State Takes Steps to Foster Innovation and Improve Quality of Care

In an effort to foster innovation and improve care within the state’s Medicaid program, the Pennsylvania Department of Human Services (DHS) recently released requests for proposals (RFPs) for physical health services provided through HealthChoices — the state’s mandatory Medicaid managed care program. It also, in collaboration with the Pennsylvania Department of Aging, outlined its vision for Community HealthChoices (CHC), Gov. Wolf’s program for managed long-term services to support older individuals and adults with physical disabilities.

“When fully implemented, these changes will mark the most significant changes to Medicaid in Pennsylvania since the Department first moved to mandatory managed care 18 years ago,” said the state in a news release. “We must continue to innovate and move forward if we are going to provide the high-quality health care that all Pennsylvanians deserve. As the biggest insurance payor in the commonwealth, our hope is that these changes will encourage innovation in the private sector as well.”

RFP’s for Physical Health Services Provided through HealthChoices/New Contracts

To drive Pennsylvania’s Medicaid system towards these better outcomes, the new contracts will set targets for all contracted MCOs to increase the percentage of value-based or outcome-based contracts they have with hospitals, doctors, and other providers to 30 percent of medical funds they receive from DHS within three years. The result will be that billions of dollars will be invested in options such as:

  • Accountable Care Organizations (voluntary networks of hospitals, doctors, and other providers that work together to provide coordinated care to patients) — Learn what questions physicians should ask when considering to join an ACO in PAMED’s video and Quick Consult.
  • Bundled payments (increases value-based purchasing) — Education from PAMED on bundled payments is coming soon.
  • Patient-centered medical homes
  • Other performance-based payments

The contracts will also include better integration of the physical and behavioral health systems and approaches like telemedicine to help serve areas of the state that do not have easy access to doctors. Learn more about PAMED’s advocacy efforts to ensure appropriate patient safeguards and standards and support coverage and insurance payments for telemedicine services in Pennsylvania .

“If you pay for services, you will get services, said DHS Secretary Ted Dallas. “If you pay for outcomes, you will get outcomes.”

“When awarded, the contracts will require the managed care organizations (MCOs) to increase the amount of money they spend on contracts that reward value, care coordination, and better health outcomes rather than simply paying for services as they are provided. The result will be a system that focuses more on the patient as a whole and provides higher quality care to those in the Medicaid system,” said the state’s news release.

The State’s Vision for CHC

DHS, in partnership with the Pennsylvania Department of Aging, released a more detailed concept paper outlining its vision for CHC. Highlights include:

  • Coordinates physical health and LTSS through CHC managed care organizations (CHC-MCO).
  • Provides participants with a choice of two to five CHC-MCOs in each region.
  • Includes value-based incentives to increase the use of home and community-based services and meet other program goals.
  • Creates a system that allows Pennsylvanians to receive services in the community, preserves consumer choice, and lets consumers have an active voice in the services they receive.
  • Standardizes measures of both program and participant-level outcomes to assess overall program performance and improve CHC over time.
  • CHC-MCOs will be accountable for most Medicaid-covered services, including preventive services, primary and acute care, LTSS (home and community-based services and nursing facilities), prescription drugs, and dental services.
  • Participants who have Medicaid and Medicare coverage (dual eligible participants) will have the option to have their Medicaid and Medicare services coordinated by the same MCO.
  • Behavioral health services continue to be provided through the behavioral health managed care organizations (BH-MCOs), but CHC-MCOs and BH-MCOs will be required to coordinate services for individuals who participate in both programs.

Learn more in the state’s news release on the concept paper.

“CHC is a significant shift from the commonwealth’s current, fractured approach to providing these services and will enhance care for seniors and persons with disabilities through better coordination of care,” said the state’s news release. “The result will be that more Pennsylvanians will be served in the community instead of in nursing homes or other facilities.”

CHC will support individuals dually eligible for Medicare and Medicaid, older adults, and adults with physical disabilities in the most integrated settings possible. CHC will serve an estimated 450,000 individuals, including 130,000 older persons and adults with physical disabilities who are currently receiving LTSS in the community and in nursing facilities.

Pennsylvania Is Taking More Steps Toward Value Based Care

In another step toward value-based reimbursement, the Pennsylvania Department of Health (DOH) recently said it wants insurance companies to pay physicians and hospitals based on how effectively they treat patients and the quality of care provided, not just on the number of patients they see. The results will then help set statewide goals for expanding value-based health care payments across Pennsylvania.

How Can Pennsylvania Physicians Be Prepared?

Physicians — regardless of practice type, setting, specialty, or geographic location — are filled with uncertainty with a multitude of changes to the health care delivery system. It will take investments of your time, energy, skills development, money, and the learning of new capabilities to be successful in value-based delivery.

Where you can hone the skills needed to succeed and thrive in value-based delivery systems?

  • Register for the online, on-demand modules. The first four, which cover topics including practical health informatics, using the data toolbox in your practice, quality management, and process improvement, are available now. The last two modules, which cover lessons learned from the managed care era and population health, will soon be available. You can earn up to 1 credit of CME for each online course.
  • Sign up for the final live workshop being held at PAMED in Harrisburg on Oct. 9. Attendees can earn up to 5 credits of CME for attending this workshop.

This CME series on value-based care is facilitated by PAMED member Ray Fabius, MD, a nationally respected expert in quality and population health.

But, I don’t think I need this training right now, you may think. Learn what sprung Dr. Fabius into action and you might change your mind.