“Medicaid. In many doctors’ offices and health systems across the country, it’s code for medically challenging, socially complex, costly, and under-reimbursed,” says Sachin Jain, President and Chief Executive Officer for CareMore Health System. “The very mention of Medicaid draws shrugs and in some cases a fast sprint in the other direction.”
But when CareMore was approached by its sister company, AmeriGroup, to build a new model for managing Medicaid patients, they embraced the opportunity. In just 2 years, CareMore has served more than 20,000 Medicaid individuals in Iowa and Tennessee. The organization continues to rapidly evolve its Medicaid care model based on lessons they’ve learned along the way.
Lesson 1: deliberate people and culture. “You simply can’t build a Medicaid model of care with people who don’t want to take care of complex patients with socioeconomically challenging circumstances,” says Jain.
Instead, you need medical professionals who are driven by a commitment to work with society’s most vulnerable populations. “These are leaders who see their work as being grounded in something bigger than themselves. And you need that, because this certainly isn’t work for the faint of heart,” says Jain. “Everyone talks about a culture of caring, but building it, and more importantly, sustaining it, is hard work that must be approached with all deliberateness. There isn’t a population of patients who needs it more.”
Lesson 2: payer and provider marriage. CareMore is both the health plan and the provider organization for its Medicare and Medicaid patients. In close alignment with AmeriGroup, the organization works to prevent avoidable hospitalizations and chronic disease catastrophic events, and it sometimes brings care to patients rather than waiting for patients to come to them.
In Des Moines and in Memphis, for example, CareMore’s outreach teams regularly knock on patients’ doors to invite them to come to their offices. And when a patient lives too far from a care center to travel, they’ll send a doctor to the patient’s home. “This marriage of payer and provider means that you’re willing to invest resources, both time and money, to go above and beyond what is customary to take better care of patients and manage costs out of our system,” Jain says.
Lesson 3: designing for purpose. “In health care, we’ve adopted the egalitarian ideal that everyone should be treated equally. But patients with more intense resource needs require a different, more intensive health care system than other kinds of patients,” Jain says. When CareMore began its new Medicaid care model, they initially tried to retrofit much of what they did for high-cost, high-need Medicare patients. Some of that retrofitting succeeded, but some did not.
“Working with the Medicaid population has reminded us that there’s a necessary exercise in continuously redesigning care to fit the needs of the specific population that you’re serving,” says Jain. For example, 9–5 office hours typically work well for Medicare patients, but they don’t for Medicaid patients, who often can only seek care before or after work and end up at the emergency room where no appointments are required. Recognizing this, CareMore now enables open-access scheduling for same-day walk-in appointments and extended office hours.
“I do believe that we can transform Medicaid from a stepchild in the health care delivery system to a foundational building block of American health care delivery,” says Jain.
From the NEJM Catalyst event New Risk, New Business Models held in Boston, October 6, 2016.