most practices don’t have, says Dr. Born- stein. TMA helped her launch a medical home pilot among seven North Texas practices and several private payers in 2008 as executive director of the Texas Medical Home Initiative.
“The issues we have in the Medicaid world are similar to those in the private world: In order for practices to do the work of transformation, it takes resourc- es, and it takes resources up front. And I don’t just mean increased payments, al- though you think that would be a given in Medicaid,” she said. “It’s one thing to get an extra $2 per member per month because you’ve demonstrated [qual- ity improvements]. The catch-22 is that practices have to invest in the infrastruc- ture to do it. And when it comes down to it, it’s difficult to get folks to commit to funding.”
The average primary care practice
does not have the financial wherewithal to set up the basic information technol- ogy or patient registries needed to track patients’ health, or the time to shut off the phones for one hour per week to create medical home policies and pro- cedures. And compared with private pa- tients, coordinating and improving care for Medicaid patients accustomed to going to the emergency department for primary care could prove more difficult. On top of that, “Medicaid has a lot of red tape” physicians have to cut through, Dr. Bornstein says. Reform “is more challenging in Med- icaid, but it can be done,” she says, add- ing that there is more evidence now that new delivery and payment models such as medical homes are working to im- prove care and reduce costs. “In Texas, it’s frustrating to see the evidence and not have champions to step up.”
Moving the needle Medicaid managed care plans — whose contract payments also are at risk if they don’t improve quality — say they are taking steps to incentivize change. But they agree the task is challenging. Some plans have begun experiment- ing with new models, but the movement is not widespread. Driscoll was the first Medicaid HMO to initiate a shared sav- ings program that financially rewards
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