Innovative Medicaid: State-Backed Strategies for Better Health

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Introduction

This document presents key discussions from the sixth annual health policy symposium hosted by the Center for Medical Ethics and Health Policy at Baylor College of Medicine. The symposium's central theme was "legislating health: the role of the state in health policy," highlighting the significant influence states wield in shaping healthcare landscapes and discussing contemporary challenges. The format of the event encouraged candid conversations among experts, foregoing slides to foster direct dialogue and provide practical takeaways for participants navigating the complexities of health policy.

The symposium featured Charlene Wong, a pediatrician and health services researcher with extensive experience in policy roles intersecting with Medicaid at academic, local, state, and federal levels, and Ryan Van Ramshorst, a pediatrician by training and the Chief Medical Officer of the Texas Medicaid program.

The discussion underscored that Medicaid is a federal-state partnership program, where the federal government (CMS) establishes a fundamental "floor" of requirements, but states retain the flexibility to expand coverage and benefits beyond this minimum. The context for the discussions on innovation was the expectation that states will soon face increased responsibility and flexibility, alongside potentially reduced funding, making innovation crucial for maximizing the benefit derived from available resources.

Medicaid Innovation Examples and Strategies

Both panelists provided specific examples of innovation within Medicaid programs, illustrating how states can push the boundaries of traditional healthcare delivery.

Charlene Wong's Examples of Innovation:

• The Integrated Care for Kids (INC) Model: This model, launched in North Carolina with funding from the Center for Medicare and Medicaid Innovation (CMMI), was notable as the first child-focused model undertaken by CMS. Charlene described it as "integrated care on steroids," extending beyond physical and behavioral health integration to include connections with schools, juvenile justice, and services addressing health-related social needs (e.g., food and housing).
  • A key innovation was data linkage: The INC model linked Medicaid, school, and juvenile justice data, providing insights into children's lives that are typically unavailable in traditional healthcare systems, such as school absenteeism or juvenile justice involvement.
  • It also incorporated an alternative payment model to incentivize holistic support. An example was the "kindergarten readiness promotion bundle for primary care," a unique quality measure that rewards clinicians for preparing children for kindergarten, moving beyond traditional measures like emergency department visits.
  • Addressing the challenge of funding and initial pushback, the model secured $16 million in new federal dollars from CMS and leveraged in-kind resources from health systems and payers. While forecasting savings was challenging for actuaries, preliminary estimates for children with complex medical and social needs indicated a 25% reduction in costs, alongside improvements in outcomes.
  • Further innovation within the INC model involved modifying quality measures to specifically reward efforts in closing disparities in well-child visit rates among different demographic groups, such as Black/African American babies compared to white or Asian babies.
• Billion-Dollar Roadmap for Behavioral Health Investment: Charlene also mentioned North Carolina's initiative to create a strategic plan for behavioral health investment, like Texas's efforts. This involved prioritizing investments across the behavioral health continuum and securing an increase in Medicaid reimbursement rates for behavioral health providers, which was crucial for their viability. This came alongside an $800 million historic investment in behavioral health and Medicaid expansion in North Carolina.
• 1115 Waiver for Health-Related Social Needs: North Carolina gained significant attention for using an 1115 waiver (a mechanism allowing states to test new approaches) to address health-related social needs.
  • Approved in 2019 with $650 million in funding, this waiver enabled universal screening of all Medicaid beneficiaries for needs like food insecurity and housing instability.
  • Crucially, it allowed Medicaid funds to pay for non-traditional medical services such as weekly food boxes, emergency housing assistance, transportation support, and trauma-informed care. These services were delivered through regional networks, initially piloted in rural regions.
  • Preliminary evaluations showed that this approach led to fewer emergency department visits and hospitalizations, resulting in $85 less per member per month in costs, demonstrating both individual and systemic benefits. CMS has approved a statewide expansion, pending state funding.

Ryan Van Ramshorst’s Examples of Innovation:

• Managed Care Medicaid Program: Texas operates one of the largest Medicaid programs in the country through a managed care model, with 16 Managed Care Organizations (MCOs) serving approximately 4.2 million Texans. These MCOs receive a per member per month payment to manage risk and serve as key extensions of the state in community engagement and provider enrolment. This shift towards managed care, exemplified by the "STAR" (State of Texas Access Reform) programs, has been ongoing for two decades and is considered innovative.
• Quality Improvement Initiatives through Affinity Groups: Building on the managed care model, Texas participates in affinity groups to drive quality improvement.
  • One notable project focused on well-baby visits, utilizing W15 and W30 metrics (measuring well-child visits for 15- and 30-month-olds respectively), which correlate with crucial preventive measures like immunization rates.
  • By collaborating with MCO quality teams and employing Plan-Do-Study-Act (PDSA) cycles, they successfully "moved the needle" on well-child rates, showcasing effective state-MCO collaboration.
• "In Lieu Of Services" Vehicle for Coverage: Ryan highlighted this "wonky" but powerful innovation within managed care programs. It allows MCOs to cover alternative, cost-effective services that are not typically part of a state's Medicaid plan, if they are optional for the MCO to offer and the enrollee to accept.
  • A prime example is the coverage of intensive outpatient services for severe mental illness as an alternative to psychiatric hospitalization, addressing a critical gap in the behavioral health continuum of care.
  • This mechanism has been instrumental in Texas's efforts to implement its children's behavioral health strategic plan, which seeks to develop a more robust continuum of care, especially for children in foster care. Ryan noted that other states also use this vehicle for various non-traditional medical services.

Measuring Innovation and Key Metrics

The panelists emphasized the critical role of measurement in determining the success of innovative initiatives.

• Well-Baby Checks and ROI: While pediatricians instinctively know the importance of well-baby visits, the direct financial return on investment (ROI) is challenging to quantify with hard numbers. Children, being generally healthy, do not incur high costs, and longitudinal studies needed to demonstrate long-term savings are difficult and expensive to fund. However, proxy measures like vaccine-preventable illness rates or age of autism diagnosis are used, and health plans generally see a return on investment.
• "Measure What You Treasure": Charlene advocated for focusing on health outcomes rather than just process measures. She also highlighted the issue of too many quality measures, suggesting a need to narrow down to a "universal foundation" for greater impact.
• Desired Outcome Measures:
  • Dr. Wong desired outcome measures for adults include diabetes control and hypertension control, which require electronic clinical quality data beyond mere claims data. For children, she listed kindergarten readiness rates and high school graduation rates as vital indicators of health and well-being.
  • Dr. Van Ramshorst prioritized measures that matter most to families, especially for children and adults with disabilities. He suggested assessing caregiver support and burnout (often survey-based) and evaluating the health, safety, and independence of individuals as they transition from childhood to adulthood. These measures go beyond typical clinical metrics like asthma medication ratios or emergency room visit rates.
• Challenges in Measurement: A significant concern is that clinicians serving more vulnerable populations (who may face challenges like food insecurity or unsafe environments) might appear to perform worse on outcome measures, as these are heavily influenced by social determinants beyond their control. Strategies to mitigate this include using social vulnerability indices for risk stratification and holding healthcare entities accountable for the health of a geographic area rather than just their direct patients. The shift from claims-based measures (derived from billing data) to more complex, non-claims-based measures (like surveys or linked social data) is also a key challenge and opportunity.
• Communicating Data Effectively ("Social Math"): To make quantitative data more compelling, especially to policymakers or the public, Charlene recommended using "social math". This involves translating complex percentages or statistics into relatable, understandable analogies (e.g., "driving while texting is like driving the length of a football field blindfolded" instead of a percentage increase in accident risk). This approach is crucial when paired with qualitative stories to create a more impactful message.

Career Advice for Aspiring Health Policy Professionals

Both panelists, having successfully navigated careers at the intersection of clinical practice and health policy, offered practical advice for those interested in similar paths:

• Dr. Van Ramsh's Advice:
  • Seriously contemplate becoming a Medicaid provider to directly contribute to those in need.
  • Cultivate curiosity about health policy, including how the system operates and the legislative process.
  • Read foundational documents, such as Texas's "pink book" (the Texas Medicaid and CHIP reference guide), which offers insights into program operations.
  • Become aware of the full suite of programs offered by Medicaid, CHIP, and other state agencies, even if not an expert in all, and know who to refer patients to.
• Dr. Wong's Advice:
  • Seek out specific training programs like the National Clinician Scholars Program or T32s that offer opportunities to learn about policy levers and research that informs policy.
  • Identify and engage with mentors, including those with direct policymaking experience, who can guide academic and research pursuits toward policy relevance.
  • Be helpful: Offer analytical and evaluation capabilities to state agencies, as they often lack such resources. Even simple analyses can be incredibly valuable. Policymakers frequently seek external expertise, and being a reliable source of information, even if not a deep expert in every niche, makes one a trusted resource. Charlene noted that offering insights, even when outside one's direct area of deep expertise, can be incredibly valuable to policymakers facing urgent decisions.

The discussion concluded by reinforcing the immense potential for innovative and bipartisan approaches within Medicaid to efficiently benefit populations, fostering hope for continued progress in health policy. The panelists underscored the ongoing need for both rigorous data and compelling human stories to effectively influence policy and drive meaningful change.

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