospital Transformation
• Express Lane Eligibility
• Foster Care Coordination
• Health Access/Right Time (HeART)

Purchasing Quality Health Outcomes Pushing Out Excess Costs Providing Value to the Taxpayer

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 Connection 20,604

MHN to MCO Transition

Managed Care Conversion

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)

Managed Care Conversion

> 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

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

Managed Care Conversion

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
• ffice 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

10.08% 11.92% 10.12% 9.83% 9.62% 8.31% 9.36% 7.85% 6.57% 4.66%

0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Rate State rate Median 9.49%

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

8.57% 12.11% 8.69% 8.45% 8.99% 8.31% 8.89% 7.33% 5.84% 3.80%

0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 MEDICAID rate Median 8.51%

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
• utpatient 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
• utpatient 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

• ur 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.

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

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))

Patient Centering/Pregnancy

• Centering Pregnancy is a multifaceted model of group care

that integrates the three major components into a unified program:

• Health Assessment
• Education
• Support
• 3 year consulting contract with Dr. Amy Picklesimer of

Greenville Hospital System

• During GHS’ own implementation of Patient Centering

there was a 47% reduction in low birth weight babies amongst the Centering mothers

• Address provider shortage areas
• Connects urban specialty care with

rural patients

• May increase cost efficiency
• Lessens transportation concerns
• Strengthens communication among

providers Examples of Services Include:

• Consultation – Inpatient & Outpatient
• Pharmacologic Management
• Neurobehavioral Status Exam
• E&M Office Visits

Telemedicine

Proviso 33.34 Section E(2) and Telemedicine

“The department shall develop a program to leverage the use of teaching hospitals to provide rural physician coverage, expand the use

• f Telemedicine, and ensure targeted placement

and support of OB/GYN services in at least four (4) counties with a demonstrated lack

• f adequate OB/GYN resources by July 1, 2014.”

• Selected four target counties based on

IFS Data: Bamberg, Barnwell, Allendale and Hampton

• Working with MUSC and USC to

incorporate specialty MFM care for patients that are identified as high‐risk through use of Telemedicine equipment

Proviso 33.34 Section E(2) and Telemedicine

• Next Goal: to promote intended vaginal births for primary delivery method
• SCDHHS/BOI to immediately launch a 6 month campaign with South Carolina

Hospital Association and the March of Dimes

• Each birthing hospital will receive their individual hospital‐specific

C‐section data by end of October from SCHA

• After educational campaign we will be assessing opportunities for policy and

reimbursement changes

BOI Next Phase

2nd Annual South Carolina BOI Symposium

2nd Annual BOI Symposium November 14th Featured national speakers are:

• Dr. Michael Lu, US Department
• f Health and Human Services
• Dr. Scott Berns, March of Dimes

National Office

• Dr. Kathryn Menard, UNC

Maternal‐Fetal Medicine

• Mary Alice Grady, MS, CNM,

CenteringHealthcare Institute

Thank you