Leveraging Medicaid in a Multi-Payer Medical Home Program: Spotlight on Rhode Island's Chronic Care Sustainability Initiative
Rhode Island has been successful in engaging health plans, providers, and purchasers in a multi-payer collaboration to support PCMHs, with the goal of improving chronic care for all Rhode Island adults. The leverage exerted by a multi-payer strategy, including Medicaid in this case and several others nationwide, translates into important advantages for practices, giving them a common, aligned set of goals, metrics and performance benchmarks, practice transformation resources, and incentives, across payers and purchasers, to support practice changes that will benefit all their patients.
Rhode Island’s ability to implement the CSI was enhanced by a number of factors. The distinctive leadership of the health insurance commissioner, and his preference for collaboration around policy goals rather than a purely regulatory approach, were crucial. In a different state context, mandating payer participation and the “primary care spend” could be more challenging. The small number of major payers in the state also helped, and the fact that many stakeholders knew each other and understood each other’s goals made it easier for them to “get on same page.” In addition, many Rhode Island practices and providers serve patients with a mix of health insurance, and may be receptive to participating in an initiative that standardizes the requirements and incentives they face from different payers.
But while Rhode Island has some distinctive attributes, the state has confronted some challenges and issues that are likely to be common to states pursuing multi-payer initiatives. Rhode Island’s need to identify new resources for implementation, and the finding that buy-in is important to maintain support for the initiative, are lessons useful to states broadly. The kinds of tensions between plans, practices, and providers that have required negotiation in Rhode Island are pretty universal; other states may wish to consider whether the inclusive and consensus-oriented approach to development and governance that Rhode Island adopted might help bridge differences and build trust among the stakeholders in their environments.
The reality that system-level health improvements and cost savings require change beyond the sphere of primary care is also not unique to Rhode Island, and states generally can benefit from CSI leadership’s observation that specialists, hospitals, and others in the medical neighborhood must also be engaged for multi-payer medical home initiatives to succeed most fully. While the CSI model may not be feasible in other states, or may warrant adaptation, it demonstrates how Medicaid’s role as a major payer can be leveraged to transform health care delivery and payment. As the ACA expansion of coverage brings more Americans into the health care system, and states and other entities seek to improve care delivery and orient payment toward performance, both the scale and momentum of multi-payer efforts like the CSI can be expected to grow.
This Kaiser Commission on Medicaid and the Uninsured (KCMU) issue brief was prepared by Marsha Gold and Winnie Wang of Mathematica Policy Research and Julia Paradise of the Kaiser Family Foundation.
The authors express their appreciation to David Bourassa, Renee Bromley, Deidre Gifford, Debra Hurwitz, Mack Johnston, David Keller, and Renee Rulin, whose expertise and insights were invaluable to this project.