Improving Outcomes and Reducing Costs for Medicaid Managed Care Patients
- By: NYSHealth
- Date: February 2017
- Priority Area: Advancing Primary Care
- Type: Grant Outcome Reports
- Category: Grant Outcome Report
- Grantee Name: Refuah Health Center
Refuah Health Center (Refuah) is a federally qualified health center that serves low-income residents in the Hudson Valley region. In 2012, NYSHealth awarded Refuah a grant to partner with Fidelis Care, one of the largest Medicaid managed care plans in New York State, and Health Management Associates (HMA), to collect and then analyze claims to identify unnecessary utilization and costs. At the time, Refuah lacked information on the utilization patterns of its patients outside of its center, such as costs of emergency, specialty, and hospital care. Under this grant, it aimed to use the data/information collected to implement new payment schemes for lowering health care costs and improving quality services for its patients.
Grantee: Refuah Health Center
Dates: November 2012 – October 2014
Grant Amount: $198,800 (original); $159,040 (revised)
Grantee Website: http://refuahhealthcenter.com/
Grant ID: 12-01493
Outcomes and Lessons Learned:
NYSHealth originally awarded Refuah a two-year grant of $198,000 (followed up with a 1-year grant extension) to establish a partnership with Fidelis Care and HMA to:
- Develop and implement a data-driven plan to improve patient outcomes and reduce costs for Refuah’s Medicaid managed care patients;
- Align incentives and accountability between Refuah and Fidelis Care; and
- Implement clinical and operational practices at Refuah that support the improved model of care and financial accountability.
Without notifying NYSHealth, Refuah made several project changes over the course of the grant period that significantly altered the project’s original purpose and scope of activities:
- HMA, a lead partner, left the project in 2014;
- Data received from Fidelis Care were deemed by Refuah as being not accurate and therefore could not be used as initially envisioned for the project;
- No clinical or operation practices for improvement were identified; and
- Focus of the project was changed without NYSHealth’s approval to a value-based dental pilot program, which differed significantly from the grant’s original focus to improve outcomes and reduce costs in key clinical cost categories for Refuah’s Medicaid managed care patients.
Additionally, Refuah was unable to complete or deliver significant grant activities as outlined in the original project scope, including:
- Project implementation and work plans with details on key findings/activities, major milestones and responsibilities, and evaluation/performance-monitoring activities; and
- A summary report to be developed with Fidelis Care on highlighting the processes, outcomes, major obstacles, and solutions of the project. The report was intended to serve as guidance for other organizations interested in pursuing a similar strategy.
Although this grant helped Refuah to establish a quality reporting and data analysis system, as well as position it to successfully apply as a lead Performing Provider System (PPS), it did not meet its intended grant goals and activities. Additionally, NYSHealth made several unsuccessful attempts to contact Refuah to discuss the changes to the grant’s scope. As a result, NYSHealth canceled the grant without distributing final payment, so the final grant award totaled $159,040.
Co-Funding and Additional Funds Leveraged: N/A