Innovations of all types are moving forward in the nation’s Medicaid managed care plans these days, innovations that will help state Medicaid programs, as they inevitably absorb large numbers of new enrollees, in the wake of the COVID-19 pandemic.
And one health plan whose leaders have been moving forward assertively has been Amerigroup Tennessee, an Anthem company. With 415,000 members and growing, the Nashville-based plan has been innovating in a state whose Medicaid landscape has been an innovative one for years, ever since the Tennessee state government incorporated TennCare in 1994, during the term of then-Governor Ned McWherter. Amerigroup Tennessee serves not only 415,000 Medicaid members; but also some Medicare members through Medicare Advantage contracts, and some dual-eligible members (Medicare/Medicaid).
Amerigroup Tennessee has been very active in several programs sponsored by TennCare, among them, as referenced in an October 31, 2019 press release:
Ø Since December 2016, TennCare has partnered with a statewide network of community mental health providers to improve care coordination for members with significant behavioral health needs. This program, called Tennessee Health Link, which serves 70,000 TennCare members, has reduced inpatient hospital admissions by 11 percent through one-on-one interaction with these members from 2013-2018. Primary care follow-up visits after acute hospital events have increased by 7 percent for active Tennessee Health Link members which allows for better continuity of care. In 2019, these Tennessee Health Link providers received almost $12 million in bonus reward payments from TennCare. “We are proud of the work we have done with TennCare to improve health care for our patients,” said Tennessee Association of Mental Health Organizations executive director Ellyn Wilbur. “TennCare consulted with providers and stakeholders and made improvements to the program design. We are so excited to see the positive results.”
Ø TennCare simultaneously invested in a Patient-Centered Medical Home (PCMH) program, working with providers who deliver primary care to more than 550,000 TennCare members. The improvements that those providers have delivered include a 68 percent improvement in controlling high blood pressure for diabetics, 40 percent increase in nutritional counseling for children and adolescents, and a 20 percent increase in childhood immunizations. In 2019, these primary care providers received over $11 million in bonus reward payments from TennCare in addition to their normal payments. Additionally, the care delivered showed positive utilization trends toward more cost-effective services such as a reduction in ER costs and ancillary services like duplicate labs and diagnostic testing.
Ø TennCare, in partnership with the Tennessee Hospital Association, is now sending alerts in real time to primary care providers in PCMH and Tennessee Health Link when their patients go to the hospital or emergency room. The Care Coordination Tool (CCT) allows providers to better detect gaps in care, proactively reach out to patients after a discharge, and “treat the whole patient” more effectively by sharing information with other providers. This data is the most actionable information that the CCT provides to PCMH and Tennessee Health Link providers.”
With regard to the PCMH program specifically, an October 2019 report from TennCare noted that “The PCMH program launched in January 2017 and serves children and adults; it aims to pay for improving health outcomes while reducing the cost of medical care. This strategy includes aligned multi-payer Patient Centered Medical Homes (PCMH) for the general population of adults and children, a Tennessee Health Link (THL) model for TennCare members with high behavioral health needs, and a Care Coordination Tool that offers additional information to primary care providers (for example, it alerts primary care providers when their patients go to the emergency room or the hospital).” What’s more, that report noted, “Tennessee built on the existing PCMH efforts by providers and payers in the state when creating its robust PCMH program and aligning payers on the critical elements. As of October 2019, approximately thirty-seven percent of TennCare members are attributed to a PCMH. In the two years since the program launched, there have been meaningful improvements across quality, cost, member experience, and provider experience. These improvements have been greater and had more impact on members attributed to a PCMH and enrolled in a THL than on members who were not attributed in a PCMH or enrolled in THL.”
Recently, Robert Garnett, who has been with Amerigroup Anthem for 14 years and who has been the health plan’s president and CEO since November 2018, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding some of those innovations. Below are excerpts from that interview.
Tell me about your health plan’s participation in the innovative TennCare programs?
TennCare has really been at the forefront among state-led, state-driven programs. Some states have said, we’d like each of the MCOs [managed care organizations] to have a PCMH program, but haven’t been prescriptive about what that looks like. TennCare took a pretty prescriptive approach, and they attached funding to it, too, so it really accelerated faster than elsewhere. And it’s morphed into a little bit more customized for each practice. There’s a significant amount of reporting on quality and cost efficiency metrics; spending time with members, clinical access, quality access, hooking into EMRs, really taking it to the next level, but at the same time, expecting documented improvement.
A couple of metrics that stand out—we’ve seen a 68-percent improvement in controlling high blood pressure for diabetics, in the last two years. We’ve also seen a 40-percent increase in nutrition counseling for children and adolescents, and a 20-percent increase in childhood immunizations. And that’s been through a lot more engagement. We have a dedicated team within our larger provider services organization that handles contracting, etc.; and as part of that, we have a dedicated team whose sole purpose is supporting these PCMH practices, giving them best practices on coding, on interventions, connecting them with support around SDOH in particular, and referrals to social supports like food and housing. So, really working closely with these folks, especially giving them really good analytics, so they can understand which HEDIS gaps they need to close [in HEDIS measures—measures in the Healthcare Effectiveness Data and Information Set from the Washington, D.C.-based NCQA, the National Committee for Quality Assurance]. A lot of these practices are super-motivated, or they wouldn’t be in the program; but they don’t necessarily know exactly how to improve.
We’ve seen quality improve across 16 of 18 core quality measures—HEDIS and HEDIS-like. We’ve seen total cost of care decrease by about 3 percent in the second year of the program, relative to a control group. So there was obviously some initial investment. So we’ve seen a pretty rapid return relative to what was invested in the program, and that’s just in the second year; so we would expect there to be continued improvement as we go. We did see that office and clinic care increased, so more members are making and keeping appointments. And that’s a good thing; the Medicaid population has historically had high no-show rates—but that’s improved in the PCMH program. We’ve seen a lot of non-emergent ED use decrease. For our members, it doesn’t them any more to go to the ED than to go to their PCP. So we’ve spent a lot of time identifying, literally sometimes within 24 hours—Mark was at the ED for a service that he clearly could have been at the PCP for—sending the data to the care managers, so they could emphasize the right place, right time, for care. We’ve also gotten them to increase access to weekend and evening hours. And more anecdotally, we’ve gotten pretty high satisfaction rates from providers.
What have been some of the challenges and opportunities in Medicaid managed care, with regard to care management?
There are a number: you have a transient population that’s accessing care from a variety of points. In a traditional PCMH population in Medicare, it’s about making coordination as electronic and digitized as you can. For providers to make the investment in Medicaid is challenging. So the juice has got to be worth the squeeze for the providers; there’s got to be more funding and incentive to make it worth their time. The second element is that providers have been bombarded by too much information. In trying to serve these large panel sizes, the data’s really got to be on point, lasered in, and useful, to help them manage better. Groups can’t work 100 reports off a paper spreadsheet.
In that regard, integrating workflows into EHRs [electronic health records] is very important. It’s much easier for us to have a two-way interface around quality than sending a one-way email that they [the physician groups] have to take and then operationalize in their systems. So the incentive arrangement has to be clear enough for the providers and worthwhile for them to make the investment in those populations. Second, providing the right information to allow them to incorporate into their operations. We’re supporting them, we’re not asking them to work with a different system than those they’re already working with; but really meeting the practices where they are.
The third element is that it’s sometimes challenging for practices that have demonstrated improvement, when the bar gets raised every year—it gets harder and harder for them to hit metrics. So, there should be a nice pathway for those practices at the low end and for which there’s a lot of room for improvement, as well as for those high-performing practices, to still earn incentive dollars. Traditionally, in a lot of these programs, the bar just keeps getting raised every year. And when you’re in the top right of the quadrant, with high quality and low cost, the improvement bar gets raised almost to the point of being unreasonable. So the incentives have to be very easy to understand. And you’ve got to have some “ramp” to it. There has to be a system that helps them get to the right place, but also still rewards them for getting to the right place.
How do you see things evolving forward over the next few years?
I think that we’ll continue to see states further formalizing programs like these that we’ve been discussing; but also moving into behavioral health. We have a behavioral health version of the PCMH program, in Tennessee. And new arrangements with facilities on the inpatient side and also on the behavioral health side, but also on the outpatient side; and a continued shift into risk-based, shared-savings arrangements. We’ve seen an increasing number of providers asking about these arrangements, seeking them out. That’s a contrast to a few years ago, where many providers said, I’m really not interested. There’s been some disruption—we get approached by vendors and provider start-ups that are going straight to risk. Some physician groups are approaching us, particularly those purchased by larger entities or entities trying to disrupt the traditional payer space, and they’re saying, let’s do a shared-savings program in year one. And it’s pushing some of the traditional group practices to evolve forward as well.
What are your high-level thoughts on data and IT?
Data is very, very important. Working with providers, it goes back to what I said before about meeting them where they are. A couple of years ago, payers had this idea that they would post information on their portal and that providers would be able to absorb it. What we’ve started to do is to create more of an interoperable feed or process, so that regardless of which EHR they’re using, they can “inject” it without having to go onto use a different system for Amerigroup than they would use for United, for example. In other words, it’s about meeting them where they are; some providers are on one major version of an EHR, while others are on a different one. So we’re using our traditional care management platform that has a ton of clinical data, but we’re also using wraparound tools like Tableau, to help them visualize data. So it’s really evolved from, here you go, and take this data and run, to helping them consume data; that left many providers feeling overloaded with data. So it’s about really shifting to meet them to where they are, and providing the data in a format that they can consume in a variety of ways. Doing so has really driven a lot of improvement.
One thing that I think is important to mention is that I think you’ll see states become more prescriptive in their programs, whether it’s PCMH or behavioral health; but there will still be space for health plans to innovate in this area. A couple of things that we’ve introduced and that I’m starting to see become a much bigger focus, are a couple.
You’re working forward in several areas, correct?
Yes, we are—for example, we’ve got an obstetrics incentive program called “OB QIP.” It’s a shared-savings program offered specifically to OB/gyns. In 2019, we saw an 80-percent improvement in quality measures—timeliness of prenatal care, postpartum visits, c-section rate, and post-partum addiction treatment. There’s a framework within the program, and there are some areas for improvement.
Also, there will be a lot of focus around behavioral health across the industry. We have a behavioral health inpatient facilities improvement arrangement, and the acronym there is BHFIP, Behavioral Health Inpatient Facilities Incentive Arrangement. This is pretty early on, we just started it last year, but we’re really continuing to work with our BH inpatient facilities. We have now five providers on it and are excited. That’s really around the same kind of methodology, a blend of cost and quality—looking at a visit, post-discharge within 7 days; and 30-day HEDIS-type follow-ups, and cost and quality, and providing additional payments. We’re also involved in a Pediatric Residential Treatment Quality Incentive Program, which involves a blend of quality and cost measures. A discharge incentive—to get the care right and discharge the member appropriately. An incentive around getting the care right and timely and preventing an unnecessary readmission.
Meanwhile, TennCare has led an episodes of care program; we operationalize it. It was implemented in 2014, and they’ve rolled it out across a significant number of areas, including perinatal episodes, asthma episodes, and joint replacement—various buckets of episodes. There’s incentive for providers, giving them additional payment for quality and cost, and also providing a penalty to those providing care at higher cost, reinvesting dollars from high-cost providers to lower-cost providers.
So we have a big blend of state-driven programs, which will always be there; but we’ve also extended beyond that to offer shared-savings types of arrangements in the OB area, in inpatient behavioral healthcare.
