The Primary Care Collaborative (PCC) has released a report describing eight payment and care delivery strategies for strengthening primary care in Medicaid, independent of other policy options, such as eligibility or benefit expansions.
From the report, “Access & Equity in Medicaid," here are the eight recommendations:
• Report and increase the share of Medicaid spending going to primary care
• Increase payment to primary care clinicians
• Support behavioral health and primary care integration
• Pay for community health workers
• Encourage Patient-Centered Medical Home (PCMH) attributes, including care coordination
• Pursue population-based payment models
• Stratify data and incorporate health equity quality incentives into payment models
• Increase federal funding for community health centers and create new access points
During a recent PCC webinar, Leighton Ku, Ph.D., M.P.H., a professor of health policy at George Washington University and director of its Center for Health Policy Research, spoke about why these recommendations were made.
The first two recommendations involve payment. Ku noted that there's a fair amount of evidence that primary care services in general and in Medicaid, in particular, are underfinanced. Some of this involves increasing reimbursement rates for providers but potentially doing other things to expand primary care, he explained. The first recommendation is to try to bolster efforts to increase the share of Medicaid spending that is going to primary care. “There's been research that suggests that there's an inverse relationship between spending on primary care and the extent to which there's the need for things like emergency rooms and hospitalizations,” Ku said. He added that the evidence indicates that Medicaid pays less than Medicare pays to primary care clinicians and less than is paid by commercial insurance. “So one of the underlying concepts that comes through consistently is to increase the primary care payment rates to physicians,” he said.
The third strategy is to support behavioral health and primary care integration. “There are shortages, in particular, of behavioral health providers, but there's more that can be done to integrate behavioral health and primary care in a variety of ways,” Ku said. Models, such as the Collaborative Care Model are well tested, and widely used in a variety of settings, such as community health centers, to do a better job of providing behavioral health services and thereby improving people's health outcomes.
Another recommendation is to pursue value-based payment models. Ku noted that the Centers for Medicare and Medicaid Services and a number of managed care programs and states across the country are trying to do these things. “Nonetheless, the evidence is still in development,” he said. “Some of these things have not been in use very broadly. We've been learning a little better what works and what doesn't work. There's strong belief that these models can be helpful.”
The next step is to stratify data and incorporate health equity quality incentives into payment models. Ku said we don't always analyze the data that helps us understand where health inequities might be, and then build in incentives to try to improve health equity.
Ku noted that community health centers, which serve around 30 million Americans, about half of whom are on Medicaid, are doing an unusually effective job in combining primary care services, along with other services to reduce emergency room use and inpatient hospitalization and save money. “So increasing federal funding for community health center could help,” he said. “Congress has yet to reauthorize funding for community health centers for the coming year. This will be something important to watch for."
Another strategy is to pay for more community health workers. When we think of primary care providers, we think of physicians, nurse practitioners, and physician assistants, Ku said, “but there's a whole range of staff who can be doing things to help, and community health workers can be particularly important to the extent that they are able to better communicate and understand the needs of patients, and do things like home visiting.” Once again, there's data that shows that more support for community health workers really pays off in improved health, he added.
The final strategy is to encourage patient-centered medical home attributes, including care coordination.
A panel discussion after Ku’s presentation included Christine Nguyen, M.P.H., the manager of health equity strategies at Families USA. “Medicaid, more than any other program or payer has the potential to reduce decades of healthcare disparities and improve health outcomes for vulnerable communities,” she said. “So Medicaid is that source of care that we really need to think through when we're thinking about equity, and in primary care specifically. In theory, primary care is where we're having a lot of our initial interactions with the healthcare system, so as much as we can make the delivery and integration of primary care more equitable, especially for the Medicaid population, the more we can advance health equity.”
Nguyen said Families USA has been doing advocacy work around pushing the health system to collect more race and ethnicity data. “We're really pushing for this because we know how important better data is to inform our equity work,” she added, “because we really can't be working on addressing health disparities if we don't know where those disparities exist, and the current data collection standard just isn't enough.”
Another panelist was Matt Salo of Salo Health Strategies, a healthcare consulting firm. He was the founding executive director of the National Association of Medicaid Directors.
Salo spoke to some of the economic realities of making significant changes at the state level in Medicaid. If you want to motivate the system to do something different, you have to build in financial payment incentives, he noted. “There is a lot of talk in this report about how to get there in terms of paying more for primary care providers and covering community health workers,” he said. “But one of the things that I think is going to be a challenge — to put a state government lens on all of this is — is that Medicaid officials have to think about the big picture of what are the financial consequences of changes or decisions that we make.”
If you say we'll just pay certain parts of the system more, that may cause a budget increase, he said. Medicaid, which is already the largest or second-largest component of every state budget, doesn't have the capacity to just pay parts of it more, Salo added. It might be a good thing, but what are the consequences of that? The trade-off is: do we pay more to the parts we want to increase and improve? And does that go hand in hand with perhaps paying other parts less —finding other parts of the system that we don't want to incentivize, whether that's medical errors, or inappropriate care? The challenge, of course, is there is a party whose ox is gored when they get paid less. “For these changes to be self-sustaining, they have to have buy-in at all levels. And that really is part of the challenge here.”