Better Care for Medicaid Patients Works, but Report Finds Gaps Based on State Policy

Figuring out how to reduce the nation’s healthcare tab is not easy, but there’s mounting evidence that it starts with treating chronic conditions before they become a crisis—and that means access and care coordination.

This is especially true for those who rely on Medicaid. A recent essay from leaders at CareMore Health, a division of Anthem, outlined the insurer sought to transform the way patients in Medicaid experienced the healthcare system, starting with getting more from it, not less.

CareMore’s leaders acknowledged that some thought their quest was daunting. Historically, physicians have not always welcomed Medicaid patients, for reasons of low reimbursement and administrative hurdles. Those that did accept it sometimes required long waits for appointments.

But in 2017, data suggested this had stabilized amid a push among professional groups to call on physicians to accept Medicaid patients, so they were not forced to seek care in the emergency department (ED) for want of a provider. Former CMS Administrator Andy Slavitt is leading an initiative under Avia to transform how health systems deliver Medicaid—specifically to make sure Medicaid beneficiaries are seen in a timely manner so they don’t go to the ED.

The CareMore results show that some key steps and individuals can make care for Medicaid patients successful and reduce costs:

• Community health workers, who are specially trained social workers, are deployed to overcome barriers to get patients in to see the physician.
• Care management specialists make use of dashboards and patient metrics to organize appointments, arrange for transportation, or even visit the patient’s home to review medications.
• “Extensivists” are physicians who see patients both in the hospital and beyond, such as in rehabilitation centers, until the patient is ready to go back to primary care.
• Collaborative behavioral health is fully integrated into care so primary care doctors know how these issues could be affecting overall care.
• Hiring practices were revamped to ensure that each team member had bought into the philosophy of changing a person’s approach to health.

It’s a tall order, but it’s backed by a compensation system that rewards better outcomes, and it’s working: CareMore reported that in Tennessee, for example, its Medicaid patients spent 10% to 17% fewer days in the hospital, had 21% to 22% fewer ED visits, and 23% to 28% fewer specialist visits than other Medicaid managed care beneficiaries in similar areas.

Sachin Jain, MD, MBA, the CEO of CareMore, said in an email to The American Journal of Managed Care^® that CareMore has no trouble finding physicians and other team members willing embrace its approach.

“There are people in every community in America who are passionate about making sure that seniors and other vulnerable populations get outstanding care. We have not had any challenge finding people who are drawn to the mission.”

The trouble is, this kind of care is not available everywhere. Good care cannot be delivered if the poor cannot enroll in Medicaid in the first place. The 17 states without Medicaid expansion include many with the worst health outcomes among the working poor, and a new report from the Government Accountability Office (GAO) shows this makes a different in whether people seek care.

Gaps in whether poor seek care

The report, requested by Senator Ron Wyden, D-Oregon, found that nearly 20% of low-income people in states that did not expand Medicaid said they passed on medical care they needed in the prior year because they couldn’t afford it. In states that did expand the program, the share was just 9.4%.

The Affordable Care Act allowed states to expand Medicaid to households making up to 138% of the federal poverty line, which is $34,640 for a family of 4 or $16,750 for an individual. Expansion is on the ballot in several states. An estimated 5.6 million uninsured low-income adults have income levels that meet the requirements for Medicaid expansion. However, estimates from this sample, prepared by the 2016 National Health Interview Survey, show that 3.7 million of these adults live in states without Medicaid expansion.

Besides skipping care generally—even if they had a doctor—about 8% of people in states without expansion skipped medication or rationed doses, compared with 5% in expansion states. And about 22% of those in non-expansion states skipped dental care, compared with 15% in expansion states. Dental care is a popular service in Medicaid managed care plans.

Specialist care has historically been especially hard to find among the poor. The GAO report found that 11% of those in nonexpansion states were unable to afford a specialist visit, compared with 6% of low-income adults in expansion states.

Low-income adults in the expansion states were less likely to report unmet medical needs than those in states without Medicaid expansion, although similar numbers reported having a usual place to go for healthcare. The percentage of low-income adults who had any unmet medical need was 26% in the expansion states and 40% in the states without Medicaid expansion, the report found.

The GAO report echoes an analysis in Health Affairs last month, which found that last year, gains in the rate of insured Americans slipped backward in 2017, especially in states that did not pursue Medicaid expansion.