Prevention, care coordination and Medicaid.
Health promotion has traditionally been the province of the U.S. public health infrastructure. The health care delivery system and health insurance are largely financed by treating illnesses, not preventing them. An enormous opportunity exists in linking the health, health care and insurance infrastructures to a model of health promotion. Over the past five years, employers, in particular, have increasingly recognized that many illnesses are preventable and are a result of lifestyle or modifiable risk factors. For example, Harvard researcher, Danaei Goodarz, recently published that one out of five Americans will die as a consequence of tobacco use and one out of 10 as a result of obesity. Self-insured employers driven, in part, by concerns of lost productivity, rising health care expenses and employee retention have been investing aggressively in wellness and prevention programs offered by their health insurance carriers or provided directly to the employer by private companies. For the most part, these programs are independent of the health care delivery system; they focus on assessing risk, raising awareness, developing skills, setting goals, monitoring the progress of employee and dependents' risk factor modification, and administering incentive programs.
Employer prevention interventions tend to be blends of individual interventions (telephonic counseling, Internet, biomonitoring, reward programs) as well as work site or group interventions (walking clubs, tobacco-free campuses). Public health interventions complement these interventions with a focus on community and state interventions, such as addressing food deserts, walking paths, or regulations on tobacco control. An emerging area will be the health care delivery system's further embrace of health promotion activities. This area will involve payment changes that promote health maintenance and anticipatory management. The initial focus will be on covering and encouraging clinical preventive services and immunization recommendations. For the Medicaid program, these programs will be receiving an additional federal match in 2013. Tobacco cessation will be covered for pregnant mothers receiving Medicaid in the fall of 2010. Not all health promotion counseling needs to be done, however, by physicians; who will provide these services and how they are financed will be the subject of demonstration projects.
Before delving further into the applicability of these programs for Medicaid, it is important to note that prevention and health promotion activities are not de facto cost savings. Interventions to promote lifestyle changes vary in expense and are not uniformly successful. The disease prevented may have been years away from occurring without the intervention, and the number of individuals who need to change behavior to affect one disease event may be higher than expected. To offset these factors, prevention initiatives generally fall into two buckets--low cost, low touch and high cost, high risk. The high-cost, high-risk bucket is reserved for individuals or populations with high prevalence, high severity, and highly affected conditions. For example, interventions may be focused on those with heart failure who smoke or people with diabetes who have had a heart attack. These secondary and tertiary prevention programs, broadly named disease management programs, have not, for the most part, delivered expected results. Disease management programs are now focusing on being much cheaper for lower risk individuals or are being reserved for even higher risk individuals. Many current employer-supported prevention and wellness programs are claiming huge and quick returns on their lighter touch prevention investments which are encouraging, but these investments need to be subjected to more rigorous evaluation. These are beginning to occur and are the aim of the federal reform demonstrations.
There are three major reasons why prevention programs are so relevant for the Medicaid program: the size of the program, the opportunity for impact given the population's demographics and disproportionately high rate of conditions and risk factors.
With implementation of federal health care reform, the Congressional Budget Office estimates that Medicaid will grow to cover more than 65 million low-income Americans from its coverage of almost 50 million individuals. Medicaid and CHIP will cover many more people than Medicare--currently the two programs roughly cover the same number of people.
While the expansion of Medicaid is focused on adults without dependent children, over half of Medicaid recipients are children, caregivers or pregnant women. In most states, at least one out of every four children and one out of every three pregnant mothers receive health coverage through Medicaid or CHIP. Furthermore, low-income pregnant mothers, children, and their caregivers have disproportionately higher rates of tobacco exposure, obesity, physical inactivity, cavities, high blood pressure and other risk factors and conditions. The Centers for Disease Control and Prevention estimate that 35 percent of adults in the Medicaid program use tobacco compared with about 20 percent of adults in the overall population. The rates of passive tobacco exposure for children roughly approximate these rates. Importantly, more and more medical literature is establishing that behaviors established in early childhood and even during pregnancy set a course for higher rates of preventable disease as adults. Therefore, efforts to promote healthy lifestyles for Medicaid recipients may potentially have great impact in terms of extending life expectancy and reducing premature disability.
As states consider participating in prevention demonstration projects for Medicaid recipients, I suggest focusing on five areas: tobacco control, obesity prevention, cavity-free programs, depression and anxiety management, and blood pressure control. Tobacco exposure is the leading cause of premature disability and death in the United States. Low-income children are at the epicenter of the obesity epidemic.
The rate of cavities is significantly dropping in high- and middle-income populations and effective interventions exist to prevent caries. The data on differential rates of depression and anxiety for low-income and middle income populations are sparse. However, I propose considering this area because of the Medicaid program's historic focus on meeting the needs of individuals with psychotic disorders. Prevention demonstration projects offer the opportunity to further develop how behavioral health programs can more fully meet the needs of children, pregnant mothers and caregivers facing depression, anxiety and coping disorders. High blood pressure is the second leading cause of preventable premature death after tobacco use.
Medicaid officials will find existing private, community, provider and public health efforts promoting most of these initiatives. In many cases, representatives are already at the table, but often Medicaid is not, and other participants are surprised by Medicaid's interest. Partnership and collaboration opportunities abound and provide infrastructure, leverage, innovation and community priority to help guide which programs are most needed and most likely to succeed. These discussions offer an opportunity to see how current community initiatives are addressing the needs of low-income populations and also engage Medicaid providers, such as safety net providers, in these efforts.
A final point in considering prevention initiatives involves measurement. An enormous challenge presented by Medicaid's participation in prevention initiatives is measurement of baselines and success. Medicaid's data systems are centered primarily on eligibility and medical claims. Neither system measures health. Claims systems may offer insight into care provided, such as fluoride sealants applied or tobacco cessation products prescribed, but these systems will not offer insight into changes in the percentage of children with cavities or pregnant mothers who are smoking. The claims systems, however, will provide data for costs of care. Population survey data exist in each state through the efforts of public health departments; determining whether insurance status can be added to their question list is one way to help track the impact of interventions.
The Agency for Healthcare Research and Quality uses the following as working definition: "Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves marshaling personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care." (http://www.ahrq.gov/clinic/tp/caregaptp.htm).
The number of providers and provider types involved in treating a person with an illness can be innumerable and extends beyond primary care, specialists and hospitals to include multiple provider types such as pharmacists, home health providers, nursing homes or physical therapists. Improper and incomplete handoffs between providers' accounts for duplication of services, medical errors, readmissions and avoidable utilization of health care resources.
Care coordination is not explicitly funded in most fee-for-service settings; rather, providers are expected to have systems for managing referrals and information from other providers. Care coordination makes these expectations much more explicit and embodies them in the form of a care coordinator, which can be considered a new provider type. Case management tends to be comprehensive care coordination for a highly complex person or a person with acute and intense needs. Care coordination retains a person-based perspective but focuses more on how to help the person efficiently and effectively navigate a complex health care delivery system. There are several major care coordination models that dominate most discussions arising from commercial and Medicare models; however, care coordination as applied in Medicaid populations may need to be reconsidered as issues of poverty, complexity and social services play more prominent roles in Medicaid.
The most commonly discussed model of care coordination is linked to the medical home. In addition to establishing a usual source of primary care, a core element of the medical home is coordinating care amongst providers. The medical home promotes team-based care and recognizes that a primary care provider will not provide all care coordination services, but a member of the care team--often a paraprofessional--serves as communicator and facilitator for patients seen in a practice.
Another model of care coordination is largely hospital-based and is referred to as care transitions. These programs emphasize that patient outcomes, particularly readmission rates, can be reduced through structured care transition programs that emphasize clear discharge instructions, which are reaffirmed at a post-discharge visit and a prompt follow-up appointment with the primary care provider.
A third model of care coordination is traditional, managed care case management. In this model, a nurse or social worker helps an acutely ill patient--a person undergoing a transplant or who has had multiple traumas or with a highly complex situation--with additional oversight services to ensure timely provision of appropriate and non-duplicative services.
The care transitions model has been rigorously evaluated, primarily in the Medicare population. Case management is a core component of nearly every capitated managed care plan. Care coordination as a dimension of the medical home model is hard to evaluate since it is part of a much broader intervention. Several medical home studies have shown promise.
Federal health care reform includes several demonstrations that call for evaluation of different care coordination interventions in Medicaid populations. These are explicitly mentioned in care coordination demonstrations, and implicitly included as components of medical home and accountable care demonstrations. These demonstrations are scheduled as soon as January 2011. Similar to the prevention demonstrations, the federal government is very interested in evaluating their impact before making these services a requirement.
As the Medicaid program considers care coordination, take note of three key demographic issues: the particular needs of persons with disabilities, low-income children and their caregivers, and maternity-related opportunities. Persons with disabilities, though a small percentage of the Medicaid population, account for a large percent of expenditures. Care coordination for this population may most replicate the case management programs of traditional managed care. One key element that care coordination can address is transitions from childhood to adulthood for young recipients with disabilities. Care coordination for persons with psychotic disorders represents another opportunity to better link behavioral and physical health systems. For example, many treatments for psychosis result in higher rates of diabetes and cardiovascular risk factors that are modifiable. Systems to ensure provider linkage have value in reducing morbidity. Better coordinated care for children in foster care and clients with developmental disabilities also stand out as potential areas for focused care coordination.
Low-income children and their caregivers account for the majority of Medicaid recipients. Unlike persons with disabilities, this population is not on Medicaid very long and their per-capita costs are not very high. While the population is sicker than middle-income populations, the opportunity for care coordination is better linkage between social services, health-care services, and public-health services. In most states public health and social services are administered at the county level and Medicaid at the state level. Lighter touch-care coordination that lets primary-care providers know more about food assistance, inexpensive vaccination, and other antipoverty interventions--and that also helps county social service workers be aware of the medical home provider--may increase efficiency and effectiveness to help clients get out of poverty quicker.
Finally, it is important to note that the most frequent reasons for hospitalization in Medicaid are maternity-related. In Medicare, heart failure, ischemic heart disease and respiratory illnesses such as chronic obstructive pulmonary disease and pneumonia are the common causes for hospitalization. Programs designed to reduce readmissions in a Medicaid population must be customized for the frequent causes of readmission.
In addition to determining the population of interest, there are several other key considerations: defining measurable outcomes of interest, determining the qualifications of care coordinators, picking a control group, and leveraging existing care coordination efforts.
Perhaps the biggest risk I see with care coordination efforts is lack of clarity on expected outcomes, particularly with medical home care coordination efforts. Federal demonstration projects are interested in determining whether interventions save money and improve health outcomes. To save money, the intervention must be sufficiently effective and affordable and the preventable event sufficiently frequent and costly. If one of these variables is out of line, cost savings will be very difficult to demonstrate. Readmissions in Medicare represent such an opportunity--determining the relevant intervention and preventable event in Medicaid will require ingenuity and modeling.
The qualifications of care coordinators will follow upon determining the intervention. If there is a continuum of intervention from navigation to case management, intervention costs rise so the impractability of the intervention and cost and frequency of the condition must also increase.
There are two broad ways to establish a comparison group to measure impact--comparing against a historic benchmark or comparing against a concurrent population not offered the intervention. Both approaches have advantages and disadvantages. The advantage of the historic group is its convenience and low cost, plus it allows for broad participation in the intervention, which promotes equity. The disadvantage is the potential influence of other factors that change over time (inflation rates, technology, epidemics). It may be difficult to determine whether changes in performance are due to environmental or intervention causes. The other approach involves not offering the intervention to a concurrent group and comparing the two groups head to head. This approach has the advantage of eliminating many temporal biases and being a much more robust design. The disadvantage is that some groups may feel left out and there may be other biases introduced by geography. The benefits of a concurrent, comparison group in general outweigh its shortcomings.
States will find that many providers are offering care coordination services, particularly integrated delivery networks, long-term care providers, community health centers, and other larger, horizontally or vertically integrated providers. The demonstration projects may offer a source of explicit funding for services that have been funded from other lines of business or through charitable contributions. Existing services offer many advantages in terms of expertise, infrastructure and rapid time to deployment. However, the risk is that there may be no incremental benefit unless the population or the scope of services is expanded.
Prevention and care coordination demonstrations offer states an opportunity to evaluate innovative enhancements to their programs with federal grant financing. While these innovations appear to be worthwhile, they appropriately deserve rigorous evaluation before broader adoption. Consideration of the preceding principles may help maximize the success of your initiatives.
Sandeep Wadhwa was Medicaid director for the Colorado Department of Health Care Policy and Financing until August 2010. He is now vice president, Coding and Reimbursement, for 3M Health Information Systems.
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|Publication:||Policy & Practice|
|Date:||Oct 1, 2010|
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