Health care providers involved in removing appendixes or uteruses, treating children for pneumonia or treating children or adults for urinary tract infections would be eligible for potential financial bonuses and penalties from Arkansas' Medicaid program under rules reviewed by an advisory panel on Friday.
The rules would add appendectomies, hysterectomies, the treatment of urinary tract infections in hospital emergency rooms and treatment of pediatric pneumonia to a state program that seeks to reduce the costs of certain "episodes of care."
Started in 2012, the program rewards providers whose average cost of providing such an episode a year is below a level considered commendable and penalizes those whose costs are considered excessive.
Legislation sponsored by Sen. Missy Irvin, R-Mountain View, in 2013 created the Healthcare Quality and Payment Policy Advisory Committee to review rules related to the program.
Members of the committee weren't appointed until last fall, and Friday was the first time the committee has reviewed rules implementing new episodes.
The members recommended changes to a few details.
For instance, the committee recommended that, in addition to having low costs, hospitals be required to use chest X-rays on at least 75 percent of pneumonia patients who are age 6 months to 4 years to be eligible for bonuses.
As currently written, the rules call for the Medicaid program to track X-ray use, but they don't make X-ray use a requirement of eligibility for bonuses.
Instead, the draft rules call for hospitals to be disqualified from receiving bonuses if they prescribe antibiotics to more than 80 percent of children with pneumonia. The committee recommended that the Medicaid program track antibiotic use but not tie it to the bonuses.
William Golden, the Medicaid program's medical director, said most cases of pediatric pneumonia are caused by viruses and aren't affected by antibiotics.
Jacqueline Gorton, a Medicaid episode design manager, said staff members at the state Department of Human Services will either make the changes recommended by the committee or issue a written statement outlining the reasons the department is not making a change, as required by the 2013 law.
Golden called the discussion "extremely constructive."
"There were many suggestions here that were very useful," he said.
The episodes of care program is part of the state's Health Care Payment Improvement Initiative, which is aimed at curbing the growth of spending in the state's Medicaid program.
Under another part of the initiative, known as the patient-centered medical home program, Medicaid and private insurers make upfront payments to doctors who agree to take steps to better coordinate patient care.
Arkansas designed the programs with help from a $42 million grant from the federal Centers for Medicare and Medicaid Services' Innovation Center, which was created by the 2010 Patient Protection and Affordable Care Act. The grant was awarded in 2013 and expires at the end of this year.
The Medicaid episodes already in place are for upper respiratory infections, maternity care, congestive heart failure, knee or hip replacement, attention deficit hyperactivity disorder, gall bladder removal, colonoscopy, tonsillectomy, oppositional defiant disorder, coronary artery bypass grafting, asthma and chronic obstructive pulmonary disease.
Arkansas Blue Cross and Blue Shield and QualChoice Health Insurance have also implemented some of the episodes along with Medicaid.
The Human Services Department will hold a public hearing in July on the rules implementing the four episodes reviewed by Healthcare Quality and Payment Policy Advisory Committee on Friday, Gorton said.
The rules will then go to the Arkansas Legislative Council for approval.
She said the department hopes to give health care providers information in October on their costs associated with the episodes over the previous year.
The first bonuses or penalties for those episodes, in connection with care provided in 2017, would likely be awarded in April 2018, she said.
Members of the committee are appointed by the speaker of the House and Senate president pro tempore.
Davy Carter, speaker of the House from 2013-14, and Michael Lamoureux, who was senate president pro tempore during that period, said Friday that they didn't remember why they didn't appoint members.
"I didn't even know [the committee] existed until you just told me," said, Lamoureux, who left the Senate to work for the governor's office.
Jonathan Dismang, who has been Senate president pro tempore since January 2015, said he didn't recall a reason for the delay in the appointments.
Jeremy Gillam said he had a long list of appointments to make after he took over as House speaker in 2015, and the episodes committee "slipped through the cracks" after the 2015 Legislative session.
The members are Medicaid Director Dawn Stehle; Bradley Bibb, a family physician in Jonesboro; Elizabeth Blankenship of Heber Springs, who represents the Arkansas Assisted Living Association; David Deaton, administrator of Ozark Health Medical Center in Clinton; John Henderson, chief medical officer at White County Medical Center in Searcy; Brant Joyner, who owns two assisted living facilities in Searcy; David Norsworthy represents the Arkansas Health Care Association; Vicki Pennington, who represents the HomeCare Association of Arkansas; Joel Pritchett, who represents the Arkansas Association of Area Agencies on Aging; Jason Richey, family practice doctor in Paris; and Joanna Thomas, a medical director for Arkansas Blue Cross and Blue Shield.
The committee also has one vacancy, Gorton said.
Metro on 05/07/2016