Nearly three years into an effort to transform Medicaid across Colorado, hospital readmissions and orders for high-cost imaging scans are down, resulting in millions of dollars in health care savings.
Now comes the big test.
The recent influx of nearly 180,000 Medicaid sign-ups through the Affordable Care Act marks a new phase in the effort to vastly change the way Colorado's program works - an initiative touching nearly every new enrollee, while carrying the potential for millions in health care savings.
By offering bonus payments and incentives to physicians and a handful of organizations dotting Colorado, Medicaid officials aim to reduce health care costs while improving patient care - the main goal of health care reform.
At first blush, the Accountable Care Collaborative program appears to be working, state Medicaid officials say. The program saved $44 million from July 2012 through June, largely by pairing patients with a go-to physician and coordinating specialists' care, a report to legislators found.
But the price tag for making those gains reached $36.4 million that year, dropping the savings to $7.6 million (program officials say the savings estimate was conservative).
Despite those gains, a few central questions remain: Will the adults who recently became eligible for expanded Medicaid benefits through the Affordable Care Act embrace the reforms?
Will health care providers shift the way they've traditionally done business?
Or will patients continue visiting costly emergency rooms and a hodgepodge mix of providers while neglecting the root causes of their chronic conditions?
"What we are doing is a process," said Carol Bruce-Fritz of Community Health Partnership, which is heading up the initiative across the Pikes Peak region, reaching about 84,000 people at last count. "And it takes a long time to kind of turn the tide for a program like this. It's huge."
The initiative centers around the idea of pairing patients with a primary care "home" - a physician whom patients know well and who serves as their main point of contact for health-related needs. Without one, Medicaid officials say, physicians can't properly manage chronic conditions - a main driver of health care costs.
The results can be frustrating, said Dr. Bruce MacHaffie, a Colorado Springs pediatrician who participates in the initiative.
For example, several times a year, parents seek help with recurring ear infections in their children. But when MacHaffie tries to bill their insurance for treating the underlying cause, problems arise.
The reason? No single doctor tracked each previous trip those children made to urgent care clinics or emergency rooms, he said.
"If you don't have one person keeping an eye on the whole thing, things don't get done," he said.
That's where the Accountable Care Collaborative comes in.
First, patients must designate a doctor whom they wish to see regularly - a process tracked by the state via a database showing where patients seek care, based on billing codes.
Seven organizations covering the state have been tasked with coordinating the effort.
Each organization, called a Regional Care Collaborative Organization, carries out that task differently - a nod to differing health needs across the state, Medicaid officials say. In general, they created networks of providers for Medicaid patients. And they facilitate doctors' referrals to the specialists in each organization.
"For some of the providers that are medical homes, this kind of fits into what they've been moving toward, or focusing on," said Pam McManus, Peak Vista Community Health Centers' chief executive. The nonprofit treats the most Medicaid patients in the Pikes Peak region and has been working on the initiative with help from the local organization. "But for Medicaid, I believe that this is a very innovative step."
The initiative factored heavily into Christine Briggs' decision to stop accepting new Medicare and Tricare patients and work more heavily through Medicaid.
On Wednesday, Briggs, a nurse practitioner, reviewed a blood test while a patient sat on an exam table, clutching gauze from where an assistant pricked his finger.
"Have you been eating greens?" she asked, her voice accusatory. Too many green vegetables can thicken the blood, raising the man's risk for clots, Briggs said. She recommended aspirin for the time being.
Normally, if the man had needed more advanced care from a specialist, Briggs would have had to embark on a laborious task of finding clinicians and filling out paperwork. For the owner of a small practice, Family Integrative Health Center of Colorado Springs, that can mean time away from patients, she said.
But the regional organization overseeing El Paso County helps connect her with specialists, easing the process.
"Especially for someone who is an office of three, we don't have a big staff," Briggs said. "They're (Medicaid officials) kind of the extension of my staff."
Change takes time
While health care providers bill Colorado's Medicaid coffers each time a patient seeks care - the typical fee-for-service model - the physicians and regional organizations also receive a special pot of money to help foster better, coordinated care. Physicians receive extra money, too.
And incentives sweeten the pot.
When a region hits certain benchmarks for lowering hospital readmissions, high-cost imaging scans and emergency room visits, the state bumps up those payments to the organizations and the physicians.
So far, the results have been encouraging, said Marc Williams, a Medicaid spokesman.
The new enrollees were automatically placed in the initiative, and more than half of the other Medicaid patients have been moved into the program.
Among people in the initiative, hospital readmissions dropped at least 15 percent from July 2012 through June and high-cost imaging services dropped 25 percent, according to the program's most recent annual report.
Patients with chronic obstructive pulmonary disease, hypertension and diabetes fared particularly well, the report said.
The rate of emergency room visits, however, failed to meet the state's benchmark. They rose more slowly than Medicaid clients who weren't enrolled in the initiative but remain above the state's goal, the report said.
The state also tracks child checkups, but that aspect began July 1, and a year's worth of data hasn't been collected.
Doctors working to educate patients about the appropriate time to visit an emergency room will be key in lowering that figure, Williams said.
"When we talk about the Medicaid population, sometimes, many times, people have not had coordinated health care before," Williams said. "And their instinct, when they've had something go wrong in the past, is they go to the ER to get it taken care of.
"It's kind of an 'old habits are hard to break' kind of thing."
The effect of nearly 180,000 additional adults in the Medicaid program remains to be seen.
"We figure that about half of the (local) patients that are now on Medicaid expansion were actually being seen by Peak Vista in their uninsured clinic," said Dr. Joel Dickerman, who also serves as the regional organization's medical director. " . What we don't know is, those that weren't before, how sick are they?"
Pairing patients to physicians also may take some time.
A "significant" number of the people who recently signed up for Medicaid through the Affordable Care Act's expansion appear to have been going without a primary care home, Williams said.
State officials are analyzing patients' health care habits, such as how often they visit a doctor, where each patient seeks care and whether they routinely go back to a specific physician.
At least one in five Medicaid patients in the region who are tagged as being a part of the initiative had no primary care home. And across the state, about 70 percent of people enrolled in the program remained without a go-to doctor, Williams said.
Even if a patient gets paired with a doctor, there's little keeping them from going to the emergency room.
Colorado has long suffered from a shortage of primary care physicians, meaning long appointment wait times. In addition, Medicaid reimbursement rates traditionally kept physicians from joining the program - though the agency reported increasing its provider network by about 9 percent, as of late March.
And Medicaid's fee for seeking care from an emergency room is less than its fee for visiting a primary care physician - leaving little incentive not to seek same-day care at the hospital.
The program charges $2 for each doctor's visit. By comparison, emergency hospital visits are free and nonemergency hospital visits, as well as outpatient care co-pays, are $3.
"Before we just ignored cost - we just did what was convenient," Dickerman said. "The bottom line to me is convenience does cost money. And we created a health care system that has, unfortunately, confused convenience for access.
"There's a fine line between the two."