Even though your practice is not participating in the initial phase, here is what you need to know:

 
Patient Attribution and “the letter”:
HCPF (Colorado Medicaid) is in the process of enrolling approximately 8,600 patients in each of the seven (7) RCCO regions, including approximately 2,900 children. The Accountable Care Collaborative Process is considered a passive enrollment process for patients. Passive enrollment is the process where patients are enrolled into a plan if they do not respond and choose a plan for themselves. When a client is passively enrolled into the ACC, the state’s database system (MMIS) enters an enrollment for them effective the first of the following month (typically about 45 days). The information is sent electronically to HealthColorado, who then sends out a packet of information. The packet gives the client information about the plans available to them, and gives them 30 days to opt-out of the ACC before it becomes effective. The Accountable Care Collaborative (each RCCO), Rocky Mountain Health Plan, Denver Health Medicaid Choice, the Primary Care Physician Plan, and Fee for Service (Regular Medicaid) are all considered plans.

This packet includes a letter that assigns the Medicaid member to the ACC, assigns them to an RCCO and assigns them to a particular ACC contracted primary care provider (PCMP) (please see below under “More information” for a link to the letter templates).  Many families need help in understanding the letters.   Some families do not receive the letter.   There is a chance that your patient will be assigned to another provider (another medical home).  If the client does not respond to the letter, the patient will be enrolled in the ACC, assigned to the RCCO for the region in which the patient lives and assigned to a provider. The method that HCPF uses to assign patients to their correct medical home has some problems.  Some patients are being mis-assigned.  Patients have the option to select a different PCMP (medical home) than appears on the letter.  If your patient has inadvertently been assigned to another practice, the patient must call Health Colorado to make any changes!  Clients may call to change doctors within the plan at any time. If a client calls to change doctors, the effective date of the change is the first of the month after the request is made.  If you see the patient at a time when they are assigned to another PCMP, you will still be paid Medicaid fee-for-service, but will not be eligible for the PMPM until the patient changes their provider selection.

If a client calls HealthColorado to remove themselves from the ACC plan within the first 30 days, the enrollment is voided out of the system and never becomes effective for the client. If the client does not respond to the letter, the client is then enrolled into the ACC. Once the enrollment has become effective, the client can still disenroll from the plan for the next 90 days by calling HealthColorado to disenroll. If the client calls, the change in enrollment is effective the first of the month after the change is requested. After the first 90 days, the client can only change plans once a year during their open enrollment. Open enrollment is the two months before the month of birth. If a client calls during their open enrollment to change plans, the effective date of the change is the first day of their month of birth.  Non-participation in the ACC will not affect the patient’s Medicaid eligibility or Medicaid services.

You and your practice staff need to be knowledgeable about the letter that will be mailed to patients so that you can help explain the importance of this letter and counsel your patients appropriately, should they desire to make any changes. Here are some possible strategies:

Proactively educate your patients about this letter using one or more of these methods:

• In person when the patient is in the office
• A posted notice in the office where patients can see it
• When parents of children on Medicaid call the office
• A handout
• Encourage your patients to call your office if they need help with the letter.

Explain the Health Colorado letter to the patient: (Remember, not all patients will receive this letter!)

• “You may get enrolled in a new Medicaid health plan.  This plan does not affect your eligibility for Medicaid, nor does it affect the services that you can receive.”
•  “You may get a letter in the mail that looks like this (show them the template)”
• “If you receive this letter, make sure that our office or one of our physicians is listed as the Primary Care Medical Provider in the letter” - “If we are, you need not do anything else”
• “If no assigned provider is listed or if another practice/physician is listed in the letter as the PCMP, make sure you call 303-839-2120 immediately to have that changed to our practice/physician”. Help the patient make the phone call if possible.
• Explain to the patients that “If you do not wish to participate in this plan, call 303-839-2120 immediately.  Participation in this plan or not participating in this plan in no way effects your Medicaid benefits.”
• IMPORTANT: If your practice will not be participating in the initial phase of the ACC, and your patients receive a letter assigning them to the ACC, you should advise your patient to call and opt out of the ACC and back into regular fee for service Medicaid so they can continue as your patient.

To participate:
Providers interested in participating in the program may contact the RCCO in their area.  CCHAP staff are available to help you think through whether or not to participate in the early phases or wait until later to participate.  We have helped a number of practices with this decision.  CCHAP is working closely with the RCCOs with the offer to do whatever we can to help make the initial phase (pilot phase) successful.

More information:
For more information and document links, please see this web page:
http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1233759745246

As always, CCHAP is here to help you with information and support.  Feel free to contact:
Kevin Heckman (CCHAP administrator): Kevin.heckman@childrenscolorado.org, 720-777-6309
Steve Poole, M.D., steven.poole@childrenscolorado.org, 720-777-6004

- Top of Article - Top of Newsletter - CCHAP Home -

Practice Manager's Corner

CCHAP Practice Manager Meeting – Thursday August 18th

Our next Practice Manager meeting will be on Thursday August 18th at noon. The meeting will be held at Children's Hospital Colorado. We will discuss updates to Colorado Medicaid Reform and the RCCOs; Patient Attribution and Enrollment Letters; Practice Expectations and Care Coordination and Recent Changes to Medicaid Coding and Reimbursement. More details coming via email...

Medicaid Reform - Accountable Care Collaborative Update from HCPF
State Medicaid has begun contracting with participating Primary Care Medical Providers (PCMPs) for program implementation into the Accountable Care Collaborative program. These PCMPs are located in defined focus communities of the Regional Care Collaborative Organizations. As of June 30, 2011 there were a total of 30,177 clients enrolled into the Accountable Care Program:
RCCO 1 – Rocky Mountain Health Plans had 5,747 clients;
RCCO 2 – Colorado Access had 4,764 clients;
RCCO 3 – Colorado Access had 3,229 clients;
RCCO 4 – Integrated Community Health Partners had 5,377 clients;
RCCO 5 – Colorado Access had 2,323 clients;
RCCO 6 – Colorado Community Health Alliance will have their first members beginning 9/1/2011
RCCO 7 – Community Care of Central Colorado had 8,737 clients.
For the month of July 2011, enrollment letters were sent to approximately 13,000 clients state-wide (all regions), bringing the total number of client enrollment letters sent to 43,000. As of the end of June 2011, the total opt-out rate for all regions was 1.68 percent.
If you would like more information, please contact Sarah Roberts.

New Developmental, Depression, and Autism Screenings Policy
Effective for dates of service on or after August 1, 2011, the Department of Health Care Policy and Financing has issued the following policy for developmental, depression, and autism screenings, and has set the following rates for CPT codes 96110 and 99420. The Colorado Medical Assistance Program will reimburse developmental screening code 96110 at $17.00 and depression screening code 99420 at $10.08. Click this link for more details: August 2011 Medicaid Provider Bulletin

NOTE: Medicaid inadvertently loaded an incorrect reimbursement rate for 96110 ($13.37) as of July 1st. The rate will be corrected to $35.83 for dates of service in July and the applicable claims will be reprocessed. These claim corrections should process in late August.

Effective August 1st the rate for 96110 will be reduced to $17.00.

CHP+ Patient Eligibility Issues
Both CCHAP and Colorado Access have been hearing from members and providers that they are getting very frustrated with eligibility issues. We wanted you to be aware that these problems are not occurring within the Colorado Access system. Colorado Access is, however, working with the State and Maximus to correct the current problems.

CHP+ Eligibility Issues:
The State is currently experiencing an increased volume of eligibility issues that stem from the CBMS/MMIS system problems.  Per the State this system issue is slated to be corrected in November 2012.  The system issue is having the following impacts:
•    The Web Portal will show CHP eligible but will not indicate which HMO the member is on
•    The Web Portal will show CHP eligible but an eligibility file does not get sent to the HMO plan - therefore the HMO plan shows no coverage
•    System issues are causing members to term in error

Member Impacts:
•    Members are unaware that there is a problem with their eligibility until they attempt to receive medical care or pick up meds at a pharmacy
•    Members are being turned away from appointments because providers can not verify eligibility
•    Members are not getting necessary medications

For assistance with CHP+ eligibility issues:
Maximus: Providers should first call 1-800-359-1991. There is an IVR (interactive voice response) option on this line that may be helpful to check on eligibility status. There is also a new number dedicated to providers: 1-877-311-4540, but please note that this is not an interactive voice response line and has limited resources available to answer your calls.
MOVEit  is a web based application implemented by MAXIMUS to help providers communicate with MAXIMUS and get updates and issues resolution. MOVEit uses email-like communications, referred to as “packages” that are encrypted during delivery to safely and securely transmit protected health information e.g. ID and social security numbers, names, etc…To sign up for MOVEit: Send a request to eemapsupport@maximus.com
Colorado Access Customer Service is available between the hours of 8:00 a.m. and 6:00 p.m. Monday through Friday. They can be reached at (303) 751-9051, toll free 1-800-414-6198 or TTY for the deaf or hard of hearing at 1-888-803-4494.
CCHAP is available to help by calling 720-777-6363.

Medicaid EHR Incentive Program
The Medicaid EHR Incentive Program will provide incentive payments to eligible providers as they adopt, implement, upgrade or demonstrate "meaningful use" of certified EHR technology. CORHIO will be responsible for program coordination as well as provider education and communications, providing a central point of contact on behalf of Medicaid. For more information, please contact Bill Heller

Emergency Room Visit Team
Colorado Medicaid clients use the emergency room more frequently than the national Medicaid managed care average. An informal analysis showed that approximately 15 percent of emergency room visits in 2008 were true emergencies. To view a Colorado map that illustrates ER utilization by county, please click here.
A team was formed in April 2009 to reduce the number of unnecessary emergency room visits. Recommendations stemming from that team resulted in the FY 2009- 2010 second quarter rate of emergency room visits being 9 percent lower than the FY 2010-2011 second quarter rate (880 vs. 804, respectively).
A 2012 Emergency Room Visit Team was convened to get input on how to further reduce the rate of emergency room visits. Team participants include representatives from organizations closest to the issue: Colorado hospitals, the Colorado chapter of the American Academy of Pediatrics, emergency room physicians, community mental health centers, Medicaid and CHP+ contracted HMOs, community health clinics, Behavioral Health Organizations and the newly designated Regional Care Collaborative Organizations. We will be investigating the feasibility of the ideas from the group and will provide updates.
If you would like more information, please contact Katie.Brookler@state.co.us.

Providers Serving Pregnant Women Office-Administered Injections:
Medicaid Coverage of Injections for Prevention of Preterm Birth
Effective for dates of service on or after August 1, 2011, Colorado Medicaid will cover 17α hydroxyprogesterone caproate (17P) injections for the prevention of preterm birth. Click this link for more details: August 2011 Medicaid Provider Bulletin

- Top of Article - Top of Newsletter - CCHAP Home -

Cultural Values of Latino Patients and Families

By Marcia Carteret, M. Ed.

Failure to understand and respond appropriately to the normative cultural values of patients can have a variety of adverse clinical consequences: reduced participation in  preventive screenings, delayed immunizations, inaccurate histories, use of harmful remedies, non-compliance, and decreased satisfaction with care to name a few. A primary challenge in working with patients from different cultural backgrounds is being able to use cultural generalizations appropriately without losing sight of the individual patient/family. To succeed in this challenge, clinicians must keep in mind that variations occur between cultural subgroups just as individuals subscribe to group norms to varying degrees. Factors such as socio-economics, education, degree of acculturation and English proficiency have an enormous impact on a person’s health beliefs and behaviors.

In this article we will take a look at Latino culture specifically, keeping in mind that a wealthy Cuban American who has been in the United States for many years will likely have cultural values that are markedly different from a recent immigrant to the US from Mexico. Please also check out the article archives at www.dimensionsofculture.com for more articles about health care for Latino cultures.

Definitions: Latino vs. Hispanic

The term Latino denotes all persons living in the United States whose origins can be traced to the Spanish-speaking regions of Latin American, including the Caribbean, Mexico, Central American, and South America. ( Flores 2000) The term Hispanic was created by the U.S. federal government in the early 1970s in an attempt to provide a common denominator to a large and highly diverse population with connection to the Spanish Language. It is often considered a somewhat narrow indicator by those who prefer the term Latino. Interestingly, “Hispanics” are a race to the United States Department of Justice when it enforces provisions of the civil rights laws, but Hispanics are not a race to the Bureau of the Census.

A Collectivist Culture With Strong Family Values (Familismo)

Latinos tend to be highly group-oriented. A strong emphasis is placed on family as the major source of one’s identity and protection against the hardships of life. This sense of family belonging is intense and limited to family and close friends. People who are not family or close friends are often slow to be given trust. The family model is an extended one; grandparents, aunts, cousins, and even people who are not biologically related may be considered part of the immediate family. The term Latinos use to describe their supreme collective loyalty to extended family is familismo. Financial support of the family by the individual and vice versa is important and expected. The decisions and behavior of each individual in the extended family are based largely on pleasing the family; decisions are not to be made by the individual without consulting the family. Failure of the clinician to recognize familismo can potentially lead to conflicts, non-compliance, dissatisfaction with care and poor continuity of care.  Familismo can delay important medical decisions because extended family consultation can be time consuming. To gain the trust and confidence of the Latino patient/parent, it is important to solicit opinions from other family members who may be present and give ample time for the extended family to discuss important medical decisions.

A Hierarchical Culture That Values Respecto

The term power distance is used in the field of intercultural communications to compare the extent to which less powerful members of a society accept that power is distributed unequally.  When power distance in a society is high, people tend to believe that everyone has their rightful place and they understand that not everyone is treated equally.  When power distance is low, people believe that everyone should have equal rights and the opportunity to change their position in society. In Latin American cultures, people tend to expect status differences between members of a society which is very different from U.S. American culture. Latinos place a high value on demonstrating respecto in interactions with others, which literally translates into respect. Respecto means that each person is expected to defer to those who are in a position of authority because of age, gender, social position, title, economic status, etc. Healthcare providers, and doctors especially, are viewed as authority figures. Thus, Latino patients/parents will tend to demonstrate respecto in healthcare encounters. They may be hesitant to ask questions or raise concerns about a doctor’s recommendations, being fearful that doing so might be perceived as disrespectful. They may nod to demonstrate careful listening and respect when a doctor is talking, rather than agreement about treatment.
Respecto is also expected on a reciprocal basis by Latinos when dealing with healthcare professionals. This is especially the case when a young doctor is treating an older Latino patient. It is important to approach Latino patients/parents in a somewhat formal manner, using appropriate titles of respect (Senor [Mr.] and Senora [Mrs.] and appropriate greetings [good morning or good afternoon]. This is especially true with older Latinos. U.S. Americans are recognized the world over as being highly informal. We jump to a first name basis with strangers almost immediately, signaling a collapse of status differences by doing so. Good intentions aside, people from many traditional cultures will not appreciate this informality. It will make them uncomfortable and may even be seen as rude behavior in certain situations.

Hierarchy in Latino Families

Latino families are often stratified based on age and sex. Generational hierarchy is expected – grandparent, child, grandchild. The oldest male (direct relative) holds the greatest power in most families and may make health decisions for others in the family. Latino men traditionally follow the ideal of machismo. They are expected to be providers who maintain the integrity of the family unit and uphold the honor of family members. Many Latino females, at least publically, are expected to manifest respect and even submission to their husbands, though this compliance varies by individual and is affected by acculturation in the U.S. Women follow the ideal of marianismo which refers to the high value Latino women place on being dedicated, loving and supportive wives and mothers. They are responsible for teaching Latino children culture and religion and for being ready to help those in need both in the family and community. It bears repeating that upward mobility, education and other societal factors are changing the above, but in isolated communities and among new immigrants, little has changed.

Latinos and Uncertainty Avoidance/Fatalismo

“A basic fact of life is that time goes only one way. We are caught in a present that is just an infinitesimal borderline between past and future. We have to live with a future that moves away as fast as we try to approach it, but onto which we project out present hopes and fears. In other words, we are living with an uncertainty of which we are conscious.” (Hofstede 2001)
Because human beings display a variety of cultural attitudes about controlling external forces, our attitudes about time, destiny and fate can be dramatically different.  In US American culture, we struggle to accept things as they are which creates high levels of stress and anxiety in our lives.  Our inner urge to be busy is directly correlated to a need to control life’s uncertainty and feelings of powerlessness toward external forces.  We focus on the individual as the locus of control in decision making and put little faith in fate or karma. We also exhibit an adversarial relationship to time, constantly needing to control the time shortage we face. We believe that multi-tasking is an important skill to develop and we rely heavily on technologies to help us do things like check our email while eating breakfast.
Latinos, by comparison, often have a strong belief that uncertainty is inherent in life and each day is taken as it comes. The term fatalismo is often used by Latinos to express their belief that the individual can do little to alter fate. This mindset manifests in health beliefs and behaviors in significant ways.  Latino patients are more likely than whites to believe that having a chronic disease like cancer is a death sentence. They may prefer not to know if they have cancer, and may believe that cancer is God’s punishment. As a result of fatalismo, Latino patients may be less likely to seek preventive screenings and may delay visiting a western doctor until symptoms become severe. They may avoid effective therapies for cancer and other chronic diseases, especially radical new treatments and invasive procedures. (Flores 2000)
It makes sense that a culture tolerant of uncertainty tends to have a relaxed attitude towards time. Many Latinos definitely treat time as flexible and do not value punctuality the way their healthcare providers may expect them to. In fact, within the Latino community, not being on time is a socially accepted behavior. This explains a tendency for Latino patients/parents to show up late for healthcare appointments fully expecting to be able to see their provider. Similarly, Latinos are more accepting of certain levels of chaos and don’t expect orderly processes. The western medical model, with its focus on data gathering and tracking, and its insistence on adhering to specific appointment procedures, may seem unduly regimented to less acculturated Latinos, especially those who are new immigrants.

Task vs. Relationship/Simpatia and Personalismo

If U.S. Americans are time and task-oriented, Latinos tend to be more focused on relationship. The word simpatia means “kindness” and refers to an emphasis on politeness and pleasantness even in the face of stress. Latinos expect that healthcare providers demonstrate simpatia and personalismo which translates into “formal friendliness.” Latinos may read the neutral or businesslike affect of western doctors as negative. If the physician seems hurried, detached and aloof, the Latino patient/parent may experience resentment and be dissatisfied with care. This of course reduces the likelihood of compliance with the doctor’s recommendations for treatment and follow-up. A physician should be attentive, take their time, show respect, and if possible communicate in Spanish. Physical gestures such as handshakes or even placing a hand on the shoulder help to communicate warmth. Latinos also expect their healthcare provider to exhibit confidence.

Conclusion

Healthcare providers need to be familiar with the normative cultural values affecting interactions with their patients from different cultures. While it is impossible to know everything about every culture, clinicians can learn about important cultural values by using published references, consulting colleagues from other ethnic groups, and speaking to interpreters and community members. It is also important to learn to ask patients questions in a culturally sensitive way, understanding that fear of making mistakes in communicating with them blocks the exchange of vital information.
The information provided here about Latino culture is meant to assist clinicians by providing a general framework. No hard and fast rules about interacting with Latino patients and families are being offered because they would lead to stereotyping. A cross-cultural mindset requires understanding one’s own health beliefs and behaviors first and then applying that baseline of understanding as a means of making effective comparisons across cultures. Clinicians should keep in mind that individuals subscribe to group norms to varying degrees. Factors such as socio-economics, education, degree of acculturation and English proficiency have an enormous impact on an individual’s health beliefs and behaviors. All these factors challenge one’s ability to understand and treat patients in cross-cultural settings, but meeting those challenges can be vital in reducing health disparities for Latino Americans in the U.S.

Sources Referenced for this Article
1. Hofstede, GH. Cultures Consequences. Second Edition 2001
2. Flores G. Vega LR. Barriers to Health Access for Latino Children: a review. Family Med 1998:30:196205
3. www3.Baylor.edu/Charles_Kemp/Hispanic_health.htm

- Top of Article - Top of Newsletter - CCHAP Home -

We are on FACEBOOK!

 
Click on the Facebook icon, below, to connect with us on Facebook and get the most up to date information about CCHAP! We will also, from time to time, highlight other important and time sensitive topics such as:

• Medicaid reform updates (the ACC and the RCCOs)
• Coding, Billing and Reimbursement changes
• Medical Homes for Children
• EHR Incentive and “Meaningful Use"
• “Best Practices” and Quality Improvement
• How to Maximize Reimbursement

Our intent is that you will use our Facebook page in conjunction with our CCHAP.org web page and other CCHAP e-mail blasts.

It is our hope to:

• network and interact with CCHAP affiliated practice managers, staff and providers
• provide timely, up-to-date updates for our affiliated practices
• link practices to meaningful content

Follow us on Facebook today!

- Top of Article - Top of Newsletter - CCHAP Home -

August 8, 2011

Infant oral health: The importance of medical providers & patient education

By: Cavity Free at Three and Healthy Teeth Happy Babies

You probably know that Early Childhood Caries (tooth decay) is the most common childhood disease in the United States. But, did you know that Colorado’s kids miss nearly 8 million hours of school annually due to acute oral pain and infection? (CDPHE, 2005)  The tragedy is that it doesn’t have to be this way because dental disease is virtually 100% preventable.

Oral health problems are especially prevalent in low socio-economic status (SES) populations.  More than 57% of Colorado third graders have experienced caries; that number jumps to over 72% among low SES third graders.

Regular dental care is an essential component of improving Colorado’s oral and overall health. However, even in the best cases, parents and children are in the dentist’s office only 2 days a year. This means that medical providers and public education campaigns are critical to providing supplemental care and information. Here are a few easy behavior changes you can share with your patients to keep their families healthy 365 days a year:

• Do not share spoons, forks, cups or anything else that could transmit cavity-causing germs
  
  
• No juice or sweet drinks, even milk, in the baby-bottle or sippy cup outside of mealtimes
  
  
• Never put your child to bed with a bottle or sippy-cup
• Clean baby’s gums with a clean washcloth morning and night; after the first tooth, brush with a small smear of fluoride toothpaste twice a day
  
  
• Take your child to the dentist as soon as the first tooth erupts or before age 1

Colorado is in the fortunate position of having both the clinical and social resources available to empower the high-risk population to take control of their oral health. Cavity Free at Three and Healthy Teeth Happy Babies are working together to supply providers with the information and resources they need to improve infant oral health.

For information about free trainings that allow providers to receive Medicaid reimbursement for dental care and program resources, contact Karen Savoie at: 303-724-4750, Karen.Savoie@ucdenver.edu or visit www.CavityFreeAtThree.org.

To order free bilingual patient education materials or find resources for dental treatment options in your area, contact Miles Graham at: 303-825-6100, Info@HealthyTeethHappyBabies.com or visit www.HealthyTeethHappyBabies.com.   

- Top of Article - Top of Newsletter - CCHAP Home -

Copyright 2011 Colorado Children's Healthcare Access Program and other entities as noted.

 CCHAP Home > Newsletter Articles > Newsletter 52, August 2011