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Different populations require different approaches
The Medicaid and Medicare populations call for two very different strategies for preventing hospital readmissions, according to Michael Birnbaum, director of policy at United Hospital Fund's Medicaid Institute in New York City.
"It's important to remember how different Medicaid's high-cost patients are, especially those with the highest costs," says Mr. Birnbaum. "Certain service delivery approaches developed to reduce Medicare spending may work very well for Medicare populations, but when they are applied to high-cost Medicaid patients, they just may not fit."
For example, people who are employed and privately insured are likely to have less severe mental health conditions, such as generalized anxiety disorder or mild to moderate depression, than people covered by Medicaid, who can't work due to severe mental illness.
"Medicaid cares for lots of adults who don't participate in the workforce for a broad number of reasons," says Mr. Birnbaum.
Sean Cavanaugh, United Hospital Fund's director of health care finance, says that when studies showed that 18% of Medicare patients were readmitted, the general reaction was, "That's much too high, and we can do better. What do we need to do?" He says that the same reaction is likely from Medicaid directors who learn of high readmission rates, but that the answer to the question "What can we do?" is likely to be different.
"The answer is they need to do the things that Medicare's new payment policies are encouraging, plus a lot more," he says. This is particularly true for high-cost clients, who are likely to have multiple co-morbidities and a range of poverty-related problems, including housing issues.
When United Hospital Fund provided grants to several hospitals to learn more about their high-cost Medicaid patients, they saw "dramatic problems that extend beyond the health care system," says Mr. Cavanaugh. "Improving discharge planning and better transitions of care, and better handoffs from hospital to home care are important, but they are not nearly enough for this population."
While some high-cost clients are difficult or impossible to engage, members of another subset of this group are genuinely interested in improving their health. "From listening to our grantees, it seems that some high-cost Medicaid patients are almost impossible to engage," says Mr. Cavanaugh. "However, others, even with all of their problems, respond to new programs and forms of assistance."
Still, getting Medicaid beneficiaries to respond to some of the more traditional approaches for Medicare populations, such as better discharge planning, can be challenging.
"When you talk about discharge planning, for Medicare beneficiaries the assumption is that you have family caregivers, a relatively stable home environment, and at least the home health benefits covered by Medicare," says Mr. Birnbaum. In contrast, with Medicaid's high-cost cohort, you may face a patient with unstable housing arrangements and weak family and social supports. In addition, the beneficiary may reside in a state without robust home care benefits.
"So, there are core assumptions about how you approach discharge planning in Medicare that just don't translate to Medicaid. And then there's the matter of implementing a plan of care for a schizophrenic with a chemical dependency, a challenge that's essentially faced only by Medicaid," says Mr. Birnbaum.
Mr. Cavanaugh gives the example of diabetics. "This is a group of people you don't want to see hospitalized ever, and certainly not re-hospitalized. That is considered a preventable admission," he says. The usual approach is to give the patient glucose monitors to check blood sugar at home, with a home health nurse sent occasionally if there is a need to enhance the intervention.
"That all makes a lot of sense for many Medicare patients. But when you go to the Medicaid context, let's say the patient has an unstable home situation. The glucose meter might get lost or damaged, and you don't know how to follow them if you want to call them," says Mr. Cavanaugh.
Some enhanced intervention programs are now giving cell phones to high-cost users, paid for outside of Medicaid, so they can be contacted for follow-up. "Under the old math, it didn't make sense for anybody to do this," says Cavanaugh. "Who is going to give a patient a cell phone and not get paid by Medicaid, to try to reduce utilization that is getting reimbursed by Medicaid?"
However, if payment policies don't pay for avoidable readmissions, "then the math starts changing. Some of these changes on the margins start to make more sense," says Mr. Cavanaugh. "I think we are a long way from solving this, but I think health care reform is starting the conversation about changing the reimbursement structures."
On the Medicare side, in contrast, there is a lot of robust information about what works. This means that the federal government can institute clear incentives and even penalties on the fee-for-service side.
"With Medicare, you can do readmission penalties and value-based purchasing and hospital-acquired condition penalties," says Mr. Birnbaum. "But this is still in the development stage on the Medicaid side."
Another factor is that in a fee-for-service environment, high-cost patients for Medicaid are high-revenue patients for hospitals. "So, when you're talking about changing the math, you really need providers at the table," he says. "Right now, providers can have strong incentives to admit and readmit Medicaid patients."
The potential impact of health care reform on rethinking service delivery for Medicaid patients is substantial. "You have $10 billion in new federal pilot funding. These are not, by necessity, budget-neutral demonstrations. There is money on the table and a lot of focus on making new investments to see what works," Mr. Birnbaum says.
Once again, though, the outlooks are quite different for Medicare and Medicaid. "On the Medicare side, there is an opportunity to save substantial money because of policies that have already been developed and have just been enacted," says Mr. Birnbaum. "On the Medicaid side, you are hoping for some bright ideas, not even necessarily to take hold, but to bubble up, so they can be tested and refined. For Medicaid, this is definitely at an embryonic stage."