As Managed Care Addresses the Social Barriers to Health, Medicaid Plans Lead the Way

May 27, 2020
The leaders of the Menges Group, a consulting firm that produced a recent study on Medicaid managed care innovation for AHIP, and an AHIP policy leader, discuss the pop health challenges and opportunities facing plans now

At a time when potentially millions more Americans will be entering Medicaid managed care programs, because of COVID-19-related unemployment, the good news is that Medicaid managed care plans nationwide have been innovating around population health management and care management strategies. On May 6, the Washington, D.C.-based AHIP (America’s Health Insurance Plans), the national health plan association, published the results of a study conducted by the Menges Group, a consulting firm, for AHIP, on that subject.

The study, entitled “The Value Of Medicaid Managed Care: Innovating In Medicaid,” focuses heavily on innovations in telehealth and in the areas around the social determinants of health (SDOH). As the leaders at AHIP noted on that date, this research is particularly important in the context of the unfolding of the COVID-19 crisis, as one in five Americans rely on Medicaid for their healthcare coverage today, with two-thirds of enrollees served by a Medicaid managed care health plan. Medicaid enrollment could increase by 11 to 23 million as a result of COVID-19. Health insurance providers are working with federal, state and local leaders to overcome the crisis, and they remain committed to delivering access to high-quality care and innovations to improve health and outcomes that Medicaid managed care enrollees deserve.

The study, entitled “The Value Of Medicaid Managed Care: Innovating In Medicaid,” focuses heavily on innovations in telehealth and in the areas around the social determinants of health (SDOH).

Among the major takeaways from the study released on May 6:

             Medicaid managed care plans are creating and covering telehealth programs that expand access to care and increase the ability of doctors to coordinate care for patients. These solutions address rural access to care, behavioral health services, and chronic pain management.

             Medicaid managed care plans are demonstrating breakthrough programs to reduce social and financial barriers to health, such as deploying mobile produce markets with fresh vegetables to neighborhoods with limited supermarket access, or teaching enrollees with chronic health conditions how to cook healthy meals.

             Medicaid managed care plans are improving the ways enrollees can access provider networks, including creating tools that allow enrollees to more easily locate doctors in their networks, view practice information, and rate their doctors.

As the report notes, “Many state Medicaid agencies use formal procurement processes to select and contract with qualified Medicaid managed care plans. In most states, the Medicaid agency releases a Request for Proposal (RFP) that requires Medicaid managed care plans to implement innovative care delivery solutions. solutions. The Menges analysis reviewed state Medicaid RFPs and accompanying model contracts and scopes of work from recent procurements in eight states,” the report notes. The Menges Group also reviewed 14 Medicaid plan proposals submitted in 6 states.”

As the report states, “In recent years, state Medicaid procurements have added significant requirements, calling for Medicaid managed care plans to address a range of innovations and improvements in care delivery and benefits. The procurement process also encourages Medicaid managed care plans to make commitments that exceed state contract requirements to earn contract awards. These efforts have allowed Medicaid programs with Medicaid managed care plans to offer high-value initiatives that improve care and outcomes for their residents while controlling costs for taxpayers. The findings show that Medicaid managed care plans collaborate with their state partners to deliver successful public private partnerships uniquely tailored to meet the needs of each individual state and the populations that are served by that state’s Medicaid program, proving that when the public and private sector work together, Americans get the quality and value they deserve.”

A week after the release of the report, Healthcare Innovation Editor-in-Chief Mark Hagland interviewed three people connected to the report’s findings: Joel Menges, CEO of The Menges Group, and Richael O’Hagan, a managing consultant with the firm; and Rhys Jones, AHIP’s vice president for Medicaid policy and advocacy. Below are excerpts from that interview.

Looking at the results of the study, how did its results fill out the picture that you were hoping to be able to analyze?

Rhys Jones:  We commissioned the large report that came out in a series of topical briefs. We’ve been looking for ways to really substantiate the value of Medicaid managed care for a number of years now. This goes back to some of the discussion a few years ago in Congress, where they were looking for ways to reform Medicaid. And we wanted to give some better perspective on some of the notions people have, such as, Medicaid is a broken system, we’d be better off without it, that kind of thing; and also, to help substantiate the value that Medicaid managed care is bringing, beyond the core Medicaid program.

That was the context behind the genesis of this study, and there’s a lot to talk about there. And the way that managed care plans really help extend some of the types of best practices that we find in commercial and Medicare plans, into the Medicaid environment, is one of the most gratifying things to me. Medicaid managed care plans are addressing what we’re referring to as the social barriers to health; the term “social determinants of health” is a little bit too obvious, too a priori to me. They’re really addressing the social barriers to health now.

Joel Menges: We certainly had pretty strong expectations regard what we would find. We wear the hat most often of being consultants to the Medicaid managed health plans; we also do research for AHIP. But a lot of the work we do involves supporting Medicaid plans in their bids for contracts; and a small number receive their contracts through competitive procurement processes; and the intensity of the battle to win those contracts drives innovation. So we came into the project with some knowledge f this.

Let’s talk about your core findings, and your interpretation of those findings?

Richael O’Hagan: There were a few main themes that came out in the report. We’re seeing a lot of focus on the innovations at the community level, and applying a population health framework to Medicaid managed care. They’re looking at really understanding their populations, including the social barriers to care, and applying their innovations not only to their complex populations, but to broad health and wellness work.

And what we’ve seen managed care plans do to accomplish that, is working with a lot of community-based organizations, leveraging them to deliver a comprehensive approach; and also working with their provider networks to address chronic condition management, and behavioral and physical health integration, among other issues.

Has member or patient engagement been a major challenge that health plan leaders have had to address?

O’Hagan: Yes, both states and managed care plans are very aware of the member engagement issues; we’re seeing increased use of services like mobile vans and other mobile services, and working with their provider networks on increased evening and weekend hours, all to reach members. And working with community health workers who are best engaged with those populations and are often of those populations themselves. Those are among the most effective ways to reach those people. And also, we see high rates of emergency department utilization, so also looking for ways to engage with them around ED use, sometimes, in the ED.

Menges: For me, some of the defining features here—I firmly believe and have experienced, that the engagement and care coordination that occur in the Medicaid sector, sit far above what occurs in Medicare and commercial managed care. Managed care funnels volume to the providers, and there is a thoughtful tiering of benefits in terms of being in and out of network, in the commercial and Medicare arenas, that offer financial incentives. All of that’s out of the window in Medicaid. Providers won’t do discounted deals, because the rates are so low to begin with, and you can’t do financial incentives with an impoverished population. So they’ve really had to focus on core innovation.

Jones: At a high level, what really distinguishes Medicaid plans versus FFS and other programs, is that whereas providers like primary care physicians may be trying to adhere to specific schedules, such as seeing 10 patients per hour, for example, what really drops in between the cracks is member or patient engagement, and that’s what care management programs do. The managed care plans are able to take care of everything in between, following up to make sure somebody got a service, referring them to a community organization, doing the blocking and tackling to fully connect them.

So the people at the health plan level are the ones connecting the dots, in all this?

Jones: In many cases, yes. And there’s stratification. There’s more of that intensity when someone has multiple chronic conditions and functional impairments; or for a pregnant mom, the main engagement might be around remembering to take her vitamins or go in for a well check, for example.

When you look at the subject of social barriers, how do you see the issue, and how it will evolve forward?

Menges: Health plans are looking at dietary behaviors, food, housing, and education, in the same way that they’re trying to discern about a person’s characteristics and activities, in the same way they’re looking at diabetes or cardiovascular illness; they so profoundly affect health status, that addressing them along with the clinical issues, makes sense.

O’Hagan: States are putting more structure around that, for example, pin term predictive modeling, to add in social barriers elements. And addressing issues of food security and housing needs—and also simply finding out how things affect people over time, such as adverse childhood experiences, and trauma-informed care. Kentucky, for example, has put a huge emphasis on that, for example, in terms of focusing on screening for trauma; and using early childhood programs and home visiting, to better connect with people early on.

Jones: What Medicaid plans do with social barriers—in some cases, it’s really connected a specific individual to services that that person needs. But sometimes, it functions at the population health level. So if a plan sees that its members in the city of Baltimore, or in the city of New Orleans in a certain ward, that they’re affected by one element—I’m thinking of a case in Louisiana that I was aware of, where they did a lot of work with a local agency, and that agency did congregate meals and operated a food bank. The plan I used to work with gave a grant to that agency to set up a produce program. It would go into certain areas of the community every couple of weeks, with fresh produce, etc. That’s an example of a population-level intervention that serves all of the members that community.

What will the next two or three years look like in this area?

Jones: The reason that we’re speaking from different parts of the country today—with the COVID-19 pandemic, the implications for Medicaid are really quite profound. With 30 million and counting who have lost their employment, a good number of those folks may go onto Medicaid for at least a while, depending on how long this lasts. States are already facing revenue shortfalls, however, because of lost tax revenues and because of increasing unemployment claims. So this extraordinary situation will tax everybody’s creativity in terms of how this continues to function, given that the funding of Medicaid will be seriously be jeopardized. And we’re all looking to what the federal response will be. It will be very challenging; this will probably be one of the biggest tests of the state-federal partnerships involved in financing all of this.

Menges: I’ve heard some very sobering statements from folks in epidemiology about us being in the second inning of this pandemic. But in terms of the social determinants of health, I feel we’re in the second or third inning of something good, in terms of moving forward. And we’re seeing a very exciting outward push in terms of the plans going as far as they can go, in identifying and addressing these dynamics, and it’s a wonderful train to be on.

O’Hagan: We’re going to continue to see a move towards expanding that population health approach. So, look to see plans moving forward, and addressing specialized populations—members who were previously incarcerated, children who have been in the foster care system.

Jones: I do have optimism that if the ongoing funding of Medicaid can be solved, I think that we are going to see continuing engagement of managed care plans, and more and more contributions, as they think about ways in particular to address the social barriers of health, but also work more closely with providers to implement more value-based purchasing arrangements. So overall, I’m optimistic, if we can solve the funding issue.

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