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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 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

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  1. Evidence-Based Medicaid: Health Care That WorksPay for Performance: Health Care That Adds Value Jeff Thompson MD MPHChief Medical OfficerWashington Medicaid Program

  2. Evidence meets Performance • Medicaid will do P4P in situations unique to Medicaid • Bariatric Surgery • Managed Care • ADHD Drugs

  3. 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

  4. Performance: Community ADHD Drug Prescribing Practices for Medicaid FFS Children Age 17 and under FY2005

  5. 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

  6. Performance: Community Outcomesin Bariatric Surgery

  7. 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)

  8. Performance: Medicaid Pays a Premium for Centers of Experience

  9. 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)

  10. 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

  11. 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

  12. 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

  13. 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?

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