Some 68 million Americans receive coverage through Medicaid, the federal-state health plan for lower-income Americans, making it the single-largest source of health coverage in the United States. Much of the growth in health insurance coverage under Obama Care comes from the expansion of Medicaid.
Yet the Medicaid program has changed little since it was first created in 1965. In most settings, it has mimicked the design and dysfunction of other health insurance programs. Patients receive coverage for basic primary care and a set of acute care services when they are sick and often suffer from poor access to care, a problem exacerbated by the scarcity of providers who accept Medicaid. There is little that aims to protect and preserve their health and is designed to meet their special needs of the population that receives Medicaid.
We believe redesigning Medicaid may represent the single greatest opportunity to improve health care in the United States. Over the past year, CareMore and Amerigroup, two subsidiaries of Anthem, have collaborated to launch a new model in Memphis, Tennessee, that began providing care for 14,400 Medicaid members last January 1. In addition to providing traditional health care coverage, they have built a number of innovations to meet the specific needs of Medicaid beneficiaries. Our vision is to reconceive Medicaid as a care-delivery model rather than as an insurance program. While we admittedly are still in the early days of applying the model, we believe the initial results are promising.
The model includes the following elements:
Comprehensive care centers with integrated primary care. One of the key gaps in American primary care is the availability of programs to address the chronic disease needs of individual patients. Primary care providers are limited in their ability to manage patients’ chronic diseases — because the primary mode of delivering care is through episodic office visits. Off-site, telephonic, disease-management programs have rarely been successful because they are disconnected from patients’ primary care physicians and nurses.
To support the needs of Tennessee Medicaid beneficiaries, we launched three comprehensive care centers, assigning patients to primary-care nurse practitioners who have access to
number of on-site disease-management programs to help patients manage their individual medical conditions. Patients have access to specialized medical assistants and nurse practitioners who deliver carefully curated programs for diabetes, hypertension, congestive heart failure, and other conditions. The care centers also employ a staff of health care navigators who proactively reach out to engage members who otherwise might not access services. In our first three months, we have completed 2,000 patient care visits for over 1,000 patients.
Healthy Start. Upon entry into our Medicaid program, patients participate in a 90-minute “Healthy Start” assessment at a Care Center that aims to understand the patient’s physicial, behavioral, and cognitive health. Routine lab and other bio-metrics are part of the assessment as well. This assessment allows us to identify at-risk patients and begin to intervene to reduce risk. Patients are asked about their health habits, past medical conditions, and personal medical history. Beyond a typical patient history and physical, the Healthy Start approach organizes how patients will use all the services and programs at the Care Center to best manage their health. In our early experiences, we have identified many previously undiagnosed illnesses and those patients are now receiving treatment. Over 930 patients have completed Healthy Starts, resulting in 1,009 referrals to specialists for assessment or diagnostic testing.
Medical “extensivists.” One major defect in care for most patients in American health care and Medicaid beneficiaries in particular is dropped balls. Patients suffer when patients transition into and out of primary care settings and hospitals that are poorly linked. A different set of clinicians will see patients in the hospital, at post-acute rehabilitation facilities, and at primary care offices. Within our program, extensivist clinicians follow patients across all sites of care. Extensivists typically have smaller patient loads and more intensively follow patients across all parts of the system to reduce errors and prevent the need for readmission to the hospital. When the same person is seeing you in the hospital and the care center, there is a greater likelihood that your care plan will be effectively and efficiently carried out. This approach builds on CareMore’s experience reforming care for elderly Americans in Medicare — which has led to readmission rates across regions that are 40% lower than the national average.
Integration of behavioral and chronic care. Many Medicaid patients who suffer from chronic diseases also suffer from behavior health problems such as depression and anxiety. Depression and anxiety can often make patients’ ability to manage their chronic disease significantly worse, but behavioral health and chronic disease are typically treated and managed as distinct entities. CareMore has built an integrated approach to managing the two. Through the Healthy Start program 15% of patients (120) with previously undiagnosed or undertreated mental illnesses were seen by in-house psychiatry nurse practitioners or therapists.
Open access, extended hours primary care to reduce ER use. Medicaid patients are high utilizers of emergency rooms — often because there is poor access to primary care services. This leads to unnecessarily costly hospital visits. To help improve service to Medicaid beneficiaries, CareMore and Amerigroup have strategically placed comprehensive care centers in locations across Memphis in the communities in which they live. Patients have access to care from 7 a.m. to 7 p.m. and same-day appointments are offered six days a week. In the first two months, 12% of patients have been walk-ins. While 30% of patients have been “no-shows” for appointments, that’s a low number for the Medicaid population. All in all, we believe that our alternate scheduling system is filling an important need for patients who otherwise might be seen in emergency rooms.
Remaking American health care will require us to think about rethinking our insurance programs and reconceiving them as health care delivery platforms — a realization that is slowly surfacing but has largely remained absent in discourse about Medicaid. Hopefully, our efforts in Memphis will help pave the way to new models of care for some of our most vulnerable populations. Innovations in the delivery of health care cannot succeed if they leave out the patients and populations who need it most.