Although some of the numbers documenting access to care in Texas are less than encouraging, the shift to value-based care in Medicaid is showing positive signs, a panel collectively told the Texas Medical Association’s Winter Conference on Saturday at the Hyatt Regency Austin.
The Access Expansion session included San Antonio pediatrician Ryan Van Ramshorst, MD, the outgoing chair of TMA’s Select Committee on Medicaid, CHIP, and the Uninsured, who was recently named chief medical officer at the Texas Health and Human Services Commission. Also on the panel were Dallas internist Sue Bornstein, MD, a member of TMA’s Board of Trustees and executive director of the Texas Medical Home Initiative; and Stephanie Muth, director for Texas Medicaid.
Dr. Van Ramshorst told the audience the state is seeing a concerning increase in Texans without insurance. The Lone Star State is now dead last in the nation in insurance coverage, with 19 percent of its residents uncovered in 2018 — somewhere between 4 million and 4.5 million people. About 835,000 of those Texans are children, he said.
“When you look at those figures, just shy of half are eligible for programs like Medicaid and CHIP that all of us in this room are going to work collectively to make better,” Dr. Van Ramshorst said. “So that’s the state of affairs when it comes to insurance in Texas: a tremendous opportunity for us to remain involved.”
Also, he noted, Medicaid isn’t available to all poor or low-income women; for instance, women who aren’t pregnant and earn more than $230 per month don’t qualify unless they have a disability. At 60 days postpartum, a new mother no longer receives Medicaid services.
Dr. Bornstein noted the success of value-based payment initiatives in helping to keep Texas Medicaid’s costs in check relative to the nation. Over the past 10 years, the per-capita cost for Texas Medicaid has grown by 14 percent, she said, which compares favorably to the national per-capita cost growth of 30 percent. That has occurred despite the 41-percent increase in Texas Medicaid caseload over the same span. Value-based care — featuring such components as incentive payments, accountable care organizations (ACOs), care coordination, and patient-centered medical homes — also can reduce physician burnout, Dr. Bornstein said.
She stressed that “any kind of value-based program — whether it’s a patient-centered medical home, an ACO, any of those things — needs a strong primary care component to be successful.”
Ms. Muth said incentivizing value-based care is based on the three factors known as the Triple Aim: Experience of care, health of population, and per-capita cost. She said Medicaid is seeing progress with alternative payment model agreements, with 274 such agreements in 2017, 38 percent associated with primary care. Managed care organizations (MCOs) paid practitioners more than $85 million in incentive payments, she said, with 60 percent of those for primary care.
Positive outcome trends in Medicaid, she said, include decreases in preventable admissions and readmissions, and an increase in adolescent well-child visits. Some MCOs’ alternative payment model agreements include what she called “administrative relief,” with fewer prior authorization requirements.
“I think there is a lot of promise as we continue to go down this journey, but recognize that the programs need to meet the providers where the providers are, and we have to continue to evolve what this model looks like in Texas,” Ms. Muth said.