QUALITY: When Medicaid Gets Health Right

We've written in the past about the North Carolina Medicaid Medical Home model, and its success in providing high quality care to vulnerable populations while saving money. The Kaiser Foundation's Drew Altman focuses on Community Care of North Carolina in his latest commentary. We aren't going to rehash the program here, (read our earlier posts or this Kaiser issue brief) but we were interested in what he identifies as the "few big messages to take away from this experience." The emphasis is ours:

One is the evidence that basic delivery changes have the potential to make a difference and produce savings.  This is not cutting edge or controversial comparative effectiveness research or complex payment reform; it's basic, sensible care management with the delivery system and data system changes necessary to make it happen.  I suspect a number of variations on this approach could be effective depending on local circumstances.  The key is providing a usual source of care and truly managing care for those who need it most, whether that is called "primary care case management" as it was 25 years ago, or an "enhanced medical home" as it is in North Carolina. 

A second message is that Medicaid, often characterized in public debate like other public programs as lagging behind the private sector in its ability to innovate, can be a leader in demonstrating how to improve care and lower costs through delivery system changes. 

A third message is about the importance of focusing efforts on the sickest, highest cost patients, because they have the greatest health care needs and account for such a substantial share of health care spending.  A small percentage of the U.S. population (five percent) accounts for nearly half of health care spending.  If we want to get a handle on increases in spending in Medicare and Medicaid, we will need to do more to reach out to and more effectively manage care for these high cost groups.

Other states are putting some of these lessons to work; Indiana, for instance, has been doing a lot on chronic disease management for its Medicaid population. And some community health clinics, like the Urban Health Plan in the Bronx we wrote about earlier this year, have learned as North Carolina has that you can provide a lot better care to poor people when social workers team up with the medical staff to address the context as well as the complications. That's often not the case, another example of  penny wise, health care system foolish.

One last comment. There is a certain amount of urban myth -- I haven't seen it in writing, but I've heard a lot of offhand remarks in health policy settings -- that the North Carolina program is working because it's only treating healthy kids. That's not the case. It's treating some healthy kids -- and it's enabling some kids stay healthy. But it's also treating people with serious chronic illnesses.  And it's doing a very good job.