January 12, 2017
Many individuals enrolled in Medicaid also access services from other state human services agencies and community-based providers. Deploying a “whole person” approach for enrollees—supported by modern tools and one-to-one support—can increase beneficiary engagement while lowering a state’s overall costs and administrative burden.
The Medicaid landscape is changing
Since implementation of the Affordable Care Act (ACA) in January 2014, Medicaid enrollment has been steadily increasing. As of August 2016, the latest period for which data is available, more than 73 million Americans were covered by Medicaid.i This is approximately a 28% increase from the enrollment period just prior to the first Marketplace Open Enrollment period in October 2013.ii In addition to Medicaid’s traditional coverage of low-income families, low-income elderly individuals, and individuals with disabilities, in many states Medicaid now covers adults without dependent children. Also, more Medicaid beneficiaries in need of long-term services and supports (LTSS) are being served in home and community-based settings rather than nursing homes and institutions.
There has also been significant growth in the number of Medicaid beneficiaries receiving services through a managed care model rather than the traditional fee-for-service (FFS) payment model. According to the Centers for Medicare & Medicaid Services (CMS), more than 70% of Medicaid enrollees are served through managed care delivery systems.iii This number is expected to grow as states, seeking more predictable budgets, transfer higher risk individuals and more complex and costly services from FFS to managed care.
CMS released a final Medicaid Managed Care rule in May 2016 giving states increased flexibility in developing and designing their managed care programs. However, with that flexibility comes greater oversight and an expectation of better healthcare outcomes and cost control. To meet the new regulatory requirements, states will need to implement innovative strategies to ensure the services they are paying for lead to improved care quality and lower costs over time.
While there will be pressure on health plans and providers to change how they provide care to achieve targeted outcomes, true improvements in population health can only be achieved if consumers are fully engaged in managing their own health.
Engaging consumers in this new landscape
States will need to start thinking outside the box to determine the most effective and efficient means of engaging Medicaid beneficiaries in taking responsibility for their care, particularly given the greater diversity of enrollees, broader range of care settings, and increased focus on value-based and managed care.
My conversations with state policy leaders have revealed the need for a new approach to effective consumer engagement that is focused on individuals’ complete health and well-being, including appropriate social and environmental factors. Medicaid agencies should consider the value of shifting some responsibilities from health plans and providers to a centralized entity that is better equipped to conduct outreach, promote consumer-directed care, and track utilization for enhanced data analytics. The ideal centralized approach, which would recognize the unique needs of different Medicaid populations and encourage self-directed care, would encompass the following:
- Data-driven, individualized patient education to get beneficiaries more engaged in their health outcomes
- Greater integration between state health and human services agencies, including the ability to refer and track the use of social services
- Consolidated data collection and analytics to inform best practices for case management and care coordination for individuals accessing services through multiple avenues
- Risk assessments at time of enrollment to improve completion rates
- Real-time referrals to community-based services and resources based on health assessments
One way in which states can be innovative in this regard is to expand the role of the Enrollment Broker to include these components as well as responsibility for conducting enhanced patient education and engagement as part of the managed care enrollment process. Enrollment Brokers are contractors that facilitate enrollment of Medicaid beneficiaries into the Medicaid managed care delivery system, and ensure they have a neutral source of information about their choices and rights under managed care. For example, using the enrollment process to conduct health assessments more effectively, while the state has a captive audience, will help managed care organizations (MCOs), providers and the state capture necessary information that is often much harder to obtain once the member has been enrolled.
Enhanced care coordination with less duplication
States often have fragmented systems and no way to track or coordinate Medicaid beneficiaries’ overall healthcare, social, and environmental needs. Multiple state agencies, providers, health plans, and community-based organizations end up spending significant time and money on the same individual without improving outcomes.
Medicaid MCOs are responsible for managing the individual’s healthcare needs, but have also begun to refer members to community-based organizations. Some even pay for ancillary services or items–food, housing, clothing, etc.–for their members in recognition that those factors affect overall health. At the same time, the individual may be receiving services through programs funded by the state’s human services agency, for example, community health centers or community-based organizations. Each entity may not know what services the individual is already receiving, leading to duplication and waste.
To combat this, states should consider the value of using an Enrollment Broker to:
- Enroll individuals in a health plan.
- Collect health status information at the time of enrollment.
- Provide education and engage beneficiaries in their care management.
- Be the central point to coordinate and track Medicaid beneficiaries’ use of healthcare and social services.
By employing an Enrollment Broker to connect individuals to social services, track consumer use, and share information with state agencies, community organizations, health plans, and providers, state agencies and providers will be able to develop better care coordination and management strategies.
Not a one-size-fits-all approach
The centralized approach aimed at addressing the whole person must be flexible to allow for differences between individuals. Medicaid covers a wide variety of low-income individuals who often face barriers to accessing appropriate care due to transportation, paid time off from work, language, culture, need for specialty care, etc. Developing a consumer engagement strategy for the Medicaid population requires a multi-pronged approach that utilizes the latest technology but also maintains a robust human outreach component.
Additionally, as the saying goes, “if you have seen one Medicaid program, you have seen one Medicaid program.” Every state Medicaid program is unique in who is eligible and how the delivery system is structured. This needs to be considered when developing an effective consumer engagement solution that can be applied across multiple states.
Opportunity for innovation
The new managed care rules and the push for delivery system reforms create a prime opportunity for states to rethink and reshape how they communicate with and engage Medicaid beneficiaries in their healthcare. Innovation in this area is critical to getting a handle on rising healthcare costs, and more importantly improving the health and well-being of the individuals served by the Medicaid program.
(This article was published by HIT Leaders and News in December 2016.)
i Centers for Medicare & Medicaid Services; Medicaid & CHIP: August 2016 Monthly Applications, Eligibility Determinations and Enrollment Report November 3, 2016, https://www.medicaid.gov/medicaid/program-information/downloads/august-2016-enrollment-report.pdf.
ii The Henry J. Kaiser Foundation, “Total Monthly Medicaid and CHIP Enrollment,” August 2016, http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=0.
iii The Centers for Medicare and Medicaid Services, “Medicaid Managed Care Enrollment and Program Characteristics, 2014,” Spring 2016. https://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/medicaid-managed-care/downloads/2014-medicaid-managed-care-enrollment-report.pdf