Innovative approaches improve care, save costs for Medicaid recipients
Innovative approaches improve care, save costs for Medicaid recipients
MCOs meet the challenges of a difficult-to-manage population
Health plans are coming up with innovative ways to coordinate care for the country’s Medicaid beneficiaries, a population whose challenges include almost as many social issues as medical ones.
According to Washington, DC-based America’s Health Insurance Plans (AHIP), a national association representing health care insurers, an analysis of numerous studies found that managed health care for Medicaid recipients saves up to 19% when compared to Medicaid fee-for-service arrangements.
The report cites statistics from the Centers for Medicare & Medicaid Services (CMS) showing that 59% of Medicaid participants are enrolled in some kind of managed care plan and those members accounted for less than 20% of all Medicaid expenditures.
Case studies in the report show how Medicaid managed care plans demonstrate quality improvement and cost containment through innovative programs tailored to meet the needs of a high-risk population.
"Health plans are reaching out to underserved parents and children, to the elderly and disabled, and to patients struggling with chronic illnesses who have never had an ongoing relationship with caring health professionals, says Karen Ignagni, AHIP’s president and chief executive officer.
Consider these statistics:
- AHIP has issued a report showing the effectiveness of Medicaid, concluding that Medicaid managed care saves up to 19% when compared to Medicaid fee for service.1
- Pennsylvania’s Medicaid HMOs saved the state $2.7 billion over the past five years, according to a study by The Lewin Group.2
- Optima Health, with headquarters in Virginia Beach, VA, estimates that its community-based pregnancy programs have helped avoid nearly 3,000 days in the neonatal intensive care unit since 2002, and that for every dollar spent on the program, the plan saved $2.80.
- Keystone Mercy Health Plan, based in Philadelphia, estimates savings of as much as $115 per member per month in its intensive case management program for high-risk members.
- Louisville-based Passport Health Plan’s Medicaid managed care programs, covering 135,000 members, have saved Kentucky $191 million in the eight years it’s been in operation.
The Medicaid population is difficult to manage and presents challenges that case managers typically don’t encounter with the commercial population.
These members tend to be sicker than a commercial population, with more comorbidities. They’re less likely to seek routine medical care, instead visiting the emergency department and getting so sick that they may require hospitalization.
The members are hard to reach, and when the health plan does find them, they’re often reluctant to talk with people they don’t know.
These members have tremendous psychosocial needs that make it impossible for them to seek care in a timely manner and comply with their treatment plans.
Many Medicaid recipients don’t even have basic needs such as food and shelter on a regular basis.
"If the member constantly worried about those two issues, they’ll never start thinking about their long-term health care needs," says Helen Homberger, RN, director of medical management and Early Periodic Screening, Diagnosis, and Treatment for Passport Health Plan.
They often have to make choices — to pay the rent or pay the electric bill or buy medicine.
"We have to work on meeting those basic needs of food and shelter before the members can begin to focus on their long-term health care needs," says Randy Simmons, RN, manager, case and utilization management.
The members targeted by Medicaid managed care programs are a challenge to locate. Some members do not have telephones. Many have cell phones, but there’s no easy way to get the number unless the member supplies it, and the phones often are in and out of service.
Some members change addresses frequently, and many have a fear of home visits. If a social worker attempts to visit them, the family members may be afraid to open the door to a stranger.
"With the Medicaid population, a big challenge is being able to reach them. We do not have accurate telephone or address information for about 23% of the members," says Jane Israel, RN, executive director of clinical initiatives for Keystone Mercy Health Plan.
When members are referred for intensive case management, Keystone Mercy’s rapid response team attempts to locate them and goes into the community to find them if necessary. After a member’s immediate needs are taken care of, he or she is referred to case management.
One of Passport Health Plan’s most successful techniques for locating members is to contact the pharmacy where they had their last prescription refilled. Often pharmacies have a current address, Homberger says.
"We work very hard to get membership materials to our members so they can contact us. We work with physician offices because if a patient trusts any part of the health care system, they trust doctors. If anyone can reach them, it’s the physician office," adds Karen Bray, RN, CDE, disease management program director for Optima Health in Virginia Beach, VA.
But locating the Medicaid members only is the first challenge, Bray points out.
"Once you clear the hurdle of not being able to reach them, you have to gain their confidence before you can help them. The members don’t feel like the health care system is on their side and feel powerless to deal with such a complex system, Bray adds.
Optima Health partners with Virginia’s Comprehensive Investment program (CHP, which provides nurses and outreach workers to visit high-risk pregnant women and their families in the community).
"We look for an organization with this kind of model who can help us to reach out to the community. Many of these agencies are funded by grants. As an insurance company, we have an opportunity to offer a contract that is ongoing. It’s a win-win situation," Bray says.
Case managers who work with the Medicaid population have to understand their challenges in order to help them manage their care, adds Homberger.
"When you work with this population, you have to realize that their plans for the future are not the same as those of members with a commercial health plan. These are people whose idea of long term is next week. It’s hard to get them to see that they need to take their medication for six months to evaluate how effective it is," she says.
It takes patience and persistence when working with some of the Medicaid population, Homberger adds.
For instance, when a member has diabetes, the case manager calls him or her on the telephone to ask the blood sugar level. If the member hasn’t checked, the case manager stays on the telephone while he or she does check and praises the member for taking care of his or her health.
"We may have to call daily for a while to get the member to buy into the program. This lets the member know that someone is interested in them and in their condition," she says.
References
- America’s Health Insurance Plans. Innovations in Medicaid Managed Care. Available on-line at www.ahipresearch.org/pdfs/InvMedicaidMCare05.pdf.
- The Lewin Group. Comparative Evaluation of Pennsylvania’s Health Choices Program and Fee-for-Service Programs. Available on-line at www.lewin.com/Lewin_Publications/Medicaid_and_S-CHIP/default.htm.
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