DHS Health Care Services Study:
Potential Coverage Strategies for
the Non-Disabled Population
Michael Bailit
Bailit Health Purchasing, LLC
March 18, 2004
Goals of Study
1. Identify where cost savings can be
realized in MA, GAMC, MNCare. We
are considering:
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–
–
What to cover (e.g., perhaps eliminate services
that add little value to members’ health).
When to cover (e.g., perhaps require trial of less
expensive alternatives before approving a more
expensive service).
How to cover (e.g., perhaps use aggressive care
management models to maximize effectiveness
of services).
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Goals of Study
2. Utilize an open process to obtain a wide
range of opinions and ideas.
•
•
Create work groups of key interested parties,
including DHS staff, stakeholders, & experts.
Solicit suggestions, as well as reactions to
possible programs, from the work groups.
3. Develop cost savings estimates.
4. Prepare a report for the legislature by
1/15/05.
5. Seek to “do no harm.”
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Study Structure
• Three bodies identifying and reviewing
strategies:
– Stakeholder Work Group
– Health Services Experts Advisory Panel
– DHS Work Groups
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Ordering of Meetings for
Each Population Group
1. Stakeholder Work
Group (1/29)
2. Internal DHS Staff
Work Group (2/10)
3. Health Services
Experts Advisory
Panel (2/24)
4. Stakeholder Work
Group (3/18)
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Timeline
• By 1/20/04: create study committees (DHS,
Stakeholders and Advisory Panel)
• By 4/30/04: complete study of non-disabled
population
• By 8/16/04: complete study of disabled
population
• By 11/30/04: complete study of elderly
population
• By 1/15/05: submit report to legislature
– 12/10/04: draft report to DHS
– 01/03/05: final draft report to DHS
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Option #1
• Eliminate coverage of
services that research
evidence indicates are
inappropriate, and
sometimes,
potentially harmful.
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Option #1: Eliminate Coverage
of Unnecessary Care
1. Develop a medical policy function and medical
management plan within DHS to review
current coverage policy.
2. Create a DHS-HMO Medical Policy
Committee to review coverage policy and
ensure consistent application across DHS and
its contractors.
3. Initiate a multi-state sponsored initiative to
review medical evidence and make coverage
recommendations modeled on the Oregon State
EPC for state Medicaid pharmacy.
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Option #1: Eliminate Coverage
of Unnecessary Care
4. Expand current prior authorization activities to
address those services that are frequently
delivered inappropriately.
5. Reduce reimbursement rates for services that
are documented to be used inappropriately in
high frequency.
6. Profile providers to identify those providers
who appear to be providing services
inappropriately and provide feedback.
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Option #2
• Support statewide
infrastructure
development that will
improve efficiency
and quality.
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Option #2: Support Statewide
Infrastructure Development
1. Participate in statewide discussions to
develop a web-based EMR exchange.
2. Support adoption of EMR by rural
practices and community clinics.
3. Support use of a Smart Card for MA,
GMAC, and MNCare enrollees.
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Option #3
• Apply a cost/benefit
test to coverage policy
for medical scanning
and medical products.
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Option #3: Cost/Benefit Test for
Medical Scanning and Medical Products
• Under prescribed situations cover only
those medical scanning services and those
medical products that evidence finds to be
most cost-effective.
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Option #4
• Cautiously pursue
disease management
(DM) strategies.
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Option #4: Disease Management
1. Implement well-designed pilot programs for the
fee-for-service population.
2. Evaluate the effectiveness of HMO DM
strategies for DHS-enrolled populations.
3. Develop prescribed requirements for HMO DM
programs.
4. Consider option of one DHS-wide DM vendor.
5. Partner with other purchaser organizations and
the Department of Health to develop provider
capacity to deliver DM services (implement the
Chronic Care Model).
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Option #5
• Explore the use of
predictive modeling
to prevent near-term
hospitalization.
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Option #5: Predictive Modeling
• Explore the use of commercial predictive
modeling software and care programs to
identify MHCP recipients who are likely to
need extensive care or are likely to be
costly in the future, and to intercede to
assist them and avoid the need for future
service use.
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Next Steps
• DHS staff will further explore the feasibility of
the strategies identified to date.
• Stakeholders with comments on the strategies
presented today should submit them to Michael
Bailit.
• A shorter list of strategies will be developed for
the report with estimated savings for each one.
• First stakeholder meeting re: under 65 disabled
population scheduled for 5/13.
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Key Contacts
• Michael Bailit
[email protected]
781-237-5111
• Tom Fields
[email protected]
651-297-7303
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