Best Practices in Medicaid - Missouri
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Consumer-directed care demonstrations (include number of beneficiaries served now and in any expansion plans)
Consumer-directed care allows a MO HealthNet participant, who lives in their own private residence or the home of a family member, to recruit, hire, train, and supervise individuals providing care in their home. The participant is responsible for employing individuals who are registered, screened, and employable pursuant to the Family Care Safety Registry, Employee Disqualification List, and applicable state laws and regulations. A financial management provider selected by the participant performs payroll and fringe benefit accounting functions including, but not limited to, collecting timesheets and certifying their accuracy, transmitting individual payments to the personal care attendant on behalf of the participant, ensuring all payroll, employment, and other taxes are paid timely and submitting claims for payment with MO HealthNet. The provider also provides training and orientation to the participants on the skills necessary to recruit, employ, instruct, supervise and maintain the services of attendants. In state fiscal year 2008 (July 1, 2007 – June 30, 2008), 9,851 participants received State Plan personal care, consumer directed, services. An additional 144 participants received personal care through the independent living waiver.
Delivering high quality, coordinated, long-term care for the disabled and/or the infirm
Missouri was awarded a Medicaid Transformation grant from CMS in the fall of 2007 for purposes of developing a web-based tool to determine a participant's need for home and community based services. The grant period ends in March, 2009.
Use of health information technology (electronic health records, e-prescribing, electronic billing, etc.)
Missouri's Medicaid providers have utilized an electronic health record since 2006. The electronic health record is a web-based tool that physicians and other health care providers use to access electronic health records for Medicaid patients. Treating providers can view a patient's medical history including diagnoses, procedures, and prescribed drugs. Physicians can electronically submit prescriptions and request pre-certification for imaging procedures and durable medical equipment. All of this is done in a secure environment, and the entire system is Health Insurance Portability and Accountability Act (HIPAA) compliant. Recent enhancements to the tool include importing laboratory data and integrating a medication possession ratio for medications used to control chronic conditions.
Expanding coverage through private sector initiatives
The Health Insurance Premium Payment (HIPP) program pays private health insurance premiums, co-payments, and deductibles for participants in lieu of paying more costly medical care expenses. The HIPP program is based on cost-avoidance instead of cost-recovery. MO HealthNet provides wrap around services so all MO HealthNet covered services are available to HIPP participants. Since MO HealthNet is the payer of last resort, the state is able to ensure participants retain their private insurance by purchasing the coverage when it is determined to be a cost effective to the state.
Transparent and publicly-accessible measurements of patient outcomes and/or quality improvements
Consumer's Managed Care Guide – Managed care organizations are evaluated on their commercial, MO HealthNet, and Medicare product lines in the areas of access to care, quality of care, and customer satisfaction. The Consumer's Managed Care Guide, published by the Missouri Department of Health and Senior Services (DHSS), shows how well MCOs are delivering care and customer service to their members. This guide helps consumers, employers and other purchasers with their health insurance selection.
Through the Chronic Care Improvement Program (CCIP), a Quality Improvement Council is working with providers from around the state to develop measures and standards for a pay for performance program. This work may serve as a foundation for the Professional Services Payment Committee to expand P4P for the broader population. The initial CCIP P4P payment, issued to providers in the second quarter of 2008, was developed based on provider’s individual results for several standard, peer-reviewed and best-practice clinical outcomes for each of the participant's conditions managed through CCIP. These best practices include use of inhaled corticosteroids for asthmatics, regular acquisition of glycosylated hemoglobin values and screening ophthalmology examinations for diabetics, use of beta blockers and ACE inhibitors for participants with congestive heart failure, measurement of lipid profiles for participants with coronary artery disease, and annual influenza immunizations. Subsequent P4P payments are expected to be issued on a quarterly basis for the CCIP.
Efforts to combat fraud and abuse
Program Integrity Unit best practices include efforts designed to offer providers the opportunity to voluntarily review their billing practices and identify overpayments associated with industry wide issues.
This type of self-audit program is an effective way to realize savings and cost avoidance when it is not practical to conduct extensive audits due to budget constraints.
What changes would you make to the federal Title XIX so that you could provide better services to individuals and families on Medicaid in your state?
The Social Security Act provides for demonstrations that can be used to test or provide alternative mechanisms for delivery of care or expand populations to enhance the program. One important facet of the demonstration approval process is budget neutrality. Current application of budget neutrality leaves states with little flexibility to test and develop new initiatives. The current approval requires a narrow application of allowable costs and impacts to savings. Cross program impacts are not recognizable in the budget neutrality analysis. Quality initiatives that positively impacting populations but are difficult to quantify are also impacted.