Medicaid M Health Plans of AmericaWelcome to the third edition of the Medicaid Health Plans of...

MHPA’s2009-2010

Best PracticesCompendium

www.mhpa.org

A Compilation of Best Practices within the Medicaid Health Plan Community

M MedicaidHealth Plans ofAmerica

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MHPA 2009-2010 Best Practices Compendium

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Introduction

A Special Message fromThomas L. Johnson, MHPA Executive Director

Welcome to the third edition of the Medicaid Health Plans of America’s Best Practices Compendium. Once again, the Compendium highlights how Medicaid managed care plans around the country combine innovation, expertise and caring to offer their members programs and services that improve health status for Medicaid recipients of all ages.

Medicaid Health Plans continue to make significant contributions to positive health outcomes of health plan members in an era where government resources are increasingly scarce. Our plans are a strong

public-private partnership relationships with the states, and we work together in the best interests of our members.

The Medicaid industry has grown each year over the past 10 years, and more than 70 percent of those eligible for Medicaid are now members of a Medicaid Health Plan. Medicaid is the largest health insurer in the country now, serving more than 44 million individuals. The industry remains committed to offering quality care while controlling rising costs.

In this Compendium, we have included excellent examples of the most effective best practices in use today. Also included in this Compendium is statistical data about the industry from the 2008 Centers for Medicare and Medicaid Services (CMS) National Summary of the Medicaid Managed Care Program and Enrollment. We hope you find the information in this report helpful, and we look forward to continuing our mission to improve the health and quality of life of our members.

Sincerely,

Thomas L. Johnson Executive Director Medicaid Health Plans of America

About MHPA and This Compendium

Medicaid Health Plans of America (MHPA) is the leading trade association solely focused on representing Medicaid health plans. MHPA is a nonprofit, tax-exempt organization formed in 1993 and incorporated in 1995. The Association provides advocacy, research, analysis and organized forums that support the development of effective policy solutions to promote and enhance the delivery of quality health care.

MHPA’s 2009-2010 Best Practices Compendium is a compilation of the best practices put forward by the Medicaid health plan community. This booklet, published annually, is provided as a valuable reference tool.

The Compendium also features Centers for Medicare and Medicaid Services (CMS) statistical data on the state of the managed care industry as well as a listing of the current state Medicaid directors and an MHPA-member/vendor health plan resource directory.

InTroDuCTIon

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Table of Contents

Part I: Best Practices Compendium

The 2009 Best Practices (submissions listed alphabetically by title)

After Care Program (Chartered Health Plan with Beacon Health Strategies)............................................................... 7Asthma Disease Management Program (Passport Health Plan)............................................................................... 8 Asthma Medication Promotion Program (AmeriHealth Mercy Family of Companies).......................................... 9At the Heart of the Community’s Health (Midwest Health Plan)............................................................................ 10Automated Primary Care Provider (PCP) Assignments (Select Health of South Carolina, Inc.)......................... 11Beta-Blocker Initiation and Persistence Program for Members with Recent Myocardial Infarction (Horizon NJ Health).................................................................................................................................................... 12Body Mass Index Training and Promotion Program: Childhood Obesity (WellPoint).................................... 13Caring for Culture – Caring for Women (Midwest Health Plan)............................................................................. 14Caring Voices, Pre-programmed Cell Phones (Centene).......................................................................................... 15Community Baby Shower (Keystone Mercy Health Plan)........................................................................................... 16CONNECTIONS Plus™ (Centene)............................................................................................................................... 17DEAL: Diabetic Eyes for Active Living (Health Partners of Philadelphia, Inc.)........................................................ 18Diabetes Disease Management Program (Passport Health Plan)............................................................................. 19Dilated Retinal Eye Outreach Program (Horizon NJ Health)................................................................................... 20Early Periodic Screening Diagnosis and Treatment (EPSDT) Program (Passport Health Plan)...................... 21Emergency Room Initiative (MDwise, Inc.).................................................................................................................. 22ER Initiative (Health Partners of Philadelphia, Inc.)........................................................................................................ 23ER Utilization Program (Passport Health Plan)........................................................................................................... 24 “Gift for Life Program” Community Health Intervention Program (Keystone Mercy Health Plan)................. 25Glorious Women Assembly (Passport Health Plan).................................................................................................... 26Healthy Hoops®: Using Basketball to Help Children Better Manage Their Asthma (Keystone Mercy Health Plan).................................................................................................................................... 27Health Literacy and Plain Language Resource Guide (AmeriHealth Mercy Family of Companies).................... 28HEALTHYwomen (MDwise, Inc.).................................................................................................................................. 29HEDIS Provider Poster (MDwise, Inc.)......................................................................................................................... 30Improving Health through Integration and Alignment of Gaps in Care Data (AmeriHealth Mercy Family of Companies with Keystone Mercy)............................................................................................................................ 31Lipid Management Improvement through Drug Utilization Review (Horizon NJ Health)............................. 32Lower Mode Transportation Services (Horizon NJ Health)..................................................................................... 33Medicaid Recertification Outreach (Select Health of South Carolina, Inc.).............................................................. 34Mitchell Math and Science Elementary School – PE4Life (Select Health of South Carolina, Inc.)...................... 35 “Move It,” In-School Program Fighting Childhood Obesity (MDwise, Inc.)...................................................... 36Obstetrical Case Management Program (Molina Healthcare of Missouri).............................................................. 37Primary Care Physician Involvement in the Improvement of Dental Visit Rates (Horizon NJ Health)........ 38Primary Care Provider Incentive Program (AmeriHealth Mercy Family of Companies)......................................... 39

Promoting Electronic Prescribing (Midwest Health Plan)......................................................................................... 40 “Smiling Stork” Prenatal Dental Program (Health Partners of Philadelphia, Inc.).................................................. 41Start Smart for Your Baby ® 17P Program Impact on Reducing Premature Birth (Centene).......................... 42Start Smart for Your Baby ® Notification of Pregnancy Process (Centene)........................................................ 43State Sponsored Business Telemedicine - Increasing Patients’ Access to Care (WellPoint).......................... 44Texas Health Passport and Its Impact on Psychotropic Medication Utilization in Texas Foster Children (Centene)...................................................................................................................................................................... 45Using Technology to Create Care Management Efficiencies (Horizon NJ Health)............................................ 46YES, You Can! Smoking Cessation Program (Passport Health Plan)..................................................................... 47

Part II: State of the Medicaid Managed Care Industry & Information

CMS Statistical Information (Graphs & Charts)

Managed Care Trends................................................................................................................................................... 49Medicaid Managed Care Enrollment........................................................................................................................ 50Dual Eligible Enrollment.............................................................................................................................................. 51Number of Managed Care Entity Enrollees by State............................................................................................ 52National Breakout of Managed Care Entities and Enrollment......................................................................... 53Total Annual Medicaid Population Distribution by Year: Managed Care vs. Other.................................... 54Number of Managed Care Entities by State............................................................................................................ 55Regional Break-out of Medicaid Managed Care Enrollment.............................................................................. 56States with Comprehensive Health Care Reform Demonstrations .................................................................. 57Medicaid Managed Care Enrollment........................................................................................................................ 58Managed Care Entity Types........................................................................................................................................ 59Number of Prepaid Inpatient Health Plans and Enrollment by State............................................................... 60Number of Prepaid Ambulatory Health Plans and Enrollment by State......................................................... 61

State Medicaid DirectorsList of State Medicaid Directors................................................................................................................................. 62

resources for Medicaid Health Plans

MHPA Member & Vendor Resources...................................................................................................................... 68

IndexBest Practices Submitted by Health Plan ................................................................................................................. 76

TABLE of ConTEnTS

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BEST PrACTICES SuBMISSIonS

Part I: Best Practices Compendium

Chartered Health Plan with Beacon Health StrategiesAfter Care Program

DESCrIPTIon: Research1,2 indicates that an individual’s chances of being readmitted to a hospital after an inpatient psychiatric admission are significantly reduced if the person is seen by an outpatient mental health provider within seven (7) days of discharge, or at least within 30 days of discharge. The District of Columbia requires health plans to report seven- and 30-day ambulatory follow-up rates, and, along with NCQA, uses the data to monitor a health plan’s performance. When Beacon’s partnership with Chartered began in May 2008, Chartered’s seven-day and 30-day rates were too low to be considered reportable by NCQA. ACTIon TAKEn: Beacon has a set of interventions to improve seven and 30-day follow-up rates called the After Care Program. Beacon DC-based clinicians work with hospital staff from the day of admission to ensure an appropriate transition plan for the member is completed and agreed to by the member, or their guardian. Prior to discharge the member is provided with a written reminder indicating dates, location and contact information for the ambulatory services that are to occur soon after discharge. Shortly after discharge the member is contacted to address any obstacles to keeping the appointment, as well as to remind them of their follow-up care. After the appointment, the member’s attendance is confirmed with the provider. Most kept appointments are also confirmed with a claim. However, since some appointments are with out of network providers, funded by the local Department of Mental Health, Beacon confirms them with an Encounter Verification Form (EVF) the provider is asked to sign.

ouTCoMES: In the two years prior to engaging Beacon, Chartered did not have final seven-day and 30-day HEDIS rates that indicated members were being followed effectively after discharge. The following table presents follow-up data for the two years prior to Beacon’s involvement and data for 2008 in which Beacon provided services eight of 12 months.

Performance Year Seven-Day follow-up rate �0-Day follow-up rate

2006 �.�% 6.1%

200� 9.�% 11.6%

2008 2�.� ��.9%

_____________1 Identifying Risk Factors and Key Strategies in Linkage to Outpatient Psychiatric Care. American Journal of Psychiatry 157 (10): 1592–8. Boyer, C. A., D. D. McAlpine, K. J. Pottick et al. 20002 Predictors of Receipt of Aftercare and Recidivism Among Persons with Severe Mental Illness: A Review. Psychiatric Services

47 (5): 487–96. Klinkenberg, W. D., and R. J. Calsyn. 1996

ConTACT: Anne Clements, LICSW DC Program Director for Beacon Health Strategies, Chartered Health Plan [email protected]

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Passport Health PlanAsthma Disease Management Program

DESCrIPTIon: According to the National Institute of Health and the National Heart, Lung and Blood Institute, from 1980 to 1996 the number of Americans diagnosed with asthma more than doubled to almost 15 million. In 2004, asthma was responsible for 1.8 million emergency department visits, 497,000 hospitalizations with asthma as the primary diagnosis and 4,055 deaths nationwide. Healthy Kentuckians 2010 reports over 220,000 Kentuckians are affected by asthma with 72% in persons under age 45 with increasing prevalence in all ages, especially children. Passport Health Plan is located in the “hay fever belt” and has an average of 5,900 eligible members with asthma. ACTIon TAKEn: Based on claims data as well as hospital and prescription drug use, Passport Health Plan stratifies members based on the severity of their illness and the types of services they have used (inpatient admissions, emergency room visits). Asthma care managers contact members by phone to evaluate the severity of their asthma, identify their needs and determine their level of knowledge about asthma. Based on this information, they work with members and their physicians to develop an Asthma Action Plan that includes goals for improved health and arrange for home visits as needed. Members receive educational materials and services tailored to their specific needs. All newly identified members with asthma receive a welcome packet with educational materials about the physiology of asthma, signs and symptoms, environmental factors that exacerbate asthma, and effective medications. Asthma care managers provide outreach visits to physician offices to inform the doctors and office staff about the program, distribute program clinical practice guidelines, educate office staff on member referral process, and arrange for staff education as needed. Additionally, the Plan has two special programs to help support members with asthma, YES, You Can! Smoking Cessation program and Healthy Hoops® program. Since Kentucky has the highest smoking rate in the nation, the YES, You Can! program helps members quit smoking and provides ongoing counseling, support and medications. Healthy Hoops is a program that uses basketball and fun to focus on the needs of kids with asthma. Under the guidance of celebrity basketball coaches and medical experts, children between the ages of 7 and 13 and their families, participate in a full day of health awareness, entertainment, asthma screenings and basketball drills and skills workshops.

ouTCoMES: Passport Health Plan has seen significant improvement in the percentage of members taking controller medications. The percentage of members taking controller medications increased from 75.68% in 2001 to 96.3% in 2008. In addition, a six-month study of 747 Passport Health Plan members treated with controller medications showed a continued medication compliance rate of 90% (671 members). The study also revealed that these members showed a decrease in emergency room visits, inpatient days and an overall decrease in medical costs.

The YES, You Can! program has seen a 43.5% quit rate. The Healthy Hoops program served 71 members in its inaugural event; 33 of those members were referred for a medication change and 31 were referred to a specialist for additional care. Additionally, Passport Health Plan held the highest HEDIS score in the nation for members ages five to nine receiving the appropriate asthma medication, and the second highest score nationally for all ages combined for 2007.

In recognition of the program’s success, the Robert Wood Johnson Foundation’s Center for Health Care Strategies chose the Plan’s Asthma Disease Management program for its Best Clinical and Administrative Practices award in 2002.

ConTACT: Jill Bell Vice President, Public Affairs, Passport Health Plan (502) 585-7983, [email protected]

AmeriHealth Mercy Health PlanAsthma Medication Promotion Program

DESCrIPTIon: AmeriHealth Mercy Health Plan implemented an aggressive campaign to help members with asthma in the fall of 2007. This program identified members via pharmacy claims who were using their beta-agonist (rescue) inhaler more than twice a week without being on concomitant therapy with a controller inhaler. According to the National Heart Lung and Blood Institute’s (NHLBI) asthma guidelines, these patients are classified as having mild, persistent asthma, and the recommended therapy for this group is an inhaled corticosteroid in addition to a rescue inhaler. ACTIon TAKEn: First, we sent identified members letters explaining why they were selected, how to know if they had poor control of their asthma, and urging them to speak to their physician to receive a controller medication to help control their asthma. Four educational handouts were included to help patients learn more about their disease state. Second, AmeriHealth Mercy sent primary care practitioners detailed member reports that included: (1) utilization rates of both metered-dose inhalers and nebulized rescue medications for all identified panel members; and (2) highlights of the NHLBI’s recommendations for use of controller medications. We also included information about covered, formulary inhaled corticosteroids.

ouTCoME: About 1,800 Medicaid managed care members were identified and included in two mailings. Four to six months after each mailing, approximately 20 percent of eligible members had started controller meds. In addition, about a third of these members were no longer using beta-agonists more than two times a week. Finally, in the total population of asthmatics, the percentage of members taking too much beta-agonist medications but no controller fell from 7 percent to around 2 percent. New members to AmeriHealth Mercy, and members newly diagnosed with asthma since the first mailing, are felt to account for the similar number of new cases eligible for intervention in April as compared to September.

ConTACT: Lawrence E. Kay, MD Senior Medical Director, AmeriHealth Mercy Health Plan (717) 651-3571; [email protected]


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Midwest Health PlanAt the Heart of the Community’s Health

DESCrIPTIon: Midwest Health Plan took the lead in planning, coordinating, and carrying out an all-day Health Fair in the east Dearborn community, where a large proportion of its Arabic population resides. One-third of the MHP population is Arabic and often hard to reach for preventive health due to cultural beliefs. So to offer health screenings, education and information in conjunction with other local organizations in a familiar setting, proved to be winning approach.

ACTIon TAKEn: MHP partnered with the Arab Community Center for Economic and Social Services (ACCESS), Midwest Medical Center, the Oakwood Hospital Asthma Education Department and Blue Care Network to host a the Health Fair. Registration/screening forms served as the basis for routing members to the appropriate station for screenings and exams. Educational presentations were conducted dealing with asthma, women’s health, and men’s health. Additional education was done around fire safety by the Dearborn Fire Department, healthy eating, body mass index and cancer by the American Cancer Society. Written information was available in Arabic and Arabic speaking representatives from MHP and ACCESS were available.

ouTCoME: More than 900 persons attended the day-long event in 2007 and over 500 attended in 2008. The event was termed a HUGE SUCCESS as screenings were non-stop during the five-hour fair. Working with local organizations expanded the scope of advertising in the community and made people feel comfortable in attending. A handful of people were sent to the urgent care department that day based on the results of their medical screenings, addressing immediate medical needs. The education around disease states, screening results and nutrition, assists members in better understanding their health conditions.

ConTACT: Kathleen M. Harkness, RN, MS, CPHQ Senior Director of Corporate Quality, Midwest Health Plan (313) 586-6063; [email protected]

Select Health of South CarolinaAutomated Primary Care Provider (PCP) Assignments

DESCrIPTIon: Medicaid recipients often do not have a medical home or primary care provider. As a result, many beneficiaries don’t receive services until urgent or emergency care is needed. In an effort to increase access to primary care for its membership, Select Health works to contact new members and assign them a PCP. Select Health had traditionally used telephonic outreach for PCP assignments — a process that was labor-intensive and often ineffective due to outdated or incorrect member contact information. ACTIon TAKEn: In 2008, Select Health designed and implemented a process that utilized an algorithm to automatically identify and assign PCPs.

Each month, the automated process reads the members’ eligibility record and identifies members who are enrolled more than 30 days without a PCP assignment. The process then searches for any other family members with an assigned PCP. If another family member is located with an assigned PCP, the algorithm verifies that the PCP is age and gender appropriate and makes the assignment. If a family relationship is unsuccessful, the algorithm makes the assignment based on the PCP’s geographic proximity while ensuring the PCP’s age/gender appropriateness.

The member address file is created daily for all PCP assignments and placed on a secure FTP site. Select Health’s ID card vendor retrieves the file daily and processes the ID cards with the PCP’s name. The ID cards and accompanying letters are mailed within 24 to 48 hours. The Member Services Department attempts to follow up on returned ID cards.

ouTCoME: The automated process has nearly eliminated any manual intervention and has increased the likelihood that the member will accept his/her PCP assignment. Additionally, the automated process has cut down on the amount of time it takes to make an assignment. The manual assignment process took as many as three to four days to complete with less than optimal matches. Now, the automated process takes only minutes.

ConTACT: Tracy Pou Director of Communications, Select Health of South Carolina (843) 569-1759; [email protected]


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Horizon nJ HealthBeta-Blocker Initiation and Persistence Program for Members with recent Myocardial Infarction

DESCrIPTIon: Horizon NJ Health has a comprehensive Pharmacy Case Management (PCM) program conducted through pharmacist-based interventions in order to improve members’ quality of care. PCM identifies members, including those with recent myocardial infarction, to ensure appropriate medication therapy is initiated such as beta-blockers based on national guidelines. Initiation and continuation of beta-blocker therapy can lead to decreased mortality. ACTIon TAKEn: Clinical Pharmacists follow all members with recent myocardial infarctions to ensure initiation and maintenance of beta-blocker therapy. They ensure that the members are initiated on beta-blocker therapy in a timely manner by following up with a member’s physician as needed. In addition, clinical pharmacists work collaboratively with case management nurses to assist members in ensuring ongoing medication compliance with beta-blocker therapy.

ouTCoME: During the 2008 HEDIS period, 100% of the eligible Horizon NJ Health plan members managed under the beta-blocker program remained compliant with beta-blocker therapy after a myocardial infarction

ConTACT: Jennifer Gauweiler Clinical Pharmacy Manager, Pharmacy Services, Horizon NJ Health (609) 718-9216; [email protected]

WellPointBody Mass Index Training and Promotion Program (Childhood obesity)

DESCrIPTIon: Childhood obesity continues to be a significant epidemic with nearly one in three children in the US either overweight or obese. The annual cost of obesity is estimated to be $139 billion. Direct costs account for over half of the total cost. Obesity-related annual costs for treating children more than tripled from 1979 to 1999. Prevention, early identification, and appropriate management of obesity can result in decreased costs. Some of the challenges in addressing the obesity epidemic include the multi-factorial causes of obesity, lack of physician training, slow evidence-base on effective interventions, and few established standards of care. ACTIon TAKEn: Given the importance of BMI as a screening measure and primary care settings as strategic venues to screen, in 2006, WellPoint implemented a BMI training program for clinical staff in pediatric and family medicine offices in California. Key components of the program included raising awareness, empowering clinical staff with knowledge, training to screen by calculating and plotting BMI, assisting physicians in providing anticipatory guidance on nutrition and physical activity, and overall obesity related care. A tiered approach was implemented, offering in-person workshops, online, and CD training. The plan also collaborated with the California Child Health and Disability Prevention Program (CHDP).

ouTCoME: Sixty-three workshops have been conducted in California, Indiana, Nevada, and West Virginia; over 2,400 clinical staff, school nurses, and health educators trained. Workshop assessments and physician surveys indicate that the program improved BMI knowledge and skills, and increased BMI use. CHDP’s reimbursement form was revised to include BMI percentile. NCQA invited the California plan to participate in a pilot to assess new childhood obesity performance measures; the new 2009 HEDIS measures include child BMI and BMI percentile.

In the case of obesity, prevention and early identification are key strategies to achieve better health, patient satisfaction, and lower health care costs.

ConTACT: Kevin Hayden President, State Sponsored Business, WellPoint (805) 384-3511; [email protected]


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Midwest Health PlanCaring for Culture – Caring for Women

DESCrIPTIon: Midwest Health Plan serves a culturally and linguistically diverse Medicaid population in Southeastern Michigan. In 2006, the Plan’s HEDIS results indicated health disparities in female preventive health measures that were consistent with national trends. Caring for Culture – Caring for Women was initiated to educate women and to create a culturally sensitive environment that would support preventive female health among its largely Arabic, African American and Hispanic population. ACTIon TAKEn: MHP added a full-time nurse to focus on female health. Action steps were structured to remove language barriers, provide culturally sensitive outreach to pregnant women, and provide incentives to providers and members for women’s preventive health care services. Specific steps included:

Making courtesy calls and mailing educational materials to pregnant and new Moms;

Adding bilingual customer services staff (2 Arabic and 2 Spanish speaking) and working with providers to increase bilingual office staff;

Holding community health fairs; and Implementing a pay-for-performance bonus program that offers financial incentives to providers for

preventive female health services.

ouTCoMES: Midwest Health Plan realized significant improvements in female health HEDIS measures:

Measure 2006 2007 2008 2009 Stat. Sig. Improvement?*

Timeliness of Prenatal Care 68% 76% 86% 89% YesPostpartum Care 46% 51% 62% 63% YesCervical Cancer Screening 62% 64% 70% 73% YesChlamydia Screening - combined 43% 56% 61% 62% Yes

*Statisticalsignificancetestedfrom2006and2007to2009usingChi-squared.

ConTACT: Kathleen M. Harkness, RN, MS, CPHQ Senior Director of Corporate Quality, Midwest Health Plan (313) 586-6063; [email protected]

Centene CorporationCaring Voices, Pre-Programmed Cell Phones

DESCrIPTIon: Caring Voices is an off-shoot of Centene’s CONNECTIONS Plus™ program. This program provides pre-programmed cell phones to mental health members without access to a reliable phone and was designed to improve communication between the members and their case manager. If a member doesn’t have access to a phone, it can limit their access to quality health care. By removing this barrier these high-risk members can be case managed and see an improvement in their health care as well as feel empowered to be an active member of their health care team. We currently have 115 members enrolled in the Caring Voices program.

ACTIonS TAKEn: Members receive a phone after determining eligibility and agreeing to be in active case management. The phone is pre-programmed with contact numbers for providers, pharmacy, transportation, home health, social services, NurseWise (24/7 nurse advice line), ‘911’ and the National Domestic Violence Hotline.

Phones have walkie-talkie and texting features giving members’ additional means to converse with case management. Phones are distributed by Connections Representatives; ensuring members are educated on the phones’ usage. The phones provide easy access to their health care team and give members a sense of security, independence and self-worth; important feelings to instill in those with mental illness.

ouTCoME: We reviewed 91 members 90 days prior to receiving the phone compared to 90 days after receiving their Caring Voices phone. We demonstrated statistically significant declines in certain measures after receiving the phone such as a 52% decline in ED visits and 87% decline in psychiatric admissions. A control group was used in this study ruling out regression to the mean being the cause for the significant declines in the intervention group.

Our goal is to increase utilization of this program, continue to show decreases in inpatient and emergency room visits and increase doctor visits, prescriptions and quality of life.

ConTACT: Janice Linehan PA-C, Director MemberConnections, Centene Corporation (314) 725-4477; [email protected]


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Keystone Mercy Health PlanCommunity Baby Shower

DESCrIPTIon: Keystone Mercy Health Plan, in partnership with a coalition consisting of local health care providers, hospitals and community-based organizations, developed the Community Baby Shower to provide pregnant women with early access to prenatal care, dental screenings, community resources and WeeCare case managers. The event brings valuable resources directly to the communities our members reside in and increases their access to needed health care services, including oral health screenings for expectant mothers. Community Baby Showers provide women in a targeted geographic area with an opportunity to self-identify as pregnant, while receiving valuable information and resources, without the stigma of being labeled “at-risk” for a poor birth outcome.

ACTIon TAKEn: The Community Baby Shower provides pregnant women with the opportunity to meet with a WeeCare case manager and aims to increase awareness of maternity case management program resources and support services available to them. The event provides a fun, intimate setting and serves as a forum for expectant mothers to network with other soon-to-be moms. Presentations at the Baby Shower covered topics from maintaining a healthy pregnancy, to stress management, to signs of pre-term labor. Participants were entered in raffles throughout the event to receive baby items such as: cribs, strollers, diapers, car-seats, books and diaper bags. An onsite dental clinic was created to provide oral health care and transportation to the event was provided to ensure that all participants were able to attend. All attendees received health education information and a self-referral form to the WeeCare Program. Follow-up care was scheduled for many of the women in attendance.

ouTCoMES: Keystone Mercy Health Plan hosted two Community Baby Showers over the past 12 months.

Over 600 program participants 66 pregnancy dental screenings Over 50% of the women in attendance requested a personal case manager from WeeCare.

ConTACT: Tonya Moody Associate Vice President, Health Promotions & Program Development, Keystone Mercy (215) 863-5700; [email protected]

Centene CorporationConnECTIonS Plus™

DESCrIPTIon: CONNECTIONS Plus™ is a cell phone program developed for high-risk members who have limited or no access to a safe, reliable phone. The program puts free, pre-programmed cell phones into the hands of the members. This program seeks to eliminate lack of safe reliable access to a telephone as a barrier to coordinating care, thus reducing avoidable adverse events such as inappropriate emergency room utilization, hospital admissions, and premature birth. Members are identified through case management activities or through a referral. CONNECTIONS Plus™ is available to high-risk members in all Centene health plans. ACTIon TAKEn: If the member is eligible, a case manager refers them to CONNECTIONS Plus to receive a cell phone. The Connections Representative (CR) is notified of the request and places the order, indicating all of the member’s provider contact information. The phone is pre-programmed to only allow specific numbers that are important to the member’s health care and safety. Pre-programmed numbers include the members physician, specialty physicians, case manager, NurseWise (our 24/7 nurse advice line) and any identified community resources. The CR conducts a home visit, educating the member on phone features and appropriate reasons to contact pre-programmed numbers.

ouTCoMES: Centene reviewed data from 75 aged, blind and disabled members in our Ohio health plan. Inpatient admissions and emergency room visits utilization data was reviewed for the four months prior to receiving the phone compared to four months after receiving the phone. Admissions per 1,000 and Days per 1,000 for this group decreased 62% and 65% respectively and were statistically significant. ER visits per 1,000 decreased significantly by 44%. This analysis shows by eliminating communication barriers and providing members with resources connecting them with their health care team, we will see statistically significant reductions in inappropriate inpatient and emergency room utilization.

ConTACT: Janice Linehan PA-C, Director MemberConnections, Centene Corporation (314) 725-4477; [email protected]

BEST PrACTICES SuBMISSIonSBEST PrACTICES SuBMISSIonS

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Passport Health PlanDiabetes Disease Management Program

DESCrIPTIon: Passport Health Plan recognizes that Kentucky is ranked seventh in the Continental United States in incidence of diabetes. In 2005, the Kentucky Diabetes Fact Sheet reported 8.9% percent of Kentuckians had a diagnosis of diabetes and an estimated 111,900 individuals had undiagnosed diabetes resulting in a total of 385,900 (approximately one in every eight adults) diagnosed and undiagnosed cases of diabetes. Furthermore, diabetes is the fifth leading cause of death by disease in Kentucky, and Kentucky Medicaid spent $611 million on diabetes in 2003. ACTIon TAKEn: Passport Health Plan uses claims and pharmacy data to identify adult members with diabetes. All newly identified members receive a welcome letter that introduces them to the program and provides information on how to contact a diabetes care manager. On a quarterly basis, all program participants receive educational materials, including dietary recommendations. The Plan sends reminders for eye exams and other diabetes related testing twice a year. Diabetes care managers contact members who have had an emergency room visit or hospital admission for diabetes and may not be managing their diabetes appropriately. Diabetes care managers assess members’ needs and provide information about the disease. The Plan stratifies members based on the severity of their disease and the types of services they have used. Members receive educational materials and services tailored to their specific needs.

ouTCoMES: In 2007, Passport Health Plan achieved continued improvement in the following areas:

An increase in members who received a HbA1c to 86.17% from 64.93% in 1999. A decline in members who noted poor control of diabetes with a HbA1c of greater than 9.0% to

31.29% from 49.05% in 1999. An increase in members who received a diabetes eye exam to 54.42% from 37.91% in 1999.

ConTACT: Jill Bell Vice President, Public Affairs, Passport Health Plan (502) 585-7983; [email protected]

Health Partners of Philadelphia, Inc.DEAL: Diabetic Eyes for Active Living

DESCrIPTIon: Health Partners is a health plan that provides Medical Assistance access to quality care for under-served residents in the Greater Philadelphia region. Our 153,000 members are some of Philadelphia’s most fragile residents.

Due to cuts in the state Medicaid budget for Fiscal Year 2006, Health Partners eliminated its member eyeglass benefit. When we reviewed our HEDIS scores for Diabetic Retinal Eye Exams (DRE), we found that the number of diabetic adults who were screened had decreased to 38.44 (HEDIS 2007 reported rate) from 55.79 (HEDIS 2006 reported rate). We questioned diabetic members anecdotally as well, and discovered that they did not visit their PCP for this vital eye exam because the eyeglass benefit was no longer standard. ACTIon TAKEn: Our goal was to do all we could to change this behavior, which was literally putting our members’ sight at risk. Health Partners created the “Diabetic Eyes for Active Living” Program, or DEAL, to educate diabetic members about the importance of regular eye care, and to incentivize the desired behavior.

Through DEAL, members may self-refer for a dilated eye exam from any Health Partners participating vision care provider. If corrective lenses are needed, the provider issues a prescription. Members can have prescriptions filled at the exam site (in most cases) or by any optician in our network. Health Partners will cover one pair of eyeglasses or contacts (and one replacement pair of glasses of the same type, in the event of loss or breakage) yearly.

To ensure maximum awareness of the new DEAL initiative, Health Partners reached out to adult diabetic members with a series of mailings, explaining the benefit and the importance of annual dilated eye exams in the early diagnosis of diabetes-related eye problems. Members who still did not take advantage of having an annual eye exam received a reminder midway through the year, and follow-up calls were made by our Disease Management staff to encourage participation. Health Partners also reached out to our provider network, requesting that they partner with us in reminding members of this benefit.

ouTCoMES:

DRE rates for the 2005 measurement year, prior to the elimination of the eyeglass benefit, 55.79 (HEDIS 2006 reported rate) for our diabetic members.

DRE rates for the 2006 measurement year (HEDIS 2007 results) showed an administrative rate of 39.96. This represented the year the benefit was eliminated.

DRE rates for the 2007 measurement year (HEDIS 2007 results), when DEAL debuted in the Fall, our administrative rate was 41.88.

DRE rates for the 2009 measurement year (HEDIS 2008 results), we have achieved an administrative rate of 54.5.

ConTACT: Mary K Stom, MD Chief Medical Officer & Senior Vice President of Healthcare Management, Health Partners of Philadelphia (215) 991-4267; [email protected]


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Horizon nJ HealthDilated retinal Eye outreach Program

DESCrIPTIon: The Horizon NJ Health Dilated Retinal Eye Examination Outreach program is specific to members with diabetes. This proactive member outreach program works with our vision vendor, Davis Vision, to encourage members with diabetes to obtain dilated retinal eye examinations for early identification of diabetic retinopathy and prevention of blindness.

In addition to member outreach at scheduled intervals, an enhanced communication process is established between the primary care physician and the vision vendor. The PCP receives notification of the completion of the dilated retinal eye examination by mail. ACTIon TAKEn: The Member Outreach Program includes:

A welcome mailing with an introductory letter encouraging eye care benefit utilization, informative brochure on diabetic retinopathy, and a personalized vision provider list.

Members who have not utilized the benefit within three months of the welcome mailing receive a second mailing including a reminder notice and provider list.

A third mailing is completed when a member has not utilized the benefit within six months of the second mailing.

Those members who have not utilized their examination benefit by nine months from the initial welcome mailing receive a telephone call to further encourage them to schedule a visit with their eye care provider. Return calls come directly to the diabetes disease management nursing staff allowing for additional education.

An annual reminder mailing (365 days from the last visit) is sent, including an updated vision provider directory.

ouTCoMES: HEDIS Results demonstrated significant improvement following the implementation of the program. HEDIS results increased from 30% in 2007 to 54% in 2008.

ConTACT: Dee Rago Director of Healthcare Management, Education and Outreach, Horizon NJ Health (609) 718-9220; [email protected]

Passport Health PlanEarly Periodic Screening Diagnosis and Treatment (EPSDT) Program

DESCrIPTIon: EPSDT preventative health services are available to all members under the age of 21. Approximately 70% of Passport Health Plan’s population is under the age of 21. National Child Advocates successfully lobbied to ensure Medicaid children received preventative health services to prevent childhood illnesses. As a result, each state is required to provide outreach and education to this population. In 1997, the Centers for Medicare & Medicaid Services (CMS) established an 80% EPSDT compliance/participation goal to be met by 2006.

ACTIon TAKEn: EPSDT staff members make phone calls to families who haven’t received the recommended EPSDT screening. Members who cannot be reached by phone are provided with a home visit through Passport Health Plan’s contract with the Department of Health. EPSDT screens are also a part of the Plan’s Provider Recognition Program. Providers are incented for increasing their screening and participation rates. Providers receive monthly “screens due” reports for their panel that identifies members due for EPSDT screenings.

ouTCoMES: In 1997, the statewide EPSDT screening rate was 17% prior to Passport Health Plan’s inception. Since 1997, The Plan has improved the EPSDT screening rate to a remarkable 93%. In 2007, Passport Health Plan also exceeded the goal set by CMS and achieved a well child compliance rate of 93% and a participation rate of 71% for the federal fiscal year ending September 30, 2008.

In 2008, Passport Health Plan showed improvement in the areas of well-child visits, annual dental visits, and childhood immunizations when compared to 2007:

The number of childhood immunizations increased 7.9%. The number of annual dental visits for children ages 2 to 21 increased 2.62%. The number of well-child visits for children in the first 15 months increased 0.97% and children 3 to

6 years old increased 1.55%.



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MDwiseEmergency room Initiative

ProGrAM DESCrIPTIon: MDwise actively promotes the medical home by an initiative to identify members seeking emergency room services for symptoms that are not emergent or life-threatening per the prudent layperson definition of an emergency. The MDwise emergency room initiative strives to identify members as soon as possible after their emergency room visit to engage the member in education about when to use the emergency room and to assure that the member knows how to contact his/her primary physician.

ACTIon TAKEn: The MDwise emergency room initiative began in 2007 with St. Vincent Hospital in Indianapolis. When a MDwise member is seen in their emergency room, a software program generates a fax to MDwise immediately after the visit. The notification includes demographics as well as the date and time of visit, presenting symptom, disposition and any other instructions provided to the member. Once notification is received, a nurse reviews the encounter to determine the best intervention that meets the individual member’s needs, which could include referral to disease or case management, education about when to use the ER, or pregnancy program.

ouTCoMES: The MDwise outreach department educated MDwise members seen in the St. Vincent ER for non-life threatening symptoms and educated them about when to use the ER, made certain they knew how to contact primary physician and the MDwise nurse triage line. There was a 42% reduction in emergency room utilization among the members who received the outreach education in 2007.

Program highlights include: Referral of members for case or disease management Earlier identification of pregnant women and children with special needs Referral to member advocates to educate about when to use ED and provide other resources Reduction in ER visits

ConTACT: Maggie Moss RN, BSN Director Medical Management, MDwise (317) 630-2825; [email protected]

Health Partners of Philadelphia, Inc.Er Initiative

DESCrIPTIon: Health Partners is a health plan that provides Medical Assistance access to quality care for underserved residents in the Greater Philadelphia region. Our 153,000 members are some of Philadelphia’s most fragile residents.

That includes using the Emergency Rooms of local hospitals for low acuity care rather than seeking treatment from the member’s selected PCP. For the year 2006, Health Partners reviewed ER utilization and determined that lower severity ER visits accounted for 81.9 percent of overall ER visits.

ACTIon TAKEn: Our goal was to decrease ER utilization of non-emergent care by 1 percent, while encouraging improvement in proper use of the facility through a combination of outreach and education. Health Partners is working in tandem with four of our high volume participating provider hospitals, one of which is a children’s hospital. We started with two full-time ER coordinators but have increased to six full-time coordinators to handle the growing volume. Automated messages, contracted by Health Partners, comprised the scope of the telephonic outreach.

The initiative began in February 2007 with two hospitals and a third was added early 2008.

Ongoing tactics include:

• Real-time telephonic outreach and/or notification letters to members after they have used the ER inappropriately

• Notification letters to providers when members on their panel have utilized the ER (sent within two days of member being seen in ER)

• Health care events/Health Fair education• ER utilization on provider profiles

These tactics offer the added opportunity to:

Facilitate coordination of services (pharmacy, transportation, DME, etc.,) in order to decrease barriers that may contribute to ER utilization.

Increase follow-up PCP visits post ER utilization Increase the ratio of PCP visits to ER visits Compare various types of outreach (i.e. automated messages, coordinator calls, health fair

education) to see which methods were most successful

ouTCoMES: We have reduced low acuity ER visits in our target hospitals from an average of 83.7% in 2007 to 80.2% in 2008 whereas in non-target hospitals the LANE rate increased from 70.5% in 2007 to 72% in 2008.


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The initiative continues and Health Partners continues to drill down on data collected to determine reasons for high ER utilization (access vs. behavior, etc.)

ConTACT: Shelley Stevens Director, Case Management, Health Partners of Philadelphia (215) 991-4019; [email protected]

Passport Health PlanEr utilization Program

DESCrIPTIon: According to the CDC’s report on the Annual Number of Visits to Hospital Emergency Departments, nationwide ER visits in 2006 totaled 119.2 million as compared to 110 million nationwide in 2004. This report also notes that Medicaid recipients including the SCHIP program accounted for 82 per 100 persons seen in the ER with Medicare recipients being 48 per 100 persons. Approximately 12.1% of all ER visits are classified as non-emergent by the triage process. Non-emergent use of the ER for primary care services plays a major role in the Plan’s total ER Utilization. The ER Utilization Program is targeted at reducing the non-emergent use of the ER. ACTIon TAKEn: Passport Health Plan identifies members by the ER facility reports and through claims review. Those identified by the facilities are reviewed and categorized by chief complaint and discharge diagnosis. Those members seen in the ER for non-emergent care are contacted by the Plan’s ER Coordinator. The ER Coordinator provides education regarding the appropriate use of the ER, plan benefits such as the 24-hour nurse line for medical advice, use of immediate care centers, and use of after-hours calling to their PCP. The ER Coordinator also evaluates for any barriers the member may have to receive care from the PCP, provides the member with the phone number of their PCP, and encourages follow-up. In addition, the Plan mails targeted educational material for specific non-emergent chief complaints. The materials offer home care solutions such as who can treat colds and when to call the provider. A registered nurse is available to answer any questions or concerns the member may have. Members are also identified quarterly by claims data. Any member with a quarterly increase of five or more ER visits from the previous quarter and or 12 ER visits in a rolling quarter are referred to Case Management for outreach and care coordination. Members with asthma, diabetes, or a high-risk pregnancy are referred to specific disease management programs.

ouTCoMES: Passport Health Plan has achieved a 10% reduction in the Plan’s ER rate from 2005 to 2007 equating to $1 million in medical cost savings.


Keystone Mercy Health Plan “Gift for Life Program” Community Health Intervention Program

DESCrIPTIon: Minority women have significantly higher mortality rates from breast cancer as compared to Caucasian women. Experts hypothesize that minority women have higher mortality rates, in part, because the cancer is often detected in later stages of the disease. A mammography screening is proven to be the most effective method to detect breast cancer at early and treatable stages. Keystone Mercy Health Plan implemented the Gift for Life program to address some of these health disparities. This program targets non-compliant women ages 40-64 who have never had a mammogram or it has been over three years since their last mammogram, women who would not get a mammogram were it not for this outreach program. ACTIon TAKEn: Gift for Life is a comprehensive strategic marketing and outreach campaign designed to increase breast cancer screenings for non-compliant women. A market research study was conducted to better understand the barriers and identify opportunities to increase the use of preventive measures. Then coordinators facilitated access to care by strategically scheduling mammography appointments at radiology centers, notifying members’ physicians about the appointments, setting up follow-up appointments, providing transportation and incentives. Keystone Mercy also contracted with mammography vans to provide care in the community where members live.

ouTCoMES: The Gift for Life initiative shows that a more structured program combined with strong outreach activity and appropriate incentives are necessary to increase the mammography screening rate among women in the target population. The qualitative and quantitative outcomes demonstrate:

Providing a comprehensive holistic approach to engaging non-adherent women Bringing services to members in the community motivates women to participate Re-connecting the members with the providers Eight hundred and four mammograms were completed in a 6-week period in 2008.

Gift for Life Program has a positive impact on compliance and improving the quality of life of our members and it has been expanded for 2009.

ConTACT: Maria Pajil Battle Senior Vice President, Public Affairs and Marketing, Keystone Mercy Health Plan (215) 863-5609; [email protected]


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Passport Health PlanGlorious Women Assembly

DESCrIPTIon: In most communities in the United States, women tend to care for their families before addressing the needs of their own health and welfare. There is a high prevalence of major health concerns among women of color and those living in poverty. According to the Office of Minority Health, Poverty disproportionately affects women. Nearly 13 million women live in households with incomes below the Federal poverty level. Poor or near-poor women are more likely than high-income women to report fair or poor overall health and limitations of activity. They are also more likely to report having anxiety or depression, arthritis, asthma, diabetes, hypertension, obesity and osteoporosis. However, women still remain as one of the last minorities to recognize and validate their own health concerns. In addition, refugee and immigrant women who have or will access both public and private health care services continue to struggle to assimilate to health care practices and services in the United States, and to those offered within Passport Health Plan’s service area. These refugees and immigrants also show poor health outcomes and status.

ACTIon TAKEn: Passport Health Plan created the Glorious Women Assembly (GWA) in 2007 to focus on the health needs of women. The GWA is a special annual event focused on celebrating womanhood by encouraging women to make, and/or renew their commitment to health. The event offers women a day to focus on themselves and receive pertinent health information in a sharing and warm environment. During the GWA, women discuss their health concerns with providers and other women in the community, and service providers are available to provide information and conduct important screenings such as mammography. The Plan uses HEDIS data to determine the subjects covered and information provided to the women. The HEDIS data identifies areas for improvement among women’s health outcomes.

ouTCoMES: Since the program’s inception, Passport Health Plan has seen a drastic improvement in the event’s participation and diversity. The event’s attendance improved from six women in 2007 to 71 in 2009. In 2009, the Plan served the most diverse group of women to date, ranging in ages from 20 to 89 years old. Women who speak English, Spanish, Russian and Karen were also represented. Additionally, in 2009:

18 women were given on-site mammograms. 2 additional women were examined by a Plan provider and referred for further diagnostic treatment. 2 women scheduled dental appointments and requested dental office information. The Leukemia & Lymphoma Society reported that they had the opportunity to meet with several

women who could benefit from their services.


Keystone Mercy Health Plan Healthy Hoops®: using Basketball to Help Children Better Manage Their Asthma

DESCrIPTIon: An innovative health education program, Healthy Hoops, was created in 2003 to address the growing number of children with asthma by using education and entertainment to teach children with asthma and their families how to manage their illness. Other key components of this program is the Professional Development Series, offered separately to both nurses and recreational coaches, and the “Living with My Child’s Asthma” parent education community sessions. The use of basketball with involvement of local celebrity coaches showcases Keystone Mercy’s ability to ‘think outside the box’ and provide participants with an entertaining, educational outlet to learn disease management.

ACTIon TAKEn: The Program uses basketball as a platform to teach children with asthma and their families how to manage their disease. In addition to the semi-annual Healthy Hoops Basketball Challenges, Keystone Mercy introduced a new component to the program in 2008. Healthy Hoops partnered with the Charlie Mack Celebrity Basketball Game. Local children and their families were invited to attend. Upon arrival, and prior to ticket distribution, the children went through spirometry, BMI and blood pressure screenings and received nutritional information. After screenings, the entire family was provided with tickets to the game.

During the past year, over 125 nurses and Police Athletic League (PAL) recreational coaches were educated through the Professional Development Series. The Healthy Hoops Coalition also hosted a series of the “Living with My Child’s Asthma” parental education sessions. Over 100 parents received asthma education in these intimate sessions in which parents supported each other through maintaining an open dialogue and peer-to-peer education.

ouTCoME: A study of Healthy Hoops participants attending events in Philadelphia in 2006/ 2007 and a 133 sub-group of all Keystone Mercy member participants in 2008 (results validated through claims) showed a significant improvement in asthma management and quality of life each year. Based on claims data:

Emergency room visits related to asthma attacks: Decrease by 6% in 2006/2007, and 41% in 2008 with related costs decreasing by 30% in 2008.

Inpatient visits due to asthma-related problems: Decrease by 22% in 2006/2007, and 78% in 2008 with related costs decreasing by 88% in 2008.

Healthy Hoops participants also use their medicines more effectively. In 2006/2007, Healthy Hoops participants on average showed an 12% percent increase in the use of controller medications which help reduce severe asthma attacks.

In 2006/ 2007, Healthy Hoops participants showed greater lung capacity and strength. Sixty-eight percent of participants either improved or maintained stable FEV1 measurements, and 62 percent of participants either improved or maintained stable FVC measurements.

ConTACT: Flora M. Castillo Vice President, Corporate Marketing, AmeriHealth Mercy Family of Companies (215) 863-5605; [email protected] www.healthyhoopsprogram.com


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AmeriHealth Mercy family of CompaniesHealth Literacy and Plain Language resource Guide

DESCrIPTIon: Low health literacy is a problem that leads to poor health outcomes for millions of Americans and costs the health care industry an estimated $60 billion a year. Consumers with low health literacy cannot read, understand, or act on health information and instructions. Limited health literacy hurts patient care, and is a stronger predictor of health than age, education, race or ethnicity and income.

ACTIon TAKEn: The AmeriHealth Mercy Family of Companies formed a partnership with Health Literacy Innovations (HLI) to author, develop and distribute the nation’s first comprehensive guide which brings together health literacy resources that health care professionals need. The guide contains over 350 links, providing access to guides, toolkits, action plans, literacy assessment tools, government resources, software tools, books, videos and more.

The guide, which is distributed for free, was made available to health plans, managed care organizations, state Medicaid departments, physicians, hospitals and other various types of organizations.

ouTCoMES: The impact of the Health Literacy and Plain Language Resource Guide will be seen over time. The guide not only raises more awareness of the issue at hand, but it provides resources for physicians to help reduce the problem. Addressing the issue of health literacy will eventually result in major savings in the health care industry. The Health Literacy Resource Guide was distributed a number of ways, both electronically and hard copies of the Guide.

Health Literacy Innovations and all lines of business for the AmeriHealth Mercy Family of Companies made the guide available on their websites.

All lines of business for the AmeriHealth Mercy Family of Companies provided the guide on their provider portal websites.

AmeriHealth Mercy Family of Companies Provider Representatives, who meet regularly with contracted physicians, are distributing hardcopies and CDs of the guide.

Measures of Success include the following:

Empowering providers to increase health literacy among patients. Providing health literacy technical and policy assistance to customers. Empowering individuals to make better health decisions, resulting in fewer hospitalizations, less

primary care physician visits, and better compliance with physician’s orders. Providing better health outcomes for populations at greatest risk, reducing health disparities. Training all staff who publish patient communications and who have direct interaction with

patients, on the phone or in person.

ConTACT: Flora M. Castillo Vice President, Corporate Marketing, AmeriHealth Mercy Family of Companies (215) 863-5605; [email protected]

MDwiseHEALTHYwomen

DESCrIPTIon: MDwise has demonstrated its commitment to civic and social responsibility since 1994. Our mission is to enhance member satisfaction and lower total health care costs by improving the health status of our members through the most efficient provision of quality health care services. At MDwise, we believe we have a responsibility to invest in the communities we serve. In an effort to enhance the lives of women, MDwise has initiated the HEALTHYwomen program. ACTIon TAKEn: The MDwise HEALTHYwomen program is a faith based initiative that addresses the health needs of women of all ages, with particular focus on women and girls at risk due, for example, to low income or prevalent health risks connected to race. The program is unique, in that it partners with faith-based organizations to host, in a non-threatening setting programming on women’s health issues, such as chronic conditions which lead to diabetes, heart disease, cancer, asthma, and obesity. The program is based on a successful women’s health ministry program operated by Keystone Mercy Health in Philadelphia, PA. Their program has been successful because faith-based organizations are often the first and most consistent point of contact among minority women and their families and communities.

ouTCoMES: Well over 200 women of diverse backgrounds gathered at Martin University for the first annual HEALTHYwomen Conference. The conference was well received by the participants, local community organizations, volunteers and speakers.

Program highlights included:

Free health screenings Workshops on money management, spirituality, domestic violence, parenting Dynamic speakers relaying the importance of caring for our mind, body and spirit. Staff of dedicated volunteers committed to providing a welcoming environment for our guests Free luncheon Musical entertainment – Christian Rap, Latin, Gospel, Contemporary Christian

Services provided to guests included:

Translation services for attendees with language barriers. Day Care to parents in need. Transportation provided to MDwise members without transportation.

. ConTACT: Mary Ellen Ballard Special Project Manager, MDwise (317) 630-2830; [email protected]


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MDwiseHEDIS Provider Poster

DESCrIPTIon: HEDIS rates are used to measure the performance of health plans and their providers on important preventive and clinical services. Like all Medicaid health plans, MDwise employs efforts to improve HEDIS rates. In 2009 boosting the MDwise HEDIS rates can lead to an annual payout to MDwise providers while contributing to the quality of care for MDwise members. ACTIon TAKEn: As a corporate quality initiative MDwise designed a HEDIS poster for providers to help them understand key HEDIS measures and associated opportunities to increase rates. The poster tool is visually appealing and easily understandable. A chart displays key HEDIS measures along with their prescribed frequency, the specific screening, tests and care required, opportunities to incorporate such as well care during a sick visit for children and adolescents, prenatal and postpartum care provide cervical cancer screening, appropriate coding, and the category of providers that may provide the services.

ouTCoMES: In the first month more than 1,000 posters were distributed to MDwise providers and feedback on their usefulness has been positive. MDwise is receiving daily requests from providers for the poster. MDwise is currently designing a methodology to measure the impact of the poster tool on HEDIS rates.

ConTACT: Barbara Killila Quality Improvement Manager,MDwise (317) 822-7257; [email protected]

Keystone Mercy Health Plan and AmeriHealth

Mercy Health PlanImproving Health through Integration and Alignment of Gaps in Care Data

DESCrIPTIon: AmeriHealth Mercy Health Plan and Keystone Mercy Health Plan recently implemented a new service that helps network doctors, case management staff, member services staff and members themselves identify gaps in members’ care. For example, when network providers check patient eligibility online, the system not only checks eligibility but also determines if there is an unmet care need or care gap, such as an overdue mammogram – a test that could save the patient’s life. We have closed the information loop by using technology to share the same data, albeit with different views, with different audiences. After implementation of a little over a year, selected HEDIS rates are already showing improvement. ACTIon TAKEn: Using the Thomson Reuters’ Rules Engine, a care gap data is identified, reported, and pushed out to the various audiences via integration with other technologies, including the in-house case management system, a provider self-service reporting application, and the provider portal. For example:

Providers receive electronic member lists showing care gap data on care which is missing or coming due. They can access either full member panel lists or individual member data before seeing a patient.

Member services representatives can communicate needed care to members when the members call for other reasons.

Case managers access care gap data enabling them to discuss needed care with members.

ouTCoMES: After a phased-in implementation of a little over a year, selected HEDIS rates are already improving. Among all 30 care gap measures reported, 11 measures were focused on for improvements in HEDIS results. Results thus far show that for one plan, Keystone Mercy, rates improved in 10 of the 11 measures; 6 of the 11 improved enough to increase in NCQA percentile rank for Medicaid plans. At AmeriHealth Mercy, HEDIS rates for 10 of 11 measures improved and four of the 11 measures increased in percentile rank.

ConTACT: Scott Fox Director, Informatics, AmeriHealth Mercy Family of Companies (215) 937-5307; [email protected]


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Horizon nJ HealthLipid Management Improvement through Drug utilization review (Dur)

DESCrIPTIon: Horizon NJ Health has a comprehensive retrospective DUR program that systematically collects and analyzes data on drug utilization. Retrospective review identifies members, including those with diabetes and/or acute cardiovascular events, who do not obtain recommended annual low density lipoprotein (LDL) testing or do not fill appropriate medications such as statins in accordance with national guidelines for those with elevated LDL levels. Targeting elevated LDL levels is important since it is a marker for increased risk of cardiovascular events. ACTIon TAKEn: Targeted letters are sent to both eligible members with diabetes and/or acute cardiovascular events and the member’s PCP. Members are targeted if they do not have an LDL level on file or if they have an elevated LDL level with no corresponding statin filled within the previous 12 month period. Members were considered to have an elevated LDL if their levels were >100 mg/dl with a corresponding diagnosis of diabetes or acute cardiovascular events or if their levels were >70 mg/dl and they had both diagnoses.

ouTCoME: In October 2008, one year after the original mailing, 29% of the targeted members subsequently had an LDL level taken as suggested and 15% of the members identified as having an elevated LDL were initiated on statin therapy.

ConTACT: Jennifer Gauweiler Clinical Pharmacy Manager, Pharmacy Services, Horizon NJ Health (609) 718-9216; [email protected]

Horizon nJ HealthLower Mode Transportation Services

DESCrIPTIon: Horizon NJ Health members encounter obstacles with follow-up medical care due to social and economic barriers. One such obstacle is the inability to get transportation to medical appointments. Medicaid provides transportation for lower mode (cab service) through the Medicaid County Livery Systems. Horizon NJ Health provides transportation services for those members who need to travel by upper mode (invalid coach/wheelchair or ambulance). Contractually, Horizon NJ Health must also provide transportation for those members that are referred to participating providers that are more than 30 miles from their residence. Additionally, there are occasions that a member who normally uses the Medicaid County Livery System needs to be seen by their doctor for an urgent need but they do not have enough notice to arrange for the transport through their county. These members do not necessarily need to travel by invalid coach/wheelchair or ambulance but this was the only mode of transportation available for Horizon NJ Health members to utilize. ACTIon TAKEn:

Worked with contracting to developed a network of lower mode (cab service) providers Piloted the lower mode/cab service transport through Horizon NJ Health for a six week period in

limited counties Educated team members to the criteria for appropriateness of lower mode/cab service Educated the Medical Directors and Case Managers regarding the use of the Medicaid County

Livery System cab service versus Horizon NJ Health’s lower mode/cab service transportation

ouTCoMES:

Improvement in member satisfaction as members who do not require upper mode (invalid coach/wheelchair or ambulance) transportation were transported in the manner that was consistent with their functional status.

82 members were able to be transported via the lower mode (cab service) instead of upper mode (invalid coach/wheelchair or ambulance) through Horizon NJ Health during the six week pilot period resulting in a 73% decrease in cost for the 82 transports.

Contracting added additional lower mode (cab service) providers to the network. Expanded Horizon NJ Health lower mode (cab service) transportation throughout the State of New

Jersey. Clinical review of End Stage Renal Disease members currently transported via upper mode (invalid

coach/wheelchair or ambulance) transport to transition those appropriate to lower mode (cab service).

ConTACT: Theresa Golden, RN, CMCN Supervisor, Non-Clinical Precertification Unit, Horizon NJ Health (609) 718-9553; [email protected]


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Select Health of South CarolinaMedicaid Recertification Outreach

DESCrIPTIon: Select Health utilizes a multi-faceted member outreach and education strategy. One component of the overall strategy is to ensure that members renew their Medicaid benefits. Members who fail to renew risk losing their health plan membership and access to health care benefits. ACTIon TAKEn: Select Health maintains a four-step process to increase the likelihood that members will follow the Medicaid recertification guidelines.

First, Member Services receives a monthly report that lists all members who are due for Medicaid recertification in 45 days. The Member Services Department sends a mailer to the identified members that includes the date their review form must be returned to the state Medicaid office. The mailer also encourages members to contact their caseworker or the Member Services Department with any questions regarding the form.

Second, Member Services receives a monthly report that lists members who are due for recertification in 15 days. The Member Services Department also sends these members a mailer, but the message is more urgent. Select Health utilizes on-site Department of Health and Human Services (DHHS) workers who access the state Medicaid system and respond to specific member questions regarding recertification.

Third, Member Services conducts telephone outreach to members who are on the 15-day recertification list. During the call, the Customer Service Representative follows a brief script and answers member questions.

Fourth, Member Services receives a monthly report that lists members who were involuntarily disenrolled. These disenrollments are often the result of members not completing and returning their review form to Medicaid. Due to the urgency of having these members reinstated, the on-site DHHS workers conduct outreach calls in an attempt to resolve issues. Successfully reinstating members within 60 days allows them to automatically return to Select Health.

ouTCoMES: The four-step process increases member retention, reinstates members who originally lost eligibility and helps build a lasting relationship with members..


Select Health of South CarolinaMitchell Math and Science Elementary School – PE�Life

DESCrIPTIon: According to 2008 data provided by the Center for Disease Control (CDC), South Carolina had a prevalence of obesity among adults greater than 30%, which ranks it as the fifth heaviest state in the nation. Additionally, the rate of childhood obesity has tripled with more than 18.9% of children ages 6 to 19 diagnosed as clinically obese. This epidemic has been shown to increase the likelihood of developing chronic health conditions such as hypertension and Type 2 diabetes. In response, Select Health of South Carolina, Mitchell Elementary School and other community organizations have partnered and adopted PE4Life, a nationally-recognized program that re-introduces physical education programs in schools. ACTIon TAKEn: The PE4Life program is modeled after the Naperville, Illinois initiative, which demonstrated significant academic improvements when pairing exercise and learning. The plan strives to inspire active, healthy living by advancing the development of daily physical educational programs for all children. The program incorporates an Action Based Learning Lab, which features activities to improve the brain’s ability to follow words, recognize patterns and solve problems. Select Health recognized the opportunity to reduce childhood obesity while making our educational programs and preventive care services available to our members and the entire community.

ouTCoMES: On April 30, 2009, Select Health’s Community Liaison Department sponsored the grand opening of Mitchell’s AMX (All Minds Exercise) Room featuring interactive exercise equipment designed to promote an active and healthy lifestyle while increasing cognitive and behavioral outcomes. Several hundred children, parents and community members participated in the inaugural event. The pilot program, which will recommence in the 2009-2010 school year, will feature data-driven results based on the following measures:

Decreased body mass index (BMI) Decreased behavioral referrals Increased standardized testing scores Reduced absences/tardy data Improved parental involvement Improved academic performance



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MDwise“Move It,” In-School Program fighting Childhood obesity

DESCrIPTIon: Currently, overall obesity rates in Indiana are around 25% with childhood overweight in Indiana estimated to be around 20-40%. In both cases the numbers seem to be increasing. The medical problems associated with this overweight state are likewise increasing. These include diabetes, high blood pressure and heart disease. (Indiana State Department of Health)

ACTIon TAKEn: MDwise teamed up with Radio Disney Indianapolis WRDZ 98.3 FM in to present Move-It!, a youth fitness program that encourages an active lifestyle for kids. Move It! is a national initiative and Radio Disney’s response to an epidemic effecting kids of all ages . . . Childhood Obesity.

Radio Disney showcased the importance of staying active through the theme “Get Off Your Seat and On Your Feet”! Each tour stop was a high energy, interactive show featuring music and prizes all while highlighting the benefits of exercise. Children enjoyed Ms. Bluebelle, the MDwise mascot, performing the Cha Cha Slide.

ouTCoMES: Move It! will have reached over 5,500 students in 26 schools by the end of the 2008-2009 school year. A maximum of 250 students participate in each event – an ideal size for leading the students.

Over 50% of the students that participated in Move-It! during the 2007-2008 school year were on a free/reduced lunch program at their school.

Each child received a goodie bag which included a letter from MDwise to parents about the importance of healthy eating and exercise, a Ms. Bluebelle card with the MDwise toll free number for a health message, and stress balls.

ConTACT: Mary Ellen Ballard Special Project Manager, MDwise (317) 630-2830; [email protected]

Molina Healthcare of Missouri obstetrical Case Management Program

DESCrIPTIon: Premature babies are one of the largest cost drivers for Molina Healthcare of Missouri (MHMO), a 78000 member Missouri Medicaid managed care plan. In 2007, preterm births accounted for only 0.1% of MHMO membership, but these members accounted almost 5% of our total medical costs. The costs of prematurity are not just financial. Children that survive are faced with a multitude of medical issues, including cerebral palsy, blindness, deafness, behavioral disabilities and developmental delay. Very Low Birth Weight (VLBW, < 1500g) and Extremely Low Birth Weight (ELBW, < 1000g) babies are our most vulnerable and costly members.

ACTIon TAKEn: Since 2005, MHMO has provided Obstetrical CM (OBCM) to every pregnant member. OBCM starts with early identification of pregnancies and specific interventions based on the MHMO Pregnancy Risk Screening Assessment. OBCM formulates individualized care management plans to accomplish these objectives, and includes identifying, tracking and monitoring all pregnant members throughout their prenatal and postpartum care.

Pregnant members receive an initial telephone assessment. Tiered interventions are based on information gained from these assessments and through our obstetrical provider partnerships. Interventions range from monthly phone contact to daily home health nursing visits, depending on the pregnancy risk factors and complications identified.

ouTCoMES: During 2005-2008, there has been an inverse relationship between the increasing rate of OBCM and decreasing birth rates of VLBW and ELBW babies: as effective OBCM goes up, these birth rates go down. Appropriate management of the MHMO Medicaid population with intensive OBCM has lead to a significant decrease in the rate of VLBW and ELBW babies. This has been both a positive financial impact on MHMO and — more importantly — a positive effect on our members’ quality of health and well being in the short and long term.

ConTACT: Robert J. Profumo, MD Chief Medical Officer, Molina Healthcare of Missouri (800) 875-0679 x239270; [email protected]

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Horizon nJ HealthPrimary Care Physician Involvement in the Improvement of Dental Visit rates

DESCrIPTIon: Physicians are the best advocates for the promotion of good health. They can also be excellent advocates for promoting good oral health and the relationship oral health has to overall health.

Studies have demonstrated that dental disease is the most prevalent, preventable disease among US pre-school children and most prevalent in individuals with the lowest socio-economic status. Dental disease can begin when the first tooth erupts but dental visits do not usually occur, nor do referrals to dentists from physicians occur, until all the primary teeth have erupted. With the busy schedules that primary care physicians maintain and the multitude of illnesses they treat, focusing on oral health is not always possible. ACTIon TAKEn: It was decided to include dental visit rates as part of the ongoing physician profiling initiative.

Physicians are provided with a listing of all panel members’ names addresses and phone numbers ages 2-21 who have not had a dental visit by mid-calendar year. They are also provided with the dental visit rate calculation of their panel from the previous calendar year. A visit rate goal is clearly defined as is the importance of regular dental referrals at earlier ages and the promotion of good oral health as it relates to overall health. ouTCoMES:

Improved awareness of oral health by members and physicians. Data extending six months from the intervention demonstrated that 24% of the members in the

targeted population visited the dentist as opposed to only 10% in the same targeted population from the previous year when the intervention was not in place. This outcome has continued from 2007 to 2008.

Greater emphasis on dental disease prevention. Oral health care needs identified and treated earlier. More members in dental homes. Future decreased dental and medical costs for children.

ConTACT: Brian J. Bastecki, DMD Dental Director, Horizon NJ Health (609) 718-9564; [email protected]

AmeriHealth Mercy Health PlanPrimary Care Provider Incentive Program

DESCrIPTIon: AmeriHealth Mercy Health Plan converted from a passive pay-for-access incentive program to a new performance data-driven Primary Care Provider Incentive Program in June 2008. The new program rewards primary care practices for effective control of chronic conditions, care coordination, wellness promotion, and office systems that demonstrate effective prevention of emergency room (ER) visits. ACTIon TAKEn: The program includes two ER components, a quality component, and a component to encourage complete coding and ability to risk-stratify PCP panels. The ER utilization component measures overall ER utilization per 1,000 members per year and non-emergent ER utilization rates. The quality component of the program is based on six preventive and chronic care HEDIS measures. Performance incentive payments for group practices are based on the performance of the practice group/site rather than individual physician performance. AmeriHealth Mercy also added an incentive for practice groups that significantly improve, even if they were not among the best-performing 45 percent of participants.

ouTCoMES: AmeriHealth Mercy has completed two six-month cycles of its new Primary Care Provider Incentive Program – one in June 2008 and one in December 2008. Multiple face-to-face meetings have been held with key PCP sites preceding and in follow-up to these results to discuss good and not-so-good results, and strategize together how to improve them for the next PIP cycle. Overall results have been published in our provider newsletter for both cycles. These efforts, combined with pre-implementation regional and phone-in meetings with our network, have led to excellent PCP acceptance and engagement. Early results are trending favorably, though it is too early to prove cause and effect.

ConTACT: Lawrence E. Kay, MD Senior Medical Director, AmeriHealth Mercy Health Plan (717) 651-3571; [email protected]


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Midwest Health PlanPromoting Electronic Prescribing

DESCrIPTIon: Electronic Prescribing (e-prescribing) can reduce medical errors, decrease pharmacy costs and increase efficiency. The eHealth Initiative reports that e-prescribing could reduce the nation’s health care costs by $2.9 billion. Recognizing the potential benefits of e-prescribing, Midwest Health Plan (MHP) initiated an effort in 2005 with its high volume providers to implement e-prescribing with Zink™. Zink™ is a web-based prescribing tool that allows physicians to review recent patient history, check formularies, and transmit the prescription to a pharmacy. Midwest continued to promote e-prescribing over the next few years, and Midwest’s Pharmacy Benefits Manager, CVS Caremark also supports e-prescribing. ACTIon TAKEn: High-volume Providers (PCPs with over 100 members) were invited to multiple breakfast meetings where electronic prescribing was discussed and Zink™ was demonstrated. Follow up was conducted with all the high volume providers from 6/05 through 7/06. Through the next few years, Midwest encouraged its Primary Care Providers to implement e-prescribe through face to face meetings with our Provider Representatives. Electronic prescribing has also been encouraged through articles in our Provider Newsletter.

ouTCoMES: The use of electronic prescribing among MHP’s provider network has steadily increased. Results from our 2009 MHP Provider Satisfaction Survey indicate 21% of respondents are using e-prescribe. The number of electronic prescriptions sent to the pharmacy has more than doubled since August 2008 (as diagrammed below) when 1,216 electronic prescriptions were processed through CVS Caremark. This is due in part to Midwest promoting and educating providers about e-prescribe. It should be noted that the total number of prescriptions written using e-prescribing methods is understated as many of our providers use e-prescribe to check the formulary, check for drug allergies, check for drug interactions, and write the prescription, by using e-prescribing, then print the prescription and give it to the member to take to their pharmacy of choice. These prescriptions are not counted in the total number of prescriptions submitted electronically.

ConTACT: Kathleen M. Harkness, RN, MS, CPHQ Sr. Director of Corporate Quality, Midwest Health Plan (313) 586-6063; [email protected]

Health Partners of Philadelphia, Inc.“Smiling Stork” Prenatal Dental Program

DESCrIPTIon: Health Partners is a not-for-profit health plan that provides Medical Assistance access to quality care for under-served residents in the Philadelphia region. Our 153,000 members are some of Philadelphia’s most fragile residents.

Slightly more than half of our members are female, and almost half of those are of childbearing age (15-44). As such, Health Partners focuses a great deal of resources on prenatal education and care through “Baby Partners,” Health Partners’ Healthy Mother and Baby Program.

The Baby Partners program is designed to collaborate with our members and our provider network to improve prenatal and postpartum care.

Research shows that pregnant mothers who have gum disease have a greater chance of delivering a premature baby. Health Partners wanted to encourage members to seek dental care during their pregnancies and reinforce lifelong positive dental behaviors for both mother and baby.

ACTIonS TAKEn: Our Baby Partners program partnered with our dental provider, Doral Dental, to create the “Smiling Stork” Program. We reviewed the data from mid-2006 to mid-2007 and found that only 17 percent of our pregnant members sought dental care during their pregnancies.

Through the Smiling Stork Program, Doral Dental sent comprehensive mailings to pregnant members identified by Health Partners. The goal was to compare the number of women who sought dental care before receiving the mailing with the number who visited the dentist after receiving the mailing.

The Smiling Stork kit included three pieces:1. A Pregnant Woman’s Guide to Healthy Gums booklet2. A booklet of tips to keep baby’s teeth healthy3. A “prescription” with Health Partners’ Member Services number (to help members find a dentist or

answer questions — dental care does not require a referral)

Health Partners and Doral Dental also sent mailings to Health Partners PCPs and dental providers. This information advised them of the pregnant member initiative and the anticipated increase in calls, as well as research that highlighted the association between periodontal disease and premature birth.

ouTCoME: Month-by-month graphs show a definite increase in the number of women who visited the dentist after receiving the Smiling Stork mailing. From June 2007 through October of 2008, the percentage of pregnant members who sought care increased anywhere from 8 to 25 percent, with the average increase being 12 percent (data after October of 2008 is yet to come, as these women have not delivered yet and we are awaiting dental visit claims).


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The Smiling Stork Program continues to be a success. Health Partners looks forward to continually increasing the percentage of pregnant members who seek dental care and starting both mom and baby on the road to good dental care. Further, this affords Baby Partners with the opportunity to address any issues members or dental providers report regarding access to care or cultural barriers.

ConTACT: Mary K Stom, MD Chief Medical Officer & Senior Vice President of Healthcare Management, Health Partners of Philadelphia (215) 991-4267; [email protected]

Centene CorporationStart Smart for Your Baby ® 1�P Program Impact on reducing Premature Birth

DESCrIPTIon: The Start Smart for Your Baby ® 17P Program identifies women less than 28 weeks gestation who may qualify for 17 alpha-hydroxyprogesterone caproate (17P). The 17P drug is endorsed by American College of OB-GYN to prevent premature birth in women who have had previous spontaneous premature birth. Members are identified as potential candidates for 17P based on a Notification of Pregnancy form completed by the member, OB staff or physician, case management assessment or claims history based on prior pre-term delivery. If a member qualifies based on initial assessment and approval by their physician, they’re enrolled in the 17P Program. ACTIon TAKEn: A process of early identification using a variety of data sources was established along with an educational program aimed at physicians, their office staff, and plan members in order to increase 17P utilization in appropriate candidates. Once the candidate met the qualifications for the program and the physician prescribed 17P, arrangements to administer the injections either in the physician office or through home health were made by the case management team. Case management also included: weekly member contact, communication with OB, educational materials, locating providers for home health or DME, referrals for transportation and post-partum welcome home assessments.

ouTCoMES: Deliveries with a gestational age of less than 35 weeks decreased significantly from 41.67% in the control group to 26.42% in the 17P group when 17P was initiated by 28 weeks gestation. NICU admission rates decreased from 45.00% in the control group to 33.68% in the 17P group, and were nearly statistically significant.

Offering 17P as a benefit has a positive effect on reducing the rate of recurrent pre-term delivery and rate of NICU admission in a managed Medicaid population. There was no decrease in effectiveness with delay in initiation of 17P provided it was started by 28 weeks gestation

ConTACT: Mary Mason, MD Senior Vice President and Chief Medical Officer, Centene Corporation (314) 725-4477; [email protected]

Centene CorporationStart Smart for Your Baby® Notification of Pregnancy Process

DESCrIPTIon: The Start Smart for Your Baby ® Notification of Pregnancy (NOP) System quickly and efficiently identifies members who are pregnant via the submission of a Notification of Pregnancy form completed by the member, OB staff or physician, or health plan. This form tells the health plan about the member’s current contact information, provider information, Estimated Date of Confinement, and medical history as pertaining to pregnancy. Based on this information, a risk score is assigned which determines the course of action taken in regard to the member’s pregnancy. ACTION TAKEN: A goal of obtaining more Notifications of Pregnancy was achieved by educating and

encouraging physicians and plan members as well as offering incentives for submission of the information. Once submitted, members receive a mailing including pregnancy related educational materials as well as an incentive booklet to track prenatal appointments which can be turned in for gift items.

Based on the risk score from each Notification of Pregnancy, members are contacted for placement into case management when necessary. Case management includes regular member contact, communication with the OB, educational materials, referrals for transportation, and post-partum follow-up.

ouTCoMES: In 2008, deliveries with birth weight less than 2500 grams decreased significantly from 11.75% in the group with no NOP to 10.71% in the NOP group. Deliveries with gestational age less than 37 weeks decreased significantly from 10.91% in the no NOP group to 9.29% in the NOP group. Deliveries with documented birth status of “Seriously Ill” decreased significantly from 10.86% in the no NOP group to 9.67% in the NOP group.

Obtaining a Notification of Pregnancy has a positive effect on reducing the rate of babies born ill, premature or with low birth weight in a managed Medicaid population.

ConTACT: Mary Mason, MD Senior Vice President and Chief Medical Officer, Centene Corporation (314) 725-4477; [email protected]


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WellPointState Sponsored Business Telemedicine - Increasing Patients’ Access to Care

DESCrIPTIon: There are great levels of disparity between healthcare available to urban and rural patients.

Many rural medical facilities are designated as Health Professional Shortage Areas (HPSA), having very limited, if any, access to specialty medical care. Rural residents requiring access to specialty health care often wait months to receive an appointment and have to travel great distances to urban medical centers. Unfortunately, for many this becomes a complete deterrent to health care.

With over 36 million residents, California is the most populous state. However, over 92% of the state’s land mass is designated as rural with many counties designated as HPSA. services. ACTIon TAKEn: Telemedicine is a powerful health care delivery system that significantly reduces disparities and service barriers. Telemedicine uses telecommunications technology, diagnostic equipment, and computers to exchange medical information between locations, allowing the patient the convenience of not having to travel great distances to seek care, take time off from work or school, maintain their relationship with their PCP, and receive faster diagnosis and treatment.

In operation since 1998, the California Anthem Blue Cross Telemedicine Program offers access to over 25 specialties, including Dermatology, Psychiatry, Endocrinology, Neurology, and Pediatrics.

Anthem supplies the equipment and software, conducts trainings, and provides informational materials to the sites to ensure program sustainability and longevity.

ouTCoMES: The Telemedicine Program has allowed patients to receive consultations from the top medical specialists in California. Because Telemedicine is easily accessible, patients are more apt to use this resource to seek treatment, which may provide an earlier detection and diagnosis, preventing escalation of conditions. When conditions are diagnosed weeks or months after they are first suspected, treatment is usually more invasive, much costlier, and less successful. Telemedicine is also used by PCPs to obtain second opinions on difficult cases to avoid misdiagnosis and prescribing ineffective medications. Increased access to care means early identification and treatment of conditions, resulting in better health outcomes and lower health costs.

As of May 2009, Telemedicine sites have produced over 15,682 clinical and over 5,348 non-clinical consults.

ConTACT: Kevin Hayden President, State Sponsored Business, WellPoint (805) 384-3511; [email protected]

Superior Health Plan network – STAr Health, Centene CorporationTexas Health Passport and Its Impact on Psychotropic Medication utilization in Texas foster Children

DESCrIPTIon: Health Passport (Passport) is a leading edge, patient-centric electronic community health record for Foster Care Children in the state of Texas. Passport is used by over 9,900 provider users, 5,000 state employees, and 100 local health plan staff. Passport can collect patient demographic data, clinician visit records, dispensed medications, vital sign history, lab results, allergy charts, immunization data, and other appropriate documentation. Providers can directly input additional or updated patient data and documentation into the Passport. All information is accessible anywhere, anytime to all authorized users, including health plan staff, greatly facilitating coordinated care among providers and our Case Managers. ACTIon TAKEn: Overuse of psychotropic medications is a nationally recognized issue for Foster Care children. In 2005 the Texas Department of State Health Services released a practice parameter entitled Psychotropic Medication Utilization Parameters (PMUP) for Foster Children.

Health Passport aids in reducing the overuse of psychotropic medications in the Foster Care population through accessibility of information, and a review process based on established parameters. With these parameters put in place - psychotropic medication prescribing patterns have improved significantly. This best practice involving the use of Health Passport and the PMUP review process is utilized for Foster Children who are prescribed psychotropic medications.

ouTCoMES: The impact of the best practice initiative on the target population has been significant. To date, there has been a 17% reduction in the overall prescribing of psychotropic medications, but more specifically an almost 50% reduction in the number of children prescribed a psychotropic medication for 60 or more days. Even more dramatic have been the decreases in the prescribing of non-stimulant medications, as well as overall polypharmacy which were 70% and 74% respectively without increase in psychiatric hospitalizations.

This positive impact has created a sense of significant accomplishment and a drive to continue serving this vulnerable population.

ConTACT: Barbara Richardson Star Health, Manager of Quality Improvement (512) 692-1465 ext. 22014; [email protected]


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Horizon nJ HealthUsing Technology to Create Care Management Efficiencies

DESCrIPTIon: The use of technology is important to enhance the care management process for members, providers and care management staff. Horizon NJ Health recognized the importance of creating a medical management system (CaseTrakker) that allows efficient documentation of member and provider interactions as well as the ability to monitor and measure these interactions. This member centric system enables staff access to important member data (claims and demographics), educational tools and communications, criteria, policies, web based data systems, and more, in a single source of reference. Care managers as well as pre-cert and concurrent review staff communicate “real time” via a referral system. ACTIon TAKEn: A detailed query was developed for each Care Manager, this query can be searched for any time period. The query includes daily tasks, internal referrals and activities that are due. The tasks are rated by a red-yellow-green visual for completion and tasks that may be at risk and internal warnings are generated from referrals if care plans have overdue goals that need to be addressed. Queries are audited daily by an assigned supervisor to assure referrals are completed and appropriately distributed.

The upgrade also provides the Care and Disease Managers with a member centric case view that is organized in a concise efficient manner. Screen tabs are shown containing member information needed throughout the care and disease management process.

ouTCoMES: Implementation of Care Management documentation template to assist Care Managers in assuring all relevant points of member interaction are satisfied.

Automation of Health Risk Assessment (Complex Needs Assessment) and Care Plan for all members Create efficiencies for referral process Interdepartmental referrals are referred to queues based on member category and need – Special

Needs Care Management and Outreach , Case Management and Disease Management Referrals are reviewed daily by supervisors/managers for assessment of quality and appropriateness Addition of medical claims into Case Trakker as well as access to important external Web sites

creates efficiencies for our staff Addition of other insurance, eligibility and PCP history Member centric activity documentation

ConTACT: Pamela Persichilli Director, Clinical Operations, Horizon NJ Health (609) 718-9193; [email protected]

Passport Health PlanYES, You Can! Smoking Cessation Program

DESCrIPTIon: The CDC notes, “Cigarette smoking remains the leading preventable cause of death in the United States accounting for approximately one of every five deaths (438,000 people) each year.” Currently, the CDC estimates that 20.9% of adults smoke cigarettes in the United States. It has been estimated that along with the significant health toll, the economic burden is more than $75 billion a year in medical expenses with another $92 billion per year in lost productivity. Currently, the state of Kentucky has one of the highest rate of smokers at 28.7%. Each year more than 8,000 Kentuckians will die of illnesses caused by tobacco use. ACTIon TAKEn: In 2007, Passport Health Plan implemented a smoking cessation pilot program for 200 members. The Plan took a pharmacological and behavioral modification support approach. In the program, each member is assigned a care manager who contacts them weekly during the initial 12 weeks and then at six, nine and 12 months. Passport Health Plan collaborates with community support resources and web-based support services to offer as much support to the member as possible. The Plan developed a series of educational materials to assist members with any issues they experience. Some examples include nicotine-withdrawal triggers, deep breathing, exercise, and diversion techniques. Passport Health Plan also provides the practitioner with a progress report every four weeks during the initial 12 weeks.

ouTCoMES: In 2007, Passport Health Plan enrolled 229 members and had 106 members verbalized being smoke-free and staying smoke-free at the one-year time-frame. This is a 47% quit rate. Most members utilized an oral stop smoking medication and a small number utilized a nicotine replacement patch. Due to the success rate, the Plan has continued to offer this program to members. In 2009, the Plan enrolled 268 members and 109 members have verbalized being smoke-free for a 41% quit rate.

ConTACT: Jill Bell Vice President, Public Affairs, Passport Health Plan (502)585-7983; [email protected]

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2008 ��,1�2,�91 ��,�2�,�82 1�,�1�,209 �0.91%

200� ��,962,2�1 29,�6�,098 16,�99,1�� 6�.10%

2006 ��,6�2,6�2 29,8�0,�06 1�,822,2�6 6�.��%

200� ��,�92,�2� 28,��,�8� 16,816,��0 62.9�%

200� ��,��,9�� 26,91�,��0 1�,��2,�8� 60.68%

200� �2,��0,�19 2�,262,8�� 1�,��,8�6 �9.11%

2002 �0,1��,��9 2�,11�,668 1�,029,8�1 ��.�8%

2001 �6,�62,�6� 20,��,81� 1�,�88,�� 6.82%

2000 ��,690,�6� 18,�86,1�� 1�,90�,22� ��.�6%

1999 �1,9�0,188 1�,��6,60� 1�,18�,�8� ��.�9%

1998 �0,896,6�� 16,��,996 1�,�22,6�9 ��.6�%

These figures represent point-in-time enrollment as of June 30th for each reporting year.

The unduplicated managed care enrollment figures include enrollees receiving comprehensive benefits and limited benefits. This table also provides unduplicated national figures for the Total Medicaid population and Other population.The statistics also include individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.

Part II: Managed Care Industry Statistical Data

The following pages offer the most current statistical data released from the Centers of Medicare & Medicaid Services (CMS) on June 30, 2008.

ToTAL MEDICAID MAnAGED CArE oTHEr % MAnAGED CArEYEAr PoPuLATIon PoPuLATIon PoPuLATIon EnroLLMEnT

CMS Statistics Managed Care TrendsAs of June 30, 2008

CMS STATISTICAL InforMATIon

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Medicaid Managed Care Enrollment - As of June 30, 2008

roW nAME of MEDICAID MAnAGED CArE PErCEnT In no. STATE EnroLLMEnT EnroLLMEnT MAnAGED CArE

The unduplicated Medicaid enrollment figures include individuals in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards. The unduplicated managed care enrollment figures includes enrollees receiving comprehensive and limited benefits.

Alabama 188,��2Alaska 12,�19Arizona 1�2,6��Arkansas 10�,�8�California 1,060,610Colorado �0,92�Connecticut �9,928Delaware 21,��2District of Columbia 1�,86�florida �9�,0��Georgia 2��,9�2Hawaii 2�,620Idaho 2�,68�Illinois 2�2,2�9Indiana 119,800Iowa �0,�90Kansas �9,819Kentucky 1�9,600Louisiana 161,2�8Maine 80,21�Maryland 90,21�Massachusetts 2��,2�2Michigan 226,21�Minnesota 11�,�9�Mississippi 1��,��8Missouri 1��,��9Montana 18,�6�nebraska ��,1��nevada ��,2�0new Hampshire 20,82�new Jersey 181,�62new Mexico �6,89�new York 62�,22�north Carolina 2��,0�2north Dakota 12,069ohio 2�8,6��oklahoma 9�,�8�oregon �8,960Pennsylvania �20,9�9Puerto rico 21�,�98rhode Island ��,�0�South Carolina 128,110South Dakota 1�,�91Tennessee 2��,816Texas �28,�08utah 20,��Vermont 2�,�99Virginia 1�0,��8Washington 128,20�West Virginia 6�,��Wisconsin 182,9��Wyoming 8,6�1

national Total 8,11�,282

Dual Eligible Enrollment -As of June 30, 2008

This table provides an unduplicated number of Medicaid dual eligibles receiving full or partial Medicaid benefits.

STATE MEDICAID DuAL ELIGIBLES

1 Alabama �6�,91� �0�,�66 6�.9�%2 Alaska 96,80� 0 0.00%� Arizona 1,0�8,6�� 9�9,�0� 90.��%� Arkansas 622,�91 �00,21� 80.�6%� California 6,606,89� �,�08,909 �1.60%6 Colorado �29,89� ` �1�,2�� 96.�6%� Connecticut ��,�19 28�,�6� 6�.��%8 Delaware 1�2,899 11�,2�6 6�.66%9 Dist. of Columbia 1�6,0�2 92,98� 6�.��%10 florida 2,2�6,01� 1,��1,62� 6�.��%11 Georgia 1,2�1,�� 1,16�,88� 91.86%12 Hawaii 211,10� 166,9�8 �9.08%1� Idaho 18�,�9� 1�6,268 8�.�9%1� Illinois 2,106,�00 1,16�,�00 ��.�2%1� Indiana 881,888 629,�10 �1.�0%16 Iowa �62,80� 29�,88� 81.��%1� Kansas 2�8,�0� 2��,�0� 8�.�8%18 Kentucky ��1,911 66�,�90 90.8�%19 Louisiana 1,006,8�2 692,099 68.��%20 Maine 2�8,��1 16�,28� 6�.11%21 Maryland �10,�90 �16,�� 2.66%22 Massachusetts 1,1��,1�� 696,801 60.�2%2� Michigan 1,��,2�6 1,�6�,�82 88.12%2� Minnesota 61�,�9� �8�,02� 62.�6%2� Mississippi 669,690 �8�,1�� 2.��%26 Missouri 8��,112 810,828 9�.��%2� Montana 82,8�2 29,8�1 �6.01%28 nebraska 202,29� 1�1,62� 8�.8�%29 nevada 188,8�1 1�6,��9 82.90%�0 new Hampshire 11�,�96 88,026 ��.�6%�1 new Jersey 91�,�0� 6�9,�86 �2.1�%�2 new Mexico ��2,629 29�,066 62.01%�� new York �,1��,101 2,�1�,��1 6�.��%�� north Carolina 1,��,�60 90�,�2� 66.88%�� north Dakota ��,��6 �1,216 �8.29%�6 ohio 1,�8�,99� 1,2��,�66 �1.�0%�� oklahoma �8�,0�� 10,�68 8�.60%�8 oregon �1�,9�6 �81,101 91.18%�9 Pennsylvania 1,8��,�89 1,�8�,082 81.11%�0 Puerto rico 1,016,0�� 98�,68� 96.91%�1 rhode Island 1�8,119 110,196 61.8�%�2 South Carolina 689,��8 6�6,��1 9�.82%�� South Dakota 102,�� 101,2�9 98.8�%�� Tennessee 1,20�,1�6 1,20�,1�6 100.00%�� Texas �,0�1,201 2,116,�9� 69.�9%�6 utah 208,009 1�8,�� 8�.��%�� Vermont 1�1,260 128,608 91.0�%�8 Virgin Islands 6,668 0 0.00%�9 Virginia ��,�1� ��2,�01 62.68%�0 Washington 960,881 8�8,��1 89.��%�1 West Virginia �11,06� 1�8,699 ��.�9%�2 Wisconsin 90�,�� ,168 �2.2�%�� Wyoming 61,08� 0 0.00%

ToTALS ��,1�2,�91 ��,�2�,�82 �0.91%


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commercial medicaid-only

STATE HIo MCo MCo PCCM PIHP PAHP PACE oTHEr

Alabama 0 0 0 �1�,991 �0�,�66 0 0 0Alaska 0 0 0 0 0 0 0 0Arizona 0 0 9�9,�0� 0 9�,�9� 0 0 0Arkansas 0 0 0 ��2,�� 0 �2�,22� 0 0California ��2,0�9 2,822,�62 8�� 0 119 �12,��6 2,101 0Colorado 0 0 ��,�91 2�,610 �0�,019 0 1,16� 0Connecticut 0 0 0 0 28�,�6� 0 0 0Delaware 0 0 106,26� 0 0 0 0 8,969Dist of Columbia 0 0 89,�22 0 �,�6� 0 0 0florida 0 66�,�� 1�8,6�� ,8�� 92,002 �01,��8 228 9,0��Georgia 0 0 �2�,621 10�,��9 0 1,16�,88� 0 0Hawaii 0 10�,��6 61,212 0 1,81� 0 0 1,�0�Idaho 0 0 0 1��,190 0 1��,91� 0 0Illinois 0 122,100 �2,000 1,00�,�00 0 0 0 0Indiana 0 12,90� �69,810 �6,8�2 0 0 0 1��Iowa 0 �,�6� 0 1��,029 29�,88� 0 0 0Kansas 0 0 1�2,8�2 21,�98 2�0,�2� 2�0,�2� 21� 0Kentucky 0 0 1��,066 29�,6�0 066�,�90 0 0Louisiana 0 0 0 692,0�8 0 0 �1 0Maine 0 0 0 16�,28� 0 0 0 0Maryland 0 0 �91,2�� 0 0 2�,180 12� 0Massachusetts 0 1��,�00 26�,969 29�,��2 �16,�98 0 1,960 0Michigan 0 0 99�,8�2 0 1,�6�,�82 0 �0� 0Minnesota 0 ��9,1�1 ��,88� 0 0 0 0 0Mississippi 0 0 0 0 0 �8�,1�� 0 0Missouri 0 0 ��,868 0 0 �6�,�6� 196 0Montana 0 0 0 �1� 0 0 0 0nebraska 0 �2,�16 0 �9,86� 0 0 0 1�1,62�nevada 0 88,8�1 0 0 0 1�6,��9 0 0new Hampshire 0 0 0 0 0 88,026 0 0new Jersey 0 2�0,�2� �18,861 0 0 0 0 0new Mexico 0 22�,6�� 6�,821 0 292,8�9 0 ��6 0new York 0 819,6�1 1,8��,28� 1�,18� 21,2�1 0 �,0�0 8,��0north Carolina 0 0 0 890,�� 6�,8�� 0 0 0north Dakota 0 0 0 �1,216 0 �,82� 0 0ohio 0 0 1,2��,��9 0 0 0 91� 0oklahoma 0 0 0 10,�� 0 892,��2 0 0oregon 0 28,�2� 2�8,2�2 6,��1 �62,992 �69,9�9 6�9 0Pennsylvania 0 968,�1� 0 261,820 1,��,90� ��,62� 1,��8 0Puerto rico 0 966,282 0 0 �1�,�61 0 0 0rhode Island 0 �1,8�1 68,�� 0 0 �6,69� 108 0South Carolina 0 0 18�,�26 ��,689 0 6�6,926 �69 0South Dakota 0 0 0 �9,�82 0 0 0 100,66�Tennessee 0 �66,��8 ��0,�88 0 8�1,1�8 0 �16 1,889,��Texas 0 1��,�01 1,1��,6�� ,�6� �28,68� ��,99� 902 0utah 0 0 0 �9,�8� 229,�9� 1�9,81� 0 0Vermont 0 0 128,��1 0 0 0 �� 0Virgin Islands 0 0 0 0 0 0 0 0Virginia 0 282,11� 1��,�91 �2,�00 0 ��2,20� 19� 0Washington 0 �1�,�� 0 �,1�8 8�8,��1 �9,99� 268 0West Virginia 0 1�8,699 0 19,�90 0 0 0 0Wisconsin 0 �82,91� 89,69� 0 699 0 8�� 0Wyoming 0 0 0 0 0 0 0 0

number of Managed Care Entity Enrollees by State - As of June 30, 2008

This table provides duplicated figures that include enrollees receiving comprehensive and limited benefits. Total number of enrollees includes those who were enrolled in more than one managed care plan. Figures also include individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.

ToTALS ��2,0�9 9,�80,6�� 11,�29,�89 6,66�,�98 9,06�,��9 �,�0�,��9 1�,�0� 2,189,9�6

CMS Statistics national Breakout of Managed Care Entities and EnrollmentAs of June 30, 2008

MAnAGED CArE EnTITY TYPE # of PLAnS # of EnroLLEES

Health Insuring organization � ��2,0�9

Commercial Managed Care organization 160 9,�80,6��

Medicaid-only Managed Care organization 1�� 11,�29,�89

Primary Care Case Management �� 6,66�,�98

Prepaid Inpatient Health Plan 1�� 9,06�,��9

Prepaid Ambulatory Health Plan �� ,�0�,��9

Program of ALL-inclusive Care for the Elderly �9 1�,�0�

other 12 2,189,9�6

ToTAL 61� �6,92�,�88

This table provides duplicated figures by plan type. The total number of enrollees include 13,496,806 individuals who were individuals who were enrolled in more than one managed care plan. It also includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards


��


��

Total Annual Medicaid Population Distribution by YearManaged Care vs. otherAs of June 30, 2008

commercial medicaid-only

STATE HIo MCo MCo PCCM PIHP PAHP PACE oTHEr

Alabama 0 0 0 1 2 0 0 0Alaska 0 0 0 0 0 0 0 0Arizona 0 0 2� 0 1 0 0 0Arkansas 0 0 0 1 0 1 0 0California � 2� 1 0 1 12 � 0Colorado 0 0 2 1 6 0 1 0Connecticut 0 0 0 0 2 0 0 0Delaware 0 0 2 0 0 0 0 1DC 0 0 � 0 1 0 0 0florida 0 2� 2 1 2� � 2 �Georgia 0 0 � 1 0 1 0 0Hawaii 0 � 1 0 2 0 0 1Idaho 0 0 0 1 0 � 0 0Illinois 0 1 1 1 0 0 0 0Indiana 0 2 � 2 0 0 0 1Iowa 0 1 0 1 1 0 0 0Kansas 0 0 2 1 1 1 2 0Kentucky 0 0 1 1 0 1 0 0Louisiana 0 0 0 1 0 0 1 0Maine 0 0 0 1 0 0 0 0Maryland 0 0 � 0 0 � 1 0Massachusetts 0 2 2 1 1 0 6 0Michigan 0 0 1� 0 18 0 2 0Minnesota 0 6 � 0 0 0 0 0Mississippi 0 0 0 0 0 1 0 0Missouri 0 0 6 0 0 1 1 0Montana 0 0 0 1 0 0 0 0nebraska 0 1 0 1 0 0 0 1nevada 0 2 0 0 0 1 0 0new Hampshire 0 0 0 0 0 1 0 0new Jersey 0 2 � 0 0 0 0 0new Mexico 0 2 1 0 1 0 1 0new York 0 22 16 � 16 0 � 1north Carolina 0 0 0 2 1 0 0 0north Dakota 0 0 0 1 0 1 0 0ohio 0 0 8 0 0 0 2 0oklahoma 0 0 0 1 0 2 0 0oregon 0 2 1� 1 9 8 1 1Pennsylvania 0 11 0 1 �8 2 � 0Puerto rico 0 12 0 0 2 0 0 0rhode Island 0 2 1 0 0 1 1 0South Carolina 0 0 � 1 0 � 2 0South Dakota 0 0 0 1 0 0 0 1Tennessee 0 � 6 0 2 0 1 2Texas 0 6 1� 2 1 1 2 0utah 0 0 0 1 11 1 0 0Vermont 0 0 1 0 0 0 1 0Virgin Islands 0 0 0 0 0 0 0 0Virginia 0 � 2 1 0 1 � 0Washington 0 8 0 1 1 2 1 0West Virginia 0 � 0 1 0 0 0 0Wisconsin 0 19 � 0 2 0 1 0Wyoming 0 0 0 0 0 0 0 0

number of Managed Care Entities by State - As of June 30, 2008

ToTALS � 160 1�� 1�� 9 12


�6


��

regional Break-out of Medicaid Managed Care Enrollment - As of June 30, 2008

uS MEDICAID MAnAGED CArE % rEGIon BEnEfICIArIES % nATIonAL MAnAGED rEGIon EnroLLMEnT EnroLLMEnT EnroLLED In MAnAGED CArE CArE EnroLLMEnT

I - Boston 2,282,1�9 1,��1,�81 6�.��% �.�0%

II - new York 6,08�,�1� �,��8,000 �1.6�% 1�.0�%

III - Philadelphia �,908,028 2,822,8�� 2.2�% 8.��%

IV - Atlanta 8,96�,118 �,02�,11� �8.��% 21.01%

V - Chicago �,8��,6�9 �,29�,��1 6�.�0% 1�.8�%

VI - Dallas �,�26,220 �,112,6�0 �1.82% 12.�0%

VII - Kansas City 1,6�6,921 1,�11,8�� 90.16% �.�2%

VIII - Denver 9��,8�9 ��,896 80.�9% 2.26%

IX - San francisco 8,0��,�6� �,681,800 �8.12% 1�.01%

X - Seattle 1,66�,028 1,�9�,�00 8�.9�% �.18% ToTALS ��,1�2,�91 ��,�2�,�82 �0.91% 100.00%

The unduplicated managed care enrollment figures include enrollees receiving comprehensive benefits and limited benefits. This table also provides unduplicated Medicaid enrollment figures by region. The enrollment figures include individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.

Arkansas 622,�91 1,696 �00,21� 80.�6%

Arizona 1,0�8,6�� 1�9,29� 9�9,�0� 90.��%

Delaware 1�2,899 19,916 11�,2�6 ��.��%

florida 2,2�6,01� 20�,�� 1,��1,62� 6�.��%

Hawaii 211,10� 22,6�1 166,9�8 �9.08%

Indiana 881,888 1�,0�8 629,�10 �1.�0%

Kentucky �1�,961 0 ��8,11� 62.�6%

Maryland �10,�90 2�,180 �16,�� 2.66%

Massachusetts 1,1��,1�� 9�,�66 696,801 60.�2%

Minnesota 61�,�9� ��,�0� �8�,02� 62.�6%

new York �,1��,101 �1�,120 2,�1�,��1 6�.��%

oklahoma �92,��6 0 �11,�� 69.��%

oregon �1�,9�6 2�,�26 �81,101 91.18%

rhode Island 180,86� 21,91� 11�,106 6�.09%

Tennessee 1,20�,1�6 �2,99� 1,20�,1�6 100.00%

utah 208,009 19,221 1�8,�� 8�.��%

Vermont 1�1,260 �6,��0 128,608 91.0�% ToTALS 1�,28�,0�6 1,2�2,��1 10,98�,110 �1.86%

uS MEDICAID EXPAnSIon MAnAGED CArE % EnroLLED InSTATE EnroLLMEnT EnroLLMEnT EnroLLMEnT MAnAGED CArE

States with Comprehensive Health Care reform Demonstrations - As of June 30, 2008

The unduplicated managed care enrollment figures include enrollees receiving comprehensive benefits and limited benefits. This table also provides unduplicated Medicaid enrollment figures by region. The enrollment figures include individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.


�8


�9

rAnK STATES WAIVEr TYPE MAnAGED CArE EnroLLMEnT STATES 1-10

1 California 191�(b), 19�2(a), 191�(a), PACE �,�08,909

2 new York 111�(a), 191�(a), PACE 2,�1�,��1

� Texas 191�(b), 19�2(a), 191�(b)/(c), PACE 2,116,�9�

� Pennsylvania 191�(b), 191�(a), PACE 1,�8�,082

� florida 191�(b), 111�(a), 191�(b)/(c), 191�(a)/(c), PACE 1,��1,62�

6 Michigan 191�(b), PACE 1,�6�,�82

� ohio 19�2(a), PACE 1,2��,�66

8 Tennessee 111�(a), PACE 1,20�,1�6

9 Georgia 191�(b), 19�2(a), 1902(a)(�0) 1,16�,88�

10 Illinois 19�2(a), 191�(a) 1,16�,�00

Subtotal 1�,��9,�10 national Managed Care Grand Total ��,�2�,�82 Percentage �1.90%

STATES 11-20 11 Puerto rico 191�(a) 98�,68�

12 Arizona 111�(a) 9�9,�0�

1� north Carolina 191�(b)/(c), 19�2(a) 90�,�2�

1� Washington 191�(b), 19�2(a), PACE 8�8,��1

1� Missouri 191�(b), 1902(a)(�0), PACE 810,828

16 Massachusetts 111�(a), PACE 696,801

1� Louisiana 19�2(a), PACE 692,099

18 Kentucky 111�(a), 19�2(a), 9102(a)(�0) 66�,�90

19 new Jersey 191�(b), 19�2(a) 6�9,�86

20 South Carolina 19�2(a), 191�(a), 1902(a)(�0), PACE 6�6,��1

Subtotal �,868,�90 national Managed Care Grand Total ��,�2�,�82 Percentage 2�.��% Medicaid Managed Care Enrollment - As of June 30, 2008

The unduplicated managed care enrollment figures include enrollees receiving comprehensive benefits and limited benefits.

CMS Statistics Managed Care Entity Types - As of June 30, 2008

STATE

Arizona 88,0�9 Arkansas ��,6�� California 110,�� ,�02 12,8�8 1,89� Colorado �,0�1 �,�90 �2,1�6 1,1�� Dist. of Columbia 182 florida 22,69� 10,��6 9� 219 290Georgia 129,9�9 Idaho 1�,026 1,0�8 Indiana Iowa �0,96� Kansas �2,�00 �2,�00 199 Kentucky 12,��8 88,�00 Louisiana �� Maryland 11� Massachusetts 1�9 1,8�� Michigan �0� Minnesota ��,��8 Missouri 1�9 Mississippi 68,0�0 nebraska 19,�02nevada ��,2�0 new Jersey 16,�96 new Mexico �1� new York �,96� 1,021 18,�9� 2,�69 north Carolina �2,82� 1�,2�9 ohio �66 oregon �0,�2� 1,660 �8,�09 ��,��8 6�2Pennsylvania 1,��8 �90 20�,9�1 1,26� Puerto rico 21�,�� ,96� rhode Island 1�,2�9 10� South Carolina 128,110 �61 Tennessee 19�,2�8 1�8,�� 299 19�,�28Texas 82,866 �8,2�0 26,�82 8�1 utah �,�� 19,929 1�,�91 Vermont 1�,�2� �� Virginia 10�,�01 18� Washington �� 18,1�� 2�9 Wisconsin 18,88� 8��

ToTALS 110,�� 8�0,�66 110,9�8 6�8,�06 �0�,�82 1�,�62 21�,�62

HIo MCo oTHErPACE PAHP PIHPPCCM

*Thistableprovidesduplicatedfiguresthatincludeenrolleesreceivingcomprehensiveandlimitedbenefits.Total number of enrollees includes those who were enrolled in more than one managed care plan. Figures also include individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards..


60


61

CMS Statistics number of Prepaid Ambulatory Health Plans (PAHPs) and Enrollment by StateAs of June 30, 2008

State

AK

CA

fL

GA

ID

KS

KY

MD

MS

Mo

nV

nH

nD

oK

or

PA

rI

SC

TX

uT

VA

WA

Totals

Medical- only

1

�

1

1

�

Medical- onlyEnrollees

1,0�8

2�,180

�81,�6�

18�

�08,20�

MH

1

1

MHEnrollees

2�0,�2�

2�0,�2�

Substance useDisorders

1

1

Substance useDisorderEnrollees

9,�92

9,�92

Dental

12

1

2

�

1

2�

Dental Enrollees

�12,��6

209,69�

1�6,8�9

�60,1��

�6,69�

1,1��,9�0

Transpor-tation

1

1

1

1

1

1

1

1

1

2

1

1

1�

Trans-portation Enrollees

�2�,22�

�0,96�

1,16�,88�

66�,�90

�8�,1��

�6�,�6�

1�6,��9

�10,�68

��,9�8

6�6,��1

1�9,81�

��2,20�

�,2��,819

Disease Mgmt.

2

1

1

1

1

2

8

Disease Mgmt.

Enrollees

20,�18

88,026

�,82�

�8,6��

��,99�

�9,99�

2��,208

CMS Statistics number of Prepaid Inpatient Health Plans (PIHPs) and Enrollment by StateAs of June 30, 2008

State

Alabama

Arizona

California

Colorado

Connecticut

DC

florida

Hawaii

Iowa

Kansas

Massachusetts

Michigan

new Mexico

new York

north Carolina

oregon

Pennsylvania

Puerto rico

Tennessee

Texas

utah

Washington

Wisconsin

ToTALS

# ofMedical- only PIHPs

2

1

2

1

21

�

2

�2

Medical- onlyEnrollees

�0�,�66

12,�98

28�,�6�

�,�6�

6�,6�0

1��

�9,90�

929,�10

# ofMHPIHPs

1

�

6

2

18

1

9

9

1

�2

MH PIHPEnrollees

119

�90,�21

�2�,�62

1,81�

1,�6�,�82

292,8�9

�62,992

169,889

8�8,��1

�,96�,262

# of MH & SuD PIHPs

1

1

1

1

��

2

2

1

2

�6

MH & SuD Enrollees

9�,�9�

29�,88�

�16,�98

6�,8��

1,��,��1

�1�,�61

8�1,1�8

�28,68�

699

�,916,81�

# of SuD PIHPs

1

1

SuD Enrollees

2�0,�2�

2�0,�2�

Long- Term Care PIHPs

16

16

Long- Term CareEnrollees

21,2�1

21,2�1

*MH denotes Mental Health


62


6�

AlabamaMs. Carol H. Steckel, MPH, CommissionerAlabama Medicaid Agency 501 Dexter AvenueP.O. Box 5624Montgomery, AL 36103-5624 (36104 FedEx)Commercial: (334) 242-5600Fax Number: (334) 242-5097

AlaskaMr. Jerry Fuller, Medicaid DirectorMedicaid and Health and Social ServicesFrontier Building, Suite 9023601CStreetP.O. Box 240249Anchorage, Alaska 99524-0249Commercial:(907)269-7800FaxNumber:(907)269-0060

American SamoaMr. Andy Puletasi, Medicaid Program DirectorMedicaid Program DirectorLBJ Tropical Medical CenterPago Pago, AS 96799Commercial: (684) 633-4590Fax Number: (011) 684/633-1869

ArizonaMr. Anthony D. Rodgers, DirectorArizona Health Care Cost Containment System (AHCCCS)801 East JeffersonPhoenix, AZ 85034Commercial: (602) 417-4711Fax Number: (602) 252-6536

ArkansasMr. Roy Jeffus, DirectorDivision of Medical ServicesDepartment of Human ServicesP.O. Box 1437, Slot S401Little Rock, AR 72203Federal Express (112 West 8th Street)Slot S401Little Rock, AR 72201-4608Commercial: (501) 682-8740Fax Number: (501) 682-1197

CaliforniaMr. Toby Douglas, Chief Deputy DirectorHealth Care ProgramsDepartment of Health Care Services1501 Capitol Avenue, 6th FloorMS 0002Sacramento, CA 95814Commercial: (916) 440-7400Fax Number: (916) 440-7404

ConnecticutMr. David Parrella, DirectorMedical Care AdministrationDepartment of Social Services25 Sigourney StreetHartford, CT 06106Commercial: (860) 424-5116Fax Number: (860) 424-5114

ColoradoDr. Sandeep Wadhwa, Medicaid DirectorMedical & Child Health Plan Plus Administration Office Department of Health Care Policy & Financing1570 Grant StreetDenver, CO 80203-1818Commercial: (303) 866-5929Fax Number: (303) 866-3476

DelawareMs. Rosanne Mahaney, Acting Director Division of Medicaid and Medical AssistanceDepartment of Health and Social Services1901 N. Dupont HighwayP.O. Box 906, Lewis BuildingNew Castle, DE 19720Commercial: (302) 255-9535Fax Number: (302) 255-4413

District of ColumbiaMr. John McCarthy, Deputy DirectorDepartment of Health Care Financing825 North Capitol Street NESuite 5135Washington, DC 20002Commercial: (202) 442-9050Fax Number: (202) 442-4790

State Medicaid DirectorsAs of June 18, 2009

Ms. Julie Hudman, PhD., DirectorDepartment of Health Care Financing825 North Capitol Street NESuite 5135Washington, DC 20002Commercial: (202) 442-9050Fax Number: (202) 442-4790

floridaMr. Carlton D. Snipes, Deputy SecretaryAgency for Health Care Administration2727 Mahan DriveMail Stop 8Tallahassee, FL 32308Commercial: (850) 488-3560Fax Number: (850) 488-2520

GeorgiaMr. Jerry Dubberly, Medicaid Director Medical Assistance PlansDepartment of Community HealthTwo Peachtree Street, Suite 36450Atlanta, GA 30303Commercial: (404) 651-8681Fax Number: (866) 283-0128

GuamMs. Theresa L. Arcangel, AdministratorBureau of Health Care Financing AdministrationDepartment of Public Health and Social Services123 Chalan KaretaMangilao, Guam 96913-6304Overseas Operator: (671) 735-7282Fax Number: (671) 734-6860

HawaiiDr. Kenneth S. Fink, Division AdministratorMed-Quest Division Department of Human Services601 Kamokila Blvd., Room 518PO Box 700190Kapolei, HI 96709-0190Commercial: (808) 692-8050Fax Number: (808) 692-8155

IdahoMs. Leslie Clement, AdministratorDepartment of Health and WelfareDivision of Medicaid3232 Elder StreetBoise, ID 83705Commercial: (208) 334-5747Fax Number: (208) 364-1811

IllinoisMs. Theresa Eagleson, Medicaid DirectorMedical ProgramsIllinois Department of Healthcare and Family Services201 S. Grand Avenue, East, 3rd FloorSpringfield, IL 62763-0001Commercial: (217) 782-2570Fax Number: (217) 782-5672

IndianaMr. E. Mitchell Roob, Jr., DirectorMedicaid Policy and PlanningFamily and Social Services Administration402 W. Washington Street, Room W382Indianapolis, IN 46204-2739Commercial: (317) 233-4690Fax Number: (317) 232-7382

Patricia Casanova, Interim Medicaid DirectorOffice of Medicaid Policy and PlanningFamily and Social Services Administration402 West Washington, Room W461, MS 25Indianapolis, Indiana 46204-2407Commercial: (317) 234-2407Fax Number: (317) 233-4693

IowaMs. Jennifer Vermeer, Medicaid DirectorIowa Medicaid EnterpriseDepartment of Human Services100 Army Post RoadDes Moines, IA 50315Commercial: (515) 725-1123Fax Number: (515) 725-1360

KansasMr. Andrew Allison, PhD, Medicaid Director and Deputy DirectorKansas Health Policy Authority900 SW Jackson Avenue, Suite 900-NTopeka, KS 66612Commercial: (785) 368-8162Fax Number: (785) 296-3468

KentuckyMs. Elizabeth A. Johnson, CommissionerDepartment for Medicaid Services275 East Main Street, 6 West AFrankfort, KY 40621Commercial: (502) 564-4321Fax Number: (502) 564-0509

STATE MEDICAID DIrECTorS

6�


6�

LouisianaMr. Jerry Phillips, Medicaid DirectorState of LouisianaDepartment of Health and Hospitals628 North 4th StreetBaton Rouge, LA 70802-9030Commercial: (225) 342-3891Fax Number: (225) 342-9508

MaineMr. Tony Marple, DirectorOffice of MaineCare ServicesBureau of Medical ServicesDepartment of Health & Human Services#11 Statehouse Station 442 Civic Center DriveAugusta, ME 04333-0011Commercial: (207) 287-2093Fax Number: (207) 287-2675

MarylandMr. John G. Folkemer, Deputy SecretaryHealth Care FinancingDepartment of Health and Mental Hygiene201 West Preston Street-Room 525Baltimore, MD 21201Commercial: (410) 767-4139Fax Number: (410) 333-7687

MassachusettsMr. Tom Dehner, Medicaid DirectorOffice of Medicaid1 Ashburton Place, 11th FloorRoom 1109Boston, MA 02108Commercial: (617) 573-1770Fax Number: (617) 573-1894

MichiganMr. Paul Reinhart, Medicaid DirectorMedical Services Administration Michigan Department of Community HealthCapitol Commons Center, 7th Floor400 S. Pine StreetLansing, MI 48913Commercial: (517) 241-7882Fax Number: (517) 335-5007

MinnesotaMr. Brian Osberg, Medicaid DirectorDepartment of Human Services540 Cedar StreetP.O. Box 64983St. Paul, MN 55164-0983Commercial: (651) 431-2189Fax Number: (651) 431-7421

MississippiDr. Robert L. Robinson, Executive DirectorState of MississippiDivision of Medicaid550 High StreetSuite1000Walter Sillers BuildingJackson, MS 39201-1325Commercial: (601) 359-9562Fax Number: (601) 359-6048

MissouriDr. Ian McCaslin, M.D., M.P.H., DirectorMO HealthNet DivisionDepartment of Social Services615 Howerton Court P.O. Box 6500Jefferson City, MO 65102 Commercial: (573) 751-6922Fax Number: (573) 751-6564

MontanaMs. Mary Dalton, DirectorDepartment of Public Health & Human ServicesP.O. Box 4210111 N. SandersHelena, MT 59604Commercial: (406) 444-4084Fax Number: (406) 444-1970

nebraskaMs. Vivianne M. Chaumont, DirectorDivision of Medicaid and Long-Term CareNebraska Department Health and Human Services 301 Centennial Mall South, 3rd FloorP.O. Box 95026Lincoln, NE 68509-5026Commercial: (402) 471-2135Fax Number: (402) 471-9449

nevadaMr. Charles Duarte, AdministratorDivision of Health Care Financing and Policy1100 E. WilliamsSuite 101Carson City, NV 89710Commercial: (775) 684-3677Fax Number: (775) 687-3893

new HampshireMr. Nicholas A. Toumpas, CommissionerNew Hampshire Department of Health and Human ServicesOffice of Commissioner129 Pleasant StreetConcord, NH 03301-6521Commercial: (603) 271-5254Fax Number: (603) 271-4727

Ms. Kathleen Dunn, Acting Medicaid DirectorHealth Policy and MedicaidOffice of Commissioner129 Pleasant StreetConcord, NH 03301-6521Commercial: (603) 271-5254Fax Number: (603) 271-4727

new JerseyMr. John R. Guhl, DirectorDepartment of Human ServicesDivision of Medical Assistance and Health Services7 Quakerbridge PlazaP.O. Box 712Trenton, NJ 08625-0712Commercial : (609) 588-2600Fax Number : (609) 588-3583

Ms. Valerie J. Harr, Deputy DirectorDivision of Médical Assistance and Health Services7 Quakerbridge PlazaP.O. Box 712Trenton, NJ 08625-0712Commercial : (609) 588-2601Fax Number : (609) 588-3583

new MexicoMs. Carolyn Ingram, DirectorMedical Assistance DivisionNew Mexico Human Services DepartmentP.O. Box 2348Santa Fe, NM 87504-2348Commercial: (505) 827-3106Fax Number: (505) 827-3185

new YorkMs. Deborah Bachrach, Deputy CommissionerOffice of Health Insurance ProgramsNew York State Department of HealthEmpire State PlazaRoom 1466, Corning Tower BuildingAlbany, NY 12237Commercial: (518) 474-3018Fax Number: (518) 486-6852

north CarolinaDr. Craigan L. Gray, DirectorDivision of Medical AssistanceDepartment of Health and Human Services1985 Umstead Drive, 2501 Mail Service CenterRaleigh, NC 27699-2501Commercial: (919) 855-4100Fax Number: (919) 733-6608

Ms. Tara R. Larson, Chief Clinical Operations Officer Division of Medical AssistanceDepartment of Health and Human Services1985 Umstead Drive, 2501 Mail Service CenterRaleigh, NC 27699-2501Commercial: (919) 855-4100Fax Number: (919) 733-6608

north DakotaMs. Maggie D. Anderson, DirectorDivision of Medical ServicesND Department of Human Services600 E. Boulevard Avenue, Dept. 325Bismarck, ND 58505-0250Commercial: (701) 328-1603Fax Number: (701) 328-1544

northern Mariana IslandsMs. Helen Sablan, AdministratorMedicaidCommonwealth of the Northern Mariana Islands PO Box 409CKSaipan, CM 96950Commercial: (670) 664-4884Fax Number: (670) 664-4885

ohioMr. John R. Corlett, Medicaid DirectorOhio Department of Job and Family ServicesOffice of Ohio Health Plans50 W. Town Street, 4th FloorColumbus, Ohio 43215Commercial: (614) 466-4443Fax Number: (614) 752-3986

Ms. Cristal Thomas, Executive DirectorExecutive Medicaid Management Administration77 South High Street30th Floor Columbus, OH 43215Commercial: (614) 644-0935Fax Number: (614) 466-9354


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oklahomaMr. Mike Fogarty, CEOOklahoma Health Care Authority4545 N. Lincoln Boulevard, Suite 124Oklahoma City, OK 73105Commercial: (405) 522-7417Fax Number: (405) 530-3202

Ms. Lynn V. Mitchell, M.D., MPHMedicaid DirectorOklahoma Health Care Authority4545 N. Lincoln Boulevard, Suite 124Oklahoma City, OK 73105Commercial: (405) 522-7365Fax Number: (405) 530-3218

oregonMr. Jim Edge, State Medicaid DirectorDivision of Medical Assistance ProgramsDepartment of Human Services500 Summer Street, NE E49Salem, OR 97301-1079Commercial: (503) 945-5772Fax Number: (503) 373-7689

Mr. James Toews, Assistant DirectorSenior and People with DisabilitiesDepartment of Human Services500 Summer Street NE, E-02Salem, OR 97310-1015Commercial: (503) 945-6478Fax Number: (503) 373-7823

PennsylvaniaMr. Michael Nardone, Deputy SecretaryMedical Assistance ProgramsDepartment of Public WelfareHealth and Welfare Building, RM 515Commonwealth Avenue & Forster StreetP.O. Box 2675Harrisburg, PA 17105Commercial: (717) 787-1870Fax Number: (717) 787-4639

Puerto ricoMr. Miguel Negron-Rivera, Executive Director Commonwealth of Puerto RicoDepartment of Health-Medicaid ProgramP.O. Box 70184San Juan, Puerto Rico 00936Commercial: (787) 250-0453Fax Number: (787) 250-0990

rhode IslandVacant Division of Health Care QualityDepartment of Human Services600 New London AvenueCranston, RI 02920Commercial: (401) 462-3575Fax Number: (401) 462-6338

South CarolinaMs. Emma Forkner, DirectorDepartment of Health & Human Services P.O. Box 82061801 Main StreetColumbia, SC 29201-8206Commercial: (803) 898-2504Fax Number: (803) 255-8338

South DakotaMr. Larry Iversen, Medicaid Director Medical ServicesDepartment of Social ServicesKneip Building700 Governors DrivePierre, SD 57501-2291Commercial: (605) 773-3495Fax Number: (605) 773-5246

TennesseeMr. Darin Gordon, Director/Deputy CommissionerState of TennesseeBureau of TennCareDepartment of Finance and Administration310 Great Circle RoadNashville, TN 37243Commercial: (615) 507-6443Fax Number: (615) 253-5607

TexasMr. Chris Traylor, State Medicaid DirectorAssociate Commissioner for Medicaid/CHIPTexas Health and Human Services Commission11209 Metric Blvd., Building HMail Code H100P.O. Box 85200Austin, TX 78758 (78751 Fedex) Commercial: (512) 491-1867Fax Number: (512) 491-1977

utahMr. David Sundwall, Executive DirectorDepartment of HealthP.O. Box 141000Salt Lake City, UT 84114-1000Commercial: (801) 538-6111Fax Number: (801) 538-6306

Mr. Michael Hales, Director Division of Health Care FinancingUtah Department of HealthP.O. Box 144102Salt Lake City, UT 84114-3101Commercial: (801) 538-6689Fax Number: (801) 538-6860

VermontMs. Susan W. Besio, DirectorOffice of Health AccessAgency of Human Services312 Hurricane Lane, Suite 201Williston, VT 05495Commercial: (802) 879-5901Fax Number: (802) 879-5962

VirginiaMr. Patrick Finnerty, DirectorDepartment of Medical Assistance Services600 East Broad Street - Suite 1300Richmond, VA 23219Commercial: (804) 786-8099Fax Number: (804) 371-4981

Virgin IslandsMs. Priscilla Berry-Quetel, Executive DirectorBureau of Health Insurance and Medical Assistance3730 Estate AltonaFrostco Center, Suite 302St. Thomas, USVI 00802Commercial: (340) 774-4624Fax Number: (340) 774-4918

Ms. Karen Virgil, Assistant DirectorBureau of Health Insurance and Medical Assistance3730 Estate AltonaFrostco Center, Suite 302St. Thomas, US Virgin Islands 00802Commercial: (340) 774-4624 Fax Number: (340) 774-4918

WashingtonMr. Douglas Porter, Assistant SecretaryDepartment of Social and Health ServicesHealth and Recovery Services Administration8th AvenueP.O. Box 45502Olympia, WA 98504-5502Commercial: (360) 725-1867Fax Number: (360) 586-9551

Ms. Kathy Leitch, Assistant SecretaryAging and Disability Services AdministrationP.O. Box 45050Olympia, WA 98504-5050Commercial: (360) 725-2260Fax Number: (360) 407-0304West Virginia

Ms. Marsha Morris, CommissionerBureau for Medical ServicesDepartment of Health & Human Resources350 Capitol Street - Room 251Charleston, WV 25301-3706Commercial: (304) 558-1700Fax Number: (304) 558-1451

WisconsinMr. Jason A. Helgerson, State Medicaid DirectorDivision of Health Care FinancingDepartment Of Health and Family Services1 West Wilson Street - Room 350PO Box 309Madison, WI 53701-0309Commercial: (608) 266-8922Fax Number: (608) 266-6786

WyomingMs. Teri Green, State Medicaid AdministratorOffice of Health Care FinancingWyoming Department of Health6101 Yellowstone Road, Suite 210Cheyenne, WY 82009Commercial: (307) 777-7531Fax Number: (307) 777-6964

The above information was provided courtesy of the National Association of State Medicaid Directors as of June 2009.


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AffInITY nETWorKS, InC.

Arthur AndersonPresidentEmail: [email protected] Wilson Blvd.#102-205Arlington, VA 22201Direct: (703) 538-4616www.affn.com

Affinity Networks is a technology service and integration firm specializing in the development and implementation of revolutionary electronic solutions. Affinity Networks provides services for Government and Commercial clients predominantly in the Healthcare, Homeland Security, Law Enforcement and Transportation sectors. This small, privately held firm consists of a management team with over 50 years of experience in the field of information technology solutions. Affinity Networks is supported by Noesis and Bearing Point. These partner firms assist in the integration of specialized applications and equipment and support Affinity Networks in the management of these efforts.

THE AMErIHEALTH MErCY fAMILY of CoMPAnIES

Leslie Zavodnick Vice President, Corporate InitiativesEmail: [email protected] 200 Stevens Drive Philadelphia, PA 19113 Direct: (215) 937-8263 www.amerihealthmercy.com

The AmeriHealth Mercy Family of Companies comprises the largest organization of Medicaid managed care plans in the United States, touching 6.5 million lives nationwide. They are

resources for Medicaid Health Plans - As of October 20, 2009

the nation’s expert and industry leader in the delivery of quality health care to low-income populations covered by publicly-funded programs, including Medicare, Medicaid and State Children’s Health Insurance Programs. AmeriHealth Mercy’s five product lines include full-risk Medicaid managed care, management and administrative services, behavioral health services, care management and pharmacy benefits management for Medicaid and Medicare Part D. Its programs offer improved health outcomes for members and have saved millions of dollars in public funds.

BEACon HEALTH STrATEGIES, LLC

John Colburn, PhDDirector of Clinical DevelopmentEmail: [email protected] 500 Unicorm Park DriveWoburn, MA 01801Direct: (781) 994-7133 Main: (781) 994-7500www.beaconhealthstrategies.com

Beacon Health Strategies is a behavioral health management organization specializing in the development and management of behavioral services for a wide variety of customers including integrated health care delivery systems, academic medical centers, health maintenance organizations and state and local governments. Beacon integrates managed care operations and information technology to improve the quality, effectiveness and efficiency of health and human services.

BLoCK VISIon, InC.

Stephanie LucasSenior VP, Sales & Account ServicesEmail: [email protected] Columbia Turnpike Suite 209A, North TowerFlorham Park, New Jersey 07932Direct: (973) 514-1191www.blockvision.com

Block Vision is a national vision benefits manager, arranging services for more than 3 million covered lives across the country. They offer programs on a private-label basis through managed care organizations, dental plan, insurance companies and other third party payors, as well as directly to employer groups. Our programs include Commercial, Medicaid and Medicare product lines.

BurCH ConSuLTInG, LLC

Helen C. BurchPrincipal7300 Rosemead LaneChesterfield, VA 23838(804) 716-0460Mobile (804) 399-0627Email: [email protected] Burch Consulting provides consulting services to a variety of clients including managed care organizations, governments and employers. Areas of expertise include managed care, Medicaid, SCHIP, Medicare, workers’ compensation, provider network development, program development and implementation, business and strategic planning, marketing, and regulatory compliance. Prior to founding Burch Consulting, Helen held positions with Managed Care Advisors, Inc., as Vice President and PHP Healthcare Corporation and DC Chartered Health Plan as Director of Business Development.

ConnoLLY HEALTHCArE

Neal MillerDirector, Business DevelopmentEmail: [email protected] Danbury RoadWilton, CT 06897Direct: (203) 529-2196www.connollyhealthcare.com

Establishing itself in 1979 as a recovery audit pioneer, Connolly Healthcare introduced medical claim data mining audits to the healthcare industry in 1998, and is now recognized by commercial and government health plans as the recovery audit expert. With the industry’s large and fast growing volume of complex medical claim transactions, small errors can quickly add up to millions of lost dollars. That’s why four of the largest six insurance payers and other major insurers use Connolly.”

DCA

Behzad MohazzebiPresident & FounderEmail: [email protected] Corporate Center3000 Atrium WaySuite 221Mt. Laurel, NJ 08054Main: (856) 273-6960www.dcasolutions.com

DCA (Dynamic Commerce Applications, Inc.) established in 1991 assists both Medicare and Medicaid plans to overcome the challenge of Risk Adjustment Payment that impacts their bottom line revenue and quality of patient care. DCA is privately held and its management team is highly recognized for their expertise and being practical. DCA is also known for supporting clients all the way.

rESourCES for MEDICAID HEALTH PLAnS

AdvantageMHPAPREFERRED VENDOR OF MEDICAID HEALTH PLANS OF AMERICA


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Forest Pharmaceuticals, Inc., a wholly-owned subsidiary of Forest Laboratories, Inc., manufactures, distributes, and sells Forest-branded ethical prescription products in the United States and Puerto Rico. Our Vision is to serve as a leader in the Pharmaceutical industry, nationally and locally, by contributing safe and effective pharmaceutical therapies that improve the quality of life of patients everywhere.

furST GrouP/MPI

Deanna L. BanksVice PresidentEmail: [email protected] Market StreetSuite A#607Philadelphia, PA 19103Direct: (610) 430-6884Main: (800) 642-9940www.furstgroup.com

Furst Group provides a “total solution” approach to traditional executive search, as well as an array of consulting products tied to what we refer to as the Human Capital Interaction. Our firm has extensive experience working with Managed Government Programs, specifically, Medicare programs to include Medicare Advantage, PDP, Private Fee for Service, Medicare Supplement, MediGap and Corporate Retirees.

GorMAn HEALTH GrouP

John K. GormanPresident & CEOEmail: [email protected] 36th Street, NWSuite 1000Washington, DC 20008Direct: (202) 364-8283www.gormanhealthgroup.com

ELI LILLY & CoMPAnY

John H. PoulinManager, Professional Relations Email: [email protected] Corporate CenterIndianapolis, IN 46285Direct: (317) 277-8173www.lilly.com

Eli Lilly and Company is a leading, innovation-driven corporation committed to developing a growing portfolio of best-in-class and first-in-class pharmaceutical products that help people live longer, healthier and more active lives.

EPSTEIn BECKEr & GrEEn

Clifford BarnesPartnerEmail: [email protected] 25th Street, NW#700Washington, DC 20037Direct: (202) 861-1856www.ebglaw.com

Founded in 1973, Epstein Becker & Green, P.C. is a national law firm with global reach that takes a “boutique approach” to five complementary areas of practice: business law; health care and life sciences; labor and employment; litigation and real estate. EpsteinBeckerGreen’s commitment to these practices reflects its founders’ belief in focused proficiency paired with seasoned experience. Each practice is comprised of teams of experienced attorneys with the flexibility to take on cases of all sizes, and the mandate to deliver truly professional service.

ESA MAGELLAn BIoSCIEnCES

Mike CampisiSenior Director, Sales & Marketing Email: [email protected] Alpha Road Chelmsford, MA 01824Direct: (978) 987-3879 www.esainc.com

ESA Biosciences, Inc. enables answers to pressingapplications challenges by applying its expertise inspecialty detection and electrochemistry, combinedwith components, kits, and reagents, for analyticallaboratories, commercial diagnostics laboratories,and the clinical point-of-care setting. Founded in 1968, ESA is a wholly owned subsidiary of Magellan Biosciences, Inc.

fIrST rECoVErY GrouP

David RosenPresidentEmail: [email protected] West 9 MileSuite 1544Southfield, MI 48075Direct: (248) 443-4800www.firstrecoverygroup.com

First Recovery group is largest independent healthcare cost management company focused solely on claims recovery. Our exclusive SubroMAX® data mining system typically identifies twice as many cases and leads to as much as four times the dollars recovered.

forEST PHArMACEuTICALSErin NewtonRegional Account Manager Email: [email protected] York RoadParkton, MD 21120Office: (410) 357-4886V-mail: (888) 430-5227 x8110104www.forestpharm.com

Gorman Health Group helps execute the mission of the Federal health programs by providing exemplary counsel, products, and services to Medicare and Medicaid’s private sector partners. Our expert model brings together senior managed care professionals and veteran regulators to provide strategic, operational, financial, and clinical services to managed care organizations, pharmaceutical companies, PBMs, advocacy groups and others.

HEALTH MAnAGEMEnT SYSTEMS

Christina DragonettiExecutive Vice PresidentEmail: [email protected] Park Avenue, SouthNew York, NY 10016Direct: (916) 760-5100www.hmsy.com

HMS leads the nation in cost containment, coordination of benefits, and program integrity services for government healthcare programs. Using information technology and data-mining techniques, HMS identifies other insurance coverage, coordinates benefits, and recovers overpayments.

MEDCo HEALTH SoLuTIonS

Michelle VancuraSenior Vice President, Managed Medicaid Health PlansEmail: [email protected] W24130 Riverwood Drive Waukesha, WI 53188 Direct: (262) 312-3551 www.medco.com

Medco is a leading pharmacy benefit manager (PBM) with the nation’s largest mail order pharmacy operations. Medco assists its customers to moderate the cost and enhance the quality of prescription drug benefits provided to members nationwide.


EPSTEIN BECKER & GREEN, P.C.

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MErCK & Co., InC.Paul J. Bader, RPhCustomer Strategies and Solutions, US Commercial OperationsEmail: [email protected] Sumneytown PikeP.O. Box 4West Point, PA 19486Office: (267) 305-0237Fax: (267) 305-8533www.merck.com

Merck & Co., Inc. is a global research-driven pharmaceutical company dedicated to putting patients first. Established in 1891, Merck discovers, develops, manufactures and markets vaccines and medicines to address unmet medical needs.

MorrIS AnD GunTHEr ASSoCIATES

Peter D. GunterPartnerEmail: [email protected] Ambassador WaySuite 102Baltimore, MD 22310Direct: (312) 224-8036www.morrisgunter.com.com

Morris & Gunter Associates helps businesses raise performance, mitigate risks and innovate. It employs a novel criteria-driven approach to understanding and tuning performance drivers. This approach blends strategy, risk management, operational performance improvement and change management to produce desired results. The approach is scalable and adaptable to any organization. Our proprietary tools and approach focus on tangible and intangible tasks required to operate an enterprise. Intangibles — such as decision-making, communication, innovation and execution — account for more than 50 percent of your organization’s value. Stakeholders can use our tools to enhance specific performance drivers and rapidly understand, communicate and measure progress..

oPTIMETrA, InC.

Holly Smith Director of Business DevelopmentEmail: [email protected] Red Rock Ranch RoadMonument, CO 80132Direct: (719) 964-2323www.optimetra.com

Optimetra specializes in providing solution-oriented business development and project management services to healthcare organizations. Our services can best be summarized as:

Competitive analysis and market positioning

Leadership and development of proposal response

Implementation planning and project management

Project management education and training

orTHo-McnEIL JAnSSEn PHArMACEuTICALS, InC.

Tom KnoxStrategic Market Director -KY/SC (Strategic Business Group)Email: [email protected] Mill Hopper RoadJacksonville, FL 32258Direct: (859) 485-4901www.ortho-mcneil.com

Ortho-McNeil® is a healthcare company that draws on the rich patient care heritage of its two sister companies, Ortho-McNeil Pharmaceutical and Janssen Pharmaceutical. Both of these pharmaceutical companies are pioneers and leaders in various areas such as pain management, acid reflux disease and infectious diseases that remain central to Ortho-McNeil® today. Ortho-McNeil® is uniquely poised to serve the broad needs of Primary Care as well as hospitals and other care facilities. Our goal is to provide the most comprehensive and innovative treatments to advance patient care.

roCHE DIAGnoSTICS

Robert McDanielManager of Government MarketingEmail: [email protected] Hague RoadIndianapolis, IN 46250Direct: (317) 521-4523www.roche.com

Roche plays a pioneering role in health care. As an innovator of products and services for the early detection, prevention, diagnosis and treatment of diseases, Roche contributes on a broad range of fronts to improving people’s health and quality of life. Roche is providing the first products that are tailored to the needs of specific patient groups. Our mission today and tomorrow is to create added value in health care by focusing on our expertise in diagnostics and pharmaceuticals. Roche is the world leader in in-vitro diagnostics and drugs for cancer, transplantation, and active in other major therapeutic areas with a high medical need such as autoimmune diseases, inflammatory diseases, virology, metabolic disorders and diseases of the central nervous system.

SELLErS DorSEY

Nancy L. HardySenior Vice PresidentEmail: [email protected] S. Broad StreetSuite 1802Philadelphia, PA 19102Direct: (215) 279-9745www.sellersdorsey.com

Sellers Dorsey, a market-leading healthcare consulting firm, specializes in creating transformational change in public healthcare programs. Highly regarded for its strategy and insight, our firm is at the forefront of Medicaid and healthcare reform. As we focus our efforts on eliminating the ranks of the uninsured, Sellers Dorsey designs and implements exceptional solutions for our clients by providing an effective combination of policy acumen, political savvy and professional

PHArMASTAr

Bob TannerDirector of OperationsEmail: [email protected] 3217Eau Claire, WI 54702-3217(888) 298-7770www.pharmastaronline.com/

PharmaStar is a transparent pharmacy benefit manager (PBM) with a wide range of tools available to streamline your pharmacy benefit program. In addition, PharmaStar is equipped to manage Part D specific PBM needs. Our focus on personal service, flexible programs and 24/7 availability is what makes PharmaStar your PBM on your time. Nobody likes talking to a machine and PharmaStar believes that you shouldn’t have to. At PharmaStar, a friendly pharmacy technician will answer the phone whenever you call. When your members need questions answered, their pharmacist can call us anytime. Our staff is empowered to resolve issues quickly, resulting in less waiting and better service for you and your members.

QuADruS

Erling HansenChairmanEmail: [email protected] 9th Street, SWWashington, DC 20024Direct: (202) 554-5716www.quadrusonline.com

PharmaStar



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skill. Sellers Dorsey is at the nexus of policy, politics and business in the transformation of healthcare. Our innovative strategies enable us to realize breakthrough results, assuring the mutual benefit and interest of both public and private sector clients. We understand that fundamental change requires commitment from state and federal governments as well as private business to achieve tangible, progressive results. Sellers Dorsey partners with states, counties, municipalities, healthcare providers, advocacy organizations and other industry stakeholders.

SIGnATurE GEnoMICS

Jacqueline ThreadgillManaged Care DirectorEmail: [email protected] Morrison RoadPrinceton, NJ 08540Direct: (609) 945-1651www.signaturegenomics.com

Signature Genomic Laboratories is dedicated to the clinical use of genomic information and pioneering new, revolutionary diagnostic tools to improve human health and well-being. Signature Genomic Laboratories, LLC was established as a partnership between Signature Genomic Services, Pathology Associates Medical Laboratories and Sacred Heart Medical Center. Founded in 2003, Signature Genomic Laboratories was the first laboratory to provide microarray-based diagnostic testing of individuals with mental retardation and birth defects with its proprietary SignatureChip®. Signature Genomics now has 117 employees and has processed over 36,000 cases since its inception.

TAX & fInAnCIAL GrouP

James E. TownesFinancial PlannerEmail: [email protected] MacArthur Blvd., Suite 300Newport Beach, CA 92660Direct: (949) 223-8283Toll-free: (800) 373-2177 www.tfgroup.com

Established in 1970, Tax and Financial Group (TFG) is a leading financial services firm headquartered in Newport Beach, California with offices in Orange and San Diego Counties, Honolulu and Seattle. TFG is comprised of over 120 individuals dedicated to assisting a successful clientele with the creation, management and preservation of wealth. It brings expertise in: exit strategies; employee stock ownership plans; business transfers; employee retention programs; executive compensation strategies; strategic estate planning; and employee benefits. TFG retains multiple experts in several areas of specialty. Each has maintained a vigorous continuing education program to keep current on financial products, tax laws, advanced strategies and legislation that can impact our clients.

TMG HEALTHJohn MontagueDirector of Business DevelopmentEmail: [email protected] South Warner Road, Suite 400King of Prussia, PA 19406Direct: (610) 878-9111www.tmghealth.com

TMG Health is the leading Business Process Outsourcing provider to the Medicare, Medicaid and Group Retiree health plan markets. Learn about TMG Health at www.tmghealth.com.

uS PrEVEnTIVE

Virginia Lee, RN, BSHSMVice President, Product DevelopmentEmail: [email protected] Gran Bay ParkwayJacksonville, FL 32258Office: (904) 281-0006 x1237www.uspreventivemedicine.com

The idea for U.S. Preventive Medicine® originated more than 50 years ago, with the death of Chris Fey’s father. Chris Fey is the founder and CEO of U.S. Preventive Medicine, Inc. His father passed away three days after his first birthday from colon cancer. Something else happened. His brother-in-law had a massive stroke at the age of 39. He survived the stroke, but he’ll never be the same. At U.S. Preventive Medicine, we are trying to prevent these types of devastating events from happening to people. We also are working to stop another form of devastation occurring in our country… financial devastation. At U.S. Preventive Medicine we do one thing…and we do it very well. Prevention. U.S. Preventive Medicine has developed a suite of prevention, early detection and chronic condition management products and services that improve health outcomes while reducing health care costs.

VITAS HEALTHCArE CorP

Brian Thomas ConnorVice President, National AccountsEmail: [email protected] South Biscayne BoulevardMiami, FL 33131Direct: (305) 350-4349www.vitas.com

VITAS Innovative Hospice Care®, a pioneer and leader in the hospice movement since 1978, is the nation’s largest provider of end-of-life care. Our name is derived from the Latin word for “lives” and symbolizes the VITAS mission: to preserve the quality of life for those who have a limited time to live. ensuing value proposition of a $27B annual cost savings to the US Healthcare system. Headquartered in Miami, Florida, VITAS operates 46 hospice programs in 15 states and the District of Columbia.VITAS has enjoyed dynamic growth since its founding as a volunteer organization by a United Methodist minister and an oncology nurse. Today, VITAS employs 9,000 professionals who care for terminally ill patients daily—primarily in the patients’ homes, but also in the company’s inpatient hospice units as well as in hospitals, nursing homes and assisted living communities/residential care facilities. VITAS team members include registered nurses, licensed practical nurses, home health aides, physicians, social workers, chaplains and other caregiving professionals.



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InDEX

MDwise, Inc. – � SubmissionsEmergency room Initiative........................................................................................................................ 22HEALTHYwomen.......................................................................................................................................... 29HEDIS Provider Poster.................................................................................................................................30 “Move It”, In-School Program fighting Childhood obesity.......................................................... 36

Midwest Health Plan – � SubmissionsAt the Heart of the Community’s Health............................................................................................. 10Caring for Culture – Caring for Women............................................................................................... 14Promoting Electronic Prescribing............................................................................................................ 40

Molina Healthcare of Missouri – 1 Submissionobstetrical Case Management Program............................................................................................... 37

Passport Health Plan – 6 SubmissionsAsthma Disease Management Program................................................................................................. 8Diabetes Disease Management Program............................................................................................... 19Early Periodic Screening Diagnosis and Treatment (EPSDT) Program..................................... 21Er utilization Program.............................................................................................................................. 24Glorious Women Assembly...................................................................................................................... 26YES, You Can! Smoking Cessation Program....................................................................................... 47

Select Health of South Carolina, Inc. – � SubmissionsAutomated Primary Care Provider (PCP) Assignments.................................................................. 11Medicaid Recertification Outreach......................................................................................................... 34Mitchell Math and Science Elementary School – PE�Life.............................................................. 35

WellPoint – 2 SubmissionsBody Mass Index Training and Promotion Program (Childhood obesity).............................. 13State Sponsored Business Telemedicine-Increasing Patients’ Access to Care..........................44

Index

The 2009 Best Practices (listed alphabetically by health plan)

AmeriHealth Mercy family of Companies – � SubmissionsAsthma Medication Promotion Program............................................................................................... 09Health Literacy and Plain Language resource Guide....................................................................... 28Improving Health through Integration and Alignment of Gaps in Care Data......................... 31Primary Care Provider Incentive Program............................................................................................ 39

Centene – � SubmissionsCaring Voices, Pre-Programmed Cell Phones...................................................................................... 15ConnECTIonS Plus™............................................................................................................................... 17Start Smart for Your Baby ® 1�P Program impact on reducing premature birth..................... 42Start Smart for Your Baby ® Notification of Pregnancy Process................................................... 43Texas Health Passport and Its Impact on Psychotropic Medication utilization in Texas foster Children.......................................................................................................................... 45

Health Partners of Philadelphia, Inc. – � Submissions(DEAL) Diabetic Eyes for Active Living............................................................................................... 18Er Initiative.................................................................................................................................................... 23“Smiling Stork” Prenatal Dental Program........................................................................................... 41

Horizon nJ Health – 6 SubmissionsBeta-Blocker Initiation and Persistence Program for Members with recent Myocardial Infarction................................................................................................................................................... 12Dilated retinal Eye outreach Program................................................................................................. 20Lipid Management Improvement through Drug utilization review (Dur)......................... 32Lower Mode Transportation Services.................................................................................................... 33Primary Care Physician Involvement in the Improvement of Dental Visit rates.................. 38Using Technology to Create Care Management Efficiencies......................................................... 46

Keystone Mercy Health Plan – � SubmissionsCommunity Baby Shower............................................................................................................................ 16“Gift for Life Program” Community Health Intervention Program............................................. 25Healthy Hoops®: using Basketball to Help Children Better Manage Their Asthma............. 27Improving Health through Integration and Alignment of Gaps in Care Data ........................ 31

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1140 Connecticut Avenue, NW, Suite 505

Washington, DC 20036(202) 857-5720; fax (202) 857-5731

[email protected]; www.mhpa.org

M MedicaidHealthPlans ofAmerica

Ensuring Access to Better Health Care

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