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Primary care practices will need extra help to transform
When Craig Thiele, MD, chief medical officer of Dayton, OH-based CareSource, the state's largest Medicaid managed care plan, thinks of 2014, he remembers the need to "be sure, from the sheer aspect of supply and demand, that we don't get into trouble."
To be ready for the influx of millions of Americans onto the Medicaid rolls, he says, there is no question that the number of primary care providers must increase significantly.
"We have been working on this for a good long while with our networks, but this took it up a couple of notches," says Dr. Thiele. "You can't wait until you have a flood of people moving into the market."
One challenge is that many of the newly insured will be in the health insurance exchanges, says Dr. Thiele, which will probably have a higher pay rate than Medicaid. "We are getting very serious about finding ways to make it easier for our providers," he says. "'Making it easier' is our mantra."
Providers are not only paid less to care for Medicaid patients, says Dr. Thiele, but they also have more administrative burdens to contend with. For this reason, he says, CareSource is implementing a "first call" resolution process and an easier appeals process.
"We are looking at anything and everything that we can do to remove those hassles, to the point where that isn't what they think about with a Medicaid managed care plan," says Dr. Thiele.
Partner with providers
Another key, says Dr. Thiele, is partnering with providers in helping them to manage Medicaid patients more easily. As part of a patient-centered medical home pilot, a case manager was assigned to help providers with practice transformation, he reports.
It was discovered that practices needed a great deal of help to implement open access scheduling, disease registries, and other approaches to better manage patients with complex health needs, says Dr. Thiele. Depending on the size of the practice, he adds, onsite case managers were sometimes needed.
Providers now use CareSource's Clinical Practice Registry to keep track of which members are overdue for diagnostic tests, says Dr. Thiele. "We reward them for improving on those same measures for which we provide the tools," he says. "We are now part of the solution, and not just a payer."
Notably, says Dr. Thiele, the medical home pilot consists mostly of "mainstream" practices varying in size from 200 to 5000 members. "We didn't just want the early adopters," he explains. "We have to help them get there. It's certainly not a cookie-cutter approach."
The payer's approach is to make it easier for the practice to do better on the measures, explains Dr. Thiele, then reward them for it financially. "If we get that practice to do everything better, and they are being rewarded for it, now they will say, 'I want more of your patients in my practice,'" he says.
Providers are notified if a member goes to the ER or the hospital or fills a prescription, adds Dr. Thiele, and a 24-hour nurse advice line is made available to patients. "That drives quality, but it also reduces some of the workload off the provider," he says. "It makes their lives easier."
A single model
Each of the state's six other Medicaid managed care plans agreed to use the same medical home model, reports Dr. Thiele. "We went to the Ohio Department of Jobs and Family Services and shared that with them," he says. "That shows that we can work together on certain things that are very important."
If a given physician in the community is presented with the medical home option, says Dr. Thiele, he or she will consider the fact that CareSource comprises only a small percentage of their practice. However, he explains, if all of the Medicaid managed care plans are using the same medical home model, that percentage might increase to 20% or even 40%.
"That provider won't be as excited about the medical home option, if different plans are giving them different models," says Dr. Thiele. "If we bring them the one model, and say, 'All the Medicaid managed care plans are behind this,' that simplifies things for them."
CareSource is currently working to make the pharmacy benefit simpler for providers, says Dr. Thiele, given the fact that the seven plans each manage the state's formulary a little differently. "That is something we are discussing with the state now," he says. "They have been very open to working with us on solving some of these barriers."
Some providers will not accept any patients outside commercial payers or Medicare, notes Dr. Thiele. "By allowing more dollars to flow through programs that improve outcomes, that will allow more growth to occur in the safety net system," he says. "I think it will encourage even providers who aren't in the safety net system to be curious."
Contact Dr. Thiele at (937)-531-2132 or email@example.com.