Government Technology - June 2008 - (Page 26)

The MMIS also gives doctors reports on their patients’ ER visits compared to the patients of other doctors in their regions. Equally important is that states avoid using Medicaid tracking and management systems to publicly rate physician performance, said Keckley. 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 In 2003, the track symptoms of potentially Oklahoma Health costly ailments before they Care Authority advance to the expensive stages (OHCA) had of care. The OHCA employs trouble keeping nurses who use MMIS data to just 100 dentists monitor Medicaid patients. If contracted with a nurse notices treatments for Medicaid. Using potential symptoms of interest, the state’s Medhe or she intervenes with the icaid Management Information patient and doctor to check for System, the serious conditions. OHCA now boasts “The classic would be idenmore than 700 tifying patients with high blood dental contracts, pressure, diabetes and other according to chronic conditions that are very Mike Fogarty, responsive to treatment, but that CEO of OHCA. 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. But Keckley warned government officials to be careful about how they introduce predictive modeling programs to doctors wary of states meddling in treatment. He said these initiatives could be more attractive to doctors if states connected tax incentives to them, or subsidized purchases of electronic medical records systems for doctors. Medicaid by the Numbers The Oklahoma Health Care Authority implemented a centralized management system for its Medicaid program. The system, implemented in 2003, tracks inappropriate emergency room (ER) use and allows doctors to submit Medicaid claims electronically. The state reports the following results: • A 42 percent reduction in ER visits by Medicaid patients, resulting in a $8.3 million savings. The automated system now handles roughly 95 percent of the 3 million claims processed annually by Oklahoma’s Medicaid program. Nearly 10 percent growth in the number of doctors willing to treat Medicaid patients from 2004 to 2007. • • “[It’s critical] that this does not become a platform for writing report cards that are in the newspaper on which doctors get the best results, that it doesn’t become a basis for transparency and performance reporting,” Keckley said. He said that would likely result in doctors only choosing Medicaid patients who they thought would improve their scores. A Step Ahead of Fraud Medicaid fraud is lucrative. Unscrupulous providers double-bill Medicaid programs for services, which can lead to significant extra costs. Patients, for example, trick the system into giving them narcotics they can sell on the street. 26 JUNE_08 California made tracking this fraud a major IT agenda in early 2000, hiring EDS to handle the details. The Golden State now heralds its per-recipient Medicaid costs as the lowest in the nation. California routinely changes its tactics to keep pace with offenders, said Stan Rosenstein, deputy director of medical care services for the California Department of Health Services (DHS). “When you approach fraud and abuse, the people who are committing it get much more sophisticated. They change their patterns in reaction to us. They study us. They see what we’re doing and change their fraud patterns to avoid what we’re looking at,” Rosenstein said. He said tracking fraud was relatively easy at the beginning of the EDS partnership, because the crimes were less sophisticated. For example, the agency caught “phony providers” billing for services from “offices” that turned out to be empty lots. “Sometimes they’d just have a mail drop,” Rosenstein said. “As we found the easy things, they got more sophisticated and used technology to get there.” In early 2007, the DHS implemented software to search for new fraud patterns that weren’t yet familiar to agency analysts. “In the past, we had to say, ‘Here’s a pattern of treatment,’ and we’d profile for that known pattern [in the system]. The [new software] looks for the new patterns without us having to program it to say, ‘Here’s what we think could be happening,’” Rosenstein said. “It asks, ‘Are they getting too many services? Are they getting services from multiple physicians? What’s their emergency room usage? Are they getting lots of narcotics from going into the emergency room?’ It’s predictive. It tries to look at the behaviors that occur or could have occurred before we’ve identified the pattern. It will tell us what it believes to be an emerging fraud pattern.” Using predictive analytics, the software changes the agency’s detection practices as offenders change methods. The system uncovered numerous fraud innovations. For example, the software notices when doctors give tests or treatment outside of their specialty. “We found situations where a physician would always do the same set of tests when they saw [patients]. For example, they would do nerve conduction tests. Everybody they http://www.govtech.com

Table of Contents Feed for the Digital Edition of Government Technology - June 2008

Government Technology - June 2008 Contents Point of View The Last Mile Big Picture On the Scene Four Questions For... 3 Technologies That May Change Your Job ...And Your Life Loosening Medicaid's Grip Better Living Through Technology Immersive Itineraries Help Yourself Taking the Bait Shared Connection Up Close Spectrum Products Personal Computing signal:noise Digital Communities Contents Digital Tactics for a U.S. Recession E-Dilemma Stifling Community Innovation Leadership Interview Estonia Becomes E-Stonia If It Were Up to Me …

Government Technology - June 2008

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