CareSource Clinical Practice Registry – The Perfect Tool to Streamline Your Practice

Author : serves as an information source for those who are interested in helping shape a new system of health care delivery.

Nov 16th, 2010 | by

Earlier this year, we launched an innovative, online tool for provider practices called the CareSource Clinical Practice Registry. We’ve seen adoption of the tool really take off mainly because the kind of information that the Clinical Practice Registry provides has traditionally been elusive when it comes to Medicaid patients.

A provider in our network – Dr. Barb Bennett, Family Practice Physician and past president of the Ohio Osteopathic Association – was kind enough to provide her points of view regarding the tool, and how it helps her organize her practice.

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.

The Registry also impacts HEDIS scores. It helps identify many HEDIS mandated screenings, including women’s health and well-child screenings. By identifying the HEDIS screenings through the Registry, HEDIS quality scores improve, and most importantly, so do the health of our members.

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To Empower or To Manage… That Is the Question

Author : serves as an information source for those who are interested in helping shape a new system of health care delivery.

Oct 20th, 2010 | by

Lately there has been a lot of conversation around patient empowerment – an ambiguous term, but one that is fodder for many conversations across the health care industry. Patient empowerment – to put it simply – is about providing the necessary tools and information to a patient so that he or she can take a more active and involved position in his or her health care.

It seems common sense – people want to control their own destiny. But the debate is whether people really want to be empowered when it comes to their health care and what empowerment really means. Would people rather take direction and be ushered through the health care system or do they want to find their own information and formulate their own options for care?

The answers to these questions would have a profound impact on how health plans engage with their members.

They Want to Be Empowered
If the answer is that patients want to be empowered, then you have to look at the kinds of tools and information being provided. You may consider introducing more online applications that let people manage their eating habits or exercise regime. You may introduce materials that help patients better engage with his or her doctor – like a “Top Ten Questions to Ask the Doc” brochure. Or perhaps you publish more information about formularies and how different drugs react with one another so the patient can be more acutely aware of how his or her body will react to certain prescriptions.

They Want to be Managed
If the answer is that people don’t want to take a proactive role in their health care, and instead would rather be managed through the system, then this introduces a whole other operational philosophy. If this is the answer, then you may want to hire more case workers and nurse-hotline employees.

A system of greater follow-up with patients would be a good element to introduce – like doctors or case managers calling a patient after a prescription is filled to make sure they understand the instructions of use. Materials could be introduced around when to see your doctor, and what tests or procedures are important based on life stage. A more concerted effort to getting patients in to see the doctor more regularly is another strategy that may result.

Health Care Reform Thinks Empowerment
It’s obvious through the health care laws that our leadership believes people want to be empowered. It’s why policies like covering some preventive care procedures or allowing a woman to see her OB/GYN without needing a pre-authorization from her PCP are now in place.

But the question is still a perplexing one that needs to be answered. So we are out in the field right now asking about this very thing. Do people want to be empowered to address their health care needs, or do people want the system to better manage how and when we access it? What’s your hypothesis?

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Turning Downside Upside Down

Author : serves as an information source for those who are interested in helping shape a new system of health care delivery.

Apr 20th, 2010 | by

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?

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The Holidays are a Time for Reflection

Author : Toni Bigby

Consumer Advocacy at CareSource Over 11 years of experience working with Ohio’s Medicaid program promoting the importance and availability of health care coverage for Ohio’s underserved populations; Responsible for working with statewide consumer advocacy groups to advance key initiatives to provide value-added benefits to CareSource members; Charged with engaging members to bring their voice to the forefront to inform internal business operations

Nov 24th, 2009 | by Toni Bigby

The holiday season is now upon us.  And while this time of year is supposed to be a joyous time spent with family and friends, I find myself reflecting on the lives of people that find the holiday season to be just another reminder of their economic circumstance.  The underserved – particularly those at or below the poverty level – will experience the holidays in a much different way. With more and more families facing job loss as a result of the recession, many will not have Thanksgiving feasts…many will be struggling to find ways to “make the season bright” for their children.  Many are turning to the social services available within their community just to make it through another month.

Throughout my time at CareSource and with Ohio’s Medicaid program, I’ve learned to have a deep appreciation for the challenges faced by the underserved.  Sure, we can try to conceptualize what a day in the life of someone living in poverty is like, but CareSource has exposed me to a much more profound way to think about the priorities of the underserved…and they did this by proactively organizing an interactive event for CareSource employees called the “Poverty Simulator.”

Because our company prides itself on helping the underserved better their lives by improving their health care, our organization does some pretty unique things to help us appreciate the challenges our members face each day – and how they prioritize getting their most basic needs met.  This Poverty Simulator – organized by Think Tank, a non-profit organization that strives to build communities where all people can thrive – does just that…it allowed us to put ourselves in the shoes of our members through role-play, to gain a fuller appreciation of barriers that often preclude them from accessing health care services responsibly.  It’s all done in an effort to teach us why our members make the decisions they make; ask the question they ask; need the support services they need; and where their health care fits in to the grand scheme of things they consider vital… Why? All so we can better serve them.

We’ve held this event four times this year for our employees who have described the event as “heart-wrenching,” “mind-blowing” and “eye-opening.” The simulator has been so enlightening that we included it as part of an event we hosted on Capitol Hill that allowed health care experts and interested parties to experience it firsthand. The purpose was for those following and influencing the health care debate to gain a better understanding of how poverty impacts the way people prioritize and access health care – even if it is made available to them at no cost.

It’s so easy to make general assumptions about why people make the decisions they make.  But quite frankly, until you actually walk in the shoes of the underserved, it is very difficult to appreciate the complexities of living in poverty.  Please take a few minutes to see what the Poverty Simulator is all about.  I think you’ll find it offers a unique and profound approach for helping organizations understand the needs of its customers, and how CareSource excels at building a culture of compassion, dignity and excellence.

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The Government Says Questions are the Answer. Our Question is: Have You Tried It?

Author : Toni Bigby

Consumer Advocacy at CareSource Over 11 years of experience working with Ohio’s Medicaid program promoting the importance and availability of health care coverage for Ohio’s underserved populations; Responsible for working with statewide consumer advocacy groups to advance key initiatives to provide value-added benefits to CareSource members; Charged with engaging members to bring their voice to the forefront to inform internal business operations

Nov 13th, 2009 | by Toni Bigby

The “Questions” Campaign

Our Federal Government is investing in a consumer education campaign called “Questions are the Answer.” The idea is to encourage people to watch out for themselves a little better -  be their own advocate by asking their doctors questions like “why do I need this surgery?” and “are there any side effects from this drug?”

I have a question. Well, actually two. Why are we as health care consumers who collectively spend trillions of dollars each year on health care likely to ask more questions about a $15 dinner than a doctor’s diagnosis? Why isn’t there a menu listing the costs associated with the services/procedures/drugs that a doctor says we need before we decide whether or not we can actually afford the service?  The way we pay for health care is like we have a high interest credit card with no limit. We buy now and pay later – so much later that our future generations will still be paying because many of us are hesitant to ask: “Do I really need this? Is this my only option? Should I get a second opinion?”

Who is Responsible?

Yes, doctors should elicit patient questions and answer them fully.  And many doctors – but not all – even take the opportunity to answer the questions their patients don’t think to ask like – “What are your health care goals? Do you want to live pain free?  Be able to play competitive sports?  What are the side-effects you have experienced from this particular drug or procedure?”

But docs cannot bear the weight of this burden alone, nor should they. Patients have a responsibility to become informed and to take necessary actions to improve their health. Families ought to help in the decision-making process and be supportive. Health plans should be well equipped with clinicians and medical professionals that proactively help their members understand what options they have (and quite frankly, they probably have a little more time than a doctor can spare during a typical office visit).

Yes, patients should ask at least the obvious questions outlined at the link referenced above. But the historical reluctance to question the health care provider continues to linger on…Don’t get me wrong – I appreciate the wealth of knowledge that doctors amass. Often times, they know too much which makes it that much harder to communicate to those of us who can’t even remember our own blood type. And besides, it’s hard to ask a question of someone who’s halfway out the door, instructing you to come back for another billable visit and who’s just probably told you something you didn’t necessarily want to hear.

So What’s the Point?

My point is, even if you engage your doctor in meaningful conversation about his/her diagnosis, the doctor should not be the only one responsible for deciding what is best for you. Each one of us should have an entire team established– us, as the health care consumer, our family, our doctor, and our health plan – all working together in unison. Why? Because too many of us pay for decisions made simply because the doctor “says so.” WE as a country need to decide collectively that WE will begin to make informed decisions in the future – not just the billable ones charged to an unrestricted credit card.

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Physician-Know Thy Patients!

Author : Craig Thiele, M.D.

Chief Medical Officer, CareSource Over 16 years of clinical leadership experience with a strong background in case and disease management. Oversees clinical and quality initiatives at CareSource and manages medical policy, clinical care guidelines, utilization parameters, and quality assurance for its health plans.

Aug 18th, 2009 | by Craig Thiele, M.D.

So here’s an interesting story:
A doctor I work with encountered a pretty common situation with a patient.  She’d prescribed an inhaler for a patient complaining of shortness of breath. On a follow-up visit, the patient said his symptoms had not changed. Normally, the doctor’s response would be increased dosage, new medication, or perhaps additional tests. But in this case, the physician had the Member Profile CareSource provides at hand, showing that the patient had not filled the first prescription in the first place. What ensued was five minutes of patient education explaining the importance of the medication, exploring why the prescription was not filled, a new copy of the prescription, and a successful treatment at no unnecessary cost.

We hear a lot about the need for digital medical records to provide complete, detailed, accessible record of treatment: they will certainly help cut costs and improve care in the long term.
But valuable as such records are, what they can’t provide is the topline overview of an individual’s health status that can help doctors when they first meet a patient or provide information for quality ongoing care…the kind of broad-spectrum profile of age, family status and other personal information, prescriptions ordered and filled, preventive screenings, previous providers, even non-medical issues affecting health and well-being.
With such a record in hand, any doctor—whether, in any emergency room, urgent care facility, clinic or private office in the U.S.—could jump-start the process of caring for a new patient, or providing quality long-term care for a current patient with a holistic picture that goes beyond the medical situation at hand.

A concise profile like the one CareSource has developed gives physicians, specialists and other providers integrated, up to date information about their patients electronically, so they can provide faster, more accurate assessments and diagnosis, treatment decisions that integrate with the patient’s other care, insights into behaviors that could affect outcomes, and potential problems that may not be presented in the office visits. All that adds up to better information, better care…and lower costs.

Care Management:  Where Aggregated Patient Information Lives

The reason currently utilized personal health records, valuable as they will be, can’t do this job alone is simple:  they may or may not be accurate or complete. Physician records are more reliable, but only cover care the specific doctor provided directly. They likely don’t contain information about which prescriptions were filled (and who prescribed them), what emergency room visits transpired across the state, nor important medical diagnoses from the patient’s past. Knowledge of this information can affect patient diagnosis, care and health.

But that’s precisely the information CareSource gathers using multiple information sources. We realized that the information we already have on our members could be put to excellent use by providers to the benefit of their practice, their patients, and health care costs overall.

Granted, it was no simple matter to find a way to make all this information easily available to providers.  But now, CareSource Member Profiles are up and running. Physicians now have critical information at their fingertips including:

  • Member demographics
  • Primary care provider information
  • Prior prescribing information (updated daily)
  • Historical diagnoses
  • Patient-specific quality metrics (such as mammography screening, A1C value, and more)
  • Prior hospital admissions
  • Emergency room visits
  • Specialist visits
  • Case management activity

It’s About Relationships, Too
What we’ve already discovered since CareSource Member Profiles have been available is that they create a virtuous cycle.  Patients have a better feeling about a doctor who understands them, so they rely on that doctor’s opinion more, in lieu of using providers who are not familiar with their medical history. In addition to reaching positive outcomes, physicians with enough information can empower patients to take better care of themselves. By investing in tools physicians appreciate and use every day, CareSource builds stronger relationships with providers based on a lot more than making payments to providers caring for our members.  And that means, as our nation moves toward health care reform, we will be able to work together to evolve a system that puts the resources of physicians and care management companies to their best and highest use.

As an emergency room doctor asked when we first presented Member Profiles, “why don’t all care management companies do what CareSource is doing?”  The answer:  I hope someday they will.

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