I read with great fascination a Health Affairs Blog article that appeared late last week, regarding the challenges faced by the leaders of North Carolina’s Medicaid Program.
As I wrote yesterday, “A team of healthcare policy researchers investigated issues around Medicaid utilization in one rural North Carolina county, and come to some broader conclusions about the challenges of Medicaid management nationwide. In “Hot-Spotting North Carolina’s Medicaid Transformation,” published online on Nov. 5 in the Health Affairs Blog, Kushal T. Kadakia, a Rhodes Scholar pursuing an MSc in global health at the University of Oxford; Shivani A. Shah, an M.D. candidate at Harvard Medical School; and Barack D. Richman, J.D., Ph.D., a professor of all and of business administration at Duke University and a visiting scholar in the Department of Medicine at Stanford University, find that a severe shortage of physicians and challenges with transportation are keeping that county’s residents massively using hospital emergency departments and the county’s Emergency Medical Service (EMS) out of sheer necessity. At the core of the crisis: that county, on state’s mountainous western border, has only four physicians serving the entire county. Among other recommendations, the researchers insist, must be an investment in telehealth capabilities, and the empowerment of local public health officials.”
Those researchers found that Medicaid patients in Graham County, a rural county on the state’s mountains western border, face tremendous challenges in accessing care, with literally only four physicians in the entire county, intense difficulties around transportation. As a result, they not surprisingly end up using the EMS as their “Uber,” as the researchers note; and they routinely use emergency departments for primary care, as actual physician-delivered primary care is so difficult to access. The researchers write in their article, “What causes a county to become the state’s costliest place for health care? This was the riddle that guided our research. We expected to see lavish technologies and patients with complicated conditions, but the answer we found was quite different: When Medicaid beneficiaries became sick, they went to the hospital because no physician was nearby. And because transportation was often lacking, these patients called for an ambulance. In short, they sought the most expensive care because that was the only care available. It is not novel to discover a linkage between longstanding provider shortages in rural areas and communities’ poor health outcomes,” they note. “Yet, while researchers and reporters have rung alarm bells about hospital closures, less attention has been paid to the gradual decay of the outpatient care delivery infrastructure.”
The key point here is that it’s easy to making sweeping generalizations about the need to curb costs and improve patient outcomes in Medicaid; but the reality of conditions on the ground in Graham County, North Carolina, with a tremendous lack of physician availability and transportation challenges, shows once again that a lot of the core issues facing state Medicaid programs are not purely or even mostly clinical in nature. Those researchers recommend a restructuring and redeployment of the clinician (including mid-level practitioner) workforce in Graham County, and the extensive use of telehealth capabilities, particularly with regard to the use of specialist services.
The bigger picture
Every state has specific challenges around its Medicaid program, but innovations are now taking place in a variety of states that might be applied nationwide.
As Senior Editor David Raths reported on November 2, one of the more exciting situations involves California, where, uniquely, Medicaid is known as MediCal. As Raths reported on that date:
“Among efforts to focus healthcare spending on social needs, California’s 25-county Whole Person Care (WPC) pilot has probably drawn the most attention. The WPC pilots are testing whether local initiatives coordinating physical health, behavioral health, and social services can improve health outcomes and reduce medical costs. Up to $1.5 billion in federal funds are available over the five years of the demonstration, matched by $1.5 billion in local funds from the pilots. Over the past several years, the California Department of Health Care Services (DHCS) has been aggressive in working to redefine its Medicaid program, Medi-Cal, by piloting care coordination and social service-related initiatives such as Whole Person Care. Now DHCS has released an ambitious roadmap to expand those offerings and others to all Medi-Cal enrollees.
Called CalAIM (California Advancing and Innovating Medi-Cal), the 120-page proposal seeks to build on the successes of waiver demonstrations such as Whole Person Care, the Coordinated Care Initiative, and public hospital system delivery transformation. CalAIM leverages Medicaid as a tool to help address many of the complex challenges facing California’s most vulnerable residents, such as homelessness, insufficient behavioral health care access, children with complex medical conditions, the growing number of justice-involved populations who have significant clinical needs, and the growing aging population. Recognizing the social basis of many care needs, the proposal calls for non-clinical interventions focused on a whole-person care approach that target social determinants of health and reduce health disparities and inequities. The hypothesis is that taking a population health, person-centered approach to providing services will improve outcomes and ultimately reduce the per-capita cost over time.”
As Raths noted, CalAIM has three primary goals: to identify and manage member risk and need through Whole Person Care approaches and addressing social determinants of health; to move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility; and to improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems and payment reform.”
All of this is tremendously ambitious, but even more importantly, it’s comprehensive. And that is one of the reasons that that program being launched in California could really provide leadership for the entire country, around the integration of the social determinants of health into care management in the Medicaid program, as well as with regard to the application of a person-centered approach to Medicare care management.
Nor is California alone in beginning to integrate the social determinants of health into Medicaid program-based care management; Massachusetts is moving forward significantly also. As Raths wrote yesterday, “One of the avenues health systems are exploring in terms of addressing social needs is nutrition. But is there research demonstrating that health systems paying for nutrition support leads to better health outcomes? That’s what legislators in Massachusetts want to find out. Massachusetts Democratic State Sen. Julian Cyr and House Rep. Denise Garlick have introduced a bill that would establish a pilot program to give individualized nutrition services —including meals, groceries, or grocery money—to residents enrolled in Medicaid and then measure the impact of doing so on people’s well-being and the state’s bottom line.
As Raths noted, “The bill would require the Executive Office of Health & Human Services to implement a Food and Health Pilot Program to demonstrate the impact on health outcomes and cost effectiveness of medically tailored nutrition services for MassHealth enrollees diagnosed with diet-related health conditions.” Among the elements to be included will be meals tailored to individual medical conditions by registered or qualified nutritionists; non-prepared grocery items selected for patients by registered dietician nutritionists; and subsidies for free or discounted nutrient-dense food.
Meanwhile, things are moving forward along another dimension in the District of Columbia. As Raths reported on November 7, “The Centers for Medicare & Medicaid Services (CMS) has approved a Medicaid demonstration project that broadens treatment services available to Medicaid beneficiaries living in Washington, D.C., diagnosed with serious mental illness (SMI) and/or serious emotional disturbance (SED). CMS also approved the District’s request to begin providing new services for its beneficiaries diagnosed with substance use disorder (SUD). The District is the first in the nation to receive federal approval of the new SMI/SED opportunity first described in a letter to state Medicaid directors in late 2018. The SMI/SED section 1115 demonstrations,” he noted, “will allow state Medicaid programs to overcome a longstanding payment exclusion which will, in turn, allow them to treat individuals with serious mental illness who are short-term residents in settings that qualify as institutions for mental disease (IMD). The District is also taking advantage of CMS’s demonstration opportunity that offers similar flexibilities for Medicaid beneficiaries diagnosed with opioid use disorder (OUD) or other SUDs.”
And that’s not all. As Raths reported on November 8, “As part of its long-term effort to make data more accessible to researchers and citizens, the Centers for Medicare & Medicaid Services (CMS) has released its research-ready Transformed Medicaid Statistical Information System (T-MSIS) data, a collection of Medicaid and CHIP data files. Over the last five years,” he noted, “CMS and state governments have worked to improve the quality and integrity of the data states submitted to T-MSIS. The result is better beneficiary-level data on the Medicaid and CHIP program than has been available before. CMS is continuing to work with states to improve reporting to ensure that future data releases will be even better.”
What’s more, the T-MSIS data set contains enhanced information about beneficiary eligibility; beneficiary and provider enrollment; service utilization; claims and managed care data; and expenditure data for Medicaid and CHIP. “CMS,” he noted, “called the milestone release part of its MyHealthEData initiative to get data into the public domain to promote data-driven solutions, help ensure sound program performance, support improvement, and identify and prevent fraud, waste and abuse in the Medicaid and CHIP programs. CMS and researchers can use the data to analyze what states and the federal government are paying for Medicaid and CHIP services. These data provide information on utilization and spending under Medicaid managed care, and are needed to enable research and analysis to improve quality of care, assess beneficiary care costs, and enrollment and improve program integrity, CMS said in a press release. The availability of T-MSIS data is essential to allow monitoring and oversight of Medicaid and CHIP programs, to enable evaluation of demonstrations under section 1115 of the Social Security Act, and to calculate quality measures and other metrics.”
What’s incredibly heartening about all of these different advances is that they are moving Medicaid forward in different ways across different states and locations, and, in the case of the release of the T-MSIS data set, through the facilitation of data exchange. I’ve been saying for a couple of years now that everyone should be watching and tracking developments in Medicaid programs and in Medicaid managed care (and honestly, every single state program now is becoming a managed care program, but explicitly and implicitly), because if care management can be made more clinically effective and cost-effective and can improve patient/beneficiary outcomes, in Medicaid managed care programs, any such advances could set the pace for the entire U.S. healthcare industry. And they will be able to help Medicaid program managers address issues such as those faced by program managers in Graham County, North Carolina. As we all know, the leaders and managers of Medicaid programs continue to operate on incredibly tight budgets. And what they can achieve in terms of care management successes will really point to what is achievable U.S. healthcare system-wide. Watch for it.
