evidence-based medicaid: health care that works pay for performance: health care that adds value...
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Evidence-Based Medicaid: Evidence-Based Medicaid: Health Care That WorksHealth Care That Works
Pay for Performance: Pay for Performance: Health Care That Adds ValueHealth Care That Adds Value
Jeff Thompson MD MPH
Chief Medical OfficerWashington Medicaid
Program
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
2
Evidence-Evidence-Based Based
MedicaidMedicaid
Evidence meets PerformanceEvidence meets Performance
Medicaid will do P4P in Medicaid will do P4P in situations unique to situations unique to MedicaidMedicaidBariatric SurgeryBariatric SurgeryManaged CareManaged CareADHD DrugsADHD Drugs
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
3
Evidence-Evidence-Based Based
MedicaidMedicaid
Medicaid’s grading system for Medicaid’s grading system for service authorizations service authorizations (WAC 388-501-0165)(WAC 388-501-0165)
DSHS generally approves above the line
Below the line, provider needs to show the evidence or DSHS will disapprove via Prior Authorization
A = Randomized controlled clinical trials (cannot be based on Type III or Type IV evidence alone)
B = Consistent and well done observational studies (cannot be based on Type IV evidence alone)
C = Inconsistent studies
D = Studies show no evidence, raise safety issues, or no support by expert opinion
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
4
Evidence-Evidence-Based Based
MedicaidMedicaid
Performance: Performance: Community ADHD Drug Community ADHD Drug Prescribing Practices for Medicaid FFS ChildrenPrescribing Practices for Medicaid FFS Children
Sedatives
Methylphenidate7,303Amphetamine Salts
5, 188
Dextroamphetamine565
137 108
31
80
60
Age 17 and under FY2005
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
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Evidence-Evidence-Based Based
MedicaidMedicaid
Payment:Payment: ADHD 2 ADHD 2ndnd Opinion OpinionProcess for Process for ChildrenChildren
HRSA Pays Three Hospitals to Review ($225)HRSA Pays Three Hospitals to Review ($225) ADHD in < 5 year olds,ADHD in < 5 year olds, At high doses (120/60)At high doses (120/60) In combinations In combinations
>300 cases logged to date.>300 cases logged to date. 60% are approved60% are approved 40% are changed by the second opinion40% are changed by the second opinion ROI 3:1ROI 3:1
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
6
Evidence-Evidence-Based Based
MedicaidMedicaid
Performance: Performance: Community OutcomesCommunity Outcomesin Bariatric Surgeryin Bariatric Surgery
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
7
Evidence-Evidence-Based Based
MedicaidMedicaid
Process: Going from a D Process: Going from a D to a B Gradeto a B GradeSurgery gets a Surgery gets a “B” for “B” for diabetics who are diabetics who are obeseobese (BMI >35) and a (BMI >35) and a “D” “D” for other co-morbid for other co-morbid conditions (WAC 388-551-1600conditions (WAC 388-551-1600 Aug 2004))
6-month pre-op staging 5% weight loss
Nutritional, endocrine, and surgical consultation
3 Centers of experience (< 2% mortality, 15% morbidity and 50% weight loss)
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
8
Evidence-Evidence-Based Based
MedicaidMedicaid
Performance: Performance: Medicaid Pays a Medicaid Pays a Premium for Centers of ExperiencePremium for Centers of Experience
Year Total Payment (P) # Clients Avg Admission PUPM ALOS2002 $734,288 60 $13,351 $1,020 6.52003 $970,298 79 $14,928 $1,024 6.82004 $135,366 10 $13,537 $1,128 7.42005 $99,174 8 $12,397 $1,033 5.42006 $55,792 6 $9,299 $775 6.2
30 days ReadmissionsCosts # Costs #
$49,151 3 $74,229 3$80,227 7 $52,809 4
$0 0 $22,219 2$21,629 1 $21,629 1
$0 0 $18,320 2
Outliers
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
9
Evidence-Evidence-Based Based
MedicaidMedicaid
Performance: Medicaid Performance: Medicaid Managed CareManaged Care
Incentives in place since 2004Incentives in place since 2004 Incentives for HEDIS Incentives for HEDIS
measuresmeasures 2 year old immunizations2 year old immunizations 3 categories of well child care 3 categories of well child care
(birth to 15 months; 3 – 6 years and 12 (birth to 15 months; 3 – 6 years and 12 to 21 years)to 21 years)
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
10
Evidence-Evidence-Based Based
MedicaidMedicaid
Performance: Medicaid Performance: Medicaid Vaccinations Vaccinations
Well-Child CareWell-Child Care Birth to 15 Birth to 15
monthsmonths 2004 – 43.7%2004 – 43.7% 2005 – 41.4%2005 – 41.4% 2006 – 47.0%2006 – 47.0%
3 to 6 year olds3 to 6 year olds 2004 – 53.5%2004 – 53.5% 2005 – 53.0%2005 – 53.0% 2006 – 55.0%2006 – 55.0%
12 to 21 year olds12 to 21 year olds 2004 – 35.2%2004 – 35.2% 2005 – 36.8%2005 – 36.8% 2006 – 32.0%2006 – 32.0%
Combo 1 Immunization Combo 1 Immunization raterate
2004 – State average 2004 – State average 66.9%66.9%
2005 – State average 2005 – State average 69.9%69.9%
2006 – State average 2006 – State average 74.1%74.1%
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
11
Evidence-Evidence-Based Based
MedicaidMedicaid
Structure and ProcessStructure and Process
Formal link with Washington State Child Formal link with Washington State Child Profile Immunization RegistryProfile Immunization Registry
Plans uniformly using robust methods Plans uniformly using robust methods Implementing stronger interventions to Implementing stronger interventions to
improve immunization careimprove immunization care Some plans are rewarding Some plans are rewarding
providers/clinics financially for improved providers/clinics financially for improved performanceperformance
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
12
Evidence-Evidence-Based Based
MedicaidMedicaid
Performance: Based on Performance: Based on OutcomesOutcomes
DSHS set aside $1,000,000 each to be paid for DSHS set aside $1,000,000 each to be paid for improved performanceimproved performance 1,000,000 for improved immunizations1,000,000 for improved immunizations 1,000,000 for improved well-child care1,000,000 for improved well-child care
Calculations based on point system rewards Calculations based on point system rewards plans forplans for Current year performance relative to other plansCurrent year performance relative to other plans Improvement from previous year to current year Improvement from previous year to current year
relative to other plansrelative to other plans Four highest performing plans share rewardsFour highest performing plans share rewards
Jeff Thompson MD MPH
Chief Medical Officer
Washington Medicaid Program
13
Evidence-Evidence-Based Based
MedicaidMedicaid
Performance Based Care:Performance Based Care:What’s Important?What’s Important?
Mortality vs. Morbidity?Mortality vs. Morbidity? Process vs. Outcomes?Process vs. Outcomes? My Value vs. A Payer’s ValueMy Value vs. A Payer’s Value Local control/measures? vs. Local control/measures? vs.
Central control/measures?Central control/measures? All Politics is Local vs. All Quality is All Politics is Local vs. All Quality is
Central?Central?