Ohio submits proposal to coordinate medical care

ANN SANNER Associated Press Published:

COLUMBUS, Ohio (AP) -- A proposal to better coordinate medical care for some of Ohio's sickest, most expensive and difficult to treat patients should lead to more people getting services at home and community-based settings, rather than in more costly nursing homes or other institutions, the state's Medicaid director said Monday.

The state submitted details Monday to the federal government on its plans to change the way health care is delivered to Ohioans enrolled in both Medicaid and Medicare. Federal officials must approve the alterations. AARP Ohio and the Ohio Association of Area Agencies on Aging have expressed their support of the proposal.

Ohio Medicaid Director John McCarthy said among other factors, the state would judge how successful the changes are based on whether they enable more people to receive medical treatment and other supportive services from the comfort of their own homes.

About 64 percent of Medicaid spending in the last budget year was on institutions, compared with 36 percent on home and community-based care. But the state's two-year budget puts those spending figures closer to 58 percent for nursing homes and hospitals, and 42 percent on home and community-based care by 2013.

McCarthy said he wants to see the spending continue to move on a path that's more evenly split.

"We do not want to see that go in the wrong direction," he said.

Other ways to measure the success of Ohio's pilot program have yet to be determined, and it's unclear whether the state would have to pay any upfront costs to implement the changes, McCarthy said.

But better coordinated medical care leads to a patient's better health, he said, which trims costs in the long run.

More than 182,000 Ohioans are enrolled in both Medicare and Medicaid. While they make up only 14 percent of total the state's Medicaid enrollment, they account for almost 40 percent of total Medicaid spending, according to state figures.

The proposal covers almost 115,000 of the so-called "dual eligible" individuals in seven urban regions, with the idea that it would expand to all the state's Medicaid-Medicare enrollees after three years.

The federal Medicare program serves the elderly and disabled, while Medicaid provides coverage for the poor though 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, officials say.

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.

The state wants to better link the two programs so that the beneficiaries only have to work with a single entity to receive the services.

Ohio's plan is designed to eliminate unnecessary health tests, prevent medication errors and keep people healthier and out of emergency rooms.

The three-year pilot program could end up being a model for other states, officials who drafted the plan have said.

The target date for the plan to take effect is Jan. 1, though there would be a transition period to the new managed care system.

People who fall under the three-year pilot program would not see any immediate changes to their providers, though they could later.

Patients could keep their same primary care doctors and specialists for at least the first year. Otherwise, they would have to pick new physicians if those doctors weren't in the new provider network. And highest-risk sick patients could keep their same doctors and visiting nurses for the first 90 days.

Beneficiaries are guaranteed the option of keeping the same nursing homes and case managers for the duration of the test run.

The ability to keep the same case worker was a critical issue for the state's dozen Area Agencies on Aging, which respond to the needs of older adults.

The agencies' staffs serve as case managers. They help people navigate Medicaid, figure out their long-term care needs and see what daily services they need to remain in their homes or elsewhere, said Larke Recchie, executive director of the Ohio Association of Area Agencies on Aging.

Recchie said the state's proposal preserves the agencies' relationship with enrollees.

"People in the community know where to call," she said. "It's a familiar and reliable source of assistance."