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Chronic Homelessness and High Users of Health Services: Report from a Meeting to Explore a Strategy for Reducing Medicaid Spending While Improving Care

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There is evidence that homeless people, especially the chronically homeless, incur high health care costs, much of which may be paid for with Medicaid funds. There is also evidence that health care costs are reduced when homeless people with intensive medical needs enter supportive housing, which combines affordable, stable housing with care workers who assist residents in managing health, mental health, substance abuse, and employment issues.
This evidence provides an opportunity for states to reduce Medicaid costs by increasing their investment in housing. In April 2007, a small group of homeless and housing advocates, state health care leaders, and managed care providers met to explore this opportunity.
Meeting participants examined the experience of three supportive housing programs that have demonstrated a positive relationship between providing supportive housing to the chronically homeless, changes in health care utilization, and reductions in medical costs. Participants also identified opportunities for and barriers to the potential of supportive housing to reduce Medicaid costs.

chronic_homelessness.pdf 346.2 KB

 

Safety Net Workforce in the Context of Health Care Reform

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In the drive by many states to craft programs to expand health coverage to reach more, if not all, of their uninsured population, the focus has been on the cornerstone implementation issues of mandates and affordability. Less attention has been paid to the question of whether there is adequate provider capacity to deliver care, especially to those who could gain coverage under state health reform.
The National Academy for State Health Policy (NASHP), under a National Cooperative Agreement with the Health Resources and Services Administration (HRSA), Bureau of Primary Health Care (BPHC) is working to better inform state policy makers on how actions to expand coverage may affect the health care safety net, and particularly federally funded community health centers. This State Health Policy Briefing is intended to stimulate dialogue and promote collaboration between state government and safety net providers in addressing shared missions and goals for assuring access to care for vulnerable populations.
As part of this National Cooperative Agreement, NASHP convened in May 2007 a day-long meeting of representatives from the primary care office (PCO) and primary care association (PCA) in six states, along with state policy makers who are members of NASHP steering committees. The discussion showed that there was concern about workforce shortages facing safety net providers, and how the safety net would be affected by health care reform efforts that seek to expand health coverage. Will the newly insured create a wave of new demand that will overwhelm the health care infrastructure? Is that infrastructure already overwhelmed? How will state policy makers and health centers meet this challenge?
To further examine these questions, NASHP staff conducted site visits to two states that are in two very different places along the continuum of health care infrastructure and health care reform efforts – Massachusetts and New Mexico.
Three lessons emerged from the discussions in each state, and these lessons are broadly applicable to how policy makers in any state might think about the role that health centers should play in the context of workforce planning and health care reform.
Lesson 1: State policy makers and health center representatives need to have consistent, well-developed lines of communication, so that they can respond quickly and effectively to new issues and opportunities as they arise.
Lesson 2: Health centers are now facing challenges in workforce planning at all levels, from clinicians to front-office staff to executives. States and health centers must work together with other stakeholders to coordinate and integrate planning for workforce issues affecting the health system.
Lesson 3: Even in the context of efforts aimed at providing “universal” health care coverage, health centers will continue to have a role in caring for underserved communities, responding to the needs of new populations, and providing enabling services beyond medical care.
Health care reform in the states is often a bold experiment. Prospects for success are uncertain. As states embark on their reform efforts, they ought to pause to think about the condition of their safety net.

shpbriefing_safetynetworkforce.pdf 144.9 KB

 

The Effects of Medicaid Reimbursement Rates on Access to Dental Care

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Dentists cite three primary reasons for their low participation in state Medicaid programs: low reimbursement rates, burdensome administrative requirements, and problematic patient behaviors. In the late 1990s and early 2000s, a number of states took dramatic steps to try to improve access to dental care in Medicaid. Alabama, Michigan, South Carolina, Tennessee, Virginia, and Washington employed a variety of approaches to address access concerns. They raised reimbursement rates, revamped administrative structures and processes, and conducted outreach and education to both providers and patients.
This study, sponsored by the California HealthCare Foundation, focuses on the efforts of these six states and compares their experiences to California’s. The National Academy for State Health Policy (NASHP) conducted a literature review and 26 key informant interviews to answer the question: what effect does raising Medicaid reimbursement rates have on access to dental care?
In the six states examined, provider participation increased by at least one- third, and sometimes more than doubled, following rate increases. The study found that rate increases that at least bring rates to a level where they meet the provider’s overhead expenses are necessary – but are not sufficient on their own – to improve access to dental care. Easing administrative processes and involving state dental societies and individual dentists as active partners in program improvement are also critical. Administrative streamlining and working closely with dentists can help maximize the benefit of smaller rate increases, and mitigate potential damage when state budgets contract.

CHCF_dental_rates.pdf 344.4 KB

 

The CMS August 2007 Directive: Implementation Issues and Implications for State SCHIP Programs

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This State Health Policy Briefing discusses the August 17, 2007 letter from the Centers for Medicare and Medicaid Services (CMS), which has major implications for the State Children’s Health Insurance Program (SCHIP) and children’s health coverage. Among states and advocates alike, there is concern that aspects of the directive work against achieving the goals of SCHIP and the broader purpose of assuring that children have health coverage and access to quality care.
 
This paper examines the four requirements within the directive that are of greatest concern to states. It also provides details and context on CMS’s directive requirements, background on current state policy and practice related to each requirement, along with a discussion of the issues and implications for states in assessing the feasibility and implications of responding to the new requirements.

shpbriefing_cmsdirective.pdf 225.1 KB

 

State Health Policies Aimed at Promoting Excellent Systems: A Report on States’ Roles in Health Systems Performance

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This report presents findings from the State Health Policies Aimed at Promoting Excellent Systems (SHAPES) project undertaken by the National Academy for State Health Policy with support from The Commonwealth Fund. The project built on the work of  The Commonwealth Fund’s Commission on a High Performance Health System to explore the roles that States play in influencing key health system components such as insurance coverage, quality of care, and information and provider infrastructures.

After conducting surveys of multiple agencies in states across the country, as well as reviewing related literature, the authors found that states are pursuing system improvements across the full spectrum of their authority, including health care purchasing, regulation of providers, reporting of performance data, integration of public health with health care approaches, and improving the availability and affordability of health insurance. Despite this activity, this study finds room for states to do much more. The report also concludes that ongoing efforts to track, study and diffuse information on state activities could accelerate adoption of promising polices and practices.

A shorter summary report of themes published by The Commonwealth Fund – States’ Roles in Shaping High Performance Health Systems – can be found on the Fund’s Web site by clicking here.

Shapes Report 886.3 KB

 

Medically Needy: An Option Worth Revisiting?

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Medicaid medically needy programs allow states the option to expand Medicaid coverage to people with high medical expenses and who otherwise would be ineligible due to income or resource limits. To qualify, individuals “spend down” into Medicaid coverage by paying out-of-pocket medical expenses to lower their income to a predetermined level.
Currently, 33 states and the District of Columbia operate medically needy programs. In 2003, more than 3.4 million people – 6.3 percent of the Medicaid population – received coverage through a medically needy program at an annual cost of $27 billion — 9 percent of total Medicaid expenditures. These programs also allow states to expand Medicaid benefits to certain populations otherwise neligible for Medicaid, notably young adults ages 19 to 21.

shpmonitor_medicallyneedy.pdf 270.6 KB

 

State Health Reform: How Do Dental Benefits Fit In? Options for Policy Makers

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This paper discusses the options that states have to include dental benefits in a health care reform plan, if the state desires to do so. Oral health resides, for all intents and purposes, in a different world from general health. Dental care is separate in financing and insurance; provider education, licensing, and regulation; and service delivery.
While ambitious health care reform plans have been undertaken in several states and proposed in others, no recent reforms have included dental benefits for the majority of those who are included in the new coverage. The primary barrier for states in including dental coverage is cost – although the traditional separation of general health and oral health – is a factor.
States considering adding dental benefits to their health care reform plans have three approaches they can take. They can: use Medicaid as a vehicle for providing dental benefits; offer a private dental insurance product for those not enrolled in Medicaid or already covered by dental insurance; or combine Medicaid and private insurance in a “connector” approach.
The paper looks at the advantages and disadvantages of each of these three approaches. It also discusses the continuing importance of public oral health efforts and the dental safety net, whether or not dental coverage is included in health reform efforts.

Dental Options 400.1 KB

 

The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives

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According to the Institute of Medicine (IOM), preventable medical errors are a leading cause of death in the United States. Yet, state officials who focus on patient safety have few venues to meet, share innovative strategies, and problem solve with each other because patient safety initiatives originate in a variety of state agencies.
This report summarizes the Pennsylvania Learning Exchange, an event that brought state officials to Pennsylvania in September 2007 to learn about the state’s successes, challenges, and key elements of its patient safety initiatives. The event was supported by the Commonwealth Fund.
Pennsylvania’s initiative is a model for developing a comprehensive, interagency approach to address patient safety within a broader context of state health policy and as a critical component of health reform. The Prescription for Pennsylvania coordinates patient safety efforts under an umbrella entity (the Governor’s Office of Health Care Reform) and involves multiple agencies. The learning exchange event focused on Pennsylvania’s innovative strategies, including its successful efforts to call statewide attention to the issue of patient safety; build a case for change; translate data into practice and policy; and create a state infrastructure to address the issue. It also provided an opportunity for visiting state officials to share their own innovations.
The purpose of the learning exchange was to enable state officials to explore policy and operational issues, identify emerging issues, develop policy solutions, and improve state health policy and practice.
Ten Pennsylvania patient safety officials from key state agencies were host officials. Participants included 24 state officials representing eleven states. All visiting officials provided short written summaries of what they gained from the learning exchange and how they planned to apply this new knowledge to their state’s work to improve patient safety.

Pennsylvania Learning Exchange 448.2 KB

 

Strategies States Can Use to Support the Infrastructure of a Medical Home

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The purpose of this State Health Policy Briefing is to examine strategies states can use to recognize and support medical practices that function as a medical home. This is the second in a series of briefs produced by the National Academy for State Health Policy (NASHP) in partnership with the Patient Centered Primary Care Collaborative (PCPCC).
In order to support medical homes, payers – including state Medicaid and SCHIP programs – must define what they expect practices to do and how they will know when practices are meeting those expectations. This paper briefly reviews what states should measure. The paper looks at how three states are combining strategies to support medical homes.

State Medical Home Strategies 124.3 KB

 

SCHIP and Adolescents: An Overview and Opportunities for States

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Over the past decade, the State Children’s Health Insurance Program (SCHIP) has made great strides in increasing health care coverage among youth under age 19. However, this overall success masks an important disparity – adolescents are more likely to be uninsured than younger children. As state policy makers and program administrators seek to build on their successes to reach more of those eligible for SCHIP, special attention should be paid to adolescents. SCHIP coverage can not only improve teens’ health, but can reduce the burdens of chronic disease in adulthood.
Adolescents have distinct service utilization and developmental health care needs, which should be addressed in the design of each state’s SCHIP program. Outreach, benefits, service providers, and quality measurement and improvement are all program elements that can be examined and tailored to meet adolescents’ needs.
This State Health Policy Briefing provides an overview of adolescents’ characteristics and health care needs and offers guidance on how to tailor state SCHIP programs to better target the health care needs of low-income adolescents.

SCHIP and Adolescents 191.8 KB

 

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