- Email: [email protected]
States’ Influences on Medicaid Investments to Address Patients’ Social Needs
RESEARCH ARTICLE
States’ Influences on Medicaid Investments to Address Patients’ Social Needs Laura M. Gottlieb, MD, MPH,1,2 Andrea Quiñones-Rivera, MDc,3 Rishi Manchanda, MD, MPH,4 Holly Wing, MA,1 Sara Ackerman, PhD, MPH5 Introduction: Relationships between socioeconomic adversity and poor health have been well documented. Given these associations, Medicaid MCOs (MMCOs) have shown increasing interest in addressing social determinants of health (SDH) to improve health and decrease healthcare costs. The authors sought to better understand how contractual relationships with State Medicaid Agencies influence MMCO investments in addressing members’ SDH. Methods: In 52 semi-structured key informant interviews, MMCO executives representing 17 geographically diverse MMCOs ranging in size, commercial status, and state participation in Medicaid expansion were asked to describe existing state and other influences on MMCO SDHrelated activities. The authors followed an established iterative coding, thematic development, and interpretation process to analyze all interview transcripts. All data were collected and analyzed between November 2014 and November 2015. Results: Informants highlighted both general and state-specific regulations that limit MMCOs from incorporating SDH-oriented solutions into care delivery, including regulations governing claimable expenses, rate determination, and enrollment eligibility. MMCO leaders also made recommendations to State Medicaid Agencies to help overcome perceived barriers. Conclusions: MMCO experiences should inform new strategies to sustainably implement SDH innovations. An initial promise of managed care was that an MMCO that improves member health through cost-efficient innovations would benefit financially. The views expressed in these interviews challenge this framework’s suitability for promoting SDH innovations, as many SDH-promoting services may instead translate into financial losses for MMCOs, even as they produce positive impacts on members’ health. Am J Prev Med 2016;](]):]]]–]]]. & 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
I
n early 2016, the Center for Medicare and Medicaid Innovation announced a 5-year multimillion-dollar grants program to test a new model of care called Accountable Health Communities, which will fund grantees to systematically identify and address the social needs of Medicare and Medicaid beneficiaries. The announcement is built on a growing body of evidence linking unmet social needs, such as food insecurity and inadequate housing, with poorer health outcomes,1–6 and reflects increased interest across the healthcare sector around addressing patients’ social needs to improve health.7–12 The Accountable Health Communities
experiment will fill critical evidence gaps about the healthcare impacts of interventions at the intersection of medical care and social services.
From the 1Center for Health and Community, University of California, San Francisco, San Francisco, California; 2Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California; 3School of Medicine, University of California, San Francisco, San Francisco, California; 4Health Begins, Studio City, California; and 5 Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California Address correspondence to: Laura Gottlieb, MD, MPH, 3333 California Street Suite 465, San Francisco CA 94118. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2016.07.028
& 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Am J Prev Med 2016;](]):]]]–]]] 1
2
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]]
To better understand existing policies that impact the implementation and sustainability of programs similar to those proposed in the Accountable Health Communities experiment, this study examines the experiences of Medicaid MCOs (MMCOs) in establishing programs that link medical and social care delivery. As part of the Medicaid transition from fee-for-service toward valuebased payment models, many MMCOs have shown an increased interest in interventions that address social determinants of health (SDH).12,13 SDH interventions supported by Medicaid managed care programs include efforts to increase food security, housing stability, employment, education, and access to other material resources.12–18 This study specifically explores the role of State Medicaid Agency (SMA) policies in incentivizing or de-incentivizing MMCO-led clinical programs that address patients’ SDH, and offers insight into the roles that SMAs can play to improve the sustainability of programs like the Center for Medicare and Medicaid Innovation pilots.
METHODS Participants This study analyzed MMCO leaders’ perspectives on barriers and incentives to support SDH interventions. Data were gathered in two phases, the first between November 2014 and April 2015 and the second from June through September 2015. Phase I included key informant interviews with MMCO leaders; Phase II included in-depth case studies of six MMCOs in five states.
A National Advisory Committee provided recommendations on MMCOs participating in innovations around SDH and helped identify organizations to target for study recruitment. The committee included experts from Medicaid managed care, state Medicaid programs, and health services research. Chief executive officers, chief financial officers, chief medical officers, and other organizational leaders were approached via e-mail and invited to participate. In Study Phase I, interviews were conducted with 26 of the 30 leaders approached. In Phase II, six onsite case studies were conducted with additional leaders at five of the 16 MMCOs contacted in Phase I and one additional plan. All case studies included in-person, indepth interviews with three or more MMCO leaders. The six MMCOs in the case studies were invited to participate with the goal of highlighting specific program innovations described in Phase I interviews or based on innovations reported by National Advisory Committee members.
Data Sample Phase I phone-based semi-structured interviews were conducted by authors LG, RM, and SA. Phase II in-person semi-structured interviews were conducted by authors LG, RM, SA, and AQR. All interviews lasted approximately 45–60 minutes and were audiorecorded. Participants were asked to describe perceived state, federal, and other organizational influences on SDH-related activities in their MMCO and to reflect on ways states could influence future investments. The research was approved by the University of California, San Francisco Committee for Human Subjects Research. Interviews were conducted with 52 leaders (including 26 Phase I and 26 Phase II interviews) from 17 MMCOs that together provide care in 22 states and the District of Columbia. MMCOs included in the final sample operate in geographically and demographically
Figure 1. Geographic distribution of key informants’ MMCO-enrolled populations. a Across the study, key informants represented MMCO leadership teams at national, regional, or local levels. When plan penetration spanned states, we included only those states (depicted here in gray) whose MMCO operations were under the direct influence of the informant. MMCO, Medicaid Managed Care organizations.
www.ajpmonline.org
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]] diverse regions across the U.S., including both states that do and do not receive federal Medicaid expansion dollars (Figure 1). MMCO membership size ranged from 5,902 to 9.3 million enrollees. Fourteen of the MMCOs are non-profit companies; three are publicly traded for-profit companies.
Statistical Analysis Each interview was professionally transcribed and uploaded into the online qualitative analysis software Dedoose, version 5.1.226.2.10. Researchers followed an iterative coding, thematic development, and interpretation process.19,20 At least three researchers read each transcript. The team discussed emerging themes related to MMCO financial structures and state Medicaid policies and developed a list of codes based on these themes. As coding continued, the team members discussed the coding process, identified new themes, and developed new codes to capture these themes. After codes were assigned, the team continued to meet and discuss interpretation until consensus was reached. Data analysis occurred between January and November 2015. This process included making sense of ambivalent and contradictory statements and articulating common themes.
RESULTS The MMCO leaders perceived significant state-level regulatory hurdles to MMCO deployment of health care–based SDH interventions.a Additionally, although the sample size was too small to identify response differences by state (e.g., Medicaid expansion/nonexpansion) or MMCO (e.g., number of beneficiaries, for-/non-profit status), participants’ accounts illustrate the importance of individual states’ regulatory climates. Characterizations of SMAs’ influence on SDH initiatives ranged from antagonistic to hands off to supportive. Despite challenges, many MMCOs have developed innovative strategies to address their members’ social and economic needs. Details about MMCOs’ full range of SDH-related programs will be reported elsewhere.
1. State Regulations Impact Adoption and Sustainability of Social Determinants of Health Interventions Interviewees indicated that the absence of designated funding mechanisms to support SDH interventions has limited MMCO investments and program sustainability. In particular, MMCO leaders identified state-level regulatory barriers in the following domains: claimable expenses, premium rate determination, contractual requirements to address SDH, and Medicaid eligibility rules. These themes were identified among states that have expanded Medicaid and those that have not, although barriers to innovation were perceived to be higher in states not accepting federal Medicaid expansion dollars. ] 2016
3
Claimable expenses and future premium rates. States are required to cover federally mandated core medical services and may also select from a range of optional coverage benefits.21 In general, SMAs determine what constitutes an “allowable” benefit, including the content, dose, and duration of those benefits.22 Several MMCO leaders cited their SMAs’ narrow scope of covered optional services as limiting deployment of SDH interventions: “we’re only paid to pay for physician, and hospital, and pharmacy care. But we know that the way to improve health and, ultimately, our financial sustainability is to spend money on other things. So, how do we do that?” Because SDH-related services provided by plans are not allowable medical expenses, they are often paid out of the MMCO’s administrative budget, via a “community benefit” budget, or by an MMCO-sponsored foundation. For small plans in particular, covering services that are not reimbursable can mean assuming increased financial risk: “Even though I think [SDH] expenses in this line should be medical expenses, there is no way to report them that way… . They have to be administrative costs. And therefore, they sort of indirectly eat into profits.” According to informants, premium rate determination policies exacerbate the problem of claimable expenses. Though MMCOs have some flexibility in using capitation payments to support both claimable and noncovered services, future premium rates are determined in large part only by an MMCO’s claimable expense history. The contribution of administrative expenses to rate calculations is capped, and non-covered services cannot be included in the base to calculate future premium rates. As a result, if an MMCO spends less on medical expenses one year, the amount paid per member by the SMA to an MMCO will likely decrease in the next contract cycle. So, if an MMCO were to invest in SDH interventions that effectively reduce medical expenses, state regulations governing claimable expenses may actually contribute to loss of revenue in subsequent years: “Because nontraditional services and supports don’t count as part of your rate determination for successive years, if you do too much of it, it erodes your rates to an unsustainable level.” In this way, effective SDH interventions could threaten the long-term financial stability of an MMCO by prompting premium reductions over time. This has more-profound implications for smaller health plans. a There was some ambiguity about the definition of “the state” throughout the interviews; though the questions were geared toward SMA’s roles in relation to MMCO contracts, many informants also made reference to state legislatures in their responses. The authors refer to statewide regulations that apply to MMCOs as “state-level” policies and regulations.
4
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]]
Contractual mandates. A small proportion of interviewees mentioned that their state contracts already include requirements to ask about or address members’ SDH. More often, MMCO leaders reported that there were no specific contractual requirements related to SDH. When these requirements did exist, they did not necessarily translate into intended MMCO activities: “Putting it in the contract hasn’t helped make it more widespread… our clinicians won’t do it because they are lacking the infrastructure and the tools to make it really happen.” Informants also noted that low compliance was also related to a perceived lack of enforcement by the state, which sends a mixed message about the importance of SDH work. Medicaid eligibility and membership. The MMCO leaders reported several ways state-level regulations around eligibility and membership impact SDH investments. If SDH interventions lift members out of poverty, members may lose eligibility for Medicaid benefits. States determine income-based eligibility and how often it is reassessed; fear of losing members could have implications on an MMCO’s willingness to intervene around income security. One interviewee explained: “So, isn’t that the real goal to get people out of poverty, and health being one of the barriers or problems. So, a real measure of success would be lower membership. That contradicts our…financial [structure].” It is important to note that concern about the loss of members due to their increased socioeconomic wellbeing was not expressed by all MMCO leaders, nor was it used to justify inaction around members’ social needs. Informants also reported that an MMCO’s SDH interventions disproportionately may attract high-risk patients, thereby incurring increased expenses related to those members’ social and medical needs. Simultaneously, membership “lock-in” periods,23 during which MMCO members cannot change plans, may contribute to risks resulting from SDH investments. In a state with short lock-in periods, members who receive SDH services may transfer to other plans, so any benefits from addressing social needs may not be realized by the investing plan. Grant making. Several MMCO informants described grants to community organizations as one key strategy used to address members’ SDH. This philanthropy was indirectly related to state context in that it was influenced by broader state-level legislative, policy, and regulatory environments.24 In states that had not accepted Medicaid expansion dollars, grant making was perceived as one of the only feasible strategies available to address Medicaid beneficiaries’ SDH, both because of limited financial resources and tighter perceived limits to flexible
spending. In many of these cases, MMCO leaders described strategically supporting SDH grants for activities that would not meet allowable expenses requirements, including those that provide housing, care coordination, food, and other social services. These grants are provided directly though MMCO community benefit programs or indirectly through external foundations resourced by MMCO profits. Centers for Medicare and Medicaid Services waivers. Multiple MMCO leaders described Centers for Medicare and Medicaid Services (CMS) waivers as powerful tools in driving innovation of healthcarebased SDH interventions.25 CMS waivers allow state Medicaid programs to waive compliance with federal regulations and accept MMCO claims for nontraditional services without compromising their state’s federal matching funds. Waivers enable funding flexibility that can be used to support SDH-related interventions. Several informants mentioned state applications for waivers to support SDH interventions integrated into Medicaid long-term services and supports, in particular. Section 1115 waivers tend to be the largest in scope and support “experimental, pilot, or demonstration projects” that, according to federal regulations, “promote the objectives” of Medicaid.26 Many innovative interventions described by respondents have been made possible by such waivers. One participant noted that “[states with waivers have] forced the recognition that these social determinants of health need to be addressed.”
2. Medicaid MCO Recommendations to State Medicaid Agencies Interviewees made several recommendations to SMAs interested in facilitating innovation in MMCO SDH investments. These include encouraging states to act as conveners; advocates (for waivers/policies); funders; and even evaluators of SDH-related interventions. Many of these recommendations involve strategies to decrease regulatory barriers and increase the flexibility of MMCO spending in this field. In states that have not accepted Medicaid expansion dollars, the recommendations included expanding Medicaid eligibility. Clarify funding mechanisms. As repercussions of SDH program spending on future premium rates were understood to be significant deterrents to SDH investment, many MMCO leaders recommended that SMAs increase funding flexibility to support provision of health-related social services. MMCO leaders in some states reported that CMS and SMAs already are exploring strategies to increase flexibility in how Medicaid dollars are used: “The state’s acknowledging that there’s a third category that’s needed, and they’re terming this flexible services… www.ajpmonline.org
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]]
the state is trying to develop a criteria and a reporting mechanism for this category.” Several interviewees advocated for re-classification of food, housing, and other non-medical services as claimable expenses that would count toward rate determinations. Others cautioned against reclassifying social services as covered medical benefits on both financial and ethical grounds. Not only would it be prohibitively expensive for MMCOs to routinely provide social services to a much larger proportion of the Medicaid population, but such a shift would also raise a more fundamental question about the purpose and obligations of Medicaid: is Medicaid the ideal mechanism to address social needs? “What I worry about in this day and age of really embracing the social determinants of health is that there will be a tremendous push to make that into treatments and care that then have to be paid for in the healthcare system. We can’t keep doing that, right?” Finally, MMCO leaders expressed concern about sustaining SDH programs after CMS waiver expiration, as many waivers provide crucial funding and guidance for innovative SDH programs. They noted that access to additional federal grants and shared savings dollars would help to fill this gap. The MMCO leaders described a desire to improve coordination between CMS and state Medicaid programs. They reported that lack of coordination increases ambiguity around federal law interpretation and can increase MMCO concerns about penalties from unintentional failures to comply with state or federal regulations. This fear discouraged MMCOs from integrating SDH innovations. Increase Medicaid MCO input into policy-making. The MMCO leaders suggested increasing MMCO stakeholder engagement in state discussions around waivers, rules, and regulations aimed at increasing MMCOs’ SDH activities. In one state, though MMCO input on waivers was requested by the SMA, the CMS waiver application was seen as a largely SMA activity. Though some MMCO leaders indicated that state contractual requirements could serve as powerful motivators for MMCOs to address SDH, other leaders cautioned against that mechanism, given that existing SDH requirements have not reflected the financial and infrastructural capacities of MMCOs. Regardless of the ultimate opinion on contracts, the impression captured from informants is reflected in the following comment: “When the state tries to do a policy without talking to the people on the ground, they come up with crazy ideas… To formulate good policy, they need to include the people they’re trying to regulate.” The MMCO leaders also noted that although there are public resources for various SDH-related services, such as housing and early childhood interventions, they are ] 2016
5
rarely integrated across government sectors. For MMCOs, this has translated into difficulty “piecing together…money from different pots to meet a client’s overall set of needs.” One strategy suggested by informants was that SMAs act as key interagency conveners to streamline collaboration and funding opportunities. Facilitate program evaluation and data sharing. A lack of accessible data on reproducible models for SDH intervention design and return on investment produced by these interventions was often cited as a deterrent to SDH initiatives. Although the economic impact of most medical procedures is unknown, MMCO leaders felt the lack of program evaluation and return on investment data for SDH programs particularly acutely—perhaps because these programs are more difficult to justify than traditional medical services. Describing a lack of in-house evaluation expertise and resources, several MMCO leaders suggested that SMAs could serve as catalysts for improved evaluation, data sharing, and dissemination of best practices.
DISCUSSION Findings shed light on the complex relationships between state-level policies and MMCO’s attempts to address members’ health-related social needs. Although CMS increasingly supports a wide range of disease prevention efforts,27–29 MMCO leaders nonetheless reported significant regulatory barriers to incorporating SDH-oriented solutions into routine healthcare delivery. The managed care model asserts that an MMCO that reduces medical costs by improving member health and healthcare delivery will benefit financially. The views expressed in these interviews challenge this framework’s suitability for promoting SDH innovations because many SDH-promoting services may instead translate into financial losses. The potential erosion of future premiums, financial penalties, and increases in high-risk membership serve as disincentives for MMCO investments in this arena. These disincentives may translate to related efforts to address members’ SDH through moretraditional MMCO service delivery areas, like behavioral health integration or primary care transformation.
Limitations Although sampling attempted to maximize diversity, participants represent only a small fraction of the nation’s MMCOs. Moreover, the sample was not large enough to capture variation in perspective by plan type or specific regulatory differences between states, which may be particularly relevant for MMCOs operating in more than one state. Another limitation is introduced by the exclusive focus on the perspectives of MMCO leaders.
6
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]]
Future interviews with state and federal Medicaid staff could reveal additional incentives and limitations around how government policies could support MMCO efforts to address SDH. Non–health sector studies also might include questions on whether health-related arguments could catalyze increased funding for social services from other sectors, which may serve as a more efficient use of government resources.30 Although these qualitative findings are not intended to be generalizable, they are nonetheless broadly relevant, particularly given that informants described payment systems and regulatory barriers that are common across MMCOs and SMAs.
CONCLUSIONS It is notable that the funding barriers identified by informants have not completely prevented MMCOs from employing innovative strategies (e.g., waivers, grants, and community partnerships) to address their members’ social needs. However, MMCO leaders recommend that SMAs strengthen MMCO SDH investments by clarifying financial incentives, increasing MMCO engagement in state regulatory decisions, and better aligning federal and state funding and regulations. Without these changes, the Center for Medicare and Medicaid Innovation pilot programs, regardless of impacts on patient health, are unlikely to become sustainable components of the healthcare delivery system.
ACKNOWLEDGMENTS The authors acknowledge the Commonwealth Fund for their support and Stephanie Chernitskiy for assistance editing the manuscript and creating Figure 1. Laura Gottlieb, MD, MPH, and Andrea Quiñones-Rivera, MDc, contributed equally to this work and are co-first authors. No financial disclosures were reported by the authors of this paper.
REFERENCES 1. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80–94. http://dx.doi.org/10.2307/2626958. 2. Adler NE, Stewart J, eds. Socioeconomic status and health in industrial nations: social, psychological, and biological pathways. Ann N Y Acad Sci. 1999;896:1–503. 3. Adler NE, Stewart J. Preface to the biology of disadvantage: socioeconomic status and health. Ann N Y Acad Sci. 2010;1186:1–4. http: //dx.doi.org/10.1111/j.1749-6632.2009.05385.x. 4. Kaplan GA, Shema SJ, Leite CM. Socioeconomic determinants of psychological well-being: the role of income, income change, and income sources during the course of 29 years. Ann Epidemiol. 2008;18 (7):531–537. http://dx.doi.org/10.1016/j.annepidem.2008.03.006. 5. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annu Rev Public Health. 2011;32:381–398. http: //dx.doi.org/10.1146/annurev-publhealth-031210-101218.
6. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129(suppl 2): 19–31. 7. Beck AF, Henize AW, Kahn RS, Reiber KL, Young JJ, Klein MD. Forging a pediatric primary care-community partnership to support food-insecure families. Pediatrics. 2014;134(2):e564–e571. http://dx. doi.org/10.1542/peds.2013-3845. 8. Dubowitz H, Feigelman S, Lane W, Kim J. Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model. Pediatrics. 2009;123(3):858–864. http://dx.doi.org/ 10.1542/peds.2008-1376. 9. Garg A, Marino M, Vikani AR, Solomon BS. Addressing families’ unmet social needs within pediatric primary care: the Health Leads model. Clin Pediatr (Phila). 2012;51(12):1191–1193. http://dx.doi.org/ 10.1177/0009922812437930. 10. Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296–e304. http://dx.doi.org/10.1542/peds.2014-2888. 11. Sege R, Preer G, Morton SJ, et al. Medical-legal strategies to improve infant health care: a randomized trial. Pediatrics. 2015;136(1):97–106. http://dx.doi.org/10.1542/peds.2014-2955. 12. The Menges Group. Positively impacting social determinants of health: how safety net health plans lead the way. www.communityplans.net/ Portals/0/Fact%20Sheets/ACAP_Plans_and_Social_Determinants_of_ Health.pdf. Published 2014. Accessed November 25, 2014. 13. Gottlieb L, Garcia K, Wing H, Manchanda R. Clinical interventions addressing non-medical health determinants in Medicaid Managed Care. Am J Manag Care. 2016;22(5):370–376. 14. WHO Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health, CSDH Final Report. Geneva: WHO, 2008. 15. Meyer H. A new care paradigm slashes hospital use and nursing home stays for the elderly and the physically and mentally disabled. Health Aff (Millwood). 2011;30(3):412–415. http://dx.doi.org/10.1377/hlthaff. 2011.0113. 16. Sandberg SF, Erikson C, Owen R, et al. Hennepin Health: a safety-net accountable care organization for the expanded Medicaid population. Health Aff (Millwood). 2014;33(11):1975–1984. http://dx.doi.org/ 10.1377/hlthaff.2014.0648. 17. Grimes KE, Mullin B. MHSPY: a children’s health initiative for maintaining at-risk youth in the community. J Behav Health Serv Res. 2006;33(2):196–212. http://dx.doi.org/10.1007/s11414-006-9013-7. 18. Bielaszka-DuVernay C. Vermont’s blueprint for medical homes, community health teams, and better health at lower cost. Health Aff (Millwood). 2011;30(3):383–386. http://dx.doi.org/10.1377/hlthaff. 2011.0169. 19. Coffey AJ, Atkinson PA. Making Sense of Qualitative Data: Complimentary Research Strategies. Thousand Oaks, CA: Sage Publications; 1996. 20. Denzin NK, Lincoln YS, eds. The SAGE Handbook of Qualitative Research. 3rd ed, Thousand Oaks, CA: Sage Publications; 2005. 21. Centers for Medicare and Medicaid Services. Benefits. Medicaid.gov. www.medicaid.gov/medicaid-chip-program-information/by-topics/ benefits/medicaid-benefits.html. Accessed December 23, 2015. 22. Kaiser Commission on Medicaid and the Uninsured. Federal core requirements and state options in Medicaid: Current policies and key issues. Issue Brief. https://kaiserfamilyfoundation.files.wordpress.com/ 2013/01/8174.pdf. Published 2011. Accessed December 23, 2015. 23. National summary of state Medicaid manged care programs: program descriptions as of July 1, 2012. www.medicaid.gov/medicaid-chip-program-information/by-topics/data-andsystems/downloads/medicaid-mcenrollment-report.pdf. Published 2012. Accessed December 23, 2015. 24. Silow-Carroll S, Rodin D. Forging community partnerships to improve health care: the experience of four Medicaid managed care organizations. Issue Brief. 2013;19. www.commonwealthfund.org//media/
www.ajpmonline.org
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]] files/publications/issue-brief/2013/apr/1687_silowcarroll_forging_com munity_partnerships_medicaid_managed_care_ib.pdf. Accessed December 23, 2015. 25. Centers for Medicare and Medicaid Services. Waivers. Medicaid.gov: keeping America healthy. www.medicaid.gov/Medicaid-CHIP-Progra m-Information/By-Topics/Waivers/Waivers.html. Accessed November 1, 2015. 26. Musumeci M. Key themes in captiated Medicaid managed long-term services and supports waivers. Issue Brief. http://files.kff.org/attachment/ key-themes-in-capitated-medicaid-managed-long-term-services-and-sup ports-waivers-issue-brief. Published 2014. Accessed December 23, 2015. 27. Wachino V. Coverage of housing-related activities and services for individuals with disabilities. CMCS Informational Bulletin.
] 2016
7
www.medicaid.gov/federal-policy-guidance/downloads/CIB-06-262015.pdf. Published 2015. Accessed May 4, 2016. 28. Office of the Assistant Secretary for Planning and Evaluation. Medicaid and permanent supportive housing for chronically homeless individuals: emerging practices from the field. https://aspe.hhs.gov/report/medicaidand-permanent-supportive-housing-chronically-homeless-individualsemerging-practices-field. Published 2014. Accessed May 4, 2016. 29. Mann C. Medicaid payment for services provided without charge (free care). www.medicaid.gov/federal-policy-guidance/downloads/smdmedicaid-payment-for-services-provided-without-charge-free-care.pdf. Published 2014. Accessed May 4, 2016. 30. Bradley EH, Taylor LA. The American Health Care Paradox: Why Spending More Is Getting Us Less. New York, NY: Public Affairs; 2013.
States’ Influences on Medicaid Investments to Address Patients’ Social Needs Laura M. Gottlieb, MD, MPH,1,2 Andrea Quiñones-Rivera, MDc,3 Rishi Manchanda, MD, MPH,4 Holly Wing, MA,1 Sara Ackerman, PhD, MPH5 Introduction: Relationships between socioeconomic adversity and poor health have been well documented. Given these associations, Medicaid MCOs (MMCOs) have shown increasing interest in addressing social determinants of health (SDH) to improve health and decrease healthcare costs. The authors sought to better understand how contractual relationships with State Medicaid Agencies influence MMCO investments in addressing members’ SDH. Methods: In 52 semi-structured key informant interviews, MMCO executives representing 17 geographically diverse MMCOs ranging in size, commercial status, and state participation in Medicaid expansion were asked to describe existing state and other influences on MMCO SDHrelated activities. The authors followed an established iterative coding, thematic development, and interpretation process to analyze all interview transcripts. All data were collected and analyzed between November 2014 and November 2015. Results: Informants highlighted both general and state-specific regulations that limit MMCOs from incorporating SDH-oriented solutions into care delivery, including regulations governing claimable expenses, rate determination, and enrollment eligibility. MMCO leaders also made recommendations to State Medicaid Agencies to help overcome perceived barriers. Conclusions: MMCO experiences should inform new strategies to sustainably implement SDH innovations. An initial promise of managed care was that an MMCO that improves member health through cost-efficient innovations would benefit financially. The views expressed in these interviews challenge this framework’s suitability for promoting SDH innovations, as many SDH-promoting services may instead translate into financial losses for MMCOs, even as they produce positive impacts on members’ health. Am J Prev Med 2016;](]):]]]–]]]. & 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
I
n early 2016, the Center for Medicare and Medicaid Innovation announced a 5-year multimillion-dollar grants program to test a new model of care called Accountable Health Communities, which will fund grantees to systematically identify and address the social needs of Medicare and Medicaid beneficiaries. The announcement is built on a growing body of evidence linking unmet social needs, such as food insecurity and inadequate housing, with poorer health outcomes,1–6 and reflects increased interest across the healthcare sector around addressing patients’ social needs to improve health.7–12 The Accountable Health Communities
experiment will fill critical evidence gaps about the healthcare impacts of interventions at the intersection of medical care and social services.
From the 1Center for Health and Community, University of California, San Francisco, San Francisco, California; 2Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California; 3School of Medicine, University of California, San Francisco, San Francisco, California; 4Health Begins, Studio City, California; and 5 Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California Address correspondence to: Laura Gottlieb, MD, MPH, 3333 California Street Suite 465, San Francisco CA 94118. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2016.07.028
& 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Am J Prev Med 2016;](]):]]]–]]] 1
2
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]]
To better understand existing policies that impact the implementation and sustainability of programs similar to those proposed in the Accountable Health Communities experiment, this study examines the experiences of Medicaid MCOs (MMCOs) in establishing programs that link medical and social care delivery. As part of the Medicaid transition from fee-for-service toward valuebased payment models, many MMCOs have shown an increased interest in interventions that address social determinants of health (SDH).12,13 SDH interventions supported by Medicaid managed care programs include efforts to increase food security, housing stability, employment, education, and access to other material resources.12–18 This study specifically explores the role of State Medicaid Agency (SMA) policies in incentivizing or de-incentivizing MMCO-led clinical programs that address patients’ SDH, and offers insight into the roles that SMAs can play to improve the sustainability of programs like the Center for Medicare and Medicaid Innovation pilots.
METHODS Participants This study analyzed MMCO leaders’ perspectives on barriers and incentives to support SDH interventions. Data were gathered in two phases, the first between November 2014 and April 2015 and the second from June through September 2015. Phase I included key informant interviews with MMCO leaders; Phase II included in-depth case studies of six MMCOs in five states.
A National Advisory Committee provided recommendations on MMCOs participating in innovations around SDH and helped identify organizations to target for study recruitment. The committee included experts from Medicaid managed care, state Medicaid programs, and health services research. Chief executive officers, chief financial officers, chief medical officers, and other organizational leaders were approached via e-mail and invited to participate. In Study Phase I, interviews were conducted with 26 of the 30 leaders approached. In Phase II, six onsite case studies were conducted with additional leaders at five of the 16 MMCOs contacted in Phase I and one additional plan. All case studies included in-person, indepth interviews with three or more MMCO leaders. The six MMCOs in the case studies were invited to participate with the goal of highlighting specific program innovations described in Phase I interviews or based on innovations reported by National Advisory Committee members.
Data Sample Phase I phone-based semi-structured interviews were conducted by authors LG, RM, and SA. Phase II in-person semi-structured interviews were conducted by authors LG, RM, SA, and AQR. All interviews lasted approximately 45–60 minutes and were audiorecorded. Participants were asked to describe perceived state, federal, and other organizational influences on SDH-related activities in their MMCO and to reflect on ways states could influence future investments. The research was approved by the University of California, San Francisco Committee for Human Subjects Research. Interviews were conducted with 52 leaders (including 26 Phase I and 26 Phase II interviews) from 17 MMCOs that together provide care in 22 states and the District of Columbia. MMCOs included in the final sample operate in geographically and demographically
Figure 1. Geographic distribution of key informants’ MMCO-enrolled populations. a Across the study, key informants represented MMCO leadership teams at national, regional, or local levels. When plan penetration spanned states, we included only those states (depicted here in gray) whose MMCO operations were under the direct influence of the informant. MMCO, Medicaid Managed Care organizations.
www.ajpmonline.org
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]] diverse regions across the U.S., including both states that do and do not receive federal Medicaid expansion dollars (Figure 1). MMCO membership size ranged from 5,902 to 9.3 million enrollees. Fourteen of the MMCOs are non-profit companies; three are publicly traded for-profit companies.
Statistical Analysis Each interview was professionally transcribed and uploaded into the online qualitative analysis software Dedoose, version 5.1.226.2.10. Researchers followed an iterative coding, thematic development, and interpretation process.19,20 At least three researchers read each transcript. The team discussed emerging themes related to MMCO financial structures and state Medicaid policies and developed a list of codes based on these themes. As coding continued, the team members discussed the coding process, identified new themes, and developed new codes to capture these themes. After codes were assigned, the team continued to meet and discuss interpretation until consensus was reached. Data analysis occurred between January and November 2015. This process included making sense of ambivalent and contradictory statements and articulating common themes.
RESULTS The MMCO leaders perceived significant state-level regulatory hurdles to MMCO deployment of health care–based SDH interventions.a Additionally, although the sample size was too small to identify response differences by state (e.g., Medicaid expansion/nonexpansion) or MMCO (e.g., number of beneficiaries, for-/non-profit status), participants’ accounts illustrate the importance of individual states’ regulatory climates. Characterizations of SMAs’ influence on SDH initiatives ranged from antagonistic to hands off to supportive. Despite challenges, many MMCOs have developed innovative strategies to address their members’ social and economic needs. Details about MMCOs’ full range of SDH-related programs will be reported elsewhere.
1. State Regulations Impact Adoption and Sustainability of Social Determinants of Health Interventions Interviewees indicated that the absence of designated funding mechanisms to support SDH interventions has limited MMCO investments and program sustainability. In particular, MMCO leaders identified state-level regulatory barriers in the following domains: claimable expenses, premium rate determination, contractual requirements to address SDH, and Medicaid eligibility rules. These themes were identified among states that have expanded Medicaid and those that have not, although barriers to innovation were perceived to be higher in states not accepting federal Medicaid expansion dollars. ] 2016
3
Claimable expenses and future premium rates. States are required to cover federally mandated core medical services and may also select from a range of optional coverage benefits.21 In general, SMAs determine what constitutes an “allowable” benefit, including the content, dose, and duration of those benefits.22 Several MMCO leaders cited their SMAs’ narrow scope of covered optional services as limiting deployment of SDH interventions: “we’re only paid to pay for physician, and hospital, and pharmacy care. But we know that the way to improve health and, ultimately, our financial sustainability is to spend money on other things. So, how do we do that?” Because SDH-related services provided by plans are not allowable medical expenses, they are often paid out of the MMCO’s administrative budget, via a “community benefit” budget, or by an MMCO-sponsored foundation. For small plans in particular, covering services that are not reimbursable can mean assuming increased financial risk: “Even though I think [SDH] expenses in this line should be medical expenses, there is no way to report them that way… . They have to be administrative costs. And therefore, they sort of indirectly eat into profits.” According to informants, premium rate determination policies exacerbate the problem of claimable expenses. Though MMCOs have some flexibility in using capitation payments to support both claimable and noncovered services, future premium rates are determined in large part only by an MMCO’s claimable expense history. The contribution of administrative expenses to rate calculations is capped, and non-covered services cannot be included in the base to calculate future premium rates. As a result, if an MMCO spends less on medical expenses one year, the amount paid per member by the SMA to an MMCO will likely decrease in the next contract cycle. So, if an MMCO were to invest in SDH interventions that effectively reduce medical expenses, state regulations governing claimable expenses may actually contribute to loss of revenue in subsequent years: “Because nontraditional services and supports don’t count as part of your rate determination for successive years, if you do too much of it, it erodes your rates to an unsustainable level.” In this way, effective SDH interventions could threaten the long-term financial stability of an MMCO by prompting premium reductions over time. This has more-profound implications for smaller health plans. a There was some ambiguity about the definition of “the state” throughout the interviews; though the questions were geared toward SMA’s roles in relation to MMCO contracts, many informants also made reference to state legislatures in their responses. The authors refer to statewide regulations that apply to MMCOs as “state-level” policies and regulations.
4
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]]
Contractual mandates. A small proportion of interviewees mentioned that their state contracts already include requirements to ask about or address members’ SDH. More often, MMCO leaders reported that there were no specific contractual requirements related to SDH. When these requirements did exist, they did not necessarily translate into intended MMCO activities: “Putting it in the contract hasn’t helped make it more widespread… our clinicians won’t do it because they are lacking the infrastructure and the tools to make it really happen.” Informants also noted that low compliance was also related to a perceived lack of enforcement by the state, which sends a mixed message about the importance of SDH work. Medicaid eligibility and membership. The MMCO leaders reported several ways state-level regulations around eligibility and membership impact SDH investments. If SDH interventions lift members out of poverty, members may lose eligibility for Medicaid benefits. States determine income-based eligibility and how often it is reassessed; fear of losing members could have implications on an MMCO’s willingness to intervene around income security. One interviewee explained: “So, isn’t that the real goal to get people out of poverty, and health being one of the barriers or problems. So, a real measure of success would be lower membership. That contradicts our…financial [structure].” It is important to note that concern about the loss of members due to their increased socioeconomic wellbeing was not expressed by all MMCO leaders, nor was it used to justify inaction around members’ social needs. Informants also reported that an MMCO’s SDH interventions disproportionately may attract high-risk patients, thereby incurring increased expenses related to those members’ social and medical needs. Simultaneously, membership “lock-in” periods,23 during which MMCO members cannot change plans, may contribute to risks resulting from SDH investments. In a state with short lock-in periods, members who receive SDH services may transfer to other plans, so any benefits from addressing social needs may not be realized by the investing plan. Grant making. Several MMCO informants described grants to community organizations as one key strategy used to address members’ SDH. This philanthropy was indirectly related to state context in that it was influenced by broader state-level legislative, policy, and regulatory environments.24 In states that had not accepted Medicaid expansion dollars, grant making was perceived as one of the only feasible strategies available to address Medicaid beneficiaries’ SDH, both because of limited financial resources and tighter perceived limits to flexible
spending. In many of these cases, MMCO leaders described strategically supporting SDH grants for activities that would not meet allowable expenses requirements, including those that provide housing, care coordination, food, and other social services. These grants are provided directly though MMCO community benefit programs or indirectly through external foundations resourced by MMCO profits. Centers for Medicare and Medicaid Services waivers. Multiple MMCO leaders described Centers for Medicare and Medicaid Services (CMS) waivers as powerful tools in driving innovation of healthcarebased SDH interventions.25 CMS waivers allow state Medicaid programs to waive compliance with federal regulations and accept MMCO claims for nontraditional services without compromising their state’s federal matching funds. Waivers enable funding flexibility that can be used to support SDH-related interventions. Several informants mentioned state applications for waivers to support SDH interventions integrated into Medicaid long-term services and supports, in particular. Section 1115 waivers tend to be the largest in scope and support “experimental, pilot, or demonstration projects” that, according to federal regulations, “promote the objectives” of Medicaid.26 Many innovative interventions described by respondents have been made possible by such waivers. One participant noted that “[states with waivers have] forced the recognition that these social determinants of health need to be addressed.”
2. Medicaid MCO Recommendations to State Medicaid Agencies Interviewees made several recommendations to SMAs interested in facilitating innovation in MMCO SDH investments. These include encouraging states to act as conveners; advocates (for waivers/policies); funders; and even evaluators of SDH-related interventions. Many of these recommendations involve strategies to decrease regulatory barriers and increase the flexibility of MMCO spending in this field. In states that have not accepted Medicaid expansion dollars, the recommendations included expanding Medicaid eligibility. Clarify funding mechanisms. As repercussions of SDH program spending on future premium rates were understood to be significant deterrents to SDH investment, many MMCO leaders recommended that SMAs increase funding flexibility to support provision of health-related social services. MMCO leaders in some states reported that CMS and SMAs already are exploring strategies to increase flexibility in how Medicaid dollars are used: “The state’s acknowledging that there’s a third category that’s needed, and they’re terming this flexible services… www.ajpmonline.org
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]]
the state is trying to develop a criteria and a reporting mechanism for this category.” Several interviewees advocated for re-classification of food, housing, and other non-medical services as claimable expenses that would count toward rate determinations. Others cautioned against reclassifying social services as covered medical benefits on both financial and ethical grounds. Not only would it be prohibitively expensive for MMCOs to routinely provide social services to a much larger proportion of the Medicaid population, but such a shift would also raise a more fundamental question about the purpose and obligations of Medicaid: is Medicaid the ideal mechanism to address social needs? “What I worry about in this day and age of really embracing the social determinants of health is that there will be a tremendous push to make that into treatments and care that then have to be paid for in the healthcare system. We can’t keep doing that, right?” Finally, MMCO leaders expressed concern about sustaining SDH programs after CMS waiver expiration, as many waivers provide crucial funding and guidance for innovative SDH programs. They noted that access to additional federal grants and shared savings dollars would help to fill this gap. The MMCO leaders described a desire to improve coordination between CMS and state Medicaid programs. They reported that lack of coordination increases ambiguity around federal law interpretation and can increase MMCO concerns about penalties from unintentional failures to comply with state or federal regulations. This fear discouraged MMCOs from integrating SDH innovations. Increase Medicaid MCO input into policy-making. The MMCO leaders suggested increasing MMCO stakeholder engagement in state discussions around waivers, rules, and regulations aimed at increasing MMCOs’ SDH activities. In one state, though MMCO input on waivers was requested by the SMA, the CMS waiver application was seen as a largely SMA activity. Though some MMCO leaders indicated that state contractual requirements could serve as powerful motivators for MMCOs to address SDH, other leaders cautioned against that mechanism, given that existing SDH requirements have not reflected the financial and infrastructural capacities of MMCOs. Regardless of the ultimate opinion on contracts, the impression captured from informants is reflected in the following comment: “When the state tries to do a policy without talking to the people on the ground, they come up with crazy ideas… To formulate good policy, they need to include the people they’re trying to regulate.” The MMCO leaders also noted that although there are public resources for various SDH-related services, such as housing and early childhood interventions, they are ] 2016
5
rarely integrated across government sectors. For MMCOs, this has translated into difficulty “piecing together…money from different pots to meet a client’s overall set of needs.” One strategy suggested by informants was that SMAs act as key interagency conveners to streamline collaboration and funding opportunities. Facilitate program evaluation and data sharing. A lack of accessible data on reproducible models for SDH intervention design and return on investment produced by these interventions was often cited as a deterrent to SDH initiatives. Although the economic impact of most medical procedures is unknown, MMCO leaders felt the lack of program evaluation and return on investment data for SDH programs particularly acutely—perhaps because these programs are more difficult to justify than traditional medical services. Describing a lack of in-house evaluation expertise and resources, several MMCO leaders suggested that SMAs could serve as catalysts for improved evaluation, data sharing, and dissemination of best practices.
DISCUSSION Findings shed light on the complex relationships between state-level policies and MMCO’s attempts to address members’ health-related social needs. Although CMS increasingly supports a wide range of disease prevention efforts,27–29 MMCO leaders nonetheless reported significant regulatory barriers to incorporating SDH-oriented solutions into routine healthcare delivery. The managed care model asserts that an MMCO that reduces medical costs by improving member health and healthcare delivery will benefit financially. The views expressed in these interviews challenge this framework’s suitability for promoting SDH innovations because many SDH-promoting services may instead translate into financial losses. The potential erosion of future premiums, financial penalties, and increases in high-risk membership serve as disincentives for MMCO investments in this arena. These disincentives may translate to related efforts to address members’ SDH through moretraditional MMCO service delivery areas, like behavioral health integration or primary care transformation.
Limitations Although sampling attempted to maximize diversity, participants represent only a small fraction of the nation’s MMCOs. Moreover, the sample was not large enough to capture variation in perspective by plan type or specific regulatory differences between states, which may be particularly relevant for MMCOs operating in more than one state. Another limitation is introduced by the exclusive focus on the perspectives of MMCO leaders.
6
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]]
Future interviews with state and federal Medicaid staff could reveal additional incentives and limitations around how government policies could support MMCO efforts to address SDH. Non–health sector studies also might include questions on whether health-related arguments could catalyze increased funding for social services from other sectors, which may serve as a more efficient use of government resources.30 Although these qualitative findings are not intended to be generalizable, they are nonetheless broadly relevant, particularly given that informants described payment systems and regulatory barriers that are common across MMCOs and SMAs.
CONCLUSIONS It is notable that the funding barriers identified by informants have not completely prevented MMCOs from employing innovative strategies (e.g., waivers, grants, and community partnerships) to address their members’ social needs. However, MMCO leaders recommend that SMAs strengthen MMCO SDH investments by clarifying financial incentives, increasing MMCO engagement in state regulatory decisions, and better aligning federal and state funding and regulations. Without these changes, the Center for Medicare and Medicaid Innovation pilot programs, regardless of impacts on patient health, are unlikely to become sustainable components of the healthcare delivery system.
ACKNOWLEDGMENTS The authors acknowledge the Commonwealth Fund for their support and Stephanie Chernitskiy for assistance editing the manuscript and creating Figure 1. Laura Gottlieb, MD, MPH, and Andrea Quiñones-Rivera, MDc, contributed equally to this work and are co-first authors. No financial disclosures were reported by the authors of this paper.
REFERENCES 1. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80–94. http://dx.doi.org/10.2307/2626958. 2. Adler NE, Stewart J, eds. Socioeconomic status and health in industrial nations: social, psychological, and biological pathways. Ann N Y Acad Sci. 1999;896:1–503. 3. Adler NE, Stewart J. Preface to the biology of disadvantage: socioeconomic status and health. Ann N Y Acad Sci. 2010;1186:1–4. http: //dx.doi.org/10.1111/j.1749-6632.2009.05385.x. 4. Kaplan GA, Shema SJ, Leite CM. Socioeconomic determinants of psychological well-being: the role of income, income change, and income sources during the course of 29 years. Ann Epidemiol. 2008;18 (7):531–537. http://dx.doi.org/10.1016/j.annepidem.2008.03.006. 5. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annu Rev Public Health. 2011;32:381–398. http: //dx.doi.org/10.1146/annurev-publhealth-031210-101218.
6. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129(suppl 2): 19–31. 7. Beck AF, Henize AW, Kahn RS, Reiber KL, Young JJ, Klein MD. Forging a pediatric primary care-community partnership to support food-insecure families. Pediatrics. 2014;134(2):e564–e571. http://dx. doi.org/10.1542/peds.2013-3845. 8. Dubowitz H, Feigelman S, Lane W, Kim J. Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model. Pediatrics. 2009;123(3):858–864. http://dx.doi.org/ 10.1542/peds.2008-1376. 9. Garg A, Marino M, Vikani AR, Solomon BS. Addressing families’ unmet social needs within pediatric primary care: the Health Leads model. Clin Pediatr (Phila). 2012;51(12):1191–1193. http://dx.doi.org/ 10.1177/0009922812437930. 10. Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296–e304. http://dx.doi.org/10.1542/peds.2014-2888. 11. Sege R, Preer G, Morton SJ, et al. Medical-legal strategies to improve infant health care: a randomized trial. Pediatrics. 2015;136(1):97–106. http://dx.doi.org/10.1542/peds.2014-2955. 12. The Menges Group. Positively impacting social determinants of health: how safety net health plans lead the way. www.communityplans.net/ Portals/0/Fact%20Sheets/ACAP_Plans_and_Social_Determinants_of_ Health.pdf. Published 2014. Accessed November 25, 2014. 13. Gottlieb L, Garcia K, Wing H, Manchanda R. Clinical interventions addressing non-medical health determinants in Medicaid Managed Care. Am J Manag Care. 2016;22(5):370–376. 14. WHO Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health, CSDH Final Report. Geneva: WHO, 2008. 15. Meyer H. A new care paradigm slashes hospital use and nursing home stays for the elderly and the physically and mentally disabled. Health Aff (Millwood). 2011;30(3):412–415. http://dx.doi.org/10.1377/hlthaff. 2011.0113. 16. Sandberg SF, Erikson C, Owen R, et al. Hennepin Health: a safety-net accountable care organization for the expanded Medicaid population. Health Aff (Millwood). 2014;33(11):1975–1984. http://dx.doi.org/ 10.1377/hlthaff.2014.0648. 17. Grimes KE, Mullin B. MHSPY: a children’s health initiative for maintaining at-risk youth in the community. J Behav Health Serv Res. 2006;33(2):196–212. http://dx.doi.org/10.1007/s11414-006-9013-7. 18. Bielaszka-DuVernay C. Vermont’s blueprint for medical homes, community health teams, and better health at lower cost. Health Aff (Millwood). 2011;30(3):383–386. http://dx.doi.org/10.1377/hlthaff. 2011.0169. 19. Coffey AJ, Atkinson PA. Making Sense of Qualitative Data: Complimentary Research Strategies. Thousand Oaks, CA: Sage Publications; 1996. 20. Denzin NK, Lincoln YS, eds. The SAGE Handbook of Qualitative Research. 3rd ed, Thousand Oaks, CA: Sage Publications; 2005. 21. Centers for Medicare and Medicaid Services. Benefits. Medicaid.gov. www.medicaid.gov/medicaid-chip-program-information/by-topics/ benefits/medicaid-benefits.html. Accessed December 23, 2015. 22. Kaiser Commission on Medicaid and the Uninsured. Federal core requirements and state options in Medicaid: Current policies and key issues. Issue Brief. https://kaiserfamilyfoundation.files.wordpress.com/ 2013/01/8174.pdf. Published 2011. Accessed December 23, 2015. 23. National summary of state Medicaid manged care programs: program descriptions as of July 1, 2012. www.medicaid.gov/medicaid-chip-program-information/by-topics/data-andsystems/downloads/medicaid-mcenrollment-report.pdf. Published 2012. Accessed December 23, 2015. 24. Silow-Carroll S, Rodin D. Forging community partnerships to improve health care: the experience of four Medicaid managed care organizations. Issue Brief. 2013;19. www.commonwealthfund.org//media/
www.ajpmonline.org
Gottlieb et al / Am J Prev Med 2016;](]):]]]–]]] files/publications/issue-brief/2013/apr/1687_silowcarroll_forging_com munity_partnerships_medicaid_managed_care_ib.pdf. Accessed December 23, 2015. 25. Centers for Medicare and Medicaid Services. Waivers. Medicaid.gov: keeping America healthy. www.medicaid.gov/Medicaid-CHIP-Progra m-Information/By-Topics/Waivers/Waivers.html. Accessed November 1, 2015. 26. Musumeci M. Key themes in captiated Medicaid managed long-term services and supports waivers. Issue Brief. http://files.kff.org/attachment/ key-themes-in-capitated-medicaid-managed-long-term-services-and-sup ports-waivers-issue-brief. Published 2014. Accessed December 23, 2015. 27. Wachino V. Coverage of housing-related activities and services for individuals with disabilities. CMCS Informational Bulletin.
] 2016
7
www.medicaid.gov/federal-policy-guidance/downloads/CIB-06-262015.pdf. Published 2015. Accessed May 4, 2016. 28. Office of the Assistant Secretary for Planning and Evaluation. Medicaid and permanent supportive housing for chronically homeless individuals: emerging practices from the field. https://aspe.hhs.gov/report/medicaidand-permanent-supportive-housing-chronically-homeless-individualsemerging-practices-field. Published 2014. Accessed May 4, 2016. 29. Mann C. Medicaid payment for services provided without charge (free care). www.medicaid.gov/federal-policy-guidance/downloads/smdmedicaid-payment-for-services-provided-without-charge-free-care.pdf. Published 2014. Accessed May 4, 2016. 30. Bradley EH, Taylor LA. The American Health Care Paradox: Why Spending More Is Getting Us Less. New York, NY: Public Affairs; 2013.