Idaho Medicaid VCOs ask lawmakers to keep with current system

BOISE — Idaho’s recently developed value-care organizations are asking the state to continue to improve the Medicaid health system before moving on to something else.

The Medicaid Managed Care Task Force has been meeting throughout the interim to look into using managed care organizations, or MCOS — contracting with a third-party agency to administer and oversee Medicaid benefits — to control increasing costs in the health program.

Task force members have also considered the costs and benefits of Idaho’s current system for managing Medicaid through value-based care organizations, called VCOs, which were implemented statewide in 2022. Last week, the task force heard from four VCOs that operate in Idaho as well as a representative from the Northwest Portland Area Indian Health Board who spoke about managed care.

“The initial results from value care organizations are promising, but they’re in really kind of a weird period,” Matt Wimmer, director of network enhancement at Idaho Community Health Center Network of Idaho, said Oct. 5 at the state Capitol. “... Regardless of what the delivery system is, or the system of care, VCO or MCO, our centers are going to do their thing. They’re going to carry out their missions to serve all Idahoans, but we’d like the opportunity to prove the VCO model.”

The system involves contracting with smaller organizations and ties reimbursement payments for quality and efficiency of care provided. Most of those who spoke last week argued that the VCOs tend to be more locally focused and more nimble than MCOs, making them able to change more quickly to suit local populations. But as smaller organizations, it’s harder for them to take on as much financial risk as MCOs if they don’t meet patient care metrics.

The Community Health Center Network of Idaho is the state’s second-largest VCO and consists of 14 federally qualified health centers.

Wimmer said the state’s VCO agreement terms were rather “aggressive” with how much downside risk had to be accepted. Downside risk means the providers will share the losses if they don’t meet performance targets.

“I don’t think it’s unfair to characterize the VCO program as, if not the most, one of the most, aggressive value-based payment programs that is run by a state in the nation,” Wimmer said.

Delana Quinlin, executive director of AdvantagePoint Northwest VCO, said her organization had seen substantial reduced cost through referral control and reviewing high costs and utilizations.

She said the VCO will have $900,000 in net savings that go back to network providers this quarter, and it met nearly all its performance targets for emergency department utilizations, readmission rates, breast cancer screening, diabetes testing and wellness visits.

However, the current system has its challenges, she said.

The way the VCO operates now, organizations may be hurt by their own success, Quinlin said, because the organization’s performance targets are set against its prior year’s numbers.

“Each year we are required to outperform ourself,” Quinlin said. “Quality targets continue to be set higher and, usually using national thresholds as a guide, but networks may be performing at the highest across the state and are still required to improve against ourselves.”

She and other organizations also noted that there are problems with having enough data. Someone enrolled in Medicaid who had received a mammogram while on different insurance wouldn’t be counted properly in the metrics. She said this is particularly a problem because many Idahoans use Medicaid as a secondary insurance.

She recommended that Idaho should pursue a hybrid model with both VCOs and MCOs.

“By offering a hybrid model, we could support allowing VCOs to choose their level of comfort within managing this population,” Quinlin said. “... From our VCO’s perspective, aligning the intentions between the VCO and the manager of the state’s program is the only way for continued success and growth.”

The Pocatello Children’s Clinic opted to become a VCO as an independent clinic.

“We have always been in support of the concept of the VCO program,” said Jessica Perry, an administrator at the clinic. “... Instead of negotiating fee schedules and all that stuff, now we’re getting together in the same room and collaborating to talk about what’s the best outcome for the patient.”

She said all of the state’s VCOs regularly meet to talk about best practices and share ideas for improving outcomes and efficiency.

Using the savings, the clinic has been able to hire care coordinators who reach out to patients to remind them to have preventative check-ups or screenings, which can save money down the line by keeping patients out of emergency rooms.

Perry also had concerns about her organization being measured against its own success.

She wants to stick with the VCO program and continue to make improvements to it rather than switch to an MCO. Perry said she worried that moving to managed care would revert the save to a “reactive approach,” rather than proactive care.

Castell is Intermountain Healthcare’s population health platform company, serving people in Idaho, Utah, Montana, Colorado and Nevada.

Castell has been supportive of the value-based care model, said Executive Director of Government Programs Eric Cragun.

“The direction we’re going is the right direction,” Cragun said.

Like others, he said the VCO program in Idaho hit at a difficult time, coming off the pandemic and ending of the public health emergency.

He recommended evaluating the program’s success after more time.

He recommended ensuring the Idaho Department of Health and Welfare has adequate resources to track and standardize data. He also said the baseline target-setting was a challenge and recommended changing targets to make sure they are meaningful and achievable.

Karol Dixon, director of government affairs and health policy for the Northwest Portland Area Indian Health Board, recommended the Legislature ensure the tribes are able to participate in the process.

She also recommended that, for either an MCO or VCO, technical assistance be provided to ensure the 100% federal reimbursement rate for tribal members is always applied — this creates a benefit for the tribal member and the state.

The task force is expected to meet again on Oct. 16 and members will share their ideas for recommendations to the full Legislature.

Lawmakers return to the Capitol in January and will then get to decide on whether to turn the recommendations into legislation.