In order to combine Medicaid health services to make them more efficient, you first have to understand the landscape of what’s out there, how it works together and where it overlaps.
In Clark County, the task of mapping that landscape has fallen on a relatively new organization called the Southwest Washington Accountable Community of Health, or SWACH. The nonprofit, multi-sector, multi-county collaborative is one of nine Accountable Communities of Health in Washington state, set up in 2017 as part of the Section 1115 Medicaid transfer waiver program that lets states take Medicaid distributions in a lump sum and manage the program themselves.
The goal of the ACH groups is to get a wide variety of health-related organizations together to figure out how to best streamline services and provide a less expensive, broader range of care, said Dawn Bonder, CEO of SWACH.
“The system is so siloed,” Bonder said. “The health system is so focused just on medical care – and it’s siloed even beyond that.”
Physical health services – which are often split out into specialties – are also frequently separated from mental health, addiction treatment services, dental care and more broad social services like housing for the homeless and food pantries. But when it comes to overall health, only somewhere between 5 percent and 30 percent is determined by physical health services, Bonder said.
“The rest is where you live, what food you have, your socioeconomic status,” she explained.
The five-year goal of SWACH – which covers Clark, Skamania and Klickitat counties – is to look at the whole picture, meet with independent groups and find new synergies between them.
Southwest Washington includes about 7 percent of the state’s Medicaid recipients, Bonder added.
Through 2017 SWACH met with Legacy Health, PeaceHealth, Providence Health Services, The Vancouver Clinic, Vancouver Public Schools, the Vancouver Housing Authority, the Council for the Homeless, the Clark County Sheriff’s Office and Clark County Public Health, among others.
Dawn Tolotti, an executive at Providence Health Services, said she thinks the effort will pay off for the region. She likes the ACH structure and thinks it will provide better cohesion than prior efforts to combine services.
“In general for this community and the Southwest Washington market, this is not unlike work we’ve collectively tried to do in the past,” Tolotti said. “What the ACH structure does for our region is provide that structure and certainly some funding to come together, design and implement.”
Those efforts can also pay off for the broader community beyond Medicaid recipients, because when care groups find more cost-effective ways of providing services, they often spread those to the public sector, Bonder said.
“The idea is we continue to shift what providers are doing inside their clinics and with community organizations and social services,” Bonder said. “The more providers alter their work flows the more it will flow over into commercial players.”
Looking at a wider array of care providers beyond the typical health care groups is also much needed – and will find much more holistic approaches to care, Tolotti said.
“What I like about the ACH structure, it’s across our continuum,” Tolotti said. “It’s not just providers and behavioral health. It’s housing, food, jails. It really is the community coming together as a whole.”
After meeting with key players, SWACH submitted its project plan for assessing the region in November of 2017. The plan received 100 percent funding from the state, which the group is very proud of, Bonder said.
“The money that comes to ACH to pay for this work is earned incentive dollars,” Bonder explained. “The state has $1.25 billion in incentive dollars. ACHs can earn those dollars by reaching reporting or performance measures.”
The work right now is focused mainly on four subject matter areas: 1. Integrating behavioral and physical health services; 2. Addressing the opioid crisis; 3. Focus on chronic disease management and prevention; and 4. Coordinate community care.
Southwest Washington is actually ahead of the curve on the first area, Bonder said.
“Southwest Washington was the early adopter, the lone adopter, two years ago in 2016,” Bonder said. “We completed a transition where all our mental health services joined with physical health services (for Medicaid). We have already seen, not marked improvement, but small improvements in getting services paid for.”
Coordinating community care
One issue that came to the forefront in discussions was the way ambulance services are handled.
Ambulances only get paid if they bring people to the emergency room. But some patients may be better served by ambulances dropping them off at other places, such as a behavioral health center.
The problem now is that ambulances can’t get paid to drop a patient off at a behavioral health center. And the lack of flexibility also adds stress to emergency room services.
“When anyone calls an ambulance, EMS, the service only gets paid if they do one thing, bring you to the emergency room, so that’s what they’re going to do,” Bonder said. “One thing we’re looking at is how can EMS have some decision-making power in cases like that and still get paid.”
Wound healing is another area where ambulance services could play a more serious role. Wound care is often done at nursing homes by staff with far fewer qualifications. Ambulance crews can also do that sort of care at the site of a patient’s home. But because ambulances are only paid when they bring patients to the hospital, they can’t provide that sort of on-site care, Bonder said.
“Wound healing is a real issue, especially with people with addiction issues,” Bonder said. “EMS can do a great job with wound care, but they’re not authorized to do that. So, why not?”
And the ambulance discussion is just a small example of the wide array of topics that SWACH will look to address, she said.
“These are the kinds of conversations that ACH can start to convene, bring to the table and say ‘here’s a performance measure we need to do a better job on,’” she said.
Tolotti said Providence and other groups in Southwest Washington are looking forward to continuing those talks.
“We like collaboration,” Tolotti said. “I think we do go further and faster when we work together. The opportunity to think more differently and collaboratively is exciting. I think we can learn from each other.”