The Aligning Roles of Medicaid and Public Health

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: Medicaid and public health on the same page—working together, building trust, and improving health outcomes for people across the country.

DEBORAH FOURNIER:
Public health is so excited about its data and its evidence, and it's looking for a partner through which it can deploy those interventions that are evidence-based; and that doesn't necessarily mean that they're looking for a giant check from Medicaid.

MARK LARSON:
Yeah, I think Medicaid is excited about both what can be accomplished in terms of serving individuals when we partner with public health. But I also think that they're excited about building relationships with partners in public health through a structure that allows them to explain to others some of the technical challenges that they have to face.

J.T. LANE:
It has taken what we had—the resources we had, the knowledge we had, the data we had— and leveraged it in a new way.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today we discuss the benefits of Medicaid and the public health departments in the states and territories working together—with help from the Centers for Disease Control and Prevention—to improve communication, create efficiencies, and break down barriers that get in the way of doing good for people in need.

J.T. Lane is a former assistant secretary in Louisiana's Office of Public Health. He'll be along later to address the value of working with Medicaid on several health issues.

But first, we talk big picture and the benefits of CDC's 6|18 Initiative with Deborah Fournier, senior director of clinical to community connections at ASTHO, and Mark Larson, senior vice president of policy for the Center for Health Care Strategies in New Jersey.

Both are former Medicaid directors—Fournier in New Hampshire, and Larson in Vermont.

FOURNIER:
So, I think all governments are trying to think about how to be as effective and efficient as they can be; and you have these two-powerhouse health-related agencies, and we are starting to see a desire for and the capability to have them share goals but use their specific tools to help to advance or reach those goals.

And that's the nut of what Mark and I are trying to explore together.

LARSON: And I think if we look historically, public health had a very clear role in trying to support the health of an entire state population, and Medicaid had a specific role in trying to support the health of those individuals who were enrolled in coverage through Medicaid and over the years.

Particularly as Medicaid's role has expanded and it has covered more people, I think we are starting to recognize how Medicaid can play a larger role in supporting the health of an entire population.

And as Medicaid is trying to serve its members better, it’s realizing that goal of achieving better outcomes for those in Medicaid involves reaching beyond the traditional domain of healthcare services to many of the areas public health and other social service providers have been involved.

And so, Medicaid also is evolving to expand its partnerships with others who serve the same population.

JOHNSON:
Medicaid is an insurance program, so it has an entirely different—or at least historically has had—an entirely different focus than have people in the public health arena, right?

I mean, you think of them as being out giving shots and cleaning up things and keeping people healthy in the hands-on way, where Medicaid is about paper and benefits and that sort of thing, right?

FOURNIER:
Medicaid thinks about eligibility and enrollment, who is okay to come through our doors, and it thinks about benefits, which services do they cover, and which providers do they have, and what do they pay those providers to provide the services to the people they cover. And it tends to be a sub-set of a state. It's not open to anybody in any jurisdiction, right. There are really specific routes of entry. Public health, as you said, worries about clean water for everyone about foodborne illness outbreaks for everyone, worries about lead blood levels for everyone in this state, and vaccinating an entire state for, whether it's childhood diseases or flu and pneumonia.

And so, by necessity, they intersect at points, but they have very different orientations about what their goals are and who their main stakeholders are and what their, what their business lines are, for lack of a better word.

JOHNSON:
But we're finding that there are some commonalities, and that's what you're trying to exploit.

FOURNIER:
Exactly. Mark said it really well that, you know, as Medicaid becomes a bigger and more significant user of state Resources, it is starting to think about not just the individual collections of services that it provides, but it is starting to think about improving outcomes of its people, which pushes it more in a community-wide public health direction, right. And as Medicaid gets, takes up a larger and larger share, perhaps in some States of covering a state's population, public health, thinks, oh, you are you're covering folks. I want to make sure I get to because they are often complicated, expensive, fragile folks who need a lot of support.

JOHNSON:
So how has this rolling out, and how long have we been at it?

FOURNIER:
I think the partnership between public health and Medicaid has been evolving for a number of years. We have been involved in the public health and Medicaid world in a specific effort around 6|18, which is an initiative to focus on a certain set of conditions and a certain set of evidence-based practices that we know help improve outcomes around those conditions for the past couple of years, bringing together teams for both public health and Medicaid to explore how they can work together to advance strategy, to improve outcomes for this particular condition and between a Deborah organization and mine and other partners who are, we've been trying to provide both technical assistance and also some structure to make for states to make advancements in those areas.

And States have been doing some really wonderful things together, both specific to the conditions that have been in the focus of the Initiative, but also building partnerships and learning how to work together across the two domains in ways that can help them build future Initiatives together as well.

JOHNSON:
Is 6|18 the Catalyst for what we're discussing here today, or did it start before that?

FOURNIER:
It started before that. I think 6|18 is a symptom of the work that we're doing. It's a formalized structure for deploying public health intervention inside of a Medicaid program in order to reduce the burden of disease or the acuity of that disease within the Medicaid population. And it gives the folks from those two different agencies the opportunity to begin building a partnership. But it certainly doesn't limit what they can do together. It is really just the opening bell I would say for this kind of collaboration.

JOHNSON:
And we are using the term, and we assume everyone in the public health audience knows what 6|18 is, but is there a 30 second definition for folks that expands on what Mark said?

FOURNIER:
Sure. It's an Initiative in which there are public health interventions, 18 public health interventions that are deployed for 6 specific conditions, hence the 6|18 inside Medicaid programs. And it really involves making sure that the Medicaid program the coverage aligns with those interventions. In other words, that Medicaid takes the steps to ensure that the particular tobacco cessation intervention or the particular diabetes intervention is covered and paid for and then deployed inside the Medicaid delivery system.

JOHNSON:
There are a lot of people involved, 34 States, I think, one territory, D.C.

FOURNIER:
Yep. We're in our third cohort. We've had just a great turnout every year for the States who come in and are seeking technical assistance. To really build this partnership between Medicaid and public health. And in part, that involves them really beginning to understand how the other program works. Because often, especially in the beginning years, the public health people would come and say, well, why wouldn't, why doesn't Medicaid pay for Prevention? That's dumb. What do you mean? And so, then Medicaid would say, Mark, what would Medicaid say to me, why don't you pay for these preventative things?

LARSON:
Oh, Medicaid would say, you know what, we can pay for some of those things, but it's complicated, and it takes time. And we have to go through some routines that we have to work with our federal partners on. And ultimately, I think what people heard with a bunch of blah, blah, blah, it's too complicated. The nice thing is all of this advanced because there was some relationship, and these 6 conditions and 18 evidence-based practices, were understood to be things that really were possible and allowed, I think, particularly Medicaid to get past the process and the detail to get to the, yeah, we can actually do these things together, it is possible.

JOHNSON:
Has it been tough to break down these silos? I assume it was a little bit rough in the beginning. Has it smoothed out as a getting easier as each cohort comes on board and more things are happening?

FOURNIER:
I think for the States that are, that are new to the Initiative, that initial conversation is still the same, which are conversations like what we just had, or Medicaid wanting to know why everyone comes and asks them to pay for things, right. You're just another person in the long line of people out of the Medicaid director's door who was there to ask for funding. And I think what's terrific about the partnership is that it allows also Medicaid to understand that public health is so excited about its data and its evidence, and it's looking for a partner through which it can deploy those interventions that are evidence-based.

And that that doesn't necessarily mean that they're looking for a giant check from Medicaid, but that they really genuinely want to work together to ensure that people's health improves. And I think that the technical assistance continues to evolve and improve as some of the same issues come up repeatedly, especially around the, just those cultural differences about how the programs operate and what their expectations are.

JOHNSON:
So, it's always a little bumpy in the beginning because you're charting new territory in that particular state. How is Medicaid doing with all of this? Are they getting accustomed to it? Is word spreading?

LARSON:
Yeah, I think Medicaid is excited about both what can be accomplished in terms of serving individuals when we partner with public health. But I also think that they're excited about building the relationships with partners in public health through a structure that allows them to explain to others some of the technical challenges that they have to face when adding new things to what's covered for individuals or using the Medicaid financing to advance a goal so that they can get beyond some of the jargon and the differences to be able to have a shared language and a common understanding of what can be done when they work together.

I think Medicaid folks really welcomed that opportunity to have others understand them better and to understand others better because they really do want to accomplish something that makes the difference for the lives of the individuals that they serve quite a bit.

JOHNSON:
Deb, you're sharing your head quite a bit on this, would you agree?

FOURNIER:
I do. I think having a discreet task, a joint task with, with between Medicaid and public health helps them to build that relationship and then the success in doing that. Because it is so concrete helps them to appreciate each other as partners in improving health. And like Mark said to get beyond the technicalities and the jargon and really see the shared goal of improving health outcomes for a really specific group of people, which is also a win for these governmental actors, because everyone wants to be able to tell their public official, whoever it is, the governor or the chairman of the budget committee that they're making really effective use of these public dollars.

And that it's not just us singing kumbaya and feeling good about what we're doing. We're doing actual good. And there's all this evidence to promote improved health and eventually reduced utilization of the system, which that's a win for anybody in a public agency.

JOHNSON:
The key tenants of this idea are then are better communication, more data sharing, what else?

LARSON:
I would say that the data sharing and the communication, they are all actually vehicles to what may be the most important, which is the development of trust in the relationship. And the ability to know that we can work our way through places where we don't understand each other, technical barriers, because we have enough trust in one another that we could work through to the harder thing, knowing that we can build on the relationship we have together.

FOURNIER:
Once people succeed together, they will find other things to succeed together in, right. It just opens the door. What they can imagine is possible. And then they start calling each other up and saying, hey, I heard about a thing. Do you want to talk to me about this? Cause I want to know what you're doing. This is what I'm doing. And it just builds on itself. And that's an excellent dynamic within a health agency or a health secretary.

JOHNSON:
We'll hear from J.T. Lane later in this podcast about Louisiana, but where else is this working? Well, who else can we hold up as an example of that trust growing and the results coming from it?

FOURNIER:
I think Rhode Island has had some excellent success with a home visiting program for asthma, which is expensive and chronic. And they've just really been able to build a terrific relationship between public health and Medicaid. South Carolina has done some extensive work around making tobacco cessation interventions much more widely available to their folks. That was a really big success in a jurisdiction in which that might not be the most popular topic to tackle. I mean, there's 34 States.

JOHNSON:
And we want to talk about all of them because everybody's doing something. Some are farther along than others.

FOURNIER:
Naturally, right? And some state agencies have a better culture for Collaboration among between these agencies, and others are brand new at it. And it's just important to, like Mark said, build that trust and then maintain it. Because something is going to come up. Every jurisdiction has their surprise du jour that they have to tackle. And this just helps them tackle those crises, you know, in a much more effective way.

JOHNSON:
Later, J.T., we'll talk about patients that were discovered for one of the programs they were working on, but Mark is that happening elsewhere, or are we making connections within the data that was in front of us the whole time, but we're unknown because of the silos?

LARSON:
Yeah. I think this is a story that repeats itself very often were within the silos. We tend to have an idea of people who have more significant needs and also associated to that cost more to serve. And when we actually start connecting the data, what we realized is that the population that I'm concerned about a Medicaid is actually the same population that's their concerned about it in public health. And that our partners over in corrections and or child welfare or behavioral health services are concerned about too. Because what we know is that individuals with complex health tend to have needs across a wide range of areas and need. And in order to serve them better, it is not just Medicaid or public health, or social services. Its pieces have all of them are working together in ways that create better pathways to care and to service for individuals and really break down those silos.

So, I do think that when we start seeing, the data does lend us a different view into the populations that we serve. That really reinforces the Collaboration.

JOHNSON:
Deb, I've got to imagine that it is an exciting thing to discover people who are in the system but now can be served the way we want to serve them.

FOURNIER:
Right. I mean, we want to have a holistic picture of someone's needs and not segregate them by silo. Right? Well, you have to go here for this and here for this and here for this and have none of those actors talk to each other. I think also from a public health perspective, being data-driven and being able to locate the focal point or the fulcrum of a particular issue or event or development is essential to public health practice, right? That's how you stop or slow epidemics, right? You have to start with, you know, the initial cluster and, and go out from there. And the constellation of needs that Mark is talking about starts to appear in common ways, similar to outbreaks, where you see that there was a cluster of folks who share these needs.

And it just really allows us to be smarter, so much smarter and effective about addressing their needs in a rational and effective way.

JOHNSON:
During a call to get ready for this conversation. Someone mentioned the phrase "smart government." You can also call it a "good government." Talk about why that is a phrase that we're using in this conversation. I think we've danced around a bit. Let's try to pull it together.

FOURNIER:
Mark has implicated it when he talks just now about bringing the different resources to bear on whatever the needs are, and "good government" is both efficient and effective. And so, the collaborations that we're talking about allow these partners to say, okay, this is our problem, X diabetes. And it allows one agency to say, okay, I do this part really well and allows the other agency to say, okay, I do this part really well. So, they don't have to worry about trying to be everything to all people.

They can identify what their strengths are, and they can rely on their partner to fill in the gaps. Where either they have no capacity at all, or it's just not something that was very strong in their agency. And so, it's a way of taking, there are a lot of public dollars that are used in both of these programs and ensuring that all of the state tools are being leveraged to promote health for everyone is both effective and efficient in terms of limited public resources.

LARSON:
Yeah. So, I have been a legislator serving on a budget committee. I've also been a Medicaid Director. I've worked in the non-profit delivery system, and I'm a taxpayer. And I think, you know, in what we continue to learn is that people actually want government to work well. People actually like a lot of the things, and particularly when it comes to serving individuals who have significant needs, people want government to work, and they want it to work in partnership with folks outside of the government. Well, and we also know that we only have so many dollars, and we want them to be spent well and wisely in the advancement of our health and wellbeing of residents.

JOHNSON:
Many states are working on projects as part of the 6|18 Initiative. Louisiana used the CDC program to help address. It's a challenge of unintended pregnancies. Then used another Collaboration to find people with HIV who were on Medicaid but were hidden in the data. Here's J.T. Lane, Louisiana's former assistant secretary in its Office of Public Health.

LANE:
When Louisiana started participating in the 6|18 Initiative, we chose the LARC component. LARCs for women in postpartum were bundled in payments to hospitals for delivery. And one of the challenges because of it being bundled and a LARCs having a special challenge themselves, there was less of an uptake of that as an option between patients, and there were also maybe providers that were reticent for it. And so, one of the initiatives that we are under underwent was separating the payment for LARCs in the administration of them from the delivery bundled payment itself to increase the uptake of LARC use.

JOHNSON:
How did that work? Explain that for someone like me, who doesn't really know that much about Medicaid or why unbundling makes this happened?

LANE:
Well, it's a fairly expensive device depending on the person in the program by which it's purchased. And also, it's physician-administered, unlike many other drugs that you can get, but in terms of the forms of birth control methods that are approved by the FDA, I think there are about 17 right now. And so, long-acting reversible contraception is one of those that are physician-administered. So has to be done in the physician's office and prescribed in that environment. So certainly, after a mother gives birth, that's the time, you know, to talk about, are you wanting another child? Are you planning for another child, or you don't, and so it's an effort to have that conversation and then say, here's an option to reduce unintended pregnancies long-term.

JOHNSON:
Unbundling it versus bundling it. If it's bundled, it's harder to justify?

LANE:
Yes, because it's more expensive, and providers need to work harder to convince patients necessarily. That's a good idea. And so, there's more of an incentive when you unbundle it from the overall delivery payment and put that out separately. So that from a revenue perspective, providers can sustain stock and inventory and also have an incentive though, to really focus on that as a priority, because we know that the longer term, we can save our money and improve outcomes, both for the mother and her children.

JOHNSON:
And so, here's an obstacle that is essentially as the product of bureaucracy.

LANE:
Essentially are Policy that, you know, just didn't really conceive of having that as a particular focus and Initiative at the time. And it was one, where are the benefits? If you looked at the 6 to 18, Initiative the CDC established certain criteria they use to select those six areas. And so, this is one that reached a long-term benefit. Because the advocacy in the lifetime of the LARCs are three years or five years at the time, depending upon the product used.

JOHNSON:
Identified and then solved through working together.

LANE:
That's right.

JOHNSON:
Getting out of silos.

6|18 is something we've been talking about on this podcast. There are other collaborations that Louisiana used as well. One of them helped make a significant difference in the lives of some folks who had HIV.

LANE:
That's right.

JOHNSON:
Can you talk about that one?

LANE:

Sure thing.

So, when we started collaborating, one thing that I think is important to note in these collaborations is that there's definitely got to be buy-in at the leadership level. And so, as the public health official, I met with the Medicaid director at the time, Ruth Kennedy, who became a really powerful advocate for the value of public health. And we sort of set out a plan to look at how we could help each other in terms of data sharing, what Medicaid could pay for in terms of collaboration in terms of the cost of public health, to provide. That collaboration for essentially a professional service that benefits the program tremendously. And so, HIV was one of those areas where understanding of the state's burden itself, just like CDC established their criteria for their national framework for collaboration.

We looked at our state, and we said, you know, HIV is clearly a significant issue. And so, we focused on that and that the time of the adult course, that quality measures that are established via CMS to the state Medicaid, who sees that are voluntary. The HIV viral load suppression measure among adults was only currently at the time being reported by two States that was New York and Delaware, I believe. And so, we wanted to be the third, and we wanted to do it in a way that was really meaningful. And so, we had a series of meetings with our HIV team, and I had a really awesome HIV Director at the time, Dr. Deann Gruber and her staff, a lot of data analysts, epidemiologists, and Medicaid staff, the quality improvement director, Medicaid Director, and they're staff. And we got together to talk about their various needs.

So, if you think about Medicaid managed care, what are they, you know, what influences their decision-making? And what's important to them, the quality reporting, and then for an MCO, if Medicaid attaches an incentive for good quality or a penalty for bad quality. And so, what we did was we looked at our assets, and we have care coordination and disease management resources within the HIV program. We have data. And so, if you think about public health, data systems are pretty much the gold standard of data collection. We have the known universe out there. We know all the positive tests that are reported to us. That doesn't mean we have everyone's; that everyone knows their status, or we know everyone's status. But those people that were tested, we have.

And so, we were thinking, well, how can we leverage then surveillance data in an innovative way and surveillance data in a highly confidential way and a highly secure way as well to affect quality. So, we looked at the Medicaid population. Medicaid gave us their member information. We compared that to surveillance and to sort of establish the baseline. See what may be gaps in care that we saw are gaps in the known HIV population of the time. When we looked at the 1.4 million Medicaid members. We actually, at the time, identified 1500 people that did not have an HIV-related claim that we needed to get into care that were either not virally suppressed or their viral load was not known in surveillance. Because typically, after you're positive, you get a read tested every six months to ascertain your viral load and your body so that your providers can understand that if you're a medication in your care plan are working.

And now, obviously, HIV viral load suppression is very important because it essentially nearly eliminates a person's ability to transmit HIV if they're virally suppressed. So that's why it's really critical, so it's critical for that person's life number one. And then it's also another form of Prevention.

JOHNSON:
So, they weren't getting the care they needed. They had just gotten lost in the system and, without the collaboration, would have continued to stay in that limbo.

LANE:
It's a, you know, an old story about the data itself, you know, it's only as good as it is. And so when we looked at administrative claims in the Medicaid system, this 1500 people just did not have an HIV diagnosis code associated with them, but we were able to see that in surveillance and then share that back with Medicaid securely, who was then able to set baselines and goals for the managed care organizations to reach certain levels of viral suppression and as a result, actually Louisiana even before that collaboration we were doing pretty good among people living with HIV, a viral suppression rate among the adult population of raw was a 50% when the national rate was 30%. And we were actually able to get the Medicaid population even higher after, as a result of this collaboration.

But I wonder, the power of that though, is that those 1500 people that needed to be linked to care. I wonder what would have ever happened if we hadn't done it. You know, just because there wasn't a modifier in the system for one reason or another. But it is a result of though, of have the power of public health. And as we think about it, I'm sure you may have heard the term already state and local health departments playing the role of a Chief Health Strategist at the state level for the local level. And to me, that is the actual embodiment of that role itself, where you have a public health agency taking the lead in being a strategist for a major pear in the state that covered almost 30% of the lives of the people at the state and its core, of course, even more after the state expanded the Medicaid in 2016.

So, the volume power of Medicaid becomes even more significant, and collaborations like this become even more important in terms of HIV eradication. If you think about what the current administration here in Washington will be enrolling in terms of its HIV eradication strategies. Programs like this, these collaborations are going to be more and more important. And certainly, we'll see new funding rollout to state and local health departments for more capacity building and service provision. But I think that overall, there's a lot of power in public health at the state level. And a lot that's not seen, we have meetings, we discuss this, we do these agreements, we have a data-sharing agreement.

We were one of the first to have this data-sharing agreement in place, actually in the country between public health, Medicaid, and behavioral health as well. And so, it was really, it was really meaningful work and something that we were able to build future Initiative off of. But it had a lot of. I think at the end of the day. I think it brings to bear that some of the decisions that happen and, you know, a government agency conference rooms do have implications for everyone's lives, in any jurisdiction, in this case to the states. And so, it's something we were really proud of, and we were very excited about.

JOHNSON:
This sounds like good government to me.

LANE:
Absolutely. It is absolutely good government. It's taking what we had, the resources we have, the knowledge we had, the data we had, and leveraged it in a new way.

And it was a way that, you know, if you sort of compare and maybe the old model of reporting, you know, when we get positive case report in HIV for example. That triggers a series of actions in the community where we have people in the field, DIS, the Disease intervention specialists that go in and meet with the person at the positive tests and interview them, ask them who else have you had sexual contact with? Go get those people tested and linked to care. Make sure that we're stopping the spread and make sure people are informed. That is how we've done it. And those are activities that need to be funded very well going into the future if there was going to be a full eradication of HIV and the country. But I think that what it did do was from a data standpoint was allow us to not let the data itself must be reported to the CDC necessarily and go into a report that Congress would read and then make funding decisions a year later at. let us actually take our data and do something much more meaningful with it in a much more timely manner.

JOHNSON:
Links to information about the 6|18 Initiative and other resources can be found in the show notes for this episode.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.

UNKNOWN SPEAKER:
This resource was supported by the Centers for Disease Control and Prevention. The findings and conclusions in this resource are those are the speakers and do not necessarily represent the official position of the Centers for Disease Control and Prevention.