As the health care system moves toward more sophisticated value-based payment (VBP) models, those seeking to improve efficiency continue to look to primary care as the key to prevention and better health management. And for good reason: greater use of primary care is associated with lower costs, higher patient satisfaction, fewer hospitalizations and emergency department visits, and lower mortality.

The logic behind successful VBP initiatives, however, often presumes a strong primary care system—where people can easily access primary care and get the care they need. However, low-income and vulnerable individuals have consistently lower utilization of, and access to, high-quality primary care services, as well as worse health outcomes than the general population. Moreover, primary care providers often feel under-prepared, under-resourced, and under-staffed to meet the diverse needs of low-income patients.

State Medicaid agencies have made progress with models such as the patient-centered medical home (PCMH) and Comprehensive Primary Care Plus (CPC+), but the typical primary care practice still falls short of meeting the unique health and social service needs of low-income populations. For example, food or housing insecurity, unaddressed behavioral health conditions, and challenging schedules can make it difficult for patients to engage with primary care teams in a way that truly supports them. Thus, to achieve high-performing primary care, it will take not just more investment in “bread and butter” preventive and primary care, but also more innovative approaches—ways to make primary care teams more accessible, responsive to social needs, and effective for high-need populations.

The good news is that the number of innovative care models that can be incorporated into primary care settings continues to grow. These include the IMPaCT Community Health Worker model; the Collaborative Care Model; Integrated Primary Care and Community Support; and Project ECHO, to name a few. Generally, these models support different forms of high-performing primary care for vulnerable populations, including robust primary care systems offering after-hours access, same-day scheduling, telehealth visits, connections to social services, and integrated primary care teams that treat the whole person (rather than the disease).

The bad news is that there has been relatively limited uptake of such models in primary care practices serving Medicaid populations to date, for a number of reasons: (1) state policies and managed care contracts have not generally encouraged widespread adoption; (2) provider payment models and financial incentives are not typically designed to support major changes in care transformation; and (3) primary care practices lack the time and resources to redesign their systems of care.

Medicaid Managed Care and Primary Care Innovation

State Medicaid agencies are uniquely positioned to help address these challenges and drive primary care innovation for low-income populations. With 39 states now using risk-based managed care covering over 80 percent of all Medicaid beneficiaries, the majority of states are well-positioned to use their purchasing levers to encourage more widespread adoption of advanced primary care models, just as they have done in promoting greater uptake of VBP by their plans.

For example, Tennessee strengthens the “off-the-shelf” PCMH model by requiring its three managed care organizations (MCOs) to: (1) offer technical assistance and care coordination tools to PCMH practices; (2) provide financial support to providers for practice transformation; and (3) measure participating PCMH practices based on comprehensive cost and quality measures that include behavioral health. Arizona requires its MCOs to adopt VBP strategies from a menu of options, including PCMH, shared savings, and bundled payments. It also requires MCOs to enter into VBP contracts with at least two integrated providers who offer physical and behavioral health clinical integration. New Mexico requires its four Medicaid MCOs to support Project ECHO to expand the capacity of the primary care provider network, with the goal of improving access and reducing costs associated with travel from rural counties to seek treatment from specialists.

In addition to this innovative state-based work, provider organizations have also developed new primary-care-based payment models that venture beyond the customary pay-for-performance approach. This presents an exciting and timely partnership opportunity for testing between states, MCOs, and providers. These payment models, including the Advanced Primary Care: A Foundational Payment Model and the Patient-Centered Opioid Addiction Treatment Alternative Payment Model, compensate for care not typically covered under traditional fee-for-service payment models, thereby offering needed financial support for implementing innovative care approaches.

A New Learning Collaborative

With support from The Commonwealth Fund, CHCS is launching a new initiative to help states design and implement primary care innovations through their Medicaid MCOs that help to better serve the unique needs of vulnerable populations. CHCS will work with up to five Medicaid agencies and their partners to address four priority areas:

  1. Expanding team-based community-oriented primary care models (e.g., use of community health workers, pharmacists, etc.);
  2. Integrating primary care and behavioral health;
  3. Addressing social determinants of health via primary care; and
  4. Using technology to expand access to care (e.g., via telemedicine, e-consult support for primary care providers, etc.)

To spur innovation in these areas, this project will focus on strategic levers available in Medicaid managed care states, drawing from successful approaches such as those in Arizona, Tennessee, and New Mexico. For example, participating states could require MCOs to support new care delivery and payment models for primary care practices; align MCO and provider incentives to encourage high-performing primary care across the delivery system; and explore advanced collaborative approaches between agencies, MCOs, and providers in designing and implementing new care delivery and payment models.

On May 16, 2018, CHCS invited all Medicaid agencies operating risk-based managed care programs to apply for this new opportunity, and will select participating states by the end of June. If you would like more information about this project, please contact Rachael Matulis, CHCS senior program officer, at rmatulis@chcs.org.

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Patrick Gauthier

Thank you for this great article. It is critically important that we maintain equity, parity, quality and compassion in what we are all doing. Wellness and patient-centered culture are imperative. This is particularly true where behavioral health, IDD/LTSS and social/human services are concerned. My fear is that if our focus is strictly on the bottom-line, margins, M&A, and the business side of managed care, we will lose the Heart in our systems of care and replace it with greed. We have seen that ugly phenomenon play itself out in spades in the CA substance use disorders treatment system recently. Hundreds… Read more »

Rachael Matulis, CHCS

Thank you for your thoughtful comment. We wholeheartedly agree about the importance of maintaining a focus on wellness and patient-centered culture in any delivery system reform work. We look forward to helping states work toward the very important goals you cite — quality, equity, parity, and compassion.