Maximizing Medicaid-Public Health Partnerships

September 14, 2016|3:40 p.m.| Noelle Andrade and Emily Moore

Due to their shared focus on population health, Medicaid and public health agencies are natural partners and leaders in health system transformation. Medicaid is uniquely positioned to enhance public health efforts as it is the largest source of coverage for low income and vulnerable individuals who experience the greatest health disparities. Furthermore, state and local public health agencies have a wealth of experience in implementing evidence-based public health interventions, analyzing population health outcomes, and working collaboratively with the community. Together, Medicaid and public health agencies can improve clinical and population health outcomes, address health disparities, and reduce healthcare costs.

While public health and Medicaid already collaborate in some ways, new opportunities for expanded partnership have opened up due to widespread efforts to transform the way healthcare is paid for and delivered:

Data sharing. Electronic health records (EHRs) allow clinical data to be analyzed at various levels so that best medical practices can be identified and patient outcomes can be systematically analyzed and improved. Health information exchanges (HIEs) allow healthcare providers and patients to securely access and share a patient’s medical information electronically, enabling better coordination between providers and provision of more timely, safer, and cost-effective services. Funding for some state HIE activities is available through the Medicaid EHR Incentive Program. All payers claims databases (APCDs) are large-scale repositories of healthcare insurance claims and eligibility and provider files, regardless of billing source. APCDs support analyses of healthcare utilization, cost, and trends— information that consumers may use to compare value (for more information see ASTHO’s case study on New Hampshire’s APCD). Many states are also integrating clinical and public health data in order to better understand the needs of patients and their communities, particularly with the creation of accountable care organizations, health homes, and other models that focus on community-level outcomes.

Workforce. The increased use of community health aides from outside the traditional licensed medical workforce (e.g., community health workers, patient advocates/health navigators, peer wellness specialists, and doulas) can enhance workforce reach and effectiveness. States are using these kinds of health workers to increase access to care and reduce health disparities. They have been found to be a cost-effective strategy for both Medicaid and public health. Partnering with Medicaid to incorporate and reimburse these types of providers is one way to enhance preventive health services (e.g., nutrition education, chronic disease management, linkages to health system and social service resources, home visits, and patient advocacy)

Budgeting. Public health agencies can help Medicaid develop a fiscal analysis of potential prevention programs’ healthcare savings by providing data and expertise on what to cover. Demonstrating prevention programs’ return on investment can help identify population health initiatives that would achieve both economic and health impact, thereby enabling Medicaid programs to target appropriate program investments. This capacity also allows Medicaid agencies to be responsive and accountable to the many entities that provide program oversight, including legislatures. Conversely, state Medicaid agencies can assist public health agencies with budgeting by lending their actuaries, empowering health departments to better allocate resources to meet population needs.

Medicaid policy. Thanks to the Preventive Services Rule Change, states are expanding access for preventive services by enabling reimbursement for services provided by other practitioners, not only physicians or other licensed providers. Many state Medicaid agencies are covering high-yield nonmedical services under home- and community-based and flexible services options. Public health can help Medicaid determine the kinds of nonmedical services that should be covered. The CDC’s 6|18 Initiative targets six common and costly health conditions—tobacco use, high blood pressure, healthcare-associated infections, asthma, unintended pregnancies, and diabetes— and is currently working with states’ Medicaid and public health agencies to expand coverage, access, utilization, and quality through policy change.

Innovative payment and delivery models. Agencies may develop a model of care that reaches a mutual population of concern and ensures there are proper linkages to the full array of community-based services and supports. The health home model is one example of a coordinated care model that seeks to better manage chronic conditions for complex patients (e.g., dual eligibles, those with physical and behavioral comorbidities, etc.). Additionally, many states are now using Medicaid Managed Long Term Services and Supports through capitated Medicaid managed care programs as a strategy for expanding home and community-based services. The Centers for Medicare and Medicaid Services (CMS) launched state demonstrations in 2013 to test capitated and managed-fee-for-service models to integrate care and align financing for dual eligible beneficiaries.

Another initiative related to payment and delivery reform is the State Innovation Models Initiative from the Center for Medicare and Medicaid Innovation, which have been received by 34 states, three territories, and the District of Columbia in Round One and Two funding. Innovative payment models include modified versions of the fee-for-service model that enable states to transition from a volume-based model to a value-based reimbursement model, and are thus aligned to improve health and reduce costs.

Some Medicaid and public health agencies are exploring new ways to partner to address mutual health priorities by leveraging the tools and mechanisms in Medicaid managed care. Examples of these approaches include holding plans financially accountable for performance on population health metrics and working with plans to implement quality improvement projects that have mutual Medicaid and public health outcome goals. These policy changes can be implemented through changes in Medicaid managed care contracting or, for more significant reforms, through changes to their Medicaid State Plan Amendments or applying for CMS Waivers (e.g., Section 1115 Waivers or 1915(c) waivers in the case of many home- and community-based service programs). For example, Delivery System Reform Incentive Payment (DSRIP) initiatives are a type of Section 1115 waiver that can include sweeping payment and delivery system reforms (e.g., redesigning or expanding care management and transition models, creating integrated delivery systems, supporting regional health information exchange, and incentivizing providers to meet performance metrics such as reduced unnecessary emergency room usage or 30-day hospital readmissions). Many DSRIP waivers require or rely on enhanced partnerships between healthcare providers, public health agencies and social services.

Community engagement. Medicaid can support and participate in regional collaboration between local stakeholders (including local health departments) through community empowerment models (such as Community Advisory Councils and Regional Health Improvement Collaboratives), in which providers and payers are involved with local planning processes. Activities may include developing community health needs assessments and community health improvement plans, providing measurable outcomes and data sources, and identifying evidence-based interventions.

Medicaid can collaborate with public health departments to advocate for accessible transportation and more walkable communities by assuming a stakeholder role. The lower-income populations that Medicaid serves can significantly improve their health in more accessible communities; in turn, Medicaid stands to reap cost-savings from reduced healthcare expenditures.

Key takeaways

This is an exciting time for Medicaid and public health to strengthen and build upon existing partnerships given their shared goals of maximizing health for the most vulnerable Americans. It is worth noting that many of these opportunities are occurring simultaneously and in overlapping ways (see Figure 1). Given the complexity of these different issues, Medicaid and public health bring key expertise in each of these areas and it will be important for these agencies to collaborate for greatest impact.

Figure 1: Summary of Current Opportunities and Initiatives for Medicaid-
Public Health Partnership [Click to view larger image]

Summary of Current Opportunities and Initiatives for Medicaid-Public Health Partnership

This article was published as part of the Maximizing Public Health Partnerships with Medicaid to Improve Population Health project at ASTHO. To learn more about this project and the resources available to state health departments and their Medicaid colleagues, please visit our project webpage.

 

Noelle Andrade

Noelle Andrade worked as an intern on ASTHO's Health Systems Transformation team from January 2015 until March 2016. She is currently a policy analyst at the National Committee for Quality Assurance.

 

 

Emily Moore

Emily Moore, MPH, is a senior analyst for health transformation at ASTHO, where she supports state and territorial health agencies to advance public health through activities in payment and delivery reform, public health partnership with public and private payers, and population health improvement.