Catch up – Day 12 – Medicaid at 50: State Highlight: Colorado

Basics: Colorado Medicaid covers: 1,244,031 lives

Colorado has been on the vanguard of accountable care in Medicaid. They started their Accountable Care Collaboratives in 2011 (the Affordable Care Act was just 1 year old!) with the goal of improving outcomes and saving money by using a medical home model embedded in a regional coordination strategy supported by strong data. Colorado Medicaid has produced this exciting YouTube video to teach us more!

As we look for evidence on how different models of ‘accountable care’ work, Colorado is great because they are a couple of years in and so are starting to produce some results. Plus, they’ve built strong data and analytics into their work to facilitate both patient care and evaluation. According to their 2014 Annual Report, last year the ACC overall (there are regional care organizations) generated $98-102 million in medical savings, and spent $69 million on administrative costs, for a net savings of $29-33 million.

Catch up Day 13 – Medicaid at 50: Transportation

Federal law requires state Medicaid programs to provide transportation to and from medical appointments (and related needs like picking up prescriptions). This is a really, really important benefit. Getting to the doctor can be difficult/impossible if your finances don’t allow you to own a car, or your health conditions prevent you from driving or taking public transportation (if it is available at all).

In practice, non-emergency medical transportation (NEMT) can be a big hassle. It could learn a thing or two from Uber when it comes to convenience. Drivers get lost or delayed, appointments get rescheduled last minute, and patients can end up waiting a long time. That said, it’s a great concept and NEMT programs could see quick improvements with better contracting and oversight between the state and companies who provide the services. NEMT is cheaper than using an ambulance, and ensuring that people can keep up with their appointments is far preferable to having people go to the emergency department for issues that could have been managed earlier.

Worrisomely, NEMT is one of the benefits that some states are looking to get exemptions from when they seek Medicaid expansion waivers. At a time when states like Oregon are showing that attention to social determinants of health matters for outcomes and cost, it seems counterproductive to weaken NEMT. Let’s hope that we can try improving non-emergency medical transportation services rather than losing this important benefit.

Day 11 Medicaid at 50: How to care for new Medicaid enrollees

The post below appeared on the Health Affairs Blog. Read it below or click on this link for the hits.

We May Already Know How To Reduce The High Cost Of Covering New Medicaid Enrollees

Last week, the Centers for Medicare and Medicaid Services’ independent Office of the Actuary released its 2014 Actuarial Report on the Financial Outlook for Medicaid.

Unlike previous years, this annual report is making headlines because the actuaries project that for 2014 the newly eligible Medicaid expansion population will have costs greater than the non-newly eligible Medicaid population. Continue on to the next paragraph of the report and the actuaries write that a major contributor to this increased cost projection is that states anticipated and, in their managed care contracts, accounted for high first-year costs for these new beneficiaries.

We will see whether these projections come to bear in the next actuarial report or whether states in fact overestimated these first-year costs, perhaps leading actuaries to expect that the average per beneficiary cost for the expansion population will be less than the non-expansion population in later years.

While we still do not have final figures on how much new Medicaid enrollees spent on medical care in 2014, we do have evidence—including a recent study by Naderah Pourat and coauthors published in the July issue of Health Affairs—that primary care and care coordination can help reduce the initial care costs of Medicaid enrollees entering the health care system for the first time.

After all, evidence suggests newly eligible Medicaid beneficiaries are healthier and less costly than the current Medicaid population. However, when negotiating their managed care contracts, many states estimated that the newly eligible would cost more in the first year than non-newly eligible individuals. This approach was based on the theory that the first newly eligible people to enroll would be those previously locked out of the insurance market, quickly entering the health care system with pent up demand. Additionally, they would be sicker and would require more health care services.

The estimations driven by this theory are essentially based on an adverse selection problem. But it doesn’t have to work that way. Pourat and colleagues show how, several years ago, California found a way to reduce the cost of newly insured Medicaid beneficiaries entering the health care system for the first time: care coordination.

Medicaid Expansion Presents An Opportunity

The stakes of getting this right have rarely been higher. Medicaid’s enrollment has grown by more than 12 million people since the Affordable Care Act’s first open enrollment period. The actuaries estimate that over four million people gained Medicaid coverage through Medicaid expansion in 2014, and many of these people are getting health coverage for the first time.

Studies, including the Oregon Health Insurance Experiment, show that expanding Medicaid coverage, absent care coordination efforts, increases the usage of often costly and ineffective emergency department visits. That phenomenon is not unique to Medicaid — insurance coverage reduces the financial barrier to seeking health care, driving up demand for services in all settings.

Unnecessary use of the emergency department is only a small portion of the costs associated with Medicaid. A vast majority of Medicaid enrollees go to the emergency department for actual emergencies. But, by promoting best practices of primary care adherence and encouraging beneficiaries to use of the right type of care, states like California can help reduce these initial cost increases associated with newly eligible enrollees.

The Medicaid expansion and enrollment increases represent an important opportunity for state and Medicaid managed care plans to actively reduce unneeded emergency department care. To do this, states have used methods ranging from out-of-pocket charges for emergency department trips deemed unnecessary to enrolling people in primary care practices with routine follow- ups.

Health Care Coverage Initiative

In 2005 California began implementing the Health Care Coverage Initiative that essentially acted as a medical home model for newly insured Medicaid beneficiaries in 10 counties around the state and gave enrollees a primary care provider that coordinated the person’s care.

In the initiative’s first two years, patients were not required to adhere to their chosen or designated primary care provider; they could switch providers whenever they wanted. As described in their recent Health Affairs article, Pourat and colleagues found that during this same period, the number of emergency department visits among beneficiaries remained high, attributed primarily to those enrollees who did not adhere to the same primary care provider. But that all changed in the third year when the county began actively requiring patients and providers to redirect care through their primary care provider. They instituted non-payment for visits to non-assigned providers and restricted primary care provider changes.

These policies led to greater adherence to primary care providers and reduced emergency department use and hospitalizations among enrollees who stuck with their primary care physician. While we already knew that greater continuity of care reduces emergency department usage and hospitalizations, this research provides additional evidence on the power of that payment methodology and policy structures to provide that continuity of care for Medicaid enrollees.

Next Steps

Orange County’s dual pronged financial and consumer approach to ensuring Medicaid enrollees seek care through a primary care provider is not the only way to increase primary care adherence and reduce use of the emergency department.

We need to closely study efforts to provide primary care services on nights and weekends and through retail clinics. Many newly eligible individuals have jobs without sick time that restrict their ability to make doctor’s appointments during the work week. But with these new efforts, Medicaid enrollees can get care on evenings or weekends, when many doctors’ offices are closed.

We also need to recognize which efforts have not delivered results. Evidence suggests that copayments and other restrictions on “unnecessary” emergency department visits does not reduce this utilization.

The research is unclear whether the temporary increase in Medicaid primary care payments from January 1, 2013 to December 31, 2014 led to increased utilization of primary care services by Medicaid enrollees. Starting in 2015 some states maintained the payment increases using their own funds, while others allowed the payments to return to earlier levels. This variation will allow researchers to further study the effect of provider payment on care utilization.

We have much to learn from the different approaches states are taking to reduce costs for people entering the health care system for the first time. And these lessons will have lasting relevance. In the years ahead we will continue to see long-term uninsured people entering the system. Care coordination will ensure that continuously insured people receive the right care, while saving money for states and the Medicaid program.

Catch up day 14- Medicaid at 50: State Highlight: Washington DC

Washington, DC covers 255,861 people on its Medicaid program.

Don’t even start with any “DC is not a state” nonsense.

If you’ve been paying attention — that number in the first sentence is a lot larger than many other states. DC has a generous Medicaid eligibility and high rates of poverty making the program crucial for thousands of residents.

Unfortunately, that is subject to the control of Congress. This was most recently felt during the latest government shut down. There are safeguards to keep the program going without the need for Congressional action but unlike any other state the fate of the DC Medicaid program depends on cooperation between the parties in Congress. That’s unfortunate.

Catch up day 14- Medicaid at 50: Presumptive Eligibility

Ok guys- this is literally my favorite provision of Medicaid.

The Affordable Care Act gave hospitals in states the option to do presumptive eligibility. This basically means, that a hospital could treat a person under the presumption that they are eligible for Medicaid rather than waiting until the state processes their application. But get this– it doesn’t matter if the hospital is in an expansion state or not. Obviously, the state has to abide by the Medicaid law in the state– not pretending that they live in an expansion state.

Why is it my favorite provision? I just loved working on stories like these. So fascinating!

I’m gonna quote myself or old times sake.

Federal Medicaid spokeswoman Emma Sandoe explained that the rule doesn’t actually open the doors to Medicaid expansion.

“There’s a long-running statute in Medicaid that a state can do what’s called presumptive eligibility – that means, if someone is presumed to be eligible, they can enroll,” Sandoe said. “Originally, it was for women and children. In July, we released a regulation that extends this to newly eligible people under the Affordable Care Act. It also says hospitals can make that determination.”

However, Sandoe pointed out, the rule explicitly says that presumptive eligibility must follow each state’s eligibility criteria.

“States’ eligibility rules govern this,” she explained, “and hospitals aren’t required to do it.”