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Medical home pilots, PDL changes, and local DM programs

Medicare & Reimbursement Advisor Weekly, November 13, 2009

If a medical home pilot in Illinois is successful in enhancing care and helping control costs, it may serve as a national model for health system improvement, says Scott Sarran, MD, chief medical officer at Blue Cross and Blue Shield (BCBS) of Illinois. The state’s largest payer launched a medical home program with Pronger Smith Medical Care and Elmhurst Clinic—two Chicago-area doctor groups that have both primary care physicians and specialists. Under the medical home model, treatment and referrals are coordinated centrally as a way to keep costs down. More than 20,000 Illinois BCBS members will participate; if successful, the insurer would open it up to more of its 7.2 million members.

Iowa, Nevada PDL updates

State Medicaid in Iowa began enforcing new prior authorization criteria on November 1.

Here’s a look at the criteria. Classes that were affected are AmylinoMemetics, Alpha-Blockers (urospecific), Alpha Proteinase Inhibitor Enzymes, ADD/Narcolepsy agents.

Virginia Medicaid uses Facebook

The state’s Medicaid P&T issued a survey through Facebook—the online social networking community—to gather opinions about its preferred drug list as Virginia Medicaid revises its program. The results of its qualitative study will be made available if MRAW can obtain them from Virginia Medicaid. Standby.

Spillover and Medicaid

Speaking of a PDL’s impact on phys- cians, a study was completed on this issue (Applied Economics, September 2009), which found a significant decrease in post- PDL Medicaid prescription shares of drugs excluded from the PDL. Spillovers onto third parties and the cash market were statistically significant. A more restrictive prior authorization procedure has a greater impact on prescription shares. Not surprisingly, the impact of PDLs appeared stronger among physicians with a higher share of Medicaid prescriptions.

NJ pilots routine care for uninsured

Newark, NJ, has enrolled 400 uninsured and underinsured residents in a pilot program that enables them to obtain routine medical care from family doctors. The goal is to prevent people with chronic illnesses from seeking more costly treatment at hospital emergency rooms as a last resort. The yearlong program is expected to save Newark-area hospitals more than $2 million.

Retail: Disease prevention program in Louisiana

Louisiana is the eighth most obese state in the United States, with about 30% of all residents considered medically obese. Patrick Quinlan, MD, CEO of Ochsner Health System, a nonprofit healthcare organization that includes seven hospitals and 35 health centers in southeast Louisiana, has launched the Choose Healthy program in response. For the complete story, click here.

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