Healthcare Business News

Webcast transcript: Making medicaid work

By Modern Healthcare
Posted: October 27, 2012 - 12:01 am ET

David May: Good morning. Thank you for joining Modern Healthcare's editorial webcast. Today we'll listen to a discussion with three executives—two from hospital systems and one from a governmental agency—on strategies for making Medicaid work for providers and patients. How can providers maximize reimbursement and work better with their state Medicaid programs? Before we begin, we have a few housekeeping items to address: Your phones will stay in listen-only mode during the entire webcast. However, listeners can send questions throughout this event. Our moderator will ask as many as possible before the hour is up. You can find the questions window on the right-hand side of your screen connected to the webcast dashboard that appeared when you first joined the call. A recording of today's discussion will be available on our website, Within a few days, all attendees will receive a follow-up e-mail, including a link to that recording. Slides used during today's presentations will also be available online. And now, I'd like to turn the webcast over to Rich Daly, a Modern Healthcare reporter and the moderator for today's webcast. He will introduce our panelists today. Rich?

Rich Daly: Thank you, Dave. Thank you all for joining us today. States and providers right now are facing a range of healthcare delivery and financing challenges amid ongoing tight budgets. Today, we will hear how one state and two hospital groups are addressing cost in Medicaid while working to improve care. Our first panelist today is Bill Galinsky, vice president of governmental finance at Scott & White Healthcare in Temple, Texas. Our second panelist is Beth Kidder, assistant deputy secretary for Medicaid operations at the Florida Agency for Health Care Administration. Our third panelist is Dr. Ross Wilson, corporate chief medical officer at the New York (City) Health and Hospitals Corp. Each of our panelists make a brief presentation before we move to questions. Mr. Galinsky, would you like to begin first?

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Bill Galinsky: Sure. Good morning. My name is Bill Galinsky, as Rich just mentioned, and I want to thank Modern Healthcare for this opportunity to talk about making Medicaid work. And one of things about making Medicaid work is that if the state agencies and provider community don't work together, then I don't believe Medicaid will work. And that's being demonstrated more and more throughout the country, I believe. Next slide.

We've got severe state funding issues as has been exacerbated by this recent recession. It's hitting every state. Texas has not been immune to that, although we have fared better than many states in the budgetary concerns. But at the start of our most recent biennium, we were looking at a $28 billion shortfall. Texas Legislature and budget run on a biennial basis. The Legislature is elected in even years and meets in odd years. In addition to the $28 billion shortfall that we were facing, the mantra was no taxes. That meant no new taxes, no raising taxes, no anything that looked like a tax. There was an idea floated for a while called a “quality assurance fee” that would have been essentially a net revenue tax on providers. That was squashed in the legislative session due to this mantra of no taxes—no new taxes, no any kind of taxes. Throughout the process, healthcare was a target and there were severe reductions in Medicaid and other healthcare programs. Also, the state education program was severely cut, and so working together was the only way we were going to make this move forward. And as a result of the healthcare area being a target for more and more of the responsibility for care and payment is being shifted from the state to the provider community. One of the biggest hits in the most recent legislative sessions was a 10% reduction in Medicaid rates that now has the state paying hospitals on average about 56% of cost. Though we've got to be making up for it somewhere and picking that up. Next slide, please.

So, some new initiatives that have been in the works—both through the last legislative session and just working with the state agencies—we've moved from a hospital-specific standard dollar amount to a statewide SDA, or standard dollar amount, much like the Medicare program uses. There are add-ons recognizing the higher cost of certain programs, such as medical education, trauma centers and area wage-related differences. So that's been moved to a statewide SDA. We're getting ready to go through another round of re-basing, if you will, moving from a Medicare severity adjusted DRG system to an APR-DRG system. That will take effect on September 1 of this year. Other payment reforms that have happened in this last legislative session were reduced emergency room payments for nonemergent cases, that the state has reduced payments for nonemergent cases, it seems, in the emergency room by 40%, so 60% of what we were receiving previously is what we now receive in the emergency room. It's an attempt to direct care to the more-appropriate locations; however, it's a disincentive for the providers and not much for the recipients of that care. And physician payments were relatively untouched in the last round of payment reforms. Another thing that was pushed by the state Legislature—mandated by the Legislature—was a statewide rollout of Medicaid managed care. Prior to this statewide rollout, Medicaid managed care was concentrated in the large urban markets. On March 1 of this year, we rolled it out statewide. Our health plan here at Scott & White is now a Medicaid managed-care organization. And I'd give comment on how that's going, but we're still in the very early stages of that. So we can follow-up with that on a later date offline, if anybody's interested. DSH and UPL—disproportionate share hospitals payments and upper payment limit payments—both of those programs are not state-funded. We rely heavily on transferring hospitals, transferring entities, large public hospitals to fund those programs. DSH is still an issue. There's a lot of negotiating going on right now between the Coalition of Transferring Hospitals and the provider community and the state to shore up that program and make it so that its feasibility remains intact long-term. And UPL is upper payment limit, which we had been relying heavily on in the Medicaid program throughout the state. However, UPL payments can't be made on Medicaid managed-care recipients and so as a result UPL is effectively going away with the statewide rollout of Medicaid managed care. Which bring us to the biggest new Texas initiative that's in the works, and that's 1115 waiver. And that's—next slide, please.

The 1115 waiver, I'll skip down a couple of bullets, is the Texas Healthcare Transformation and Quality Improvement Program waiver. There are two components to it: the uncompensated-care component, which is an effective replacement for the UPL program, and also a Delivery System Reform Incentive Payment component, which is where the creative genius comes into the 1115 waiver program. It provides opportunities. There are four categories of disparate projects that have a menu of different items that can be selected. Hospital providers and governmental entities that can provide transfer dollars will work together, value those projects. The transferring entity—the governmental entity—will put in the state share if you will of that in order to get a Medicaid match, and so it's an opportunity for providers to work together with their communities to look for opportunities to get additional Medicaid funding into the state. All that going on, we're still facing—the current estimates are somewhere between a $4 billion and $10 billion shortfall by the end of the biennium, which is Aug. 31 of next year. That's primarily driven by growth in caseload, which tends not to get budgeted. And we're also continuing to struggle with the federal initiatives, including the Affordable Care Act. How is the Medicaid expansion going to work under that? The Texas Department of Insurance has set aside a little bit of money to start creating the health insurance exchanges, but really not a lot of work has been done on that yet, so, as a result, once that starts rolling in full force, it will take some scrambling to get it up to speed. So those are my opening comments. Thank you for your time.

Daly: Thank you. Our next presenter is Beth Kidder. Ms. Kidder?

Beth Kidder: Yes, good morning. I'm pleased to be here. Again, my name is Beth Kidder. I'm the assistant deputy secretary for Medicaid operations in Florida. I've been with Medicaid programs for 13 years in Florida and North Carolina. Just to tell you a little bit today about Florida Medicaid and our current delivery system, and then I wanted to spend the rest of the time talking about new statewide Medicaid managed-care initiative. Florida Medicaid has 3.18 million recipients. We are the fourth-largest program in the nation. There are a lot of similarities in our program to the type of program that Mr. Galinsky was just discussing in terms of budget shortfalls and a commitment to no new taxes or increases in taxes. Medicaid budget is over $20 billion a year, and $3.4 billion of that is for hospital inpatient and about another billion in outpatient costs, outpatient hospital costs. Our current delivery system is split among a number of different programs, but they can basically be grouped into three major categories: the first is capitated payment arrangements, the second is other managed-care arrangements that are not capitated, and then the third is fee-for-service. And our population splits fairly equally among those three with the largest group in capitated arrangements at 1.2 million, about 750,000 in other managed-care arrangements and a million in fee for service. Our hospitals are paid on a per-diem basis with facility-specific rates based on cost. However, we have been directed by our Legislature to move to a perspective payment system based on DRGs, and that will happen in the next year. We are just beginning to work on that design in the upcoming months. Our latest initiative to transform the Medicaid program was mandated last year in the Legislature. We are creating a statewide Medicaid managed-care program with a goal of improving quality while containing costs as best we can. There are two components to it: a medical portion and a long-term-care portion. And the plan is for each of those two components to be competitively bid on a regional basis with 11 regions across the state. The long-term-care portion of this program is going live first and our competitive-bid document will be out by July 1 of this year with enrollment beginning next summer. The long-term-care component serves individuals 18 and older who need nursing-facility level of care, and so that will be individual vendor facilities as well as those who receive common community-based services with a nursing-facility level of care. Our managed medical assistance, another program, will go out to bid in January of 2013 with enrollment beginning in 2014. And the whole program will be fully implemented by April of 2015. At that point, we expect that 80 to 85% of our population will be in managed care. There are few populations that are carved out—the largest populations are the individuals with developmental disabilities and people who are eligible only for limited services such as family planning or emergency Medicaid for aliens. Most other populations are in the managed-care program. We have applied for federal waivers—several different waivers to implement the medical assistance and long-term-care portions, and the conversations are ongoing with federal CMS. With that, I'll reserve the rest of my time to take questions.

Daly: Thank you. And our third presenter today is Dr. Ross Wilson. Dr. Wilson?

Dr. Ross Wilson: Good morning everybody, and thank you for the opportunity to be part of this conversation. I'm the chief medical officer at the New York City Health & Hospital Corp., and I just want to spend a moment just describing that and then to talk a little bit about the changes in New York. Can I have the next slide, please?

At the New York City Health & Hospital Corp., we have a clear mission to provide the highest quality of healthcare to everybody regardless of their ability to pay, and clearly this intersects with Medicaid on a very frequent basis. We are, I think, the largest municipal public health system in the country with 11 acute-teaching hospitals, six diagnostic and treatment centers, 80 community clinics and 3,000 long-term-care beds, as well as a health plan. We have a workforce of more than 40,000 people, and an annual budget of greater than $7 billion, and Medicaid is our biggest payer. And in fact in this coming financial year, about 67% of our revenue will come from Medicaid fee-for-service, Medicaid managed care, UPL or DSH. And so the Medicaid conversation is essential to our future. We served last year more than 450,000 uninsured patients, and the majority of those patients are undocumented. On the next slide, please.

New York has undergone a significant review and transformation of the Medicaid system using the Medicaid redesign teams led by the state government. And there've been very many recommendations across multiple areas of interest with the objective of reducing cost and also maintaining or improving quality and access. A couple of the notable parts of these three design changes: The first is a cap on Medicaid expenditure, and that cap at 4% was able to be achieved this year as a cap on growth. And that cap really is one of the ways to guarantee that the system can be afforded. The second major plank is that there is a focus on achieving the triple aim or the three-part aim that the CMS talks about and others—better quality, better health and all of that at lower cost. And there's also continued focus on doing that through primary care, so connecting with patients through a primary-care base, and the model for primary care being the requirements for patient-centered medical home. The third major focus was on increasing managed care for all and folding in to this two areas that previously were not involved, and one of them was behavioral health and the other is long-term care. And that has very significant implications for us. Behavioral health and long-term care are both very major parts of our organization. And the last key part is the focus on care coordination and care management, particularly for the Medicaid high-utilizer population and through the Medicaid/Medicare health home, which was foreshadowed in the Affordable Care Act. At the New York City Health & Hospital Corp., our response to these changes in a very dynamic environment has been firstly to really focus on the triple aim—focus on providing the best quality that we can provide, really start to focus even more stringently on the health of the population we serve and its improvement through chronic-disease management and health-prevention strategies, etc., and really to strengthen our attention on cost and the various proxies that we've used to measure cost. The second major strategic change for us was really to change the focus to a systemwide relationship with our patients. Instead of a clinical, hospital or emergency department visit based focus, but a systemwide relationship for our patients over time. The third major focus was to change our focus from an inpatient model to really investing and thinking about how we provide better ambulatory services particularly primary care using the patient-centered medical-home model. And to this end, we've achieved NCQA Level 3 designation at all the primary-care sites across our whole system. That's been a very important platform for our redesign. And the last part has been to think about whether we have—to think about our system differently as a systemwide integration consistent with an ACO model. And these directions are on the next slide. Really looking at how an ACO model will actually help us integrate our system and also identify more clearly partnerships and also shared savings.

So on the next slide, I think I just want to summarize what the skill-based changes are that we're now looking at. Our focus is on the patient relationship over time, and if we provide high-quality care, we will improve the health of our patients and effectively and hopefully reduce their inpatient stays and emergency visits, and hence reduce our cost. Clearly we're expanding our skills to be able to manage in a managed-care environment. We already do that to some extent, but we expect that the percentage of patients in managed care will probably double over the next two to three years. The second thing is we want to reduce costs without cutting core services, and to that end over the last 24-25 months we have reduced our headcount across the corporation by about 2,500, most of these by attrition but some of them by targeted layoffs. And the other part of our strategy is a very strong investment in an enterprisewide Lean strategy to try to improve efficiency and reduce waste. We have strengthened our focus on quality and strengthened our reporting of performance, and all of our quality metrics are available on our Internet site. And it is clear that we're reporting to the public and showing people how we're doing, and that's easy to do when performance is good. And it's a little more stressful when some of the areas of performance are not quite as we would like them to be. The next major step is to increasingly leverage technology. We've had an electronic medical record for nearly 20 years, but we need to replace that, and we're in the process of looking at replacing for a single electronic health record across our whole system, including long-term care, outpatient clinics and hospitals, and integrating it better with the business systems, which will allow us to leverage some of the business opportunities from a electronic medical record. We've achieved NCQA designation at Level 3 for all primary-care sites, and now we want to continue to grow the standards and make the new designation requirements as they come up in 2015. We've also achieved New York state designation as a health home in Manhattan, in the Bronx, in Brooklyn and in Queens, and we are engaged very strongly in how to use that program to improve the care particularly for the Medicaid high-utilizers.

So summarizing, a lot of very major activities in our organization in response to I think very considered changes in the Medicaid program across New York state. That ends my comments for the present time. Thank you.

Daly: OK. Thank you. Thank you to all the presenters. I'd ask first that members of our audience who'd like to submit questions for our panelists, please do so through the webcast dashboard. I'll ask a couple to begin with and then we'll take some from our audience. 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?

Wilson: It's Ross Wilson here. 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 which is not based on volume but it's based on how patients' healthcare improves and health status improves over time. This is a big challenge from the clerical level, [unclear: 24:05] level, at the whole system level. And 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.

Galinsky: This is Bill. I would agree with Dr. Wilson's assessment on that. And also we found that the Medicaid population is one that's not used to having a medical home, not used to having a place—a regular physician to call on when they have issues, and far too frequently you see them in the emergency department. That's part of the driver behind the state reducing the emergency department rates for nonemergent care. So it's a difficult population. It's a learning curve, and they threw a whole lot of Texans into this bucket at one time. Granted the state and some of the managed-care organizations had that experience in the urban markets, but there are a lot of pockets of population around the state that haven't seen this before and now are having this thrust upon them and quite frankly didn't even respond to at least pick a primary physician letters and emails and things that went out. So it's a learning curve for everybody—patients, providers and state included and including also our health plan, which is now a Medicaid-Medicare organization.

Daly: OK. Thank you. 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?

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: OK. Thank you. 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: Thank you. I think that 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 the provision of those supports goes way beyond the ability of our healthcare system. 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 frequently utilizers of the emergency department, and we've found that nearly 50% of this very, very high utilize 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. We learned a lot from that program and that's informing a developing health home program. But until we have an environment where the social support for the really needy is strengthened, our emergency departments, I think, will continue to be the places for some patients to go.

Daly: OK. Thank you. 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.

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: I see. Thank you. And also, Ms. Kidder, is that something, to jump back real quick to emergency department use, is that something that Florida is taking a particular focus on? Are you all having any success or are you thinking of any initiatives that are better or less effective?

Kidder: There have been a number of initiatives around our state health department, our state has taken the lead on a number of initiatives. We did have one that was particularly successful in southeast Florida that worked very intensively with the families to connect them to the medical home, but it took several years for them really to see results. And it was very interesting to hear from this group, essentially a medical practice, or a connection of medical practices who undertook this project, that they really had to undergo a cultural change as well instead of some of the more obvious things were having extended office hours so that families that worked or had other commitments during the day could come to see the physician—the primary-care physician—after hours. Having 24-hour access to good quality medical advice to avoid that emergency room visit, and so there was success there, but again, it was a real shift in the way that that practice took on these patients as well. But nothing widespread across Florida. We have very similar difficulties in terms of seeing very intensive use of the emergency department for preventable conditions or conditions that could likely be treated by primary care. What basically we have seen is there's no one-size-fits-all solution that has come up yet.

Daly: I see. OK. Well, thank you. And moving onto billing and collections strategies, I wonder, Dr. Wilson, is there anything that your hospitals are looking at right now that you're finding for the Medicaid population is a leading issue in this area?

Wilson: Well, it is an area of focus for a lot of work on making sure that eligibility and its documentation is maintained, but we've used our Lean processes and [unclear: 34:03 ?Baxter?] processes as well to maximize the whole revenue cycle around these areas from registration all the way through to collections. And we've seen significant benefits and improvement in that area, and although we've got a significant way to go yet, I think we've had great success in using the Lean tools and improving our whole performance in this area. I think there's more work to do yet.

Daly: OK, and Mr. Galinsky, what are the primary obstacles that you are seeing right now in terms of billing and collections strategies?

Galinsky: Primary obstacles in billing and collections right now with the Medicaid program, probably the biggest immediate concern right now is just this whole rollout of the statewide Medicaid managed care. It helps for that part of the population that's on our health plan, but there's also, I believe, three other health plans in our primary communities that are Medicaid managed-care organizations, and just working with them, understanding the ins and outs of their business models to make that work. Also, we've had some issues with that—and this is part of a Lean project—as well as Medicaid has a 95 day billing deadline—timely filing deadline. And so staying within that and particularly with some provider numbers we've recently been dealing with and trying to work with the state and with the feds and within our own organization to get that worked out, has been an obstacle. And probably the last thing is our billing system will drop a bill after 30 days on a Medicaid patient, and oftentimes unless that patient is going to qualify for an outlier, then no further billing is done because the state's going to pay what the state's going to pay. We then lose the opportunity to claim those days in the DSH program—both federal and state—so we've got some issues, and we continually work through those. And as Dr. Wilson said, we're using Lean principles as well and doing the walk-throughs and trying to find those opportunities.

Daly: I see. And, Dr. Wilson, do you have any idea off hand about how many full-time employees your system devotes to the checking and enrolling Medicaid eligibility? Do you have any sense of what kind of return on investment is involved or what technology is most useful in that area?

Wilson: Rich, I'm sorry. I don't have that information at my fingertips, but we could get access to it at a later time if necessary

Daly: OK. Mr. Galinsky, how about you? Do you have any sense of that? In that area?

Galinsky: We do have a lot of our eligibility work outsourced, particularly with Medicaid. We do have some folks internal as well. I don't have specifics on the number, but I think we need more just because there's a lot of opportunity, I believe, to get people qualified that haven't been qualified for Medicaid in the past.

Daly: I see, and just to follow up on that real quick, when a patient shows up at a Scott & White facility, what systems are in place, do you know, to verify their Medicaid eligibility, and what happens if they are eligible? What happens if they aren't? Can you please answer that?

Galinsky: 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, as I said earlier, I think we've got more opportunity to go there.

Daly: I see. OK, and, Ms. Kidder, to jump back to you real quick here, there are, I guess, a number of patients that are considered eligible for Medicaid that are not enrolled. Can you give us any sense what the states' efforts are in that area in terms of finding patients or coordinating with providers, along those lines?

Kidder: In Florida we have a coordinated outreach program through what we call our KidCare program that focuses on—which includes our Title XXI as well as the Medicaid program, so the CHIP and the Medicaid work together on outreach. What we find is that for essentially every child enrolled in CHIP there are three enrolled in Medicaid. So that kind of outreach to low-income families in general tends to yield results in terms of enrollments in Medicaid and in the Title XXI program. So we have a number of different strategies in place. We contract with one of the state universities that runs a program through local community coalitions to everything from literally assisting people one-on-one with apps that are on smartphones to sign them up or to put their application in right there online to health fairs to other kinds of coalition-building with partners. So there are all kinds of activities going on that way through our university grant as well as through the organization that does our CHIP program in Florida. So those are types of things as well as we have area Medicaid offices—we have 13 offices around the state—and they participate in local community events that are community presence letting people know that Medicaid is available and assisting them with that. And then finally, in Florida eligibility is actually determined through [unclear:40:34?a or eight?] different agencies and the Medicaid agency, the Department of Children and Families does food stamps, [unclear:40:40] eligibility as well as Medicaid eligibility. And they have hundreds of community partners who work in the community to assist people with Medicaid eligibility. So it's a grass-roots level effort throughout the state.

Daly: I see. OK, and Dr. Wilson, also 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. They wanted to be able to even do some refreshing around prescriptions. 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. We've also been using some technology to improve the chronic diseases of our Medicaid patients, particularly using electronic transmission of blood sugars for hemoglobin A1Cs to electronic transmission of patients weight with heart failure, and using that to communicate with the care manager and change treatment if a patient's in their home. The take up and enthusiasm around those programs has really been very positive, and we're looking at spreading those pretty actively.

Daly: I see, and 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 CHIP 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. And so, but the younger Medicaid population is tech-savvy. The other part that we see is, and I speak a lot about our Children's Health Insurance Program because the populations move very fluidly across Title XXI and Title XIX. We have a lot of data from our CHIP population. Our vendor who works with the CHIP program has done a lot of different mechanisms to allow payment of premiums for the CHIP program of cost sharing, including smartphone apps and payment by text. And there's quite a large uptake on that as well. So I would agree with the other panelists that this is a growing area and we should be working to make as many of these technologies or access to Medicaid information through these venues as possible.

Daly: OK, and Mr. Galinsky, can you also add to that in terms of just getting us up to speed on what are you seeing from your Medicaid patients in terms of tech-savvyness?

Galinsky: I would agree with Ms Kidder I think that this is the function of society that the Medicaid population is becoming as tech-savvy as everyone else is, mostly by default in that there's not a lot of other options available. And as we continue down the tech path, you're going to do more and more things through smartphones and tablets and kiosks and other things, and it also, I believe, will help drive costs down in the long run as the patients and as the providers and everybody else becomes more tech-savvy and more comfortable with interacting with each other on that type of a basis, that there will be opportunities to reduce cost and to focus costs or focus costs and focus personnel in other more urgent areas.

Daly: OK, and also Dr. Wilson, to follow up on the managed-care question, do you see any particular opportunities to actually improve in terms of any specific initiatives to improve the care moving from the episodes care to more of an ongoing relationship, especially with the most ill Medicaid patients?

Wilson: I think there's a big opportunity to basically alter the way the patients relate to our system, and not be in a system which is volume-driven but is in fact getting the care that they need either by using technology, by using—building a relationship based on different providers, midlevel providers and physician extenders. And also starting to alter the way that patients start to take responsibility for their own care by sharing that responsibility. And I think in an environment where not entirely driven by volume and there is a shared desire to avoid inpatient use, I think we will be leveraging those aspects of managed care to get to that place. I think the biggest difficulty, for us, in this environment is being able to provide proper care coordination and care management around some of the social services that are required to keep these patients both continuing to be in care and to be out of acute hospitals. And that is really testing our system in terms of the ability for us to effectively work with many other agencies in ways that we really haven't done before. I think we've learned a lot, and I think many of the agencies that we work with have been very keen to partner and so I think as we learn more effectively how to partner and then to manage those relationships, I think our patients will benefit.

Daly: I see, and Mr. Galinsky, also along the same lines, I mean are there any specific initiatives you're seeing in terms of moving that have been successful in terms of moving from that episodic care to more of an ongoing model among the most costly Medicaid patients?

Galinsky: There has been where there are larger pockets, of concentrations of Medicaid patients. I think as the 1115 waiver works its way through the five year life of it, that we're going to see a lot more of that. As the provider community works with local communities and with the social networks, not the Facebook-type social networks but the social needs that Dr. Wilson's been talking about, and works to develop ways to bring in Medicaid funding and to make those opportunities work. And as everybody gets a clear focus on the triple aim of improving health quality and reducing costs.

Daly: OK. Thank you. And on that one question that you actually mentioned, in terms of using that kind of social networking technology, is that something your Medicaid population—I mean, is that something you've tried to do with them at all? Are they able to access that, or is there any comfort with that?

Galinsky: We don't have Facebook-type social networking available. We do have a Web—a smartphone app for our facilities. You can find a provider, you can schedule an appointment. You can do all those things through that smartphone app. I don't know what our statistics are currently on how that's grown.

Daly: And 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—particularly patients with chronic illness—to share a common platform and who want to share listens or activities or education, etc. 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: I see. And, on similar lines, can you give me a sense—a little bit more broadly to pull back—is there any particular initiatives that you all have in your system in New York that are aimed specifically at dual eligibles as one of the more—as one of the costliest—Medicaid populations?

Wilson: Well, many of the things we've talked about already are also really aimed at the dual eligibles, but particularly the focus on the triple aim, the focus on care management or care coordination, effective connection through primary care, and the effective networking of the services are very specific—you know, apply very specifically to the dual-eligible population as well. We're at the beginning of planning—both at the state and locally—about what additional programs we might be doing and what additional directions. But the main focus of most of that discussion is really on targeted care management or care coordination, and more effective tracking and reporting of both context and outcomes and costs. But in terms of particular new initiatives where I think we'll be launching some of those in the next 12 to 18 months.

Daly: I see, and Mr. Galinsky, can you tell us anything in particular, any specific examples of recent focus or efforts on dual eligibles?

Galinsky: Well, some bad news about dual eligibles in the state of Texas is that the state is no longer paying any of the deductible or coinsurance on that population. The state Medicaid program does not, as mandated by the Legislature. So, unfortunately I think it's going to result in being in ultimately limited access for the dual-eligible population because the effort won't be made in the provider community to necessarily get those dual eligibles signed up due to the fact that they know they're not going to reap a benefit, or at least there is not a perceived benefit. There are some additional benefits that front-line staff (may not) necessarily know about, but part of my job is to make them aware of that. And that's through the DSH program and ultimately through the waiver program, but with the state not paying for deductible and copays for dual eligibles, the provider community is not incentivized to try and capture that population.

Daly: OK. And Ms. Kidder, can you tell us how clear does Florida's—how clear of an idea of the size and extent and location of your dual-eligible population does the Medicaid agency have? And what recent initiatives are focused on this population?

Kidder: It depends how you count them, whether you're counting duals who receive full Medicaid benefits or duals who just received Medicaid paying their premiums and [unclear:55:11?via?] cost-sharing. But it's between 200,000 and 500,000 duals in the Florida Medicaid program. But we do have a good idea of where they are, and we have some programs that are specifically in the long-term-care area that are focused on duals. The vast majority of our long-term-care population is dual eligibles. And the population that is [unclear:?moving?55:30] is to our managed long-term-care system, is 95% of duals. And that is primarily the focus of that program. They tend to be elders, and they tend to be duals. We do have pockets in Florida, particularly in South Florida, where individuals may have immigrated and not had sufficient work experience in the United States to qualify for Medicare where we have pockets of reduced numbers of elders who are not eligible for Medicare but, for the most part, we're very aware of where they are and what they [unclear:56:10 ?consume?].

Daly: I see, and one quick follow-up actually on the subject of reimbursement: What is, I assume you're hearing from providers about reduced reimbursement rates. What are you telling providers in Medicaid when they are complaining that these cuts are impacting their ability to provide care? Are you pointing them in any direction in terms of maximizing those reimbursements or addressing that concern?

Kidder: I'm sorry, was that question directed to me or to the panel-at-large?

Daly: I'm sorry, yes, Ms. Kidder, please go ahead.

Kidder: Well, certainly it is a difficult situation because we do not direct the cuts ourselves but only administer them. We do try to train our providers on how to bill appropriately so that they aren't subject to recoupment for inappropriate—not following policy correctly, or certainly to steer them away from any fraudulent or abusive practices. We've recently launched our provider e-library, which has training PowerPoints on it. We do training via conference call that have been very well-received by our provider community that can be on extremely narrow and targeted topics, what we're seeing—problems in billing, providers billing incorrectly—or they can be much broader such as how to properly check eligibility. That actually has been our most popular one. And we've had several thousand providers take that training we're doing on a monthly basis now. And then we're also doing voiceovers on some of those PowerPoints and putting them online so that individuals can listen to the PowerPoint as well as just read it at a later date. So those are some of the initiatives that we're trying to do to ensure that providers can bill for what they're eligible for, and in the others we put the [unclear:58:09] with them, but everybody understands the situation with the budget.

Daly: I see, and this is going to have to be our last question here, but just to actually follow up on what Ms. Kidder was saying, I wonder if Dr. Wilson and Mr. Galinsky if you could address any initiatives you've undertaken—your systems have undertaken—in response to reduced reimbursement rate? I mean, 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: It's Ross 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 is: One, is to 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, I think, 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 than [unclear: 59:42?potentially?] they need to be seen. 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. And we're working hard in that area, particularly around hypertension and diabetes at the present time.

Daly: Alright. Mr. Galinsky, can you give us your system's efforts in that area?

Galinsky: Yes. Much in the same way that the New York Health and Hospitals is doing, our cost-reduction-efforts, we're feeling the squeeze everywhere on revenues—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 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, whether it's 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. We've looked at—not implemented—a plan to set up an urgent-care center outside or near our emergency department so that we can redirect those patients that are coming in that don't need an emergent level of care, nonemergent cases that could be redirected to an urgent-care center where they would receive reimbursement appropriate for that level of service but not take up the more costly services available in the emergency department. And those are the initiatives that we're really focusing on at this point, and then also trying to figure out how we can work together with the other stakeholders in the community and the transferring entities to make plans for the 1115 waiver and we're going to work under that.

Daly: OK. Thank you very much, and thank you all for joining us. Thank you to our presenters and to our audience today. Thank you for joining us, and my colleague will now finish up with a brief note. Thank you.

May: This concludes today's discussion on strategies for making Medicaid work. For those who want to view this webcast again, all attendees will receive a follow-up email with a link to the recording of the webcast available at All slides presented during this webcast will also available at that address. Thank you.

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