After months of planning and community collaboration with state and community partners, Rocky Mountain Health Plans officially launched Medicaid Prime this month. Prime provides health care services to adults and children with special needs covered by Medicaid in Delta, Garfield, Gunnison, Mesa, Montrose, Pitkin and Rio Blanco counties. Patrick Gordon, associate vice president with Rocky Mountain Health Plans, discusses the program and what it means for the community.
The Ascent: Can you offer some background on Prime?
Gordon: Our first enrollments became effective on Sept. 1. CMS has approved the reimbursement model and contract, so it's full steam ahead. We're moving quickly to enroll people throughout the region. We're very excited and honored to be part of this important opportunity to accelerate health system transformation.
Prime gives us an economic basis for care-coordination and behavioral health integration objectives; it represents an alignment of payment models and incentives for value from the purchaser, Colorado Medicaid, all the way down to front-line providers. To accomplish this, we developed a global budget for all services in the program, based on our analysis of total cost of care for the population. Prime replaces the volume-based, fee-for-service model with comprehensive, population-based payments. Participants—Rocky Mountain Health Plans, physicians, community health centers and behavioral health providers--have assumed full accountability for costs, and will share in savings. Participants retain savings only if they demonstrate value. Accordingly, Prime includes both quality improvement and cost-containment objectives.
The Ascent: How does Prime fit into Colorado's Accountable Care Collaborative efforts?
Gordon: Prime is a payment reform initiative within the ACC program. It builds on the ACC's success, which focuses on accountable communities (vs. individual organizations), health equity for vulnerable populations, data-sharing to improve population health and, of course, value over volume. The difference is the payment model: Prime represents a significant departure from traditional fee-for-service reimbursement. It's a shared savings opportunity at the community level that allows for the delivery of whole-person care. We see Prime as a flagship initiative for behavioral health integration.
The Ascent: How does Prime support behavioral health?
Gordon: You can't integrate services such as behavioral health until you look comprehensively at total cost of care. Integrated behavioral health with supporting payment reforms is the key to success in any program with cost and performance accountability. Behavioral providers now have a seat at the table, with real 'skin in the game'--sharing in savings and risk with the global budget.
Because Prime uses population-based payments, providers aren't confined to encounter-based care; they have the flexibility to address a wide array of social and behavioral determinants of health outcomes. Prime's global budgeting model gives us the flexibility to pay for community services that can't be coded and reimbursed in a traditional FFS model.
It also supports a high degree of financial, operational and programmatic integration with community mental health centers. This fosters data sharing and begins to overcome the fragmentation inherent in the behavioral health "carve out." We're fortunate to have a specific budget and performance targets to focus our work and reallocate resources for activities that create value. Reducing costs hinges on our ability to address patient needs well outside the scope of traditional clinical services. Prime gives us tools we need to do that.