In­no­va­tion by ne­ces­sity

Med­i­caid emerges as ag­gres­sive lab­o­ra­tory for de­liv­ery-sys­tem re­form

Modern Healthcare - - NEWS - By Vir­gil Dick­son

Two years ago, lead­ers of the Buck­eye Com­mu­nity Health Plan de­cided to take ac­tion af­ter not­ing an in­creas­ing num­ber of ba­bies in Ohio be­ing born with symp­toms that in­cluded seizures, rapid breath­ing and vom­it­ing. They were suf­fer­ing from neona­tal ab­sti­nence syn­drome (NAS), caused by their moth­ers’ abuse of nar­cotics such as heroin, codeine and oxy­codone dur­ing preg­nancy.

The an­nual NAS hos­pi­tal­iza­tion rate among in­fants born in Ohio grew six­fold from 14 per 10,000 live births in 2004 to 88 in 2011, and hos­pi­tal costs to­taled nearly $70 mil­lion, an eleven­fold in­crease from 2004, ac­cord­ing to the Ohio

Depart­ment of Health. Med­i­caid was the pri­mary payer.

“It got to the point where you could no longer look at those num­bers and say it isn’t our re­spon­si­bil­ity,” said Dr. Brad Lu­cas, chief med­i­cal of­fi­cer at Buck­eye, a sub­sidiary of Cen­tene Corp., a Med­i­caid man­aged-care com­pany.

In 2013, Buck­eye launched the Preg­nancy Spe­cialty Care Man­age­ment Pro­gram, which iden­ti­fies preg­nant plan mem­bers with cur­rent or pre­vi­ous al­co­hol or sub­stance-abuse prob­lems and en­gages them in ed­u­ca­tion and treat­ment pro­grams. Since the pro­gram was started, the av­er­age length of stay in spe­cial-care and in­ten­sive-care nurs­eries for the Buck­eye ba­bies di­ag­nosed with NAS has dropped steadily, from 13 days to seven and a half over two years.

This is one of many ex­am­ples across the coun­try of state Med­i­caid pro­grams and their con­tract­ing man­aged-care plans serv­ing as in­cu­ba­tors for in­no­va­tive so­lu­tions ad­dress­ing healthcare cost, qual­ity and ac­cess is­sues. The in­no­va­tions in­clude in­te­gra­tion of pri­mary care and be­hav­ioral health, telemedicine, ac­count­able care, pa­tient-cen­tered med­i­cal homes and co­or­di­na­tion of med­i­cal ser­vices with longterm-care ser­vices and sup­ports.

Sev­eral states, in­clud­ing Cal­i­for­nia, New Jersey, New York and Texas, also have de­liv­ery sys­tem re­form in­cen­tive pay­ment (DSRIP) pro­grams, which are fed­er­ally ap­proved waiver pro­grams in which fed­eral Med­i­caid fund­ing is used to cre­ate fi­nan­cial in­cen­tives for providers to pur­sue de­liv­ery-sys­tem re­forms. Those re­forms in­volve in­fra­struc­ture de­vel­op­ment, sys­tem re­design and clin­i­cal-out­come and pop­u­la­tion-fo­cused im­prove­ments.

While value-based pay­ment and de­liv­ery in­no­va­tions by Medi­care and com­mer­cial in­sur­ers have got­ten more media at­ten­tion, some ex­perts say Med­i­caid pro­grams have proven more fer­tile ground for un­fet­tered in­no­va­tion. “There is a great deal of po­lit­i­cal pres­sure to con­strain the cost of the pro­grams, and this has en­cour­aged ef­forts to im­ple­ment man­aged care and other in­no­va­tive pro­grams de­signed to re­duce spend­ing,” said Michael Gus­mano, co-di­rec­tor of the Yale-Hast­ings Pro­gram at the Hast­ings Cen­ter, a bioethics re­search in­sti­tute.

Med­i­caid’s fed­er­al­ist struc­ture has given states lots of room to experiment with new ap­proaches. The Med­i­caid pa­tient pop­u­la­tion has less po­lit­i­cal power than Medi­care’s se­nior pop­u­la­tion to re­sist changes such as manda­tory man­aged-care en­roll­ment, said Brad Wright, as­sis­tant pro­fes­sor of health man­age­ment and pol­icy at the Univer­sity of Iowa. Also, ben­e­fi­cia­ries and ad­vo­cacy groups tend to see these pro- grams as po­ten­tial im­prove­ments in qual­ity and ac­cess, given that Med­i­caid pa­tients long have strug­gled to find providers will­ing to ac­cept the pro­gram’s low pay­ments.

“We’re talk­ing about a pop­u­la­tion of very vul­ner­a­ble peo­ple with few, if any, other op­tions for be­ing able to ac­cess healthcare,” Wright said. “When the state de­cides to experiment, the ben­e­fi­cia­ries aren’t likely to be well-in­formed of these changes, to fully ap­pre­ci­ate the im­pli­ca­tions of the changes for them per­son­ally, or to be well-or­ga­nized enough to re­sist these changes po­lit­i­cally.”

The need for de­vel­op­ing cost-ef­fec­tive new ap­proaches is grow­ing as the Af­ford­able Care Act has added mil­lions of ben­e­fi­cia­ries. Thirty states and the Dis­trict of Columbia have agreed to ex­pand Med­i­caid to lower-in­come adults un­der the healthcare re­form law. States that will be­gin pick­ing up a por­tion of the costs for that ex­pan­sion pop­u­la­tion in 2017 are look­ing for ways to limit those costs with­out cut­ting el­i­gi­bil­ity or ben­e­fits.

Many gover­nors and leg­is­la­tors also are brain­storm­ing ways to take ad­van­tage of the ACA’s Sec­tion 1332 State In­no­va­tion Waiver pro­vi­sion, which al­lows states to pro­vide health cov­er­age for their res­i­dents in al­ter­nate ways as long as the cov­er­age is at least equal to stan­dard ACA cov­er­age. In the­ory, states could use the waivers to im­ple­ment tar­geted ex­pan­sions of Med­i­caid in­stead of pro­vid­ing cov­er­age to all adults up to 138 % of the fed­eral poverty level, said Ni­cole Hu­ber­feld, a re­search pro­fes­sor at the Univer­sity of Ken­tucky Col­lege of Law.

States have pur­sued Med­i­caid in­no­va­tions for cost sav­ings and qual­ity im­prove­ment largely through con­tract­ing with pri­vate Med­i­caid man­aged-care com­pa­nies. By year’s end, it’s es­ti­mated that 73% of ben­e­fi­cia­ries will re­ceive ser­vices through man­aged-care plans, ac­cord­ing to Avalere Health. Cur­rently, 37 states and the Dis­trict of Columbia con­tract with Med­i­caid plans, ac­cord­ing to Med­i­caid Health Plans of Amer­ica.

As of March 2015, 46 states and D.C. have adopted poli­cies and pro­grams to ad­vance pa­tient-cen­tered med­i­cal homes in their Med­i­caid and/or Chil­dren’s Health In­sur­ance Pro­gram, ac­cord­ing to the Na­tional Academy for State Health Pol­icy.

Some observers ques­tion whether the use of pa­tient-cen­tered med­i­cal homes and co­or­di­nated-care pro­grams, par­tic­u­larly for the gen­eral Med­i­caid pop­u­la­tion, will im­prove qual­ity or re­duce costs. They say the ev­i­dence shows

co­or­di­nated-care pro­grams are most ef­fec­tive when they tar­get high-cost adult pa­tients with chronic con­di­tions.

“Chil­dren al­ready tend to be lower cost and don’t need as much care co­or­di­na­tion,” said De­bra Lip­son, a se­nior re­searcher at Math­e­mat­ica Pol­icy Re­search. “The ini­tia­tives that seem to be the most suc­cess­ful are those that im­prove care for peo­ple with some sort of chronic ill­ness.”

Ju­lia Par­adise, as­so­ciate di­rec­tor of the Kaiser Com­mis­sion on Med­i­caid and the Unin­sured, agreed that the fo­cus should be on high uti­liz­ers. “If you can make a dent there among that pop­u­la­tion, you can make a sub­stan­tial dif­fer­ence,” she said.

Med­i­caid plans have par­tic­u­larly set their sights on con­trol­ling costs for mem­bers with be­hav­ioral health is­sues. In 2011, nearly half of adult ben­e­fi­cia­ries un­der age 65 who were el­i­gi­ble for Med­i­caid on the ba­sis of dis­abil­ity and were not also el­i­gi­ble for Medi­care had a be­hav­ioral health di­ag­no­sis, ac­cord­ing to the Med­i­caid and CHIP Pay­ment and Ac­cess Com­mis­sion. That pop­u­la­tion ac­counted for twothirds of to­tal Med­i­caid spend­ing.

In 2012, Cigna-Health­Spring, a Med­i­caid man­aged-care plan, launched its Be­hav­ioral Health In­ten­sive Out­pa­tient Pro­gram ini­tia­tive in Texas. The plan uses data anal­y­sis and clin­i­cal case re­view to iden­tify mem­bers with a history of be­hav­ioral health ser­vices who are the high­est users of ser­vices.

The pro­gram de­ploys nurse care man­agers who reach out to pa­tients and their var­i­ous providers and co­or­di­nate care. The care man­agers ac­tively seek out mem­bers in their homes, shel­ters or even in jail. They work to build a strong rap­port with mem­bers and are able to of­fer other providers in­sights into the mem­bers’ needs. The pro­gram eases pre-au­tho­riza­tion rules for cov­er­age of pre­scrip­tion drugs and other med­i­cal and be­hav­ioral ser­vices.

The pro­gram has seen no­table re­sults,

ac­cord­ing to Cigna-Health­Spring. One Med­i­caid mem­ber went from 26 hos­pi­tal ad­mis­sions in one year to two ad­mis­sions. Another mem­ber, who has schizophre­nia and lived un­der a bridge, was re­united with his fam­ily, be­came com­pli­ant with his med­i­ca­tions, and saw his ex­tremely high an­nual healthcare costs drop by nearly half.

Sim­i­larly, An­them’s af­fil­i­ated Med­i­caid plans in Ten­nessee, Texas and Vir­ginia are tar­get­ing ben­e­fi­cia­ries with be­hav­ioral health is­sues through its Ris­ing Star pro­gram. Mem­bers with three or more ad­mis­sions over a six-month pe­riod for be­hav­ioral health dis­or­ders, or who had a lengthy be­hav­ioral health hos­pi­tal­iza- tion, are as­signed to a spe­cific hos­pi­tal and provider to en­cour­age en­hanced care qual­ity. The goal is to en­able providers to be­come more knowl­edge­able about pa­tients and their con­di­tions and get pa­tients more in­volved in man­ag­ing their own health.

Like Cigna’s pro­gram, An­them’s ini­tia­tive waives prior au­tho­riza­tion re­quire­ments for cer­tain drugs and ser­vices, which makes it at­trac­tive to physi­cians. “(The doc­tors) don’t have to worry about hav­ing An­them’s med­i­cal di­rec­tor call­ing and ask­ing, ‘Why are you keep­ing a pa­tient so long, or have you tried dif­fer­ent med­i­ca­tions?’ ” said Dr. Wil­liam Wood, be­hav­ioral health med­i­cal di­rec­tor for An­them’s gov­ern­ment busi­ness di­vi­sion.

An­them data show that a year af­ter the pro­gram launched in Ten­nessee, there was a 46% re­duc­tion in hos­pi­tal ad­mis­sions among pro­gram par­tic­i­pants, a 58% re­duc­tion in to­tal in­pa­tient days, a 22% re­duc­tion in av­er­age length of stay, a 56% re­duc­tion in hos­pi­tal read­mis­sions, and a 24% re­duc­tion in emer­gency depart­ment vis­its.

Other widely adopted Med­i­caid in­no­va­tions are pri­mary-care case man­age­ment and pa­tient­cen­tered med­i­cal homes. Un­der the med­i­cal home model, a mul­ti­dis­ci­plinary team gen­er­ally led by a pri­mary-care physi­cian man­ages the health of the en­rolled Med­i­caid pop­u­la­tion. The team mem­bers make sure the mem­bers re­ceive rec­om­mended pre­ven­tive ser­vices, get care for their chronic con­di­tions, have their med­i­ca­tion dosages mon­i­tored and ad­justed, and have ac­cess to so­cial ser­vices and sup­ports.

“This works be­cause it ad­dresses some of the non-fi­nan­cial bar­ri­ers to care,” Univer­sity of Iowa’s Wright said. “It helps them co­or­di­nate their care in ways that pro­vide a big re­turn on in­vest­ment. And it works be­cause providers get paid a cap­i­tated amount to par­tic­i­pate and pro­vide these care-man­age­ment ac­tiv­i­ties.”

More than 20 state Med­i­caid pro­grams have launched ini­tia­tives that pro­vide train­ing and coach­ing to physi­cian prac­tices seek­ing to be­come med­i­cal homes, ac­cord­ing to a 2012 ar­ti­cle in Health Af­fairs.

Greater Lawrence Fam­ily Health Cen­ter, in Lawrence, Mass., has been us­ing the med­i­cal home model for about seven years, said Dr. Joseph Gravel, the cen­ter’s med­i­cal di­rec­tor. It has seen drops in un­nec­es­sary emer­gency depart­ment vis­its among Med­i­caid pa­tients.

“This has def­i­nitely been ben­e­fi­cial from the pa­tients’ point of view,” Gravel said. “Now that we have a team tak­ing care of them, and not a sin­gle per­son, all of their needs are get­ting met.”

“The ini­tia­tives that seem to be the most suc­cess­ful are those that im­prove care for peo­ple with some sort of chronic ill­ness.” Ju­lia Par­adise As­so­ciate di­rec­tor of the Kaiser Com­mis­sion on Med­i­caid and the Unin­sured

Dr. Jocelyn Hirschman ex­am­ines a new­born pa­tient at the Greater Lawrence (Mass.) Fam­ily Health Cen­ter, which uses a Med­i­caid med­i­cal home model.

Buck­eye Health Plan launched the Preg­nancy Spe­cialty Care Man­age­ment Pro­gram, which treats preg­nant plan mem­bers with al­co­hol or sub­stance-abuse prob­lems.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.