Michigan Addresses Equity Issues Through Medicaid Managed Care

As in several other states, the Medicaid program in Michigan is making progress on promoting payment models and community-based solutions to promote health equity.  “We're tying all of these pieces together: managed care, health equity and primary care,” said Kate Massey, state Medicaid director. “There are some real-life examples of how health plans have leveraged value-based purchasing in our program.”

Massey spoke about efforts under way in Michigan during a recent webinar sponsored by the Center for Health Care Strategies, entitled “Promoting Health Equity through Primary Care Innovation in Medicaid Managed Care.”

Before joining Michigan’s Medicaid agency, Massey served as chief executive officer for Magellan Complete Care of Virginia. She had previously served as vice president for Medicaid and Medicare for Kaiser Permanente of the Mid-Atlantic States, overseeing the launch of two Medicaid managed care organizations in Virginia and Maryland. She also worked for Amerigroup, where she established its Public Policy Institute and served as executive director. Earlier in her career, Massey worked at the White House Office of Health Reform, overseeing implementation of provisions in the Affordable Care Act related to Medicaid, Medicare and public health.

Massey said part of the program involves gathering data to set a baseline. “In Michigan, we have what we refer to as our Medicaid Health Equity Report,” she said. They look at certain quality measures and then break them down by race and ethnicity. “What's particularly important is that this report and this level of engagement has been going on for multiple years. We have a longitudinal assessment of how these measures have transformed over time,” she said, “and it does show that we have opportunities for improvement. With these measures, we always need to go one level deeper, to understand where there are opportunities to focus ourselves as a Medicaid agency, as well as our partners, whether those are community-based organizations, providers, or health plans.”

In adult access to preventive care, unfortunately, they still see pretty decent sized discrepancies between white beneficiaries and African-American beneficiaries, she said.

Sometimes Michigan is actually overachieving relative to national benchmarks, but that is not an opportunity for the state to rest on its laurels, Massey said. “We can still see health disparities there, even when we're above national averages.” In lead screening, for example, Michigan is performing relatively well in lead screening. A lot of this is driven, unfortunately, by the Flint water crisis. “But even though we are achieving above the national norm, we still have health disparities that we need to address. We see Hispanic populations leading the charge when it comes to some of our access and utilization, and we should want everyone to get to that higher level.”

The state has structured its Medicaid managed care program to address disparities.  “In our managed care contract, we talk about what the expectations are for health plans to perform data analytics, and we’re specific about the types of data that should feed into their enhanced understanding of the people who they serve,” Massey said. “It can be things like claims data, but it can also be other things related to how a health plan operates like utilization management data. We ask that health plans draw from the various elements of how they perform their work, and make sure that all of that is assessed and aggregated at the health plan level to directly inform their strategy. They are required to report to the Medicaid agency what the results are. We are asking for a direct tie-in between the data analytics that they perform and evidence-based clinical interventions, as well as community-based partnerships.”

Massey gave three examples of how Medicaid managed care health plans have worked with provider communities, specifically primary care.

• Foundational payments plus incentives for reducing disparities. Providers receive upfront resource funding to establish programs focused on addressing specific health disparities with the opportunity to earn additional incentive payments by demonstrating year-over-year statistically significant reductions in health disparities on targeted measures.

• Shared risk. Federally Qualified Health Centers have a withhold on all PCP claims payments with a tiered opportunity to earn based on quality benchmarks. In addition to the quality measures, providers are assigned 1-2 disparity measures with applicable races with existing disparities, in an effort to decrease their current disparity rates.

 • Withhold. Health plan withholds a portion of the PMPM capitation payment. The pediatric provider has the ability to receive the withhold amount if they achieve the agreed-upon quality metrics. The PCPs will have the potential to earn an additional incentive payment on two disparity measures.

 “These are some examples where health disparities are specifically tied in,” Massey said. “They're connected not only to our managed care program, but also to how our health plans are engaging our primary care partners.”

“There are other things that we've done with the data that either the state has collected or that health plans have collected. We make sure that part of the quality withhold dollars that the health plans are working toward earning back is related to regionally defined quality metrics that have been informed by the health equity report,” Massey said.

 For instance, there are health disparities related to the low birthweight measure, and Michigan wants to make sure it is addressing that opportunity as a community, not as discrete individual health plans. “We set collective targets, and we ask for health plans to work in partnership with one another. We also ask health plans to partner with community-based organizations and in certain cases, those can be primary care providers to make sure that they are addressing social determinants of health.” One example involves a health plan working with a provider group to promote group prenatal care that allows for more autonomous self-direction of care. “There have been other health plans that have worked with community-based partners to eliminate asthma-based triggers,” she said. “We really want to make sure that the specifics of the healthcare population really translate into how they structure the community-based partnerships.”