Evidence-Based Medicaid: Health Care That Works Pay for Performance: Health Care That Adds Value Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 2 Evidence meets Performance Medicaid will do P4P in situations unique to Medicaid Medicaid will do P4P in situations unique to Medicaid Bariatric Surgery Bariatric Surgery Managed Care Managed Care ADHD Drugs ADHD Drugs

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 3 Medicaid’s grading system for service authorizations (WAC ) DSHS generally approves above the line Below the line, provider needs to show the evidence or DSHS will disapprove via Prior Authorization A = Randomized controlled clinical trials (cannot be based on Type III or Type IV evidence alone) B = Consistent and well done observational studies (cannot be based on Type IV evidence alone) C = Inconsistent studies D = Studies show no evidence, raise safety issues, or no support by expert opinion

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 4 Performance: Community ADHD Drug Prescribing Practices for Medicaid FFS Children Age 17 and under FY2005

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 5 Payment: ADHD 2 nd Opinion Process for Children HRSA Pays Three Hospitals to Review ($225) HRSA Pays Three Hospitals to Review ($225) ADHD in < 5 year olds, ADHD in < 5 year olds, At high doses (120/60) At high doses (120/60) In combinations In combinations >300 cases logged to date. >300 cases logged to date. 60% are approved 60% are approved 40% are changed by the second opinion 40% are changed by the second opinion ROI 3:1 ROI 3:1

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 6 Performance: Community Outcomes in Bariatric Surgery

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 7 Process: Going from a D to a B Grade Surgery gets a “B” for diabetics who are obese (BMI >35) and a “D” for other co-morbid conditions (WAC ) Surgery gets a “B” for diabetics who are obese (BMI >35) and a “D” for other co-morbid conditions (WAC Aug 2004)  6-month pre-op staging  5% weight loss  Nutritional, endocrine, and surgical consultation  3 Centers of experience  (< 2% mortality, 15% morbidity and 50% weight loss)

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 8 Performance: Medicaid Pays a Premium for Centers of Experience

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 9 Performance: Medicaid Managed Care Incentives in place since 2004 Incentives in place since 2004 Incentives for HEDIS measures Incentives for HEDIS measures 2 year old immunizations 2 year old immunizations 3 categories of well child care (birth to 15 months; 3 – 6 years and 12 to 21 years) 3 categories of well child care (birth to 15 months; 3 – 6 years and 12 to 21 years)

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 10 Performance: Medicaid Vaccinations Well-Child Care Well-Child Care Birth to 15 months Birth to 15 months 2004 – 43.7% 2004 – 43.7% 2005 – 41.4% 2005 – 41.4% 2006 – 47.0% 2006 – 47.0% 3 to 6 year olds 3 to 6 year olds 2004 – 53.5% 2004 – 53.5% 2005 – 53.0% 2005 – 53.0% 2006 – 55.0% 2006 – 55.0% 12 to 21 year olds 2004 – 35.2% 2005 – 36.8% 2006 – 32.0% Combo 1 Immunization rate 2004 – State average 66.9% 2005 – State average 69.9% 2006 – State average 74.1%

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 11 Structure and Process Formal link with Washington State Child Profile Immunization Registry Formal link with Washington State Child Profile Immunization Registry Plans uniformly using robust methods Plans uniformly using robust methods Implementing stronger interventions to improve immunization care Implementing stronger interventions to improve immunization care Some plans are rewarding providers/clinics financially for improved performance Some plans are rewarding providers/clinics financially for improved performance

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 12 Performance: Based on Outcomes DSHS set aside $1,000,000 each to be paid for improved performance DSHS set aside $1,000,000 each to be paid for improved performance 1,000,000 for improved immunizations 1,000,000 for improved immunizations 1,000,000 for improved well-child care 1,000,000 for improved well-child care Calculations based on point system rewards plans for Calculations based on point system rewards plans for Current year performance relative to other plans Current year performance relative to other plans Improvement from previous year to current year relative to other plans Improvement from previous year to current year relative to other plans Four highest performing plans share rewards Four highest performing plans share rewards

Evidence- Based Medicaid Jeff Thompson MD MPH Chief Medical Officer Washington Medicaid Program 13 Performance Based Care: What’s Important? Mortality vs. Morbidity? Mortality vs. Morbidity? Process vs. Outcomes? Process vs. Outcomes? My Value vs. A Payer’s Value My Value vs. A Payer’s Value Local control/measures? vs. Central control/measures? Local control/measures? vs. Central control/measures? All Politics is Local vs. All Quality is Central? All Politics is Local vs. All Quality is Central?