Medicaid provides critical support to the some of the most vulnerable members of our society–children, pregnant women, people with disabilities, and older adults. The program also faces long-standing challenges that will require increased understanding and innovative approaches in 2021 and beyond. Federal agencies and state Medicaid directors say that funding challenges are only the beginning of the issues they see as top priorities for their programs. Others include:
- Responding to the rise in opioid use and substance use disorders (SUDs) affecting individuals, families, and communities.
- Meeting increasing and unaddressed mental health needs, including both those triggered by the pandemic and pre-existing ones.
- Leveraging Medicaid benefits to eliminate health disparities and improve health equity.
- Maintaining long-term care and supportive services for beneficiaries with disabilities or complex healthcare needs.
- Understanding and uncovering the deeply interconnected social determinants that drive the need for–or pose barriers to accessing–health support services.
To address these challenges, state Medicaid directors say they need evidence and robust data analytics to help inform policy recommendations in real-time. Abt is at the forefront of this work, helping partners and clients address short-term challenges holistically, with long-term change in mind.
Abt’s work is grounded in an understanding of both the variation and the commonalities that exist across Medicaid programs. We’ve been supporting the Centers for Medicare & Medicaid Services (CMS) and state Medicaid programs through technical assistance and evaluation services, which has given us a valuable perspective on national and state-specific issues.
“Medicaid programs differ appreciably between states,” notes Abt Principal Associate Sara Galantowicz. “However, what we know from our work with federal agencies and states is that core issues, including behavioral health and substance use, care access and quality, and an interest in payment reform, unite them. Through thoughtful data analytics, we can help connect the dots and uncover emerging trends, as well as relationships with key health drivers such as housing, education, employment, and the neighborhoods and conditions where people live, learn, work and play.”
Tackling Opioids and Substance Use Disorder Across the Lifespan
“Medicaid programs are on the front-lines of so many needs in America,” says Alicia Sparks, Abt senior associate. “Approximately 40% of individuals with an opioid use disorder nationwide are covered by Medicaid. Getting treatment is so important for recovery, and for those who live in rural areas, it can be difficult to find primary care, to say nothing of effective help for SUD. Medicaid programs are trying to help patients access evidence-based care.”
Abt is working with CMS and partners, Insight Policy Research and Urban Institute, to determine if an integrated program aimed at pregnant women with opioid use disorder (OUD) improves their care and reduces the prevalence of infants born with Neonatal Opioid Withdrawal Syndrome (NOWS). The research team is collecting qualitative and quantitative data that will describe the program outcomes from the perspective of providers, payers, and patients, informing potential future program expansions. Findings from the Maternal Opioid Misuse Initiative (MOM) are expected in later 2021.
Medicaid covers more than 7 million low-income seniors, and opioids pose a particular concern for this population. As people age, changes in metabolism, co-occurring illnesses, and drug interactions make caring for older adults challenging. Abt’s Rosanna Bertrand is leading a technical assistance project for AHRQ that’s designed to help primary care providers address opioid misuse among older adults, as well as a separate technical assistance project for the Commonwealth of Massachusetts to support nursing homes in caring for adults receiving medication for OUD. Said Bertrand, “The aging of the population combined with the opioid epidemic has placed greater demand on the need for policies, tools, and resources to support providers in the management of opioid use, misuse, and treatment across the continuum of care.”
Meeting Mental Health Needs
The Children’s Health Insurance Program (CHIP) covers beneficiaries ranging from infants to 21-year-olds. Many children and young people served by these programs are at significant risk for other challenges, from mental or substance use disorder needs related to trauma or adverse childhood experiences. To help integrate screening methods into primary care settings, school-based clinics, and community health centers, Abt’s Leigh Fischer has been leading a learning community as part of the Conrad N. Hilton Foundation’s Youth Substance Use Prevention and Early Intervention Strategic Initiative. “Some youth use substances to cope with mental health issues, and that may be particularly true given the stress and trauma related to the pandemic, systemic racism, and natural disasters exacerbated by climate change,” says Fischer. “We’re using learnings from the initiative to help providers, schools, and communities figure out how to use the best evidence to screen, provide brief interventions, and refer young people for additional help, if needed.”
For individuals of all ages, having insurance coverage is just part of the challenge when accessing mental health services. Some providers may not take their insurance, or patients may experience long wait times for outpatient mental health services. Working with the Blue Cross Blue Shield of Massachusetts Foundation, our mixed methods study found that providers were more likely to accept commercial insurance and least likely to accept public insurance – including Medicaid.
People with behavioral health conditions such as serious mental illness and substance use disorders, including opioid-use disorder, are three to six times more likely than the general population to be involved with the justice system. Without coordinated intervention, they risk losing Medicaid and other benefits, and may wind up in and out of the criminal justice system, and with inconsistent access to needed mental health and substance treatment. This costly cycle undermines recovery. In partnership with the Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation, Abt examined state and local pre-booking jail diversion programs serving this population. Five programs across the U.S. show promise that they can help break the cycle of justice involvement for people with these conditions and help them get or maintain the services they need.
Reducing Health Disparities and Improving Health Equity
Despite spending more money on healthcare than any other industrialized country, the U.S. has worse health outcomes, including the lowest life expectancy. Critically, people of color often suffer higher rates of disease and death. In 2018, the rate of infant mortality for infants of Black mothers was more than double the rate for White mothers.
To address the social determinants of health that lead to high rates of infant mortality and disparity among Black mothers, Abt is working with the Collaborative Improvement & Innovation Network to Reduce Infant Mortality (IM CoIIN). Under this program, Abt provides technical assistance to four teams across 21 states, including supporting the use of human-centered design in public health interventions that can reduce infant mortality. “Engaging program end-users is critical,” says Abt’s Lawrence Reichle. “It is easy to forget that public health literally involves the public. Innovative approaches can meet the actual needs of diverse stakeholders if they’re involved in early and often in the process. When engaging the community in design thinking approaches, it’s important to design “with” end-users and not “for” them. That’s how you develop a higher quality intervention.”
Aging in Place, Community Supports, and Long-Term Care
Overwhelmingly, older adults and people with disabilities prefer to receive healthcare and other supports in their own homes and communities. Medicaid is the largest payer for these supports, as well as for the costly alternative of institutional care. To further develop the evidence on how to help older adults age in place, Abt is evaluating the U.S. Department of Housing and Urban Development (HUD)’ s Integrated Wellness in Supportive Housing (I-WISH) model. This model placed wellness directors and nurses in HUD-assisted multifamily housing to support access to community care and help individuals achieve their health goals. Abt is researching the program’s impact on the beneficiaries, Medicaid and Medicare healthcare utilization, and housing stability.
To support monitoring access to important community-based services, Abt is providing customized technical support to the Minnesota Department of Human Services and the state Medicaid program. Our team leverages existing state data to populate a user-friendly dashboard of access indicators that helps program administrators monitor eligible beneficiaries’ access to Medicaid-funded home and community-based services (HCBS). Galantowicz says the new dashboard will allow state staff to easily see service use, assess the impact of state Medicaid policy changes, and address access gaps across regions and demographic groups. “When you choose to show the data in ways that make sense, you can truly drive data-driven decisions for the most impact.”
When individuals do need long-term care, information on provider quality is critical to making an informed choice. Abt delivers nursing home quality and other data by supporting Care Compare for Nursing Homes and its Five-Star Quality Rating System. Care Compare for Nursing Homes reports detailed information on nursing homes, including numerous measures of regulatory compliance, staffing, and quality of care. Public reporting of this information incentivizes nursing homes to achieve and maintain a high quality of care. The website is used by consumers, policymakers, researchers, and other stakeholders. The goal of the rating system is to make information on nursing home performance more understandable, enabling consumers to compare facilities.
Social Determinants of Health and Medicaid
Health systems and government services are sharpening their focus on a whole-person care approach that addresses non-medical factors known as social determinants of health. Research demonstrates that a paradigm shift that embodies a holistic approach to address physical and mental health alongside health-related social needs, like food insecurity, environmental hazards, or lack of affordable housing, can have a great impact on care delivery and health outcomes.
Abt works with the Massachusetts Medicaid agency, MassHealth, to build the capacity of Medicaid Accountable Care Organizations (ACOs) and community partners to improve outcomes for MassHealth members. Under the Delivery System Reform Incentive Payment Program, ACOs partner with community-based organizations and groups, known as Community Partners, to address members’ behavioral health and long-term services and supports needs. Our technical assistance program is helping the ACOs and community partners accelerate the inclusion of flexible services tied to areas that include community services, nutrition, and housing supports, as well as creative member engagement.
Support to Maximize Every Dollar
As the number of people eligible for Medicaid continues to grow due to COVID-related economic losses, the program faces new challenges. Healthcare costs are growing to accommodate aging Americans with more chronic health diseases. Making healthcare affordable through value-based purchasing and alternative payment models offer promising solutions. The ACO Investment Model (ACO AIM) tested an alternative payment system, offering ACOs up-front payments to encourage coordination of services and care. Abt examined the impact of this model and found it saved more than $381 million over five years.
“Medicaid is a critical safety-net program in the United States,” says Katharine Witgert, Abt principal associate and Medicaid health policy researcher. “The direct and indirect costs of the COVID pandemic have constrained already tight budgets. We’re proud to help federal, state and local programs adapt through research and real support that, at the end of the day, helps them make informed decisions so they can get the most out of every dollar.”