Defining and Delivering Value for Medicaid Beneficiaries

In recent years, there has been a regulatory shift from the traditional fee-for-service model of healthcare to one that is driven by value. But what exactly is value in Medicaid, and how can managed care organizations deliver value to their Medicaid beneficiaries?

The word “value” can have very different meanings based on who is determining the definition. Value to a physician will differ from value to a managed care organization which will differ from how a beneficiary will define value. Given how the term value will take on various meanings, let’s agree that for the sake of argument, in healthcare, value means treating the whole individual, not just their health, but also the social determinants that may impact their health.

When delivering value to Medicaid beneficiaries, payers and providers must work together to encourage consumer activation and engagement. The reason that payers need providers is simple; more likely than not, the individual’s experience lies in the trusted relationship they have with their doctor and/or nurse. Without that personal connection, a trusted relationship is challenging to foster and may hinder any progress in improving health.

Disengaged Medicaid beneficiaries result in more sporadic and severe health needs – which translates to more expansive and expensive care. Therefore, boosting the trusted relationship between the individual and provider requires investment in both time and resources. Positive interactions supporting the health consumer’s needs means listening to their needs and encouraging them to state their needs. These needs may be clinical, but they could be financial and concern lifestyle preferences.

Seeing Value in Action
Imagine a young family with two hard-working parents trying to make ends meet, but coming up short financially and struggling to feed their three kids. While it’s important to address their gaps in care including vaccinations and diabetes and asthma management, they really need help feeding the family a healthy meal, especially on the weekends when the kids don’t have school and a subsidized meal. If the health plan knew the situation and need, the opportunity to provide a great service and yield high satisfaction would boost the perceived value the Medicaid beneficiaries have of the health plan, system, and community.

Beyond satisfaction impacting the value, now the family reduces one barrier to living a healthier life through wholesome meals, which results in a lower total cost of care through better-controlled diabetes and reduces the potential for a cardiovascular-induced emergency department visit and hospitalization. The delta in the cost side of the equation could be $15,000 for three hospital visits versus $6,000 of healthy meals 2 times per week for this family of five.

If you’re a health plan executive and CFO, you see value from a 2-3 year total cost of care perspective. Investing in the Medicaid beneficiary is not only the right thing to do, but it also makes business sense. Many payer-provider organizations such as Intermountain, Geisinger, UPMC and Johns Hopkins/Priority Partners have invested in targeted communities identifying and listening to their needs to impact their health outcomes by addressing those psychosocial needs.

Leveraging Automation to Deliver Value At Scale
Some of these investments in value-based care have a targeted approach, while others touch the whole community. One such population health approach touching the whole community sprouted in Maryland to both promote preventive health, as well as support those transitioning from a hospital visit back to their home or community. The state-wide initiative engaged providers, health plans and Medicaid beneficiaries alike to improve the quality of relevant care and increase the value in Maryland.

To optimize resources, the health plan employed an automated post-discharge follow-up program that funnels through Federally Qualified Health Centers (FQHCs) across the state. Should an individual be discharged from a hospital following an acute episode, he or she would receive an automated call within 48 hours asking about their recovery. Should the individual note they had an issue, such as needing help obtaining medications or scheduling a follow-up appointment, their local FQHC is notified and manually follows up to resolve the issue.

Chase Brexton, a community health center involved in the program, had previously only been able to reach 10% of those Medicaid beneficiaries to support them with their questions when they return home. With the automated population health management program, the team is able to reach out to 100% of these members, and subsequently engage 70% of them to understand their needs. This payer-provider group added great value to the beneficiary with practical support in a scalable and cost-effective manner.

Health Plan Can Consistently Deliver Value to the Individual and the Greater Community
Medicaid tends to operate with resources and lower premiums for a sicker more needy population. The need to educate, listen to, and guide the population, as well as support providers and coordinate efforts with community resources is here and innovative organizations are seeing their investments pay off. I encourage this combination of value-based care and population health in your community.

Learn more about how CipherHealth is supporting Medicaid Beneficiaries by visiting our website.

Friso van Reesema brings over 15 years of experience to his current role as VP of Business Development for Payers at CipherHealth. In addition to the health plan perspective, Friso volunteers at Stamford Hospital in Connecticut, a Planetree re-designated site, on their Patient Family Advisory Committee (PFAC) and the Compassionate Interactions Committee. Friso earned his Master of Public Health degree from Johns Hopkins School of Public Health, studied Cultural Anthropology at Leiden University in The Netherlands, as well as earning a Masters in Business Administration from an Erasmus program in Rotterdam and Madrid.