www.chcs.org

Leveraging Medicaid to Encourage

HIT Adoption and Strengthen

Primary Care

Dianne Hasselman

2010 Medicaid Managed Care Congress

September 28, 2010

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CHCS Mission

To improve health care quality for low-income children and

adults, people with chronic illnesses and disabilities, frail

elders, and racially and ethnically diverse populations

experiencing disparities in care.

CHCS Priorities

Improving Quality and Reducing Racial and Ethnic

Disparities

Integrating Care for People with Complex and Special

Needs

Building Medicaid Leadership and Capacity

National Reach• 47 states

• 160+ health plans

The challenges facing Medicaid are

unprecedented….

• Fiscal environment demanding cuts to budget

• 15-20 million new beneficiaries by 2019

► Primary care network must be primed to absorb

tremendous influx

• State agencies are under-staffed and under-funded

► Early retirements, hiring freezes, leadership changes

following gubernatorial races

• Affordable Care Act (ACA) mandates are

overwhelming and a priority over voluntary programs

► Limited guidance from Centers for Medicare and

Medicaid Services (CMS) on ACA to date

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…but so are the opportunities.

• States continue to explore ways to support

quality improvement at the point of care;

• Federal and state funds are available for

adoption, implementation, upgrade and

meaningful use (MU) of electronic health

records (EHRs), and electronic exchange of

information; and

• Federal funding is available to states for

innovative primary care initiatives.

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Why focus on primary care transformation?

• Private physicians play a significant role in supporting the

health care safety net:1

► They account for 78% of primary care visits for patients with either

Medicaid or no insurance; and

► 63% of primary care visits for minority patients occur in private

physician offices.

• Need to address the ongoing plight of primary care:

► Continuing and dramatic decrease in medical students choosing

internal medicine; and

► Ongoing struggle of “hamster wheel” for primary care practices.

• Systems with strong primary care systems yield lower

costs and higher quality.2

1 Forrest, C & Whelan, E (2000). Primary Care Safety-Net Delivery System in the United States – A Comparison of

Community Health Centers, Hospital Outpatient Departments and Physicians’ Offices. Journal of the American Medical

Association 284 (16). 2077-2083.

2 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502.

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Five Ways Health Plans Can Support Primary

Care Transformation

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1. Proactively support adoption of EHRs and

achievement of meaningful use

2. Encourage practices to use patient registries

3. Provide supports to small Medicaid practices

for practice redesign and transformation

4. Pursue (time-limited) funding opportunities

available through Affordable Care Act (ACA)

5. Collaborate with state or regional partners to

more effectively engage provider community

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Inland Empire Health Plan

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• Non-profit Medi-Cal health plan in Riverside and

San Bernadino, California

• History of commitment to quality improvement

• Selected to contract with regional extension center

(REC) as local recruiter of practices

► Partnering with medical societies

► Engaging Medi-Cal practices in meaningful use

(outreach, education, sign contract for MU, etc.)

► Facing similar challenges as other RECs, particularly

around engaging small Medicaid practices

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Neighborhood Health Plan of Rhode Island

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• Invested significantly in community health

centers in 2007 to position them to “go

electronic”

► Today, six have fully operating EHRs; three have

signed contracts with REC

• Implemented Primary Care Infrastructure

Support program with health centers

► Today, moving towards (1) more “hands on”

assistance to help providers achieve MU, and (2)

greater alignment across HEDIS measures, PCMH

elements, and MU definitions

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Pennsylvania Medicaid and Health Plans

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• Medicaid agency and three health plans are

aligning efforts by:

► Engaging 10 small, high-volume Medicaid practices in

Philadelphia

► Providing, populating and implementing Reach My

Doctor registry

► Pedagogical tool and important step to EHR

► Providing shared Nurse Care Manager to work with

practices on redesign, care management

► Providing practice management consultant

► Convening collaboratives for participating practices

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Why focus on small practices?

• 60% of all physicians work in practices with four or fewer providers1

• Up to half of Medicaid beneficiaries are served in (under-resourced) practices of four or fewer providers

• Quality improvement efforts are often hindered by poor reimbursement and inadequate staff support2

• Few programs focus on quality in small practices, despite the practices’ large role in providing primary care in the U.S.

• It is a struggle to specifically engage small practices in transformation, including EHRs

1 American Medical Association2 Audet, AJ, Doty, MM, Shamasdin, J, and Schoenbaum, SC (May/June, 2005). Measure, learn and improve:

physicians’ involvement in quality improvement. Health Affairs; 24(3); 843-853.

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State of Michigan and Medicaid MCOs

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• Michigan Medicaid and six health plans are

aligning efforts by:

► Engaging six small, high-volume Medicaid practices

► Helping practices select and implement a registry to

measure and improve patient care

► Providing financial incentives for specific milestones

achieved

► Deploying a QI coach – representing all 6 plans – to

provide one-on-one support to each practice

► Providing NCQA’s PCC-PCMH training and tools to

participating practices

Pursue Opportunities Available through

Affordable Care Act (ACA)

• Health care reform authorizes and/ or

appropriates federal funding for several

Medicaid or state primary care-related

initiatives:

► Health Homes for Enrollees with Chronic Conditions

► Primary Care Physician Rate Increases

► Primary Care Extension Programs

► Community Health Teams to Support PCMH

• Creates opportunities to advance and enhance

HIT

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Section 2703 Health Homes for Enrollees with

Chronic Conditions

• Patients with:

► At least two chronic conditions, or

► One chronic condition and at risk of a second, or

► One serious and persistent mental health condition.

• Health home services must include:

► Comprehensive care management;

► Care coordination and health promotion;

► Comprehensive transitional care;

► Referral to community and social supports;

► HIT; and

► Patient and family support.13

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Section 2703 (continued)

• Increased FMAP funding for two years for

health home services

• Up to $25 million in planning grants to support

development

• Reimbursement may be tiered according to:

► Severity and/or co-morbidities, or

► The performance of the provider.

• CMS to provide further guidance on how health

homes will work in a managed care delivery

system

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Advancing Primary Care through Regional

Alliances

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• Multi-payer, multi-stakeholder regional alliances

► Aligning Forces for Quality (AF4Q)

► Minnesota, Cleveland, Maine, Puget Sound

• Assessing the characteristics (including HIT

adoption and use) of “high-value” practices to:

► Better understand the strengths and opportunities for

improving these practices;

► Assess what type of education, training and support

these practices might need; and

► Design interventions in partnership with the alliances

and Medicaid.

Visit www.chcs.org to….

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• Download practical resources to help improve the

quality and efficiency of Medicaid services.

• Subscribe to CHCS eMail Updates to learn about new

programs and resources.

• Learn about cutting-edge efforts to strengthen primary

care and reduce disparities within Medicaid.

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