21 Mar How Medicaid Can Be A Platform for Sustainable Health & Social Change
A recent policy brief (pdf) by a Georgetown University think tank makes the case for policymakers and advocates to look more closely at the Medicaid program’s untapped potential to address the social determinants of health (SDOH.)
Experts of all stripes have been studying the economic and clinical linkages between social, economic and environmental factors and health, they point out, but the wealth of evidence hasn’t corresponded with same degree of action at most health systems or agencies. In the public health innovation game, we call this the “research to practice gap.”
The paper serves as a great primer of the numerous channels to try and address SDOH within the Medicaid program. For those interested in strategic innovation opportunities within this $565b+ market, it also affords a trove of topic areas to explore. What follows is three of our top takeaways — As always, we’d encourage anyone interested in SDOH to read the original report.
1. SDOH supports are built into the structure of the Medicaid program
States have the prerogative to apply for funding waivers, state plan amendments, or other optional benefit programs. Other channels to fund SDOH programs are often buried within a grab-bag of hot topic areas from yesteryear: case management services, targeted care management and/or disease management programs, health homes, and so on. These are a far cry from the shiny, cash-laden incentive programs that have defined traditional federal-led reforms (i.e. Meaningful Use) — they’re smaller, less-defined, and hyper-local in nature.
This may not be enough to interest the swaths of industry opportunists looking for a red carpet into the market, and that’s fine. The transition to value-based care is proving to be more of an ultra-marathon than a 5k, with a variety of shared savings models funding experimental social support demos differently. For those with the patience and determination to explore these emerging issues, “Where can I find an example of X topic, done by Y payer” is a far more useful question for discussion than, “Are we there yet?”
The Appendix details over half a dozen state-level examples of Medicaid program reforms that include clinical level reforms (tying in case management for pregnant women in MI), improvements to risk analysis (extra social services funding for patients in ‘high stress score’ neighborhoods in MA), and several integrations into childhood education (Oregon and New York).
2. Seeing opportunities for Medicaid’s ‘invisible children’
In the first adoption phase of value-based care, quality improvement programs have tended to target high-risk, high-cost patient populations in an effort to hit performance benchmarks. Typically, this has meant focusing on adults, not children, which might help to explain why children on Medicaid receive lower rates of very basic primary care services, like vaccination (the exception here tends to be high cost children, such as those with special needs or disabilities.)
Fortunately, there is a pediatric program that enjoys a broad mandate under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Despite the sneezy acronym, the program mandates support for a long list of childhood social factors, from lead screenings to dental coverage, without requiring states to apply for waiver funding.
As healthcare systems move upstream of high-cost, high-intensity care, some states continue to grapple philsophically with whether Medicaid is at heart a program for health insurance or welfare. Yet through this uncertainty, children’s health in the safety net is steadily gaining momentum as an important focus area nearly everyone can get behind. States like Maine and New York are integrating into programs for food security and educational preparedness, while cities like Baltimore have tapped into state funding to reduce infant mortality through home screenings. Other examples abound, involving foster care, school lunches, counseling, asthma prevention, and more — have you got an interesting example to share?
3. Eligibility systems as a lever for social impact
Most states maintain separate systems to determine eligibility for Medicaid and other social programs, such food assistance through SNAP, specialized programs for the disabled, mentally ill, veterans, seniors, women, and so on. While some of these are digital, many are still paper-based, and nearly all are disconnected from each other. This burden too easily becomes a barrier to new and continued enrollment, as well as system efficiency, and it makes things needlessly complex for the very people these programs were designed to help.
Connecticut is one example of a state that’s taken a bold alternative approach. In 2012, fed up with ballooning managed care operational spend, CT decided to slash costs by running their own plan as a third party administrator at the state level. One benefit this has afforded them is the ability to screen for numerous social determinants as part of enrollment. Pennsylvania has also streamlined enrollment for Medicaid, CHIP, the state insurance exchange, and numerous safety net programs into a single site called COMPASS.
While streamlining benefits looks to become a popular topic as more states eye cost-savings opportunities, and startups develop solutions, this space remains as byzantine and regulated as you might expect — some good details and further reading in the report (page 5.)
And plenty more, too
Another tricky tangle in the evolution of SDOH strategy is the question of how to approach measurement, risk adjustment, and payment, three areas whose unifying thread is data. As we’ve seen in Minnesota, putting them all together in a statewide ACO program doesn’t happen with the flip of a switch. While the National Quality Forum has issued recommendations, measurement remains un-mandated, unstandardized, and mostly unpaid. Once again, this is not like the giant federal market opportunity enabled with the HITECH act; it’s finding progressive partners at hospitals, payers, state agencies, and other tech firms who are willing and able to tease apart this knot.
Other opportunities abound: multi-agency collaborations (between health departments and housing, corrective services, education, food shelters, and so on) referral directory tools, cross-sector impact investing, and more. States are all approaching the opportunities presented by Medicaid’s challenges differently, depending on their state’s politics and populations, as well as the unique tapestry of work being done by managed care organizations, provider systems, grant-funded demos, and more. It is true that some state leaders are driven by short-sighted political zeal in what they decide should or shouldn’t be funded. Yet there are just as many (if not more) examples of states who have taken a longer-term economic outlook, in some cases, despite their state’s macro political allegiances.
Innovation by definition involves making changes to the established order; Medicaid offers a smattering of laboratories where rules are being re-examined and fiddled with on a quickly moving timeline. This is creating a growing list of opportunities — unprecedented for the Medicaid program — for developing more responsive and proactive health programs, improving access to care at numerous administrative and clinical levels, reducing user frustration for vulnerable patients and families, and slowly uncovering potential for dramatic cost savings in the process.