Primary Care Initiatives Help Save State Medicaid Program Millions

Illinois Combines Two Programs to Improve Quality, Save Costs

July 21, 2010 04:25 pm James Arvantes

By incorporating concepts from two complementary programs that emphasize patient-centered primary care and chronic disease management to reduce costs and improve the quality of care, the Illinois state Medicaid program was able to save a total of $500 million in fiscal years 2008 and 2009. That's according to Margaret Kirkegaard, M.D., M.P.H., of Downers Grove, Ill., a family physician and medical director of Illinois Health Connect(www.illinoishealthconnect.com), or IHC, which runs the Medicaid medical home program.

The IHC program that Illinois adopted uses a patient-centered medical home model to deliver care to 1.8 million of the state's 2.6 million Medicaid recipients. In addition, another program, called Your Healthcare Plus, provides care to 260,000 Medicaid medical home recipients with one or more chronic conditions.

Together, the programs saved $180 million during the 2008 fiscal year and $320 million in the 2009 fiscal year, according to Kirkegaard. The state fiscal year runs from July 1 to June 30. Medicaid savings were calculated by looking at the costs per patient before and after the launch of the programs, said Kirkegaard.

She attributes the success of the two programs mainly to primary care. "Patient populations with better access to primary care have better outcomes and are less expensive," said Kirkegaard, adding that the cost savings in the programs are largely a result of better disease management, fewer hospitalizations and decreased emergency room use.

Taking a Closer Look

The IHC program designates individual primary care health care professionals and community health centers as medical homes, and it currently employs 5,700 participating clinicians in its medical home network.

"If you are a private practitioner and you are in a group of four doctors, we will count all four as medical homes," said Kirkegaard. However, the IHC counts each community health center as only one medical home because of Medicaid billing issues.

Kirkegaard described the medical home program as a primary care case-management initiative that operates as a hybrid; it employs a blended fee-for-service and managed care model to deliver efficient, high-quality services.

"Some of the best things we liked about managed care were an emphasis on preventive care and primary care," she said.

The IHC program does not certify practices or individual physicians as medical homes, and it does not require them to be recognized as medical homes by outside organizations, such as the National Committee for Quality Assurance.

However, it does require medical homes to meet certain standards. For example, these practices are required to provide 24/7 on-call access for patients, and physicians within an individual practice have to work at least 32 hours a week for the practice to be considered a patient-centered medical home.

Medical home practices have to meet other criteria, as well. They are required to adhere to standards for chronic disease care, and they have to provide immunizations within their practices or have an agreement with the local health department to provide immunizations.

Pay for Performance

The IHC program also pays its medical home practices an enhanced fee-for-service payment, as well as a per-member, per-month stipend of $2 for pediatric patients, $3 for adults and $4 for adults with disabilities. The program also has initiated a pay-for-performance program that pays primary care practices extra for meeting five quality metrics in the areas of developmental screening, immunizations, asthma, breast cancer screening and hemoglobin A1C testing.

"We don't have standards where we bump someone out of the network if they don't meet the clinical metrics," said Kirkegaard. "But we do monitor their progress on the clinical metrics, and we have quality assurance nurses who go out into the field and meet with practices to help them improve on their quality metrics."

Kirkegaard refers to the medical home as the heart of the IHC program and information as the program's nervous system. Data-sharing helps create a seamless system of care that makes it possible to improve the care itself, she noted.

"This is a very transient population," said Kirkegaard about patients in the program. "Patients might move from Peoria to Chicago. We have data on the care that was provided in Peoria, and we make that accessible to the practices in Chicago."

The IHC program also shares patient information with the designated medical home practices, using it as a tool to drive quality improvements. "We give them quality data -- feedback on how they are doing with their rate of Pap smears, their rate of mammograms," said Kirkegaard. "In my mind, that is kind of the nervous system of providing data back and forth so practices can use that for feedback and (to) improve."

The IHC program also provides data to the Your Healthcare Plus chronic disease program. This furthers collaboration between the medical home and chronic disease programs, Kirkegaard said. McKesson Health Solutions administers the chronic disease program, which is only available to patients with comorbid conditions who are enrolled in the medical home program.

The chronic disease program, like the medical home initiative, provides a variety of services, including calling patients to remind them to get their flu shots and sending staff members to a patient's home to review medications and enhance adherence. According to Kirkegaard, one of the reasons the two programs are so successful is that they work together to "assist the patients as much as possible."

For example, health care professionals in the IHC program work with patients to pick a medical home that is compatible with their needs. According to Kirkegaard, this is one of the key features of the program. Some patients may want to see a physician who speaks Spanish or they may need a physician who is on the bus route, and the IHC accommodates those requests, said Kirkegaard.

Continuity of Care

In addition, she noted, the medical home model promotes continuity of care and enables patients and medical home practices to build relationships.

"Each patient has their medical home," said Kirkegaard. "They know they have a unique relationship both with their physicians and the rest of the medical home team."

That is one of the reasons why the medical home is so popular with patients and physicians, said Kirkegaard. Patient surveys conducted in 2009 and 2010 found that among 390 medical home patients from metro areas, more than 97 percent said they were extremely satisfied or satisfied with their primary care practice. The results were almost identical for 390 medical home patients surveyed from rural areas in 2009 and 2010.

The IHC also conducted health care professional satisfaction surveys in 2008 and 2009 and found that more than 75 percent of 687 respondents in 2008 and more than 84 percent of 875 respondents in 2009 said they were satisfied with the administration of the IHC. Even more importantly, nearly 82 percent of respondents in the 2008 survey said the IHC program was beneficial to their patients, and more than 90 percent of respondents in the 2009 survey said the IHC was beneficial to their patients.


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