Opportunities to Improve Social and Clinical Care Coordination in Medicaid

January 27, 2017

Author: Mat Reidhead, Vice President of Research and Analytics

Throughout the inaugural weekend, the Trump administration began to demystify its plans for the future health care delivery system for socially at-risk Americans. On Jan. 22, White House Counselor Kellyanne Conway suggested President Trump’s repeal plan for the Affordable Care Act would convert the Medicaid program to block grants for states. It remains to be seen whether the move is designed to ensure President Trump’s pledge of health coverage for all, or to curtail national spending on health care by limiting safety-net funding for the poor. Conway defended the strategy by saying it would afford states the flexibility to ensure the program is administered by “those who are closest to the people in need” — at least a socially benevolent signal.

Uncertainty clouds the future of the health care system in our country. One thing is certain: New data from HIDI make very conjunctive the fact that hospitals are among “those who are closest to the people in need” in Missouri, and there is much opportunity to improve the delivery system under which they receive health care.

A recent Perspective submission in the New England Journal of Medicine highlights many of the considerations for population health and patient-centered care facing the new administration. The authors lay the claim that “as a society we are spending our health care dollars in the wrong ways for the wrong things — emphasizing treatment over prevention and medical care over social services.” They call for more attention to the social causes of downstream physical and emotional health outcomes.
Upstream interventions, such as those being carried out by the Saint Louis Integrated Health Network, help build bridges between hospitals and community health centers with the goal of connecting patients with community-based resources across the clinical and social continuum of care.

While emerging models like the Community Referral Coordinator Program at IHN solidify the place of upstreamism in the future delivery of health care, several policy decisions have placed Missouri’s collective health further downstream than other states.

  • Missouri has by far the lowest funding for public health in the nation. At $5.86 per capita, Missouri is $21.63 per person behind the national median, and $80 behind states in the top decile.
  • Missouri did not participate in expansion of health care coverage for our working poor under the ACA. This decision could place us at a permanent disadvantage in net tax outlays under a fixed block grant model compared to expansion states.
  • Missouri is set to expand the Medicaid managed care delivery model — a system that’s surprisingly woeful at living up to its name according to evidence that we and others have laid bare.

Emergency department visits for Medicaid managed care have exploded in Missouri throughout the last 10 years, with a 54 percent increase since 2006. This was compared to an 8 percent increase for traditional Medicaid during the same period. And last year, for the first time, more managed care patients visited an ED than fee-for-service in Missouri. In fairness, the data also show high utilization for certain fee-for-service patients. The shocking reveal from our latest analysis is this — virtually identical cost concentration curves for each Medicaid delivery model in the state. The rub? Managed care patients are mostly children and their parents. Conversely, fee-for-service covers virtually all clinically complex and resource-intense aged, blind and disabled beneficiaries alongside children and custodial parents outside of the existing managed care region.

Changes in the health care delivery system for our most vulnerable populations cannot be driven solely by the allure of anticipated budget predictability through block grants or managed care contracts. They must be grounded in thoughtful, patient-centered upstream approaches to the coordination of social and clinical care, aimed at improving health and well-being. The return on investment is long, but the return on mission is immediate.