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UPMC program works to revamp Medicaid payment system

James Knox | Tribune-Review
Dr. Deb Moss gives a checkup to a Medicaid patient in the Children's Hospital Office Building on Monday, Dec. 17, 2012, in Oakland. UPMC for You, a nonprofit Medicaid managed care organization, received a $440,000 grant over three years from the Robert Wood Johnson Foundation to devise a program to overhaul the Medicaid payment system.

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UPMC for You is trying to design a system to improve care for children with complex medical conditions while reducing costs.

UPMC for You, a nonprofit Medicaid-managed care organization, received a $440,000 grant over three years from the Robert Wood Johnson Foundation to overhaul the payment system for these children. Officials are hopeful the changes could become a model to revamp the entire Medicaid program.

“We're hoping that by reducing the restrictions in the way care is financed, we'll be able to provide (information) for pediatricians and families about what works and what's best for the kids,” said Dr. Deborah Moss, pediatric medical director of the program.

Partners in the project are Community Care Behavioral Health; Children's Hospital of Pittsburgh; Children's Community Pediatrics and Primary Care Center; UPMC Home Care; and pediatric specialists and pharmacists.

UPMC was one of 50 applicants for four grants to improve Medicaid, the federal program that provides health care for low-income people. The Robert Wood Johnson Foundation also gave grants to Pacific Business Group on Health in San Francisco, the Oregon Primary Care Association in Portland and the State of Vermont Green Mountain Care Board in Montpelier.

Andrea Ducas, program officer for Robert Wood Johnson, said the foundation liked the UPMC for You proposal because it targets medically challenged children who could require many trips to a doctor or hospital. Such children include those with birth defects, epilepsy, pulmonary disease or neurological disorders.

The UPMC for You model will offer families medical accounts through which they could direct part of their Medicaid allotment to services they need. A family could choose to transport a child by taxi to the doctor rather than by ambulance, for example.

“What's very novel and creative about this project is that families are involved as an integral part of the care piece,” said Pamela B. Peale, chief analytics officer for the UPMC Insurance Division. “They work with providers to decide a bundle of services that would better suit their situation.”

The idea for the program evolved from problems a patient had last year with the old system.

“The point is it won't cost more and we'll get better value for our money,” said John Lovelace, president of UPMC for You.

Bill Zlatos is a staff writer for Trib Total Media. He can be reached at 412-320-7828 or bzlatos@tribweb.com.

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