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Evidence-Based Medicaid: Health Care That Works Pay for Performance: Health Care That Adds Value. Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program. Evidence meets Performance. Medicaid will do P4P in situations unique to Medicaid Bariatric Surgery Managed Care

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evidence based medicaid health care that works pay for performance health care that adds value

Evidence-Based Medicaid: Health Care That WorksPay for Performance: Health Care That Adds Value

Jeff Thompson MD MPHChief Medical OfficerWashington Medicaid Program

evidence meets performance
Evidence meets Performance
  • Medicaid will do P4P in situations unique to Medicaid
    • Bariatric Surgery
    • Managed Care
    • ADHD Drugs
slide3

Medicaid’s grading system for service authorizations (WAC 388-501-0165)

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)

DSHS generally approves above the line

Below the line, provider needs to show the evidence or DSHS will disapprove via Prior Authorization

C = Inconsistent studies

D = Studies show no evidence, raise safety issues, or no support by expert opinion

performance community adhd drug prescribing practices for medicaid ffs children
Performance: Community ADHD Drug Prescribing Practices for Medicaid FFS Children

Age 17 and under FY2005

slide5

Payment: ADHD 2nd OpinionProcess for Children

  • HRSA Pays Three Hospitals to Review ($225)
    • ADHD in < 5 year olds,
    • At high doses (120/60)
    • In combinations
  • >300 cases logged to date.
    • 60% are approved
    • 40% are changed by the second opinion
    • ROI 3:1
slide7

Process: Going from a D to a B Grade

  • Surgery gets a “B” for diabetics who are obese (BMI >35) and a “D” for other co-morbid conditions (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)
performance medicaid managed care
Performance: Medicaid Managed Care
  • Incentives in place since 2004
  • Incentives for HEDIS measures
    • 2 year old immunizations
    • 3 categories of well child care (birth to 15 months; 3 – 6 years and 12 to 21 years)
performance medicaid vaccinations
Well-Child Care

Birth to 15 months

2004 – 43.7%

2005 – 41.4%

2006 – 47.0%

3 to 6 year olds

2004 – 53.5%

2005 – 53.0%

2006 – 55.0%

12 to 21 year olds

2004 – 35.2%

2005 – 36.8%

2006 – 32.0%

Combo 1 Immunization rate

2004 – State average 66.9%

2005 – State average 69.9%

2006 – State average 74.1%

Performance: Medicaid Vaccinations
structure and process
Structure and Process
  • Formal link with Washington State Child Profile Immunization Registry
  • Plans uniformly using robust methods
  • Implementing stronger interventions to improve immunization care
  • Some plans are rewarding providers/clinics financially for improved performance
performance based on outcomes
Performance: Based on Outcomes
  • DSHS set aside $1,000,000 each to be paid for improved performance
    • 1,000,000 for improved immunizations
    • 1,000,000 for improved well-child care
  • Calculations based on point system rewards plans for
    • Current year performance relative to other plans
    • Improvement from previous year to current year relative to other plans
    • Four highest performing plans share rewards
slide13

Performance Based Care:What’s Important?

  • Mortality vs. Morbidity?
  • Process vs. Outcomes?
  • My Value vs. A Payer’s Value
  • Local control/measures? vs. Central control/measures?
  • All Politics is Local vs. All Quality is Central?