By Tom Lacock
Wyoming Medical Society
The Wyoming Department of Health, Medicaid Division has developed three programs in an attempt to make their own programs more efficient and share some of that savings with Wyoming doctors.
Perhaps The Department of Health’s best-known program for physician incentives is its Patient Centered Medical Home (PCMH) program, which now has ten practices under its umbrella with 80 providers participating in the program. However, there are changes which will aid in increasing that number as the Department of Health has reported Cigna has modelled its own PCMH programs after the Wyoming Medicaid model. “PCMH’s have been shown to improve quality while reducing overall medical expenses” Medicaid Medical Director, James Bush, MD says. “By having multiple payers using the same quality measures and reporting platform, it reduces the offices reporting requirements and enhances their reimbursement.”
The fact Cigna is now using Medicaid’s PCMH as a model means if clinics report clinical quality measures to Medicaid, they are already collecting and reporting the same measures Cigna is seeking.
“So as long as the practice is in good standing with us, Cigna will allow them into their process as well,” said Bush. “I am working hard to have Blue Cross Blue Shield do the same as well. Eventually I am hoping with a single quality report who will meet the demands of all payers, including Medicare.”
Currently the program allows for clinics who are certified, or working towards recognition as PCMH’s by an accrediting agency such as NCQA, to receive a payment of $6 per member per month for each Medicaid patient it sees over the course of a year. Clinics must be using an Office of the National Coordinator certified EHR and provide practice data into the Department of Health’s PCMH portal on required clinical quality measures quarterly.
The Medicaid PCMH program has recently developed a new dashboard to allow clinics to review, and track provider’s progress towards goals, as well as compare provider data against the state average. Bush says there is another advantage to participating in the PCMH program, as it is aligning with federal efforts such as Meaningful Use.
“Wyoming Department of Health realizes that it is easier for physicians that we align our PCMH program with Medicare’s Quality Payment Program,” he says. “We are working on making that process as simple as possible. With the passage of MACRA, Merit-based Incentive Payments (MIPS) combines requirements of Physician Quality Reporting System (PQRS), the Value Based Modifier Program, and the Medicare EHR Incentive Program into a single reporting program. We move our PCMH program into the future, we are designing our program so that practices can have the same standards for Medicare, Medicaid, and Cigna quality programs”
Another Wyoming Medicaid program could be a dream come true for Wyoming physicians as the Pay 4 Participation (P4P) program uses Medicaid resources to help follow up with patients for care management. Pay 4 Participation allows Medicaid providers to receive additional reimbursements for providing health education to Medicaid clients with chronic illnesses, and referring their clients into the WYhealth Health Management program.
When a client is referred from a provider, a care management team member will contact the client and complete an assessment to determine the client’s level of participation and assess the client’s needs. Then, a member of the care management team will regularly contact the client to remind him or her to: receive their annual preventive screenings; make follow-up appointments with their provider as needed; and comply with their provider’s plan of care. To get started, contact Optum by email at wyhealth@optum.com or call 888-545-1710.
It comes as no surprise that the top five percent of Medicaid members accounted for 51 percent of the program’s costs in 2015. Even more specifically the top 1 percent of that 5 percent account for 21 percent of the 51 percent of total Medicaid spending.
Head spinning yet? In a nutshell, the Wyoming Medicaid program has identified a number of what it refers to as super utilizers who account for a disproportionate amount of state spending. The Medicaid program is interested in working with Wyoming physicians to get that group into managed care.
Bush points out the Medicaid super utilizer is generally an individual with a set of interacting physical and behavioral health problems such as chronic diseases, asthma, diabetes, COPD and other conditions which make it difficult to manage their own health. According to state numbers, the average super utilizer is actually 73 percent female between the ages of 45-49, with 58 percent of these patients on social security insurance.
The program has developed two prospective risk-score methods – one a clinical risk and the other a utilization risk for those who have many uses of the emergency department over the last 13 months.
Bush says the state has already identified the 1,500 highest risk clients, using scales that measure clinical risk and utilization risk, and randomly assigned 750 into treatment and control groups for research sake. The treatment list has been given to Optum, which has contracted with Wyoming for care management under the name of WyHealth. Five hundred clients will receive intensive in-person care coordination with the state tracking outcomes through Aug. 2017. The state hopes to answer the questions of which clients are most impactful; what methods work best at identifying future high-cost clients; and what kind of savings can be achieved.
If all goes well, the state will continue the program and, instead of using Optum, will contract the care management to entities made up of primary care, behavioral health, EMS, hospitals, and case managers. The hope is to eventually move to a regional model where these groups come together to create a new organization for case management. These regional entities could then directly receive the case management fees and share savings with the State.
At this point WyHealth is reaching out to providers that practices’ superutilizers to help them with more extensive case management than most practices can provide. The Dept. of Health is continuing to refine the regional model requirements to maximize success with the regional entity structure. In 2018, the RFP process for the program will get underway.