State of Vermont AGENCY OF HUMAN SERVICES

OFFICE OF VERMONT HEALTH ACCESS

312 Hurricane Lane Suite 201

Williston, VT 05495

STATE OF VERMONT

REQUEST-FOR-INFORMATION (RFI)

FOR

CARE MANAGEMENT SERVICES

Date of Issuance: May 9, 2006 RFI Meeting Date: May 31, 2006

Response Due Date: June 7, 2006

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I. INTRODUCTION

The State of Vermont, Office of Vermont Health Access, is issuing this RFI to organizations or businesses that specialize in providing care management services. The RFI describes the State’s proposed care management program for beneficiaries enrolled in its publicly funded health benefit programs, including Medicaid and the Vermont Health Access Plan. It solicits information from care management program vendors which will be used by the State in formulating an RFP for Care Management services. The State intends to issue an RFP for Care Management Services in the second half of CY 2006. Responses to this RFI will be used to assist in structuring the RFP, defining the scope of work, evaluating the services offered over the term of the contract, and creating related contractual requirements. The State is particularly interested in not-for profit entities which have expertise in this area, although any entity will be able to bid on the RFP when issued and each proposal will be evaluated solely on its merits. Vermont hopes to solicit a vendor who is willing to partner with the State based on the following principles.

• Transparency: The methods used to evaluate the effectiveness of the program should be transparent and scientifically valid, so that the State or independent evaluators will be able to independently assess the credibility of results.

• Shared Results: The State is interested in working with a vendor that is willing to share strategies, results and experiences with other state Medicaid programs, in order to enhance the state of the art among publicly financed programs.

• Flexibility: The State is looking for a vendor that is flexible in developing and modifying the program based on experience, data from the evaluation of the program, and the changing needs of the State.

• Population Based: The program should be targeted to defined populations and should seek to reduce the expected incidence and prevalence of targeted diseases, adverse events, and the unnecessary costs associated with those preventable events.

Vermont’s interest in implementing a chronic care management program is a result of the new flexibility offered the Vermont Medicaid program through the federal government’s approval of the Global Commitment to Health 1115 waiver, the state’s commitment to the chronic care model, and legislative support for the implementation of a care management system for individuals enrolled in the Medicaid program. This legislative support is evidenced in discussions of health care reform during the current (2006) legislative session, and is included in legislation adopted by both the House and Senate. Specifically, the authorization for a chronic care management program as contained in what is called “Catamount Health,” (H 861). The section addressing the chronic care management program is found in Appendix 1 at the end of this document. The full text can be found at the following web address: http://www.leg.state.vt.us/database/status/summary.cfm The State wishes to use the 1115 waiver flexibility to integrate a chronic care management program into a system of care that can be used to benefit beneficiaries, providers, and OVHA.

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II. CARE MANAGEMENT PROJECT In keeping with OVHA’s mission statement to “collaborate with other health care system entities in bringing evidence-based practices to Vermont Medicaid beneficiaries,” OVHA intends to issue a Care Management RFP during the second half of 2006. The purpose of the RFP will be find a partner with expertise in care management that will work with OVHA to improve the management of health and the use of services provided to beneficiaries with specific diseases or conditions. The contractor selected in response to the RFP will be able to demonstrate how its systems and processes will be integrated with the “Care Coordination” infrastructure that OVHA is establishing (described beginning on page 4), and within the context of efforts to establish a unified, comprehensive and state-wide approach. OVHA expects to perform the population screening and risk stratification functions and will pro-actively identify the intervention population. The Care Management vendor or vendors will work collaboratively with OVHA staff to determine which interventions are hypothesized to be the most successful and will assess the degree to which they are effective. For example, because a diabetes initiative is already under way in the state of Vermont, targeted to all citizens, it is unlikely that condition will be a priority (however co-morbidities associated with these individuals will be of great interest). Beneficiaries with behavioral health and substance abuse diagnoses and other co-morbid conditions are expected to be a priority area for the RFP. Preliminary Scope of Work Components

A. Service Integration and Collaboration

It is anticipated that the RFP will solicit services that will enhance the capacity of the Care Coordination Initiative, which targets the top 1%-2% of beneficiaries in terms of utilization or cost. Thus the Care Management vendor will be expected to collaborate closely with and complement the State’s Care Coordination initiative (see pages 4-7). It is anticipated that the Care Coordination Initiative will target up to 3,000 individuals.

B. Care Management

It is also expected that the RFP will solicit care management services for two groups: A) Intensive Care Management: Top 5-10% of selected Medicaid beneficiaries (approximately 6,000 – 12,000 individuals) in terms of utilization or cost and who have at least one chronic medical condition. B) General Care Management: Top 50% of selected Medicaid beneficiaries (approximately 60,000 individuals) in terms of utilization or cost and who have some indication of at least one chronic medical condition. Proposed program service intensity to be considered will vary by the two groups but will likely include:

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o Coordinating with the internal “Care Coordination” services, as needed. o Patient education: teaching beneficiaries about their disease(s) and/or condition(s)

(both Intensive Care Management and General Care Management). o Utilizing “Health Risk Assessment” instruments to assess a) general health status,

and b) disease specific health status, with detailed data per beneficiary made available to the state.

o Self-management resources, including collaboration with and referral to established resources such as the Healthier Living Workshop sponsored by the Vermont Blueprint for Health (Vermont Department of Health).

o Working with providers, as needed, to facilitate communication for Care Management initiatives as well as outreach for Care Coordination and the Blueprint for Health initiatives.

o In-person and/or telephonic support for program participants, including telephonic patient education and coaching.

o Decision support at the point of care: translating disease management guidelines to patient-specific recommendations for clinicians.

o Application of evidence-based guidelines: providing information to clinicians on recommended clinical management.

C. Measurement

Measurement of results and the overall success of the program will be an integral aspect of the RFP and contract. The vendor will have to agree that measurement of results will be based on a set of indicators determined by the State, with advice from the contractor and independent evaluator. The impact methodology used will not be proprietary and will be transparent, the results will be validated independently by OVHA or a separate contractor and the results and methods may be shared with others to enhance the learning potential of this work.

III. OVHA’S CARE COORDINATION INTIATIVE (Also see Appendix 2) It is expected that the Care Management vendor will collaborate and integrate their work with the OVHA’s Care Coordination Initiative. This initiative is currently under way and is described in this section. The Goal of Care Coordination In furtherance of the program flexibility granted by the Global Commitment, OVHA is committed to partnering with primary care providers, hospitals, Agency of Human Services (AHS) departments and community agencies in Vermont to address the need for enhanced coordination of services in a climate of increasingly complex health care needs and scarce resources. The Care Coordination Initiative will facilitate the patient-provider relationship by offering services that assist primary care practices in tending to the intricate medical and social needs of Medicaid beneficiaries without increasing the administrative burden. Ultimately the program will decrease inappropriate utilization of services.

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Care coordination occurs when a specified plan of care is implemented by a variety of service providers and programs in an organized fashion under the direction of a designated professional. It may involve the following: planning treatment strategies; monitoring outcomes and resource use; coordinating visits with primary care and sub-specialists; organizing care to avoid duplication of diagnostic tests and services; sharing information among health care professionals, other program personnel, and family; facilitating access to services; planning a hospital discharge; and, finally, ongoing reassessment and refinement of the care plan. (Adapted from AAP Policy Statement: “Care Coordination: Integrating Health and Related Systems of Care for Children with Special Health Care Needs.”) Method

The foundation for care coordination is backed in the desire for Vermonters to help other Vermonters. As supported by the Chronic Care Model, care coordination emphasizes evidence-based, planned, integrated and collaborative care for beneficiaries who exhibit high-prevalence chronic disease states, high-expense utilization, high medication utilization, and/or high emergency room (ER) utilization. Program Implementation Beneficiaries who will most benefit from care coordination are selected based upon criteria identified through claims data and in collaboration with their individual primary care provider. The regionally based care coordination team consisting of one Registered Nurse (RN) and one social worker will devise care plans through assessment of current treatments, services, and resources that directly address beneficiaries’ needs. The team will ensure beneficiary compliance with the care plan and will monitor appropriate ER use, hospitalizations, length of stay and discharge planning. As of January 2006, field testing has commenced and one care coordination team is working in Caledonia County (St. Johnsbury area). Beneficiaries have been identified and the care coordinators are collaborating with primary care providers to commence the care plan process. Review of Emergency Room utilization and Discharge planning is in progress, and field testing in Washington County will commence in May 2006. Personnel January ’06 – March ’06 Five staff members are needed for the first phase of the program. A Field Director for OVHA in addition to one nurse and one social worker will be the team working in Caledonia County. One nurse and one social worker will be hired to work in Washington County (Montpelier –Barre area). April ’06 – December ‘06

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Eleven more staff will be hired during this phase: an Associate Medical Director; five nurses; and five social workers. A nurse and a social worker will work at Fletcher Allen Health Care in Burlington; a nurse and social worker will be placed in the St. Albans/Morrisville region; remaining care coordination teams will be placed in counties throughout Vermont as designated.

Current Participating Practices, Agencies and Stakeholders

As of January 2006, the current participating practices, agencies and stakeholders include:

• Central Vermont Community Partnership • Central Vermont Hospital (CVH) • Central Vermont Physician Practice Corp. (CVPPC) • Central Vermont Substance Abuse Services • Community Health Center of Burlington • Corner Medical • Department for Children and Families - field service districts • Department of Disabilities, Aging and Independent Living (DAIL) • Fletcher Allen Medical Center • Northeast Kingdom Human Services (NEKHS) • Northeastern Vermont AHEC • Northeastern Vermont Regional Hospital (NVRH) • Northern Counties Health Care (NCHC) • The Health Center of Plainfield • Vermont Association of Hospitals & Health Systems (VAHHS) • Vermont Department of Health offices in St. Johnsbury, Barre, and Burlington • Washington County Mental Health • Winooski Family Health

The Vermont AHS reorganization recognized the need for coordination of services at the community level. District office co-location of care coordination resources associated with a broad range of programs will allow those resources to be deployed most effectively. The program with the strongest role to play in an individual case will be able to take the lead with the support of other specialized resources. The care coordination teams contribute a critical component to the web of support the Agency of Human Services provides and establishes a unique relationship with the primary care provider, by providing the medical focus not addressed by any other program. Care coordinators will be informed about other statewide quality improvement initiatives, and will be able to assist providers to access their benefits. For example, they may be able to suggest a beneficiary’s appropriateness for the Choices for Care Program sponsored by DAIL if the clinical condition seems to be approaching need for a nursing home level of care. Because of OVHA’s active participation in the Colorectal Cancer Screening Project, care coordinators will be able to assure providers that their complex patients are not missing out on the need for basic, age-appropriate screening. There are also opportunities for collaboration with Department of Corrections and VDH-ADAP through the Incarcerated Women’s Initiative and the Capitated Program for Opiate Dependency. The result is the opportunity to collaborate creatively to address the unique needs of Vermonters in the context of an individual’s care.

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The Care Coordination Initiative will make a significant contribution to achieving the goals of the Vermont Blueprint for Health by addressing the unique characteristics of the Medicaid population and the challenges those with chronic conditions face in participating fully within the Chronic Care Model. Many individuals will need additional support to become the “informed, active patient” the model describes. The care coordination teams (a registered nurse and a social worker) will provide this by facilitating the implementation of the essential components of chronic care management programs as identified by the state. These include team-based care, cross-consortium coordination, patient education, outreach and care management. Because the care coordination teams are local individuals, they will be able to implement these components within the context of the beneficiary’s community, considering what is available and acceptable to the beneficiary and his or her primary care provider. IV. RFI TIMEFRAMES AND MEETING The OVHA is interested in obtaining comments and perspectives from interested entities on the following issues. Responses should be sent by mail or e-mail by Wednesday, June 7, 2006 to: Julie Trottier Office of Vermont Health Access 312 Hurricane Lane, Suite 201 Williston, Vermont 05495 Tel: 802-879-5905 E-mail: JulieT@ahs.state.vt.us Meetings with OVHA Staff In addition, interested individuals or organizations are invited to schedule a brief, informal individual meeting with OVHA staff to share their comments or suggestions in response to this RFI. Meetings can be telephonic or in person and will be held during the day on Wednesday, May 31, 2006 at the above Office of Vermont Health Access address. Please contact Julie Trottier to schedule a time for your meeting.

V. RFI RESPONSES

It would be appreciated if RFI responses address, to the extent possible, the following questions. It is not necessary to respond to all questions if you do not have the information or experience to respond, however the first 4 questions are particularly important. Presentation materials are welcome.

1) Transparency: The methods used to evaluate the effectiveness of the program will

be transparent, so that the State or independent evaluators will be able to assess the

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validity of results. What is your experience in this area? What concerns do you have, if any, for using publicly available, transparent impact methods?

2) Shared Results: The State is interested in working with a vendor or vendors that is

willing to share strategies, methodologies, results and experiences with other state Medicaid programs, in order to enhance the state of the art among publicly financed programs. What is your experience in this area? What concerns do you have, if any?

3) Flexibility: The selected vendor should be flexible in developing and modifying the

program based on experience, data from the evaluation of the program, and the changing needs of the State. What has been your experience in this area? If you do not have such experience, please address your enthusiasm and/or concerns with this approach

4) Population Based: The program should be based on impacting a defined population

or populations, i.e. it should seek to reduce the rate of avoidable medical interventions among those at risk through health improvement or other ethical means. What is your experience in this area?

5) Have you had experience with offering a program in which the state (or contracting company) performed the patient selection process? If so, what issues were raised by that process? Would you stratify patients to receive different levels of intervention, if so, on what criteria would you stratify?

6) Do you have recommendations for the criteria that should be used to identify the at risk

population that will be targeted for intervention? Are you willing to partner with the State in establishing those criteria?

7) What are the criteria you have used (or may use in the future), to allow targeted patients

to “graduate” from a care management program, or to be moved to a less intense intervention level?

8) What are the most successful methods for involving health care professionals in

identifying eligible patients? What is your opinion on the use of the patient registries, an enrollment process which provides incentives and strategies for maximum patient participation, and/or a standard statewide health risk assessment for each individual that would help the state identify at risk individuals?

9) Have you had experience in working in a rural environment, and if so, are there specific

requirements that the State should include in the RFP to ensure that the services are responsive to a rural environment?

10) What time period should be set aside for implementing a chronic care management

program? What amount of time do you believe will be sufficient for health care professionals, the State, and the entity administering the program to identify and enroll

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participants?

11) Do you have experience in collaborating with practicing providers in identifying patients at risk and developing interventions for those patients? What issues should the State be sensitive to in guiding the development of those relationships?

12) If you were one of the finalists in the vendor selection process, would you want to

perform a claims analysis to better understand the characteristics of the patient population?

13) Have you had experience with offering a program that addressed the management of both the primary diagnostic condition and related co-morbid conditions? If so, what issues were raised by those services and what results was the program able to achieve?

14) It is anticipated that the RFP will have an emphasis on care management of beneficiaries with behavioral health (mental health and/or substance abuse) issues. Have you had experience in care management of individuals with these conditions, and managing both the behavioral health problems and the individuals’ co-morbid conditions? If so, what issues were raised by that program, what success has been achieved, and how valid were the methods were used to measure that success?

15) What interventions do you believe are the most successful? What interventions have the

strongest evidence of success for clinical outcomes, for economic outcomes? Please include interventions that address the unique needs of people with multiple diseases or chronic conditions.

16) What has been your experience with “guaranteed savings” contracts with government or

other agencies? What are the strengths and weaknesses of this approach at the initiation of a contract and at the end of a contracting period? What alternatives are there to guaranteed savings contracting, besides simply paying for services performed on a per-member-per-month basis?

17) Have you identified effective processes for coordinating care among health care

professionals? If so, can you briefly describe those processes?

18) Have you had any experience in working with patients who have more than one payer? Can you suggest what might be done to improve consistency in care management services among multiple payers so that care management is similar among payers?

19) What are the most effective methods of increasing communication among health care

professionals and patients? What is your opinion of patient education and patient self-management?

20) What process and outcome measures are available to provide performance feedback for

health care professionals and information on the quality of care, including patient satisfaction and health status outcomes?

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21) Would you recommend that the State develop payment methodologies that create

financial incentives and rewards for health care professionals to improve chronic care management and the quality of care, including case management fees or physician performance incentives? Have you had any experience where this has been done and if so, what were the results?

22) Do you have suggestions on the best ways to integrate the Care Management system with

the Care Coordination infrastructure that OVHA is establishing in order to create a unified, comprehensive and state-wide approach?

23) Can you share with us the educational, wellness, and clinical management protocols and

tools that you use? What mediums have you found to be the most effective in reaching the intended audience?

24) What is your experience with practitioner response to management guideline materials?

Are there some guidelines that are more readily accepted by health care professionals? What techniques would you suggest to increase use of accepted guidelines?

Response Format PLEASE LIMIT THE RESPONSES TO 15 PAGES (1” MARGINS ALL AROUND, 12 POINT ARIEL FONT OR EQUIVALENT, SINGLE SPACED) + APPENDIX. EACH APPENDIX ITEM SHOULD BE REFERENCED IN THE TEXT THAT SHOWS ITS RELEVANCE TO THE TOPIC IN THE TEXT.

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APPENDIX 1

CURRENT LEGISLATIVE LANGUAGE Sec. 6. 33 V.S.A. § 1903a is added to read: § 1903a. CHRONIC CARE MANAGEMENT PROGRAM

(a) The secretary of administration or designee shall create a chronic care management program as provided for in this section, which shall be administered or provided by a private entity for individuals with one or more chronic conditions who are enrolled in Medicaid, the Vermont health access plan (VHAP), or Dr. Dynasaur. The program shall not include individuals who are also eligible for Medicare, who are enrolled in the Choices for Care Medicaid Section 1115 waiver or who are in an institute for mental disease as

defined in 42 C.F.R. § 435.1009. The secretary may also exclude individuals who are eligible for or participating in the Medicaid care coordination program established through the office of Vermont health access.

(b) The secretary shall include a broad range of chronic conditions in the chronic care management program.

(c) The chronic care management program shall be designed to include: (1) a method involving the health care professional in identifying eligible patients,

including the use of the chronic care information system established in section 702 of Title 18, an enrollment process which provides incentives and strategies for maximum patient participation, and a standard statewide health risk assessment for each individual;

(2) the process for coordinating care among health care professionals; (3) the methods of increasing communications among health care professionals and

patients, including patient education, self-management, and follow-up plans; (4) the educational, wellness, and clinical management protocols and tools used by the

care management organization, including management guideline materials for health care professionals to assist in patient-specific recommendations;

(5) process and outcome measures to provide performance feedback for health care professionals and information on the quality of care, including patient satisfaction and health status outcomes;

(6) payment methodologies to align reimbursements and create financial incentives and rewards for health care professionals to establish management systems for chronic conditions, to improve health outcomes, and to improve the quality of care, including case management fees, pay for performance, payment for technical support and data entry associated with patient registries, the cost of staff coordination within a medical practice, and any reduction in a health care professional’s productivity;

(7) payment to the care management organization which would put the care management organization’s fee at risk if the management is not successful in reducing costs to the state;

(8) a requirement that the data on enrollees be shared, to the extent allowable under federal law, with the secretary in order to inform the health care reform initiatives under section 2222a of Title 3;

(9) a method for the care management organization to participate closely in the blueprint for health and other health care reform initiatives; and

(10) participation in the pharmacy best practices and cost-control program under

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subchapter 5 of chapter 19 of this title, including the multi-state purchasing pool and the statewide preferred drug list.

(d) The secretary shall issue a request for proposals for the program established under this section and shall review the request for proposals with the commission on health care reform prior to issuance. The issuance of the request for proposals is conditioned on the approval of the commission in order to ensure that the request meets the intent of this section, section 702 of Title 18, and chapter 19 of this title. Any contract under this section may allow the entity to subcontract some services to other entities if it is cost-effective, efficient, or in the best interest of the individuals enrolled in the program.

(e) The secretary shall ensure that the chronic care management program is modified over time to comply with the Vermont blueprint for health strategic plan and to the extent feasible, collaborate in its initiatives.

Sec. 7. PREVENTION AND CHRONIC CARE MANAGEMENT; AGENCY OF HUMAN SERVICES; IMPLEMENTATION PLAN

(a) No later than January 1, 2007, the agency of human services shall develop an implementation plan for prevention of chronic conditions and for chronic care management which at minimum meets the criteria and requirements of chapter 13 of Title 18 and section 1903a of Title 33. The agency’s implementation plan shall be revised periodically to reflect changes to the Vermont blueprint for health strategic plan. In addition to the chronic care management provided under section 1903a of Title 33, the agency may provide additional care coordination services to appropriate individuals as specified in its strategic plan. The agency shall ensure that Medicaid, Medicaid waiver programs, and Dr. Dynasaur change the payment methodologies in order to align with the recommendation of the strategic plan developed under chapter 13 of Title 18 and the request for proposals under section 1903a of Title 33. The agency shall analyze and include a recommendation as to any waivers or waiver modifications needed to implement a chronic care management program.

(b) Where permitted under federal law, the agency shall require recertification or reapplication for Medicaid, the Vermont health access plan (VHAP), and Dr. Dynasaur no more often than once a year.

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APPENDIX 2

CARE COORDINATION: PRESENTATION MATERIALS

Care Coordination

The Office of Vermont Health

Access

The Vermont Agency of

Human Services

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Overview

I. Characteristics of Vermont Medicaid

II. Components of the Chronic Care Infrastructure

III. Timeline

IV. Expenses & Savings

The Case for Care Coordination

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Poverty is a qualifying criteria.

Approximately 92 % of Vermont Medicaid beneficiaries are low income.

Federal Register, Vol. 70, No. 33, February 18, 2005, pp. 8373-8375.

22,610519,350416,090312,8302$9,570 1

Threshold IncomePersons in Family Unit

2005 HHS Poverty Guidelines

Disability is a qualifying criteria.

The Traditional Medicaid population includes the Aged, Blind, and Disabled (ABD) enrollment/eligibility group.In SFY 2004, there were 23,083 ABD beneficiaries. In SFY 2004, expenditures for ABD beneficiaries totalled$145,321,331.

– Projected expenditures for 2005 = $166,904,824– Projected expenditures for 2006 = $181,780,644

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The burden of chronic illness on low-income Vermonters is higher.

Vermont Medicaid Chronic Illness Expenditures - 2004

CONDITION DOLLARS # OF UNIQUERECIPIENTS

Depression $19,567,505.00 34,362CHF $14,037,434.00 2,971Diabetes $10,648,661.00 6,912Obesity $1,578,489.00 4,482Asthma $576,757.00 1,887TOTAL $ 46,408,846.00 50,614 *

* This number may reflect beneficiaries in multiple diagnostic categories.

The burden of substance abuseis higher.

Over 60% of admissions state-wide for substance abuse treatment were for Medicaid beneficiaries.$3.3 million was spent on substance abuse services for the 787 beneficiaries who received at least one prescription for Buprenorphine.These 787 beneficiaries accumulated an additional $7 million in medical expenses.

* 12 month period: September 1, 2004 – August 31, 2005.

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Josephine*

Josephine is a 35 year-old mother of 2 who is currently separated from her incarcerated husband, and is employed at a low-wage food service job.Josephine has 7 chronic conditions: Morbid obesity, Type II DM, Severe Leg Varicosities, Migraines, Severe Iron-Deficiency Anemia, PTSD, Depression, Severe Anxiety.Josephine is taking 7 different medications: Lexipro, Prevacid, Trazadone, Clonazepam, Phenergan PRN, Ibuprofen PRN, Ferrous GluconateTID.Josephine was seen in the Emergency Room 10 times in 2005.Josephine has 4 providers managing her care: Primary Care Provider, Gastric Bypass Surgeon, Vascular Surgeon, Therapist.

*NOTE: This is not a real person. Information is based upon claims data.

Why Choose Care Coordination?

Care Coordination maximizes health outcomes for complex Medicaid beneficiaries by ensuring access to a coordinated comprehensive treatment program.

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Key Components of a Chronic Care Infrastructure

1. Population Characteristics2. Care Interventions3. Resources 4. IT5. Health outcomes6. Cost Savings7. Medicaid Payment Structure

*CHCS, Environmental Scan: Health Supports for Consumers with Chronic Conditions; November 2005

5%

50%

100%

Percent of Population by Utilization

1%

18

5%

50%

100%

Chronic condition with complications Special populations (Buprenorphine)

Chronic condition without complications

Behavioral or genetic risk factors for disease No known chronic condition

Population CharacteristicsCare Interventions

Resources

IT

Health Outcomes

Cost Savings

Medicaid Payment Structure

1%

Multiple co-morbidities High utilization

High prevalence of psych / substance abuse

1% Intensive Care Coordination Patient Self-Management

5%

50%

100%

Co-management (RFP)

Blueprint Activities

Blueprint Activities

Care Intervention

Patient Self-Management

Patient Self-Management

Disease Management

Population Characteristics

Resources

IT

Health Outcomes

Cost Savings

Medicaid Payment Structure

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5%

50%

100%

Resources

Current OVHA/AHS StaffIn-State Out-Sourcing

Current OVHA Staff/AHS/Blueprint Partners

Current OVHA Staff/AHS/Blueprint Partners

Population Characteristics

Care Interventions

IT

Health Outcomes

Cost Savings

Medicaid Payment Structure

1% New Care Coordination StaffCurrent SURS Team

1%GCRFADS

5%

50%

100%

IT

Predictive Modeling (DSS)

PAsRegistry

Health Outcomes

Population Characteristics

Care Interventions

Resources

Health Outcomes

Cost Savings

Medicaid Payment Structure

MPD

GCR: Global Clinical Record

FADS: Fraud & Abuse Detection System

DSS: Decision Support System

PA: Prior Authorization

MPD: Multi-Payer Database

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5%

50%

100%

Health Outcomes

Prevention of co-morbidities Clinical stabilization

Decreased episodic / crisis utilization

Prevention of complicationsHealth promotion

Disease prevention Health promotion

Population Characteristics

Care Interventions

Resources

IT

Cost Savings

Medicaid Payment Structure

1%Clinical stabilization

Decreased episodic / crisis utilization

1%

5%

50%

100%

Cost Savings•Pharmacy•Long Term Care•ER •Hospitalization•Health Care Providers

Population CharacteristicsCare Interventions

ResourcesIT

Health OutcomesMedicaid Payment

Structure

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5%

50%

100%

Medicaid Payment Structure

Capitated Model(Enhanced Reimbursement

for Best Practices)

Pay for Performance(Metrics)

Population Characteristics

Care Interventions

Resources

Health Outcomes

Cost Savings

Medicaid Payment Structure

Pay for Participation (Enhanced Reimbursement for

Increased Access )

1% Care Coordination Codes

The Choice: Care Coordination

“Addressing this major root cause of Medicaid’s burgeoning growth will result in a program that delivers increased value through improved health care quality and more effective targeting of resources for our nation’s most vulnerable individuals, today and for future generations.”

CHCS, Environmental Scan: Health Supports for Consumers with Chronic Conditions; November 2005

F:\Legis 06\Disease mgt RFP\CCM RFI 4.17.06.DOC

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