Rethinking How Medicaid Patients Receive Care

In 2015, CareMore embarked on a journey to transform care delivery in Medicaid with the aim of leveraging its 20-year history in providing comprehensive care for seniors under Medicare. To many at the time, we were fools.

Critics outside of CareMore issued an ugly forecast: Our resource-intensive approach to care would never survive on Medicaid’s meager reimbursement levels. Great physicians would never choose to treat Medicaid patients. Medicaid’s ever-shifting eligibility requirements would disrupt any efforts to treat patients for years at a time. And, if we somehow overcame those hurdles, the patients themselves were too barricaded by socioeconomic barriers or structural inequalities to respond to anyone’s well-intentioned efforts to treat them.

There were internal doubts as well. CareMore’s longtime focus had been providing patient-centered, managed care to seniors in California, Arizona, Nevada, and Virginia under Medicare Advantage. Many of the organization’s veterans saw our Medicaid ambitions as an unwise detour into treacherous territory. How would we deliver care to a population overburdened with severe mental illness, food insecurity (the lack of consistent access to enough food to lead an active, healthy life) and early-onset chronic diseases — and do so in locations as disparate as Tennessee and Iowa?

Nonetheless, CareMore’s leaders decided to move ahead and launched a Medicaid care-delivery program in Memphis and Des Moines, serving 8,000 to 10,000 patients in each market. We described our early progress in this 2015 HBR article. Now, as we begin to scale our care-delivery model to multiple new geographies, we’d like to share what more we’ve learned from our experiences in the two initial markets — lessons we think are applicable to other populations as well.

Comprehensive, relationship-based primary care. Relatively few of Medicaid’s 67 million beneficiaries have a primary care doctor. Many distrust the American medical profession, but many of those who would entrust a doctor with their care can’t afford one or face logistical or geographic barriers to finding one.

Consequently, we knew that in order to serve the Medicaid population well, we needed to create convenient and completely free access to comprehensive care, staffed by clinicians who empathized deeply with our patients’ needs and who had the resources to address fundamental barriers to health.

The first step was finding caregivers dedicated to ministering to the underserved. Some of our earliest hires had lacked the true compassion needed to earn the trust of patients. Not only did this small complement of clinicians alienate patients, but they also drove away our best hires: those who had joined CareMore so they could pour their heart and soul into patient care.

So, we made radical team changes and started again with a new set of employee-screening techniques. Chief among them were behavioral-interview methods to uncover candidates’ intrinsic motivations and biases. Asking simple questions, like “tell me about a time where you helped someone change his or her approach to health,” we found, could compel candidates to share stories of guiding patients to life-changing decisions or, conversely, reveal a candidate’s contempt for individuals struggling with addiction. We also invested significant leadership time in performing final interviews for all roles — from medical assistants to physician leaders — to ensure that each team member would strengthen the team’s dedication. We now speak of finding team members who were “CareMore before they joined CareMore” — in other words, people have already demonstrated our philosophy of care in their professional journeys.

Using this approach to build each new Medicaid team, we then armed the primary care team with the operating structure, data, and incentives needed to create engagement with our patients wherever they are, enveloping them with compassion and the latest in evidence-based care.

Our primary care clinicians operate in multidisciplinary teams. Each team is assigned a group of patients near its clinic for direct oversight, to identify new problems they are facing, and trigger interventions by the right team members. For example, during a clinical huddle, a pharmacist may identify the potential for a medication complication and trigger CareMore’s mobile team to visit the patient’s home that day to review the medications being taken. CareMore teams also organize transportation for patients to medical appointments and offer same-day visits, extended hours, and online video consultations to create multiple, convenient access points for patients.

We also equip the teams with data-rich dashboards that monitor their patients’ engagement, satisfaction, and, of course, health metrics, while also tracking broader population-level trends in clinical outcomes and avoidable — and often unnecessary or harmful — procedures and hospitalizations. These dashboards combine data from health plan partners, such as claims data and approvals for hospitalizations, with electronic-medical-record data, and provide a comprehensive, real-time view of key metrics in quality, cost, and experience. As a result, these dashboards enable CareMore clinical teams to dynamically adjust their outreach and clinical priorities, shifting attention to where they can provide the most benefits to patients.

Last, in order to align our employees’ performance with our patients’ health, up to 35% of staff compensation is based on their ability to achieve engagement, satisfaction, and clinical outcome goals. Put simply, they’re rewarded for doing well by our patients.

Collaborative behavioral health. As many as 25% to 30% of adults on Medicaid suffer from serious mental-illness and substance-abuse disorders. We have found that behavioral-health issues, even when identified, are frequently misdiagnosed and mismanaged by a shifting cast of clinicians in inpatient and outpatient settings. To better serve our patients, we wove our behavioral health team’s expertise into everything we do.

Our psychiatric and therapy teams directly care for patients with more severe conditions and provide high-acuity care such as long-acting injectable antipsychotics. However, they spend equal time consulting with the primary care team on their patients’ behavioral health issues, ensuring that we find the right diagnoses and treatment options for the entire patient population.

In addition to our frontline caregivers, we add a critically-important layer of clinicians known as care management specialists, who support patients through transitions from hospitals back to their home. They visit patients with behavioral-health needs during inpatient and residential psychiatric care episodes, connecting them with the primary care team, specialists, and other resources after discharge so they are effectively engaged in continuous care. These specialists also longitudinally track patients with high-risk medical conditions such as heart failure or diabetes.

As a result of our collaborative behavioral-health model, over 75% of patients who saw CareMore’s behavioral health team in Iowa in 2017 also saw our primary care team. And in Tennessee, we reduced behavioral-health-related readmissions for our Memphis population from 40% in 2016 to 13% in 2017 and 2018.

Community and patient engagement focused on social needs. Placing clinics in convenient locations for patients isn’t enough; care delivery organizations also need to go further in meeting Medicaid patients where they live, work, and access other services. Accordingly, CareMore deploys specialists known as community health workers — often experienced social workers who act as the worried family member for high-risk patients. These specialists are trusted members of a community who have a deep understanding of the local context — be it historical, social, economic, or health-related — and how we can break through barriers that are often unseen by other health care providers.

The team reaches out to patients by phone and in person, finding them at home and alternative sites such as jails and shelters. On average, our community health workers will try to reach a high-risk patient seven times before successfully engaging them in a conversation about their health care. In each engagement, community health workers strive to understand a patient’s beliefs and social context. By forming this relationship first, community health workers can then identify concerns around housing, food, or finances that patients are sometimes too uncomfortable to convey and help them overcome that stigma to access the social and clinical services they need.

Through repeated outreach conversations in Memphis, for example, our community health team identified a patient’s primary barrier to breaking a toxic cycle of repeated hospitalizations. The obstacle: a custody battle for her child in which the woman’s behavioral health had become an issue for the court. The community health worker helped her obtain legal support, and her CareMore primary care physician submitted a letter to the court attesting to the improvement in the patient’s behavioral-health condition. The mother won custody of her child, reunited her family, and we saw her hospitalizations and unnecessary utilization plummet to zero.

Removing silos between inpatient care and the community. For many patients on Medicaid, a hospitalization is an isolating and risky interlude that threatens to undermine a tenuous balance among work, family obligations, and financial resources while imposing new health concerns and treatment plans. To ensure a return to health, CareMore actively manages patients during hospitalizations and in the crucial hours and days following their discharge. We do this by staffing clinicians who wear the CareMore title of “extensivists”: physicians who care for patients not only during hospital episodes but also through the entire post-hospitalization period, in rehabilitation facilities and the home, until the patient is ready to return to primary care.

In some geographical areas, we have so few hospitalized patients that it makes little economic sense to employ extensivists. In these instances, CareMore’s care management team meets patients during hospitalizations in person on a regular basis to form relationships and coordinate care during the post-hospitalization period.

Because of our approach to connecting hospitalizations to follow-up care and oversight, CareMore’s Tennessee extensivists were the best-performing clinicians at Methodist University’s main Memphis hospital site in 2017 as measured by observed versus expected hospital length of stay and readmission rates. The upshot: Our extensivist model helped patients get home faster and come back to the hospital less often.

Similarly, our care management team meets 80% of hospitalized patients in Des Moines in person on a weekly basis. As a result of this engagement, three-quarters of those patients follow up in our care center within a week after discharge.

Our results. In Tennessee and Iowa, CareMore has delivered outcomes that have significantly improved care and reduced its cost. From May 2017 to April 2018, CareMore’s Medicaid patients in Tennessee experienced 10% to 17% fewer days in the hospital, 21% to 22% fewer ER visits, and 23% to 28% fewer specialist visits than other Medicaid managed care beneficiaries in the same geography, across Medicaid eligibility categories.

In Iowa, the impact has been similarly sizable for those on Temporary Assistance for Needy Families (TANF) support and in the ABD cohort. These differences in avoidable utilization produced millions of dollars annually in cost of care savings for Tennessee and Iowa.

Next Steps

CareMore’s robust and durable outcomes against other primary care groups have led its leaders to aggressively scale our model to new geographies, including Washington, D.C.; Texas; and New York. This success in extending CareMore’s core principles to new populations has also led it to launch a division dedicated to designing, testing, deploying, and scaling care models and clinical innovations that radically improve population outcomes. We intend to address food insecurity through home meal delivery, bring hospital-level care into the home, and equip behavioral-health teams to provide medication-assisted treatment onsite for substance abuse.

We believe that we are proving that Medicaid managed care plans and care delivery organizations can be dramatically improved. Those improvements, in turn, can be extended to improve the cost and quality of care to other populations. The key is designing care models that cater to a population’s special needs.