This article explores how Medicaid managed care programs can better address social factors that influence health outcomes. It argues that collaboration between Medicaid managed care organizations and community-based organizations is essential to meet patients' social needs.

Key Points

• Medicaid managed care programs are required to address social drivers of health (SDOH).
• SDOH include factors like housing, food, and transportation that affect health outcomes.
• The COVID-19 pandemic highlighted the importance of SDOH.
• States are increasingly using Medicaid waivers to address SDOH.
• Recommendations for States:
  • Foster a culture of MCO accountability and innovation.
  • Leverage new Medicaid momentum.
  • Expand payment approaches to fully support MCO-CBO partnerships.

Discusses the misconception that Medicaid has no money for innovation. In reality, Medicaid plans have incentives to invest in medical and non-medical services.

Key Points

• The authors propose that startups can target Medicaid subgroups with high costs, such as seniors and people with disabilities.
• Additionally, they suggest that Medicaid plans are increasingly looking to contract out inefficiencies.

This paper examines how Medicaid agencies in 14 states engage consumers in program design, emphasizing common facilitators like leadership commitment and flexible recruitment strategies, and advocates for sharing best practices to improve engagement and address community needs.

Key Points

• There's a rise in complexity for Medicaid programs, and consumer input might be important for successful design.
• Researchers interviewed Medicaid leaders in 14 states and found big differences in how they involve consumers.
• Sharing best practices across states could help strengthen programs’ engagement efforts, identify opportunities for program improvement reflecting community needs, and increase participation among a population that has traditionally lacked a political voice.

This paper analyzed 4,774 super-utilizers in an urban safety-net system, finding that only 3% of adult patients accounted for 30% of charges, with fewer than half remaining super-utilizers after seven months, highlighting the need for improved predictive models and tailored interventions.

Key Points

• Around 3% of adult patients were identified as super-utilizers, accounting for 30% of adult healthcare charges in the study period.
• Less than half of super-utilizers identified at the start of the study remained in that category after seven months, with only 28% remaining at the end of a year.
• The transient nature of super-utilizer status highlights the need for improved predictive models and tailored interventions for different patient subgroups to manage avoidable healthcare utilization effectively.

This article provides insights into cost-effective ways to serve patients who have complex health problems and social needs.

Key Points

• The costliest 5% of patients incurred roughly 70% of all spending. Most had multiple chronic medical conditions, often with co-occurring behavioral health disorders. Many also had significant social needs, ranging from housing instability to food insecurity.
• A program in Memphis, Tennessee, reduced total spending by 37% per patient by keeping patients out of the hospital.
• The program targeted high-need, high-cost Medicaid patients with multiple chronic medical conditions and behavioral health disorders.
• The program provided patients with frequent, structured follow-ups, including weekly check-ins from a community health worker, monthly in-person visits with the entire care team, and additional customized follow-ups.
• The program also addressed patients' social needs, such as housing instability and food insecurity.
• The program led to a $7,732 (or 37%) reduction in total medical spending per patient per year. This was driven primarily by decreases in hospital utilization: Patients were less likely to be admitted to the hospital (50%decrease in rates) and had shorter lengths of stay (22% decrease).

The article outlines successful strategies used by healthcare organizations to manage cost of care, including leadership, cultural alignment, primary care based models, and organizationally based models.

Key Points

Primary Care Based Models:

• Use hospitalists to provide care for admitted patients, which can reduce lengths of stay and readmission rates.
• Implement multidisciplinary teams to coordinate care for patients, which can improve quality and efficiency.
• Focus on preventive care to keep patients healthy and out of the hospital.

Organizationally Based Models:

• Develop clinical pathways to standardize care for patients with common conditions, which can reduce costs and improve quality.
• Implement bundled payments, which provide a fixed payment for a defined episode of care, which can encourage providers to reduce costs.
• Use data analytics to identify and track areas where costs can be reduced.

The article describes a care management program implemented by Mass General Brigham, a large healthcare system. The program uses a multidimensional approach to assess patients’ needs and match them to the most appropriate care program. The goal is to provide the right care to the right patient at the right time.

Key Points

• Multidimensional assessment: Patients are assessed on a variety of factors, including their medical conditions, social determinants of health, and behavioral health needs. This helps to ensure that care plans are tailored to the individual needs of each patient.
• Stratification of care: Patients are then stratified into different care programs based on their needs. For example, patients with complex medical conditions may be assigned to a care program that provides more intensive care management, while patients with less complex needs may be assigned to a program that provides more self-management support.
• Care management: Care managers work with patients to develop and implement their care plans. They also provide ongoing support and monitoring to help patients stay on track with their goals.
• Data-driven decision making: The program uses data to track patient outcomes and identify areas for improvement. This data is used to inform the development and refinement of the care programs.

The CareMore model has generated promising results in Memphis and Des Moines, and it is now expanding to other locations. This model includes comprehensive, relationship-based primary care, collaborative behavioral health, community and patient engagement focused on social needs, and the breakdown of silos between inpatient care and the community.

Key Points

• Traditional Medicaid care models often create silos, isolating patients during hospitalization and making it difficult to manage their health after discharge.
• CareMore, a health plan, focuses on actively managing Medicaid patients during hospitalization and the crucial period immediately following discharge.
• This integrated approach includes strategies like addressing food insecurity, providing in-home care, and offering behavioral health services for substance abuse.
• The goal is to prove that improved Medicaid managed care can significantly enhance the quality and cost-effectiveness of care for various populations.
• The key lies in designing care models that specifically address the unique needs of the Medicaid population.

The article reports that the use of Medicaid wraparound services varies by state and enrollee demographics.

Key Points

• Over 60% of dual-eligible individuals use at least one wraparound service.
• These services include vision, dental, and home-based care.
• The use of these services varies by state, with rates ranging from 32% to 88%.
• Racial and ethnic minorities and younger adults are less likely to use these services.

Key Points

• California's Medicaid program, CalAIM, aims to improve health outcomes for low-income residents by addressing social needs like housing and food.
• Implementation has been challenging, with providers and insurers facing difficulties in collaboration.
• The state is making changes to address these challenges, including increasing provider payments and simplifying paperwork.

This conversation discusses the challenges and potential solutions for improving homeless shelters, emphasizing the need for low-barrier entry, staff empowerment, diverse funding, and addressing systemic issues like housing shortages.

Key Points

• Rethinking Shelter Models:
  • Lowering barriers to entry (allowing pets, fewer rules) is crucial for building trust and meeting immediate needs.
  • This approach requires a shift in staff training and culture, focusing on empowerment, relationship-building, and treating individuals with dignity.
  • Shelters should prioritize short-term stays and swift transitions to permanent housing, but this is often hampered by housing shortages.
• Funding and Sustainability:
  • Government funding is often insufficient, forcing shelters to seek diverse funding sources (thrift stores, foundations, etc.).
  • While low-barrier models might seem more expensive due to increased staff training and support, they can be cost-effective in the long run by reducing chronic homelessness.
  • Data collection is important, but qualitative data (like trust-building and meeting basic needs) is often overlooked by funders.
• Addressing Systemic Issues:
  • The lack of affordable housing is a major obstacle, requiring creative solutions like shared housing and landlord incentives.
  • Shelters often lack resources to address the root causes of homelessness, such as family conflict or lack of basic needs.
  • Collaboration with other organizations and community stakeholders is essential to tackle these complex issues.

The Pop Health Podcast sits down with Renee Hungerford and Scott Dillingham to discuss the partnership between Community Action of Orleans and Genesee and Continual Care Solutions to build a comprehensive data ecosystem for CBOs and the implications for this moment in health care with the growing use 1115 waivers to establish and support social networks of care.

This article is about financing community health worker programs through Medicaid. It discusses the challenges of finding sustainable funding for these programs.

Key Points

• The authors propose using a microsimulation model to estimate the costs of CHW programs.
• They found that the minimum fee-for-service rate for a 30-minute visit was $53.24 and the minimum capitated rate was $140.18 per member per month.
• These rates varied by location and panel size.
• The authors conclude that higher Medicaid funding is needed to support CHW programs.

The authors of this paper provide a unique question of where healthcare starts and stops.

Key Points

• Health systems are designed for the delivery of healthcare and lack the expertise or resources to tackle the complexity of social factors impacting health.
• Solutions are most effective when they come from within the community, as those organizations understand the nuances of local needs and have existing relationships of trust.
• Health systems can play a valuable role by partnering with community organizations, offering resources and data, but should avoid assuming a leading role.

Communities must lead, sectors must collaborate, investments must be strategic, data must guide action, and commitment must be long-term.

Key Points

• Community-Driven Leadership: Community members should be the driving force behind efforts to improve population health, as they best understand their own needs and priorities.
• Cross-Sector Collaboration: Achieving health equity requires collaboration across healthcare, public health, and social sectors, with open communication and shared decision-making.
• Strategic Investment: Rather than focusing on short-term projects, prioritize sustainable investment in community assets and resources that address the root causes of health disparities.
• Data-Driven Strategies: Utilize data to identify specific community needs, track progress, and guide decision-making for maximum impact.
• Long-Term Commitment: Systemic change in health outcomes requires a sustained commitment to addressing social determinants of health, not isolated programs.

This paper argues that trusted community-based organizations are crucial for bridging the gap between healthcare and social services, ultimately improving health outcomes for underserved populations.

Key Points

• Close collaboration between health systems and social service organization is necessary for improving individual and community health.
• A trusted entry point is a person or organization that can connect people with health and social services.
• Some CBOs can act as trusted entry points because they are seen as credible by the community.
• Strong relationships among community institutions are important for creating and expanding local entry points.
• The federal government can help by providing clear guidance on what community hubs and CBOs can do, and by helping to fund them.
• Community hubs and CBOs need good data collection and sharing capabilities, as well as well-developed referral systems.

This paper explores the challenges health plans face in implementing social care programs due to complex and evolving regulations.

Key Points

• Regulatory complexity is a major hurdle for social care programs. There are many different rules and requirements that health plans need to follow in order to offer social care services. These rules can be unclear and constantly changing, which makes it difficult for plans to know what is and is not allowed.
• Uncertainty about compliance can lead to plans avoiding social care altogether. Because the rules are so complex and there is a risk of getting penalized for non-compliance, some health plans may decide not to offer social care services at all.
• Clearer guidance from policymakers is needed. In order to encourage more health plans to offer social care services, policymakers need to provide clearer guidance on what is and is not allowed. This would help to reduce the risk of non-compliance and make it easier for plans to design and implement social care programs.

This article examines the role of community-based organizations (CBOs) in Medicaid programs in New York and Massachusetts. It analyzes feedback from CBOs to highlight their experiences and potential for improvement.

Key Points

• CBOs raised concerns about funding, timing, and the flow of payments.
• CBOs suggested improvements for better partnerships between CBOs and health care providers.
• The article emphasizes the need for better financial support and clearer guidelines for CBO participation in Medicaid redesigns.

John Oliver discusses why millions of people have been kicked off of Medicaid, why Medicaid access was difficult even before the current “unwinding”, and what would happen if fruits and vegetables could talk.

The article provides an examination of how Community Health Centers (CHCs) are funded and reimbursed, and discusses their role within the landscape of value-based payment.

Key Points

• CHCs are a bedrock of the social safety net in the United States, providing care to vulnerable people in their communities, often for little or no cost to them.
• CHCs operate through funding streams and reimbursement mechanisms that pose challenges to participating in newer forms of value-based payment.
• This issue brief provides a snapshot of CHCs and the people they serve, how they currently are funded and reimbursed, how they fit into the landscape of value-based payment, and how alternative payment policies can align with their mission and mandate.

This article emphasizes the importance of community care hubs in enhancing health outcomes by centralizing administrative functions, facilitating partnerships between community-based organizations (CBOs) and healthcare providers, and addressing social determinants of health through coordinated efforts

Key Points

• Community care hubs are entities that centralize administrative functions and connect community-based organizations (CBOs) with healthcare providers.
• They can improve care coordination, data sharing, and service delivery.
• There are funding opportunities for hubs through federal grants, Medicaid programs, and philanthropic sources.