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State Medicaid agencies have been retooling the way they deliver healthcare with a number of efforts to coordinate and integrate care, especially around patients with chronic and complex conditions, and use improved performance measures to drive payment incentives.
Forty-five states have care coordination activities underway, some with multiple efforts.
Medicaid care coordination strategies include health homes, patient-centered medical homes and accountable care organizations, as well as efforts to coordinate physical and behavioral health, according to a recent report from the Kaiser Commission on Medicaid and the Uninsured. All of these initiatives rely on health IT and health information exchange to be effective.
Some states have stand-alone Medicaid medical home pilots as well as patient-centered medical home (PCMH) requirements incorporated into managed care contracts. Vermont has a medical home initiative focused on the highest-risk population, while Iowa and Wisconsin have incorporated PCMH in their efforts to coordinate care for a population of patients who are at risk of two chronic conditions and have serious and persistent mental health conditions.
Medicaid is also participating in multi-payer projects that foster PCMH in Arkansas, Ohio, Washington, and West Virginia.
The Centers for Medicare and Medicaid Innovations Center has a set of demonstrations under the Comprehensive Primary Care Initiative, started in August, to promote more effective organization and delivery of primary care across payers, including Medicare and Medicaid. Projects are ongoing in the New York Hudson Valley; Cincinnati-Dayton, Ohio, and Tulsa, Okla., and the states of Colorado, New Jersey, and Oregon. The seventh project, in Arkansas, is transforming 75 selected primary care practices in PCMHs through the payment of a per-member fee for Medicaid, Arkansas Blue Cross Blue shield and other payers.
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Rural states are also participating in patient-centered medical home models, including Alaska and Wyoming, the only two states with no traditional Medicaid managed care arrangements, and South Carolina, which rewards primary care providers as they reach PCMH levels certified by the National Committee for Quality Assurance (NCQA), according to the report.
Thirteen states are pursuing accountable care organization (ACO) efforts either through Medicaid alone or in collaboration with other payers. Those states include Minnesota, New Jersey, Utah, Hawaii and Texas. California and Ohio are developing pediatric ACO pilots that will meet specific standards and be able to share in savings they realize for Medicaid.
Other states, Connecticut, Massachusetts and Oregon, are developing their own approaches based on the ACO concept.
The majority of states are taking steps within Medicaid to coordinate physical and behavioral health, which have traditionally been silos of care.
“Medicaid is the largest source of funding for public mental health services and the primary payer for anti-psychotic medications,” the report said.
Another silo that states are beginning to turn their attention to is care delivered by hospitals and long-term facilities, and the transition of patients between them.
States are also adding new or expanded quality initiatives related to care coordination, for example:
• Connecticut incorporates into contracts care management and intensive case management requirements along with analytics to profile provider performance
• Initiatives aimed at specific conditions and services, such as North Carolina’s oncology medical home and Oklahoma’s care management program focused on infant mortality
• Texas is using a survey to spotlight patient education for care coordination services
• Vermont has established public health registries and health briefs to identify gaps in care with providers.