Colorado Medicaid has three different pilots for its high-cost patients
Colorado Medicaid has three different pilots for its high-cost patients
About 24% of Colorado's Medicaid clients are either elderly or in a disability category, and this group accounts for about 66% of total expenditures. Not only does that group have disproportionately higher costs, but they also have higher utilization of hospitals and emergency departments and procedures.
"So, both from a cost and health point of view, we've got a real interest in developing systems of care that improve outcomes," says Sandeep Wadhwa, MD, state Medicaid director and chief medical officer with the Colorado Department of Health Care Policy and Financing. "We think that doing so will help us to manage our overall expenditures."
The state has implemented three different pilot programs, each with a different model for getting better outcomes and managing costs, as follows:
A managed care capitated model implemented with Colorado Access.
About 2,000 beneficiaries have enrolled in the Colorado Access pilot since its launch in June 2008. "Right now, we are just across the one-year mark. We expect over the next three to six months to look at the first year of experience," says Dr. Wadhwa.
An integrated care system with Kaiser Permanente, with Medicaid paying an administrative fee instead of a capitated contract, with enrollment beginning in August 2009.
Providers are paid for care coordination activities and establishing a medical home but continue to bill fee-for-service.
A directed effort with the Greenwood Village-based Colorado Alliance for Health Independence, a nonprofit client advocacy group.
The group emphasizes the importance of promoting client independence with more community support. "Looking at this from a client's perspective, they see opportunities that a provider wouldn't necessarily see," says Dr. Wadhwa. "This would also be an administrative services contract, so it wouldn't be full risk. They think they can get our programs through a next generation of results."
While the state's other pilots involve health care providers and payers and take an approach focused more on health and disease management, this third pilot is more focused on the client's well-being and ability to function.
Dr. Wadhwa says, "What is interesting is that they are not traditional health care providers. Their care will still be delivered in fee-for-service but will have a layer of care coordination or community support on top of fee-for-service. We believe it will reduce nursing home placements and keep people out of the hospital."
Programs need time to work
By participating in the Center for Health Care Strategies' Rethinking Care program, the programs will be evaluated with a control group in real time, so that head-to-head comparisons can be done. "We wanted to test several models of reforms, since we don't have a dominant managed care system that we need to force fit things into," says Dr. Wadhwa. "By learning from these models, we can scale them while planning our next generation of managed care, as part of a broad reform effort."
Since costs may increase in the short term, one concern is that the programs are given enough time to demonstrate results. "I feel there is a lot of pressure to cull what is working out of these programs and put them into reform quickly," says Dr. Wadhwa. "My nervousness is that we give them enough time. They are investments and we are waiting to see the results, so I can see some pressure on Medicaid as to, 'Are they paying off or not?'"
Meeting unmet needs of clients may lead to increased costs in the first six to nine months of the program, such as durable medical equipment or physical or speech therapy. Dr. Wadhwa says he expects to see some areas of drug costs go up and others go down. As for provider costs, he says he'd like to see clients receiving most of their care from a primary care physician but says they still are likely to need specialist care.
"We are hopeful that the immediately avoidable things will come down, such as ER visits. Then in a year or two, we will hopefully start to see some separation. We want to make sure that we stick with it long enough that we don't miss that separation point," says Dr. Wadhwa. "But ultimately, we will see more efficient and better health outcomes."
Contact Dr. Wadhwa at [email protected].
About 24% of Colorado's Medicaid clients are either elderly or in a disability category, and this group accounts for about 66% of total expenditures.Subscribe Now for Access
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