Check up on Colorado Medicaid

Monday, September 01, 2014 12:22 PM

Colorado Medicine sits down with HCPF Director Sue Birch

by Susan Birch, MBA, BSN, RN, Executive Director Colorado Department of Health Care Policy and Financing

As a former nurse and executive director of the Colorado Department of Health Care Policy and Financing (HCPF) since 2011, Sue Birch understands health care from both a clinical and administrative perspective.

During her time with HCPF, Birch has overseen the restructuring of the state’s Medicaid system into seven Regional Care Collaborative Organizations. By providing a home base of coordinated care for Medicaid recipients, RCCOs are intended to realize efficiencies of health information technology while meeting the unique health needs of Colorado’s diverse populations at the individual and population health levels.

To put the reforms of the past four years in perspective, Colorado Medicine asked Birch to explain HCPF’s work in decentralizing Medicaid, the increased role of Medicaid in the state’s health care system, making payments more attractive to primary care physicians, and how Colorado health care services will be funded in the future.

Colorado Medicine: How did the idea of decentralizing Medicaid come together?

Sue Birch: Colorado under the Ritter administration moved forward on health reforms. The Affordable Care Act allowed us a really strong start, getting everybody covered at the right price and in the right model of accountable care. We pushed forward with the vision for health, wellness and prevention. We have really anchored our state with leveling out regional care collaborative organizations. I am proud we have delivered on the vision, implementing a lot of change and incenting accountable care here in Colorado.

We have seven regions that are coordinated care entities. They have come together to focus on cost containment, establish a standardized level of primary care through the medical home model and use a new statewide data analytics contractor infrastructure. With the fundamental pieces in place, these regional collaborations have helped us lay the base for the health care transformation in the public sector.

One of the first things that the Hickenlooper administration did was to execute contracts in service delivery redesign. This was really a prioritization toward our valued primary care providers – the doctors, nurse practitioners and PAs who do the lion’s share of the primary care work. We will be rebidding and reworking this proposal in the coming months and years to make the Accountable Care Collaborative more robust with specialty care and public and behavioral health integration.

We have implemented the Accountable Care Collaborative (ACC) and are fully loading our Medicaid clients into RCCO and PCMHs. As of today, we have about 688,000 of our nearly 1.1 million patients in the RCCO pipeline. More care coordination work with chronic conditions and life span approaches are connecting clients and their providers. We want to assure the relationships with providers are supported so that clients don’t go to the emergency room unnecessarily. Providers are more mindful of reducing unnecessary high-cost imaging – CT scans, etc. – and reducing hospital readmissions. We are very excited about the results and progress we are making.

We also successfully executed what we call the dual contracts (clients covered by both Medicaid and Medicare). CMS had to approve how we handle and manage the chronic complex clients that comprise 17% of our population. After extensive negotiations, our team advanced Colorado as the tenth site in the nation to improve services with a value-based and shared savings approach. In our third year, we will improve specialty care with the use of health infrastructure investments like Project ECHO. In November, we’ll release more data and statistics demonstrating successes and savings. The near future holds a partnership with the foundations on vigorous evaluation methods so that our work can be replicated nationally. It’s my hope that by continuing to invest in the primary care side of our work together, we’ll see greater value and transformation in the Colorado health care system.

What sort of success stories do you think that Colorado Medical Society members will want to hear about?

CMS members have been our biggest supporters and partners. I have heard accolades for the tools and service delivery redesign that is allowing doctors to provide medicine in its pure form. Having the right tools in place in reviewing their primary care work at the individual, practice and regional levels is harmonizing our efforts. I have also heard a lot of positive feedback for the increased reimbursement and new way of moving toward incentivizing performances and valued-based payments.

Are there any statistics you’d use for how the programs are working?

Colorado is fifth best in the nation for reducing our uninsured rate from 18% down to 11% statewide, with both private and public insurance. We have almost 60% of clients in tighter care coordinated systems. More than 40,000 providers statewide see our clients in partnership with this transformation work.

How do these policies advance the Triple Aim?

It’s maybe a little difficult for the public and our politicians to understand the notion of our Triple Aim (Editor’s note: Developed by the Institute for Health Care Improvement, the Triple Aim concept aspires to optimize health system performance by improving the patient experience while improving the health of populations and reducing the per-capita costs of health care), and I can’t tell you how many people have said, “Can’t you just do one thing at a time?” But we really can’t say, “We’re just going to worry about access and coverage.” We also have to be transforming quality, moving to value-based payments and pushing wellness, prevention and health education.

The department is moving forward on pushing person-centered care. That’s going to help clients better understand their role when they go into their docs and primary care homes. We think that driving more care coordination will help docs practice better medicine and assist clients with achieving their health goals.

How do you see this decentralized approach to Medicaid looking in four years?

I am a firm believer that all health is local and individualized, so I think this regional decentralized approach will continue to deliver results. We have a push toward life span metrics and quality outcomes, using three metrics – emergency room use, high cost imaging and readmission rates. In our next phase we are focusing on integrating physical and mental health. We want to forge more understanding of how mind and body are working together or working against a person’s health status.

We want to use our RCCO platforms to drive toward better health and social well-being where it shows us savings.

Can you give us an idea of how the regional approach plays out?

We have some good case studies happening in Colorado. Our Colorado Springs community is really a leader in aging services. We have our Western Slope folks who are pioneers in payment reform. We have some great work that is emerging in north Denver. They’re all unique and specialized. But they are all advancing this health care transformation. We want these systems of care to play to their strengths and for them to keep building this team-based care model.

For example, we have partnered with the health departments to deliver on public policy about putting more teenagers on long acting, reversible contraceptives. We have seen tremendous drops in the teen pregnancy statewide.

Colorado has taken steps to increase Medicaid reimbursements and make it more palatable for primary care physicians to participate. Are you pleased with the progress of payment reform so far?

We have started the process with our West Slope partners. Getting federal approval has taken time but we are making significant headway. We have to come to grips with the notion that there aren’t really going to be new dollars, but that there should be redistributed dollars. I am very pleased with how we are progressing payment reforms. We don’t want to do things so quickly that we would cause unintended financial consequences.

That being said, it’s definitely a push-pull system with our federal partners, because we only control half of this equation with state money. We have to get federal buy-in with how we are maturing payments for our docs. We have made a complete and total commitment to the 18-month primary care rate bump extension. But we also need to understand how the savings we create are going to be sustainable. Because I don’t see huge new dollars coming into the system as we continue to move through health care reform.

I think that getting people healthier and getting them working at their maximum productivity will ultimately bear some results with our clients. We also are trying to decrease the wasteful spending that goes on. Nationally, one-third of health care spending is a complete and total waste. We’re trying to ensure that as we’re overhauling into a new system, we simplify our processes.

So, you are really hoping that the savings that you’re seeing as a result of these reforms will make the increased fees sustainable in the future?

I think we as health professionals and policymakers need to decide if we shift more resources into population health and prevention. How do we start to use the dollars in a more accountable way, so that we are only paying for evidence-based services, and that we have more quality ratings for our providers?

For example, with NICU – the new neonatal intensive care units – we want to make sure that those types of units and services are delivering the right services to the right people. We want to reduce the variation of pricing. So all of those things lead me to believe that with redistribution and accountability, paying attention to the data we have, we’ll be able to move the resources around toward the right configuration of care providers.

It sounds like the funding of the Medicaid fee bump and keeping it sustainable is a one-year-at-a-time proposition that will need to be continually tweaked as the other variables in health care play out. Is this correct?

Absolutely. As we drive more success with information systems and new health information technology, there’s so much development around simplifying rules and stripping down bureaucratic processes. We’ll be modernizing our provider enrollment processes next year, and that is going to make it so much easier for providers to work with us.

There have been some concerns about the hospital provider fee – created to fund Medicaid expansions before the ACA went into effect – and whether the dollars are being used as intended or as they could be best used. What are your thoughts?

We are so lucky in Colorado that we created a hospital provider fee scenario that pays for Medicaid expansion and is driving the uninsured rate down. We feel the hospital provider fee absolutely fulfills its intent. We are hopeful that efficiencies and transformation will drive premiums down even further. As we have more people insured, and as the federal government changes the parameters around the hospital provider fee, we have to watch that closely. As we have more technological advances, fewer people going to hospitals, more care at home, or in primary care ambulatory settings, we have to look at how we mature the idea of a hospital provider fee as well.

What are your ideas for making Medicaid more palatable for specialists? There was a bump in reimbursements for primary care codes, but not specialty care. What’s currently being done to address this disconnect?

I am really excited about where we are headed with Project Echo and the Doc-to-Doc program. I think we’ll be seeing lots of movement and improvements around getting the next layer of specialty service provision in place for our Medicaid clients.

Medicaid reimbursements: A specialist’s view

While much has been done to bridge the disparities in Medicaid reimbursements, advocacy groups and lobbyists representing Colorado physicians aren’t resting on their laurels, said Murray Willis, MD, president of the Colorado Society of Anesthesiology.

“Physician specialty societies have met monthly with Medicaid department staff to engage in candid discussions about the low reimbursement rates in Medicaid for specialty areas. We have exchanged quite a few interesting ideas. The department updated us on potential plans to improve ’access to care’ for their clients where there is difficulty in finding specialty physicians. While no solutions are tied to direct reimbursement, we are glad the conduit is there. In future conversations, it is our goal to ensure that serious consideration is given to potential changes in delivery of service models and reimbursement increases.”