An Interview with Catherine Strode
Health Affairs is the leading health policy journal in the country. The journal’s Editor-in-Chief, Alan Weil, recently gave a presentation in Denver on an overview of the evolution of the country’s Medicaid program. An elected member of the National Academy of Medicine, and an appointed member of the Medicaid and CHIP Payment and Access Commission, Alan is recognized nationally as an expert in health care policy.
In an interview with Catherine Strode, he explains why he views the future of Medicaid services optimistically for individuals in vulnerable populations.
What do you view as the major challenges of Medicaid to serve people in vulnerable populations?
“Nationally, Medicaid is in transition for how it serves some of the most vulnerable populations. Many states around the country are moving Medicaid enrollees who have been in a fee-for-service system into managed care. States are taking people with complex medical conditions, and complex social needs, and having them receive their services through a managed care organization. The promise of the move is better coordination, better integration. For those on Medicaid and Medicare, the potential is better alignment between the two programs. The risks are disruption of: long standing patterns of care, relationships with providers, and needed care being denied. States are finding that the disruption can be quite substantial. The more vulnerable the population, the more the risk of that disruption having serious medical or social implications. People who have been using Medicaid for a long time learn to navigate a fee-for-service system and find providers who meet their needs. If you are able to do that successfully, the shift to managed care can be very negative. A lot of people are unable to do that successfully so the resources managed care brings can be positive. The problem is when states make this move, they are doing it for everyone. There are some people who find themselves disrupted in really negative ways. Others who find themselves better off. There are always going to be some people in each of those categories.”
Does this evolution in Medicaid offer better health equity?
“Simply moving people from fee-for-service into managed care doesn’t improve equity. The potential is if the state, in contracting with the plan, makes equity a priority. If the plans are able to respond to that expectation, then managed care creates a point of accountability. A person facing barriers to care in a fee-for-service world is just out there on their own. The state is not going to see a problem. They are going to pay the claims but there’s no interaction that identifies the problem. When you enter a managed care system, there are people whose jobs are to assess needs. In more creative systems, there are people who look at those needs quite broadly and connect people to services. The health plan is paid a fixed amount. If there are inexpensive social barriers that are affecting people’s health, that plan has a financial incentive to help identify those needs.”
How do you see Medicaid evolving over the next decade?
“In the 1990’s states moved relatively uncomplicated populations, mainly moms and kids, into managed care. States had a couple of decades to work through those challenges and it is a fairly stable system. In the 2000’s states began also moving people with disabilities and elders into managed care. That has been a slower process; it’s far more complicated. What we’re seeing now is continuation of that trend, with increasing sophistication by health care companies and providers who understand the linkages between people’s social needs and their health. We’re seeing an increased interest in using managed care as the place to identify and address the social needs people have that drive their health expenses. The challenge is we spend so much money on healthcare and we underinvest in people’s social needs.”
Do you think health care companies are capable of addressing social needs?
“At this point, we don’t have much evidence that health systems are particularly good at addressing those needs. That is not the health system’s expertise. You have health systems hiring people, trying to figure out this world of social services. There’s no question addressing those needs is critical. The question is: who, what entities, with what resources, should be given the task of addressing those? The funding rests in health care. The logic is: if you’re getting a fixed amount, and addressing a social need will improve health, you have a financial incentive to invest in it. Trying to get the health sector to give up its money to another sector is a lot to ask. If you can’t come up with new money then you say, ‘How do we use the money we have in a more effective way?’ That’s what states that are relying more on managed care are doing. They’re saying, ‘This is where the money is. We’re going to reward you financially for making improvements.’”
Are you optimistic managed care will better address needs in the future?
“To me, optimism comes from two things. One is a sense of time. It took most of a decade to figure out how to make managed care work for medically uncomplicated populations. It’s going to take longer than that for people with more complex needs. There’s learning on part of: the state with its oversight, managed care organizations in how to best serve the populations, and providers. My other optimism is this understanding of social context. Although that’s been known for some time, I don’t think it has been embraced by the health sector until recently. As a 3.3 trillion dollar sector, it has a lot of resources to make something happen when it identifies something to be done. We’re seeing the sector as a whole understanding its role differently than it was in the past. That’s a reason for optimism.”
Catherine Strode is Advocacy Denver’s Communications and Policy Specialist. She holds a Masters degree in Public Administration with an emphasis in Health Care Policy. Catherine publishes Policy Perspective, featuring interviews with state policy makers on issues that affect the work and mission of Advocacy Denver.