Fiscal Fitness: How States Cope

Kentucky Medicaid-only plan, Passport, has saved millions by pairing quality, cost savings

Passport Health Plan, a Medicaid-only plan operating in 16 counties around Louisville, KY, has saved the state $191 million in its eight years of operation. The program provides a combination of health management, case management, and utilization management for complex, high-cost, at-risk members.

“We’re most proud of the fact that quality drives the cost savings,” says Passport’s director of medical management, Helen Homberger. “We’ve been able to show that quality and cost savings go hand-in-hand.”

Passport was started and always has been owned by local hospitals and traditional safety net providers. It has contracted with AmeriHealth Mercy Health Plan of Philadelphia to administer its programs serving 135,000 Medicaid members. The health plan provides case management for populations at risk, including mothers and children, adults and children with disabilities, and members with chronic illnesses.

The case management department is staffed with nine nurses and two social workers, each carrying an average caseload of 45-50 members. Passport Health has a separate disease management program that refers members to case management if they have extensive needs. Case managers all are cross-trained to work with members with various diagnoses.

Everybody has an area of expertise, but all case managers have varying cases, even with special programs such as HIV-AIDS, chronic obstructive pulmonary disease, or palliative care, says case and utilization management manager Randy Simmons.

One of the reasons Passport is so successful is that in addition to helping coordinate health care for members, providing member education, and encouraging members to follow their treatment plan, case managers also may help members find housing, food, transportation, or assistance in paying for prescriptions. For example, case managers coordinated the care of an infant with respiratory problems and who was ready to be discharged from the hospital, but the home environment was inappropriate and was likely to exacerbate the illness, resulting in another inpatient stay. The team worked with the local housing authority and other community agencies to find housing for the child and his mother so they wouldn’t have to live with 12 family members, many of whom smoked.

“These types of activities separate what we do from more traditional types of case management,” Ms. Homberger says.

Many referral sources

Referrals to the case management program come from physicians, area hospitals, members themselves, and sources within the health care plan. When case managers receive a referral of a member for case management services, they make every effort to contact the member by telephone. If that doesn’t work, they check claims data for a recent address.

“This population is very transient,” Ms. Homberger explains. “Their telephone number on the date of enrollment often is not valid by the time case management gets involved.”

Case managers work closely with community advocacy groups in meeting members’ needs.

“These members have so many psychological and social issues combined with their medical needs that it is sometimes difficult to meet these needs because they are outside of the benefits coverage,” according to Ms. Homberger. She also notes that educating members to comply with their treatment plan is a big issue for Medicaid recipients. “One of our greatest challenges is getting members to follow up with their primary care physician or a specialist on a routine basis rather than seeking urgent care for what could be handled in a physician’s office.”

Medicaid recipients may not be compliant with a diet because they don’t have money to buy the right foods.

“We determine what is important to the member and begin to work on those,” Ms. Homberger says.

Last fall, the Centers for Medicare & Medicaid Services (CMS) extended Passport Health’s federal waiver. It has been operating as a demonstration project with the goal of improving Medicaid patient access and controlling rapid Medicaid cost increases.

“The Kentucky partnership is among the highest-performing Medicaid managed care demonstrations in the country,” said CMS administrator Mark McClellan. “It is especially gratifying to see documented improvements in access to health care by children and an overall improvement in health outcomes for all enrollees.”

Excellent accreditation

CMS reported that Passport exceeded performance goals set by the National Committee for Quality Assurance (NCQA) in 87% of its measures. NCQA has determined that plans meeting standards at 90% of its measures are the very highest-performing plans. NCQA designated Passport as receiving Excellent Accreditation again in 2005, the highest accreditation status for services and clinical quality given to a health plan that meets or exceeds NCQA’s rigorous requirements for consumer protection and quality improvement.

Passport spokeswoman Jill Bell tells State Health Watch the plan was established with two goals: 1) improve health outcomes for the Medicaid population; and 2) control the rising cost of health care for the Medicaid population.

Ms. Homberger says the plan’s care management efforts include the typical asthma and diabetes programs as well as a coronary artery program for Medicare beneficiaries and a chronic obstructive pulmonary disease program for the plan’s new Medicaid Advantage effort for those who are dually eligible for Medicaid and Medicare.

Mr. Simmons says they have not done a cost-benefit analysis on all the programs.

“We’re impacting the health of our members and the outcomes speak for themselves,” he says. “We’re finding we may lower costs in one area but increase them in others, such as pharmacy. And then several years later, our members get the benefit of the changes.”

Passport is more able to see the benefits over time than many other plans can because it keeps its members longer because it is a sole-source contractor. Some members have been part of Passport for the full eight years. There also is a lower marketing expense.

One of Passport’s newest programs is a pilot dealing with childhood obesity.

“If a child is 10 years old and weighs 300 pounds, there is no immediate impact,” Mr. Simmons says. “But we will see two to 10 years down the road that our efforts are preventing diabetes, cardiovascular issues, and a potential future need for rehabilitation services.”

Asked what factors are most responsible for Passport’s success, Mr. Simmons notes that being a sole-source contractor allows it to take on cutting-edge programs and chart success over time.

“There are opportunities for research studies,” he says, “such as the palliative care program with early interventions and hospice care for end of life issues.”

Under that program, a grant is being used to educate the entire staff on special end-of-life issues such as pediatrics and HIV.

Another key success factor is the plan’s sponsorship by traditional safety net providers. University Health Care executive vice president Robert Slaton, one of three physicians who did a lot of the initial work in bringing Passport together, tells State Health Watch that when Kentucky’s waiver was approved, there was a threat that the state would bid the work to private carriers if providers didn’t form partnerships to take it on.

When primary care physicians were capitated, it was hard to get doctors to buy into the arrangement initially, Mr. Slaton says, and it helped to have an incentive pool and a menu of additional fee-for-service services. Over time, he says, they came to realize they were doing as well financially, if not better.

And a lot is accomplished through a partnership council that brings together many provider specialties with advocates and Passport members.

“Committees oversee clinical and quality programs,” Mr. Simmons says. “They are the people on the front lines and they let us know if something isn’t working.”

Committee members are given meals, but aren’t paid for their committee work and Mr. Simmons says it is their commitment to the members that makes the system successful.

A third success factor is that Passport looks beyond a member’s illness or health condition to environmental and psychosocial factors that have a bearing on members’ ability to follow-through with prescribed medical care.

Case managers either can be nurses or social workers. They regularly break down traditional barriers to find services their members need.

Typical efforts involve housing issues and basic sanitation in the home. They also used to provide transportation services but that responsibility now lies with other local agencies and Passport coordinates with them. Case managers often attend clinic appointments with patients as their advocate and to help them ask questions.

A day-to-day sense of wellness

“For many of our members,” Mr. Simmons says, “their sense of their wellness state extends only to the day they are living in. They aren’t looking long range. They are dealing with many other issues such as no running water, or no heat or light. It’s hard to manage your disease process if you’re worried about the basics.”

The basic impediment to success cited by Mr. Simmons is the transient nature of the membership. People often move, he says, changing their phone number and not leaving a forwarding address. Passport looks for innovative ways to track members, such as following where members have prescriptions filled and seeing if a better address has been given to the pharmacist.

Mr. Slaton says from the provider perspective, the key success factors have been: 1) Passport’s mission and the fact that people love what they are doing and want to provide good health care to the Medicaid population; 2) tracking short-term actions that improve health and eventually save money; and 3) the involvement of providers.

With more plans trying to implement disease and care management programs, the Disease Management Association of America says it is working on a uniform method for measuring and evaluating outcomes of such programs.

“This certainly stands among the disease management community’s most significant research efforts to date,” said association Quality and Research Committee chair Don Fetterolf. “Reaching consensus on a relevant and scientifically valid standard for evaluating clinical and financial outcomes is vital to the continued strong growth of disease and care management.”

Underscoring the importance of the effort is an agreement among the companies and individuals involved to support the final methodology and put on hold independent standards development projects already under way.

Initial work on the project will involve a survey of the disease management community to collect data on how disease management organizations and others now measure outcomes. The association said it will reach out to a broad coalition of public and private quality and standards-setting entities to enlist their assistance and support as the project moves forward.

Plans creatively coordinating care

A report from America’s Health Insurance Plans says its members are coming up with innovative ways to coordinate care for the Medicaid population. An analysis of numerous studies found that managed health care for Medicaid recipients saves up to 19% when compared to Medicaid fee-for-service.

The trade association for managed care plans says the Medicaid population is difficult to manage and presents challenges case managers typically don’t see in the commercial population. They tend to be sicker and have more comorbidities. They are less likely to seek routine medical care, instead going to emergency departments and becoming so ill that they require hospitalization.

“These members have tremendous psychosocial needs that make it impossible for them to seek care in a timely manner and comply with their treatment plans,” America’s Health Insurance Plans CEO Karen Ignani said. “Many Medicaid recipients don’t even have basic needs such as food and shelter on a regular basis.”

[Contact Ms. Homberger and Mr. Simmons through Ms. Bell at (502) 585-7983. Information on the Disease Management Association of America’s evaluation is available from Carl Graziano at (202) 737-5781. Information on America’s Health Insurance Plans is available on-line at]