How PrimeWest Works
Financing and Managing Health Care Costs
PrimeWest enters into a contract with and receives a fixed dollar amount from the Minnesota Department of Human Services (DHS) to purchase and/or provide health care services to PMAP beneficiaries. Health care services are delivered to enrollees through PrimeWest Health's network of contracted health and human services providers. PrimeWest Health reimburses providers on a fee-forservice basis for services rendered to enrollees. Any savings realized by PrimeWest are reinvested into strategies aimed at improving the health status of the region's Medicaid population.
PrimeWest Health allows counties to integrate Medicaid financing with the wide array of other publicly funded programs and private services delivered locally and to better coordinate these local assets.
Accessing the Program and the PrimeWest Health Provider Network
Medicaid-eligible residents enroll in the program through their counties. Once enrolled, enrollees select or are assigned a primary care provider but can seek care from any provider in the PrimeWest Health provider network for most services without need of a referral. This is PrimeWest Health's "Open Access" policy.
The PrimeWest Health network includes over 250 providers in and around the 13-county service area. These providers include physicians, hospitals, nursing homes, pharmacies, mental health and substance abuse care providers, and a host of allied health care providers. PrimeWest Health developed its provider network by contracting with any willing provider of quality care. The PrimeWest Health network strategy of inclusion rather than exclusion supports the viability of rural health care providers and the local economies to which they contribute.
Managing and Delivering Care
PrimeWest Health uses a care coordination approach to managing the health care of enrollees and pursues an open access policy rather than a gatekeeper method of managing care. PrimeWest Health's approach provides enrollees with improved access to care and a choice of providers; its approach also provides health care providers with fewer administrative burdens when providing care for PrimeWest Health enrollees.
Care coordination activities are conducted in collaboration with each county's public health and human services agencies and private sector health care providers. PrimeWest Health's Care Coordination program features four interrelated components designed to improve the health of the enrollee while reducing the cost of caring for the enrollee:
- Early problem identification and intervention, including Individual Service Plans (ISP) for high-risk enrollees with complex or potentially costly health care needs and conditions;
- Integrating and coordinating all social, mental health, chemical dependency, public health, medical, and pharmaceutical services around the needs of the enrollee;
- Identifying, analyzing, and pursuing opportunities to improve quality and service delivery;
- Addressing environmental, socio-economic, and behavioral risk factors that affect the enrollee's health and cause unnecessary (costly? avoidable?) health care service utilization.
PrimeWest Health also monitors and manages enrollee access and utilization of services to ensure that the appropriate service is provided to enrollees at the appropriate time.
Finally, PrimeWest Health continuously monitors and pursues initiatives for improving the quality of care provided to enrollees using regulatory approved and community-accepted standards and practices.