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Medicaid and The PCS

Medicaid and The PCS. Jay Feldstein, DO, CMO AmeriHealth Mercy/Keystone Mercy Health Plan. Company Overview. AmeriHealth Mercy and our affiliates comprise the largest family of Medicaid managed care plans in the United States, touching the lives of nearly 5 million members in 16 states.

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Medicaid and The PCS

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  1. Medicaid and The PCS Jay Feldstein, DO, CMO AmeriHealth Mercy/Keystone Mercy Health Plan

  2. Company Overview • AmeriHealth Mercy and our affiliates comprise the largest family of Medicaid managed care plans in the United States, touching the lives of nearly 5 million members in 16 states. • AmeriHealth Mercy is the nation’s expert and industry leader in providing managed care services and management for Medicaid and State Children’s Health Insurance Program populations.

  3. Mission and Values Mission • We help people: • Get care • Stay Well • Build healthy communities • We have a special concern for those who are poor. Values Advocacy Care of the Poor Compassion Competence Dignity Diversity Hospitality Stewardship

  4. Who We Are • Mission-driven, provider-affiliated • Largest Medicaid-only, multi-state plan with over 20 years of experience • Five distinct product lines: • Full risk health plans • Management and administrative service contracts • PerformRx pharmacy management • PerforMED care management • Behavioral Health

  5. The AmeriHealth Mercy Family of Companies

  6. Keystone Mercy Health Plan Pennsylvania

  7. THE FACTS • 300,000 MEMBERS • 200,000 ER VISITS / YEAR • $37 MILLION ER COSTS / YEAR • 20 HOSPITALS

  8. ER DIAGNOSIS • ASTHMA • CHEST PAIN • FEVER, URI • CHF • MUSCULOSKELETAL • ABDOMINAL PAIN

  9. ER ISSUES • 50% ADMITS THROUGH ER • FREQUENT FLIERS • MULTIPLE VISITS • MULTIPLE ER’S

  10. PATIENT POPULATION • MULTIPLE CO-MORBIDITIES • MULTIPLE MEDICATIONS • MULTIPLE PHYSICIANS • POOR HISTORIANS

  11. CASE EXAMPLE • 50 y.o. B/M, Diagnoses CAD, DM, HTN • HOMELESS • 68 ADMISSIONS • 10 CARDIAC CATHERIZATIONS

  12. PCS • MEDICAL RECORD AT POC • CLINICAL HISTORY • MEDICATIONS • DIAGNOSTIC TESTING • THERAPEUTIC GAPS

  13. OUTCOMES • REDUCE DUPLICATION OF DIAGNOSTIC SERVICES • APPROPRIATE MEDICATION THERAPY • REDUCE ADMISSIONS • REDUCE ER AND IP COSTS

  14. Results • 1000 RECORDS • MOST COMMON DIAGNOSES • Coma • Chest Pain • FINANCIAL

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