Loosening Medicaid's Grip

that claim no later than Thursday of the following week. Providers understand that kind of cash flow is real money. It has more value because it's quick," Fogarty said.

The system also enables providers to determine instantly whether a patient is eligible for Medicaid.

"One of the most difficult things for doctors doing business with a Medicaid program is determining whether the person they served was eligible. You can submit a perfect claim, but if it's rejected because the person you treated wasn't eligible, you're really not making progress," Fogarty said.

Another problem existed. Many smaller Oklahoma medical providers didn't have intra-office patient databases, raising questions as to how they'd electronically submit records. The OHCA doesn't purchase care from health maintenance organizations (HMOs), which means many of its providers are small, less IT-savvy practices. The OHCA system means a doctor's office merely needs a computer and Internet connection. The solution proved popular with providers. Roughly 95 percent of the 3 million claims processed annually by the OHCA now go through the automated system.

Oklahoma private practices receive almost $30 per month for each Medicaid patient. Fogarty said the arrangement offers doctors predictable revenue. It can be a sizable chunk of change for doctors who treat Medicaid patients. Changes to the payment and eligibility process seemingly have made Medicaid patients more attractive to Oklahoma physicians. In 2004, the state had contracts with 23,366 providers. By 2007, that number rose to 25,647, roughly a 9.7 percent increase.

"If they've got a panel of 500 or 1,000 patients, they know how much a month they're going to get paid for that," Fogarty said. "It also is a way for us to hold the physician responsible for making sure that patient is being taken care of. We require the physicians to submit 'encounter data.'"

That information lets the OHCA track all treatment the doctor gives the patient. The OHCA notifies each practice when any of its patients visits an ER inappropriately. Naturally the agency doesn't want to pay an ER to treat a condition that it already paid a private doctor to handle.

"If a person with a sore throat goes to see their primary care doctor, we've already paid for that. If that same person goes to an ER, we've paid twice," Fogarty said.

The MMIS also gives doctors reports on their patients' ER visits compared to the patients of other doctors in their regions.

 

Pre-Emptive Medicine

States like Oklahoma and Kansas also have a predictive modeling IT strategy for cutting Medicaid costs and simultaneously improving citizen health. Most understand that early intervention is key to avoiding grave illnesses that are costly to treat, but human nature frequently ignores that obvious wisdom. The typical outcome is a condition that might have been treated more easily and cheaply with early intervention.

Oklahoma uses MMIS to track symptoms of potentially costly ailments before they advance to the expensive stages of care. The OHCA employs nurses who use MMIS data to monitor Medicaid patients. If a nurse notices treatments for potential symptoms of interest, he or she intervenes with the patient and doctor to check for serious conditions.

"The classic would be identifying patients with high blood pressure, diabetes and other chronic conditions that are very responsive to treatment, but that can go bad very quickly without treatment. The system generates information about those patients based on what services they utilize. We have a nurse who is actively engaged with that patient and their care provider in making sure that patient is getting the treatment they need and that they're responding to that treatment," Fogarty said.

Predictive modeling is among the most promising solutions for cutting Medicaid costs, said Paul Keckley, executive director of the Deloitte Center for Health Solutions.

Andy Opsahl  |  Features Editor