Transforming DC Medicaid to Most Effectively Serve Enrollees

Improve MCO access and quality to member demographic data:

Access to demographic and social determinants of health (SDOH) data is critical to allow CHPDC to better understand and address disparities within the communities we serve. Data equips us to design and implement targeted activities that address health inequities and upstream determinants of illness. It informs CHPDC’s robust SDOH programs, including our Wellness Centers, care management programs, maternal health programs, and initiatives to address homelessness. However, the availability and quality of SDOH and demographic data are limited.

The DC Department of Health Care Finance (DHCF) should work with MCOs to improve the accuracy and completeness of this data. CHPDC supports initiatives such as the DC Community Resource Information Exchange (DC CoRIE), which captures SDOH information from various providers and organizations to serve as a central repository for providers. Building trust with enrollees on the importance of collecting this data is also paramount.

Another opportunity to increase collection of SDOH data is through the provider office. Leveraging ICD-10 Z codes, providers can capture SDOH-related information within the electronic health record. However, current use of Z codes lags due to lack of awareness, lack of education, staff limitations, and provider concerns. DHCF should work with providers and MCOs to explore how to increase uptake of these codes and more collection of SDOH data, such as providing incentives and education for providers.

Train linguistically and culturally competent providers:

Racial and ethnic minorities experience significant disparities in treatment and outcomes due to stress, stigma, lack of access to care, and other factors. To address these disparities, the District should invest in pipeline programs that recruit diverse candidates and train culturally and linguistically competent providers. For example, the DC Workforce Investment Council provided $250,000 per year in grants to increase the number of District residents employed in the healthcare industry. CHPDC also supports requiring providers to complete cultural competence and implicit bias training to address certain negative beliefs or unconscious bias in the healthcare setting.

Improve maternal health:

Medicaid plays a pivotal role in maternal health, covering more than 40% of births across the United States and in the District. Nevertheless, maternal and infant health outcomes and disparities remain a significant challenge. DC’s maternal mortality rate in 2019 was 35.6 per 100,000 live births, exceeding the national average of 29.6. The District also experiences stark disparities in infant health. In 2016, the District’s infant mortality rate among Black mothers was 4.5 times that of white mothers, with rates highest in Wards 5, 7 and 8.

DC should continue to explore and invest in innovative models that provide enhanced prenatal and perinatal care to women. CHPDC supports Medicaid coverage of doulas, as provided in the Budget Support Act of 2021. Doula services have been shown to have lower rates of preterm and cesarean birth. CHPDC also supports the Certified Midwife Credential Amendment Act of 2021, which establishes scope of practice and licensure requirements for Certified Midwives and provides for Medicaid coverage.

In expanding the kinds of providers that can deliver maternal health care, CHPDC also recommends that such providers are trained to address psychosocial issues unique to the needs of Medicaid enrollees.

Collaborate with MCOs to address SDOH needs:

SDOH serve as the basis for deep disparities in health outcomes. Addressing them is critical to resolving longstanding health inequities within our communities. Given Medicaid’s coverage of low-income and vulnerable individuals, MCOs are uniquely positioned to identify and address these disparities.

Recent CMS guidance identifies various strategies and authorities that can be leveraged to equip MCOs to address SDOH. We recommend DHCF work with MCOs to investigate these programs and flexibilities to understand how we can better meet the needs of the District, including potentially:

• Pursuing an 1115 waiver that provides the District with greater latitude to obtain federal matching funds for SDOH-related services. For example, North Carolina has an 1115 waiver that supports individuals with housing, food and transportation insecurity.
• Providing increased flexibility around “in-lieu-of” services to address SDOH needs.
• Encouraging proliferation of SDOH-focused value-based care models, including pay-for performance, shared savings/risk, pay for success and capitated arrangements.
• Encouraging cross-sector collaborations with other District social service agencies and programs, such as pooled funding arrangements across multiple state agencies.

Expand access to housing and housing-related supports:

The evidence is clear—access to housing impacts health outcomes. Lack of housing or poor housing conditions can impact chronic disease management, impede access to healthcare services, and exacerbate mental health conditions. Research has shown supportive housing leads to a decrease in emergency department use and helps people with disabilities live stably within the community. Housing provides those experiencing homelessness protection from extreme weather conditions, a place to store medications, and reduces other dangers.

MCOs are well situated to help identify and address housing instability and homelessness. Moreover, the case management and data analytics tools CHPDC uses position us well to identify and support our enrollees with housing needs.

CHPDC recommends several actions to DHCF to better equip MCOs to support enrollee housing needs and improve health outcomes. First, DHCF should foster more cross-sector collaborations with other District agencies, such as the Department of Housing and Community Development (DHCD), to support MCO housing-related projects and remove cumbersome administrative barriers. For example, DHCF and DHCD recently worked together to produce 54 affordable housing units in Ward 4 for low-income seniors with assisted living needs. CHPDC is eager to provide support such as temporary housing for our highest risk members.

Second, DHCF should investigate innovative 1115 waivers to incorporate and test further expansions of housing-related support within the Medicaid program. For example, Arizona submitted an 1115 waiver proposing coverage of short-term transitional housing and eviction prevention services for those experiencing homelessness or housing instability.

Finally, CHPDC supports further District investments in affordable housing, including both rental payment assistance programs and capital subsidies to create affordable housing. To that end, we look forward to the District’s continued use of American Rescue Plan Act dollars to further these efforts.

Increase participation on advisory boards:

To ensure enrollee needs are heard and addressed, CHPDC recommends DC take steps to increase community participation in advisory boards. Potential solutions include providing enhanced incentives, conducting outreach, alleviating potential barriers such as childcare and transportation, and providing the equipment and training necessary to participate.

Require OTPs to report prescribing of SUD medications to the District’s PDMP:

Per a recent Substance Abuse and Mental Health Services Administration final rule, states are allowed to request Opioid Treatment Programs (OTPs) submit medication information to a state’s Prescription Drug Monitoring Program (PDMP) after obtaining patient consent. Previously, OTPs were generally not allowed to disclose information to a PDMP. This practice has dangerous consequences for patients. For example, a physician outside the OTP may not be aware the patient is already receiving methadone, leading to duplicate or conflicting prescriptions that could lead to overdose or death.

MCOs and providers should have a comprehensive view of their Medicaid enrollee’s health records to ensure high-quality and coordinated care can be provided. Requesting OTPs submit data to the District’s PDMP will improve care coordination and better prevent opioid overdose and therapeutic duplication. It will also allow MCOs and providers to have a more holistic view of their Medicaid enrollees.

Establish a District-wide policy on prescribed suboxone above the FDA-approved amount:

The Food and Drug Administration (FDA) identifies the target dosage for suboxone to treat opioid use disorder generally between 16mg/4mg to 24mg/6mg buprenorphine/naloxone per day, depending on the particular patient. The FDA also notes dosages above 24mg/6mg have not shown clinical significance. CHPDC understands that currently, there is great variation in suboxone prescription patterns in the District, leading to confusion and potential patient safety concerns.

As such, CHPDC recommends DHCF establish a District-wide policy for prescribed dosages above 24mg/6mg. Such dosages should only be provided if certain guardrails are in place, including ensuring the patient is actively participating in a substance use counseling or treatment program.

CHPDC recognizes the need to ensure broad access to treatment for individuals coping with substance use disorder. However, this need must also be balanced to ensure patients are adequately protected, advocated for, and supported on their path to recovery. These guardrails will help strike this balance.

Prevent future drug carveouts:

DHCF should not require additional drug carveouts. When MCOs have line of sight into the entire continuum of a member’s care, including medical, behavioral and pharmacy benefits, they can coordinate care for their members and ensure patient safety by monitoring for errors such as harmful drug interactions.

In addition to increased care coordination—drug carve-ins can reduce costs for the DC Medicaid program. A 2015 study, which compared state Medicaid programs that carved in prescription drugs to those that did not, found that carve-in programs slowed the growth of Medicaid expenditures. Across the 28 states using the carve-in model, net costs per prescription were 14.6% lower for MCO-paid prescriptions than the average in fee-for-service (FFS) states, suggesting total Medicaid savings of $2.06 billion for states deploying the carve-in model.

Continue to provide MCOs with the flexibility to manage their own formularies:

MCO formularies undergo frequent review and are carefully managed to ensure the most clinically effective medications at the lowest net cost are available. DHCF and the DC Council should not mandate Medicaid coverage of expensive brand-name drugs when equally effective lower-cost alternatives are available.

Study the impacts of telehealth:

Telehealth played a vital role during the pandemic, ensuring individuals had continued access to care, preserving critical healthcare resources, and reducing the spread of COVID-19. As we look to the future of telehealth in a post-pandemic world, CHPDC recommends DHCF work with MCOs to examine the value, cost, access and quality of audio-only and video visits, as well as the comparative effectiveness of different modalities of care in different situations.

CHPDC believes there is no one-size-fits-all approach for telehealth policy. Telehealth may be more appropriate in certain clinical scenarios (e.g., teletherapy) versus others. This is especially true for audio-only visits, which may not be appropriate for services that require a video/image (e.g., dermatology). Adapting telehealth flexibilities and mandating payment parity without careful consideration and study may result in unintended consequences and widen healthcare access disparities, especially among those without access to broadband.

Telehealth coverage should also be sensitive to the unique circumstances of Medicaid enrollees. Telehealth, including audio-only, may be more appropriate for certain individuals without access to visual technology. Telehealth may also be more appropriate for individuals who need additional flexibility to visit the doctor due to hourly wage employment and lack of transportation options.

Expand Broadband:

Almost 1 in 3 Americans who lack access to the internet are covered by Medicaid. Given the rapid acceleration of telehealth during the pandemic, disparities in broadband access can translate into disparities in healthcare access. Broadband is also an important SDOH that can influence many other aspects of daily life, such as online learning and searching for employment. However, significant gaps in broadband access persist, exacerbating inequity in healthcare access and other socioeconomic disparities.

CHPDC supports the District’s budgetary commitments to expand broadband. We emphasize that solutions to broadband access will differ across urban and rural areas. While infrastructure is important, urban communities such as DC may benefit from payment assistance to subscribe to such services.

Carve-in behavioral health care services:

Over the last decade, more and more states have moved towards carving behavioral health care services into MCO contracts. As of 2020, 23 states carve in specialty outpatient mental health services; 28 states carve in inpatient mental health services; and 29 states carve in inpatient and outpatient substance use disorder (SUD) services. The District also recently began the planning process to carve in certain behavioral health care services, starting in October 2022.

CHPDC supports these efforts and looks forward to continued collaboration with DHCF and the DC Department of Behavioral Health in the Behavioral Health Stakeholder Advisory Workgroup. Greater behavioral and physical health care integration will better equip us to deliver coordinated, whole-person care to our members, improving outcomes, costs and quality.

Create incentives to train and recruit high quality and diverse behavioral health providers:

Nationally, shortages are projected for six behavioral health types, including psychiatrists, behavioral health counselors and social workers, by 2025. The District contains ten mental health professional shortage areas, with only 5.3% of needs met. In FY 2019, 20% of District Medicaid beneficiaries had an SMI, SED or SUD diagnosis, and 9.3% of DC residents reported an unmet behavioral health need. To promote the growth of the behavioral health workforce, the District should:

• Establish a loan forgiveness program for students choosing behavioral health specialties
• Provide funding support for behavioral health residency programs
• Support pipeline programs that train linguistically and culturally competent providers to improve behavioral health workforce diversity
• Encourage delivery of behavioral health care interventions by other allied health professionals, including licensed clinical social workers

Support innovative models that integrate behavioral health with primary care:

Medicaid enrollees coping with behavioral health diagnoses are more likely to have multiple co-occurring chronic health needs, such as diabetes, cancer and asthma. However, behavioral and physical health care is often siloed in practice—resulting in undiagnosed and unmet needs in primary care clinics and mental health settings. This results in additional costs—the addition of mental illness to common chronic physical conditions can increase healthcare costs by up to 75%.

DHCF should work with MCOs to encourage provider care models that integrate behavioral and physical health to provide whole-person care to Medicaid enrollees, facilitating earlier diagnosis and treatment. Models can expand the types of providers that can provide behavioral health care services, such as counselors, peer-to-peer support and community health workers. Screeners that identify patients with behavioral health issues could also be required within the primary care settings.

Support value-based care models that integrate care:

The behavioral health carve-in also presents a unique opportunity to leverage value-based care approaches to incentivize greater integration and management of behavioral health care issues. We encourage DHCF to work with MCOs and providers to explore and pilot innovative models that build upon the District’s current value-based care initiatives and advance the delivery of behavioral health care and the transition from volume to value.

DHCF can look to other state Medicaid programs that have implemented value-based care initiatives within their behavioral health care delivery systems. For example, Arizona launched a Targeted Investments Program that allows health plans to make payments to providers building infrastructure for delivering integrated physical and behavioral health care services. New York has implemented an “Integrated Primary Care with the Chronic Care Bundle” that holds providers responsible for the cost and quality of services related to 14 chronic conditions incorporating both behavioral and physical health.

Implement an MLTSS program:

Use of managed care to deliver long-term services and supports (MLTSS) is becoming increasingly common in the United States. The number of states using MLTSS grew from eight states in 2004 to 24 states in 2018. State Medicaid agencies cite many reasons for switching from FFS to managed care, including improving member experience and health outcomes, increasing access to services, introducing more budget predictability, and better managing costs. The use of Home and Community-Based Services (HCBS) has also gained prominence in recent years. Individuals increasingly prefer to live and receive care at home rather than in an institutional setting, such as a nursing home. HCBS is also a priority for the Biden Administration.

Individuals requiring LTSS are among the most vulnerable, high-cost beneficiaries enrolled in Medicaid. By implementing a managed care approach, MCOs can effectively coordinate care and better assist individuals in integrating into an HCBS setting. Among those states with MLTSS, Medicaid beneficiaries consistently report better experiences with care, higher quality of life and better access to HCBS.

Given the clear benefits of MLTSS and the national trend towards HCBS and MLTSS, CHPDC recommends DCHF explore implementing an MLTSS program in the District. Pursuing more integrated models of care for this vulnerable population aligns with our mission, and we are eager to partner with DHCF in exploring avenues to better serve and care for these individuals.

Address home care workforce shortages:

Despite increased interest in and demand for HCBS, shortages in the home care workforce continue to grow. The Bureau of Labor Statistics estimates demand for home care workers will increase by 34% over the next decade, and another estimate finds there could be a shortage of over 355,000 home care workers by 2040. This, in part, is due to the aging population, with 20% of the US population projected to be age 65 or older by 2030. The home care workforce also endures low wages and poor benefits, translating into high turnover rates.

CHPDC supports the workforce investments DHCF has requested in its HCBS spending plan to leverage the 10% enhanced federal match provided by the American Rescue Plan Act. As these enhanced funds expire in mid-2022, CHPDC recommends the District continue to invest in the following solutions to address workforce shortages and improve retention:

• Increase reimbursement rates for home care worker services and ensure rate increases translate to increased worker wages.
• Expand professional development and training opportunities for workers.
• Explore partnerships with academia and other organizations to provide opportunities for home care workers to advance their careers and grow into other health professions.
• Establish pipeline programs that recruit and train home care providers.
• Address ancillary costs incurred by home care workers, such as transportation to patient homes.
• Establish pay-for-performance metrics that reward home care agencies on certain staffing metrics, such as team development efforts, consistent staffing and proper training.