Medicaid
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Creating quality for kids: A review of Ohio Medicaid’s focus on value based reimbursement

August 26, 2019
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Before taking office, then Governor-elect Mike DeWine signaled that children’s issues would be a central component of his policy platform with the creation of the Office of Children’s Initiatives in January 2019. Ohio Medicaid plays a major role in the health care of Ohio’s children, with nearly half of all kids (1.2 million) receiving coverage through the program, mostly through managed care organizations (MCOs). Unfortunately, Ohio’s performance relative to children’s health is consistently mediocre. Outside of the well-known issues with high infant mortality rates, (particularly for African-Americans), Ohio is consistently in the bottom half of states to ensure that federally mandated Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services are received. In fact, as we have written about previously, no single measure in the “healthy children and adults” or “women’s health” payment streams tied to MCOs achieved the highest rating possible as noted in the state’s most recent external quality review.

 No single measure in the “healthy children and adults” or “women’s health” payment streams tied to MCOs achieved the highest rating possible as noted in the state’s most recent external quality review.

The significance of effective coverage cannot be understated. Research regarding the impact of coverage has been connected to:

Ohio’s CPC program began in 2017 and is a value-based reimbursement program centered on team-based primary care, sometimes referred to as patient-centered medical homes. Eligible practices, which opt-in, receive a per-member per-month payment and the potential for shared savings payments, in addition to continuing to bill for their standard suite of services. The practices are then provided access to data and reports that help them understand and fine-tune their performances relative to peers, within specific populations and with information on cost and quality. While many practices were already serving children in Medicaid, and there were metrics tied to EPSDT, there was no specific model tied to children as a unique population. CPC for Kids, then, builds on the existing CPC framework and ties in incentives that increase performance in key areas for individuals under the age of 21.

 Comprehensive Primary Care for Kids adds metrics tied to immunizations, tobacco cessation and lead screening.

Notably, CPC for Kids adds metrics tied to immunizations, tobacco cessation and lead screening. What’s more, lump sum bonus dollars are available for practices that focus on foster care children, integrate behavioral health into usual care, address specific wellness measures and create better linkages to behavioral health providers and schools. These risk-adjusted, geography-informed wellness measures include lead testing, Adverse Childhood Events (ACEs) or social determinants screening, tobacco cessation, fluoride varnishing and breastfeeding. Practice scoring for bonus payments will include a risk adjustment factor based on the Ohio Opportunity Index to adjust for disparities due to patient location and local environments.  

One need look no further than the City of Cleveland to understand the significance of what this program can accomplish if practices take advantage of these resources. Recently, I moderated a panel at the Lead Safe Summit in Cleveland that focused on screening and testing by medical professionals. The physicians on the panel described how the linkages between practices, families, managed care and community agencies are not sufficient to meet the federally required standard of two lead tests for children under the age of two.

 According to data from the Ohio Department of Health, 13,030 children were tested at least once in Cleveland in 2018.

According to data from the Ohio Department of Health, 13,030 children were tested at least once in Cleveland in 2018. Census data shows that there were about 68,000 children (of all ages) in Cleveland eligible for Medicaid (below 200 percent of the Federal Poverty Level, FPL). Extrapolating the statewide average of kids from birth to age six who are eligible for EPSDT (32.2 percent) to the number of total children in the city below 200 percent FPL (68,000), you would have 21,941 children in the City of Cleveland who would be eligible and should receive a test. This means that 59 percent of kids in Cleveland who should receive at least one test are:  

A systemic approach to preventing lead poisoning in children requires more than incentivizing testing. It requires a comprehensive strategy built around housing as a social determinant and effective case management between MCOs, providers and community agencies. With that said, this example is but one of many where Ohio’s delivery system underperforms and where other measures tied to EPSDT and quality remain stagnant. CPC Kids, then, is a recognition of this reality and a policy strategy of how Medicaid reimbursement can be leveraged to create practice change. Hopefully, with active participation by providers and plans, improved outcomes for foster kids, stability for children exposed to trauma and numbers of vaccinated and lead tested children will increase.

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