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In NJ, Horizon Looks at Patient Engagement, Mental Health to Narrow Disparities

Mary Caffrey
The effort to address healthcare disparities in a wealthy state comes as Medicaid is at a crossroads. A recent report found the $15.5 billion program falls short in key areas, and the governor is trying to extract money from Horizon's Medicaid reserves, set aside to pay claims, for an addiction program.
Going into communities makes sense, because it’s there that health systems can stop diseases like diabetes, congestive heart failure, and asthma, which are all much higher among minority populations. “You have to ask yourself, ‘why?’" Alexander said. “We spend a lot on people in the hospital, but very little is spent on prevention and wellness. Others have reached the point of calling it ‘sick care.’”

This approach will be necessary as new payment models call on health systems and practices to assume more risk, something required under the Medicare Access and CHIP Reauthorization Act. While Medicaid is not included, Horizon last year launched a series of risk-sharing agreements with several major health systems in New Jersey, called OMNIA.

Medicaid is at a crossroads in New Jersey. In March, the NJ Health Care Quality Institute released a landmark report that found the $15.5 billion program now delivers care to 1 in 5 state residents but still falls short in key ways, spending far too much on things like C-sections and missing opportunities for efficiency. The report included 24 recommendations it said could save at least $100 million and deliver better care for 1.8 million enrollees.

Historically, New Jersey’s low reimbursement rates have made it hard for Medicaid patients to get in to see the doctor—a recent Kaiser Family Foundation report listed the state as 1 of 5 with below average rates of physicians taking part in Medicaid. And, there’s a new threat, as the insurer is locked in a battle with Governor Chris Christie, who has tried to get $300 million from Horizon’s Medicaid reserves—money used to pay claims—for a state addiction fund.

Learning From Those New to Medicaid
During his remarks, Alexander said those newly enrolled in Medicaid—the expansion population—often had been without insurance for years, even though many were working. Horizon found there were 2 places they showed up right away—the ED and the dentist.

“It turns out they were really, really sick,” he said. “They were probably living in a whole lot of pain.”

Later, in an interview with The American Journal of Managed Care®, Alexander said that Horizon has learned from this population over time. Do patients new to Medicaid go to the ED because they can’t get an appointment, or because that’s all they know?

“It’s multifactorial,” he said. Often, it’s the sense of urgency, he said. Finally insured, this group is anxious to get care. But Horizon is getting better at working with these patients upfront, and it has systems in place to follow-up with those who land in the ED to get them a primary care doctor. “If the PCP schedules you too far in advance, we’ll schedule you another one,” Alexander said. Horizon also works with Federally Qualified Health Centers, and recent changes to increase reimbursement to academic medical center have helped.

Over time, patient behavior changes. Patients diagnosed in the ED with diabetes or heart disease “don’t see it as the optimal place to go,” he said.

Are low reimbursement rates still a problem? “Without question it has an effect,” Alexander said. Recent increases for academic centers aside, “The state doesn’t give us this business so we can get rich as a health plan.”

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