Evidence-Based Medicaid: Health Care That Works Pay for Performance: Health Care That Adds Value

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

• Medicaid will do P4P in situations unique to
  Medicaid
• Bariatric Surgery
• Managed Care
• ADHD Drugs

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Medicaids 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
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Performance Community ADHD Drug Prescribing
Practices for Medicaid FFS Children
Age 17 and under FY2005
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Payment ADHD 2nd OpinionProcess for Children

• HRSA Pays Three Hospitals to Review (225)
• ADHD in lt 5 year olds,
• At high doses (120/60)
• In combinations
• gt300 cases logged to date.
• 60 are approved
• 40 are changed by the second opinion
• ROI 31

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Performance Community Outcomesin Bariatric
Surgery
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Process Going from a D to a B Grade

• Surgery gets a B for diabetics who are obese
  (BMI gt35) 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
• (lt 2 mortality, 15 morbidity and 50 weight
  loss)

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Performance Medicaid Pays a Premium for Centers
of Experience
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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)

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Performance Medicaid Vaccinations

• 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

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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

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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

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Performance Based CareWhats Important?

• Mortality vs. Morbidity?
• Process vs. Outcomes?
• My Value vs. A Payers Value
• Local control/measures? vs. Central
  control/measures?
• All Politics is Local vs. All Quality is Central?