This year has brought a lot of changes to healthcare systems around the country, and this is especially true in states that are taking advantage of ACA regulations to expand Medicaid. For physicians and provider organizations, this may mean balancing larger patient populations that require more coordinated care with value-based payment programs being implemented by both public and commercial payers in the state.
In Louisiana, the Medicaid program that previously went by the name Bayou Health will now be called “Healthy Louisiana.” Newly covered Healthy Louisiana members will be integrated into already-existing quality improvement programs that are implemented by Medicaid managed care organizations. Louisiana contracted with five health plans to administer the Bayou Health program, all of which will continue to administer the new Healthy Louisiana program. Three of the plans use prepaid full-risk capitated model, and two plans are paid under a shared savings model. Health plans under both payment models are evaluated using the same HEDIS standards used by many state governments who administer Medicaid through managed care.
After the Medicaid expansion is fully implemented, the five Healthy Louisiana health plans will continue to report HEDIS quality measure data to the state, which will impact payment amounts each year. Incentive-based quality measures for both prepaid and shared savings plans focus on adult access to preventative health services, diabetes care, chlamydia screening, and well child and adolescent visits. This means that providers who see Medicaid beneficiaries under these plans can expect to be held to the same rigorous HEDIS benchmarks that the plans must meet in order to ensure that a high quality standard is kept even as the Medicaid population grows.
There are potentially a lot of pay-for-performance dollars on the line for providers who will see Healthy Louisiana patients starting this year. In 2015, UnitedHealthcare Community Plan of Louisiana awarded more than $3.4 million in bonus payments to 249 physician practices statewide for improving the quality of care for people enrolled in UnitedHealthcare’s Medicaid plans. While many providers in Louisiana may be used to participating successfully in Medicaid pay-for-performance programs, it will become more difficult to maintain the same levels of quality and care coordination when new coverage begins on July 1, 2016. Current projections are that at least 375,000 people will eventually be enrolled in Healthy Louisiana.
Blue Cross Blue Shield of Louisiana (BCBSLA) covers 63% of the large group market and 81% of the small group market, making it one of the largest health insurance providers in the state. In 2013, BCBSLA launched Quality Blue Primary Care (QBPC), a population health and quality improvement program based on the value-based approach that is making big strides to improve quality and support care coordination for patients in Louisiana.
In its first year, QBPC was embraced by providers around the state, with 450 primary care physicians participating, and early results showed the program has already made an impact on chronic disease management. Providers enrolled in QBPC have their performance measured against established program clinical quality and efficiency measures in exchange for a per member care management fee that covers services not typically included in fee-for-service reimbursement.
Earlier this year, the Gulf South Quality Network and UnitedHealthcare launched an accountable care program that changes the incentives for how people’s medical care is paid for in Louisiana by moving away from a fee-for-service system to one that rewards the quality of patients’ health outcomes and has the potential to reduce overall costs. Gulf South Quality Network is a physician-led clinically integrated network of over 1,500 healthcare providers in the medical and surgical specialties, including primary care. Through this collaboration, UnitedHealthcare and Gulf South Quality Network will work closely to better coordinate patients’ care, using shared technology, real-time data and information about emergency room visits and hospital admissions, and services designed to help patients manage their chronic health conditions and encourage healthy lifestyles.
Physicians and provider organizations in Louisiana are on the cusp of a major change to the state’s healthcare system when Medicaid enrollment numbers jump in just 6 short weeks. Given the many other priorities that these organizations must balance, including quality improvement and value-based payment programs from commercial payers and federal quality reporting programs such as PQRS and the upcoming MACRA, it is important for providers to leverage available resources and tools to ensure that quality is maintained while new changes are implemented. Stay up to date by subscribing to our newsletter.
Photo credit: Jason Mrachina
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