Where did summer go? It’s back to school time once again. The “Back to School” season has almost become a holiday. There are so many rituals associated with back to school:

Buying new school supplies like pencils, notepads, crayons, calendars, folders…maybe a new backpack?

Examining the clothing situation–new shirts, pants, socks…perhaps replacing those shoes that were outgrown during the summer?

Checking your schedule twice to make sure you’re ready to adapt to a new normal for the next nine months!?!?!?

How about getting that doctor’s appointment for an annual check-up?
Unfortunately, this ritual doesn’t always seem to make the list, which is why we partnered with our state-level association, Ohio Association of Health Plans, to launch a statewide campaign called “Get Your Well On.”

The goals of the “Get Your Well On” campaign are simply stated:

• Promote the importance of having a consistent relationship with your primary doctor
• Encourage responsible health care engagement and healthy living

Simply stated…but profoundly inspiring. Frankly, it’s our responsibility as Medicaid Care Coordination plans to forever promote the benefits of good health to our members. But this partnership with our industry in Ohio has been an inspirational experience.

Our organization – OAHP – has partnered with associations and communities across the state to bring this message to the urban, suburban and rural. Organizations like the Ohio PTA, Ohio Benefit Bank, Ohio Association of Second Harvest Food Banks, Ohio Child Care Resource & Referral Association, Ohio Council of Churches, Special Olympics Ohio, Family Children First Councils, Ohio After School Network, and many, many more have been instrumental in championing our cause.

We are meeting at a true grassroots level with people that are touching the lives of hundreds of thousands of Ohioans. And they are so appreciative of the materials we are giving to them:

We’ve been organizing events in Columbus, Cleveland, Dayton, Toledo, Akron and more…inviting the passionate agencies at the community level to hear our message. We’ve partnered with large conferences to voice our point of view to hundreds at a time.

The basic comment we get most often as we engage with communities—

“This information can never be promoted enough. Thank you for giving me the tools to help promote this to the people I work with.”

Medicaid Care Coordination plans are forever promoting healthy living and prevention to our members. It’s the philosophy of this type of health care delivery. Our “Get Your Well On” campaign is casting a larger net across Ohio, touching lives beyond the underserved.

So maybe a new back-to-school ritual for all of us should be a reflection on our health in general…and then the drive to take action. Our Governor made it official this week with his proclamation. Now we all have a friendly reminder to “Get Our Well On.”

Earlier this summer, our company hosted a retreat which included two national speakers– Dr. David M. Cutler and Thomas Dehner, JD. We invited these leading health care experts to meet with us because of their insights into health care reform, and the transformation that is currently taking place in this industry.

A little background on Dr. Cutler – he is a Harvard professor, and he served on the economic council during the Clinton years. More recently, he was senior health care advisor to President Obama. And, he is intimately involved in strategies around financing health care in our country. So his points of view were particularly eye-opening.

As the Massachusetts Medicaid director, Thomas Dehner led efforts related to the Medicaid components of the Massachusetts Health Care Reform Law. Now a principal with Health Management Associates, Inc., his viewpoints on lessons learned and future implications were also very enlightening.

There was a point in the presentation where Dr. Cutler gauged the difficulty for the health care industry to convert. He proclaimed the following:

• Insurance reform is easy
• Coverage expansion is more difficult (he called it Medium)
• Improving the value of care is the most difficult (or Hard)

It was an interesting assessment, and it sparked a lot of conversation.

Insurance Reform is Easy

First off, none of what needs to happen within the health care system is easy to change. But what makes insurance reform “easier” than transforming other aspects of the health care system is because insurance reform relies heavily on policy and laws. The introduction of federal policy allowing parents to keep their children on their health plan until age 26 is a perfect example of how policy can quickly affect immediate change.

Coverage Expansion is Medium

Expanding health coverage to more Americans is certainly a more difficult goal to achieve. Two reasons expansion is harder:

1. The exchange could create a mass rush to the health care “storefront”. People who have not had access to health care will now be eligible, and that may empower a lot of people to act. How will our system react?
2. At the same time, it’s also difficult to get people to enroll. Dehner said this is “a close-to-impossible job” despite the federal dollars set aside for outreach. Communication and promotion will be the key to educating the public about the availability to get coverage. But even with substantial outreach, there will be plenty of people that are eligible for public health care programs and subsidies, but just won’t know it or don’t recognize ongoing health coverage as a priority. So finding these people and getting them into the system presents a challenge.

Improving the Value of Care is Hard

This is by far the most difficult area to transform—but not impossible. All players within the health care arena are being pressured to find ways to reduce cost while increasing quality…and that can sometimes appear to be an oxymoron. But we are already seeing solutions that will help move this goal along:

• Technology
  The more we integrate technology into the health care system – and that includes technology that provides information, not just devices – the better coordinated the system will be, and the better doctors will be at providing the right kind of care at the right time and place.
  
  
• Case Management/Coordination
  What case management and health care coordination does is put prevention and wellness at the center of caring for patients. By integrating case managers more into the system, patients, providers and insurance companies can be held more accountable, helping increase quality of care. Also, case management ensures that patients are using the health care system responsibly, and that lowers cost.
  
  
• Streamlining Administrative Duties
  It’s estimated that highly trained registered nurses spend one-third of their time charting patient status and there are more administrative personnel on staff than nurses. That’s a lot of resources being devoted to what could be considered “lost productivity.” The industry needs to continue pursuing automation and streamlining this aspect of the business-side of health care.
  
  

Hard, Harder, Hardest – But Worth the Pursuit

There are many challenges ahead for this industry. But so much progress has already been made in a very short time. As long as the players within the health care industry continue to collaborate, we will reach our goal. And once we’ve reached our destination as an industry, we’ll look back and understand that the pursuit was worth it. Because we’ll all eventually benefit from the transformation of health care.

What do you think are the hardest aspects of health care reform to further implement?

A significant part of our role as a health care facilitator is to help health care professionals better care for their Medicaid patients by providing information, tools and outreach. But historically, delivering a comprehensive health record of a Medicaid patient to a provider has been difficult. Yet providers need information to offer a proactive approach to managing chronic conditions and overall preventive health care for this population.

It’s quite common in the commercial insurance world for providers to be able to access patient health information through the insurance company. This is typically done through a secure, online tool that nearly all commercial insurance companies have developed on behalf of their provider networks. Why it’s a harder proposition for Medicaid plans to aggregate that kind of data s is because Medicaid patients use the health care system sporadically and inconsistently. This is mainly due to trying to deal with the intense social and economic challenges they face on a daily basis.

A Revolutionary New Tool for Providers

At CareSource, we’ve recently introduced a revolutionary new online tool for our providers. We call it the CareSource Clinical Practice Registry. We’ve created comprehensive reporting of all our Medicaid members.

What is the CareSource Clinical Practice Registry?

The primary benefit of the CareSource Clinical Practice Registry is population management. Providers can quickly and easily sort their CareSource membership into actionable groupings. It is a proactive approach to patient care and helps place emphasis on the need for preventive care.

For example, a Primary Care Provider (PCP) can sort the list to identify all of those with chronic conditions like diabetes. From the list of diabetics in the practice, the provider can identify those who need to come in for a visit, and proactively call to schedule an appointment. The report is color coded, so the provider can identify areas of focus. It can also be downloaded as a PDF or in an Excel spreadsheet format.

We are proud of this new online tool, and will be working closely with providers over the next several months to ensure that this resource becomes a cornerstone to health management of his or her Medicaid patients. It’s one of the first of its kind in the Medicaid arena, but it’s also an essential tool for helping keep Medicaid patients healthy.

On behalf of the 844,000 Medicaid consumers we serve, we thank you, Congress, for extending $16 billion in enhanced Medicaid funding to assist states who are experiencing the worst budget shortfalls in history. Our government did what’s right and necessary for people who are desperate for help today.

Nearly 3.3 million more people were enrolled in Medicaid in June 2009 when compared to June 2008 (based on Kaiser Commission on Medicaid) and states are financially strapped – three-fifths of them have expressed a critical need for assistance with its Medicaid programs. Plus, many families continue to feel the burden of the Great Recession as demonstrated by the U.S. unemployment rate of 9.7% (June 2010). It is our obligation as a country that believes in providing opportunity for all to take care of those that need help. And that’s what Congress did this week by a vote of 247 to 161.

Again, thank you, Congress for leading our nation out of the Great Recession.

In this tumultuous and uncertain political year, some things are very clear. State budgets are facing serious deficits. For millions of Americans, the Great Recession is not over. We see it firsthand here at CareSource. In fact, as the nation’s second largest Medicaid health plan, we know there are 844,000 CareSource members who are faced with the realities of the economic downturn each day. Subsequently, this has increased the demand for Medicaid and other important services families need to survive. Simply put, Washington must do more to address the devastating impact of these tough economic times.

Every day, we see the consequences of high unemployment in our states. With more people out of work, more families are relying on Medicaid to provide essential medical care. Any delays may force families who are already struggling to maintain basic necessities to forgo the health care coverage they fundamentally deserve and more importantly – the coverage they desperately need.

Yet efforts in Congress to approve a six-month extension of higher federal Medicaid assistance to the states are being blocked. Instead of voting as if the economy is strong, Congress should take the pressure off states by passing this temporary extension now. Otherwise we could see drastic cuts in health care for the most vulnerable, education, and other critical services. These cuts will only delay the day that we will see the economy actually recover.

Sincerely,

Janet Grant
External Affairs
CareSource

Dear President Obama,

Thank you…thank you for the release of the Patient’s Bill of Rights. This public proclamation that describes how patients will be protected by the rising costs and complexities of the health care system is exactly what this country needs. It is fundamentally consistent with the philosophies of our nation. The Patient’s Bill of Rights builds a foundation that allows opportunities to exist, opportunities open to all, and most notably our country’s underserved population.

Underserved people continue to suffer in our country. And one of the most profound challenges to this demographic is having the forum to voice opinion. Underserved communities struggle to be heard…struggle to tell their stories…struggle to instill empathy in those most able to be helpful.

The Patient’s Bill of Rights gives the underserved a voice. It protects them from elements that have been traditionally uncontrollable. It protects our children, it protects those with pre-existing conditions, and it protects women. But most importantly, it protects the integrity of our country and the goodwill we extend to our citizenship.

So thank you, Mr. President, for embracing our country’s underserved, and moving hope to what is tangible. And we’re happy to answer your request and spread the word about the new Patient Bill of Rights.

The Patient’s Bill of Rights
“Starting in September, some of the worst abuses will be banned forever. No more discriminating against children with pre-existing conditions. No more retroactively dropping somebody’s policy when they get sick if they made an unintentional mistake on an application. No more lifetime limits or restrictive annual limits on coverage. Those days are over.” – PRESIDENT BARACK OBAMA

President Obama announced a Patient’s Bill of Rights made possible under health reform—a basic set of consumer protections.

The Patient’s Bill of Rights:

1. Prevents insurance companies from canceling your policy if you get sick. Right now, insurance companies can retroactively cancel your policy when you become sick if you or your employer made an unintentional mistake on your paperwork.
2. Stops insurance companies from denying coverage to children with pre-existing conditions. Beginning in September, discrimination against children with pre-existing conditions will be banned—a protection that will be extended to all Americans in 2014.
3. Prohibits setting lifetime limits on insurance policies issued or renewed after Sept. 23, 2010. No longer will insurance companies be able to take away coverage at the very moment when patients need it most. More than 100 million Americans have health coverage that imposes lifetime limits on care.
4. Phases out annual dollar limits on coverage over the next three years. Even more aggressive than lifetime limits are annual dollar limits on what an insurance company will pay for your health care. For the people with medical costs that hit these limits, the consequences can be devastating.
5. Allows you to designate any available participating primary care doctor as your provider. You’ll be able to keep the primary care doctor or pediatrician you choose, and see an OB-GYN without referral.
6. Removes insurance company barriers to receiving emergency care and prevents them from charging you more because you’re out of network. You’ll be able to get emergency care at a hospital outside of your plan’s network without facing higher co-pays or deductibles or having to fight to get approval first.

The passing of health care reform means a lot of good things for underserved populations throughout our country – most notably, an increase in both Medicaid eligibility and Medicaid reimbursement rates for primary care providers in the next few years.

But with every up side – our most vulnerable population being taken care of as an upside in this case – there is always a downside. And unfortunately, providers see the increase in Medicaid eligibility as potentially having a downside impact on their businesses. It’s not because doctors don’t want to help those that can’t afford care. Doctors have consistently absorbed the costs of seeing economically-challenged patients, whether the patient is on Medicaid or not. The downside, to put it bluntly, is about reimbursement rates.

The Downside Dissected
Currently, doctors simply do not get reimbursed as much for services rendered to a Medicaid patient. State Medicaid programs, out of fiscal necessity, have negotiated lower rates with providers and hospitals than commercial insurance plans offer because of the scarce resources available to fund public health programs. And as a Medicaid managed care plan, we aren’t in a position to provide the same level of reimbursement to doctors that commercial plans can offer because our revenue is based on the Medicaid fee schedule. We already allocate over 90 percent of our revenue to medical care and keep our administrative costs around five percent and it still only pays providers about 85 percent what Medicare pays.

But that doesn’t mean there aren’t other ways for Medicaid managed care plans to help doctors see the value in dealing with Medicaid patients and plans. Some states embrace Medicaid managed care over fee-for-service because Medicaid plans have the flexibility to create services and programs specifically designed to help doctors better engage with his or her Medicaid patients– something fee-for-service simply can’t accomplish.

At CareSource, we have been working closely with our provider networks in Ohio and Michigan to reduce administrative barriers and bring the added-value services providers need to better engage with our members. And paying over 95% of our clean claims quickly is a key focus because we recognize that providers rely on us to keep their doors open.

But we have introduced other programs too…

Health Care Home – A Pilot Program on the Rise
We are piloting a program called Health Care Home. This program truly bridges the gap between the patient, the practice, and the health plan. We offer a unique set of services to assist the practice, the patient and their family. For example, we assign a case manager to work with each practice, sharing data, clinical information, immediate access to after-hours nurse triage information, and assistance with office resources. We can assist physicians by identifying areas of need and cooperatively enhance practice capabilities. Health Care Home also allows for outcome-based reimbursements beyond negotiated Medicaid reimbursements to incent providers to prioritize Medicaid patients.

Putting Technology to Work
In addition, we have created similar online administrative tools to those that commercial plans offer to their provider networks. This includes online preauthorization forms, online claims submission and tracking. Unlike commercial plans, we initiated the availability of online member profiles. The CareSource Member Profiles give providers a detailed medical history of their CareSource patients – a typically elusive piece of information since Medicaid patients tend to access the health care system in spontaneous and unpredictable ways.

A Resource for Your Patients During Off Hours
We also have in-house 24-hour nurse and triage call centers that have been URAC Accredited for our members. This benefits providers because obviously their offices are not open 24-hours a day. “CareSource 24” – as we call it – provides a resource for members who face medical issues when their primary care provider’s office is closed. The goal is to provide comprehensive and coordinated services, 24 hours a day, 7 days a week. Our focus is to make sure services are available whenever they are needed.

Combating the ‘No Show’ Issue
Because Medicaid plans work with many families who may not have access to reliable transportation, we offer transportation as a covered service. Providers can take more comfort in knowing that their Medicaid patients will have a greater likelihood of showing up for appointments because plans like CareSource offer this benefit in a way that is more accessible to its members than the fee-for-service system. A simple call to our member services line puts them in touch with our transportation vendor. In addition, CareSource case managers provide direct education to members about the importance of keeping their appointments and the impact no-shows have on a doctor’s office. Another way to break down barriers that preclude access and make a provider’s job a little easier.

Growing in the New Era of Health Care
The important point to this article is this – Medicaid will always guarantee providers some form of reimbursement for the medically necessary services they render to eligible members. But plans like ours prioritize the development of resources that help providers in ways that don’t cost them more money and potentially save them administrative costs – online tools, call centers, integrated support services like case management, transportation…these are the services that, when absent, can make serving Medicaid patients more expensive for a provider. But programs like these are at the foundation of our business as we continue to grow in this new era of health care.

Providers reading this article – What would make dealing with Medicaid plans like ours more appealing? What can be done to make the relationship better given the constraints of reimbursement levels?

It’s that time of year again. Census time. Yes, this year we have to take 10 minutes out of our busy schedules and answer 10 easy questions… and we’re done – for 10 years! Simple questions that determine how $400 Billion – yes, that’s BILLION -get distributed to each state.

During the 2000 Census collection, over 70% of Americans sent their surveys back as instructed. But many surveys had to be completed with the help of U.S. Census workers who traveled door to door canvassing the streets to find individuals who just couldn’t find the time to make this a priority. And why shouldn’t they just wait for a knock on the door?

Get this: For each percentage point we can raise the response rate, the feds reportedly will save about $85 million on door-to-door workers. Isn’t that reason enough?

But the population that traditionally struggles to complete their Census forms is the people we serve each day here at CareSource. Why? Because this population tends to be transient – not typically staying at one residence for any prolonged period of time. They also may not have an official address, or they may be homeless, or they live in a communal living situation. Whatever the case, during this census period, it’s extremely important that we get the people in our underserved communities counted.

That’s why CareSource is joining the national effort to reach out to our members to reinforce the importance of completing their census form. Our 820,000+ members qualify for Medicaid coverage and have income below 200 percent of the poverty level. Because the deadline is quickly approaching, we are posting information to our Web site as a reminder for both members and our vast provider network (22,000+ providers, 210 hospitals). We’re also adding a hold message on our customer service line (pending state approval) to encourage our members to “Be Counted” and why it’s so important.

But we didn’t stop there. As a large employer, we have also encouraged our 900 employees to complete their census forms and have reiterated why it’s so important for a publicly funded, not-for-profit company like CareSource to support this national endeavor. Recurring messages will be sent to employees to provide constant reminders prior to the April 15th deadline.

According the NAACP and the federal government, here is why it is so important to get everyone counted – especially families struggling with poverty:

• Federal Funds: For each 100 people not counted, a community risks losing an estimated $1.2 million over the next decade for federally funded programs including: Medicaid, public housing assistance, child health programs, Head Start, transit programs, and more.
• Political Representation: States use census numbers to redraw all political boundaries and determine which states gain or lose representation, including Congressional Districts, state house and senate districts for city councils, school committees and county board.
• Public Infrastructure: All levels of government rely on census numbers to locate vital public works like schools, health centers, public transportation, highways, and affordable housing.
• Private Investment: Businesses large and small use census numbers to identify new markets, select sites for operations, make investment decisions and determine the goods and services offered.

When families do not participate in the census, it means their communities lose access to money, resources and power. On behalf of our country’s underserved communities, please encourage the families and organizations you interact with to complete and return their census form. It’s easier than ever. The 2010 Census form asks 10 questions and takes about 10 minutes to complete. But the key is – IT MUST BE MAILED BACK TO BE COUNTED. Simply mail it back using the postage-paid return envelope by April 15, 2010. Telephone assistance in filling out the form is also available by simply calling 1-866-872-6868.

For those who do not respond, census workers will visit households that do not return forms to take the count in person. But don’t forget – the higher the participation rate, the cheaper the census will cost taxpayers. Just think – if we increase the rate of response from 70 to 80 percent, that’s an estimated $850 million in savings!

It’s easy. It’s important. It’s safe. For more information about the 2010 Census and the “Take 10″ initiative, visit www.2010census.gov.

On behalf of the 15 million Americans who will be eligible for Medicaid as a result of health care reform…we thank you.

On behalf of the children that need health care to support every possible opportunity for a successful and productive life…we thank you.

On behalf of Americans who must choose between buying food and getting health care…we thank you.

On behalf of the senior citizens who are wondering how to maintain their health on a modest budget…we thank you.

Despite the contentious year-long debate, Congress has done what’s right for the American people. Making health care a right – not a privilege – is a fundamental element that has been sorely missing from the ideals of our nation…until now!

Was this the best possible outcome? Probably not.

Does the new legislation fix every problem that ails the current health care system? No, not really.

But it is definitely a start. We elected our leadership to do what is best for the American people given the challenges our country is currently facing. Right now, what is best has arrived in the form of a new and improved health care system that will turn away no one; that will take care of our children; and most importantly, that is in reach to all Americans.

CareSource applauds our Congressional leaders for the following provisions included as part of health reform measures:

• Expansion of Medicaid to everyone (under age 65) below 133% of the Federal Poverty Level by 2014– removing categorical eligibility which currently forces many individuals in poverty to go uninsured.
• Creation of state-based health exchanges through which individuals can purchase coverage, with premium and cost-sharing credits available to individuals and families with incomes between 133 percent and 400 percent of the poverty level, or $14,404 to $43,320 for individuals and $29,326 to $88,200 for a family of four.
• An individual mandate for all to ensure all Americans participate in the insurance risk pool resulting in lower cost coverage options for all. Requires insurers to cover those with pre-existing conditions, removes lifetime limits, prohibits rescission of coverage and mandates prevention services be covered at 100 percent.
• Equalization of treatment of managed care and fee-for-service under the Medicaid drug rebate program.
• Closure of the Medicare prescription drug “doughnut hole” by 2020.
• Reauthorization of the Medicare Advantage Special Needs Plan program.
• Improved coordination for Medicare and Medicaid dual-eligibles.

Each of these provisions propels our country into a new era in health care for which we should embrace and build upon. There are many that vow to fight the passing of this bill, and that’s to be expected. But we should applaud all of our policymakers for remembering why and how this nation was created…to be a land of opportunity, of freedom, and of equality. Thank you, Congress, for doing what’s right for all people.

Ohio’s underserved population got a positive boost this past week from our Federal government and Governor Ted Strickland. The first was Ohio receiving over $700-million in federal assistance for Medicaid. The second is our Governor’s commitment to U.S. Health and Human Services Secretary Kathleen Sebelius’ challenge to get all eligible children enrolled in Medicaid/State Children’s Health Insurance Program (SCHIP) and keep them covered longer. These are tremendous strides that our Federal and State governments have taken to further its commitment to America’s children.

In Ohio, where we have an unemployment rate of 10.8% and a multi-million budget gap, we are seeing more and more people needing the many social services that help keep our Ohio families afloat. Medicaid is one program in particular that has experienced a surge in enrollment. So receiving more federal assistance is extremely helpful in keeping Medicaid enrollees covered and making sure they are accessing the health care system responsibly.

Next, our Governor’s commitment to making sure every child eligible for Medicaid/SCHIP is enrolled is also greatly needed. There are 77,000 children in Ohio that are currently uninsured but actually eligible for Medicaid/SCHIP today. The income limit for children to receive health care through Medicaid/SCHIP is currently capped at 200% of the poverty level (or a little over $44,000 for a family of four). So we stand equally committed to finding these children, and making sure they all get access to primary and preventative health care.

But finding all children eligible to be enrolled with Medicaid/SCHIP is a little trickier than you might think. In addition to concentrated grassroots outreach, we need Ohio’s Medicaid program to implement new strategies that lessen the barriers to entry. Here are three strategies to consider:

• Express Lane Eligibility – Essentially, this will help get children covered when their families opt to receive assistance through other public programs like school lunch or food stamps. States can use the relevant findings from these other public programs to determine their eligibility for Medicaid/SCHIP without requiring the family to resubmit and/or re-verify their personal information.
• 12-month Continuous Coverage – In Ohio, families with children receiving Medicaid/SCHIP need to re-apply every 12 months to maintain their coverage. During this 12 month period, a child can become ineligible for Medicaid/SCHIP for a variety of reasons. Most notably, is not keeping their redetermination appointment for other public assistance programs (e.g., cash assistance or food stamps). This causes children to inappropriately lose their coverage. By guaranteeing 12 months of coverage to children, we ensure our eligible kids don’t lose coverage while ultimately improving overall health outcomes.
• Presumptive Eligibility – Allows trained qualified entities to screen a child or pregnant woman’s eligibility for Medicaid/SCHIP. If presumed eligible, a child or pregnant woman can receive all health services covered under Medicaid until a final determination is made. Presumptive eligibility would allow uninsured children and pregnant women to begin the Medicaid application process, obtain needed medical services while also ensuring the health care provider is reimbursed for services rendered.

It’s clear that needless administrative barriers are simply making health care access harder and harder for underserved populations. These three strategies are common sense approaches that will ensure the nation’s underserved get the coverage they need – when they need it.

Questions for our readers – What do you think of the Federal and state measures described above? Is it a good use of federal dollars to help states with their Medicaid programs? Are these suggestions for CHIP enrollment enough to capture all the children eligible for the program?