Ore­gon of­fers lessons in serv­ing new Med­i­caid pa­tients

Modern Healthcare - - NEWS - By Vir­gil Dick­son

For new Med­i­caid en­rollees in Ore­gon, the first visit with their doc­tor in some ways is like a first date. When Dr. Christina Mi­lano, a fam­ily physi­cian and as­sis­tant pro­fes­sor at the Ore­gon Health & Sci­ence Univer­sity, has her ini­tial visit with a pa­tient who signed up for the state’s ex­panded Med­i­caid pro­gram, she doesn’t do a for­mal med­i­cal eval­u­a­tion. In­stead, she uses the visit as a chance for her and the pa­tient to get to know each other. For her, the meet­ing helps her form an in­di­vid­u­al­ized care plan. For pa­tients, it gives them a chance to de­cide if they want her to be their doc­tor.

But it’s not just her that pa­tients have to de­cide about. It’s her whole staff, be­cause Mi­lano is part of a pa­tient-cen­tered med­i­cal home team that will be work­ing with the pa­tients to man­age their health. So that first visit in­cludes a tour to give pa­tients the chance to meet the nurses and other pro­fes­sional staff. “We make a huge ef­fort to un­der­score the re­la­tion­ship as­pect from the very be­gin­ning,” Mi­lano said.

Many of these pa­tients have never had health in­sur­ance or a reg­u­lar care­giver and they don’t nec­es­sar­ily know how to use the health­care sys­tem ef­fec­tively. Mi­lano wants to is build a strong bond with new pa­tients to help them stay healthy, use the sys­tem prop­erly and avoid un­nec­es­sary use of the hospi­tal emer­gency depart­ment, which tra­di­tion­ally has been a pri­mary source of care for unin­sured Amer­i­cans. Pri­mary-care providers through­out the coun­try will face the same chal­lenge with mil­lions of Amer­i­cans newly en­rolled in ex­panded Med­i­caid pro­grams un­der the Pa­tient Pro­tec­tion and Af­ford­able Care Act.

A re­cent study of Ore­gon Med­i­caid pa­tients pub­lished in Health Af­fairs found that a lack of re­la­tion­ship-build­ing be­tween ben­e­fi­cia­ries and physi­cians— not trou­ble find­ing a pri­mary-care physi­cian—was the key rea­son en­rollees overused the ED. The re­searchers found that 40% sought care in­fre­quently be­cause they said they were con­fused about their ben­e­fits, faced ac­cess bar­ri­ers, had neg­a­tive in­ter­ac­tions with providers, or felt that care was un­nec­es­sary. Most of those stud­ied said they ex­pe­ri­enced sub­stan­tial im­prove­ment to their health­care af­ter months or years of work­ing closely with a provider.

“Pa­tients who had a bad ex­pe­ri­ence were some­times ret­i­cent to use care, which de­creased the value of cov­er­age,” said the study’s lead au­thor, Heidi Allen, an as­sis­tant pro­fes­sor of so­cial work at Columbia Univer­sity. “Pa­tients did the best when they felt in part­ner­ship with a provider, that they were work­ing to­gether to­ward shared goals.” That was par­tic­u­larly true for people with com­plex health is­sues.

In 2012, the CMS awarded Ore­gon $1.9 bil­lion to trans­form its Med­i­caid pro­gram by es­tab­lish­ing re­gional co­or­di­nated-care or­ga­ni­za­tions us­ing the med­i­cal home model. Ore­gon has to pro­duce sig­nif­i­cant sav­ings or it will face a big loss in federal Med­i­caid fund­ing. Be­fore the CMS waiver, re­searchers found that new Med­i­caid pa­tients in Ore­gon used the ED 40% more than the con­trol group of people who were unin­sured, with most of those ED vis­its be­ing un­nec­es­sary.

A sub­stan­tial amount of re­search shows that the med­i­cal home model helps re­duce un­nec­es­sary ED vis­its for low-in­come ben­e­fi­cia­ries, said Melinda Abrams, vice pres­i­dent for de­liv­ery sys­tem re­form at the Com­mon­wealth Fund. Last month, Ore­gon Med­i­caid of­fi­cials re­leased data show­ing that ED vis­its by Med­i­caid benefi- cia­ries in the new co­or­di­nated-care or­ga­ni­za­tions de­creased 13% in the first nine months of 2013 com­pared with the same pe­riod in 2011.

Providers and health plans say it’s crit­i­cal to give new Med­i­caid en­rollees a full ori­en­ta­tion about their ben­e­fits and how to use the health­care sys­tem, and quickly con­nect them with their provider.

Kaiser Per­ma­nente Health Plan of the North­west, which serves nearly 12,000 Med­i­caid ben­e­fi­cia­ries in Ore­gon, uses non-clin­i­cian staffers called nav­i­ga­tors who reach out to ben­e­fi­cia­ries by phone within a month of their en­roll­ment. The nav­i­ga­tors ori­ent them to Kaiser and its ben­e­fits, in­form­ing them how to use the 24-hour nurse ad­vice hot­line and ur­gent-care cen­ters. They help the new mem­bers fill out a short health screen to iden­tify their health needs. The nav­i­ga­tors may sched­ule the mem­ber’s first ap­point­ment with a pri­mary-care doc­tor whose prac­tice will serve as their med­i­cal home.

Us­ing nav­i­ga­tors to con­nect mem­bers quickly with pri­mary care and chronic-care man­age­ment is cru­cial and is likely to re­duce ED use, said Lynn Barker, di­rec­tor of Med­i­caid and Char­i­ta­ble Pro­grams at the health plan. But there are still lots of un­knowns, such as whether no shows for ap­point­ments will be a sig­nif­i­cant prob­lem.

Ex­perts hope other states learn from the med­i­cal home strat­egy Ore­gon has used for get­ting new Med­i­caid en­rollees into a man­aged, re­la­tion­ship-based health­care pro­gram. Just giv­ing people in­sur­ance with­out guid­ing them through the sys­tem is reck­less, said Marc Wil­liams, a spokesman for Colorado’s Depart­ment of Health Care Pol­icy and Fi­nanc­ing, which is us­ing the med­i­cal home model. “It’s like giv­ing a 16-year-old the keys to a new Fer­rari and they don’t have a driver’s li­cense,” he said.

Dur­ing a first visit at Ore­gon Health, pa­tients get to meet the en­tire pro­fes­sional staff.

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