Medicaid Prime

Background

Medicaid Prime launched in September 2014 as a two-year pilot with a simple goal: Improve the health of individuals and the community while reducing costs and improving efficiency.

The community-based approach brings together payment reform, population health management and whole-person care in Western Colorado. Prime primarily serves adult Medicaid enrollees and a small number of children in six counties: Garfield, Gunnison, Mesa, Montrose, Pitkin and Rio Blanco.  

The Colorado Department of Health Care Policy and Financing (HCPF) approved a plan submitted by Rocky Mountain Health Plans (RMHP) for a Medicaid payment reform project--the Accountable Care Collaborative (ACC) Payment Reform Initiative--that encompasses physical health, behavioral health and substance abuse services. Colorado lawmakers authorized the ACC to move toward a more cost-effective and accountable system of care for those who qualify for both Medicare and Medicaid services.

Prime’s purpose is to align the way providers are paid with quality-improvement and cost-containment objectives for the Medicaid program. Key themes include:

  • Value, not volume
  • Accountable communities, not individual providers
  • Health equity for vulnerable populations
  • Behavioral health integration and whole-person care
  • Reduced health plan "red tape" to enable providers to make efficient, evidence based decisions
  • Prioritizing resources while accounting for everyone
  • Sharing burdens and benefits with partners
  • Improving efficiency as coverage expands
  • Sharing data to improve population health

Shared Savings Outcomes - Year 1

  • RMHP, partnering providers and community agencies met total cost and quality targets established by the State of Colorado for the first year of the Colorado Payment Reform Initiative for Medicaid Expansion, authorized on Colorado House Bill 12-1281.
  • Approximately 35,000 people with Medicaid coverage, including adults in the expansion categories, people with disabilities and dual Medicaid / Medicare eligibility, and children with special health care needs have been served by the program.
  • Retention of savings within the global budget for the program is contingent upon achievement of quality performance regarding diabetes management, obesity, depression and patient activation.
  • A total of $5,082,684 was distributed by RMHP to eligible primary care and mental health providers, who were also accountable for aligned quality performance targets in the same domains.
  • 60% of the shared savings was distributed to primary care providers. 30% of the shared savings payment was distributed to community mental health centers. 10% of the payment was retained by RMHP.
  • 48% of the physician groups participating in the program achieved quality targets necessary to qualify for payments, which were distributed on the basis of attributed patient volume and risk scores.
  • The physician groups serve 73% of the total attributed patient population enrolled in the program.
  • RMHP and partners are on track to achieve similar results for the second year of the program, which ended on June 30, 2016.
For more information, please see Prime Year 1 Practice Outcomes