Improving Access and Quality of Care for TennCare Members

The Tennessee Academic Affiliate Physician Directed Payment Program, a Value-Based Medicaid Managed Care Initiative

Faced with growing financial constraints and critical population health issues among their Medicaid patients, two major academic medical centers—East Tennessee State University (ETSU) and University Clinical Health (UCH), affiliate of University of Tennessee (UT) Health Science Center—partnered with TennCare, Tennessee’s Medicaid agency, on a value-based Medicaid managed care supplemental payment initiative. This program—designed and implemented by Sellers Dorsey—has resulted in a measured increase in care coordination and enhanced access to health services for Medicaid enrollees in Tennessee.

Program Focus

Sellers Dorsey worked with ETSU, UCH and TennCare to create a new funding stream, focused on three main priorities:

  • Care coordination.
  • Prevention and treatment of opiod abuse.
  • Early and focused engagement for maternity and pediatrics.

Emerging Impacts

Among several of its notable outcomes, the Tennessee Academic Affiliate Physician Directed Payment Program has achieved:

  • 20% Decrease in Patients with Unmanaged Diabetes a result of expanded care coordination
  • 15% Increase in Well Child Visits a result of increased access to pediatric care
  • 70% Increase in Follow-Up Visits for Patients with Substance Use Disorder a result of expansion of opioid use disorder treatment infrastructure

Program Creation

Sellers Dorsey worked with TennCare and the physician practice plans at ETSU and UCH on the following:

  • Program Preparation and Design, including identifying quality improvement metrics and data sources, establishing the supplemental payment calculation methodology, and identifying eligible providers.
  • Program Approval Process, including establishing policy rationale, facilitating review with the State and supporting the CMS approval process.
  • Program Implementation, Operations, and Management, including facilitating ongoing coalition input and coordination.

This program involves one of the most robust quality-based scoring methods in the country, featuring 21 quality metrics including 12 patient-centered medical home (PCMH) measures.

“Because of this program, we have quadrupled access to behavioral health services, and we have been better positioned to support our communities during the challenges of COVID-19.
Rusty Lewis, Associate Dean for Finance & Administration, ETSU