To facilitate greater control by consumers over the use of funds for home and community based services, individuals with developmental disabilities may use a fiscal intermediary. This intermediary functions as the payroll agent for the consumer, ensuring that appropriate taxes are withheld, including withholdings for social security, worker’s compensation and unemployment insurance. Use of the fiscal intermediary eventually will allow families and individuals to manage their personal budget, give control over what services they choose to purchase and how much of a particular service they may want to purchase. The services include attendant care, habilitation, individually designed living arrangements, housekeeping and respite.

 

Self Directed Attendant Care (SDAC) is an Arizona initiative that provides a Consumer Directed Care option for elderly and/or physically disabled ALTCS members receiving Home and Community Based Services (HCBS). SDAC offers ALTCS members the option to directly hire, and supervise their own attendants, personal care providers or homemakers without going through an agency. It empowers members to have more control over their lives, leading to increased satisfaction and improved quality of life. Individuals have the right and the ability to make decisions about how to best get their needs met. This includes determining who will provide the services they need and when the services will be provided. This service option will begin implementation on September 1, 2008. To allow certain SDAC consumers to direct some of their skilled care needs to their SDAC caregiver, Arizona passed Senate Bill 1329 into law during the 2008 legislative session.  Implementation of this addition to SDAC is expected to occur in early 2009.

 

On October 1, 2007, after AHCCCS received a waiver from the Centers for Medicare and Medicaid Services (CMS), spouses were allowed to serve as paid caregivers. Using a spouse as a paid caregiver is an attendant care service option that allows a spouse, who is qualified to provide basic health care services to his/her husband or wife, to be compensated for providing the attendant care services. Per the CMS waiver, ALTCS members selecting this option will be limited to 40 hours per week of attendant care or like services (homemaker and personal care). Allowing married members this service option will assist in reducing the challenges of ensuring an adequate caregiver workforce so that other ALTCS members can also choose to live at home

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To facilitate coordination of care for dually eligible individuals, eight AHCCCS Medicaid managed care organizations are designated Medicare Advantage Special Needs Plans. Individuals enrolled with these health plans are able to obtain all Medicaid and Medicare services, including Medicare Part D services, from a single health plan. Other AHCCCS Managed Care Organizations (MCOs) are also encouraged to improve care coordination for dually eligible individuals and/or to develop a formal relationship with a Medicare Advantage Plan or an MA Special Needs Plan.

AHCCCS, Arizona’s single Medicaid agency, was awarded a Medicaid Transformation Grant on January 25, 2007 to develop and implement a web-based health information exchange (HIE) utility to give all Medicaid providers instant access to patients' health information at the point of service. The Federal funds are being used to support the planning, design, development, testing, implementation, and evaluation of the AHCCCS Health Information Exchange (HIE).

 

Our goal is to achieve:

·         Better coordination of care for members with acute and chronic diseases

·         Better coordination between behavioral and physical health services

·         Enhanced opportunities for self-management through personal health information and integrated wellness applications

·         Improved quality of care oversight and transparency through timely performance information

·         HieHR use by 90% of providers by 2011

·         Reduction in Medicaid program medical costs by ~ 3% and reduction in administrative costs by ~2%

 

Benefits include:

·         Creating a "virtual medical home" that makes critical healthcare information available when and where it is needed

·         Enhancing coordination of healthcare across the continuum of care

·         Improving quality and controlling costs by reducing duplicative services, medication problems, delays in care, and the likelihood of medical errors

·         Reducing administrative costs and minimizing delays in provider payments

 

As a first step towards this connectivity, a smaller scale “proof of concept,” consisting of a federated health information exchange (HIE) and secure web-based viewer will begin in fall 2008 and end in December 2008. This prototype HIE will enable a small group of authorized AHCCCS registered clinicians to match patient demographics, locate relevant clinical information, and view individual patient documents. Because this is a federated exchange, AHCCCS will not collect or store clinical data; rather, the HIE will provide the means to locate and view information available from the health care facilities participating in the “proof of concept.”

 

The “proof of concept” provides AHCCCS and its partners the time to focus on developing the agreements, policies, procedures, and processes integral to the secure and successful sharing of electronic health information in Arizona. The “proof of concept” will include:

·         Hospital Discharge Summaries (from three major hospital systems in the metropolitan Phoenix area)

·         Laboratory Test Results (from a major Arizona commercial laboratory service provider)

·         Medication History (from a pharmacy information exchange company)

 

These “starter” record types were identified by clinicians as being of the highest value with respect to records that could be made available through the HIE. Although the sites and users will be limited during the “proof of concept,” AHCCCS is committed to maximizing the clinical information available to providers using the HIE at the selected emergency and ambulatory sites to aid in treatment decisions.

  

On May 1, 2008, Governor Napolitano issued Executive Order 2008–21, the “Patient Safety and      e-Prescribing Initiative”. It encourages all entities in the State of Arizona to promote and adopt  e-prescribing. Specifically, the Executive Order charges AHCCCS and other state agencies to:

·         Significantly increase the utilization of e-prescribing in Arizona

·         Work with Arizona Health-e Connection and its EAzRx initiative to make Arizona a leader in E-prescribing practices,

·         Implement measures to reduce medication errors for enrolled individuals and control costs related to such errors through increased e-prescribing use by contracted health plans and providers, and

·         Work with Arizona Health-e Connection to develop strategies to promote patient awareness and use of consumer tools related to medication safety. Tools include Med Forms or other personal health records that encourage Arizona consumers to routinely maintain a list of all drugs and medications being consumed and to review this list with health care providers.

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The AHCCCS approved e-Prescribing project is to facilitate the qualitative, technological and collaborative infrastructure necessary to modernize the prescribing processes for the AHCCCS Health Care System. This interoperable system will support the National Council for Prescription Drug Programs (NCPDP) Standards for electronic receipt and transmission of eligibility information, medication histories, formulary and benefit information and prescriptions between all stakeholders as appropriate.

 

The focus of the e-Prescribing initiative is to identify and cultivate the optimal partnering structure involving acute, behavioral health & long term care providers, prescribers, pharmacies, health plans, pharmacy benefit managers, hospitals, professional organizations, institutes of higher education, government agencies and other stakeholders as appropriate.

 

The overall goal of the AHCCCS e-Prescribing Initiative is to:

·         Improve patient safety,

·         Enhance the quality of care, and

·         Reduce health care costs for all entities and across all lines of business.

Health-e-Arizona

 

Health-e-Arizona is an internet based, paperless screening and application tool for Medicaid and SCHIP as well as Food Stamps, TANF and selected community based health care programs that use One-e-App, software developed by the California HealthCare Foundation, to screen applicants and direct the application electronically to the most appropriate agency and office.  Health-e-Arizona was implemented in 2002 at the El Rio Health Center, a large, multi-service federally qualified health center. Because many individuals who seek assistance at community-based organizations such as El Rio may be eligible for Medicaid or SCHIP, the organizations assist individuals with the application process.  Using Health-e-Arizona, community based organizations can receive a real-time preliminary determination regarding eligibility in substantially less time than when using the paper-based system. Thus, Health-e-Arizona improves overall access to health care while enhancing efficiency for community organizations, the AHCCCS administration, and applicants.

 

AHCCCS expects to implement a second version of Health-e-Arizona in late 2008. This version will be accessible to the public, enabling them to screen themselves for potential benefits, apply and submit documentation, and sign their application electronically. This version will be available in English and Spanish.

Arizona Health Query (AZHQ) is an integrated database that is a collaborative project between Arizona State University (ASU), School of Engineering, Department of Informatics and health care partners across the State. AZHQ serves as a repository of health care data from public and private data partners throughout Arizona, and includes data from the Arizona Health Care Cost Containment System (AHCCCS).

 

AZHQ is unique in that it allows for aggregation of comprehensive health information over time and across delivery systems. This aggregation of information provides for ongoing community-wide assessments and benchmarking, offers opportunities for studies and comparisons specific to the needs of individual data partners, and ultimately informs health care policy. Such widespread collaboration between statewide healthcare organizations and delivery systems is rare. In fact the AZHQ program recently won the ASU President’s Medal for Community Embeddedness.

 

AZHQ faculty and staff have the expertise, experience, and infrastructure necessary to implement this project and have undertaken extensive measures to ensure data integrity and security. AZHQ maintains compliance with privacy regulations set forth in the Health Insurance Portability and Accountability Act (HIPAA), de-identifies all personal health information, and requires approval of data partners when using information in community studies.

 

AHCCCS, the provider of healthcare coverage to approximately 18% of the State’s population, has participated as a data partner since AZHQ’s inception. The partnership, which continues to reap dividends for AHCCCS, ASU, and Arizona citizens, has been recognized nationally as a model for collaboration between academia and the healthcare community.

 

AHCCCS has created a data warehouse and decision support system, containing a broad spectrum of data, including data related to claims and encounters, financial matters, health plans, providers, recipients, reference, and reinsurance. The major goals of the data warehouse and decision support system are to:

·         Enhance staff capabilities to administer, plan, and evaluate performance of AHCCCS programs, contractors, and providers;

·         Enhance user-directed data access, reporting, and analysis capabilities at varying levels of user sophistication; Augment measurement of costs, utilization, and quality of care findings against relevant norms utilizing normative data models;

·         Support AHCCCS actuarial analyses requirements and rate setting activities, encounter and claims analyses, medical care quality studies, utilization review and access to care analyses, and fraud and abuse detection.

 

AHCCCS has incorporated two software solutions to process inbound/outbound health transactions.  The Foresight© validation suite of products allows AHCCCS to apply X12 and NCPDP standards in addition to AHCCCS based standards to incoming and outgoing transactions.  The IBM© Websphere Translation Extender (WTX) is used to translate inbound/outbound health data. The major goals of the EDI Data Exchange process are to:

·         Accurately validate data from trading partners

·         Allow trading partners to view results via the web based component, Transaction Insight©

·         Supply statistics to AHCCCS management

·         Maintain a seamless process of inbound and outbound data to the PMMIS

  

 

Established in 1986, Healthcare Group of Arizona (HCG) is a community-rated health plan that provides healthcare coverage for nearly 30,000 members. A mission-driven program, HCG is designed to insure the uninsured small business community. HCG offers businesses with 2 – 50 employees, as well as political sub-divisions, both an HMO- and a PPO-type plan with multiple benefit options. HCG also offers a dental and vision plan that raises enrollment in all plans and makes HCG one of the largest state initiatives nationwide to provide health insurance for small businesses.

 

Requirements for membership in HCG include:

·         A requirement that employees be uninsured for six months (the “bare period”). This applies to the business itself and not to individual employees.

·         A restriction on using AHCCCS rates as default rates for hospital reimbursement

·         Limitations on contracting with insurance brokers and paying broker commission

·         Restrictions on dollars spent on marketing and administration

 

Healthcare Group has turned the corner following previous year losses and has completed the year with a small profit. A variety of program changes and administrative cost reductions have led to significant financial turnaround and sustainability with future government subsidies. 

 

 

EIM is the process of combining business intelligence (BI) and enterprise content management (ECM) to form an enterprise perspective.  The critical characteristics of successful EIM strategy include:

·         A solid infrastructure and foundation of core technologies and well-integrated products that provide inter-component data movement, metadata management, master data management, data quality, and data integration

·         An overall architecture specifically designed to evolve, replacing outdated components with more modern technologies over time

·         Well-disciplined methodologies and work processes for managing the lifecycle, introducing new functionality, incorporating new source systems and data feeds, and expanding the breadth of the EIM environment.

·         A realistic alignment with the organizational structure and culture

 

Key objectives include the ability to:

·         Eliminate or significantly reduce the proliferation of “spreadmarts”

·         Transparently distribute enterprise-wide information in consistent, actionable formats

·         Leverage existing technologies and enable future capabilities

 

AHCCCS plans to employ a variety of practices in support of transparency, including:

Posting Performance Measure results on the AHCCCS website

Posting Performance Improvement Project results on the AHCCCS website

Using publicly reported data to inform Pay-For-Performance programs

Efforts to combat fraud and abuse

The AHCCCS Office of Program Integrity (OPI) takes a three-pronged approach to combating health care fraud in the Arizona Medicaid Program (AHCCCS): a strong civil enforcement through the use of civil monetary penalties, a criminal enforcement program in conjunction with the Arizona Attorney General and the various county prosecutors, and prevention efforts that encourage providers to adopt compliance programs and accept responsibility for policing their own activities. In essence, preventing fraud where possible and pursuing civil and criminal remedies when it is required or necessary. The OPI is committed to tough but responsible enforcement of state, criminal, civil and administrative laws and rules, as well as strong partnerships with health care providers to promote compliance within the industry.

 

The AHCCCS administration and the OPI are committed to providing a coordinated framework, through the AHCCCS sponsored Compliance Officer Network, for the contracted health plans to fight health care fraud that impacts AHCCCS. This focus coordinates the civil/administrative approach and the criminal prosecution of individuals and providers engaging in health care fraud. The Director and managers of the Office of Program Integrity travel throughout the state to provide fraud awareness briefings to AHCCCS contractors, AHCCCS field offices, and to any group that requests a speaker.

 

The Office of Program Integrity seeks to achieve the following objectives:

·         To punish wrongdoing,

·         To deter others from committing fraud,

·         To assure the credibility of the Medicaid providers,

·         To protect the integrity of the Medicaid program and safeguard the public trust, and

·         To educate Medicaid members and providers about the need to prevent health care fraud and to foster compliance within the industry.

Medicaid Transformation Grants

As the single State Medicaid Agency providing health care coverage for over one million Medicaid and SCHIP beneficiaries. AHCCCS has received Medicaid Transformation Grant funding. The funding is allocated to provide cost, quality, episode of care, and evidence based medicine information to beneficiaries, providers, health plans, and the AHCCCS Administration for the purpose of facilitating effective decisions and evaluations via a Value Driven Decision Support Tool Box (The Tool Box). AHCCCS implementation of the Tool Box for the purposes indicated is referred to as the Electronic Clinical Decision Support (ECDS) project.

Through the use of decision support tools, the ECDS project is expected to:

 

·         Assist patients, health care providers, Managed Care Organizations (MCOs), and Arizona’s Medicaid program managers in making informed decisions that lead to improved health outcomes

·         Enhance communication and improve relationships among beneficiaries, providers, health plans, and the AHCCCS Administration

·         Employ evidence-based medicine guidelines and episode of care analytics, including predictive modeling applications, to facilitate responsible data reporting

·         Ensure visibility of quality and cost data to encourage providers to excel

·         Promote cost-effectiveness in the Medicaid and SCHIP programs, saving state and federal tax dollars

 

 

 

The benefits of this project include:

·         Enhanced ability of stakeholders to access, understand and use information that is helpful raising health literacy, reducing health disparities and in consumer driven health care decisions (e.g. choosing a health plan, selecting preventive or disease management opportunities, deciding on treatment modalities)

·         Improved communication related to episodes of care as well as patient adherence to preventive strategies and treatment protocols.

·         Improved patient and provider decision-making as a result of the exchange of relevant evidence-based medical practice guidelines and cost of care information.

·         Improved quality of care oversight through the timely production of performance information.

·         Timelier public reporting of quality and cost

·         Increased ability for MCO contractors to identify variations in quality of care and, as a result, more effectively direct their medical management interventions

·         More effective and timely AHCCCS program management and oversight

·         Reliable information that can be use by AHCCCS and MCOs to establish performance based incentive programs.

·         Reduction in overall Medicaid expenditures due to cost-effective choices

·         Ultimately, a sustainable information infrastructure aligned with organizational objectives

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Virtual Office

The maintenance of a competent workforce that supports Agency goals is critical. Key issues that impact or are impacted by the AHCCCS workforce include aging workers, absenteeism and turnover, budget constraints, and technological capabilities. To address these realities, AHCCCS will continue to assess its Virtual Office (VO) Program for further expansion. Consumer-directed care demonstrations (include number of beneficiaries served now and in any expansion plans)

Thus far, VO benefits to AHCCCS include an increase in productivity and a decrease in turnover, absenteeism, and operational costs.  Benefits to employees include increases in job satisfaction and quality of life, and decreases in stress and costs associated with gas, work attire, and after school care. Benefits to the State include environmental improvements such as reductions in fuel consumption, traffic, and pollution.

 

Based on findings thus far, AHCCCS plans to expand its VO Program from the current 350 workers to 450 by the end of fiscal year 2009. Measuring and evaluating quality indicators and cost-effectiveness, educating others, and sharing best practices, will play a major role in ongoing programmatic efforts.

Graduate Medical Education (GME)

In 2006 Governor Napolitano signed into law a hospital loan program created by the Legislature to fund start-up and ongoing costs for GME programs at Arizona hospitals. The hospital loan program allows AHCCCS to provide interest-free loans of up to $500,000 each to Arizona hospitals to assist with the establishment of new GME programs in the state.

AHCCCS awarded interest-free loans to three Arizona hospitals for the establishment of GME programs totaling $1.4 million. They included one to Yavapai Regional Medical Center (YRMC) in Prescott, which has been offered a loan of $500,000. YRMC plans to establish two GME programs in osteopathic medicine for 10 new residents beginning July 2009. At full capacity, the programs will provide for the training of 30 residents in Internal Medicine and Family Practice.

Another loan was awarded to University Physicians Hospital (UPH) in Tucson. UPH plans to use the $500,000 loan to establish seven GME programs among a total of 28 new residents starting in July 2008. At full capacity, the programs will provide for the training of 118 residents in Emergency Medicine, Family Medicine, Internal Medicine, Neurology, Ophthalmology, Psychiatry, and Radiology.

The third loan was awarded to Phoenix Children's Hospital (PCH). PCH, an established training hospital in pediatric medicine, will use the $400,000 loan to offer fellowships in Pediatric Hematology & Oncology to two new fellows beginning July 2008.  At full capacity, the program is designed to train a total of six fellows.