Fred Buckwold, MD, FACP

• Former Chief Medical Officer of Community Health Choice, the Medicaid health plan of the Harris County Hospital District (now doing business as Harris Health System).

• Previous medical director experience in Medicaid, Commercial and Medicare managed care with UniCare (division of Anthem), United Health Group, Cigna and FHP

• Board certified in Internal Medicine, Infectious Diseases, and also Quality Assurance and Utilization Review

• Practice experience in Texas: San Antonio, 1979 - 1988

Medicaid Eligibility in Texas (specific to NFP)

• Federal Poverty Level (FPL) is currently $12,490 for one person household

• Add $4,420 for each additional person in the household

• For pregnant women and children under age 1 is 198% of FPL (so, for a one person household is $24,730)

• For children age 1-6 is 144% of FPL (so, if a two person household is $24,350)

• Note that pregnant women lose Medicaid eligibility 60 days post partum

• Can then go into the Healthy Texas Women program

Healthy Texas Women Program

• Healthy Texas Women program, launched in 2016 is a combination of previous Texas Women’s Health Program and the Expanded Primary Health Care for Women.

• Women can receive benefits if they are:• 18 to 44 years old (ages of 15 to 17 years old with parental

consent)• A U.S. citizen or legal immigrant• Uninsured• Not pregnant• Income at or less than 200% FPL

• $33,820 for 2 person household• $42,660 for 3 person household

Funded exclusively with General Revenue. Medicaid funds are no longer utilized in order to exclude Planned Parenthood

Texas CHIP Perinatal Program

• Provides prenatal & postpartum care to pregnant women ineligible for Medicaid primarily due to immigration status (income below 200% FPL)

• Upon delivery, CHIP Perinatal newborns move to Medicaid or CHIP based on FPL.

• Members receiving CHIP Perinatal benefits are exempt from 90-day waiting period & cost-sharing

• Perinatal benefits are limited to professional and outpatient services: • Prenatal & postpartum visits

• Delivery

• Prenatal vitamins and limited pregnancy related services

Managed Care

• Managed Care Organizations (MCO) are types of health care delivery systems organized to manage cost, utilization, and quality

• There are several types of MCO, most commonly Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO)

• Point of service plans (POS) are a combination of those two

What is Texas Medicaid/CHIP Managed Care?

• Health care provided through an HMO with a network of doctors, hospitals, and other health care providers responsible for managing and delivering quality, cost-effective care while ensuring appropriate utilization, containing costs, and reducing fraud and abuse.

• The State pays each MCO a flat monthly capitation rate for each client enrolled (“per member per month” or “pmpm”), rather than paying for each unit of service provided

• MCOs contract with providers (physicians, hospitals, laboratories, imaging facilities, ancillary providers, etcetera) to provide care to their members

Texas Medicaid Delivery Models

Managed Care Programs in Texas

• STAR – provides primary and acute care services to children, pregnant women, and extremely low

income parents with dependent children

• STAR+PLUS – provides acute and long-term services and supports to individuals with disabilities and

elderly people

• STAR Health – provides a comprehensive and integrated health services for children in foster care

• STAR Kids – provides acute and long-term services and supports for children with disabilities

• Dual Eligible Integrated Care Demo – provides and coordinates care for individuals enrolled in both

Medicare and Medicaid under one MCO

Fee-for-Service (FFS)/ Traditional Medicaid

• A few eligibility categories remain in FFS (e.g. certain long-term services and supports programs)

• Individuals in FFS can choose any Medicaid provider

• FFS does not offer the management or utilization controls that managed care provides

Texas MCO Map

Managed Care Model Cost Savings

Managing Care

• All STAR MCOs have a high risk OB “disease management” program

• MCO medical directors have heard presentations about NFP but most are not significant referral sources

• Lots of other things are presented at those meetings, so the NFP message doesn’t always sink in

• Many think they are already on top of their high risk moms but don’t realize the overall benefit of NFP

• Some may have issues if the local NFP is aligned with a specific MCO (i.e. fear of losing members to a competitor)

• Educating the MCO nurses may be more effective than the medical directors

Managing Care

• Managing care is centered on ensuring quality by following evidence-based guidelines, pushing preventive care and, often most critical, coordinating care

• For some individuals this is not always cheaper than non-managed care, but this usually reduces overall costs while improving overall quality

• Managed care medical directors do not intend to deny needed care – they’re aim is to improve quality care and overall population health in support of the national Health Care Triple Aim

The Health Care Triple Aim

• It used to be thought that cost, quality, and access created an “iron triangle” where increasing quality meant increasing cost or decreasing access was necessary to decrease cost. But that is not true - in most cases, improved quality and access reduces cost.

• Our goal should be to improve health outcomes for individuals and populations while improving their experience of care and, at the same time, reducing per-capita costs.

•This can be achieved by all stakeholders (doctors, hospitals, health plans, patients, employers, and policy makers) working collaboratively.

Working with the MCO

• All your clients should be on Medicaid (or CHIP P) and be in one of the MCOs

• If the client has any high risk issues (e.g. elevated BP) you should ensure coordination with the attending physician AND the MCO. May need the client to make the call or obtain written consent to talk to the MCO (they may need to see this) to assist in care coordination and possibly enroll in their high risk OB management program

• If the MCO won’t talk to you, please send info on to supervisor for escalation so that the MCO can be educated