Sustainable Approach to Justice, Equity, Diversity, and Inclusion Through Better Quality Measurement.

The US health care industry has broadly adopted performance and quality measures that are extracted from electronic health records and connected to payment incentives that hope to improve declining life expectancy and health status and reduce costs. While the development of a quality measurement infrastructure based on electronic health record data was an important first step in addressing US health outcomes, these metrics, reflecting the average performance across diverse populations, do not adequately adjust for population demographic differences, social determinants of health, or ecosystem vulnerability. Like society as a whole, health care must confront the powerful impact that social determinants of health, race, ethnicity, and other demographic variations have on key health care performance indicators and quality metrics. Tools that are currently available to capture and report the health status of Americans lack the granularity, complexity, and standardization needed to improve health and address disparities at the local level. In this article, we discuss the current and future state of electronic clinical quality measures through a lens of equity.

Implementing Value-Based Primary Care Delivery in Federally Qualified Health Centers.

Federally Qualified Health Centers (FQHCs), like many health systems, are in transition toward alternative/advanced payment and reimbursement models. Gradually, fee-for-service reimbursements will be replaced by value-based payments with shared accountability for patients' health care outcomes. This article provides a description of an FQHC Primary Care Collaborative (FPCC) model and preliminary outcomes. This collaborative is an advanced payment model resulting from a partnership between Priority Partners Managed Care Organization (PPMCO), Maryland Community Health System, LLP, and 7 Maryland FQHCs. The FPCC model builds on shared measurable health care outcomes to establish an advanced care delivery model that is tailored to the needs of providers and their patients. PPMCO provided prospective payments to the 7 FQHCs based on their patient population size and total historical cost. Each FQHC had specific health outcomes targets for each fiscal year (FY) to maintain funding. Although FQHC implementation approaches varied, the FQHCs used their payments primarily for outreach and care coordination resources, and to develop processes and structures to improve care delivery outcomes. A 3-year assessment of this program revealed a 35% reduction in emergency department visits and an 11% reduction in hospitalizations for Medicaid beneficiaries across all 7 FQHCs. The FPCC 3-year investment of $4.4M yielded a cumulative cost savings of $19.4M, resulting in a cumulative 3:1 return on investment. There is limited evidence for implementation and outcomes of non-state, Medicaid payer-specific, advanced payment models in FQHCs. This article provides a collaborative framework other Medicaid managed care organizations can adopt and build on.

Building a Medicaid Ambulatory Complex Care Program Within an Urban Medical Home.

Five percent of Medicaid patients account for 50% of total costs. Preventable costs are often incurred by patients with complex medical, behavioral, and social needs who disproportionately utilize acute care services. Evidence for design, implementation, and evaluation of complex care programs in the urban Medicaid population is lacking. The article provides a description of a complex care program (CCP), challenges, and early outcomes based on a pre-post evaluation. The CCP was located within an existing urban medical home. Patients were eligible if they lived within 10 miles of the clinic and had at least 2 inpatient visits and/or 3 emergency room visits within the prior 6 months. Ambulatory Care Groups® were used to predict estimated total costs of patients, who were included if potential cost savings exceeded $5000. Patient experience and quality of care were assessed using validated measures and costs. Return on investment was calculated based on investment and cost savings. Costs include visits (clinic, specialty, and emergency room), hospital admissions, medications, tests and services, as well as salary and benefits of clinical staff. Eighty-six of 211 eligible patients (41%) were enrolled during the first 18 months of the pilot program. There were positive trends in quality metrics and patient satisfaction. The pre-post evaluation demonstrated a reduction in emergency room visits and hospitalizations (67% and 65%, respectively), which resulted in a 2.2:1 return on investment. This article offers lessons learned to colleagues considering population health approaches in the care of high-risk Medicaid patients.