Medicaid Reform Requires Outcomes-Based Innovation, Better Data

August 22, 2017 - Medicaid has steadily provided low-income patients with quality healthcare coverage and could further improve by addressing problematic areas through outcomes-based innovation and data analytics infrastructure, according to commentary published in JAMA.

Former CMS Administrators Andy Slavitt and Gail Wilensky recognized that current policy debate at the federal level has threatened Medicaid as a result of proposed cuts in tabled ACA repeal and replace legislation.

Even though the debate has subsided in recent weeks, the one-time CMS leaders observed that continuing discussions on Medicaid must remind stakeholders of the program’s value to millions of beneficiaries who rely on Medicaid coverage.

“Medicaid has become a major focus in the debate over repealing the Affordable Care Act (ACA), because the proposed replacement bills go beyond the ACA into the underlying Medicaid program that was originally passed by Congress in 1965,” wrote Slavitt and Wilensky.

“As we have overseen the Medicaid program at various stages, we are familiar with its successes, its areas for improvement, its effect on state budgets, and its importance to millions of ordinary people who count on the program and will need it in the future,” they continued.

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While the pair recognized Medicaid’s success, they called attention to weak spots in the program that can be addressed through six distinct policy adjustments.

They recommended the following changes:

Make Medicaid into an outcomes-based program

The authors believe that Medicaid is a program that is could focus on improving patient outcomes outside of the hospital as well as traditional healthcare delivery, because of the shift over the years CMS has taken to evaluate outcome measures.

To achieve this, the authors believe that recording population health management measurements and attributing scorecards to patient outcomes could be a viable first step.

“Metrics such as the early diagnosis of illness, incidence of low-birth-weight infants, maternal mortality, and the efficiency of care delivered could form the basis of such measures,” Slavitt and Wilensky said.

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“Although there has been some recent progress identifying a core set of measures for children and adults, a scorecard on a core set of metrics would have to be developed for this purpose.”

Improve Medicaid financing that increases state accountability:

A problem the authors have with current financing for state programs is that funding is based on large supplemental pools like Medicaid disproportionate share hospital [DSH] payments and uncompensated care pools.

They believe that states aren’t held accountable to patient care and the other factors of health that affect Medicaid beneficiaries in these risk pools, because states don’t have to do much else to receive these funds.

Slavitt and Wilensky recommend that states should be evaluated on how they are using Medicaid funds, and if the funds go towards health improvement of beneficiaries. Both agree that financing should also address the social determinants of health, or socioeconomic factors that affect health outside of traditional healthcare facilities.

“Although the two of us differ on the appropriate future of federal matching in Medicaid, we agree that the federal government needs to review allowable state funding for Medicaid in a thoughtful manner,” Slavitt and Wilensky said.

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“Finally, we support financing strategies that would encourage investments in the social determinants of health, which are the cause of so many health disparities and undesirable outcomes.”

Ensure proper care access:

Even though recent data has shown that Medicaid beneficiaries have similar levels of healthcare access as private plan members, Slavitt and Wilensky noted that healthcare access is a problem for some beneficiaries.

According to the duo, improving healthcare access across the Medicaid program is a primary concern of the program and that tailoring community-level healthcare access can help expand access.

Both authors reiterated that eliminating non-accountable funding to states also expands access by allowing states to improve provider reimbursement rates, which could boost provider access to access-challenged areas.

“There’s been an often-quoted statistic that one-third of physicians won’t see Medicaid patients,” the authors maintained. “Although this is only slightly higher than other insurance programs, there is appropriate concern about access to specialists and home-based and community-based services, which varies broadly by state and is of particular concern in rural areas and where reimbursement rates are too low."

“Eliminating nonaccountable pools of funding would allow states to improve their reimbursement rates to specialists and help to expand access,” they continued. “Access challenges, where they continue to exist, should be targeted and fixed, just as they are in other insurance programs.”

Invest in health information technology, data, and analytics infrastructure:

Earlier this year when Slavitt was Acting Administrator, he and the previous National Coordinator for the ONC Vindell Washington wrote in a blog post about the importance of data access in value-based reimbursement.

“While the tools are improving, some clinicians remain frustrated by the limited usability of their technology and data, from their inability to easily enter and access key information when and where they need it at the point of care to challenges in accessing timely feedback on the quality of care in their practice,” the officials wrote to the successors.

Wilensky and Slavitt emphasized the potential and importance of having a strong data analytics infrastructure within Medicaid, because of how data can integrate with value-based best practices such as community care and care coordination.

“For Medicaid to deliver on its potential, the program needs to use best practices in home-based and community-based care and other programs that use social workers, home care attendants, and other resources to keep families together, coordinate care, and allow people to be treated in the most comfortable, cost-efficient settings,” argued Slavitt and Wilensky.

“To do this, Medicaid needs a more up-to-date, sophisticated cloud computing infrastructure for data, technology, and care coordination. These investments can be made in ways that allow each state to benefit from national investments but are customized to meet local challenges.”

Coordinate programs for dual-eligible beneficiaries and other populations:

Slavitt and Wilensky contend that beneficiaries eligible for both Medicare and Medicaid would benefit if both programs coordinated services for these dual-eligible individuals.

Accordingly, an increase in Medicare and Medicaid coordination can help improve the care for individuals who do not directly benefit from private healthcare services and programs.

“There are growing, expensive populations that do not fully benefit from investments in care coordination commonly used in the private sector,” Slavitt and Wilensky claimed.

“The relationship between the Medicare and Medicaid program for US residents who are served by both programs should be improved, just as the relationship between Medicaid and private programs should be made more fluid for people who have fluctuating incomes.”

Reduce administrative burden on states, increase rate of innovation:

States have opened more doors in how flexible they can be with their Medicaid spending via 1115 State Innovation Waivers. These waivers are state request for approvals that allow states to invest Medicaid funds in non-traditional spending.

For example, the state of Alaska opened a reinsurance program through the waivers that helps them mitigate high healthcare costs that previously destabilized part of the state’s insurance markets. Other states such as Kentucky, Maine, Massachusetts, Texas, and several more have submitted and received waiver approval.

According to Slavitt and Wilensky, waivers and other methods to increase Medicaid innovation will help promote the health of Medicaid beneficiaries in each state, and allow other states to learn best care practices from each other.

“Medicaid is a highly flexible program, with a variety of different approaches designed to serve the frail elderly, provide substance abuse treatment, create innovative payment approaches, and capitalize on mobile technology,” they noted.

“Allowing states to move more quickly is laudable, but we must also be sure to have guardrails to ensure that federal tax dollars are being used to improve the health of target populations, that the results of innovations are measured, and that best practices can be spread between states.”