Medicaid solution is a health-care solution

Nearly 30 percent of the population of Mesa County receives health-care coverage through Medicaid. If you add the subsidized products available through the healthcare exchange, it’s closer to 40 or 50 percent of the population that relies on government-funded health care.

Thankfully, over the course of decades, we’ve distinguished ourselves as a community that maximizes health-care outcomes by providing Medicaid patients with mainstream access to the same network of physicians available to anyone.

The idea is simple: By emphasizing preventive care, the Western Slope Medicaid model seeks to keep people healthy and avoid the costlier expense of disability or treating disease.

And it works. When the state of Colorado agreed to an expansion of Medicaid under the Affordable Care Act, it sought to change the Medicaid payment model and delivery system.

The state adopted a proposal put forth by a Western Slope team of Rocky Mountain Health Plans, providers, physicians and hospitals that had already achieved distinction for its prevention-based approach to containing costs.

Moving from a volume-based model that reimbursed providers for every service they delivered, the new model provides incentives for providers to stay within a fixed budget that’s based on the number of Medicaid patients in the system. If they exceed spending limits, providers eat the cost. But if they stay under budget and hit targets for wellness outcomes, funds are returned to the state and a portion are returned to the community.

The only way to make this approach successful is to better get ahead of the root causes and behaviors that lead to debilitating disease and expensive treatment.

The Rocky team has achieved financial targets for two budget cycles. Last year the system returned $5 million to the community to be reinvested in primary care and mental health.

It was rewarded for this strong performance with a grant that will accelerate the evolution of this community-based health-care model. Rocky Mountain Health Plans will coordinate distribution of $4.5 million over the next five years from the Centers for Medicare and Medicaid Services to improve communication and data sharing among physicians, nonprofits, human-services agencies and others to provide better, and ultimately, less expensive, care.

In essence, the Rocky consortium is getting at the root drivers of health-care outcomes and costs. Coverage is just the tip of the iceberg. It’s the gaps, risks and behaviors that occur “upstream” — before a patient sees a doctor — that can be costly.

“Even if we went to a perfectly efficient system, it would still only drive about 10 percent of future costs,” said Patrick Gordon, associate vice president of community integration for RHP. “Behavior, environment, social factors — those are the things that really dictate whether the cost curve is accelerating or moderating.

“So this work that we’re taking on is very important,” he added. “Many people in health care are focused on that now. What’s different is that this community is actually organized enough to do something about it, which is why we had this recent recognition.”

This approach has focused on lowering costs for Medicaid patients, but it provides solutions for health care at large. The grant will allow the Rocky consortium to better align the health-care system with human services and further bend the cost curve.


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