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Early Provider Perspectives Within an Accountable Care Organization
Jill A. Marsteller, PhD, MPP; J. Hunter Young, MD, MHS; Oludolapo A. Fakeye, MA; Yea-Jen Hsu, PhD, MHA; Maura McGuire, MD; Matthew G. Poffenroth, MD, MBA; and Scott A. Berkowitz, MD, MBA
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In Louisiana, Necessity Breeds Innovation to Bring Medicaid Expansion
Mary K. Caffrey
Using a Modified Next Generation ACO Benchmark Can Improve the MSSP
Lulu Liu, MA; Richard Svoboda, MA; and Yuting Zhang, PhD

In Louisiana, Necessity Breeds Innovation to Bring Medicaid Expansion

Mary K. Caffrey
How does a state with almost no money launch Medicaid expansion? Louisiana health officials used data they already had, and in doing so, have created a model that could be used elsewhere.
When historic floods struck the Baton Rouge area last month,1 Louisiana health officials were able to offer the working poor who fled their homes something they could not give to the musicians, waiters, and hotel maids left homeless by Hurricane Katrina 11 years ago: access to healthcare.

Just a few months ago, those left in the “coverage gap” after the US Supreme Court left Medicaid expansion up to the states would have been out of luck. But on July 1, 2016, Louisiana became the 31st state under the Affordable Care Act (ACA) to bring Medicaid to those earning up to 138% of the federal poverty level (FPL).2 With a goal to enroll 375,000 in this population the first year, by August 24, 2016, the state had reached 289,742—past the three-fourths mark, according to an e-mail from Louisiana Department of Health (LDH) spokeswoman Samantha Faulkner. That means more than 11,000 individuals gained coverage through expansion in just the 2 weeks following an August 10, 2016, update3—and Faulkner confirmed for The American Journal of Accountable Care (AJAC) in an interview that some flood victims had signed up in shelters.

Louisiana’s simplified enrollment process—which makes heavy use of data already on hand—has created a new model for states with no stomach for bureaucracy. By design, expansion is like flipping a switch. With limited effort for the enrollees, Louisiana is giving coverage to thousands of low-wage workers and self-employed contractors who drive the tourism economy. That is as it should be, according to Governor John Bel Edwards, who has traveled the state to emphasize that far from a handout, 70% of those gaining coverage are working folks, people “caught in a trap.”4

To find those eligible, Louisiana has deployed longtime LDH staff into clinics and hospitals to capture potential enrollees at the point of care. And, in a move destined to be copied, state officials used data from the Supplemental Nutrition Assistance Program (SNAP) to identify families likely eligible. So far, according to Faulkner, this method accounts for 23,413 Medicaid certifications, although many involve more than 1 person.

Edwards’ decision to plow ahead with expansion amid a budget crisis has gained notice. In late August, he was named to Modern Healthcare’s “Top 100 Most Influential People in Healthcare,”5 at number 35—while a governor who is scaling back Medicaid expansion, Matt Bevin of Kentucky, came in at 89. Edwards calls expansion, “the easiest big decision I’ll ever make” and said work remains on delivery system and payment reform.

In June, Mary Caffrey, managing editor of the Evidence-Based series from The American Journal of Managed Care, visited New Orleans during the early days of enrollment to hear from providers and an advocate for safety net clinics about the promise of Medicaid expansion after a long wait and what it might mean for Louisiana.

Serving the Poor for Generations

It was mid-morning, and the Daughters of Charity Health Center on Carrollton Avenue was bright and busy. One of 9 centers the Catholic order operates across 25 miles, the Carrollton site, was bursting with patients, mostly women and children. In the waiting area for the optometry and dental clinics, there was not a chair to be had.

The Daughters have cared for New Orleans’ poor since before the Civil War,6 and today, 90% of the clinics’ patients earn less than 200% of the FPL, with 70% below the 100% mark.7 According to Daughters of Charity vice president and chief operating officer Frank Folino, 24% of the clinics patients are self-pay, so a sizable number of them might need to see the young woman tucked in a quiet corner who registers patients for Medicaid expansion, which was scheduled to take effect in a few weeks.

Behind the young woman, separated by a partition, was a longtime employee from the state’s Medicaid office. Armed with digital application tools and a direct line to the state capital, he had been dispatched from LDH to handle Medicaid renewals and to speed eligibility for anyone who signs up at the Carrollton clinic. The idea is to integrate Medicaid enrollment right into the workflow, when patients are least likely to be lost. Although the numbers of these trained staff were still small in June, Faulkner said they were projected to grow to 100 at 80 sites.

There is much hope that Medicaid expansion has finally come to one of the country’s poorest states, but no one is blind to the challenges that remain. Those who have never had insurance must learn to use it, and there are questions on whether there will be enough primary care doctors for this new wave of patients. The governor himself has said that Medicaid payments to doctors must increase to ensure access over the long haul. And, according to Susan Todd, executive director of 504HealthNet, a health policy umbrella for 60 primary and behavioral healthcare sites in the New Orleans region,8 everyone must remember there will still be uninsured individuals after expansion.

Expansion on a Shoestring Budget

“This is right versus wrong, not right versus left,” Edwards said on the first day of enrollment (June 1, 2016) during a visit to University Medical Center (UMC), the $1.2-billion replacement for historic Charity Hospital, which served generations of New Orleans’ poor before it shuttered after Hurricane Katrina. “At the end of the day … we’re going to improve health outcomes. We want a better quality of life for our people. We want them to be happier, healthier, more productive people.”9,10

When he campaigned last fall, Edwards promised Medicaid expansion knowing full well that a budget deficit awaited his arrival. He got expansion rolling with an executive order on January 12, 2016, his second day on the job.11 Weeks later, his administration announced the shortfall was worse than expected: this years $24.5 billion budget had a gap of $943 million, with a deficit of $2 billion looming for the fiscal year that started on July 1, 2016.12 Keeping his promise would take creativity, because the legislature would not pay for administrative help, even though expansion is projected to save $184 million.2

“We didn’t get one additional dime from the state,” said Secretary of Health Rebekah Gee, MD, MPH, MS, in her June interview with AJAC. That meant no money for new staff to figure out who was eligible—to say nothing of funds for education or advertising. So, Louisiana tapped eligibility data it already had, using rolls from existing Medicaid waivers and the SNAP data, a first among the states. Gee’s move to “outstation” the LDH Medicaid staffers—like the one at Daughters of Charity—counted as a piece of Louisiana’s 25% share of the administrative costs of enrollment (the federal government is paying 75%), according to information from state health officials.

With these steps, Edwards and Gee have rewritten the playbook for low-cost, low-bureaucracy Medicaid enrollment that is well-suited to expansion’s holdout states—places where poverty and chronic disease exceed the norm, along with resistance to government spending. And it’s all working. In the week before expansion coverage took effect, new or expanded benefits were already scheduled to reach more than 225,900 people at 100% to 138% of the FPL; these included families of 4 earning $33,564 or single adults earning $16,404, according to LDH data provided to AJAC. Thus, Louisiana enrolled 60% of its eligible population in less than a month; more than 186,800 of them were automatically signed up when enrollment opened on June 1, 2016.

Use of SNAP Data Is a Novel Idea

A week into enrollment, Gee had the number of new Medicaid enrollees at her fingertips: 197,026 at that point. Most of them were transferred based on eligibility for 2 existing programs: 1) 61,000 enrollees who had limited primary care and behavioral health benefits through the Greater New Orleans Community Health Connection (GNOCHC)—a program funded in the aftermath of Hurricane Katrina that concluded when Medicaid began July 1, 2016—living in New Orleans and 3 parishes (counties) that make up the immediate suburbs; and 2) enrollees across the state with income levels just above traditional Medicaid who were receiving various family planning, contraception, and screening services under a separate Medicaid waiver.

Louisiana broke new ground with its use of SNAP eligibility rolls to quickly qualify individuals. Gee explained in the interview that SNAP clients received a notice letting them know of their likely Medicaid eligibility, along with 3 income-related questions. Clients could respond by phone, fax, e-mail, or regular mail. Within days, Gee said, the state Medicaid office had fielded 10,000 phone calls; over time, the state expects up to 105,000 people to enroll this way, because in the future, low-income families will be able to enroll in SNAP and Medicaid at the same time.

Louisiana hospitals, which went through a transformative relationship with the state’s charity care system under Edwards’ predecessor, Bobby Jindal, have greeted expansion warmly.5 It comes a year into the life of UMC, which was under construction before the Supreme Court ruled that Jindal could decline Medicaid expansion dollars.2,5

Rachel Verville, system vice president for Revenue Cycle at LCMC Health—which operates 4 hospitals in the New Orleans area besides UMC—has seen Medicaid expansion in former posts in Massachusetts and New Hampshire, and is impressed with Louisiana’s innovation. “It’s very refreshing to use data that is already available,” she said in an interview with AJAC, adding that the automatic enrollment from GNOCHC (pronounced no-key) will allow a smooth transition for these patients.

Gee had to fill gaps to cover Louisiana’s share of administrative costs. With a background in academia, she tapped the Robert Wood Johnson Foundation, the Kaiser Family Foundation, and other sources. To promote expansion, Gee and Edwards toured the state, answering constituent questions and drawing free media coverage. “People want to know, ‘Is this real Medicaid?’ We’ve had some tears shedded,” Gee said. “We’ve had a lot of happy faces at these enrollment events.” What didn’t happen, based on interviews and media reports, are the computer glitches and downtime that plagued the ACA’s early days.

For Some, Coverage for the First Time

Grasping the magnitude of Louisiana’s expansion requires understanding of just how hard it was to get traditional Medicaid. According to data provided by Louisiana LDH, the previous income limit for parents and caretaker relatives (if a child 19 years or younger was at home) was 24% of the FPL for a family of 4—just $5820 a year, or $485 a month. Adults without children could not get coverage at all unless they qualified for disability.

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