Two physician practice plans wanted to work with their Medicaid agency to receive additional funding to help address the opioid epidemic after identifying increased costs of emergency department utilization resulting from effects of addiction in their state. The Medicaid agency became engaged in the initiative and wished to explore opportunities to make headway in a number of significant health priorities beyond the opioid epidemic. The physician practice plans were then challenged to devise a Medicaid financing solution to relieve immediate financial pressures while addressing the state’s goals connected to care coordination, prevention, treatment, and maternity and pediatric care, as well as comply with CMS’ rules for Medicaid financing initiatives.

The Collaboration

Our two physician group clients needed to design and implement functional and operational components to shift the focus from volume to value to make a difference in the quality of care for Medicaid patients in their state. Recognizing the goal to deliver high-quality, cost-effective care, Sellers Dorsey helped redefine and refocus the physician groups’ efforts on issues with the greatest potential impact over the course of 18 months. Through the engagement, Sellers Dorsey provided each client the technical structure and policy framework to address each party’s goals. Our team worked with the practice plans to determine appropriate quality goals and metrics, define focus areas for improvement, and utilize a nationally recognized value-based payment framework. Additionally, we assisted the clients with state and federal approval processes, payment development, and drafting of official documents.

The Results

The goal and outcome were a program design that would pay the physician practice plans in recognition of both infrastructure investments and their performance on quality measures, with increasing amounts of payment at-risk each year. As a result of the initiative, our clients can better meet the needs of their patients in ways for which they previously did not have the necessary resources. The practice plans receive a combined total of $16 million in new funding each year, enabling the plans to promote population health strategies that support increased care coordination and management for Medicaid enrollees across primary care, specialty care, and behavioral health care. In the first year of the program, the physician practice plans earned a total quality-based payment of nearly $1 million, as a result of their strong performance on 12 quality measures. Sellers Dorsey made this possible by understanding our clients’ needs, managing program expectations, and collaborating with the state to achieve shared policy goals that ultimately improve the lives of vulnerable populations.