APNewsBreak: Details emerge on Ohio's health plan

ANN SANNER Associated Press Published:

COLUMBUS, Ohio (AP) -- The state's plan to streamline medical care for some of its sickest, most expensive and difficult to treat patients includes changes designed to eliminate unnecessary health tests, prevent medication errors and keep people healthier and out of emergency rooms.

The proposal for those enrolled in both Medicaid and Medicare could end up being a model for other states, said Ohio officials who drafted the plan. The officials are expected to send the details on Monday to the federal government, which must sign off on the changes.

While the final details were still being worked out, state officials told The Associated Press on Friday that people who fall under the three-year pilot program would not see any immediate changes to their providers, though they could later.

There would be a transition period to the new managed care system, said Greg Moody, the director of the governor's Office of Health Transformation.

"It's not so much changing the faces they see -- the case worker and others who treat them in their homes -- but trying to better coordinate the things they don't see that may be out of whack," Moody said in an interview.

Moody said the plan would not lock patients in to certain providers but give them a choice.

Choice was among the top concerns brought to state officials by those enrolled in the programs, as well as from advocate groups such the Ohio Olmstead Task Force, which monitors long-term care issues for people with disabilities.

The group's chair, Shelley Papenfuse, said she hopes to see more details Monday on how the state plans to ensure patients have the options they need. In particular, she wants beneficiaries in wheelchairs to be able to keep providers who meet their accessibility needs, such as adjustable examination tables or X-ray machines.

Papenfuse said she had hoped the state would build into the proposal a requirement that there be a specific number of providers that meet those conditions. Without it, she said, "I think we could make it worse when we move over to the new system."

The federal Medicare program serves the elderly and disabled, while Medicaid provides coverage for the poor through state and federal funding.

The two programs operate fairly independently of each other. Medicare generally helps pay for doctor and hospital visits, along with prescription drugs. Medicaid typically helps pay for long-term care, such as nursing homes, among other services.

As a result of the lack of connection between the two programs, some patients are more costly to the system, Moody said. For instance, a patient could be discharged from a hospital to a nursing home instead of to a less expensive home-based care because the two programs aren't talking to each other in the same setting.

"For folks with the most complicated health conditions, the system is very fragmented and kind of works against them," Moody said. "What we're trying to do with this is get all of it organized together in a way that there's a coherent benefit for Ohioans on both Medicare and Medicaid, so they don't have to struggle to where to go."

Ohio is proposing a three-year pilot program, beginning with those beneficiaries in seven mostly urban regions across the state. The target date for the phased-in changes to occur is Jan. 1.

There are about 196,000 so-called fully enrolled "dual eligible" people in Ohio on both programs. They make up a small fraction of the 2.2 million people getting services through Medicaid but account for about 46 percent of Medicaid long-term care spending and 16 percent of behavior health service spending, state figures show. Oftentimes, they have multiple chronic conditions and require more extended care needs.

Ohio officials are trying to address what they see as inefficiencies in the fee-for-service program.

"We pay if you show up to the emergency department. We pay if you're in to see the doc," Moody said. "We don't pay them to coordinate."

The state expects the proposed changes to provide savings, but officials don't have an estimate on how much. Their proposal asks that the federal government evenly split with the state any Medicare savings it would recoup from the changes.

The services available to beneficiaries aren't expected to change, but how those services are coordinated will.

Under the initiative, Ohio would contract with an entity to become the single point of contact for beneficiaries. The contractor would have to keep a centralized record available to all the doctors, nurses and other practitioners involved with the enrollee's care and have an "aggressive process" to review all hospital admissions and nursing home placements to see whether they were appropriate or avoidable.

The model spells out that a health care professional must be able to take enrollees' calls, assess their situations and take action at any time of day. In addition, the plan emphasizes periodic visits to the beneficiaries' homes, so they can be assessed in their own environments.

After the plan is submitted Monday, the state will work with Washington on any revisions before it gets finalized. And federal officials will conduct their own public comment period on the plan.