Managing the Future of Medicaid.

Opinion VIEWPOINT Andrew B. Bindman, MD Departments of Medicine and Epidemiology and Biostatistics, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Corresponding Author: Andrew B. Bindman, MD, Departments of Medicine and Epidemiology and Biostatistics, Philip R. Lee Institute for Health Policy Studies, 3333 California St, Ste 265, University of California, San Francisco, San Francisco, CA 94143 (andrew.bindman @ucsf.edu). jama.com Managing the Future of Medicaid During the past 50 years, Medicaid has improved health and saved lives among the millions of people in the United States who otherwise would have been uninsured. 1,2 Given the high level of medical need among the increasing number of people who rely on Medicaid for health care coverage, there is a social responsibility to maximize the value of the available resources. States have developed strategies to contain Med- icaid costs for their enrolled populations; however, these approaches tend to be counterproductive to the goals of providing high-value health care. For example, most states have set physician payment rates for Medicaid be- low rates paid by private insurers and by Medicare. Low payment rates reduce physicians’ participation in Med- icaid and undermine beneficiaries’ access to care. 3 Some states have created administrative barriers to enrollment in Medicaid by requiring individuals to com- plete complicated forms and to frequently demon- strate that they are eligible for re-enrollment. Barriers to enrollment result in disruptions in coverage, which are associated with subsequent expenses related to in- creased rates of preventable hospitalizations. 4 Although these counterproductive, short-term bud- get-cutting maneuvers have enabled Medicaid to sur- vive over the past 50 years, these approaches are not a sustainable strategy for the program in an environ- ment in which the public and policy makers expect greater demonstrated value. Medicaid’s future re- quires a transformation in how it delivers services to ob- tain a higher return, measured as health care quality and outcomes, for its investment. Medicaid has enormous assets to make this possible, but they need to be devel- oped to create a health care system that is made more efficient through population health management. Population health management uses automated and updated information to support the systematic evalua- tion and addressing of the preventive and chronic care needs of a group of patients. The goal is to maximize these patients’ health while minimizing their health care expenditures. This typically means reducing the need for emergency department visits, hospitalizations, and high- cost procedures and imaging studies. Medicaid faces a challenge in creating an integrated, more efficient delivery system, but it has the advantage of having clinicians who share an interest and often an orga- nizational mission to care for the underserved. Although thesevaluesalonearenotenoughtoensurebestpractices, they are a valuable starting place for engaging Medicaid cli- nicians to pursue a shared approach to care. This opportu- nity requires organizational leadership to establish priori- ties and expectations for achieving goals. The opportunity is squandered when Medicaid programs offer payment rates that are so far below those of other payers that clini- ciansarediscouragedfromparticipatingintheprogramand are made to feel that their contributions are not valued. Medicaid has the ability to innovate through state and local variation. State Medicaid programs can use state plan amendments, waivers, and other legal au- thorities to try new approaches. For example, this is the basis for differences across states in payment ap- proaches and in the availability of optional benefits, such as home- and community-based service programs as an alternative to nursing facility care. State variation provides an opportunity to learn from natural experiments but is an underdeveloped resource. Therehasbeenaninsufficientefforttosystematicallylearn fromthisvariationandtodevelopstrategiestorapidlyscale upthebestideasacrossstates.Evenwithinstates,thereare missed opportunities to study innovative practice ap- proaches and to align policies to support and expand suc- cessful strategies to have a broader influence. As a result, successes such as the use of care coordination to reduce hospitalizations among high users of emergency services in Camden, New Jersey, are slow to spread among Medic- aid clinicians within the state and across state lines. 5 Data are critical to support this learning process and to support the implementation of the most successful strategies. State Medicaid programs have enrollment, claims, encounter, long-term care assessment, and other data, which could be used for rapid cycle evaluation and to characterize the population’s needs to support a pro- cess of systematically aligning Medicaid’s resources with beneficiaries’ needs to maximize efficiency. While the opportunity exists to use Medicaid’s data as the basis of a population management strategy, sev- eral steps are needed to turn this potential into a reality. Data collection needs to become comprehensive, timely, and accurate using standards and definitions that are con- sistent within and across state programs. Medicaid needs to develop reproducible methods for combining its dif- ferent sources of data and for potentially linking these data with other state and federal data to create robust assessments of its beneficiaries. The integrated data need to be turned into actionable information using standard- ized performance metrics and disseminated to those who can act based on the information. For example, health in- formation exchange with practitioners, such as those working in emergency departments, could enhance their overall understanding of a beneficiary’s needs and sup- port decision making. More efficient sharing of data with researchers and other stakeholders could support rapid cycle evaluation of new programs and potentially lead to discoveries of unrecognized patterns of care, which could become the focus of improvement efforts. This ap- proach of using data to improve care is being used in some integrated delivery systems. 6 The Centers for Medicare & Medicaid Services (CMS) is investing in a data strategy to pursue these goals, which if successful would allow CMS to help state Medicaid pro- grams to make better use of their own data and to cre- (Reprinted) JAMA July 28, 2015 Volume 314, Number 4 Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/934258/ by a UCSF LIBRARY User on 05/10/2017