A lot of things are happening these days when it comes to care delivery for Medicaid beneficiaries, as state Medicaid programs are increasingly taking advantage of federal rules that allow them the flexibility to facilitate changes in the ways in which beneficiaries receive care and care management. As a 2018 “explainer” from the New York City-based Commonwealth Fund explains it, “Medicaid grants states autonomy in how they run their programs. Under a provision of the Social Security Act, Section 1115, the U.S. Secretary of Health and Human Services (HHS) can waive federal guidelines on Medicaid to allow states to pilot and evaluate innovative approaches to serving beneficiaries. The Centers for Medicare and Medicaid Services (CMS), a government agency, reviews each waiver application to ensure not only that it furthers the core objective of Medicaid — to meet the health needs of low-income and vulnerable populations — but also that the proposed demonstration does not require the federal government to spend more on the state’s Medicaid program than it otherwise would.”
The most innovative states are moving forward with alacrity. Among them, as Senior Contributing Editor David Raths wrote in November of last year, “The State of Oregon is developing ambitious plans to create value-based global budgets for managed care organizations that will better drive investments in health equity…. Oregon is requesting authority to create coordinated care organization (CCO) value-based global budgets that will better drive investments in health equity, incentivize spending on health-related services, and be developed to cover all reasonable, appropriate costs of running the CCO program while increasing at a predictable growth rate in line with the state’s cost growth target.” The waiver renewal application was submitted on Feb. 22 of this year, and “If approved the application will sharpen the focus of Oregon’s Medicaid program, also known as the Oregon Health Plan (OHP), towards achieving health equity,” Oregon Medicaid officials stated.
Indeed, the shift to a focus on whole-person care has actually been developed since 2016 as formal concept in California, where Medicaid is known as Medi-Cal. As that state’s Medi-Cal program states on its website, “The overarching goal of the Whole Person Care (WPC) Pilots is the coordination of health, behavioral health, and social services, as applicable, in a patient-centered manner with the goals of improved beneficiary health and wellbeing through more efficient and effective use of resources.”
In an issue brief sponsored by the Kaiser Family Foundation and published on March 17, Michelle Tong and Elizabeth Hinton provided readers with a detailed analysis of the WPC program, whose pilots began back in 2016. As those two researchers wrote in March, “WPC pilots demonstrated improvements in select health utilization and outcomes, care coordination, and delivery of housing services.” Analyses have shown that “WPC pilots improved rates of follow-up after hospitalization for mental illness, initiation and engagement in alcohol and drug dependence treatment, and timely provision of comprehensive care plans and suicide risk assessments. The interim evaluation found that emergency department (ED) visit rates from WPC Pilot Year 1 to Pilot Year 2 decreased by 19 percent for WPC enrollees and 8 percent for the control group, a significantly larger decrease for the WPC enrollees, although analysis of pre-WPC enrollment compared to post-enrollment ED visit rates found no difference for both groups.” The authors note that a significant number of “[S]tates are expanding benefits such as community-based mobile crisis intervention services and screening, expanding the use of telehealth for behavioral health, and using managed care organizations to deliver services. In addition to California, Colorado, Massachusetts, Montana, and Washington are advancing broad behavioral health initiatives spanning many areas. Key lessons from California to date show that such initiatives require integrated data systems, adequate funding streams, and multi-sector provider partnerships to coordinate services.”
A broad shift—in recognition of the need to address health holistically
What do these various developments mean? “There is a clear realization, and has become more prevalent after COVID, that if you want to really impact the quality of life and enable people having a healthy life, that’s influenced by things like access to stable housing, healthy food, safe neighborhoods, transportation, good education,” says Sandeep Sabharwal, a managing partner and board member at the Naperville, Ill.-based Impact Advisors consulting firm. Sabharwal has been consulting around payer-provider issues for nearly 20 years. “Medicaid provides coverage for 1 of every 7 adults and 1 of every 2 children in the US and is the largest payer from the low-income population; so by definition, it is the largest payer serving those impacted by the social determinants of health. And as states are pivoting more towards value-based care, it’s their intent to improve the overall health of the beneficiaries and drive value—which means they will have to start integrating different strategies.”
What are some of the practical steps that Medicaid officials are taking right now? “Quite a few of them,” Sabharwal says. Indeed, he reports, “We did an analysis six months ago of 40 states, and found that 90 percent of those contracts include at least one contractual requirement related to the social determinants of health. And they’re most common in the area of care management; so it’s becoming a norm for MCOs to screen for SDOH, have them refer to social services, and even coordinate with state and federal programs. Second, in terms of staffing and the workforce, a majority of states with Medicaid managed care contracts, they’re requiring the MCOs [managed care organizations] to hire a housing specialist onto staff, and include staff who speak different languages; and also hire digitally native people to help drive social determinant adoption.”
What’s more, Sabharwal says, Data and analytics will be at the absolute center of all this activity, as the data will facilitate so much advancement in this area. “Different states are leveraging these 1115 waivers to develop SDOH-focused models; Delaware and Virginia, are examples,” he says.
Lita Willis, Commissioner in the Cleveland Health Department’s Division of Health Equity and Social Justice, says, “It’s very obvious why it’s so important” to shift towards the concept of whole-person care management. “But as providers, sometimes we can get caught up in, we only have so much time. We’ve been talking about this for years, and then after the murder of George Floyd in May 2020,” she says, a broad commitment to addressing social issues became cemented, and “these things are now on the records, on the books. So folks are saying, you’ve made this declaration, what’s next? And the City of Cleveland was very astute: they stood up a community coalition and also this division of health equity and social justice.”
Karen Amstutz, M.D., chief medical officer at the Philadelphia-based AmeriHealth Caritas health plan, which offers Medicaid plans in eight states and the District of Columbia, says that “The pandemic illustrated this: that health is driven by more than just access to care. Medicaid directors at the state level really are concerned about the whole person, and in that context, they’re thinking about the 80 percent of health not directly related to medical care.”
One example of the progress being made, Dr. Amstutz says, is the advances taking place in the Gravity Project, a public initiative whose partners are working to “develop data and exchange standards to represent patient level social determinants of health [SDOH] data documented across four clinical activities: screening, assessment/diagnosis, goal setting, and treatment/interventions.” Progress in that area, she says, “has everything in common with structured information on the EHR [electronic health record] side. We have to develop similar data standards and taxonomy for the information. AmeriHealth Caritas is very involved in the Gravity Project; as Amstutz emphasizes, there are terminology issues to resolve, which encompass SDOH data to be turned into coded information; and also technical issues to work out, around FHIR-based harmonization. The SDOH domains are already well-developed, with six of the ten SDOH domains about 70-percent complete, she reports.
Meanwhile, Amstutz underscores that, at AmeriHealth Caritas, whose focus encompasses Medicaid, CHIP (Children’s Health Insurance Plan), and Medicare members, “Our focus begins the minute we’re meeting a member, whether through a call center, a care manager, or a community connector. We try to make sure that we’re assessing both that member’s health needs and their social determinants of health—do they have a stable living situation, stable food, income? We really have a big focus on making sure we understand and have information.” And, she says, What I would want providers to know is that we’re each bringing strengths to this conversation, as we switch to a more holistic approach to care. And collaborating around workflow will be important; with regard to strategic IT, we’re seeing solutions being developed to address connectivity. Providers, health plans, and community-based organizations—we’re all committed to building that ecosystem” of data and information to support the whole person.
