How Are States Using Managed Care Contracting to Improve Primary Care?

Nov. 23, 2020
Addressing social determinants of health and integrating behavioral health into primary care are common goals in Medicaid managed care

Managed care contracting is one key lever state governments have to set priorities for healthcare improvement. A recent panel discussion described how states are using their managed care purchasing authority to advance primary care models.

Since 2018, the Center for Health Care Strategies (CHCS), with support from the Commonwealth Fund, has been working with states on a project called “Advancing Primary Care Innovation in Medicaid Managed Care.” The project focuses on using managed care purchasing authority to advance primary care models that aim to address one or more of the following care delivery components: (1) addressing social determinants of health; (2) integrating behavioral health into primary care; (3) using technology to improve access to care; and (4) enhancing team-based primary care approaches that better meet the community’s needs.

During phase one, CHCS supported efforts in Hawaii, Louisiana, Pennsylvania, Rhode Island and Washington. Phase two involved Delaware, Nevada, Tennessee, Texas and Virginia.

On Nov. 19, CHCS brought together some state leaders to discuss their progress and goals.

Judy Zerzan-Thul, M.D., chief medical officer for the Washington State Health Care Authority (HCA), noted that the state has made progress in a number of areas of healthcare innovation previously, “but primary care is not one of them.”

She likened the traditional primary care model to the combustion engine of a car — sort of old-fashioned and all the same. “We are changing that model and moving to the electric vehicle version of primary care,” she said. “We are restructuring and realigning,” and that includes risk-adjusted quality measures.

The state has been working on how it can advance primary care, and not just in Medicaid, but with a multi-payer lens so that there is alignment across all payers in terms of both quality metrics and payment.

According to its published roadmap, HCA’s vision for 2025 is that value-based payment (VBP) arrangements will be aligned across all public purchasing programs, and they will advance multi-payer primary care models where appropriate. In addition, these payment arrangements will be rooted in data-driven policy making, requiring HCA to collect and use actionable data to reinforce accountability among delivery system networks as well as provider and managed care organizations (MCOs). 

Zerzan-Thul said that providing per-member, per-month capitated payments will allow practices to use a whole-team approach and provide care in different ways that are not just face-to-face visits. “Using telehealth and e-mail with patients is going to be key, as well as focusing on behavioral health integration and social determinants of health,” she explained. HCA’s approach includes incorporating measures to address SDOH and expanding access to nontraditional services as well as requiring coordinated efforts across Washington’s health and social service agencies.

Zerzan-Thul also noted that HCA is hiring a health equity executive to help it focus on reducing disparities in quality measures by race and ethnicity, among other things. “The first measure we have decided to focus on is depression management, where we have noticed a big gap. That is in the wheelhouse of primary care — identifying and treating anxiety and depression.”

Re-thinking primary care’s role in the pandemic

David Labby, M.D., Ph.D., has been involved in Oregon’s primary care transformation for years. He is the former chief medical officer and currently a health strategy advisor for Health Share of Oregon, a coordinated care organization (CCO) that serves Oregon Health Plan (Medicaid) members in Clackamas, Multnomah and Washington counties. He noted that relative to other states, Oregon is pretty far ahead in advancing primary care. For years it has been working on making patient-centered medical home standard; behavioral health integration is widespread as is the use of telehealth. “We are pretty proud of our primary care work,” he said, “although there is still a ton to do, such as bringing addiction medicine into primary care.”

Labby said it was kind of a shock that the COVID response tended to ignore primary care’s role, because the pandemic has totally overwhelmed public health, and there is little to no connectivity between public health and primary care. “We need to rethink this model and how primary care fits into the rest of the system. The risk is that we default to doing what we have always done, but just a little better.

Primary care practices have been hit hard by the inability to get personal protective equipment and the financial instability of fee for service. MCOs can help push a payment model not driven by fee for service, he said. “We need to rethink primary care,” he said. Who gets vaccinated is going to come down to trust. Primary care plays  a huge role in reconnecting trust to help get the population immunized.”

When the pandemic hit, Health Share of Oregon set a target of reaching out to 20 percent of members who are considered high risk because they have chronic diseases to ask about their needs. “We found huge needs. They weren’t surprising needs — food insecurity, isolation, and housing; COVID just made them worse.”

So there was a sudden shift in how MCOs engage with the community around social needs. But once they identify needs, they need to figure out how to get members food or housing when they have no structured relationships with community-based organizations. So they are working on  connecting to community-based organizations in a more structured way, and building a systemic approach to using community health workers. “We have invested in statewide technology to connect social services,” he said. Primary care practices can use it to access services, and there is a feedback loop. It can also give the state and MCOs data about what social needs are and help identify where more investment is needed.  “We haven’t had that type of data before,” Labby said. “It can help us create a health strategy for the community.”

Behavioral health integration in the Keystone State

David Kelly, M.D., is chief medical officer for the Pennsylvania Department of  Human Services’ Office of Medical Assistance Programs, which overseas Medicaid managed care. He said Pennsylvania has had a patient-centered medical home program in Medicaid since 2016, and it now involves approximately 1,500 practices serving 800,000 members. He added that approximately 100,000 of those members persistent serious mental illness.

Kelly said that during the pandemic it has been very helpful that MCOs pay those medical homes per-member, per-month fees so there is a cash flow. The Commonwealth also has worked on behavioral health integration, and some practices have integrated behavioral practitioners into their practice. Federally qualified health centers can bill for both types of visit on the same day. “We have a patient-centered medical home learning network that continues to meet virtually and that has been helpful in terms of sharing best practices and common challenges, he added.

The patient-centered medical homes are required to do social determinant screening at least once per year,” Kelly said, and during the pandemic that has been helpful in terms of identifying patients’ non-medical needs. “We have been collecting this data and putting Z codes into claims. The key issue is knowing what are the community resources and getting members there. We have an RFP out to get a statewide system so that providers and MCOs can be talking to the same system to refer and track people. We are excited about getting that up and running in 2021."

In terms of reducing disparities, Pennsylvania has created an incentive program with the MCOs to close gaps in measures such as well-child visits and blood pressure control, both pertinent to primary care. “We want MCOs to stay focused on identifying and closing those gaps,” he said.  

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