Editor's note: The following is an edited excerpt of the transcript of a May 22 editorial webcast, “Making Medicaid Work,” conducted by Modern Healthcare. The panelists were Bill Galinsky, vice president of governmental finance at Scott & White Healthcare in Temple, Texas; Beth Kidder, assistant deputy secretary for Medicaid operations at the Florida Agency for Health Care Administration; and Dr. Ross Wilson, corporate chief medical officer at the New York City Health and Hospitals Corp. In a discussion moderated by Modern Healthcare Washington reporter Rich Daly, the three panelists discussed strategies for how healthcare providers can maximize Medicaid reimbursement and work more collaboratively with their state Medicaid programs.
Rich Daly: My first question is for the hospital representative. I wonder if you could give us any examples of the types of challenges presented by the movement to more managed care for the Medicaid population and how your hospitals have tried to overcome those obstacles?
Dr. Ross Wilson: I think there are significant mechanical obstacles, but there are also cultural obstacles to move our system and all systems from a volume-driven model, where people are thinking about how many visits or how many beds or how many something to a relationship that is not based on volume but it's based on how patients' healthcare improves and health status improves over time. … And at the present time to have both models going simultaneously where a significant percentage of our patients are managed and relationships are managed, a significant percentage of these are service- or activity-based, provides a very major challenge to the technical management. And this transition over time is challenging a lot. And I'm not sure we have all the right answers to it.
Daly: My next question is for Ms. Kidder. Can you tell us when states talk about Medicaid managed care, what exactly do they mean? And are states paying capitated rates to providers? Are you looking to enroll patients in private plans that will coordinate their care?
Beth Kidder: When you talk about Florida in this context, we have about every kind of model that you could possibly imagine going on at the same time. We have what you would consider private health maintenance organizations under capitated arrangements at full risk for all of the medical services. We have what we call provider service networks, which have to be majority provider-owned and some of which operate under capitated arrangements and some of which operate fee-for-service with a cost reconciliation at the end of the year to ensure that there are certain levels of savings achieved. We have primary-care case management, which is technically a managed-care model.
What it is in Florida is individuals having a primary-care practitioner that they are assigned to, that they have chosen who gets a modest monthly fee to serve as the gatekeeper for their care and to ensure that they can get connected to specialty care as needed and do some basic authorization of services. Those are at least three of the models operating. We have nuances among all of them. As far as I know, other states have similar mixes. They might not have all of them at once like we do in Florida, but I think that would probably cover most models.Daly: I also wanted to follow up with Dr. Wilson. A lot of the Medicaid cost increases or one of the big drivers has been excessive emergency-department use, and I'm wondering: Did your system have any success in addressing that—excessive emergency-department use—among the Medicaid population, and if so, could you give us a couple of examples or obstacles to that?Wilson:
I think we've been working on this—despite our best efforts we've had a 5% increase in the number of emergency-department visits last year to well over a million visits across our system. Some of the problem areas when we come to address these, particularly in the Medicaid population, are the fact that many of the socially more-disadvantaged patients are using the emergency department in the absence of adequate social support, whether it's a shelter or housing or other community supports … And so we've strengthened our work with external agencies enormously. We've strengthened our work with case managers in the emergency department. We've strengthened our work in trying to connect particular groups to particular programs.
We did a pilot program called the chronic illness demonstration project at three of our hospitals at Bellevue, at Elmhurst, at Woodhull, which has actually provided intensive case management for very frequent utilizers of the emergency department, and we've found that nearly 50% of this very, very high utilizer group did have precarious housing. And the majority of them had a behavioral health or chemical dependency comorbidity or main diagnosis. With that group, we were able to demonstrate a reduction in emergency department and inpatient use and a reduction in cost to Medicaid over a period of 24 months. But the intensity of the case management required almost all of the benefits financially. Daly: And Mr. Galinsky, I also wanted to check if your hospitals have had any success in controlling prescription drug costs in terms of using PBMs or any other initiatives in the state.Bill Galinsky:
We have had some success with that. We have pharmacy benefit managers. The state Medicaid program has a drug formulary that works with many of the retail pharmacies as well as the provider community to try and reduce the costs and look for alternative medical treatment—or medication treatments that are less costly and, as a result, benefit the taxpayers of the state by keeping those costs down. They've also placed limits on the number of prescriptions that the Medicaid recipients can receive.Daly: When a patient shows up at a Scott & White facility, what systems are in place to verify their Medicaid eligibility, and what happens if they are eligible? What happens if they aren't?
When they show up, they're screened initially for insurance, for Medicaid. We have a Medicaid-eligibility vendor on site at all of our facilities. If they're not showing up as Medicaid-eligible, either through search engine or having a Medicaid card on them, then we'll begin the process of attempting to get that patient qualified for Medicaid, and have a decent success rate, but ... I think we've got more opportunity to go there.Daly: Dr. Wilson, can you give us any idea of how tech-savvy your Medicaid population is? Are they capable of taking advantage of cost-saving measures like electronic scheduling or telemedicine? Can you give us a sense of that?Wilson:
To try and understand this for ourselves, on one of our particular programs, which was patients seen in primary care if you had schizophrenia, we did some focus groups to work out what level of technology access and school level they had. Sixty percent of this population wanted to be able to communicate with us through a smartphone. They wanted to be able to schedule an appointment. ... The size of that figure surprised us a little bit, and so we think we have probably underestimated both the access to technology and also the wishes of many of our patients to use it as we go forward, and that's figuring into our technology plans as we go forward. So as we're looking at this, we're looking very hard at what constitutes elements of another patient portal or a patient health medical record and how that would interact with the rest of our systems and how that would also help improve their care. Daly: Ms. Kidder, can you give us any sense in Florida, does the state Medicaid program have any idea at this point about the tech-savvyness of its Medicaid population?Kidder:
I can't quote you the statistics right off the top of my head, but we do have a survey that is done every year on the (Children's Health Insurance Program) and the Medicaid population to determine access to the Internet, and it is a rapidly growing sector of the population. We do see a lot of uptake on what we call our recipients portal on Department of Children and Family where Medicaid recipients can get in, check the status of their eligibility and do a number of tasks such as updating addresses and so forth through the Web, and it is a rapidly growing percentage of recipients who have taken advantage of that and are using that. So I think what we are seeing is that as an overall trend, that the tech-savvyness is there. Now, the one exception to that is the senior population, where we consistently see a lot of resistance, even to automated phone systems where you have to touch 1 to get somebody or 2 to get a different department. Daly: Dr. Wilson, have you found any success with any of the social networking tools reaching your Medicaid population?
Wilson: We are in the middle of a program that was actually driven by a group of adolescent patients in one of our clinics who wanted to use Twitter to both connect with each other but also to get reminders from us about appointments and some other activities. And we are in the process of working through what that means as driven by the patients and how we can make that fit more effectively into a system that is unfamiliar with it and is learning how to use it. So I think we're looking at some pilot studies in the social networking tools because we believe partly the patients want this and they have access, and partly I think it actually has enormous ability to bring patients together … So I think there's a big possibility here where I think we're at the beginning of this journey, and I think we're being led to it by the patients who want us to go there.
Daly: Dr. Wilson and Mr. Galinsky, could you address any initiatives your systems have undertaken in response to reduced reimbursement rate? Are there any examples in particular you found where you were able to maximize reimbursement or initiatives that you undertook specifically in response to reduced reimbursement rates in Medicaid?
Wilson: I think that apart from a very general across-the-system approach to cost reduction, which we've been embarking on very steadily and trying to get efficiencies, I think in this area, the two things we've been doing are: One, actually maximize the eligible revenue that we have through the earlier things we discussed on this call—both the eligibility of Medicare recipients and the appropriate billing and collection process. But secondly we are really looking very hard at some of our chronic-disease practices, which have involved bringing patients back and having them seen more often. … I think we're also looking in the pharmaceutical and test areas as to whether the appropriate practices based on best evidence and also efficiency of follow-up. We're working hard in that area, particularly around hypertension and diabetes at the present time.
Galinsky: Our cost-reduction efforts, we're feeling the squeeze everywhere on revenue—both Medicare and Medicaid, other insurance payers—and so our cost-reduction efforts are not focused on a particular patient population, but really more on gaining efficiencies, looking at the Lean way of doing things, trying to drive waste and cost out of the system that's either duplicative or doesn't need to be there. And then a dual approach on all payers, but particularly on Medicaid, is looking for ways to maximize what we can get under the reimbursement models before us, (such as) a focused effort on coding to make sure that we're getting appropriate coding so that we're getting everything we can out of a DRG payment.