| Term | +Description | +
|---|---|
| CBO (Community Based Organization) | +A non-profit organization that provides services and support to a specific community, often focusing on social and health needs. | +
| CHW (Community Health Worker) | +A frontline public health professional who serves as a trusted link between healthcare providers and a community, often focusing on outreach and health education. | +
| Capitated Payments | +A payment model where healthcare providers receive a fixed amount per patient per month, regardless of the number of services provided. | +
| Doula | +Non-clinically trained professionals who can provide emotional, physical, and informational support and guidance during the prenatal, birth, and postpartum period + | +
| FQHC (Federally Qualified Health Center) | +A community-based health clinic that receives federal funding to provide primary care services in underserved areas. | +
| Health Coaches | +Professionals who work with individuals to set health goals, develop action plans, and provide guidance on healthy lifestyle choices. | +
| MCO (Managed Care Organization) + | +A type of health insurance company that contracts with healthcare providers to form a network and emphasizes preventative care and cost management. + | +
| Managed Care | +A type of health insurance where the insurer contracts with providers and coordinates care to control costs and improve quality. + | +
| Medicaid | +A government-funded health insurance program for low-income individuals and families. | +
| Care Manager | +A healthcare professional, often a nurse or social worker, who coordinates and manages the care of patients, especially those with complex medical needs or chronic conditions. | +
| Case Manager | +A professional who oversees and coordinates the comprehensive care of patients, typically focusing on ensuring continuity of care and appropriate resource utilization. | +
| Care Coordinator | +An individual responsible for organizing and facilitating healthcare services for patients, often acting as a liaison between patients, caregivers, and healthcare providers. | +
| Care Plan | +A personalized document outlining the goals, interventions, and actions required to address a patient's healthcare needs, developed collaboratively by the patient, caregivers, and healthcare team. | +
| Transitional Care | +A coordinated set of actions designed to ensure the safe and effective transition of patients between different levels of care or healthcare settings, such as from hospital to home or from one healthcare provider to another. | +
+
+ Breakdown (2019)
+| Group | ++ Cost + | ++ Number of People + | +Cost Ratio (Relative to Population) | +Weight of Cost to Population | +
|---|---|---|---|---|
| + Seniors + | +$122,304,815,900 (21.23%) | +8,527,000 (9.71%) | +$14,342.34 | +0.2555 | +
| + Individuals with Disabilities + | +$196,614,960,400 (34.09%) | +10,037,600 (11.42%) | +$19,571.25 | +0.3491 | +
| + Adult + | +$56,884,386,300 (9.87%) | +14,812,200 (16.87%) | +$3,838.79 | +0.0683 | +
| + Children + | +$100,323,192,200 (17.43%) | +35,361,500 (40.26%) | +$2,835.62 | +0.0506 | +
| + Newly Eligible Adult + | +$99,956,643,000 (17.36%) | +19,129,700 (21.77%) | +$5,224.39 | +0.0933 | +
| + Total + | ++ $576,083,997,800 (100%) + | ++ 87,868,000 (100%) + | ++ N/A + | ++ N/A + | +
+ Legend +
+-
+
- + Enrollees: + Individuals who are enrolled in Medicaid at any time during the calendar year. +
- + Seniors: + Includes all people age 65 and older. +
- + Individuals with Disabilities: + Includes people under age 65 who are reported as eligible due to a disability. +
- + Adults: + Generally people age 19 to 64. Adults include a small number of people who are eligible through the Breast and Cervical Cancer Prevention and Treatment Act of 2000. +
- + Children: + Generally people age 18 and younger. However, some people age 19 and older may be classified as "children" depending on why they qualify for the program and each state's practices. +
- + Newly Eligible Adults: + Adults in the expansion group who were made newly eligible for Medicaid by the ACA Medicaid expansion. +
- How Healthcare Works -
- - - - Medicaid 101 - - - - Managed Care - - - - Duals - - - - 1115 Waiver - - - - Social Care - - - - Learning the Patient Perspective - - - - FQHC/Community Health Center - - - - Trends - - - - Lessons From Founders - - - - Podcasts, Channels, Newsletters to Follow - - - - Investors Focusing on Medicaid - - -Medicaid 101
- -
-
- Breakdown (2019)
-| Group | -- Cost - | -- Number of People - | -Cost Ratio (Relative to Population) | -Weight of Cost to Population | -
|---|---|---|---|---|
| - Seniors - | -$122,304,815,900 (21.23%) | -8,527,000 (9.71%) | -$14,342.34 | -0.2555 | -
| - Individuals with Disabilities - | -$196,614,960,400 (34.09%) | -10,037,600 (11.42%) | -$19,571.25 | -0.3491 | -
| - Adult - | -$56,884,386,300 (9.87%) | -14,812,200 (16.87%) | -$3,838.79 | -0.0683 | -
| - Children - | -$100,323,192,200 (17.43%) | -35,361,500 (40.26%) | -$2,835.62 | -0.0506 | -
| - Newly Eligible Adult - | -$99,956,643,000 (17.36%) | -19,129,700 (21.77%) | -$5,224.39 | -0.0933 | -
| - Total - | -- $576,083,997,800 (100%) - | -- 87,868,000 (100%) - | -- N/A - | -- N/A - | -
- Legend -
--
-
- - Enrollees: - Individuals who are enrolled in Medicaid at any time during the calendar year. -
- - Seniors: - Includes all people age 65 and older. -
- - Individuals with Disabilities: - Includes people under age 65 who are reported as eligible due to a disability. -
- - Adults: - Generally people age 19 to 64. Adults include a small number of people who are eligible through the Breast and Cervical Cancer Prevention and Treatment Act of 2000. -
- - Children: - Generally people age 18 and younger. However, some people age 19 and older may be classified as "children" depending on why they qualify for the program and each state's practices. -
- - Newly Eligible Adults: - Adults in the expansion group who were made newly eligible for Medicaid by the ACA Medicaid expansion. -
Medicaid 101
-| Term | -Description | -
|---|---|
| CBO (Community Based Organization) | -A non-profit organization that provides services and support to a specific community, often focusing on social and health needs. | -
| CHW (Community Health Worker) | -A frontline public health professional who serves as a trusted link between healthcare providers and a community, often focusing on outreach and health education. | -
| Capitated Payments | -A payment model where healthcare providers receive a fixed amount per patient per month, regardless of the number of services provided. | -
| Doula | -Non-clinically trained professionals who can provide emotional, physical, and informational support and guidance during the prenatal, birth, and postpartum period - | -
| FQHC (Federally Qualified Health Center) | -A community-based health clinic that receives federal funding to provide primary care services in underserved areas. | -
| Health Coaches | -Professionals who work with individuals to set health goals, develop action plans, and provide guidance on healthy lifestyle choices. | -
| MCO (Managed Care Organization) - | -A type of health insurance company that contracts with healthcare providers to form a network and emphasizes preventative care and cost management. - | -
| Managed Care | -A type of health insurance where the insurer contracts with providers and coordinates care to control costs and improve quality. - | -
| Medicaid | -A government-funded health insurance program for low-income individuals and families. | -
Medicaid Managed Care
Medicaid managed care is a system in which states contract with managed care organizations (MCOs) to provide Medicaid benefits to enrollees. Instead of the traditional fee-for-service model, where healthcare providers are reimbursed for each service provided, managed care organizations receive a fixed monthly payment per enrollee to cover all of their healthcare needs.
+
+ These managed care organizations are responsible for coordinating and delivering healthcare services to Medicaid beneficiaries within a defined network of healthcare providers. They often offer a range of services, including primary care, specialist care, hospitalization, and sometimes additional benefits like dental and vision care.
Medicaid managed care aims to control costs, improve health outcomes, and provide more coordinated and comprehensive care for enrollees by encouraging preventive care and care management.
+
+ Critiques I've heard in the past is that managed care is not necessarily the best way to care for patients, but as a way to have a more predictable budget for states. Managed care may also increase the administrative burden due to increased use of prior authorizations.
+Making Managed Care Work
-Medicaid managed care is undergoing a transformation, focusing on innovative approaches to enhance patient care and address social determinants of health (SDOH). Central to this evolution is the development of predictive models that can identify patients most likely to benefit from care management interventions - [1]. These models consider both medical and social factors, such as housing and food insecurity, to tailor interventions for high-cost subgroups +
The biggest challenge in Medicaid managed care is the high cost of care, which is partly due to increasing healthcare prices. To tackle this, new methods are being used to improve patient care and address social factors affecting health (SDOH). A key part of this is creating predictive models that find patients who would benefit most from care management + [1]. These models look at both medical and social issues, like housing and food insecurity, to design better interventions for costly patient groups [2], - [3].
+ [3]. + -A key emphasis is placed on addressing SDOH within the Medicaid managed care environment - [2]. This involves collaborations between Medicaid managed care organizations (MCOs) and community-based organizations (CBOs) to provide comprehensive support for patients' social needs - [2].
+Addressing SDOH is a major focus in Medicaid managed care + [2]. This involves partnerships between Medicaid managed care organizations (MCOs) and community-based organizations (CBOs) to fully support patients' social needs + [2]. +
-To ensure the effectiveness of Medicaid programs, active engagement of consumers in program design is crucial - [4]. By incorporating patient perspectives, programs can better address community needs and increase engagement, ultimately leading to improved health outcomes +
To make Medicaid programs work better, it's important to involve consumers in designing the programs + [4]. By including patient perspectives, programs can better meet community needs and increase engagement, leading to better health outcomes [4], - [5].
+ [5]. +Integrated Care Models
+ + what is a Integrated Care Models +For high-need, high-cost Medicaid patients, integrated care approaches like the CareMore model have shown promise [6], [7]. These models emphasize comprehensive, relationship-based primary care, collaborative behavioral health services, and a strong focus on addressing social needs @@ -75,10 +74,14 @@
Integrated Care Models
For high-need, high-cost Medicaid patients, integrated care models like the CareMore model (which Cityblock is similar to) show promise. These models prioritize comprehensive primary care, collaborative behavioral health services, and addressing social needs. They aim to improve both the quality and cost-effectiveness of care for diverse populations.
-
-
- Source: Not Boring
-
+
+
+ Source: Not Boring
+
+
+ Cityblock's approach strongly emphasizes integrated care. Their care teams, comprising pharmacists, physicians, therapists, social workers, and more, work together to provide comprehensive care that addresses all aspects of a patient's health and well-being. This holistic approach aligns with the goals of integrated care models and has shown promising results in reducing hospitalizations and improving patient outcomes.
Programs for Super-Utilizers
@@ -91,47 +94,57 @@Programs for Super-Utilizers
Opportunities in Medicaid Managed Care
-Overall, the future of Medicaid managed care lies in embracing a patient-centered approach, leveraging data analytics, addressing SDOH, and fostering collaboration between MCOs and CBOs. By implementing these strategies, Medicaid programs can achieve improved health outcomes, enhanced patient satisfaction, and greater cost-effectiveness.
-A key misconception is that Medicaid managed care organizations (MCOs) would prefer to recoup profits than invest in the care of their members. In reality, MCOs are incentivized to meet a minimum capital spending requirement on medical costs and actively seek solutions to improve care delivery and patient outcomes.
-For instance, given that seniors and persons with disabilities on Medicaid incur significantly higher costs compared to other covered groups, Medicaid plans would be more willing to invest in solutions targeted at this population. Entrepreneurs could then develop higher-cost, human-mediated, and tech-enabled services that cater to the specific care needs of this group. For lower-cost populations, such as children and adults without disabilities, entrepreneurs could develop telehealth, text message, and other software-mediated models for care delivery and management - [3].
+The future of Medicaid managed care depends on focusing on the patient's needs, using data analytics, addressing social factors affecting health, and encouraging cooperation between managed care organizations (MCOs) and community-based organizations (CBOs). These strategies can lead to better health outcomes, higher patient satisfaction, and more cost-effective programs. +
+A common misconception is that MCOs prefer to save money rather than invest in their members' care. In reality, MCOs are required to spend a minimum amount on medical costs and actively look for ways to improve care and patient outcomes. +
+For example, seniors and people with disabilities on Medicaid have much higher healthcare costs than other groups. Therefore, Medicaid plans are more likely to invest in solutions for this population. Entrepreneurs can develop more expensive, human-assisted, and tech-enabled services for them. For lower-cost groups, such as children and adults without disabilities, entrepreneurs can create telehealth, text messaging, and other software-based care models. + [3] +
+ ++ Yet there are core challenges like a shortage of healthcare providers and low payment rates from Medicaid. This makes many providers choose not to see Medicaid patients because it’s not financially sustainable for them. +
++ The real change in Medicaid will come from policy. Not necessarily policy that will improve Medicaid, but policy that will address economic inequality. +
++ While there will be companies that can improve the care of those on Medicaid, we need systemic changes in America to see true improvement. +
+ +