Evolving Issues in Designing Local, Whole-Person Care Management Programs in Medicaid

Health Highlights

Introduction

Many state Medicaid programs have prioritized developing and expanding “local, whole-person care management” programs, believing that providing integrated care management closer to where enrollees live and obtain care will be more successful in helping them navigate the health care system, stay healthy and ultimately reduce costs. This article identifies emerging strategies for promoting local, whole-person care management, defined as a set of services that:

  1. Address the needs of the whole person through an interdisciplinary team that spans physical and behavioral health—including both mental health and substance use disorders (SUDs)—and social needs; and
  2. Are grounded in a trusted relationship between the individual and a consistent care manager, forged through regular face-to-face interactions.

Local, whole-person care management does not occur naturally for people served by Medicaid. In fact, both “localness” and “whole personness” cut against the grain of how health care is organized in the United States. Almost all states now use managed care as their primary Medicaid delivery system. For their members with the highest needs, Medicaid managed care plans have traditionally offered telephonic models of care management that are staffed and managed geographically far from members’ local communities. Plan-based care management programs have relatively high ratios of members to staff and are not typically organized in a way that is tightly connected to local primary or behavioral health care. With regard to whole-personness, states often have distinct agencies for mental health and/or substance use outside of their Medicaid programs, and some states carve behavioral health services out of Medicaid managed care. Delivery of physical and behavioral health services has also historically been bifurcated at the provider level, as well as in the payment system.

Strategies for Promoting Local, Whole-Person Care Management in Medicaid

To address these inherent barriers, state Medicaid programs are working toward designing and implementing care management that is integrated with enrollees’ care across their behavioral health and physical health issues, centered in the local community, and coordinated with interventions that address the social drivers of health. To achieve this vision, states are deploying the following design strategies:

1) Designating certain community-based providers as responsible for whole-person care management. Both states with and without Medicaid managed care delivery systems can leverage the health home, primary care case management, and targeted case management State Plan options to implement local care management. In states that have managed care, states can require and hold managed care plans accountable for delegating care coordination functions mandated via regulation to the community level, to the greatest extent possible.1 Whether through managed care or not, states must determine which provider types will be responsible for conducting whole-person care management. Intentionally integrated practices such as Certified Community Behavioral Health Clinics may be ideal settings from which to build whole-person care management for individuals with moderate or significant behavioral health needs, but do not have sufficient capacity on their own to serve the care management needs of the state’s Medicaid population. Thus, states may designate broader categories of providers, including patient-centered medical homes, federally qualified health centers and/or behavioral health providers to assume the role of coordinating across all of their patients’ needs, including their social needs—instead of solely being responsible for managing needs within their area of specialization. For example, in North Carolina’s Tailored Care Management program for individuals with serious mental illness, serious emotional disturbance, severe SUDs, intellectual and developmental disabilities (I/DD) and traumatic brain injury, North Carolina has established a special certification for primary care, behavioral health and I/DD providers leading care management. To facilitate a transition from plan-based to local, provider-based care management, the state has established a “glide path” under which plans must contract with certified providers and gradually increase the percentage of care management delivered at the local provider level over a four-year contract period.

2) Strengthening providers’ ability to share and use data. For care managers to help individuals navigate all of their needs, they must have access to data across multiple domains—still a significant challenge given historical silos among types of data—and must put that data to work to assess and address needs. Care managers must have a baseline level of health information technology, such as an electronic health record and care management platform, to be able to meaningfully share and use data. Historically, behavioral health providers have lagged in acquiring these capabilities, largely because of their exclusion from federal incentive programs and health information exchanges. Although federal rules still prohibit sharing certain protected SUD data among treating providers or care managers without patient consent, states are working to improve real-time data exchange between behavioral and physical health delivery systems.2 For example, California recently announced plans for a centralized, state-led “Population Health Management Service” that will improve access to claims and clinical data across delivery systems, and is one of many states that has standardized a framework under which Medicaid managed care plans must share data with care management providers on a regular basis in a standard format. Additionally, in June 2022, Vermont obtained approval under its 1115 demonstration to obtain federal Medicaid matching funds for an incentive program to strengthen health information exchange capabilities among mental health, SUD, and long-term services and supports providers.

3) Creating a more diverse care management workforce. In recent years, design of care management models has intersected with an intense focus nationwide on addressing health inequities. An increasing body of research indicates that patients benefit from obtaining care from a provider of the same racial or ethnic group. States have been thinking more intensively about how to promote access to providers—including members of the care management team—who are members of the communities they serve. Increasing the representation of historically marginalized populations in the health care workforce in general requires focused efforts across stakeholders (e.g., federal and state governments, providers, educational institutions, unions). For example, efforts may target building a more diverse pipeline, reducing the financial burden associated with education and training (e.g., scholarships, loan repayment), and creating more supportive work environments for people of color, among other strategies. Additionally, new workforce models can help improve the diversity of the workforce. For example, New Mexico allows its health plans to delegate care coordination to community health workers and has set a target that at least 3 percent of managed care organizations’ enrolled members are served by community health workers annually. The federal Coronavirus Aid, Relief, and Economic Security (CARES) Act provided substantial new investment in community health worker, promoter and peer positions, and states are identifying opportunities to deploy these individuals for purposes beyond their initial role in addressing the COVID-19 crisis.

4) Determining an appropriate role for virtual care management. Just as the clinical appropriateness of telehealth-based care is just now being considered on a large scale as a result of the COVID-19 pandemic, stakeholders are also discussing the role of remote modalities in care management. For example, if care management is virtual, does it matter if the care manager is nearby or not? There is a lack of policy consensus around virtual care management supported by video and whether it should be treated differently from purely telephonic conversations, but states’ payment models and staffing expectations will need to keep pace with technology’s evolving role. While we are likely to see guidance for care management programs that mirrors post-COVID-19 policies on primary and behavioral health delivered virtually, many enrollees with the highest needs may lack access to a smartphone. Moreover, since in-person relationships are seen as essential to the success of local care management models, states will need to strike a balance between the flexibility of virtual care management and the benefits of face-to-face contact.

5) Leveraging care management as a tool for success in value-based payment (VBP). In many states, care management programs for people with complex health needs are part of a broader strategy for population health under which providers are increasingly taking shared accountability with managed care plans and/or the state for outcomes and are reimbursed under VBP arrangements. As of July 2021, 38 states had employed at least one “financial incentive to promote quality of care.” Identifying the target population for a care management program is among the most difficult design decisions for states to make. A key part of the case for VBP is that when providers are rewarded for outcomes over volume, there is a natural incentive to build a strong foundation of primary and preventive care and to identify those for whom there is a potential for cost savings through care management, whether they are the most complex populations or those at rising risk for high-cost interventions. Accordingly, since local care management can be an important tool for providers’ success in VBP arrangements, states must consider the interaction between their care management and VBP designs.

6) Promoting accountability and evaluating results. Ultimately, states are looking for measures of how effective their care management programs are, as well as measures of return on their state budget investment in terms of decreased utilization of preventable costly services. However, constructing an oversight strategy that measures progress toward that goal is challenging. Even if care management is a stand-alone Medicaid service, it can be labor intensive in itself for both the field and the state to track exactly what services were delivered to whom. Some states are using HCPCS codes to track units of care management (even if the care management is being paid on a bundled basis), whereas other states rely solely on standardized reports to track the quantity and type of support being delivered. To promote accountability and understand the results of their programs, states must thoughtfully combine process measures, evaluation of specific quality measures, cost and utilization tracking and feedback from patients and their families. Establishing this evidence base is critical to realizing the promise of local, whole-person care management programs in the future.

Conclusion

States are continuously looking to implement interventions to improve care for Medicaid enrollees with the most significant needs. Local, whole-person care management remains a key tool for serving individuals in their communities while also advancing population health management and payment innovation.


1 42 CFR 438.208(b).

2 42 CFR Part 2.

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