Abstract
healthcare organizations across the US are developing new approaches to addressing patients’ social needs. Medicaid programs are uniquely placed to support these activities, given their central role in supporting low-income Americans. Yet little evidence is available to guide Medicaid initiatives in this area. We used qualitative methods to examine how Medicaid funding was used to support social interventions in sites involved in payment reforms in Oregon and California. Investments were made in direct services—including care coordination, housing services, food insecurity programs, and legal supports—as well as capacity-building programs for healthcare and community-based organizations. A mix of Medicaid funding sources was used to support these initiatives, including alternative models and savings. We identified several factors that influenced program implementation, including the local health system context and wider community factors. Our findings offer insights to healthcare leaders and policy makers as they develop new approaches to improving population health.
Insights Results
Overview of article/initiatives
To better understand how Medicaid investments are addressing social needs through funding and delivery of care, researchers conducted qualitative research with communities involved in Medicaid reforms in California and Oregon (e.g., Medicaid payers, provider organizations, local governments). Specifically, the models assessed were coordinated care organizations in Oregon, and California’s Whole Person Care Pilots, which are partnerships of county health departments, managed care plans, hospitals and community partners
In Oregon, coordinated care organizations (CCOs) were established under a Medicaid waiver in 2012 to purchase and provide healthcare for Medicaid patients, with flexibility to direct funding toward health-related social services. At the same time, an alternative payment methodology was introduced for federally qualified health centers that shifted reimbursement from the per visit prospective payment system to a per member per month rate
In California, Whole Person Care Pilots—partnerships of county health departments, managed care plans, hospitals, and community partners—were created in 2016 (also under a Section 1115 waiver) to coordinate healthcare and behavioral health and social services for California’s most vulnerable Medicaid beneficiaries, and the pilots were provided with up to $1.5 billion federal funding through 2021
Methods of article
Researchers conducted qualitative research with communities involved in Medicaid reforms in California and Oregon to understand how social interventions were funded and delivered. Our sample included 55 representatives from Medicaid payers, provider organizations, local governments, and community-based organizations in 6 regions across the 2 states
In Oregon, authors focused on CCO areas with community health centers that used the state’s alternative payment methodology. In California, authors focused on counties involved in the Whole Person Care Pilot program. Authors reviewed publicly available documents and contacted relevant organizations to identify a smaller number of those communities that used Medicaid funding flexibility to support social intervention
Results
Interventions to address social needs fall into 2 categories: 1) Direct services, and 2) Capacity building. Direct services include services like care coordination for multiple social needs, housing support, strategies to address food insecurity, and addressal of legal needs. Capacity building initiatives include staff training, community engagement, and investment in data and technology infrastructure
Options for Medicaid funding fall into 3 categories: 1) Conventional options (e.g., managed care, FFS); 2) Alternative models (e.g., use of Section 1115 waivers); and 3) Savings (e.g., using proportion of savings from Medicaid contracts into program to address social needs)
Contextual factors that supported implementation include: growing awareness of the impact of social determinants of health, backing of senior leaders, the organization’s mission to serve low-income patients
Contextual factors that influenced implementation include: underdeveloped systems used to identify and address social needs, ambiguity around what could be covered under Medicaid, and professional opposition to the new interventions, attitudes toward social interventions, political context, and extent of collaboration between healthcare and community-based organizations
Additional investment in Medicaid in social supports would only reach a small number of high-risk patients as interest in interventions that address patients’ social needs outpace the sector’s knowledge of what works, when and for whom
Key takeaways/implications
Overall, this study discovered that when organizations were given greater flexibility over spending, healthcare leaders made investments in a range of services to address housing, food, legal, and other social needs, as well as capacity-building interventions to strengthen healthcare and community-based organizations’ ability to respond to these needs. Sites used a mix of Medicaid funding to support social interventions, including conventional options, alternative models, and saving
Implications from these findings include the consideration of how to best integrate healthcare and social services (e.g., housing) within the context of Medicaid, concerns from leaders regarding the ability to sustain Medicaid investments in social supports (e.g., expiration of waiver funding), the centrality and consideration of community-based organizations in delivering social interventions
Limitations to the study are threefold: 1) Lack of representation of all Medicaid reform efforts across California and Oregon; 2) Inability to interview every organization involved in Medicaid-support services; and 3) Lack of patient-reported data
