Kaiser Family Foundation Survey on State Medicaid Managed Care ...

In some states, reducing avoidable ER use in Medicaid is part of a state-wide effort that may also involveother payers, statewide education efforts, establishment of nurse advice lines, and collaboration amonghospitals, health plans, and primary care providers. These initiatives often include the development ofdiversion protocols that redirect people with non-emergent needs to appropriate sites for care, such asa nearby clinic or their primary care provider. Some ER-related efforts are part of a chronic caremanagement initiative that focuses on individuals with specific diseases, such as asthma, diabetes,hypertension, or congestive heart failure. State medical home initiatives also include a focus on reducinginappropriate ER use and ensuring that care is provided in the appropriate setting. Most states areevaluating the effectiveness of their efforts to reduce ER use. Some states, but not all, reported reducedER use resulting from state initiatives.Most states report initiatives to address obesity, with Medicaid MCOs often playing a leading role.State Medicaid programs have a large stake in efforts to reduce obesity because many Medicaidbeneficiaries suffer from chronic conditions related to obesity, such as diabetes. Initiatives to monitorand reduce obesity were reported by 34 states, with Medicaid MCOs often playing a key role. Toillustrate, in Michigan, all Medicaid MCOs are required to conduct a performance improvement project(PIP) on childhood obesity, which must be evaluated by the EQRO. California and Tennessee requireMedicaid MCOs to report scores annually for the HEDIS© measure “Weight Assessment & Counselingfor Nutrition & Physical Activity for Children and Adolescents,” and other states have added otherHEDIS© measures relating to BMI. In some cases, MCOs have developed their own weight-reduction ordisease management programs for obese adult and child enrollees. A number of Medicaid programs areparticipating in state-wide obesity initiatives that involve surveys, data collection, education, and healthpromotion.All TennCare MCOs have implemented a disease management (DM) obesity program for children and adults withparticipants identified through self-referral, physician referral, and community referrals, and through other DMand care management (CM) program engagement, such as health risk assessments. Risk stratification, typicallybased on Body Mass Index and/or co-occurring conditions, determines the type and intensity of interventions,which can include educational material addressing nutrition, exercise and weight management, referrals tocommunity partners that supply weight management programs, and individual care plans addressing weight loss.The DM obesity programs are evaluated annually based on both process and outcome measures.About half the states report initiatives in Medicaid to address racial and ethnic disparities, includingparticipation in broader state efforts. Because of Medicaid’s large role in paying for births and coveringcommunities of color, the program is instrumental to efforts to narrow racial and ethnic disparities inaccess, care, and outcomes related to major chronic diseases. Federal regulations require states toprovide their contracted MCOs with data on the race and ethnicity of their Medicaid enrollees to allowhealth plans to measure, monitor, and address disparities.Just under half of state Medicaid programs (24 states) reported that they had or would have qualityinitiatives in Medicaid specifically to address racial and ethnic disparities. Numerous states reportedformal Medicaid PIPs focused on reducing racial and ethnic disparities in certain measures (e.g.,adolescents’ use of well-child visits, breast or cervical cancer screening rates), or on culturalcompetency. In one state, each MCO has a “disparity committee” that analyzes data by race andethnicity and recommends interventions for the plan to implement. Several states analyze quality databy race and ethnicity, including one state that publishes the data. A number of states reported broader40 00