Can Anthem, the insurance giant famous for the for-profit Blues, "reconceive Medicaid as a care-delivery model rather than as an insurance program"?
Five years after the Affordable Care Act, Medicaid and its companion pediatric health plan CHIP now cover 70 million Americans--a number likely to grow.
The fact that Medicaid is the country's largest single source of health coverage, yet yields suboptimal outcomes for beneficiaries, providers and taxpayers alike, has left Anthem executives Leeba Lessin and Sachin Jain, MD, with the conclusion that "redesigning Medicaid may represent the single greatest opportunity to improve healthcare in the United States."
In many places and care settings, Medicaid "has mimicked the design and dysfunction of other health insurance programs," write Lessin, president of Anthem subsidiary CareMore, and Jain, CareMore chief medical officer, in the Harvard Business Review.
"Patients receive coverage for basic primary care and a set of acute care services when they are sick and often suffer from poor access to care, a problem exacerbated by the scarcity of providers who accept Medicaid. There is little that aims to protect and preserve their health and is designed to meet their special needs of the population that receives Medicaid."
All that, while the program consumes nearly half-a-trillion in federal and state funding, about 60 percent of it for acute hospital care and 25 percent for long-term care.
While managed care in Medicaid has had mixed success and criticism from patient advocates, Lessin and Jain argue that the perfect storm of problems in Medicaid make the time ripe for managed care companies to guide Medicaid benefits to upstream, high value services like primary care and social supports that can prevent more expensive hospitalization and institutionalization downstream--particularly for the 10 million Medicaid beneficiaries who are also eligible for Medicare.
The model CareMore is applying for 80,000 Medicare Advantage beneficiaries, including several thousand Medicaid-covered dual eligibles in California, could be replicated in Medicaid, Lessin and Jain argue--through community health centers with extended hours, integrated primary care, behavioral health and chronic disease care, remote monitoring, and care team coordinators or "extensivists."
Jain, the former chief medical information and innovation officer at Merck, was hired this year in part to help CareMore "scale its models nationally."
In Memphis, Tennessee, CareMore and Anthem's main Medicaid subsidiary Amerigroup are testing these approaches in a managed care plan for 14,400 beneficiaries.
Along with covering all the traditional Medicaid benefits, the 14,400 Medicaid beneficiaries receive a 90-minute "Healthy Start" assessment at one of three CareMore comprehensive care centers, which Amerigroup spent $7 million building.
"Beyond a typical patient history and physical, the Healthy Start approach organizes how patients will use all the services and programs at the Care Center to best manage their health," write Lessin and Jain. "In our early experiences, we have identified many previously undiagnosed illnesses and those patients are now receiving treatment."
Since January, about 930 Tennessee beneficiaries have completed Healthy Starts, and 120 patients were found to have undiagnosed or undertreated mental illnesses and are now being treated by in-house psychiatry nurse practitioners and therapists.
The comprehensive care centers are also an investment in reducing Medicaid's ER costs. They're open from 7 am to 7 pm, with same day appointments available six days a week and walk-in hours on weekends. In the first two months of this year, 12 percent of patients have been walk-ins, and 30 percent of patients have been "no-shows" for appointments, which is still "a low number for the Medicaid population," Lessin and Jain write. "All in all, we believe that our alternate scheduling system is filling an important need for patients who otherwise might be seen in emergency rooms."
Physician innovator devised model as the anti-HMO
Much of CareMore's work to date--including the decade before it was owned by Anthem--has been in the Medicare Advantage population, plying the kind of multi-setting, tech-enabled primary care approach that is increasingly popular in the age of health reform. A 2011 Atlantic report on CareMore describes how the model worked for "Ellen," an 82-year-old widow in Anaheim, California:
One Wednesday morning last year, she got on her scale, as she does every morning. One hundred and forty-six pounds--wasn't that a little high? Ellen felt vaguely troubled as she poured herself a bowl of oat bran. Half an hour later, the phone rang. It was Sandra at the clinic. She too was concerned about Ellen's weight, which had jumped three pounds since the previous day. Sandra knew this because Ellen's scale had transmitted its reading to the clinic over a wireless connection.
Given that Ellen had a history of congestive heart failure, a three-pound weight gain in 24 hours was a potentially dangerous development, a sign of possible fluid buildup in the lungs and increasing pressure on an already stressed heart. Sandra wanted her to come in for an immediate visit: the clinic would provide a car to pick her up and bring her back home. Ellen's treatment began that very morning and continued for two weeks until she was out of danger. Had the warning signs not been noticed and addressed so quickly, she might easily have suffered a long, painful, and expensive hospitalization.
If Anthem ends up scaling CareMore, the success can be traced back to a Southern California physician who wanted to free himself, other clinicians and patients from the bureaucracy and profit-driven pressures associated with HMOs in the 1990s.
Sheldon Zinberg, MD, a now 82-year-old gastroenterologist, founded the CareMore Medical Group in 1993 as a network of 28 clinics. In 1997, CareMore focused exclusively on serving seniors as a Medicare Advantage plan, and started adopting non-traditional approaches that today are growing in demand--no cost transportation for seniors who can't drive, home visits to spot fall hazards, phone calls to check on weight fluctuation, and "talking pill boxes" to guide medication adherence.
After some early financial losses, CareMore earned $24 million in 2000 and kept turning a profit through the aughts and when it was acquired by private equity firm CCMP in 2006. In 2011, Anthem (then known as WellPoint) acquired CareMore for $800 million. At the time, CareMore covered about 54,000 seniors in California, Arizona and Nevada, and boasted of such metrics as a hospitalization rate 24 percent lower than average and a diabetic amputation rate among 60 percent lower than the average.