Sunday, June 27, 2010

Medicaid Patients to Surge

Speaking at the National Press Club on June 21st, Dr. Edward Miller, CEO of Johns Hopkins Medicine, and Dean of the Johns Hopkins University School of Medicine, explained how the Johns Hopkins integrated health system is able to run a very large Medicaid managed care organization called Priority Partners.

Priority Partners responsible for 175,000 lives has enrolled approximately 25 percent of Maryland’s Medicaid beneficiaries. According to Dr. Miller, Hopkins is very familiar with the numbers 32 and16 in the new healthcare reform legislation. Thirty two million is the number of individuals that gained healthcare insurance by 2019, and 16 million is the number of individuals who will gain insurance through Medicaid eligibility.

To help address the challenge, Hopkins developed a population health model to examine coverage by examining cost data in order to identify how to achieve quality health outcomes. Priority Partners population health strategy takes into account factors such as age, gender, frailty, medication patterns, lab results, claims histories, clinical events, secondary medical condition, and hospital dominant conditions.

The first step is to give each person in the program a risk score every month to determine who needs what kind of help. The focus is on self-management, behavior modification, and when necessary, intervention. A team approach is used with caregivers, family members, social workers, nurses, nurse practitioners, and a primary care physician acts as the quarterback.

Hopkins has found that an informed motivated patient with an action plan backed up by a proactive medical team, backstopped by electronic health records and transitional care, is going to have improved, higher quality health outcomes.

The second step is to stratify the population from low scores to high in the form of a pyramid. At the base of the pyramid are low severity patients approximately 70 to 80 percent of the population. In the middle of the pyramid, are the more challenging patients approximately 15 to 20 percent of the population where specific interventions are provided including technology, assisted home monitoring, health coaching, and care coordination.

However, at the top of the pyramid, there are approximately 5 to 7 percent of the patients with very serious multiple chronic conditions which results in the most costly patients. For these patients, the program provides individual case management plans, registered nurses, telemonitoring, and visits by R.N case managers.

As Dr. Miller pointed out, there are two Medicaid programs considered the most difficult and costly areas that have had good results. The first program involves End Stage Renal Disease (ESRD) often caused by diabetes and high blood pressure and all too common in the Medicaid population.

Generally, the Medicaid population has overall poor compliance, lower literacy rates, and many co-morbid conditions. By using data compilation, intervention, and care coordination, costs have been reduced in ESRD patients by 47 percent.

The second program has Hopkins providing prenatal and high risk infant care. It has been found that babies born with low birth weights account for half of the spending on births every year. In Maryland, four out of ten babies are paid for by Medicaid. Since there women are of low social economic status they have a strong potential for very low birth weight outcomes so the result is that a large percentage of Medicaid dollars are spent on the neonatal care units.

To address this issue, Hopkins has started a program called “Partners with Mom” and the first step is to identify expectant mothers within the Priority Partners program. Information is gathered on their risk factors, maternal age, substance abuse, smoking, poor nutrition, low levels of education, and chronic conditions. Follow-up is provided and care management plans with goals are developed and in addition, monitoring the expectant mother is done if needed. Today, Hopkins has a NICU admission rate lower than the state’s Medicaid population as a whole and lower than the national Medicaid population.

As Dr. Harris summarized, the fact remains that Medicaid patients require cost management strategies to be used and quality health outcomes for Medicaid patients will only result in the context of a population health patient-centered care model.