th
17
South Carolina’s
Annual
Rural Health Conference
South Carolina Department of Health and
Human Services
Health Access at the Right Time
(HeART)
Ms. Bz Giese, BSN, RN
Director, Office of Health Initiatives
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
Eligibility
SC Medicaid Total Expenditures
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: Expenditures by Eligibility Category
As of July 1, 2013
Current Budget to Year to Date
Example’s only – not inclusive of entire budget
As of July 31, 2013 * Example s only – not inclusive of entire budget
FY2014
Appropriation
Coordinated Care
FY2014
YTD
Remaining
$2,156,884,310 $137,699,779 $2,019,184,531
%
Expanded
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%
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%
6,482,544,497
549,137,587
5,933,406,910
8%
Lab and X-Ray
TOTAL SCDHHS
Budget
• 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 Clinics
F Hybrid Clinics
F Telemedicine
F After Hours Codes
F School Based Health Clinic Sustainability Model
F Community Health Workers (CHW)
Convenient Care Clinics
• 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, cont.
•
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
Hybrid Clinics
• 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
After Hours Codes
•
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, cont.
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
Telemedicine
• 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
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 use
of 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.”
Proviso 33.34 Section E(2)
and Telemedicine
•
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
School Based Health Center
Sustainability Model: CPN as Case Study
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, cont.
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
SCDHHS Community Health Workers
CHW Goals
1.
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 NP
S9445
Individual Code
S9446 Group Code
• Phase II: Introduce different care delivery models as participants in the CHW
program
Thank you!