The Medicaid Wave is Coming: Will the Healthcare System be Ready?

By Carol Sardinha

There were some stark realities shared by the experts at the recent 2nd Annual Medicaid Innovations Forum in Washington that will be of interest to Disease Management Care Blog readers:

• It’s estimated that about 15 million new individuals will qualify for and enroll in Medicaid between now and 2019 if health reform goes through as currently written. Some estimates run as high as 30 million new people coming into the Medicaid ranks. That’s a lot of new people.

• Individuals with one or more type of serious mental illness will make up the largest segment of people entering Medicaid for the first time, stated Brian Wheelan, VP of Corporate Development and Strategy at Beacon Health Strategies, which specializes in behavioral health (BH) management. These individuals have much higher mental health costs and utilization rates than the typical commercially-insured population, about three to 10 times more. Individuals with serious BH issues also have much higher incidences of co-morbidities and higher medical costs than the general population.

• In the meantime, state budgets keep getting tighter, putting more restraints on Medicaid spending.

• There is a shortage of physicians willing to treat Medicaid patients. The Medicaid Health Plans of America (MHPA) is working to address scope of practice laws so more non-physician providers, such as nurse practitioners, can be tapped to treat Medicaid patients, according to MHPA President and CEO Thomas Johnson.

• The HHS Office of Integration wants to move more dual-eligibles into managed care systems, a move supported by MHPA but opposed by the American Health Care Association (AHCA) which represents long-term care facilities. Johnson says the two associations will be having discussions on the issue.

• Medicaid eligibility enrollment systems are antiquated and cumbersome and will have to undergo massive restructuring to accommodate the influx of new beneficiaries.

This is just a small sampling of the challenges ahead. Yet even as we wait for final CMS regulations on ACOs, innovation and reform is occurring at the local and health plan level. Network Health, a Medicaid plan in Massachusetts, along with its partner delivery system, Cambridge Health Alliance has already embraced developed an operational ACO delivery model, although metrics are not in yet. MHPA’s Johnson, meanwhile, says his organization has a subsidiary devoted to best practices and a work group charged with identifying ACO models that would work best for the Medicaid population.

Still, I can’t help but worry when I hear some of these numbers and think about the difficulties of building and operationalizing truly integrated and coordinated systems devoted to caring for some of the sickest and most difficult to manage patients. Will states, providers, payers, and other entities at risk for caring for these most vulnerable patients just continue to seek to shift the risks elsewhere as they have historically? Or will they find ways to effectively manage the care of these patients so that they become collectively responsible for that care within the system?

There were many bright, dedicated people at the Conference who are devoted to making this concept work. I hope they are successful. But the clock is ticking.

Watch for a future blog post citing some of the innovations mentioned at the conference that are being used to improve care delivery and manage costs in the Medicaid population.

Carol Sardinha is a healthcare industry career specialist and strategist with expertise in managed care, Medicare, Medicaid, pharmacy benefits, and other areas. A former healthcare business and healthcare policy journalist, she most recently served as Marketing Channel Lead, Mature Markets, at Healthways. Carol is currently supporting a number of independent healthcare business and writing projects. She can be reached at: casardinhaATgmailDOTcom