Recognizing the Need for Medicaid Reform

Recommendations for Reforming Medicaid from JAMA Forum article which can be located at https://newsatjama.jama.com/2017/07/11/jama-forum-reforming-medicaid/

Summary 

Medicaid program was originally passed by Congress in 1965 and now serves more than 70 million people in 4 categories: children and mothers, seniors in nursing homes and community-based settings, people living with disabilities, and low-income people of all ages. As much as 70% of the program’s resources are devoted to people who have disabilities or live in nursing homes. However, most Medicaid beneficiaries are children and mothers and, after passage of the ACA, low-income adults and families. A state-federal partnership, Medicaid policies are driven at the state level through waivers and State Plan Amendments submitted to the federal government.

Policy Recommendations for Reforming Medicaid

  • Making Medicaid a more outcomes-based program. Metrics such as the early diagnosis of illness, incidence of low-birth-weight infants, maternal mortality, and the efficiency of care delivered could form the basis of such measures. 

  • Improving Medicaid financing. Too much funding comes from large supplemental pools (such as Medicaid disproportionate share hospital [DSH] payments and uncompensated care pools) that go to states. These pools decrease accountability because they are allocated without regard to patient care or even the numbers of people treated. Finally, we support financing strategies that would encourage investments in the social determinants of health, which are the cause of so many health disparities and undesirable outcomes.

  • Ensuring proper access to care.  Nationally there is appropriate concern about access to specialists and home-based and community-based services, which varies broadly by state and is of concern in rural areas and where reimbursement rates are too low. Eliminating nonaccountable pools of funding would allow states to improve their reimbursement rates to specialists and help to expand access.

  • Investing in a data, technology, and analytics infrastructure. For Medicaid to deliver on its potential, the program needs to use best practices in home-based and community-based care and other programs that use social workers, home care attendants, and other resources to keep families together, coordinate care, and allow people to be treated in the most comfortable, cost-efficient settings

  • Coordinating programs for dual-eligible beneficiaries (who qualify for both Medicaid and Medicare) and other populations. There are growing, expensive populations that do not fully benefit from investments in care coordination commonly used in the private sector.

  • Reducing administrative burden on states and allowing for more rapid innovation. Medicaid is a highly flexible program, with a variety of different approaches designed to serve the frail elderly, provide substance abuse treatment, create innovative payment approaches, and capitalize on mobile technology. We support the ability of states to innovate more rapidly through thoughtful reform of the waiver process and the process of submitting State Plan Amendments

GHHI’s Push for Medicaid Policy Change

After reading the JAMA Forum article summarized above it occurred to us that GHHI has been actively working to achieve these Medicaid reform recommendations from its inception. From the outset GHHI has set as one of its organizational goals to change policies within states and at the federal level to allow for Medicaid payments to reimburse for the provision of in-home environmental management services.

Along the way GHHI has learned to achieve the vision of reimbursement for comprehensive environmental management services, which combine both in-home environmental health education, comprehensive environmental assessment and remediation of triggers, requires a collective impact approach. The Collective Impact approach is premised on the belief that no single policy, government department, organization or program can tackle or solve the increasingly complex social problems that are underlying factors. The approach calls for multiple organizations or entities from housing, education, energy and health sectors, to form a common agenda, shared measurement and alignment of effort.

Our recent Pay For Success grants activities, funded by Corporation for National and Community Services the JPB Foundation, and the Robert Wood Johnson Foundation, has focused on providing business development support for asthma programs in eleven cities across the country.  Through these ongoing projects and future collaborations we are working to increase the number of in-home asthma programs that target “high utilizers” in low-income communities, and ensure they all provide comprehensive indoor environmental management services to reduce asthma triggers which are eligible for Medicaid reimbursement.

GHHI’s National Asthma Campaign Aligns with Expert Recommendations to Reform Medicaid

  • Making Medicaid a more outcomes-based program. GHHI is working to establish Environmental Management & Health Outcomes Metrics for Evaluation (EMHOME) which will include environmental management measures (housing characteristics, hazards identified, services provided) and outcome metrics (asthma control, quality of life, healthcare utilization and costs) to demonstrate efficacy and return on investment. 

  • Improving Medicaid financing. GHHI has explored numerous alternative payment methods that could allow for reimbursement including 1115 waivers, value-based payments, bundled payments, administrative billing as well as incorporating private capital through pay for success.

  • Ensuring proper access to care.  Medicaid service delivery reform has the potential to protect vulnerable populations with asthma by establishing effective state policies which incentivize coordination of services among traditional and non-medical providers. Use of community health workers can improve access to asthma care management services within the home.

  • Investing in a data, technology, and analytics infrastructure. Cost benefit analysis that relies on actuarial analysis of Medicaid claims data is key to identify the target populations and potential return on investment. Secure data sharing between sectors is necessary to identify, recruit and coordinate clinical and home-based services to “high utilizers” within asthmatic populations.

  • Reducing administrative burden on states and allowing for more rapid innovation. Strategic partnerships between MCOs/ACOs and service providers that facilitate innovative payment structures, such as value-based payments, can drive policy change at the state‘s direction without increasing administrative burden on states.

  • Coordinating programs for dual-eligible beneficiaries (who qualify for both Medicaid and Medicare) and other populations. GHHI has not directly worked on this recommendation but sees the value especially related to home interventions to prevent falls in older adults.

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