The Industry2 Addressing Determinants

of Health: Successful State and Local Approaches

5 Conflict-Free Case Management Today

7 Opioid Abuse-Deterrent Formulations: A High Public Health Priority

10 Changing Relationships: The Impact of MECT 2.0

Our Business14 A New Path Forward as Conduent

15 Xerox Recognized for Reducing Newborn Readmissions

16 Serving States Better with Medicaid Learning Center Certification

17 Pharmacy Team Wins Gold at AMCP

Your News18 Montana’s Successful

Medicaid Expansion

Addressing Determinants of Health: Successful State and Local Approaches By Steve Reynolds, CPM, MPA

In the Winter 2015 HealthFocus article “Advancing Integrated Service Delivery,” (available online at http://xrx.sm/rpt), we discussed the idea that health is more than someone’s disease state. Socioeconomic factors including housing, nutrition, mental illness, community environment, lifestyle and employment status can affect a person’s health as well as their ability to access the care needed to improve it.Continued on page 2.

Xerox Recognized for Reducing Newborn ReadmissionsOur Care Management Solutions group was recently recognized by the Case Management Society of America. At the recent CMSA Annual Conference & Expo in Long Beach, Calif., the Society presented Xerox with the 2016 Case Management Practice Improvement Award.Continued on page 15.

Montana’s Successful Medicaid ExpansionIn April 2015, Montana Governor Steve Bullock signed the Health and Economic Livelihood Partnership (HELP) Act into law, authorizing expansion of Medicaid benefits to all adults with incomes up to 138 percent of the federal poverty level. The expansion was welcomed by newly eligible Montanans in need. Early projections estimated that 23,000 residents would enroll in Medicaid.Continued on page 18.

Volume 8, Issue 2 Summer 2016

HealthFocus Government Healthcare Solutions News

Page 2

The Industry

Addressing Determinants of Health: Successful State and Local ApproachesContinued from cover.

We expanded on this idea in Winter 2016 with “Successfully Incorporating Social Determinants” (available online at http://xrx.sm/r2m), which recommended adapting an integrated service delivery model to meet holistic needs at the individual and population level. Similar to the earlier article, we proposed that population health is more than the overall health of a population; it also includes the distribution of health.1 An ideal delivery system substantially reduces or eliminates differences within a group to improve the health outcomes of the group as a whole. We also provided some initial organizational, financial, programmatic and workflow steps that programs can take to begin addressing the social determinants of health.

Examples in ActionHere, we focus on programs in the United States that have successfully adapted some of the concepts we’ve described previously. Our goal is to highlight ideas that states, counties and local governments may wish to pursue to increase the effectiveness of their assistance programs. Many of the decisions of what to undertake will depend on where they stand today in the evolution toward an integrated delivery model.

The Federal Office of Disease Prevention and Health Promotion (ODPHP) cites five broad categories of the determinants of health:2

1. Policymaking2. Social factors3. Health services4. Individual behavior5. Biology and genetics

According to ODPHP, the interrelationships between these factors determine the levels of individual and population health. The agency states that “interventions that target multiple determinants of health are most likely to be effective.” They add that the targets must span “traditional healthcare and public health sectors; sectors such as education, housing, transportation, agriculture and environment can be important allies in improving population health.”2

We’ll address aspects of these broad categories in our examples. They touch on issues of health, community health, population health and addressing the social and other determinants of health. One common theme is that none of the programs allowed perfection to get in the way of progress. They all moved forward step by step in an evolutionary process, building on past successes and adjusting to account for lessons learned.

State of MinnesotaMinnesota is consistently one of the highest-performing states in terms of healthcare indicators. The state recently ranked first overall in The Commonwealth Fund “State Health System Performance 2015” report, continuing the state’s position from previous years.3 They were also at or near the top of listings for the individual indicators that make up the overall ranking.

Minnesota employs a Statewide Health Improvement Program (SHIP). As the program states, “SHIP helps make healthy choices easier.”4 Through SHIP, communities receive support from local organizations to create programs that help individuals and communities improve overall health levels. Some of the examples they cite are:

• Safer walking and biking routes to school that help kids get the physical activity they need to stay healthy.

• Opening farmers’ markets to give families more access to fruits and vegetables.

• Encouraging workplace wellness programs to help employees improve their health and decrease healthcare costs for employers.

SHIP focuses on increasing physical activity, improving nutrition and reducing tobacco usage and exposure. The program came about because of certain health factors in the state. In Minnesota, 27.6 percent of residents are obese, the result of insufficient physical activity and unhealthy eating.5 This increases the risk for heart disease, diabetes and other chronic illnesses. The state also has a 14.4 percent cigarette usage among adults, which can lead to various cancers and heart disease. Obesity and tobacco use are the two leading causes of death in Minnesota.

The SHIP program recognizes the differences between the demographics, health issues and environmental challenges between urban and rural communities and that a one-size-fits-all approach to determinants of health will not be effective for all Minnesotans. Instead, the program is structured in a way that allows communities to employ the strategies that best address needs specific to their area. This has resulted in “Real, community-led improvements in healthy eating, physical activity and reduced commercial tobacco use.”5

Hennepin County, Minnesota Human Services and Public Health DepartmentHennepin County, Minnesota has been at the forefront of health and human services program integration. In 2004, the county reorganized six departments that had previously provided various social services, financial assistance, work support and public health programs. The consolidated organization became the Human Services and Public Health Department (HSPHD) with the over-arching vision of “better lives” and “stronger communities.”6

Two years after launching the consolidated agency, the county devoted three years to redesigning their services and processes for both adult and children services. Using a variety of project management principles, data and input from managers and staff from across disciplines, they developed a client-centered framework called the Client Service Delivery Model. This framework

Page 3

combines “financial, social services and public health services into an integrated model of services…to provide a holistic assessment of each client at initial contact.”6

This common theme of a client-centered model is shared with many Medicaid agencies and health plans. They try to assess their members across a broad spectrum of health and human service concerns. This enables them to begin addressing an individual’s issues and affect outcomes quickly. These efforts are usually combined with community and population health efforts to produce a greater overall effect on health.

Hennepin County implemented several technological supports to implement their programs. Mobile technology allows county staff to work outside of exclusive office locations, increasing their availability to members of the community. They also access and share information through the HSPHD Enterprise Communication Framework, which is “a secure web-based content and process management application that links workers, systems, cases, clients and information.”6

Since 2009, Hennepin County has used environments to test and expand their processes. This enables the county to assess their management model from a regional perspective. Over time, they have continued to expand the test by adding functions and resources.

Today, Hennepin County has several initiatives that address social determinants in the populations they serve:7

• Better Together Hennepin encourages teens to postpone parenthood until they are adults.

• Criminal Justice Behavioral Health Initiative integrates behavioral healthcare for residents of county correctional facilities.

• DART (Diversion and Recovery Team) uses an interdisciplinary team to coordinate case management, housing and chemical dependency treatment for adults struggling with substance addiction.

• Early childhood screening occurs at many county locations where adults already go for services.

• Heading Home Hennepin is a 10-year plan to end homelessness being implemented by Hennepin County and the City of Minneapolis. It brings together more than 120 local non-profit organizations, businesses, alliances and concerned citizens.

Montgomery County, MarylandMontgomery County has been on a mission to overhaul its Health and Human Services (DHHS) delivery system for many years. In 2009, the county began the Montgomery County Community Health Improvement Process. Led by the Healthy Montgomery Steering Committee (HMSC), it assessed all past and existing planning processes and compiled information related to health and well-being and the social determinants of health across several populations and communities. By 2010, HMSC established a “core set of indicators that could be examined through a comprehensive needs assessment.”8

By the time the Healthy Montgomery website launched in February 2011, there were about 100 indicators.

During 2011, the Healthy Montgomery Needs Assessment was created and used to set

priorities. Six categories were selected for action and prioritized. Two were selected for immediate action: behavioral health and obesity. The other areas were cancer, cardiovascular health, diabetes and maternal and infant health. In 2012, the Behavioral Health and Obesity Work Groups were formed. These work groups were “charged with…developing action plans that demonstrate impact on access, health inequities and unhealthy behaviors.”8

Montgomery County provides a clear example of an agency developing the organizational structure to address issues of individual and community well-being across its Health and Human Services agency. The county has assessed their needs, prioritized the issues that would be addressed and continually moved forward. The Montgomery DHHS Strategic Road Map for 2016–2018 states its “primary focus remains the delivery of high quality services.”9 Yet the agency continues working to evolve service delivery and find new ways of engaging communities.

The county’s three-year-plan sets goals for developing innovations in service delivery and to transform their organization to meet future needs.

Continued on page 4.

Page 4

The Industry

To transform organizationally, Montgomery DHHS will focus on integrating service delivery to offer the most effective and efficient services where possible. It will implement technology that supports integrated, effective and efficient service delivery; allocate financial and people resources equitably across DHHS to ensure alignment with needs and demands; engage and develop the workforce to meet changing demands; and work with public, private and community partners and the county’s citizens.

More information about the Montgomery County transformation strategies can be found on the APHSA Transformations in Action website.10

San Diego County, California San Diego is another county that has taken measured steps to create an environment for healthy living. In 2010, the county’s Board of Supervisors adopted the Live Well San Diego vision, which continues to guide programs today. Live Well San Diego had three goals: building better health, living safely and thriving. This vision included four strategic approaches for achieving these goals:

1. Building a better service delivery system

2. Supporting positive choices

3. Pursuing policy and environmental changes

4. Improving the culture within county government

San Diego County includes several stakeholder organizations to fulfill its vision and implement strategic approaches. They include “cities, schools, businesses, the military and faith- and community-based organizations, as well as residents.”11 The county uses “Top 10 and Expanded” indicators to measure progress on well-being.11 They measure five areas:

• Health

• Knowledge

• Standard of Living

• Community

• Social

San Diego County continues to move forward and in May of 2016 announced an effort to fully integrate health, human services and housing. This was a continuation of the “building a better service delivery system” strategic approach for realizing the Live Well San Diego vision. The reorganization “will further support the county’s efforts to address the needs of vulnerable residents, particularly homeless people with severe mental illnesses.”12

The four examples above provide evidence of strong efforts in the United States to address health, social and other determinants of health at an individual, community and population level. They all share the common theme of successfully (re)organizing to better serve the citizens in their care while developing new programs and continuing to evolve and expand existing programs to meet the needs of their citizens. Each organization has developed initiatives and prioritized them to meet the specific needs of their state, county or community. There are valuable lessons to be learned through all of their efforts.

References1. Kindig, David A., MD, PhD. “What Is Population

Health?” Improving Population Health [blog]. University of Wisconsin School of Medicine and Public Health, Department of Population Health Sciences. Web. Accessed January 12, 2016. Available at www.improvingpopulationhealth.org/ blog/what-is-population-health.html.

2. “Determinants of Health.” Healthy People 2020. Office of Disease Prevention and Health Promotion, n.d. Web. Accessed July 16, 2016. Available at www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health#health% 20services.

3. “Health System Scorecards.” The Commonwealth Fund, n.d. Web. Accessed July 16, 2016. Available at www.commonwealthfund.org/publications/ health-system-scorecards.

4. “SHIP: The Statewide Health Improvement Program.” Minnesota Department of Health, n.d. Web. Accessed July 16, 2016. Available at www.health.state.mn.us/ship.

5. Office of Statewide Health Improvement Initiatives. “Statewide Health Improvement Program.” Fact sheet. Minnesota Department of Health, n.d. Web. Accessed July 16, 2016. Available at www.health.state.mn.us/divs/oshii/ship/docs/shipfactsheet.pdf.

6. “Human Services Integration: Hennepin County Human Services and Public Health Department, Hennepin County, MN.” Raise the Local Voice (n.d.): n. pag. American Public Human Services Association. Web. Accessed July 16, 2016. Available at www.aphsa.org/content/dam/aphsa/pdfs/RaiseTheLocalVoice/Hennepin-County-MN.pdf.

7. “Health Care Reform.” Hennepin County, Minnesota, n.d. Web. Accessed July 15, 2016. Available at www.hennepin.us/healthcare.

8. Healthy Montgomery: Better Health through Community. Montgomery County, MD, n.d. Web. Accessed July 16, 2016. Available at www.healthymontgomery.org.

9. Strategic Road Map: FY 2016–FY 2018. Montgomery County, MD Department of Health and Human Services, n.d. Web. Accessed July 16, 2016. Available at www.montgomerycountymd.gov/HHS/Resources/Files/Reports/DHHS%20STRATEGIC%20ROADMAP%20(4)%202016_2018.pdf.

10. “Montgomery County, Maryland Department of Health and Human Services.” Transformations in Action. American Public Human Services Association, n.d. Web. Accessed July 16, 2016. Available at www.aphsa.org/content/APHSA/en/pathways/TransformationsinAction/MontgomeryCounty.html.

11. “Measuring Progress.” Live Well San Diego. County of San Diego, Calif., n.d. Web. Accessed July 16, 2016. Available at www.sandiegocounty.gov/content/sdc/live_well_san_diego/indicators.html.

12. Sturak, Craig. Web log post. CountyNewsCenter. County of San Diego, Calif., May 11, 2016. Web. Accessed July 15, 2016. Available at www.countynewscenter.com/county-integrates-hhsa-housing-department.

Back to Table of Contents

Page 5

By Frank Spinelli

Meeting the many needs of the elderly and disabled not only requires continuous long-term services and supports (LTSS), but doing so in a way that is person-centric and provides ultimate choice to the consumer. One element of this approach is responsive case management, which can include the creation of service plans, arrangement of services, resolving crisis situations and so on.

The most important function, however, involves performing assessments and identifying a participant’s needs and strengths. To sustain a quality LTSS delivery system, programs must ensure that the overall care system is integrated and free from conflict between the entities that assess a person’s need for LTSS and the entities that provide those services.

Conflict-free case management is the cornerstone of person-centered planning. Rather than being driven by the needs of the provider or payer, the focus is on the unique needs and strengths of program participants. This approach reduces biases as well as the risks for decisions to be driven by financial or personal gain. For more details on the importance of conflict-free case management and how states can foster this approach, please visit http://xrx.sm/r2i to read “Enabling Conflict-Free Case Management” from the Winter 2014 HealthFocus.

Encouragement from CMSIn recent years, the Centers for Medicare & Medicaid Services (CMS) has changed federal regulations to encourage the practice of conflict-free case management. Providers of Home and Community Based Services (HCBS) cannot provide case management or develop person-centered plans for the same people to whom they provide direct supports.

CMS has identified areas where this type of conflict of interest commonly occurs. These include providers authorizing more services than needed; providers not authorizing enough services that meet the participant’s needs due to resource restraints and programs authorizing services based on cost instead of need.

The agency is influencing national healthcare policy to address these conflicts. For example, the Affordable Care Act authorizes a Balancing Incentive Program to qualifying states that requires them to provide conflict-free case management. Additionally, Sections 1915 (i) (HCBS State Plan Option) and 1915(k) (Community First Choice Option) include requirements that establish conflict-of-interest standards for functional need assessment, as well as independent evaluation and assessment.

Continued on page 6.

Conflict-Free Case Management Today

Page 6

The Industry

These provisions target conflicts of interest that may occur when the entity being paid for services employs the person who makes service determinations. However, CMS can grant an exception if the state determines that only one entity in a geographic area is willing – and qualified – to provide case management services. CMS provides details about this in the Code of Federal Regulations (CFR) at Person-Centered Planning: 441.301(c)(1)(vi).

What States Are DoingWhile person-centered planning is a standard practice for many state LTSS providers, separating case management from service provision requires emphasis on person-centered planning and restructuring case management activities.

The trend among states to move LTSS participants to managed care is fueling the debate as to how to provide unbiased, informed and independent assessments. More than 26 states have moved or are considering a move to the managed care model, with most plans taking on risk and including some financial interest in the outcomes.1 In other words, there is not a “one size fits all” solution for states.

Examples of what states are doing include:

• Alaska currently uses a person-centered approach to service planning, though the rules include specific requirements. Among other reasons, it must be directed by the participant to the maximum extent possible, provide necessary information and support the participant in making decisions and leading the process.2

• Iowa is promoting conflict-free case management through its Balancing Incentive Program (BIP). This provision of the Patient Protection and Affordable Care Act is designed to balance states’ spending on long term supports and services (LTSS) with what they spend on long-term institutional care.3

• South Dakota is implementing conflict-free case management for people with intellectual and developmental disabilities.4

• Louisiana5 and Wisconsin6 have contracted with third-party vendors to conduct assessments and develop plans of care.

Where We Stand TodayWhere does the healthcare industry stand today when it comes to conflict-free case management? Caseloads continue to increase, costs are going up, acuity levels are increasing in community settings and access to services in some areas are problematic due to labor and services shortages. Though CMS has guidelines to address conflicts of interest in case management, it is still too early to determine their effect.

There are a few more potential issues coming in the near future, such as services and payments that are tied to outcomes and participant satisfaction. With different delivery models and payment structures in place, it is critical that assurances are in place to protect the best interests of the participant. Participants and their caregivers need to feel that the information they receive is concise and accurate. They also need plans of care that are written to their specific needs, not what is in the best interest of the provider or payer.

For truly effective service delivery, consumers must be provided with viable options, along with every opportunity to make informed choices for care. Regardless of the approach to delivering conflict-free case management, states need to develop processes and procedures to ensure there is no conflict. It’s important that they understand how care managers are paid and the financial incentives (if any) that are available to them. Assessments and care plans also need to be monitored. Inter-rater reliability monitoring and participant satisfaction surveys are two methods that can be deployed.

The bottom line is that states need to take an active role in making sure that their case management services are conflict-free. Just having language in a contract is no longer sufficient.

References1. State Medicaid Integration Tracker. Rep. National

Association of States United for Aging and Disabilities, June 10, 2016. Web. Accessed July 16, 2016. Available at www.nasuad.org/sites/nasuad/files/State%20Medicaid%20Integration%20Tracker%20%20June%2010,%202016.pdf.

2. Agnew::Beck Consulting and HCBS Strategies with support from the Alaska Mental Health Trust Authority. Conflict-Free Case Management System Design. Rep. Community Care Coalition, February 18, 2015. Web. Accessed July 15, 2016. Available at dhss.alaska.gov/gcdse/Documents/pdf/CFCMReport.pdf.

3. “Conflict-Free Case Management.” Iowa Department of Human Services, n.d. Web. Accessed July 15, 2016. Available at dhs.iowa.gov/ime/about/initiatives/BIPP/CFCM.

4. South Dakota Department of Human Services, Division of Developmental Disabilities. Conflict-Free Case Management. Informational poster. Accessed July 15, 2016. Available at dhs.sd.gov/dd/cfcm/CFCMposter.pdf.

5. Summary of Conflict-Free Case Management. Rep. Mission Analytics Group, 2015. Accessed July 18, 2016. Available at www.balancingincentiveprogram.org/sites/default/files/CFCM_State_Summary_2015.v2.pdf.

6. Stepien, Dave and Thomas, Shawn. “Department of Health Services: Independent Needs Assessments for Medicaid Fee for Service Personal Care.” WPSA Summer Conference. Great Wolf Lodge, Wisconsin Dells, WI. June 9, 2016. Wisconsin Personal Services Association. Web. Accessed July 18, 2016. Available at www.wpsa.us/sites/default/files/WPSA%20June%209%20PowerPoint_Final_DHS%20%28003%29.pdf.

Back to Table of Contents

Page 7

By Larry Dent, PharmD, BCPS

Prescription opioid products are commonly prescribed and essential for pain management. An estimated 20 percent of patients with non-cancer pain symptoms or pain-related diagnoses are prescribed opioids. However, abuse and misuse of these products have created a serious and growing public health problem.1

According to the Centers for Disease Control and Prevention, deaths from prescription opioid pain medication overdose in the

United States more than quadrupled from 1999 to 2011.2 Of the 43,982 drug overdose deaths in 2013, 37 percent were associated with prescription opioid analgesics such as oxycodone, hydrocodone and methadone.3,4 From 1999 to 2014, more than 165,000 people died from an opioid-related overdose in the United States.5

Diversion, the intentional removal of a medication from legitimate distribution systems, is a major contributor to opioid abuse and misuse. The 2013 National Survey

on Drug Use and Health reported that 67.6 percent of people who used prescription analgesics for non-medical use got them from a friend or relative by stealing them, buying them or getting them for free.6

The severity of the opioid problem has made the development of opioid abuse-deterrent formulations (ADFs) a high public health priority for the FDA. Abuse-deterrent technologies make manipulation of opioids for administration by different routes more difficult.1

Continued on page 8.

Opioid Abuse-Deterrent Formulations: A High Public Health Priority

Page 8

The Industry

Abuse-deterrent properties of opioids do not prevent abuse, but are designed to deter it. Because opioid products must be able to deliver pain relief to the patient, there may always be some potential for abuse. For example, these technologies cannot deter someone from swallowing a large number of intact pills (the most common form of abuse).

However, they can lower the risk of other forms of abuse compared to products without such properties. The science of abuse deterrence is relatively new and both the formulation technologies and the analytical, clinical and statistical methods for evaluating those technologies are rapidly evolving.1

The FDA believes it is critical to address the problem of opioid abuse while ensuring that patients in pain have appropriate access to opioid products. Moreover, it is important that opioids without abuse-deterrent properties remain available for use in some clinical settings. For example, patients in hospice care who have difficulty swallowing may need opioid products that are in solution or that can be crushed.1

Abuse-Deterrent TechnologiesThere are numerous ways that opioid products can be abused. For example, they can be swallowed whole, crushed and swallowed, crushed and snorted, crushed and smoked or crushed, dissolved and injected.1

Abuse-deterrent technologies are designed to target known or expected routes of abuse and can fall into one or more of these categories:

• Physical/chemical barriers: Physical barriers prevent chewing, crushing, cutting, grating or grinding of the dosage form. Chemical barriers resist extraction of the opioid using common solvents like water, simulated biological media, alcohol or other organic solvents. Physical and chemical barriers work by limiting drug release following mechanical manipulation of the product or change the physical form of a drug, making it more impervious to abuse.1

• Agonist/antagonist combinations: An opioid antagonist, such as naltrexone or naloxone, can be added to the formulation to reverse the pharmacologic effects of the drug, including euphoria. The antagonist is not clinically active when swallowed but becomes active when crushed, injected or snorted.1

• Aversion: Substances can be added to the product to produce an unpleasant effect if the dosage form is manipulated or exceeds the directed dosage. For example, the formulation can include a substance irritating to the nasal mucosa if ground and snorted.1

• Delivery System: Certain drug release designs, such as depot injections and implants, are formulations that are resistant to abuse. For example, a sustained-release depot injectable formulation or a subcutaneous implant may be difficult to manipulate.1

• New molecular entities and prodrugs: The properties of a new molecular entity or prodrug could include the need for enzymatic activation, different receptor binding profiles, slower penetration into the central nervous system or other novel effects. Prodrugs with abuse-deterrent properties could provide a chemical barrier to the in vitro conversion to the parent opioid, which may deter the abuse of the parent opioid.1

Abuse is defined as the compulsive, excessive and harmful use of addictive substances; misuse is the intentional therapeutic use of a drug in an inappropriate way. Drug seekers are particularly interested in extended-release (ER) formulations because they provide a higher maximum concentration of the drug than immediate-release (IR) formulations. The FDA is moving toward a requirement for all future formulations of ER opioids to contain abuse-deterrent properties.7

Page 9

Table 1: FDA-Approved Abuse-Deterrent Products

Drugs Abuse-Deterrent Technology

Embeda ER (morphine and naltrexone) Uses an opioid antagonist

Hysingla ER (hydrocodone) Uses chemical barriers

MorphaBond ER (morphine) Uses physical and chemical barriers

OxyContin ER (oxycodone) Uses physical and chemical barriers

Targiniq ER (oxycodone and naloxone) Uses an opioid antagonist

Xtampza ER (oxycodone) Uses physical barriers

Zohydro ER (hydrocodone) Uses chemical barriers

Pre-Marketing and Post-Marketing Assessments The FDA requires that pharmaceutical manufacturers conduct pre-marketing and post-marketing assessments for claims of abuse deterrence to be included in the labeling of an opioid formulation.1,8 Pre-marketing studies are primarily expected to characterize the abuse-resistance properties of a product under controlled conditions. Required laboratory tests include:

1. Assessment of how easily the abuse-deterrent properties of the formulation can be manipulated

2. In vivo studies to compare the pharmacokinetic profiles of the formulation before and after manipulation

3. A randomized, double-blind, placebo- and active-controlled study to evaluate subjective effects of the formulation, such as differences in “drug liking” in recreational drug users

Post-marketing epidemiological studies determine whether the marketed ADF results in meaningful decreases in adverse clinical outcomes related to abuse in real-world settings.1,8 One study evaluating changes in drug abuse patterns found that reformulation of OxyContin was associated with a 32 percent reduction in the rate of ER oxycodone-related poison control abuse cases. The study also found a 15 percent reduction in the rate of poisonings related to therapeutic ER oxycodone use. The rate of ER oxycodone diversion declined by 50 percent and the street price of ER oxycodone declined by 22 percent.8

As part of a Risk Evaluation and Mitigation Strategy (REMS) program, the FDA has required the manufacturers of long-acting opioids to make training in their use available to prescribers.8

FDA-Approved Abuse-Deterrent Formulations• Embeda ER (morphine and naltrexone)

is formulated as capsules of ER morphine pellets that contain a sequestered core of the opioid antagonist naltrexone. When swallowed, the morphine is gradually released and absorbed, while the naltrexone core passes through the gut intact. If the pellets are crushed, chewed or dissolved, naltrexone is released, blocking morphine-induced euphoria.8

• Hysingla ER (hydrocodone) forms a viscous gel when dissolved, making it difficult to inject through a hypodermic needle.8

• MorphaBond ER (morphine) and OxyContin ER (oxycodone) are formulated to make it difficult to cut, crush or break and when dissolved forms a viscous material that resists passage through a needle.8,9

• Targiniq ER (oxycodone and naloxone) is an opioid agonist/antagonist combination. If the formulation is crushed and administered intravenously or intranasally, high naloxone concentrations block opiate-induced euphoria and can induce withdrawal symptoms.8

• Xtampza ER (oxycodone) is mixed with wax and fatty acids to form microspheres that each contain active drug. The wax keeps the opioid from being dissolved and injected; it also prevents rapid release of the oxycodone if the capsules are mashed. Additionally, capsules can be opened to sprinkle on soft foods and then given to patients who cannot swallow whole capsules.10

• Zohydro ER (hydrocodone) incorporates excipients that form a viscous gel when the capsules are crushed and dissolved.8

Several other opioids have abuse-deterrent properties but have not been approved by the FDA as an ADF. These include Exalgo ER (hydromorphone), Nucynta ER (tapentadol), Oxaydo IR (oxycodone), Opana ER (oxymorphone), and Xartemis (oxycodone and acetaminophen).7

Continued on page 10.

Page 10

The Industry

Changing Relationships: The Impact of MECT 2.0

By Jeff Strand

In May 2016, the Centers for Medicare & Medicaid Services (CMS) released the Medicaid Enterprise Certification Toolkit (MECT) 2.0. This toolkit includes the transformed Medicaid Enterprise Certification Lifecycle (MECL) as well as new certification checklists. The revised checklist and certification review methodology emphasize CMS’s intent to significantly change the way that MMISs are procured, developed and governed.

The toolkit was developed by CMS to respond to the many changes that have transformed the modern MMIS. Its purpose is to provide a consistent, detailed process to certify an MMIS and to help states prepare for the federally required certification review of a state’s MMIS. Using the toolkit will help ensure that each new MMIS meets all federal requirements and satisfies the objectives described in its state’s Advance Planning Document (APD).

The MECT 2.0 solidifies the central role of CMS in the review and approval process of new or enhanced systems as well as their related support services. CMS is heavily focused on the program and project-based critical success factors related to these system upgrades.

To achieve its goals, CMS altered the system procurement and certification requirements significantly. Along with the new certification checklists, there are also new reporting templates, mandatory contracting language and multiple project gate reviews. The process also alters the relationships between CMS, states, solution providers, Independent Verification and Validation (IV&V) contractors and systems integrators.

Generic ADFsAlthough no generic ADFs are commercially available, it is important that generic versions of opioids are developed to ensure widespread access to safe and effective analgesics for patients who need them. The FDA recommends comparative in vitro studies to demonstrate that a generic solid oral opioid is no less abuse-deterrent than the original formulation with respect to all potential routes of abuse.

Moreover, it is important that the availability of such generics do not exacerbate the public health problems associated with prescription opioid abuse. If the generic formulation is less abuse-deterrent, it could lead opioid abusers to preferentially seek out and use this easier-to-abuse version.11

ConclusionPost-marketing epidemiologic studies of opioid ADFs show declines in ADF abuse patterns, therapeutic errors, accidental exposures and diversion of prescription opioids. The evidence indicates that reformulating abused prescription opioids to include abuse-resistant properties may be an effective approach to reduce abuse of these medications. However, a major observation from these studies shows that ADFs were associated with increased abuse of other opioids and illicit drugs. Therefore, a reasonable inference may be that the drug is being replaced with other opioids and agents that are more amenable to manipulation.

It may be concluded that the current ADF methodologies alone will not likely be adequate to curb nonmedical opioid use. However, they may be effective as part of a comprehensive effort that includes other interventional strategies such as REMS programs, state prescription monitoring and overdose prevention programs.12

References

1. FDA. CDER. Abuse-Deterrent Opioids – Evaluation & Labeling. Guidance for Industry. April 2015. Available at www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm334743.pdf. Accessed May 4, 2016.

2. Chen LH, Hedegaard H, Warner M. Drug-poisoning deaths involving opioid analgesics: United States, 1999–2011. NCHS data brief, no 166. Hyattsville, MD: National Center for Health Statistics. 2014.

3. Imtiaz S, Shield KD, Fischer B, Rehm J. Harms of prescription opioid use in the United States. Subst Abuse Treat Prev Policy. 2014; 9:43.

4. Dowel D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016; 65. Available at www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf. Accessed May 4, 2016.

5. Baumlatt JA, Wiedeman C, Dunn JR, Schaffner W, et al. High-risk use by patients prescribed opioids for pain and its role in overdose deaths. JAMA Intern Med. 2014 May; 174(5):796-801.

6. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Available at www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf. Accessed May 4, 2016.

7. Fudin J. Abuse-Deterrent Opioid Formulations: Purpose, Practicality and Paradigms. Pharmacy Times, published online on January 27, 2015. Available at www.pharmacytimes.com/contributor/jeffrey-fudin/2015/01/abuse-deterrent-opioid-formulations-purpose-practicality-and-paradigms. Accessed May 22, 2016.

8. Abuse-Deterrent Opioid Formulations. The Medical Letter on Drugs and Therapeutics, 2015; 57 (Issue 1476); p 119–121. Available at secure.medicalletter.org/sites/default/files/freedocs/w1476a.pdf. Accessed May 4, 2016.

9. Morphabond Prescribing Information, revised October 2015. Inspirion Delivery Technologies. Village Cottage, NY. Available at www.accessdata.fda.gov/drugsatfda_docs/label/2015/206544lbl.pdf. Accessed May 4, 2016.

10. Xtampza Prescribing Information, revised April, 2016. Pantheon Pharmaceuticals, Cincinnati, Ohio. Available at www.collegiumpharma.com/uploads/downloads/Xtampza-ER-Full-Prescribing-Information.pdf. Accessed May 4, 2016.

11. FDA. CDER. General Principles for Evaluating the Abuse Deterrence of Generic Solid Oral Opioid Drug Products Guidance for Industry. March 2016. Available at www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM492172.pdf. Accessed May 4, 2016.

12. Muneer S. Epidemiologic Assessments of Abuse-Deterrent Formulations. Curr Med Res Opin 2014: 30:1589–1598.

Back to Table of Contents

Page 11

To support these changes, the certification lifecycle now begins well before a Request for Proposal (RFP) is released and continues throughout the entire process of development and final review. The purpose of the certification lifecycle and each of the review milestones is to confirm that the goals and requirements established in a state’s MITA State Self-Assessment and Concept of Operation are carried throughout the renewal process – from the RFP, through development and into delivery. Each milestone review serves to verify that the requirements, solution and business processes achieve the goals for which the enhanced federal funding was sought.

The new certification process increases flexibility and enforces rigor in the steps states must take to achieve certification. States that have already released their RFPs can enter the new MECT Certification Lifecycle at various points depending on where they are in the procurement and development cycle.

The MECT 2.0 toolkit explains the new certification process through a complete set of guidance, activities, process flows, templates, roles and responsibilities, requirements and artifacts. The toolkit details the distinct activities, deliverables and expectations in each phase. Quick Reference and At-A-Glance guidance is provided for each activity.

The MECT 2.0 supports:

• System or modular development and modular certification

• COTS usage, Software as a Service and the outsourcing of Medicaid services

• Modules deployed on a staggered timeline using agile, waterfall or hybrid development

• Services may also be acquired separately from the modules, meaning the application may be developed by a vendor separate and distinct from the operational services

Continued on page 12.

Page 12

How Certification Roles Will ChangeStates

The new certification approach has the largest impact on states, beginning with the activities leading up to the RFP release. First, they must have an initial consultation with CMS. The new process requires states to release an IV&V RFP and finalize a contract with an IV&V consulting company prior to the development of the MMIS RFP. The Centers for Medicare & Medicaid Services strongly recommends that states engage a systems integrator to help with the requirements elaboration and solution design tasks for the RFP. This is a new recommendation aimed at reducing architectural integration failures.

Another new requirement is for states to use the MITA State Self-Assessment and Concept of Operations, in consultation with CMS, to select the appropriate certification checklist packet for their implementation initiatives.

Then the state and/or its designee complete all of the Project Initiation Milestone Review sections of the checklists. Along with the IV&V Certification Progress Report, these review sections inform the updated Implementation Advanced Planning Document (IAPD). The state must then plan MMIS certification milestone reviews in coordination with the CMS Central Office. Once the IAPD has been reviewed and approved, RFPs for any planned modules or replacement systems can be released.

States – including the Project Management Office and contractors – plan and manage the MMIS project as before. They ensure the IV&V contractor has access to evidence needed to prepare certification progress reports, track risks and issues and manage them through resolution. States then prepare or approve each of the required artifacts including the IAPD, the Concept of Operations document and the State Self-Assessment.

Just prior to go-live, states will go through a newly defined Operational Milestone Review to validate the system is ready and that the solution objectives have been met. A key input into this review is the Certification Progress Report produced by the IV&V. Finally, 6 months to 12 months after go-live, the traditional MMIS Certification Final Review is performed.

CMS Regional Office

The CMS Regional Office (RO) serves as a resource for states throughout the certification lifecycle. Historically, the RO had involvement at the very beginning of projects and after their completion, but had limited interaction during the solution development process. Now, they play a significantly greater role in the procurement, development and review process.

At the beginning of the lifecycle, the RO reviews and approves draft IV&V RFPs and Planning Advanced Planning Document

The Industry

New Review MilestonesThe complete MECL now has three formal CMS review milestones:

1. Project Initiation Milestone Review occurs prior to RFP release

2. Operational Milestone Review(s) happen upon completion of system/module development and testing

3. MMIS Certification Milestone Review(s) take place after system/ module stabilization

Page 13

(P-APD) and consults with states once the MMIS concept of operations (COO) is complete. As part of the CMS certification review team, the RO reviews the IV&V’s certification progress reports and participates in each of the milestone reviews. The RO approves IAPDs and development contracts and stays abreast of the state’s progress throughout the MMIS project. A state may consult with its RO at any time. While the Regional Office participates throughout the procurement and development process, the CMS Central Office retains formal approval and funding authority.

IV&V Contractors

The role of the IV&V contractor changes and expands under MECT 2.0. CMS now requires specific language in the IV&V RFP and contract verifying their independence – technically and managerially – from both the state agency overseeing the MMIS delivery and the solutions they wish to procure. The IV&V must now prepare a standardized Certification Progress Report at least every 180 days delivered simultaneously to the state and CMS, or at timeframes agreed upon by both. These reports objectively illustrate the risks, strengths and weaknesses of the project and provide recommendations for correcting any identified risks. The first report is due prior to the Project Initiation Milestone Review before the RFP is released. The scope of the IV&V contract includes planning, management and other programmatic activities in conformance with the term’s usage in federal regulations at 45 CFR 95.626.

In preparation for the MMIS certification milestone reviews, the IV&V must evaluate state documents and evidence along with any working modules or code applicable to that particular review and operational artifacts including the training plan. They then complete the reviewer comments portion of the Medicaid Enterprise Certification Checklists. The completed checklists are appended to the Certification Progress Report.

The IV&V activities begin earlier and end later than before. They start well before the RFP is released, continuing through the entire development cycle and continuing at least through the MMIS Certification Final Review.

The IV&V contractor represents the interests of CMS and provides an independent and unbiased perspective on the progress of MMIS development and the integrity and functionality of the system. CMS expects that the IV&V contractor will participate in a state’s gate reviews and inform CMS of significant risks or issues as the modules or system is planned, developed and deployed. The IV&V contractor reviews project and technical progress against the state’s baseline plans and against requirements contained within the Medicaid Enterprise Certification Checklists. The IV&V must not be the entity performing software testing or quality assurance activities.

System Integrators

CMS strongly recommends that states engage the services of a skilled system integrator, especially if they are selecting a modular approach to system procurement. This new guidance is designed to increase the likelihood of a successful implementation.

The system integrator coordinates the merger of technical solutions, modules and testing schedules. They work to ensure all modules work together seamlessly and securely. They also work to manage risks in technical or schedule slippage between modules. System integrators also negotiate outcomes to disagreements that may arise between development contractors who are developing different modules. CMS has promised additional sub-regulatory guidance on their expectations of system integrators in future State Medicaid Director letters.

ConclusionThe new certification checklist and lifecycle represent a significant shift in the CMS approach to reviewing, approving and certifying MMIS systems. Changes in the certification lifecycle focus on assisting states meet all federal requirements and satisfy the requirements in their APD. CMS hopes to reduce the number of failed or significantly delayed implementations and ensure that the federal dollars spent are achieving the desired results.

The roles and responsibilities of the various participants will change under the new method. CMS is encouraging greater oversight and reporting through the enhanced role of IV&V contractors and system integrators. They are also participating and inserting additional, formal milestone reviews into the procurement and development activities. There is now a longer lead time prior to the release of the RFP, during which states have been asked to complete more planning and preparation activities.

The ultimate goal of the MECT 2.0 is to reduce the risk of delivery failure and increase the alignment between the solution, the stated requirements and federal mandates. Medicaid requirements and objectives have changed significantly in the past 10 years. CMS has updated the certification process to align more closely to that evolving landscape.

Back to Table of Contents

Page 14

Our Business

Earlier this year, Xerox announced our New Path Forward initiative. At the end of 2016, we will separate into two independent publicly-traded companies. While the document technology company will retain the Xerox name, our business process services organization – including the Government Healthcare Solutions group – will begin a new chapter under the name Conduent.

With approximately $7 billion in 2015 revenue and 96,000 employees, Conduent will be a leading provider of business process services with expertise in transaction-intensive processing, analytics and automation. Conduent will focus on industry-specific service offerings in healthcare and transportation, as well as cross-industry service offerings in transaction processing, customer care, payment services and more.

The new company is poised for future growth and will carry on the Xerox legacy of innovation, diversity and integrity, along with an unwavering commitment to delivering the best-in-class client service that we are known for around the world.

Back to Table of Contents

To learn more about Conduent, you can watch an informational video at https://youtu.be/pJeC5CEid_8. It explains the focus of each new entity and features a few members of our East Coast operations teams. Additional information is available online at xeroxpathforward.com.

A New Path Forward as Conduent

Page 15

Xerox Recognized for Reducing Newborn ReadmissionsContinued from cover.

Our Care Management Solutions group was recently recognized by the Case Management Society of America. At the recent CMSA Annual Conference & Expo in Long Beach, Calif., the Society presented Xerox with the 2016 Case Management Practice Improvement Award.

The award highlights an individual, group or organization that uses the results of a quality and/or performance improvement project for innovation to advance the practice of case management and/or improve outcomes for a client. Xerox was recognized for using analytics to improve the care of jaundiced newborns for a state Medicaid program. “It was a privilege to help others recognize that Xerox makes a difference in lives starting as early as birth,” said Alison Keenan, Senior Business Development Specialist for the Care Management Solutions team.

In May 2014, the Care Management team reviewed the Quarterly Total Population Health Program Report with the state. The results were positive, especially in terms of low readmission rates. But wanting to take advantage of every opportunity to improve health outcomes, the team decided to dig a little deeper to see if there were hidden opportunities to improve outcomes even further.

Further data analysis uncovered higher readmission rates in newborns than any other admitting diagnosis. In particular, conditions originating in the perinatal period had a significantly higher 30-day readmission rate. The team also found that the state’s rural counties had the highest readmission rates for conditions originating in the perinatal period.

Because the team’s quality improvement process also incorporates social determinants of health, this deeper dive revealed that several rural counties received no support

from home phototherapy Durable Medical Equipment (DME). Coupled with lack of transportation, this environment caused recently discharged jaundiced infants to be readmitted to the hospital for further care.

Using this knowledge, the Xerox and state teams collaborated on care management processes and quality improvement strategies to assess the readmission problem, identify barriers and strengths, plan strategies and ultimately improve outcomes. Armed with a plan for improving transition-of-care processes within the healthcare system, they worked to implement strategies to eliminate barriers and decrease overall healthcare costs. This included educating physicians and hospital staff on improved post-discharge treatment practices, as well as:

• Collaborating with community hospitals, providers and public health nursing to identify barriers and implement improvement strategies

• Combining interventions and educational materials to increase the health literacy of members to prevent jaundice

• Referring breast-feeding mothers to public health nurses for education

• Providing coaching for new mothers with high-risk birth outcomes

• Collaborating with DME providers about the availability of home bilirubin lights and blankets

• Continuing transition of care activities for all Medicaid members discharged from the hospital

• Increasing the overall level of awareness of jaundice through educational presentations and an ongoing focus for future new mothers

Once the plan was in place, the team analyzed the data again to evaluate the outcomes. After 12 months, newborn readmission rates were reduced significantly, along with overall readmission rates, helping the state reduce Medicaid healthcare costs. In addition, the campaign and transition-of-care interventions helped the state avoid more than $1 million in healthcare costs caused by readmissions.

The Care Management Solutions team is very proud of their Case Management Practice Improvement win. “Normally when you complete a review of the numbers, you are ready to put the task behind you and move on,” continued Keenan. “Certainly in this case, it made a difference in the lives of many, both now and in the future. It is so gratifying to see that hard work really does pay off and that it matters when quality prevails.”

Back to Table of Contents

Page 16

Our Business

The most visible part of this initiative has been our partnership with the Medicaid Learning Center (MLC), a training and education company that provides online learning solutions to Medicaid professionals. Beginning in 2015, people in roles ranging from account managers to business development leaders to operations and customer care managers have enrolled in MLC’s series of courses to gain a comprehensive overview of Medicaid.

The training encompasses 26 online training modules that cover a wide range of topics. These include industry basics and terminology, stages of the procurement cycle, the MITA framework, the laws and regulations specific to Medicaid and current issues in healthcare reform. The courses not only provide in-depth studies of these areas, they also show how all of the parts of the Medicaid system work together as a whole to serve needy citizens. The modules must be completed within 90 days.

Upon successful completion, enrollees in the training are awarded a two-year MLC Medicaid Certified Professional-II (MCMP-II) certification.

The program has already had positive results. Nearly 300 members of the Government Healthcare Solutions group have received their MCMP-II certification to date; we anticipate starting another wave of this training later this year. MLC has increased their understanding of Medicaid and given them a wider perspective of the system outside of their existing roles and functional areas. They have a better idea of how their work affects other areas of the system, and because they know more about Medicaid as a whole, they can better tailor their efforts to meeting the needs of their specific state clients.

What are some of the benefits of the certification? We asked several recent graduates of the program to share their perspectives.

Serving States Better with Medicaid Learning Center Certification Many people in the Government Healthcare Solutions group have years of experience working with Medicaid programs. But that doesn’t mean we want to rest on our laurels. Over the past year, we have created new opportunities for training and employee development that increase the value we provide to our clients. What’s more, this has not been a top-down initiative; people from all levels our organization actually requested opportunities to learn about the programs they serve.

Donna Pulgiano, Contact Center Operations Manager

MLC enabled me to see the total picture. This course enabled me to view the evolution of government healthcare and see how funds and resources were provided to enhance it. I had more insight into the ultimate goals of each piece of legislation that was passed. I also better understand the federal vision and funding components as well as the steps clients must take to ensure funding. This helps me better position my staff and our internal procedures to support this evolution going forward. I feel that I am more confident that I can partner with my client to pave our road to success together.

Doug Davis, Executive Account Manager

MLC is a great refresher for someone like me who has been in “the biz” for a while. For me, the MITA sections were particularly valuable. Having up-to-date knowledge allows better communication with our clients as they are the primary ones communicating with CMS. Our team is better able to understand their

Page 17

Pharmacy Team Wins Gold at AMCP

Several members of our Clinical Pharmacy team took home a gold award for their poster presentation at the recent Academy of Managed Care Pharmacy (AMCP) Managed Care & Specialty Pharmacy Annual Meeting. The event was held April 19–22, 2016 in San Francisco.

The Annual Meeting brings together experts across the fields of managed care pharmacy, healthcare and drug therapies. Attendees include managed care pharmacists; health plan administrators and medical directors; doctors, nurses and other practitioners; formulary decision-makers; and Medicare Part D and Medicaid administrators. The conference focuses on new legislative and regulatory developments, research, formulary management and other managed care pharmacy issues.

Keeping with the Annual Meeting’s goals, the event invites groups to submit abstracts of original research to encourage the exchange of ideas. Abstracts that deliver new insights and improvements to the managed care field are published and chosen to be presented during a poster session. The abstracts and posters are judged on five criteria: relevance, originality, quality, bias and clarity. Several hundred were presented at the 2016 Annual Meeting.

Our team of Janelle Sheen, Ashleigh Holeman, Anson Williams, Doug Brink and Amy Cully leads research efforts that focus on program outcomes for our Government Healthcare Solutions group. For the Annual Meeting poster session, they submitted “Analysis of Medical Resource Utilization Secondary to Automated Prior Authorization Criteria for the Oral Atypical Antipsychotics in a Medicaid Population.”

They compared the effects of prior authorization approvals and denials for oral atypical antipsychotic medications on medical resource utilization – items such as emergency room visits and hospital admissions.

They studied two years’ worth of data from our West Virginia client’s automated prior authorization program, focusing on age, diagnosis, step therapy and use of preferred medications. They wanted to determine if the prior authorization criteria for oral atypical antipsychotics adversely affected medical utilization for the members who were denied therapy.

After analyzing the per member per month utilization rates across multiple test groups, the team confirmed that the prior authorization criteria produced no adverse effects. The results of our study reassured West Virginia that their prior authorization criteria was increasing medication safety and reducing costs without negatively affecting their members’ health.

The abstract that was the foundation for this award-winning poster was published in the April 2016 issue of the Journal of Managed Care & Specialty Pharmacy, AMCP’s peer-reviewed publication. You can read it online at http://xrx.sm/rx7 on page 63.

We’re very proud of the clinical team’s work and hope to have more original research published through AMCP in the future.

Back to Table of Contents

needs and processes; this helps us better meet their expectations. All around we have more knowledge of how CMS works and their vision for the future.

Valerie Law, Product Market Manager

MLC has improved the way I work by reminding me to set realistic expectations. The evolution of Medicaid – and especially how changes to regulation are implemented – produces ebbs and flows in the marketplace. These changes rarely produce immediate, tangible results. Monitoring a trend line for how the market adopts and even interprets these changes is critical input to setting realistic expectations.

The best thing about the MLC courses is looking at the entire Medicaid ecosystem through a holistic lens. At times, we can stay so fixated on one piece of our business that we can forget about the others. This was a good reminder of how everything fits together. The training also ensures our clients receive the support of a knowledgeable staff committed to continuing education in their business.

Jenness Vaccarella, Client Management Lead

Having a broader understanding of Medicaid and the processes required for states to update their programs is invaluable. The MLC course helped me understand the different types of waivers and approval paths from CMS required for changes. It also shed light on the tools that are available to states for Medicaid program assessment, changes and reporting. This helped me become more proactive with ideas for our client, who was very impressed that Xerox had invested in the training.

The knowledge gained from MLC helps us work better with our clients and assist them with each step of the process – especially around MITA assessments. It’s critical to gain insight into the client’s self-assessment, areas they have identified for improvement and how we can help them meet their goals. Also, most people in my role have a specific area of expertise. This training provides a broad range of information to think outside our subject matter area to assist our clients.

Back to Table of Contents

Page 18

Your News

Montana’s Successful Medicaid ExpansionContinued from cover.

In the weeks after expanded enrollment began, the state found that the expansion was much more popular than expected. More than twice that number of newly eligible citizens applied for benefits – a greater amount than could be handled by the existing enrollment infrastructure. Acting quickly, the state developed a strategy to cost-effectively update its enrollment process to help connect these needy citizens with the assistance they needed.

Montana had been working with Xerox for 32 years. In addition to supplying fiscal agent services for the state, we were also aligning Montana’s new pharmacy benefits management service with the expanded Medicaid program. The state was implementing our Xerox® Flexible Rx Solution (the first in the country to do so) with an expected launch in early December 2015. This successful relationship made us a natural fit to collaborate and help configure the state’s existing resources to administer healthcare benefits in time for the expected January 1, 2016 launch.

The first step was to deploy teams to modify the MMIS and Flexible Rx solutions to be ready to administer expanded Medicaid benefits by the launch date. Both needed to meet specific requirements from state legislation as well as the Centers for Medicare and Medicaid Services (CMS). For example, the systems had to be ready to administer benefits to members who joined under the expanded program that were different from individuals in the regular Medicaid program without any disruptions. These teams also updated a web portal that provides healthcare providers with information about the people newly enrolled, as well as the services and benefits to which they were entitled.

Page 19

The teams then turned to contacting and communicating with new members to help them enroll in the Medicaid program. Welcome kits were developed and distributed that provided program information the new members would need, such as the benefits for which they qualified, provider services available and their coverage eligibility.

The final step was providing additional training to call center staff so they would be ready to respond to enrollment and benefit questions from both members and providers over the phone.

Montana successfully launched its expansion program as scheduled on January 1, 2016. The enrollment support was prepared and the MMIS system was ready to process claims. And despite having just gone live at the beginning of December, the pharmacy team was able to change direction and support the expanded Medicaid benefits.

Montana’s expanded Medicaid program launched as smoothly as possible. Today, more than 50,000 people have medical benefits and are able to access care from doctors, hospitals, dentists and other care givers across the state. “Medicaid expansion is dramatically improving the health of our state,” said Jessica Rhoades, Policy Director of the Montana Department of Public Health and Human Services. “To date, almost 50,000 individuals have signed up for coverage. The launch of this program was a huge undertaking, and Xerox’s readiness played an important part.”

Back to Table of Contents

“ Montanans had waited years for health coverage, and we committed to Montanans that this coverage would be available on January 1, 2016. The launch of the HELP Act involved the coordination of dozens of components. Xerox’s efforts were key in helping us launch on schedule.”

– Jessica Rhoades Policy Director Montana Department of Public Health and Human Services

WritersAllyson Burroughs, Senior Editor Vice President, Marketing and Communications

Thad Thompson, Editor Manager, Marketing and Communications

Rob Carpio Marketing Specialist

Larry Dent, PharmD, BCPS Clinical Account Manager, Pharmacy Solutions

Steve Reynolds, CPM, MPA Vice President, Market Management

Frank Spinelli Vice President, Care Management Solutions

Jeff Strand Senior Business Architect, National Standards Consulting

Sharing ideas drives innovation. That’s what Xerox does with HealthFocus – highlight new ways government healthcare programs can improve health outcomes. We cover topics related to our industry, news about our business and specific issues you deal with every day. Our goal is to capture the vast array of information that affects us all and encourage conversations that broaden our perspectives.

Xerox State Healthcare, LLC 9040 Roswell Road Atlanta, GA 30350

©2016 Xerox Corporation. All rights reserved. Xerox® and Xerox and Design® are trademarks of Xerox Corporation in the United States and/or other countries. 07/16 THOTH-121 BR19375

Contact UsDo you want to share story ideas, feedback or news from your state?

Call us at 800.334.5979 x1674 or send an email to govhealthcare@xerox.com.

www.xerox.com/govhealthcare

Back to Table of Contents