A value to quality
Date: June 15, 2012
For more than a decade, Maryland has used a value-based purchasing system to evaluate the quality of care provided to Medicaid recipients on selected care measures and to hold its seven managed care organizations accountable for providing those services.
But in 2010, the state ratcheted up its benchmarks. Priority Partners, the Medicaid managed care organization half-owned by Hopkins, paid a price—more than $3 million in penalties for failing to ensure that the required number of its members received the tests and treatments the state demanded.
For Priority Partners President Robert Neall, that was a lesson learned the hard way. “The stakes had changed,” he says. “We couldn’t wait until December of 2011 to assess our progress. We needed processes in place to track progress throughout the year, and we needed to enlist the help of our providers and members if we were going to be successful.”
Neall’s challenge led to a highly successful alliance between Johns Hopkins HealthCare (JHHC), the managed care arm of Johns Hopkins Medicine that oversees Priority Partners, and Johns Hopkins Community Physicians, resulting in improved access to care, reduction in emergency department use, reduced costs and great success with the value-based measures.
“By working together and coordinating processes, scores were elevated to a much higher level,” says Jenny Bailey, director of transformation and reform at Johns Hopkins Community Physicians.
Each fall, the Maryland Department of Health and Mental Hygiene identifies 10 quality measures for the state’s Medicaid program and establishes benchmarks that the managed care organizations must meet in order to avoid penalties for not achieving them or receive rewards for exceeding them.
These value-based purchasing measures address such provider services as doctors’ visits for children and adolescents, cervical cancer screenings, diabetic eye exams, immunizations, lead screenings and postpartum exams. Each managed care organization is at risk for 1 percent of its capitation. For Priority Partners, that meant $9 million in 2011.
Priority Partners had been moderately successful in previous years, usually exceeding enough of the benchmarks to offset the penalties. In 2009, the value-based purchasing program even resulted in a $2.3 million reward to the Hopkins’ affiliate.
For 2011, the state health department announced increases in the number of Medicaid managed care members exposed to the quality measures. To answer that challenge—and avoid further penalties—Priority Partners had to improve its provider outreach to the primary care sites in its network. With more than 20,000 Priority Partners members assigned to Johns Hopkins Community Physicians for primary care, collaboration between the two organizations became essential.
Provider relations staff from Johns Hopkins HealthCare fanned out to talk with Community Physicians providers throughout the state. They were armed with opportunity reports showing Priority Partners members needing one or more of the value-based purchasing services. Providers received quarterly updates indicating which members still needed services. To increase engagement, providers were given a $25 bonus payment for every value-based purchasing measure met.
Similarly, 91,000 Priority Partners members received multiple mailings and phone calls encouraging them to sign in to a personal URL to learn about the services they needed and be rewarded with a $25 Target gift card for every measure met. The JHHC outreach team assisted members in getting appointments with their providers, made reminder calls to members and assisted with transportation to ensure the members got to their appointments.
While claims data is still being tallied for 2011, preliminary data shows that Priority Partners completely avoided the $9 million in penalties and is on track to receive at least one $900,000 reward.