Medicaid and Public Health: Focus on Asthma

Stephen Cha, MD, MHSChief Medical Officer

Center for Medicaid and CHIP ServicesCenters for Medicare & Medicaid Services

June 13, 2013June 13, 2013

Medicaid and CHIP

•The Center for Medicaid and CHIP Services is the nation’s largest insurer: almost 60 million rely on Medicaid and CHIP

•40% of births•One of every four children•Joint state-federal program

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• The Center for Medicaid and CHIP Services is working to propel positive change forward to achieve: improved health of populations, improved experience of care, and reduced trends in cost• Goal is comprehensive, integrated patient-centered care and financing that supports these goals• Encourage and support our partners in this effort by clarifying policy and providing support

Medicaid Moving Forward

52 year old male• Asthma: Maximal meds already, still with ED visits, needs environmental modification• Diabetes: Meds, counsel on weight and diet• Hypertension: Meds, counsel on weight and diet• Obesity: Counsel on weight and diet• Tobacco: Refer quitline, pt still precontemplative• History of opiate addiction: S/p treatment, in counseling, concerned now that discharged to community• Depression: Meds, therapy at community center• Unstable housing: In housing now

Case study: Assessment and plan

52 year old male• Asthma: Maximal meds already, still with ED visits, needs environmental modification• Diabetes: Meds, counsel on weight and diet• Hypertension: Meds, counsel on weight and diet• Obesity: Counsel on weight and diet• Tobacco: Refer quitline, pt still precontemplative• History of opiate addiction: S/p treatment, in counseling, concerned now that discharged to community• Depression: Meds, therapy at community center• Unstable housing: In housing now

Where can public health and prevention resources improve this patient’s health?

• Asthma• Diabetes• Hypertension• Obesity• Tobacco• History of opiate addiction• Depression• Unstable housing

Problem list for Medicaid and public health together

•Driving question: How are our policies supporting or hindering the best practices on the ground to achieve three part aim?

•Strive for seamless set of services across silos– which entity is best situated to most efficiently and effectively achieve our goals?

•Medicaid must be a partner in prevention

Support Best Practices

• Silos: • State level: Medicaid vs public health vs mental health vs

chronic disease vs substance abuse vs perinatal • Federal level: Disparate agencies and strategies

• Legal/regulatory (i.e., other licensed personnel)• Need for partnerships• Challenges in heading into 2014

Challenges

1. State plan amendments/waivers–Broad systems reform under 1115: CA, MA, TX, OR–Targeted delivery reforms under waivers: asthma, interconception, LTC–Integrated Care Models (MN)

2. New authorities under Affordable Care Act–Medicaid Quality Measurement Program, health homes, HIT–Adult Quality grants–Others: healthcare acquired conditions, tobacco cessation, prevention, etc.- Section 4106: 1% bump for USPSTF validated services- Section 4004: Education and outreach on prevention, especially obesity

3. Collaboration with Center for Medicare and Medicaid Innovation (CMMI), Medicare-Medicaid Coordination Office (MMCO)–CMMI: State Innovation Models, Strong Start, CPCi, FQHC, chronic disease prevention incentives, emergency psychiatric demonstrations, Innovation challenge grants

–MMCO: Financial alignment models

4. Other departmental collaborations: National Quality Strategy, MHI, tobacco

Lots of mechanisms exist to support Medicaid innovation

• Tobacco• Pediatric asthma

Two case study areas for improving public health via Medicaid

• Quitlines

• Pregnant women

• Coverage policies

Tobacco

Massachusetts Pediatric Asthma Pilot Program

• Goal– Improve health outcomes, reduce asthma-related emergency department

utilization and asthma-related hospitalizations, and reduce associated Medicaid costs for children with high-risk asthma.

• Strategy– Preventative care using CHWs, care teams, and recognition of environmental

factors, measured by cost savings and service utilization measures.– PMPM payment

• Focus on preventative care– Utilization of non-traditional workers for preventative care

•HEPA filters for vacuum cleaners•CHWs for home visits and care coordination

– Explicit measurement of cost-shifting vs. cost reduction and effect/interaction of pilot with other state initiatives

• Practices are eligible for up to $10,000 in infrastructure payments related to this initiative (may not be implemented)

Massachusetts Pediatric Asthma Pilot Program

• Reporting Quality to the State– Progress measured by cost savings and service utilization

•Post-intervention data compared to baseline numbers

– Reduction of ED visits and hospitalizations is primary focus•CHIPRA measure on annual asthma-related emergency room visits is required

• State Quality Reporting to CMS– State must provide status updates on a quarterly basis including

payment, service, and outcome records

• CMS stands ready to partner with states, providers, and stakeholders to accelerate our path to achieve better health, better care and lower costs• Multiple pathways to reform• Driving question should not be our authorities, but the strength of evidence and appropriateness of intervention

Summary: Medicaid on the road to reform

Questions?