Legislator Learning Collaborative: State Medicaid Innovations

In the fall 2019, United States of Care launched a Legislator Learning Collaborative (LLC) to convene lawmakers around the country to learn from each other’s experiences and leverage the knowledge of USofCare’s extensive expert network to inform state-level health reforms. The LLC includes quarterly conference calls and webinars on topical health care issues, with additional opportunities for information-sharing and collaboration.  Our first LLC webinar focused on State Innovations in Medicaid. The complete powerpoint presentation can be found here.  Keep reading for the highlights from the webinar featuring USofCare’s Policy Fellows Jason Helgerson, former Medicaid Director for New York and Wisconsin, and John McCarthy, former Medicaid Director for Ohio and Washington DC.

The Legislator Learning Collaborative is a blog series that will focus on a variety of  health care issues to inform state-level health reform efforts and utilize USofCare’s extensive network of experts to discuss policies that state legislators can implement to reduce costs, increase access, and improve health care across the country. The first legislator learning collaborative blog will focus on four different state Medicaid innovations. 

Listen to the presentation and view the slides here.

State Medicaid Innovations

Effective and impactful state Medicaid programs are not all alike and “good ideas” don’t work in all states. A lot of innovative ideas heavily focus on adding additional resources to a project, but not all big ideas require additional capital to be successful and the best solution can be improving upon what already exists. We found that specific ideas are more likely to get implemented than vague problems are to get fixed.

Social Determinants of Health

Social determinants of health (SDOH) are conditions in our environments that affect a wide range of health, functioning, and quality-of-life outcomes and risks. States have taken steps to address social determinants of health, such as access to housing, food, and education, to improve health outcomes, but progress has been slow. In an effort to accelerate efforts to address underlying SDOH, states can set minimum threshold spending requirements on social determinants of health efforts in Medicaid managed care contracts. States can also require health insurers to submit and implement plans to address the social determinants of health by committing a percentage of premiums to address underlying social determinants of health.

Through an 1115 waiver, North Carolina has committed to addressing the social determinants of health by allocating up to $650 million in Medicaid funding to Healthy Opportunities pilot programs.  These pilots can cover services that address housing, food, or transportation needs, and services and programs that address interpersonal violence and toxic stress.   

New York has also taken steps to address social determinants of health by creating a dedicated bureau within their Medicaid agency. The bureau requires all advanced value based payment contracts to include community-based organization partners who address social determinants of health. For example, the Housing is Health program through a regional New York health plan provides housing interventions, including intensive support to obtain safe and affordable housing, for those with chronic conditions.

Value Based Payments

As the largest health insurer in many states, Medicaid programs are able to drive significant changes to the healthcare system. One of these changes is transitioning from a fee-for-service payment model to value based payments. This shift will incentivize clinicians to focus on patient health outcomes rather than patient volume. 

Currently, states have taken two different approaches to encourage the switch to value based payments.

1. Design alternative payment models and require all providers to be paid in that manner in both fee-for-service and managed care. A few states use this method.
2. Require managed care plans to implement value based payment models. A majority of states use this method.

An example of a successful value based payments model is New York’s 1115 Medicaid waiver. New York is required to move 80% of all provider payments to value-based payments by 2020. Plans and providers are offered a menu of  “value-based” choices, based on state and the Centers for Medicare and Medicaid Services (CMS) guidelines, and if plans fail to hit targets they will be penalized. 

Ohio also implemented successful value based payment models — Patient Centered Medical Homes (Ohio CPC) and episodic payments — that have reduced costs and improved quality. The CPC and Episodes models represent more than 90% of the Medicaid population and has improved Ohio’s health delivery system since their implementation. In 2017, quality performance improved by 2.1% and reduced costs by over $121million.

First 1K Days Initiative

New York and a number of other states have launched the first thousand days initiative, which utilizes Medicaid resources, including value based payments to improve the health and development of New York’s infants and toddlers — during their first 1,000 days of life. Many states’ programs rarely focus on this population’s health care because it generally doesn’t cost as much. However, increased attention to this age group can improve birth outcomes and school readiness, especially for complex families. Currently, over 50 percent of infants and toddlers spend a portion of their lives on Medicaid. Stakeholder groups have created programs, such as home visiting, group-based prenatal care and reach out and read early literacy programs, to enhance access to care and improve outcomes for the youngest Medicaid enrollees.

Justice-Involved Individuals

Many people released from jail or prison have multiple chronic conditions, substance use disorders, and mental health conditions and qualify for Medicaid. In an effort to increase and ensure currently and formerly incarcerated individuals have access to and are receiving needed health care services, states are adapting their Medicaid programs to fit the needs of justice-involved individuals.

States are pursuing policies to help individuals who are being released from incarceration. Many individuals coming out of incarceration are eligible to enroll in Medicaid. States are providing enrollment support to help enroll these eligible individuals in coverage and are also providing case and care management to individuals prior to release to help ease the transition back into society. These case managers better enable continued care to be provided by setting up necessary appointments with providers ensuring prescriptions are available post release.

States have options for those currently incarcerated as well. Many states are now suspending, rather than terminating, Medicaid eligibility during a person’s incarceration to allow people to more easily re-enroll in coverage once they are released from incarceration. Further, while nothing prohibits incarcerated individuals from being enrolled in Medicaid, states are not able to claim federal matching funds for those individuals unless they receive inpatient services outside the prison or jail during their period of incarceration. 

The efforts of Medicaid programs are showing positive impacts on justice-involved individuals. In Ohio, over 94% of people going through the prerelease program who had a primary opioid use disorder diagnosis received one or more types of treatment. Additionally, 86% of people going through the prerelease program with a primary congestive heart failure diagnosis received congestive heart failure medication in 2016-2017. And in Connecticut, individuals who were enrolled in Medicaid prior to release connected to outpatient care more quickly than those that were not.

These innovations in state Medicaid programs demonstrate that creative approaches to administering Medicaid can have long-lasting and beneficial health outcomes for individuals. States are leading the way to better serve their Medicaid recipients with existing resources.     

About the Legislator Learning Collaborative:

Launched fall 2019, the Legislator Learning Collaborative (LLC) is designed to bring lawmakers across the country together to learn from each other’s experiences and leverage the knowledge of USofCare’s extensive expert network to inform state-level health reforms. The LLC will include quarterly conference calls and webinars on topical health care issues, with additional opportunities for information-sharing and collaboration.  Future topics may include: 

• Navigating health and human services budget constraints
• Rising prescription drug prices
• Mental health parity and access to mental health care/addiction services
• Addressing provider shortages through telehealth and scope of practice policy
• Promoting economic mobility and self-sufficiency
• Challenges and solutions unique to rural America

If you are a legislator and interested in participating in upcoming Legislator Learning Collaborative webinars or for more information about any of these ideas or support/technical assistance to propose and implement them in your state, contact USofCare at [email protected].  

By Jason Helgerson, Former Medicaid Director for New York and Wisconsin & John McCarthy, Medicaid Director for Ohio and Washington DC