Louisiana revamps Medicaid care coordination program

Doctor fees are more performance-based, but the move sparks an outcry from primary care physicians, hospitals and other health organizations.

By Doug Trapp — Posted Jan. 24, 2011

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Louisiana's Medicaid agency on Jan. 1 implemented a revised Medicaid care coordination program. The change is part of a larger state effort to overhaul Medicaid, but physicians are concerned about the speed at which the state is moving.

In October 2010, state health officials announced that they would end CommunityCARE effective Dec. 1 because the program wasn't improving the health of Medicaid enrollees adequately. The state also faced a $50 million budget deficit that needed to be closed. Since 2003, the program has paid primary care physicians a $3-per-patient fee each month for their practices to serve as basic medical homes.

But the CommunityCARE decision -- combined with the state's adoption of millions in Medicaid cuts and a continued state push to overhaul the Medicaid program -- sparked an outcry from primary care physicians, hospitals and other health care organizations. They formed the Coalition to Protect Louisiana's Healthcare to challenge some of the moves by Bruce Greenstein, secretary of the Louisiana Dept. of Health and Hospitals, the state's Medicaid agency.

Greenstein responded to the coalition's pressure by keeping the CommunityCARE program alive but implementing more incentive-driven pay. The state cut the base monthly care coordination fee in half and established additional bonus fees only for physicians who hit certain care quality and access thresholds.

One of the bonus standards, for instance, involves reducing nonessential emergency department visits. "We hear reports that recipients go to the ER because they can't get access to their primary care provider," said Rodney Wise, MD, medical director of Louisiana's Medicaid program.

Talks with coalition members also led Greenstein on Jan. 10 to announce the reversal of certain hospital Medicaid pay cuts for the rest of fiscal 2011, although a 2% physician pay cut effective Dec. 1, 2010, still stands.

"We are here to work together with the state's health care providers to find the best ways to be good stewards of taxpayer dollars while maintaining critical access to care for our Medicaid patients," Greenstein said in a Jan. 10 statement.

Pat Breaux, MD, president of the Louisiana State Medical Society, said physicians are sensitive to the budget challenges faced by Greenstein and the state. "We are encouraged by his willingness to hear feedback and the on-the-ground perspective of providers."

But Greenstein has not resolved all the coalition's concerns about the new CommunityCARE, said Stewart Gordon, MD, chair of the Coalition to Protect Louisiana's Healthcare and president of the Louisiana chapter of the American Academy of Pediatrics.

The coalition is pleased that CommunityCARE is continuing, but the state is implementing the new incentive payment structure before physicians know their initial rankings on the standards, Dr. Gordon said. The state announced the reformed program's details in December 2010.

The coalition also disputes the contention that the old CommunityCARE program was not effective, Dr. Gordon said. For example, the proportion of infants who received six or more checkups in the first 15 months of life increased by nearly a quarter in the last four years, according to a coalition statement.

Statistics for 2009 provided by Dr. Wise showed uneven results. Louisiana physicians exceeded national averages for appropriate use of medications for people with asthma that year, for instance, but they performed below average for diabetes care.

Medicaid reform on tap

Greenstein held nine regional meetings in December 2010 to gather public input on establishing coordinated care networks, the state's latest version of Medicaid reform. The Medicaid chief said the state's $7 billion program isn't providing enough residents the coordinated, quality care they deserve.

"Despite all the efforts of very fine doctors, hospitals and other health care providers across the state, they are trapped in a system that rewards volume over value," he said Dec. 3. "It's that system that has given us poor health outcomes, waste and inefficiency."

But the physician and hospital coalition members are concerned that state health officials are still interested in giving private managed care organizations a central role in running the state's Medicaid program, Dr. Gordon said. This would ensure that some state Medicaid funds become corporate profits. Instead, the state should embrace a nonprofit Medicaid model, he said.

The coalition is working on just such a Medicaid care coordination model that combines the best of models enacted in Minnesota, North Carolina, South Carolina and other states, Dr. Gordon said.

Dr. Wise said his state welcomes a proposal from the coalition. Meanwhile, state officials are preparing two requests for proposals -- one for a traditional, privately run managed care model, and another that would link networks of physicians and pay monthly care coordination fees while maintaining fee-for-service pay for services.

State fiscal problems also could complicate Medicaid reform. The U.S. Dept. of Health and Human Services notified the state on Jan. 3 that it must repay the Centers for Medicare & Medicaid Services nearly $240 million for overpayments the agency made to fund Louisiana State University hospitals between 1996 and 2007.

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New incentives

Louisiana halved its $3 per-patient, per-month Medicaid care coordination pay for most beneficiaries in January. However, the state is offering new performance-based fees to physicians and other medical professionals:

  • 75 cents for being the most successful at limiting emergency department visits for nonemergency care.
  • 75 cents for extending office hours by March 31. Practices with fewer than 2,000 Medicaid patients must offer at least two additional hours per week, phasing up to six hours for practices with more than 5,000 Medicaid patients.
  • 50 cents for receiving medical home certification by the end of 2011 from the National Center for Quality Assurance or under standards developed by the Joint Commission.
  • 25 cents for offering the Medicaid Early and Periodic Screening, Diagnosis and Treatment Program inside the practice.

Source: Louisiana Dept. of Health and Hospitals

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