Transforming Maryland Medicaid to Most Effectively Serve Enrollees

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. Maryland contains 43 mental health professional shortage areas, with only 34.3% of needs met. Behavioral health providers are compensated at significantly reduced levels to their colleagues in other specialties, and medical students often choose higher-paid specialties to repay their medical education debt. To promote the growth of the behavioral health workforce, Maryland should:

• Establish a loan forgiveness program for students choosing behavioral health specialties
• Provide funding support for behavioral health residency programs
• Incentivize providers to practice in provider shortage areas
• Support pipeline programs that train linguistically and culturally competent providers to improve behavioral health workforce diversity

Support models that integrate behavioral health with primary care:

The COVID-19 pandemic has exacerbated the substance use disorder (SUD) epidemic. The Centers for Disease Control and Prevention (CDC) found more than 2,700 drug overdose deaths occurred in Maryland from November 2019 to November 2020, the highest number ever recorded in a 12-month period in the state. Recognizing the importance of addressing SUD, Maryland chartered one of its Statewide Integrated Health Improvement Strategy (SIHIS) goals to address opioid use disorder (OUD). As we look to curb OUD mortality in Maryland, we must consider innovative models of healthcare delivery that provide comprehensive care.

SUD care in Maryland is often siloed – resulting in undiagnosed and unmet needs in both primary care clinics and mental health settings. Studies (PDF) show individuals with SUD to be more likely to have other chronic health conditions, including HIV/AIDS, hypertension, coronary artery disease, and hepatitis.

As we look to address SUD and improve the delivery of behavioral healthcare, the Maryland Department of Health (MDH) should encourage care models that integrate behavioral and physical healthcare. Models of coordination range from referral agreements to co-located SUD, mental health, and physical healthcare services. Such models allow providers to deliver whole-person care to Medicaid beneficiaries, facilitating earlier diagnosis and treatment.

Improve reporting on behavioral health providers:

Accurate identification of behavioral health practices and providers has been difficult in CareFirst’s service area. To identify these providers and improve access to behavioral healthcare, MDH should require licensing boards of behavioral health provider specialties to publicly report their licensed and practicing behavioral health providers in a streamlined and timely manner.

Facilitate sharing of behavioral health data:

Comprehensive access to physical and behavioral patient data on our members better equips us to deliver in-person, coordinated care and facilitate earlier identification and treatment of substance use. CareFirst recommends MDH work with MCOs and the behavioral health contractor to better leverage CRISP to foster improved data sharing.

Improve MCO access and quality to member demographic data:

Access to demographic data is critical to allow CareFirst to better understand and address disparities within the communities we serve. Data on age, race, ethnicity, sex, gender, language and disability status better equip us to design and implement targeted activities that address health inequities. However, the availability of this data is limited; one study found only 10% of MCOs to have complete data on member race and ethnicity.

MDH should take actions to improve the accuracy and completeness of this data. Building trust with beneficiaries on the importance of collecting this data is also paramount. MDH should also be required to provide this information to MCOs, rather than it be optional.

Another opportunity to increase the collection of Social Determinants of Health (SDOH) data is through the provider office. Leveraging ICD-10 Z codes, providers can capture SDOH-related information within the electronic health record. However, the current use of Z codes lags due to lack of awareness, lack of education, staff limitations, and provider concern. MDH could 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, Maryland should invest in pipeline programs that recruit diverse candidates and train culturally and linguistically competent providers. CareFirst also supports requiring providers to complete implicit bias training to address certain negative beliefs or unconscious biases in the healthcare setting.

Improve maternal health:

Medicaid plays a pivotal role in maternal health, covering more than 40% of births (PDF) across the United States and Maryland. Nevertheless, maternal health outcomes and disparities remain a significant challenge; Maryland’s maternal mortality rate in 2019 ranked 22nd among states. Black residents had a mortality rate of almost four times (PDF) compared to that of white residents. Maryland has made significant strides facilitating improvement in maternal health, including expanding postpartum coverage from 2 to 12 months and adopting the SIHIS goal to reduce maternal morbidity. As we work together to improve maternal health throughout the state, CareFirst recommends MDH continue to invest and support innovative models of maternal care.

The HSCRC recently allocated $10 million in SIHIS funding (PDF) towards MCOs to address maternal and child health. Included is funding to explore and expand innovative models of maternal care delivery, including CenteringPregnancy, reimbursement for doula services, a Home Visiting Services pilot expansion, and a Maternal Opioid Misuse (MOM) model expansion. To the extent these models prove successful in improving maternal health outcomes and reducing disparities, we hope to see sustainable financing for MCOs to continue supporting these programs.

Increase participation on advisory boards:

To ensure beneficiary needs are heard and addressed, CareFirst recommends MDH 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. MDH can also partner with other programs and entities serving Medicaid beneficiaries to effectively conduct outreach and meet beneficiaries where they are. For example, MDH could conduct outreach when Medicaid beneficiaries are on site renewing eligibility for other programs.

Collaborate with MCOs to address SDOH needs:

SDOH serve as the basis for deep disparities in social, economic, and health outcomes and are critical to resolving longstanding inequities within our communities. Given Medicaid’s coverage of low-income and vulnerable populations, we are uniquely positioned to identify and address these disparities. Specifically, we believe it is imperative to address member needs in transportation, job skills and training, and housing supports.

Centers for Medicare and Medicaid Services (CMS) guidance (PDF) identifies various strategies and authorities that can be leveraged to equip MCOs to address SDOH. We recommend MDH work with MCOs to investigate these programs and flexibilities to understand how we can better meet the needs of Marylanders:

• Pursuing an 1115 waiver that provides Maryland with greater latitude to obtain federal matching funds for SDOH-related services. For example, North Carolina has an 1115 waiver (PDF) in place that supports individuals with housing, food, and transportation insecurity.
• Advocating for straightforward federal guidance regarding the counting of SDOH-related activities as quality improvement activities, such that these activities are appropriately accounted for in medical loss ratio calculations.
• Providing increased flexibility around “in-lieu-of” services to address SDOH needs.
• Pursuing pooled funding arrangements across state agencies, such as combining Medicaid and housing funding to address homelessness.

Reduce Medicaid churn through continuous Medicaid eligibility:

The prevalence of Medicaid “churn,” or disruption in Medicaid coverage, is well known; one study found nearly 25% of Medicaid beneficiaries to change coverage within one year. A beneficiary may experience churn when they secure a modest increase or decrease in income, changing their eligibility for Medicaid in the following month.

This volatility is common among low-income households, especially due to self-employment, seasonal work, temporary work arrangements, and the variability of the gig economy. As a result, beneficiaries merely seeking to increase their incomes may inadvertently be punished for doing so.

Studies (PDF) show churn can lead to disruptions in continuity of care, poorer health outcomes, and higher costs. For example, one study found that adults with 12 months of Medicaid coverage had lower average costs ($371 per month) compared to those enrolled for six months ($583 per month) or three months ($799 per month).

To address churn, CareFirst recommends MDH implement a 12-month continuous eligibility policy to allow Medicaid beneficiaries to maintain their coverage for a year even if they experience a change in circumstance, such as income. The concept is not new – 23 states currently exercise the option to provide continuous eligibility for children enrolled in Medicaid, and 25 do the same for children in the Children’s Health Insurance Program (CHIP). Federal Medicaid experts (PDF) have previously recommended the policy, and Montana and New York also have 1115 demonstration projects that provide continuous eligibility for adult group beneficiaries. Finally, during the COVID-19 public health emergency, CMS has also required continuous eligibility to receive the 6.2% Federal Medical Assistance Percentage (FMAP) increase.

Support MCOs in delivering new drug therapies:

New high-cost specialty drugs, such as curative gene and cell therapies, are a top concern for state Medicaid agencies (PDF). These high-cost drugs are increasingly driving Medicaid drug spending. From 2010 to 2015, net spending on specialty drugs in Medicaid almost doubled, from $4.8 billion to $9.9 billion. In addition, the FDA is approving more products through the accelerated approval pathway, such as the new Alzheimer’s medication, listed at $56,000 per year.

CareFirst is committed to lowering prescription drug costs and is eager to partner with MDH in pursuing solutions to control specialty drug costs. To the extent these drugs are to be covered by MCOs, CareFirst recommends using risk mitigation strategies.

Share prescription drug data:

Access to comprehensive data on our members is critical to delivering coordinated, whole-person care. However, because certain drugs are currently carved out of the MCO program, we have limited insight into member utilization. CareFirst recommends MDH share carved-out prescription data with MCOs. When MCOs have complete insight into the entire continuum of a member’s care, they can coordinate care for their members, such as monitoring for medication adherence.

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

MCO formularies undergo frequent review and are carefully managed to ensure the most clinically effective medications at the lowest net cost are available. MDH 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, CareFirst supports Maryland’s approach to carefully study telehealth before making permanent policy decisions. It will be critical to examine the value, cost, access and quality of audio-only and video visits and the comparative effectiveness of different modalities of care in different situations.

CareFirst believes there is no one size fits all approach for telehealth policy – telehealth may be more appropriate in certain clinical scenarios (e.g., teletherapy) vs. others (telehealth for the common cold). 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 in the vulnerable Medicaid population and among those who do not have broadband.

Expand Broadband:

Medicaid populations disproportionately lack access to the internet. 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.

CareFirst supports Maryland’s budgetary commitments to expand broadband using American Rescue Plan Act funding. We emphasize that solutions to broadband access will differ across urban and rural areas. While rural communities will benefit from investments in additional broadband infrastructure, urban communities will benefit from payment assistance to subscribe to such services.

The use of managed care to deliver long-term services and supports (LTSS) is becoming increasingly common in the United States. The number of states using managed long-term services and supports (MLTSS) grew from 8 states in 2004 to 24 states in 2018 (PDF). State Medicaid agencies cite many reasons for switching from Fee-for-Service (FFS) to managed care, including improving member experience and health outcomes, increased access to services, introducing more budget predictability, and better manage 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. The Biden Administration has also recognized the importance of HCBS – recently proposing $400 billion to support investments in HCBS as part of his annual budget.

Individuals served by LTSS are among the most vulnerable, high-cost beneficiaries enrolled in Medicaid. By implementing a managed care approach, MCOs can effectively coordinate care for this population and better assist them in integrating into an HCBS setting. Notably, states often use MLTSS to rebalance individuals from institutional care to HCBS. Among those states with MLTSS, Medicaid beneficiaries consistently report (PDF) better experiences with care, higher quality of life and access to HCBS.

Given the clear benefits of MLTSS and the national trend towards HCBS and MLTSS, CareFirst recommends MDH explore implementing an MLTSS program in Maryland. Pursuing more integrated models of care for this vulnerable population aligns with our mission. We are eager to partner with MDH to explore avenues to better serve and care for this population.