Ms. Bz Giese, BSN, RNDirector, Office of Health Initiatives

South Carolina’s 17th Annual Rural Health ConferenceSouth Carolina Department of Health and

Human Services

Health Access at the Right Time(HeART)

Eligibility Current enrollment as of August 31, 2013: • Children 18 and under: 591,105

• Adults age 19-64: 326,901

• Adults 65+: 77,277• _____________________

Total: 995,283

South Carolina Medicaid expenditures have grown 38.21% from FY2007 to FY2014. This is a 4.8% annual growth.

SFY 2014 spending would be $1.2 billion (64%) higher without agency actions to control costs and improve outcomes since 2011. This would have been a 7.3% annual growth.

SC Medicaid Total Expenditures

SC Medicaid: Expenditures by Eligibility Category

Current Budget to Year to DateExample’s only – not inclusive of entire budget

As of July 31, 2013 * Example s only – not inclusive of entire budget

As of July 1, 2013

FY2014 Appropriation

FY2014 YTD Remaining %

Expanded

Coordinated Care $2,156,884,310 $137,699,779 $2,019,184,531 6%

Hospital Services 717,588,840 64,414,127 653,174,713 9%

Disproportionate Share 480,128,621 128,782,115 351,346,506 27%

Pharmaceutical Services 207,504,803 13,277,063 194,227,740 6%

Physician Services 215,045,913 11,622,396 203,423,517 5%

Lab and X-Ray 27,606,007 1,839,702 25,766,305 7%

DDSN 562,521,328 59,053,528 503,467,800 10%

DMH 154,400,000 7,205,535 147,194,465 5%

TOTAL SCDHHS Budget 6,482,544,497 549,137,587 5,933,406,910 8%

• To identify alternative methods and providers for health care delivery access at the right time and the right place

• Components of HeART include:F Retail ClinicsF Hybrid ClinicsF TelemedicineF After Hours CodesF School Based Health Clinic Sustainability ModelF Community Health Workers (CHW)

HeART Initiative

• CCCs provide episodic care for all Medicaid recipients 18 months and older

• Coverage of EPSTD well-visits are not included for children under the age of 5

• SCDHHS monitoring claims; earache and sore throat Goals: • To reduce health care costs by avoiding unnecessary

emergency room visits

• To provide a service site with extended hours for patients when primary care physician offices are closed

• To assist in supporting efforts in chronic disease management

Convenient Care Clinics

• All 28 CVS MinuteClinic locations in SC & 89 CVS MinuteClinic Nurse Practitioners are enrolled as Medicaid providers with 5 additional sites being established this year

• All MCOs have contracted with CVS MinuteClinic (BlueChoice, Absolute Total Care, Select Health and United/WellCare)

• SCDHHS/IFS is routinely monitoring claims data to assess the impact of services on health outcomes

• Walgreens Take Care clinics expect to enter the SC market in 2014

Convenient Care Clinics, cont.

• Model will give Free clinics opportunities to:- Maintain volunteer staff and utilize paid providers- Provide quality medical care to patients with low income (uninsured and Medicaid beneficiaries)- Charge fees on a sliding scale allowing free care to very low income patients

• SCDHHS visited /interviewed 34 out of 37 Executive Directors statewide

• Currently 5 free clinics are interested in transitioning into a hybrid model

Hybrid Clinics

• Effective on April 1, 2013, Primary Care providers were able to start billing for 2 after office hour codes, to help reduce the need for Medicaid beneficiaries to seek services in the emergency room

• Reimburses additional $12 per visit

• Authorized Primary Care providers are Pediatricians, Family Practice, General Practice, Internal Medicine, and Obstetrics and Gynecology

After Hours Codes

After Hours CPT codes include:

• 99050 – Service(s) provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (i.e., holidays, Saturday or Sunday), in addition to basic service

• 99051 - Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

After Hours Codes, cont.

• Address provider shortage areas

• Connects urban specialty care with rural patients

• May increase cost efficiency

• Lessens transportation concerns

• Strengthens communication among providers

Examples of Services Include:• Consultation – Inpatient & Outpatient• Pharmacologic Management• Neurobehavioral Status Exam• E&M Office Visits

Telemedicine

Proviso 33.34 Section E(2) and Telemedicine

“The department shall develop a program to leverage the use of teaching hospitals to provide

rural physician coverage, expand the useof Telemedicine, and ensure targeted placement

and support of OB/GYN services in at least four (4) counties with a demonstrated lack

of adequate OB/GYN resources by July 1, 2014.”

• Selected four target counties based on IFS Data: Bamberg, Barnwell, Allendale and Hampton

• Working with MUSC and USC to incorporate specialty MFM care for patients that are identified as high-risk through use of Telemedicine equipment

• Will utilize Telemedicine to greatly enhance the OB/GYN services available in these rural and underserved counties

Proviso 33.34 Section E(2) and Telemedicine

Goals

1. Create a sustainable model for Charleston Promise Neighborhood’s (CPN) school based clinics; lessens need for grant money

2. Utilize this model as a foundation to support SBHC’s in other schools, and helps provide another access point for medical care

• CPN Participating schools have an on-site health clinic staffed by a Nurse Practitioner :

- James Simons Elementary School - Chicora School of Communications - Mary Ford Elementary School - Sanders-Clyde Creative Arts School

(middle)

School Based Health Center Sustainability Model: CPN as Case Study

In addition SCDHHS will:

• Help facilitate using a shared eligibility worker for the CPN school district

• Partner to host health fairs that will include Medicaid enrollment and parents/community engagement in fall of 2013

• Model supports PCMH concept by ensuring the student’s PCP receives school/NP report of each visit

School Based Health Center Sustainability Model: CPN as Case Study, cont.

SCDHHS Community Health Workers

CHW Goals1. Improve patient care and health outcomes through compliance in health

screenings, maintaining office appointments, adherence to medication therapy and management of chronic diseases

2. Certification through core curriculum training program helps provide culturally and linguistically appropriate support, guidance,

encouragement and compliance with follow up care

Accomplishments• Phase I: 18 certified CHWs placed in 14 primary care practice sites (including two

FQHCs) across the state

• CPT codes for CHW services billed by MD or NPS9445 Individual CodeS9446 Group Code

• Phase II: Introduce different care delivery models as participants in the CHW program

CHW Goals1. Improve patient care and health outcomes through compliance in health

screenings, maintaining office appointments, adherence to medication therapy and management of chronic diseases

2. Certification through core curriculum training program helps provide culturally and linguistically appropriate support, guidance,

encouragement and compliance with follow up care

Thank you!