Provisions in the Affordable Care Act have expanded health care access to millions of previously uninsured Americans. In many states, the largest coverage gains have come from expansions of state Medicaid programs. Notwithstanding the benefits of expanded coverage on access and self-reported health, the Medicaid program — now the largest insurer in the country — remains rich with opportunities to ensure that all Medicaid beneficiaries receive high-value, coordinated care.
To embark on this path, many have launched new payment arrangements or expanded the use of existing alternative payment structures (such as managed care organizations) to promote the development of delivery models that improve the value of care delivered to Medicaid populations. The growth of these arrangements represents a substantial opportunity to redesign care for the vulnerable populations that need it most.
For example, CareMore Health System — a physician-founded and physician-led care delivery system and health plan based in Southern California — saw the expansion of Medicaid as a catalyst to develop new integrated care models for Medicaid beneficiaries. CareMore, a subsidiary of Anthem, previously served only senior populations through Medicare Advantage plans. The decision to expand into Medicaid was motivated by the recognition that CareMore’s organizational culture and care delivery strategy was already optimized for at-risk patients with complex medical and social circumstances.
CareMore began providing comprehensive health care services to Medicaid beneficiaries in 2014 under managed Medicaid plans operated by Amerigroup, also a subsidiary of Anthem. Under these arrangements, CareMore operates as a managed Medicaid provider — receiving capitated, per-member per-month prepayments for a population of patients and then bearing responsibility for providing all related health and wellness services. CareMore serves approximately 12,000 Medicaid patients in Memphis, Tennessee, and approximately 7,000 Medicaid patients in Des Moines, Iowa, with comprehensive services.
As CareMore clinicians and leaders worked to adapt a clinical delivery model designed for the needs of frail elders to new Medicaid enrollees, three early and important lessons have emerged:
1. New Means of Patient Engagement. The first priority was engaging patients who are passively enrolled. Amerigroup assigned a subset of new Medicaid enrollees to CareMore’s primary care group for comprehensive services. This was in contrast to CareMore’s traditional Medicare Advantage business, wherein the CareMore model was marketed directly to seniors who made active enrollment selections. Passive enrollment requires new capabilities and processes for contacting patients, teaching them about the CareMore clinical model, educating them about their health care benefits, and encouraging them to visit CareMore Care Centers for comprehensive “Healthy Start” visits. As a result, CareMore has developed strategies to identify high-risk patients from multiple data sources and engage patients via in-person outreach by care navigators. In a recent example, in-person outreach produced a 25% contact rate (20 of 80 attempts) at the homes of previously unreached patients, and 100% of those contacted scheduled an initial primary care visit. These approaches may be useful for other managed Medicaid plans and providers, as well as those targeting dually eligible Medicare-Medicaid beneficiaries, many of whom are also passively enrolled.
The second priority for patient engagement involves building literacy, trust, and engagement of new Medicaid enrollees in the broader health care system. As opposed to seniors — many of whom have lived with chronic disease and enjoyed access to health care for decades — many new Medicaid enrollees have felt marginalized by the current health care system. The result is a sense of distrust and disengagement that can hamper engagement efforts. To address this, CareMore builds partnerships with community organizations such as housing agencies and faith-based organizations. CareMore also integrates convenient access to other much-needed services, such as food, pharmacy, and transportation, to create “one-stop” shopping for patients. Delivering the best care to Medicaid beneficiaries often requires educating them about the benefits of preventive care and disease management, and fostering the development of trusting relationships with clinicians where they feel comfortable sharing the entire picture of their health.
2. Shifting Care Away from the ED. Many new Medicaid enrollees are accustomed to using the emergency department (ED) for any and all health care needs. Furthermore, Medicaid beneficiaries often hold multiple jobs and have child care responsibilities that make it difficult to access care during traditional outpatient hours. What results is continued use of the ED even after gaining Medicaid coverage. In Tennessee and Iowa, new Medicaid enrollees in CareMore’s primary care group were initially using the ED at very high rates. To provide care in the most efficient, effective, and convenient locations, CareMore has opened four Care Centers in the neighborhoods where many new Medicaid beneficiaries live and work. To better accommodate beneficiaries’ busy schedules, the Care Centers offer extended hours (7 a.m. to 7 p.m.), weekend appointments, and open access scheduling. Early data suggests CareMore patients have lower 30-day readmission rates (11% vs. 20% in Iowa) and inpatient utilization (lower inpatient bed-days at hospitals CareMore extensivists attend at).
3. Giving Primacy to Behavioral Health. Medicaid patients are disproportionately affected by behavioral health conditions including depression, anxiety, substance use, and schizophrenia. These conditions result in substantial morbidity and complicate patients’ ability to manage co-morbid conditions, such as diabetes and heart disease, leading to poor outcomes and high costs. For new Medicaid enrollees, years of poor health care access can lead to high rates of under-diagnosis and inadequate treatment.
CareMore has developed universal screening protocols to better identify behavioral health conditions among new Medicaid enrollees. In Iowa, the team found that nearly 80% of behavioral health patients have co-morbid serious mental illness and substance abuse disorders. But merely identifying behavioral health conditions is not enough. Behavioral health care in Medicaid — where carve-outs are the norm — is notoriously fragmented and ineffective. To address these limitations, CareMore Care Centers allow patients with behavioral health needs to access a co-located ecosystem of treatment options — therapists, psychiatrists, social workers, and group therapy. As a result, almost 40% of Care Center visits are now for behavioral health services, with early results showing that the majority (74%) also receive primary care and other services at the Care Center.
Notwithstanding these necessary and important adjustments, certain aspects of CareMore’s approach to caring for frail elders were readily transferrable to the Medicaid population. These include:
High-Touch Care for High-Risk Patients. The CareMore clinical model was developed and refined to provide high-touch, integrated care for frail elderly patients. At the core of the model are neighborhood care centers that strengthen primary care networks by co-locating preventive and routine services; disease management programs to improve care for chronic conditions; and the use of extensivist physicians to improve care continuity across hospital and community settings. This model of care delivery is equally effective in a Medicaid population where high-risk, high-cost patients also have multiple chronic conditions and complex care needs. In one example, a homeless patient with serious mental illness was unable to take his medications safely and reliably. The CareMore team was able to engage him in primary and behavioral health care, arrange for safe housing and transportation, and develop a medication regimen he felt comfortable with.
Going Beyond Acute Care. CareMore was founded to provide care for frail elders poorly served by prevailing delivery models. As a clinician-founded and clinician-led health system, there has always been a focus on thinking creatively and stretching the limits of the system to do what is right for patients. This may include buying an air conditioner for a senior during the warm California months or providing a safe place for homeless patients to keep key belongings. Given the challenges with trust and engagement for new Medicaid enrollees, this culture has been especially helpful in building strong therapeutic relationships with Medicaid beneficiaries in Tennessee and Iowa.
Ultimately, these core elements formed a care delivery chassis upon which necessary additions and alterations could be made to serve a new, complex, and high-need population. At times, the transition has been challenging. New Medicaid enrollees are a diverse population, often with unmet health care needs. But precisely for that reason, it is essential to develop new and innovative delivery models that take advantage of evolving payment models. Expanding coverage will fail to reach its full potential if new enrollees are funneled into a broken delivery system.
Acknowledgments: Alicia Steele Smith, Amberly Molosky, Leeba Lessin, Al King, and Edna Willingham.