Public Health: “Why can’t Medicaid pay for our stuff, haven’t they seen that it is evidence-based and will save money?”

Medicaid: “Why does everyone ask us to pay for their stuff?”

Like anyone in a happy marriage knows, it is invaluable to see the world through your partner’s lens. As the health care system undergoes significant transformation, many stakeholders and policymakers — including Medicaid and public health representatives — are seeking to change how they have traditionally worked by forging new partnerships, breaking down silos, and . . . seeing the world through each other’s lens.

With support from the Robert Wood Johnson Foundation, the Center for Health Care Strategies (CHCS) is partnering with the Centers for Disease Control and Prevention, as well as the Centers for Medicare & Medicaid Services, the Association of State and Territorial Health Officials (ASTHO), and the National Association of Medicaid Directors, and other partners to spur alignment to accelerate adoption of proven prevention strategies. Over the past three years, CDC’s 6|18 Initiative has supported Medicaid-public health partnerships in 34 states, local jurisdictions, and territories across the United States to accelerate adoption of proven prevention strategies.

In this blog, Mark Larson, former Medicaid director of Vermont and current vice president of policy at CHCS, and Deborah Fournier, former Medicaid director of New Hampshire and current senior director, Clinical to Community Connections at ASTHO, demystify the distinct yet complementary roles of public health and health care — and how these state agencies can align efforts around prevention strategies to impact health and costs.

Q: What are some common cultural and policy misconceptions that come up as obstacles to Medicaid-Public Health collaboration?

A: D. Fournier: I think public health often assumes that Medicaid is funded in the same way that public health is funded, meaning that there’s a grant, you apply for it, you receive the funding and then you report back at the end of that period about how you addressed the issue. The Medicaid infrastructure is vastly different from that, the least of which is that only certain people are eligible for Medicaid and it is not allowed to pay for services and individuals that are not covered.

M. Larson: Correct — Medicaid is a state-federal partnership and it has to navigate both state and federal authorities to make changes in policy and budget. It may appear that Medicaid does not appreciate the role of prevention, because historically, Medicaid is seen as serving simply to pay claims for enrolled individuals. Only recently has the concept of Medicaid as an active coordinator of care — with a goal of driving improvement in health outcomes — been part of the program’s identity.

Q: Why can’t state Medicaid agencies cover all evidence-based preventive services that are proven to improve health and control costs?

State Medicaid agencies have to be really clear about projected cost avoidance or demonstrable impact when they want to add a service, even if its long-term impact is evidence-based, because of the short-term timing of Medicaid’s annual budgeting cycle.

A: M. Larson: Actually Medicaid can pay for evidence-based preventive services, but it has to work through a process that can at times be excruciatingly complex. A state Medicaid program budget can equal 20-30 percent of the state’s budget.  So while it seems like including a new and relatively low-cost preventive service in a huge budget should be simple, the truth is that there is immense scrutiny of adding anything to the Medicaid budget because of its size. State Medicaid agencies have to be really clear about projected cost avoidance or demonstrable impact when they want to add a service, even if its long-term impact is evidence-based, because of the short-term timing of Medicaid’s annual budgeting cycle. Those two things — a long timeframe on realizing the impact of prevention and the short forward-looking window of a specific fiscal year — don’t always align easily.

Q:   Why do state public health departments want Medicaid to address everyone’s chronic health issues?

A: D. Fournier: From the public health perspective, they see themselves as “the people’s doctor” and are looking out for the entire population and all of its complexity throughout an entire state or territory. Medicaid operates more like an insurance program — responsible for a defined group of people and services — than like a state health agency. State agencies don’t all have the same populations to which they are obligated, which is why it is sometimes a challenge to see “the population” through the lens of other agencies or programs.

M. Larson: It makes sense to think about Medicaid’s role in supporting the health of beneficiaries over the course of the lifespan. This is part of what states can accomplish by developing cross-agency relationships and understanding of each other’s initiatives, goals, and how they operate. This also provides more opportunity for alignment with public health.

Q:   Medicaid has such rich patient-specific data. Why can’t it share more of it with public health? Also, how is public health data important to Medicaid?

A: M. Larson: Both public health and Medicaid have an obligation to protect the data they collect and to make sure it is used for the right purpose. Medicaid, because it is funding health care services, has an added responsibility because much of its data is protected health information. Beyond these technical considerations are opportunities based on relationship building, trust, and a common respect for what each agency is trying to accomplish. With this in mind, Medicaid and public health can find ways to share data in really meaningful and impactful ways.

D. Fournier: Also, public health agencies have many data sets at its disposal that provide a consolidated perspective on the top health risks and the disease burden across the state. The ability to combine these with Medicaid information around health status, service utilization, and costs can help guide a Medicaid program to think about how it needs to prioritize, what it needs to examine its own data for, and how those match up with the larger population health trends.

Q: Can you both describe the respective roles of Medicaid and public health agencies in terms of the high-burden, high-cost health conditions of focus in CDC’s 6|18 Initiative?

It’s also key to note that Medicaid-public health partnerships are not about creating similarities or converging roles. Instead, the focus is on understanding what each agency does well and leveraging those skills to achieve aligned goals.

A: M. Larson: Medicaid’s role is to be a delivery model and financing mechanism to help people gain access to services that help improve their health and quality of life. Key priorities from a Medicaid perspective are to: (1) help public health partners understand the complexity of the Medicaid bureaucracy; (2) participate in the process of envisioning and then operationalizing changes in benefits and coverage; and (3) share data. If those things can happen, you have the ability to start building a relationship with a common understanding and a shared sense of trust, which is fundamental.

D. Fournier: Public health has experience deploying interventions to improve outcomes – ranging from using community health workers to covering smoking cessation products to empowering patients to self-monitor their blood pressure. It’s also key to note that Medicaid-public health partnerships are not about creating similarities or converging roles. Instead, the focus is on understanding what each agency does well and leveraging those skills to achieve aligned goals. For example, in the 6|18 Initiative, participating state Medicaid agencies coordinate with Medicaid managed care plans to strengthen coverage of benefits and reach providers and members, while public health departments create a complementary consumer awareness campaign to increase uptake of covered services.

Q: What are some tips for successful partnership among public health and Medicaid?

Combining small successes and progress along the way can help demonstrate to internal and external stakeholders what is possible when public health and Medicaid work together and invest in the relationship.

A: M. Larson: I would reiterate that the more public health and Medicaid can understand the technical components of each other’s work, the less those become unintended obstacles to partnership. This opens the door to focus on building relationship and trust to enable collaborative work. Combining small successes and progress along the way can help demonstrate to internal and external stakeholders what is possible when public health and Medicaid work together and invest in the relationship.

D. Fournier: Each agency should put time aside to be genuinely curious and learn about what the other program is doing and what their priority goals and concerns are. After that, establish aligned goals and identify opportunities to work together. To put a fine point on it, public health: don’t start your “marriage” with Medicaid by asking them to pay for something! Both agencies should start from the assumption that they both desire to be good stewards of the people whose coverage is in their care and the related funds available to support them.

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