Oregon, New Mexico seeing good results with public health
Oregon, New Mexico seeing good results with public health
Oregon's Medicaid program has implemented a number of programs that further public health goals, according to Katherine J. Bradley, PhD, RN, administrator for the Oregon Department of Human Services' Office of Family Health in Portland.
One program aims to increase the percentage of children identified early for developmental delays. For this initiative, public health, Medicaid, and the Oregon Pediatric Society partnered under the auspices of the national ABCD (Assuring Child Health and Development) Learning Academy, sponsored by the National Academy of State Health Policy. The goal: To clarify the Oregon Health Plan policies regarding reimbursement for developmental screening in the preventive health visit for children under age 10.
"The clarification has led managed care to utilize prevention incentives and increase the use of evidence-based screening tools among its contractors," says Dr. Bradley.
Additionally, a managed care company, CareOregon, teamed with the Oregon Pediatric Society to train and educate providers in private practice and at Federally Qualified Health Centers clinics in the office process for screening and referral, leading to increased referrals to state Early Intervention services.
Evaluation of the pilot program currently is under way, and quality measures for the process and outcomes are still in development. Dr. Bradley says, though, that the project already is showing improvement in Oregon's ability to track the quality of its Early Periodic Screening, Diagnosis, and Treatment program, the child health component of the Medicaid program, which is administered through the Oregon Health Plan.
Immunization rates are targeted
The Oregon Immunization Program is collaborating with the state's Medicaid program to provide assessments of immunization rates and the state's managed care plans.
These assessments are produced through the Immunization Program's Quality Improvement Program, using data from the Immunization Registry. Each year, these assessments are presented to the medical directors and quality improvement coordinators of the managed care plans, as well as to Medicaid staff. Practices and rates are discussed, and plan-level interventions are identified.
"As a result of this work, the Immunization Program and the managed care plans have collaborated in various ways to improve immunization rates and services to clients," says Dr. Bradley.
Two examples include working to identify and correct data quality and data reporting issues, at the plan or clinic level, and conducting joint trainings of clinical staff from offices that contract with the managed care plans to improve immunization rates and practices at the clinic level.
Sixty-five percent of newborns and 61% of 1- and 2-year-oldsmore than 81,000 childrenare eligible for the Vaccines for Children program in Oregon, according to 2008 estimates. "Outcomes from the partnerships between the Oregon Immunization Program, Medicaid, and the managed care plans have the potential to reach a significant amount of children in Oregon," says Dr. Bradley.
In 2008, the Oregon Immunization Program and Medicaid worked together to calculate early childhood immunization rates for Medicaid and non-Medicaid children. Using population-based methodology, statewide and county immunization rates were estimated.
"This project allows for the tracking of immunization rates over time and for the creation of common immunization measures across DHS agencies," says Dr. Bradley.
That same year, Oregon submitted a State Plan Amendment to the Centers for Medicare & Medicaid Services (CMS) for a locally-matched pilot to provide Oregon Health Plan (OHP) coverage for Citizen/Alien-Waived Emergent Care pregnancies.
"CMS approved this, and a 15-month pilot went live in April 2008 in Multnomah and Deschutes Counties for full OHP coverage provided during pregnancy," says Dr. Bradley.
This pilot was a partnership between state Medicaid, county health departments, and community health centers to bring prenatal care to a population that had previously not had access to care.
"While the pilots have been successful, budget limitations do not allow for a statewide expansion with match provided by state general funds," adds Dr. Bradley.
Program uses school-based clinics
"Salud," New Mexico's Medicaid managed care program, and its health plans are collaborating with school-based health clinics (SBHCs) to promote weight measurement and management for children. Salud's HMOs recognize SBHCs that meet quality standards by credentialing them as providers, which enables them to bill health plans for services they provide to Medicaid clients.
Medicaid managed care companies coordinate with SBHCs around the state to reimburse them for services and also to do disease management.
The program, which began as a small pilot at 10 sites back in 1997, is now in place at 84 sites around the state, with 41 sites approved to bill Medicaid. "The initiative was born out of seeing the value of school-based clinics, because that is where kids really go for the care they need," says Carolyn Ingram, New Mexico's Medicaid director. "Initially, young children are brought in for regular checkups, but that starts to fade off as they get older. So, school is really the predominant place kids are getting services."
The program was originally funded through the Center for Health Care Strategies (CHCS) via a separate grant to CHCS from the Robert Wood Johnson Foundation, a nonprofit group in Princeton, NJ. "It took awhile for it to grow and become what it is today," says Ms. Ingram. "We have agreed to double the number of school-based clinics in the state, and managed care programs made a commitment to continue payments to those services."
Children receive preventive care, and for complex cases, the child is referred to a primary care provider in the community. "They work with the family to make sure they get follow-up care," says Ms. Ingram. "It's been very rewarding to see a program in Medicaid come to fruition, and see children and adolescents getting better care and having better outcomes."
Early Periodic Screening, Diagnosis, and Treatment visits at SBHCs rose over the course of the pilot project for adolescents ages 10-18. As a percentage of the whole, the pilot sites provided a larger share of these visits to adolescents than other providers in the pilot site communities.
Obesity, diabetes are targeted
After the SBHC pilot program demonstrated success, a healthcare quality improvement program was implemented called Envision New Mexico, patterned after Vermont's NIC/Q program. "We expanded it and changed it to make it work for us," says Ms. Ingram.
The program works with pediatric practices on specific disease management initiatives, currently diabetes, weight measurement, and obesity.
All the managed care companies that the state contracts with, large pediatric practices in the state, the University of New Mexico, and the Department of Health have agreed on all the clinical criteria they will use to control obesity and prevent diabetes.
"The managed care programs participate in this program both financially and clinically," says Ms. Ingram. "And we have had good success in starting to control the onset of diabetes and prevent obesity in school-age kids."
Another very recent initiative involves pay-for-performance for immunizations in children. For several years now, the Medicaid program has had performance measures in place for its managed care companies, holding the plans accountable for meeting certain expectations in terms of plan performance, measured by HEDIS outcome data.
"Our sister agency, the department of health, came to the conclusion that our immunization rates still were not what they needed to be in the state," says Ms. Ingram. "We had pay-for-performance at the managed care level, but we weren't seeing the outcomes we wanted. So, we started working with the managed care companies to see what we could do to incentivize physicians. We are going to pediatric practices around the state and working with the managed care companies to create a pay-for-performance initiative around immunizations at the doctor level."
Ms. Ingram says although it's still too early to share solid data, immunization rates already have started to increase as a result of the program.
Budget cuts won't affect programs
For fiscal year 2009, the state already has "trimmed back our Medicaid budget," says Ms. Ingram. "We have done some cost containment to make sure we are bringing our budget in line with the revenues we have available," she says. "The legislature and the governor's office will be redoing that. We will have to see what comes out of that, to see if we did enough cost containment."
The programs wouldn't be affected by any of the current cuts, says Ms. Ingram, but "going into FY 2010, we have said everything is on the table. We certainly wouldn't want to cut these things first, because we have seen better outcomes because of them."
However, although the programs do save money down the road, such as Envision preventing obesity, more short-term results may be needed.
"Unfortunately, when you are doing state budget planning, people don't care so much about the long-term goal of saving money," says Ms. Ingram. "It is year by yearhow much do you have to support the program this year?"
Ms. Ingram says she has been contacted by other states about these initiatives and expects that more states will move toward this type of coordination across their entire health care system.
"You really don't have a choice anymore. You are dealing with such limited money and funding, and you want to continue to do initiatives to help save money down the road," says Ms. Ingram. "So, I don't think states will be pulling back from those things. I think we will see states grow more into those areas because you're going to have to, with tight budgets."
Future plans are to expand the disease management programs to include additional conditions. "After we get one up and going and start to see outcomes, we'll move on to the next topic," says Ms. Ingram. "As a state Medicaid director, you tend to get bogged down in the day-to-day stuff. It's nice to be able to step back and see a program all the way to fruitionbecause they really do produce good outcomes."
Contact Dr. Bradley at (971) 673-0233 or [email protected], and Ms. Ingram at (505) 827-3106.Oregon's Medicaid program has implemented a number of programs that further public health goals, according to Katherine J. Bradley, PhD, RN, administrator for the Oregon Department of Human Services' Office of Family Health in Portland.
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