Details emerge on Ohio’s health plan

ANN SANNER

Asso­ci­ated Press

COLUMBUS — The state’s plan to stream­line med­ical care for some of its sick­est, most expen­sive and dif­fi­cult to treat patients includes changes designed to elim­i­nate unnec­es­sary health tests, pre­vent med­ica­tion errors and keep peo­ple health­ier and out of emer­gency rooms.

The pro­posal for those enrolled in both Med­ic­aid and Medicare could end up being a model for other states, said Ohio offi­cials who drafted the plan. The offi­cials are expected to send the details on Mon­day to the fed­eral gov­ern­ment, which must sign off on the changes.

While the final details were still being worked out, state offi­cials told The Asso­ci­ated Press on Fri­day that peo­ple who fall under the three-year pilot pro­gram would not see any imme­di­ate changes to their providers, though they could later.

The tar­get date for the plan to take effect is Jan. 1. There would be a tran­si­tion period to the new man­aged care sys­tem, said Greg Moody, the direc­tor of the governor’s Office of Health Transformation.

“It’s not so much chang­ing the faces they see — the case worker and oth­ers who treat them in their homes — but try­ing to bet­ter coor­di­nate the things they don’t see that may be out of whack,” Moody said in an interview.

Ben­e­fi­cia­ries are guar­an­teed the same nurs­ing homes and case man­agers for the dura­tion of the test run. Patients could keep their same pri­mary care doc­tors and spe­cial­ists for at least the first year. Oth­er­wise, they would have to pick new physi­cians if those doc­tors weren’t in the new provider net­work. And highest-risk sick patients could keep their same doc­tors and vis­it­ing nurses for the first 90 days.

Moody said the plan would not lock patients in to cer­tain providers but give them a choice within the network.

Choice was among the top con­cerns brought to state offi­cials by those enrolled in the pro­grams, as well as from advo­cate groups such the Ohio Olm­stead Task Force, which mon­i­tors long-term care issues for peo­ple with disabilities.

The group’s chair, Shel­ley Papen­fuse, said she hopes to see more details Mon­day on how the state plans to ensure patients have the options they need. In par­tic­u­lar, she wants ben­e­fi­cia­ries in wheel­chairs to be able to keep providers who meet their acces­si­bil­ity needs, such as adjustable exam­i­na­tion tables or X-ray machines.

Papen­fuse said she had hoped the state would build into the pro­posal a require­ment that there be a spe­cific num­ber of providers that meet those con­di­tions. With­out it, she said, “I think we could make it worse when we move over to the new system.”

State offi­cials said Fri­day there would be an ade­quate num­ber of providers to meet the needs of those in wheelchairs.

The fed­eral Medicare pro­gram serves the elderly and dis­abled, while Med­ic­aid pro­vides cov­er­age for the poor through state and fed­eral funding.

The two pro­grams oper­ate fairly inde­pen­dently of each other. Medicare gen­er­ally helps pay for doc­tor and hos­pi­tal vis­its, along with pre­scrip­tion drugs. Med­ic­aid typ­i­cally helps pay for long-term care, such as nurs­ing homes, among other services.

As a result of the lack of con­nec­tion between the two pro­grams, some patients are more costly to the sys­tem, Moody said. For instance, a patient could be dis­charged from a hos­pi­tal to a nurs­ing home instead of to a less expen­sive home-based care because the two pro­grams aren’t talk­ing to each other in the same setting.

“For folks with the most com­pli­cated health con­di­tions, the sys­tem is very frag­mented and kind of works against them,” Moody said. “What we’re try­ing to do with this is get all of it orga­nized together in a way that there’s a coher­ent ben­e­fit for Ohioans on both Medicare and Med­ic­aid, so they don’t have to strug­gle to where to go.”

Ohio is propos­ing a three-year pilot pro­gram, begin­ning with those ben­e­fi­cia­ries in seven mostly urban regions across the state.

There are about 196,000 so-called fully enrolled “dual eli­gi­ble” peo­ple in Ohio on both pro­grams. They make up a small frac­tion of the 2.2 mil­lion peo­ple get­ting ser­vices through Med­ic­aid but account for about 46 per­cent of Med­ic­aid long-term care spend­ing and 16 per­cent of behav­ior health ser­vice spend­ing, state fig­ures show. Often­times, they have mul­ti­ple chronic con­di­tions and require more extended care needs.

Ohio offi­cials are try­ing to address what they see as inef­fi­cien­cies in the fee-for-service program.

“We pay if you show up to the emer­gency depart­ment. We pay if you’re in to see the doc,” Moody said. “We don’t pay them to coordinate.”

The state expects the pro­posed changes to pro­vide sav­ings, but offi­cials don’t have an esti­mate on how much. Their pro­posal asks that the fed­eral gov­ern­ment evenly split with the state any Medicare sav­ings it would recoup from the changes.

The ser­vices avail­able to ben­e­fi­cia­ries aren’t expected to change, but how those ser­vices are coor­di­nated will.

Under the ini­tia­tive, Ohio would con­tract with an entity to become the sin­gle point of con­tact for ben­e­fi­cia­ries. The con­trac­tor would have to keep a cen­tral­ized record avail­able to all the doc­tors, nurses and other prac­ti­tion­ers involved with the enrollee’s care and have an “aggres­sive process” to review all hos­pi­tal admis­sions and nurs­ing home place­ments to see whether they were appro­pri­ate or avoidable.

The model spells out that a health care pro­fes­sional must be able to take enrollees’ calls, assess their sit­u­a­tions and take action at any time of day. In addi­tion, the plan empha­sizes peri­odic vis­its to the ben­e­fi­cia­ries’ homes, so they can be assessed in their own environments.

After the plan is sub­mit­ted Mon­day, the state will work with Wash­ing­ton on any revi­sions before it gets final­ized. And fed­eral offi­cials will con­duct their own pub­lic com­ment period on the plan.

Posted by AP News on Mar 30 2012. You can follow any responses to this entry through the RSS Feed. Comments can be made below.