Because of the great public health value of childhood vaccines, state Medicaid programs have promoted value-based purchasing (VBP) programs as a lever through managed care and fee-for-service programs to reward providers that immunize a high rate of children, who make up about 55 percent of Medicaid’s managed care enrollees nationwide.
However, COVID-19 has greatly reduced the number of children and families making in-person, well-child office visits to receive their immunizations. This disruption threatens the progress that VBP has made in rewarding increased quality care, including boosting childhood immunization rates.
In response, the Centers for Medicare & Medicaid Services (CMS) recently issued relief guidance and flexibility to state hospitals, facilities, and providers that report various measures including immunization rates as part of their participation in VBP and quality reporting programs. CMS also announced it will disregard all costs associated with COVID-19 care when performing benchmark calculations, and that states may make similar changes for VBP arrangements in the Medicaid program.
Medicaid programs have historically promoted childhood immunizations through various levers, including VBPs. Recent research shows that over half of state Medicaid agencies that contract with managed care organizations (MCOs) mandate payment reform, and as of July 2019, these MCOs provided care to about 69 percent of the total eligible Medicaid population.
To improve immunization rates, Medicaid offers various incentives in both MCO and fee-for-service arrangements. A March 2020 review by the National Academy for State Health Policy (NASHP) found that 46 states had measures or incentives to improve child immunization rates. Below are trends seen in state immunization programs:
- Thirty-eight states changed their immunization measures and incentive programs between 2016 and 2020 – 36 states added new immunization measures and incentives while two states reduced their measures;
- Nineteen states have immunization pay-for-performance measures tied to reimbursement;
- Seven states have implemented immunization managed care measures after previously having an immunization performance improvement project (PIP); and
- Twelve states adopted new immunization-related Healthcare Effectiveness Data and Information Set (HEDIS) measures, which are used to evaluate health plans.
Despite these strategies to maintain or increase immunization rates, evidence shows that immunization rates are decreasing. The pervasive fear of potential exposure to COVID-19 in doctors’ offices, as well as other social barriers, such as a lack of access to transportation, has resulted in fewer families taking their children for well-child or follow-up visits. In response, many states have relaxed telemedicine guidance to allow well-child visits to be conducted through telehealth. But because immunizations cannot be administered through telehealth, states are releasing guidance on follow-up visits for children to receive their immunizations.
State and Federal Governments Factor in the Impact of COVID-19
This major disruption in health care threatens the progress that VBP has made in improving the quality of care by rewarding positive changes and efficiency. CMS has recently issued relief guidance and flexibility to aid state hospitals, facilities, and providers that report their HEDIS and other pay-for-performance measures as part of quality reporting programs and VBP.
CMS has also announced that they will disregard all costs associated with COVID-19 care when performing benchmark calculations, and that states may make similar changes for VBP arrangements in their Medicaid programs. Few VBP arrangements currently address how emergency situations affect the quality of care or cost arrangements, but states may need to factor in this issue when executing future VBP contracts, to ensure providers are supported in administering appropriate levels of vaccinations, and to make sure children’s health is not at risk.
The National Committee for Quality Assurance (NCQA ), an organization that measures the quality of medical providers and health plans by analyzing their HEDIS data, has recommended that states continue reporting HEDIS data as usual. But, NCQA stated it will work with health plans whose ability to report data is compromised and make accommodations, and they indicated it abide by state data reporting decisions. It is essential for states to track their data accurately to inform their efforts to improve immunization rates, and track improvements in quality of care. Some states have also begun to issue their own guidance to providers on VBP payments despite potential changes in volume.
For example, MaineCare (Maine’s Medicaid program) has issued a bulletin acknowledging that providers who participate in VBP initiatives may have concerns about how changes in health care delivery will impact their performance in their alternative payment models, but that Maine Primary Care Provider Incentive Payments will be made on the existing schedule. July 2020 Primary Care Provider Incentive Payments cover a period of time not affected by COVID-19 and will be delivered as normal. January 2021 and July 2021 payments will be adjusted to exclude data from the impacted time period.
State strategies to fight the pandemic while incentivizing quality care and meeting the needs of their population continue to evolve. State and federal guidance related to VBP will be critical to ensure that increased immunization rates continue to be incentivized and health care delivery gains are maintained to keep children healthy now and after the immediate emergency subsides. NASHP will continue to track COVID-19 impacts on state health care delivery of immunizations and performance in alternative payment models.
This blog is supported by the Centers for Disease Control and Prevention.