1. The Face of Alabama Medicaid December 5, 2006

2. Demographics FY 2005 Medicaid covers: 20.7% of Alabama’s total population (includes all eligibility categories) 46% of all deliveries in Alabama 37.9% of Alabama’s children (under 19) 19.7% of Alabama’s elderly (65 and above) 74% of nursing home days in Alabama

3. Children in Working Families As of September 2005 Source: Obtained for MLIF and SOBRA populations based on information from Medicaid applications as filed.

4. Eligibles Percent Distribution by Race FY 2005

5. Aids For Physicians

6. External Communications Expanded Agency Website ListServs General Stakeholders, Pharmacy, Hospice, DME, LTC, PCCM Physicians, Transformation Stakeholders Online Publications Shopping Cart For Patient Education Materials Town Hall Meetings

7. www.medicaid.alabama.gov Changes based on input from 2004 Town Hall meetings Searchable fee schedules, databases Agency forms, manuals and brochures Link to EDS secure website Emergency and Disaster Information - Katrina Average 62,000 individual visits/month Agency Website

8. Other Activities Online newsletter, Medicaid Matters CD ROM Education for Physicians Asthma Medical Home and Health Literacy Electronic Distribution of Manuals Policy Advisory Task Forces Physicians DME PCCM LTC P&T DUR

9. Alabama’s Primary Care Case Management Waiver Program

10. Goal Improve health care outcomes for Medicaid recipients through creation of a Medical Home while containing the escalating cost of quality health care.

11. Program Redesign... This time around … A cost effective model –More program accountability –Have ability to demonstrate success More focus on affecting outcomes –Effective patient management tools through program enhancements –Patient information

12. Show Me The Money Changes... –PMP determines case mgt fee –Based on contractual components –PMP will share in any savings –Performance Measures And the Money is... –$1.60 average case management fee –22 PMPS receiving $2.60 –$625,536 in case mgmt fees/ March 06

13. PMP Decides Case Management Fee EPSDT Provider$0.45 VFC Participant$0.10 Medical Home CME$0.10 24/7 Coverage$0.85 Hospital Admitting Privileges$0.30 In-Home Monitoring (Disease Mgmt) $0.10 InfoSolutions Participant$0.50 Electronic Notices$0.05 Electronic Educational Materials$0.15 $2.60

14. Case Management Fee Components EPSDT –PMP performs own screenings Vaccines for Children –Enrolled as VFC provider Medical Home Project –Completes training regarding establishing and maintaining medical home for patients 24/7 Arrangements –Provides direct after hour coverage as specified –Does not automatically refer to Emergency Department Hospital Admitting –Has hospital admitting privileges and admits own patients

15. Case Management Fee Components In-Home Monitoring –Agrees to work with Agency/partners to place in-home monitoring services for select patients InfoSolutions –Agrees to work with BC/BS and utilize the InfoSolutions/e-Prescribing pharmacy data Electronic Notices –Agrees to receive notices from Medicaid/EDS via e-mail or fax Electronic Educational Materials –Agrees to receive educational items via electronic means/reproduce for assigned Patient 1 st patients

16. Moving Into the 21st Century Tools to Help the PMP Manage the Patient In-Home Monitoring InfoSolutions ePrescribing

17. In-Home Monitoring aka Disease Management Partnership with USA Medical School and the Alabama Department of Public Health (ADPH) Telemetry concept Targets chronic diseases through claims utilization Diabetics initial phase Monitor blood sugars, weight and blood pressure Coordination with Primary Physician Supported with case management Web based with real-time reporting available

18. InfoSolutions Purpose is to inform providers of patient activity based on Medicaid paid claims data. Desktop or PDA tool for physicians Download patient information Access prescription and medical claims history Utilization Diagnoses Lab results

19. e-Prescribing Component of InfoSolutions Download prescription history Automatically alerted to potential drug-to- drug interactions Prescribe/refill multiple medications Electronic submission of prescriptions Establish “favorites” list of frequently prescribed medications View both Blue Cross/Medicaid formulary

20. Successful … 18,458* InfoSolutions hits 6,323* e-Prescribing hits 213** PMPs contracted Additional Case Management monies paid (50¢ per patient per month) Not so successful –Termination of fees if no utilization –Reviewed quarterly *1st quarter of CY 06 ** as of April 20th

21. Patient Intervention aka Case Management Health Department case managers work with patient to resolve issues identified –Direct referral from physician (no form required) Targeted to: –Frequent use of ED –Non-compliant patients Available for: –Interaction with In-Home Monitoring –Persons identified by Agency and PMP

22. Everything You Need To Know About Your Patients Periodic Re-screen List – EPSDT (monthly) –Identification of children due a screening Referral Report (aka I Did Not Refer Report) (monthly) –Identification of instances in which the provider’s number was used without permission –Keep in mind “cascading referrals” Emergency Room Management Report (quarterly) –Identification of who is going to the ER and why Profiler (quarterly)

23. The Profiler Provider Report Card Bigger is Better Overall Patient and Cost Comparison Pharmacy Information –Including costs and utilization Performance Measures –Basis for Shared Savings Distribution –Process Measures Now –Outcomes Measures In Future

24. Generic Dispensing Rate: –The percentage of generic prescriptions ordered for the PMPs panel as compared to the peer group. Visits Per Unique Member: –Average number of visits per recipient seen by the PMP as compared to the peer group. This measure is annualized. Number of Non-Certified Emergency Room Visits: –Average number of recipients that are utilizing the emergency room as compared to the peer group. This measure is annualized. Measures of Success

25. Every noble work is at first impossible. Thomas Carlyle