Medicaid Withholds – Capitalizing on Missed Opportunities

Carrie Spunar, Director, Marketing Healthcare Consulting

quality care

The U.S. health care system is consistently challenged to deliver high-quality care at an affordable cost. Virtually every public or private payer has adopted at least one care delivery or payment model to support value-based care, such as Accountable Care Organizations (ACOs), risk-based contracts, gain or surplus sharing, performance-based incentives, or quality rating systems. All these approaches have the same set of goals—provide the right care in the most appropriate setting at an affordable price.

The Opportunity

As part of one state’s Medicaid pay-for-performance program, seven participating health plans had the opportunity to earn up to 1.25 percent of their premium and delivery payments as an incentive for achieving high performance on designated Healthcare Effectiveness Data and Information Set (HEDIS) and customized quality measures. This equates to an annual reward opportunity of more than $140 million for the managed care plans. The payout starts above the NCQA 25th percentile.

What Went Wrong – $94 Million In Lost Incentives

At the end of the measurement year, the managed care plans earned only one-third of the available incentive bonus, leaving approximately $94 million on the table. While most managed care plans in this state increased their overall quality performance, they also experienced a decline in at least one HEDIS measure. In some cases, physician practices were unable to report any data for common clinical measures, such as BMI or HbA1c control. For example, for the Diabetes HbA1c control (8.0 percent) HEDIS measure, participating managed care plans in this state’s pay-for-performance program were awarded only $1.4 million of $20.3 million possible, representing only 7 percent of the total incentive available.

How to Capitalize on Missed Opportunities

Missed opportunities for collecting and reporting patient data can adversely impact managed care plan results – and in this scenario, something as simple as physician reporting on HEDIS measures cost plans millions. Impacting quality outcomes at the point-of-care is essential to maintaining overall operational and financial health in a highly competitive market. Well-deployed interventions at the practice level can unlock millions of incentive dollars for the managed care plans and ease the burden of physicians.

Each practice faces its own unique challenges, and hands-on support in the practice is needed to uncover the root cause of the issue:

  • Is the practice not providing the services?
  • Does the practice have a process for accurately monitoring gaps in care for its assigned panel?
  • How does the practice document the services?

Once the root cause has been identified (and it’s seldom the case that quality care isn’t being rendered), an experienced coach can assist the practice in making the changes needed to move the needle on metrics. Setting processes, monitoring gaps in care, proper documentation and reporting on measures.

Medical Advantage has refined our methodology over the past 20 years working in physician practices. Our PracticeCatalyst™ approach is a proven method that leads to meaningful change and a positive return on investment for our customers. It is a hands-on approach to practice coaching that is scalable, replicable, and can be customized to meet the unique needs of each managed care plan.

Results from our PracticeCatalyst™ approach: