Complete Care of High Risk Medicaid Members

As an epidemiologist, population health officer, and healthcare executive, I have witnessed the transformative power of Medicaid in providing essential healthcare services to our nation’s most vulnerable populations. Like many of my colleagues, my commitment to preserving and strengthening the benefits of Medicaid stems from childhood. Growing up in East St. Louis, where the median household income is below?$25,000, and one-third of the population is at or below the federal poverty rate (142% higher than the Illinois average and 129% higher than the US average), our family was dependent on Medicaid coverage for preventive health care (school physicals, well-child visits), vision (I required three eye surgeries as a child), and dental screenings.??

With its unique purpose and reach, Medicaid remains a critical safety net for millions. Within this framework, two key components stand out: managing high-risk Medicaid members and meticulously adhering to redetermination requirements.

Managing High-Risk Medicaid Members: A Proactive Approach

High-risk Medicaid members, often characterized by complex medical conditions, multiple co-morbidities, and socio-economic challenges, represent a segment that, if not managed effectively, can lead to adverse health outcomes and increased healthcare costs. But why is person-centered management of this population so vital?

Improved Member Outcomes:?By identifying and providing tailored care to high-risk members, we can drastically improve their health outcomes. A more personalized approach, encompassing member location, on-site empathetic engagement, preventive care, medication adherence, and health education, can significantly reduce hospital readmissions and emergency room visits.

Cost Efficiency:?Effective management can lead to substantial cost savings for the Medicaid program. By preventing avoidable hospital admissions and focusing on preventive care, we can ensure that funds are utilized most efficiently, benefitting both the patient and the healthcare system.

Holistic Care:?Many high-risk members face challenges beyond their medical conditions, such as housing instability, food insecurity, or transportation barriers. A comprehensive management approach addresses these socio-economic determinants of health, ensuring a more holistic well-being for the member.

The Necessity of Efficient Redetermination Requirements

Redetermination, the process by which Medicaid recipients periodically validate their eligibility, is equally significant. Though administrative, this process holds immense value in ensuring the integrity and sustainability of the Medicaid program. Regular redetermination ensures that those genuinely in need continue to receive benefits. If members fall through the cracks due to lapsed redetermination, they might lose access to vital healthcare services, adversely affecting their health. Avertible membership churn can be more costly as members are located, appropriately managed, and actively engaged in behavioral change, leading to improved outcomes and then lost due to complex and often incomprehensible administrative procedures.?

Advanced use of the intersection of population health and claims data can limit the deleterious impacts of inefficient and overly stringent redetermination requirements. For example, given members' persistent and probable SDoH needs (i.e., unemployment, housing instability, and other eligibility determining factors), agencies can proactively deploy predictive population health and payor data analytics to stabilize membership attributions.?

Optimal Resource Allocation:?With finite resources, it’s vital to ensure that funds are directed where they are most needed. Efficient redetermination helps rationalize resource distribution and ensures continuity of timely and appropriate care.?

We can reduce the long-term costs associated with complications and advanced-stage diseases by managing high-risk members effectively and re-examining potentially antiquated and inflexible redetermination policies for membership stability.

As we navigate the intricacies of Medicaid, it’s imperative to recognize the interconnectedness of its components and their social and economic impact. We can ensure a more robust, efficient, and compassionate Medicaid program by managing high-risk members effectively and revisiting redetermination requirements. Through collective effort, we can make meaningful strides in ensuring that our most vulnerable populations receive the care they deserve.