Program targets high-cost, high-risk Medicaid clients

In Oklahoma, a health management program targets high-cost and/or high-utilization Medicaid clients, both adults and children. "Through predictive modeling, we identify our members, adults and children, at risk for higher costs or utilization. If they are within the targeted top 5,000 at highest risk and agree to participate, we enroll them in our health management program," says Marlene Asmussen, RN, director of SoonerCare Medicaid care management and health management.

The first tier of the health management program is limited to the top 1,000 members at risk for the highest utilization or costs. A contracted vendor's nurse care managers attempt an in-person meeting with these individuals on a monthly basis or as needed. The visit covers all aspects of self-management, including the importance of taking medications as prescribed, adherence to their prescribed medical regimen and scheduling, and keeping all medical appointments. A second tier of the health management program captures the next 4,000 members who are also at risk for high cost and/or high utilization. These members receive a monthly telephone consult from the contracted vendor's nurse care managers.

"This program is still very young, but the first indication is that there are some cost savings with the more intensive Tier 1 intervention related to hospitalizations and ER use. We are not seeing the same level of impact with the Tier 2," says Ms. Asmussen.

The program came about as a result of a legislative mandate and is limited to an enrollment of 5,000. "We are not quite at the 5,000 mark, but we may limit the program to our current enrollment due to budgetary concerns," says Ms. Asmussen. "Tier 1 of the health management program is a resource-intensive intervention, but it has certainly been beneficial for the member at risk for high cost/high utilization, and for the program."

Another initiative involves a community-based, multiagency effort for reaching out to support children with special health care needs. "This is funded through a variety of mechanisms," says Terrie Fritz, director of SoonerCare's Child Health Unit. "It is about SoonerCare Medicaid benefits, but also all of their other needs as well."

The agency has made a lot of effort to get input from consumers in order to better meet the needs of members. "Currently, we have a child health and a perinatal advisory task force with consumers on those," says Ms. Fritz. "We are also committed to launching a Consumer Advisory Task Force this year."

That Task Force is expected to answer many questions about how the program can better reach members. "As the director of child health, I will be focused on, 'How can we get you to use early intervention services and early prenatal care?'" says Ms. Fritz. "I'll be using this forum to develop ideas around better utilization of benefits, and also how we can structure services to do a better job of serving children."

As the next round of budget cuts approaches, consumers will be asked for their advice on this as well. "For the first round, we have had to cut some services and realign some benefits. We reconfigured some things, but the biggest brunt of the changes did not involve children," says Ms. Fritz. "There were some changes to behavioral health that do impact children, but for the most part, because of the stimulus money, we didn't really have to cut out benefits at this point. But those still can be on the chopping block for the next round."

Some of the suggestions made by providers on the perinatal and child health advisory task forces were implemented. For instance, there was a resounding response that if provider cuts were needed, these should be made across the board. "While I may favor child health, if we cut the specialty care, that's just as important. They told us that however deep you need to go, whether 1% or 2%, do it all the same," says Ms. Fritz.

Other suggestions were to cut coverage for dental composite, so that composite fillings for back teeth for children are no longer covered, and are instead paid for at the amalgam rate, and decreased payments for cesareans to eliminate incentives for doing these instead of vaginal deliveries. "We are trying to find strategies to improve the care overall, and get us in a direction we might have wanted to go anyway. It's a little less painful that way," says Ms. Fritz.

Contact Ms. Asmussen at (405) 522-7123 or Marlene.Asmussen@okhca.org and Ms. Fritz at (405) 7377 or Terrie.Fritz@okhca.org.