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.
New Jersey may be a high-income state, but it’s one with nagging health disparities that play out in its emergency departments, where too many of its poorer residents seek care—even if they now have coverage due to Medicaid expansion, according to a senior official with the state’s largest health insurer, Horizon Blue Cross Blue Shield of New Jersey.
Paul G. Alexander, MD, MPH, Horizon’s vice president and chief medical officer of Government Programs, offered an overview of what a history of disconnected care has meant for the state’s Medicaid population—and what can be done to better engage these patients to improve their health. His talk kicked off a daylong conference on healthcare disparities, the first for the insurer, with later sessions covering sessions on food security and mental health. Horizon provides Medicaid coverage to 500,000 people through a managed care company, Horizon NJ Health.
Alexander, who trained as an emergency department (ED) physician, said he sometimes wondered if his patients understood when he told them to follow up with their primary care physician or specialist. It’s essential, he said, for the health system to grasp that patients whose basic needs aren’t being met won’t bother with tasks like diabetic foot care. “If you don’t have a sense of financial well-being, who cares what the doctor says?” Alexander asked.
This is where care coordination, and better connections between primary and mental healthcare matter. In New Jersey, 81% of the high Medicaid utilizers have behavioral health issues, including 44% with severe mental illness; 25% of the average utilizers have behavioral health issues, including 10% with severe mental illness.
“The challenge," Alexander said, "is what do we do?” The key, he said, comes with strengthening ties to communities, looking beyond “the traditional models of care,” and filling the gaps that keep patients from being fully engaged. Alexander said when he meets with civic groups, “The community folks tend to know exactly what’s going on. I never assume I know more than they do.”
Horizon, he said, is determined to do a better job with preventive services, such as screening for breast and colorectal cancer, which are a priority under the Affordable Care Act. He said there’s also a need to reduce rates of pre-term labor and low birthweight infants, and to improve prenatal care (the hospital safety group Leapfrog and others have long cited New Jersey’s abnormally high C-section rates).
Horizon is not alone in trying to improve delivery of care to patients “in the context of their lives,” as CareMore CEO Sachin Jain, MD, MBA, put it recently. At the recent meeting of the ACO & Emerging Healthcare Delivery Coalition®, Jain talked about a CareMore initiative to address loneliness in seniors, while Michael Griffin, CEO of Daughters of Charity in New Orleans, said his team brings in lawyers to help women deal with domestic abuse and housing issues.
For many, healthy living is not easy. Getting in 10,000 steps a day is not safe in some places, Alexander said. A check for $109 will only go so far at Whole Foods, but “if I go to McDonald’s I could probably do that a couple of more times—especially if I’m not the only one in the household.”
“Poverty is the primary component, and has the greatest impact on social determinants of health,” he said.
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.”