Best Practices in Medicaid - Minnesota
The Center for Health Transformation is inviting leaders from all 50 states to share their transforming solutions for the Medicaid program. In order that key decision-makers and industry leaders from around the country may learn from others’ successes, it is our intention to provide this interactive resource for showcasing the most innovative practices in the country. Please note that the following contributions have not been edited by CHT staff and will remain open indefinitely to future updates. View Minnesota's Official Medicaid website >>
About the Minnesota Department of Human Services
The Minnesota Department of Human Services (DHS), in cooperation with its county partners, serves 670,000 Minnesotan’s. Consumers include: seniors who need help paying for hospital and nursing home bills or who need home-delivered meals, families with children who need help during a financial crisis, parents who need child support enforcement or child care money, and people with physical or developmental disabilities that need assistance to live as independently as possible.
Human services spending accounts for approximately 25 percent of the state's total budget. Of that spending, more than 90 percent is spent on health care and long-term care programs and related services, including MinnesotaCare, Medical Assistance, General Assistance Medical Care, mental health services, alternative care services, chemical dependency services and regional treatment center services.
The Department of Human Service has implemented various health care payment reform measures to help consumers get the best care and outcomes with the most value for the tax payer’s dollars. Described below are transformational reforms in detail.
Medication Therapy Management Services
The Minnesota Department of Human Services will pay qualified pharmacists for Medication Therapy Management services (MTM) for General Assistance Medical Care recipients. The MTM program was developed with the input of an advisory committee representing pharmacy groups and other interested parties.
Medication Therapy Management is a defined service or group of services that optimize therapeutic outcomes for individual patients. Some MTM services are independent of, but can occur in conjunction with the provision of a medication product. MTM will provide the following services to Medicaid recipients:
• performing or obtaining necessary assessments of the patient's health status
• formulating a medication treatment plan
• monitoring and evaluating the patient's response to therapy, including safety and effectiveness
• performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events
• documenting the care delivered and communicating essential information to the patient's other primary care providers
• providing verbal education and training designed to enhance patient understanding and appropriate use of the patient's medications
• providing information, support services, and resources designed to enhance patient adherence with the patient's therapeutic regimens
• coordinating and integrating medication therapy management services within the broader health care management services being provided to the patient.
Medical Home
Minnesota's Medicaid agency, the Department of Human Service has begun a process to transform health care delivery in the primary care setting. Legislation passed in both 2005, 2007 and 2008, combined with a Medicaid Transformation Grant has created a unique opportunity to work with providers and patients to change the structure of primary care delivery.
The Department of Human Service's vision is to create a "medical home" for patients served by public programs. This will be achieved by transforming primary care delivery to a system that proactively works in a team with patients and families to manage health and reduce the burden of chronic disease. It is expected that is approach will result in improved health with reduced costs.
The Department of Human Service will build a payment structure and an infrastructure to support this transformation. In this payment structure, primary care providers will receive a new care coordination payment to actively and prospectively coordinate the care of patients with complex and chronic illness. Initially payment will be $50 per month for members with significant medical complexity. Over time, payment will be adjusted to reflect the complexity of the patient's needs. This new payment will require fundamentally different work than is routinely provided. Pay for performance, a third payment mechanism, will follow and reinforce the expected outcomes from these projects.
Pay-for-Performance and Consumer Incentives
The Minnesota Department of Human Services will implement a patient incentive program understanding that patient engagement is a major issue for improving chronic disease care and positive results.
In order to reach optimal diabetic care, both providers and patients must be actively involved in the care and treatment of diabetes. Diabetic patients enrolled in Medicaid programs who reach optimal care, based upon the measures used for physicians under the Bridges to Excellence program, will receive a reward.
Delivering high-quality, coordinated, long-term care for the disabled and/or the infirm
Minnesota Nursing Home Report Card
Gov. Tim Pawlenty has announced a tool developed by the Minnesota departments of Human Services and Health to help consumers compare the quality of care in Minnesota nursing homes. The Minnesota Nursing Home Report Card provides consumers with information on quality of life and resident satisfaction with respect to individual nursing homes, in addition to such objective data as hours of direct care, staff turnover, proportion of single rooms and state inspection results. The Minnesota Nursing Home Report Card may be accessed on the web at: http://www.health.state.mn.us/nhreportcard/
The quality measures in the report card are:
• Resident quality of life ratings - based on annual face-to-face interviews with a sample of residents in each facility,
• Minnesota Quality Indicators - risk adjusted, assessment based measures of clinical care and outcomes,
• Hours of direct care - acuity and wage adjusted,
• Staff retention - the portion of direct care staff retained for at least a full year,
• Temporary staffing agency use - the portion of direct care staff hours provided by outside staffing agencies,
• Proportion of single rooms - the portion of beds that are private, and
• State inspection results - findings of harm or immediate jeopardy from the federal certification survey.
Using health information technology
RxConnect
In the fall of 2003, Governor Tim Pawlenty instructed the Department of Human Services and the Department of Employee Relations (the State of Minnesota employee group) as well as other state agencies, to develop new ways to help Minnesotans reduce prescription medicine expenses. The order resulted in the development of RxConnect, a website that provides information about affordable prescription options. The site includes:
• Information about medications, safety and cost-savings tips, and programs to help low-income Minnesotans find affordable medications.
• A consumer tool, RxPrice Compare, that lists prescription prices at local pharmacies.
• Information on ordering medications from Canadian pharmacies.
Minnesota RxPrice Compare is a web-based tool that enables consumers to compare local pharmacy prices of about 400 brand, generic, and therapeutic alternative medications. The site allows consumers to compare specific brand and generic prices for the same drug, the differences in price by pharmacy, and prices of therapeutic alternative medications.
Consumers may search by county, city, or ZIP code to find a medication’s price at Minnesota and border city pharmacies. Posted prices are either derived from recent claims submitted by pharmacies to DHS for payment or posted directly online by the pharmacy. If a pharmacy updates the website and then submits a claim for a price different than the posted price, the new claim price replaces the price on the website. Prices are updated by DHS every two weeks.
RxConnect provides a link to information about ordering medication from Canada. The Canadian pharmacies listed on this site have been inspected by Minnesota officials. RxConnect gives Minnesotans a safe option to access medications that may be more affordable in Canada. Minnesotans may compare the prices offered by the Canadian site with Minnesota pharmacy prices posted on RxPrice Compare.
Minnesota Health Information Exchange
In September 2007, Governor Tim Pawlenty joined with leaders from Minnesota's largest health care organizations to announce an electronic health information exchange that will connect doctors, hospitals and clinics across health care systems so they can quickly access medical records needed for patient treatment during a medical emergency or for delivering routine care.
The Minnesota Health Information Exchange will improve patient safety, increase efficiency among health care providers, and reduce administrative costs for all health care organizations. This public-private partnership plans to go live in early 2008. It will be one of the largest health information exchanges in the nation, serving more than three million Minnesotans, and additional Minnesotans will be served as more health care organizations join the exchange.
The exchange will create an electronic superhighway that allows for a secure interchange of clinical information among provider and payer. This will allow doctors to get medical information about a specific patient more quickly and cost-effectively than relying on phone, facsimile, couriers or the mail. Initially, Minnesota Health Information Exchange will provide the connectivity needed to obtain medication histories, lab orders and test results across health systems. Future electronically based services will include radiology reports; Minnesota Department of Health disease surveillance reporting; and electronic prescriptions, which will eliminate the need for doctors to write prescription orders by hand.
New State Law Requires Electronic Exchange of Administrative Health Care Transactions
A law signed by Governor Pawlenty in May 2007 will require all group purchasers and health care providers to electronically exchange the following three health care transactions: eligibility; claims; payment and remittance advice by 2009. The electronic transactions must be in a standard format, which will be adopted through a rule-making process by the Commissioner of the Minnesota Department of Health.
Expanding coverage through private sector initiatives
Minnesota Smart Buy Alliance
In 2004, Governor Pawlenty announced the formation of the Smart Buy Alliance, a public private purchasing alliance. This alliance pools their purchasing power to drive value in the health care delivery system. Their goals are to improve quality and lower costs by reducing inappropriate and unnecessary care, encouraging evidence-based medicine and use of highest-performing providers, and reducing providers' administrative costs through common reporting requirements. That is, the Alliance hopes to achieve savings in the long run through coordinating their members' expectations on quality and value based on four key buying principles:
1. Reward or require "best in class" certification. Alliance members will build on existing "best in class" certification programs in development that identify health care providers achieving certain levels of expertise, experience, proficiency, and results.
2. Adopt and utilize uniform measures of quality and results. The Alliance will adopt uniform methods of measuring quality of care and results and use them in purchasing.
3. Empower consumers with easy access to information. In addition to collecting information from providers, the Alliance will provide consumers with standardized, user- friendly information about health care costs and quality.
4. Require use of information technology. The Alliance will encourage efficiencies and quality improvements by supporting development and/or requiring adoption of interoperable health information exchange.
Transparent and publicly-accessible measurements of patient outcomes and/or quality improvements
Quality Care and Rewarding Excellence (QCare)
In July 2006 Governor Pawlenty introduced QCare-Quality Care and Rewarding Excellence-a new quality standard program that will be used by the State of Minnesota in its health care purchasing policies to reward top performing providers while saving millions of dollars in health care costs. The QCare program implements quality of care standards, sets aggressive targets for health care providers, makes measures available to the public online, and changes the health care payment system to reward quality rather than quantity.
DHS does this by implementing practice guidelines with their managed care organizations (MCOs). The MCOs adopt, disseminate, and audit the application of practice guidelines consistent with the QCare preventive care standards on the following:
• Child and adolescents immunization,
• Well-child visits,
• Chlamydia screening, and
• Breast and cervical cancer screening.
In addition, the MCO's must implement performance improvement projects. The MCOs select new projects based on one or more of the four QCare standard areas: diabetes care, cardiac care, prevention or hospital care and safety.
The MCOs must make disease management programs available for the QCare chronic diseases mentioned above and may earn financial performance payments based on the MCOs preventative care services.
Bridges to Excellence
Bridges to Excellence is the pay for performance program the Minnesota Department of Human Service uses to reward providers for optimal treatment for chronic diseases. Diabetes and cardiac diseases are the sixth and second leading cause of death in Minnesota. They are serious chronic diseases that have a substantial impact on the health of Minnesota Medicaid enrollees. In order to achieve better outcomes the Department of Human Service rewards optimal care for these two chronic diseases.
Minnesota is the first Medicaid agency in the nation to participate in Bridges to Excellence and partner with private sector purchasers in this employer sponsored pay for performance program. This program financially rewards providers based on results for optimal chronic disease care. In 2006 the Department of Human Service rewarded providers who achieved optimal care in the treatment of their diabetic patients and will rewarded for optimal care for coronary artery disease (CAD) in 2007.
Personal Health Records
On July 2008, Governor Tim Pawlenty announced a proposal to give all Minnesotans access to an online personal health portfolio by 2011. As the first step, the Governor has directed the Department of Finance and Employee Relations (DFER) to seek proposals for a secure and portable online personal health portfolio for each of the state's approximately 50,000 employees by January 1, 2009. The portfolio will offer:
• Electronic access to test results
• Access to their own medical records electronically
• Instant access to immunization records
• Prescription history & detection of interactions
Pricing and quality data to be available at a single website
At Governor Pawlenty's urging, Minnesota's private health plans have agreed to provide pricing and quality data on a single website, so consumers have a powerful tool to shop for health care in one place. To begin, consumers will find price comparison information at the yet-to-be-named website in January 2009:
• Top 90 percent of high tech imaging can and x-ray procedures (by volume)
• Top 25 lab tests by volume
• The 100 most common procedure
Future plans
Comprehensive Health Care Reform
In 2008, Governor Pawlenty signed significant health care reform legislation into law. These reforms, which include recommendations of the Governor's Transformation Task Force and the Legislature's Health Care Access Commission, create a comprehensive health care package making significant advances for Minnesotans in the following areas:
Public health
• Establishes and funds a statewide health improvement program (SHIP) to reduce the percentage of Minnesotans who are obese or overweight and reduce the use of tobacco.
• Appropriates a total of $47 million for this activity in fiscal years 2010 and 2011.
Health care coverage/affordability
• Provides MinnesotaCare coverage for an estimated 8,700 additional people by 2011.
• Expands MinnesotaCare eligibility for adults without children to 250 percent of federal poverty and parents with incomes up to $57,000 annually.
• Reduces the MinnesotaCare sliding-fee premiums to increase affordability.
• Increases outreach for state health care programs.
• Streamlines access to applications for state public health care programs and requires further study to improve coordination between state health care programs and other assistance programs.
• Requires the study and development of a proposal to promote affordable access to employer-sponsored health insurance through the use of direct subsidies and/or tax credits and deductions.
• Requires employers that have 11 or more full-time equivalent employees and do not offer group health insurance to establish and maintain a Section 125 Plan, which allows employees to purchase health insurance with pre-tax dollars. Employers have the opportunity to opt out of this requirement.
• Provides grants and tax credits to cover certain employers' cost of establishing Section 125 Plans.
• Agreement to establish a tax credit for the uninsured to purchase coverage through a Section 125 Plan.
• Creates a workgroup to make recommendations on the design of an "essential benefit set" that provides coverage for a broad range of services and technologies, is based on scientific evidence of clinical and cost effectiveness, and requires lower enrollee cost-sharing for certain services.
Chronic care management
• Promotes the use of "health care homes" to coordinate care for people with complex or chronic conditions.
• Requires DHS and MDH to develop and implement standards of certification for health care homes by July 1, 2009.
• Establishes standards for state certification of health care homes and evaluating outcomes. Health care homes will receive care coordination payments from public and private health care purchasers.
Payment reform and price/quality transparency
• Encourages quality improvement, by increasing transparency of quality and establishing a single statewide system of quality-based incentive payments to be used by public and private health care purchasers.