For lawmakers, caregivers and patients a solution to the state legislature’s multi-year process of bringing a new type of coordination to a traditional Medicaid population is set to be finalized this summer.
PASSE, or Provider-led Arkansas Shared Savings Entity, will be a new oversight entity made up of among nonprofit and for-profit health providers to manage the care of the state’s medically frail Medicaid population. It includes the elderly, developmentally disabled, and mentally ill. The deadline for these companies to apply to be in PASSE is June 15, according to the Department of Human Services and the Arkansas Insurance Department.
DHS estimates PASSE will oversee care for about 30,000 medically frail Medicaid recipients in the state.
The new effort is the result of the governor’s call from over a year ago to lawmakers to cut $835 million from traditional Medicaid costs. He said the funds would be needed to offset the state’s match rate for Medicaid expansion under the Affordable Care Act, set to increase to 10 percent or more, depending on what happens with the ACA in Washington D.C., by 2020. (A consultant’s report by the Stephen Group in 2015 found a net financial benefit to the state from Medicaid expansion.)
Partly in response to the governor’s push to cut rising Medicaid costs, the Medicaid Provider-Led Organized Care Act was passed by the legislature this year. Similar 2016 legislation called Diamond Care failed in a special session focused on passing Arkansas Works, the state’s version of Medicaid expansion under the Affordable Care Act. This session, provider-led care won out over managed care models that would have outsourced decision making to a third-party manager, neither patient advocate nor care provider.
Doug Stadter is CEO of the Centers for Youth and Families which treats kids. He's working to form a provider group that will apply to give, coordinate and improve care for the medically frail. He advocated for the provider-led model during the legislative session, which allows providers to oversee their peers, and allows them the ability to negotiate fees among themselves by forming their own networks and management structure.
“Making sure that if they’re in a day treatment, that they’re also taking their medications routinely. they’re not subject for going into an emergency room for a psychiatric emergency, they not going to be subject to going into an emergency room for healthcare, physical healthcare needs.”
The premise is that sometimes money is spent on these patients when it doesn’t have to be.
According to Arkansas Advocates for Children and Families’ health policy expert Marquita Little, medically frail Medicaid recipients are society’s costliest individuals to care for.
“You have a small percentage of the population that has a really high level of need that accounts for a great portion of the costs,” she said, and yet, there’s no funding mechanism to coordinate care.
In short, they may have multiple health problems but no one to help them stay on medications or see the big picture of their health regimen.
If they are treated by multiple providers for a range of health issues, perhaps a coordinated conversation between those doctors will result in a better healthcare regime.
For example, an asthmatic patient who would benefit from a new air conditioning unit. A coordinated care entity would be empowered to identify and address such day to day life modifications — for instance, an asthmatic patient who would benefit from a new air conditioning unit, Little offers — that could help avoid costly, catastrophic health issues later.
CEO of the Arkansas Center for Health Improvement Joe Thompson says such systemic change is part of a national move away from a fee for service model that rewards doctors and providers for the volume of visits and tests they tally, “to more of a value-based purchasing where the provider actually has some financial risk” as patients’ health declines.
“They are paid more if the outcomes are good in an efficient, low-cost manner. They owe money back if the outcome is poor or if the costs associated with the care are out of what is the norm.”
DHS will pay incentives to the provider groups if they increase efficiency, get good reviews from patients, and save the state money.
The goal is to move more medically frail Medicaid patients out of nursing homes and into their own homes, where treatment may be more affordable.
Jodiane Tritt is a spokesperson for the state’s hospital association. Her group is one watching closely to make sure rates will be adequate and a functional infrastructure will be in place in the provider network.
“So all of the things you worry about when you’re thinking about a patient’s needs, like network adequacy, and will physicians and doctors be available — will nurses be available for the patients if they need them, especially in the rural parts of the state, are at the forefront of our minds right now.”
They must have members with a range of specialties.
“The PASSE must demonstrate that it has a statewide network of providers. This network of providers includes, but is not limited to, DD and BH specialty providers, physicians, hospitals, and pharmacists,” said Bryan Bowen, Chief of Staff at DHS.
An emergency clause in the legislation allows the PASSE groups to be selected this year and for related changes to take effect immediately.