Jim Hardy

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From our likes and dislikes, to the car we drive, to our health status, we're all very different. This isn't much of a concern in everyday life, but when we're talking about the differences between commercial health plan members and Medicaid beneficiaries, these differences make caring for each group a significant challenge. 

Today, about 125 private insurers offer managed care programs to 21 million Medicaid beneficiaries nationwide.

  While the commercial and Medicaid populations receive insurance from the same source, these groups have very little in common. Their rates of chronic illnesses, mental health issues, and resource utilization for acute and chronic health issues are dramatically different. The Medicaid population insured by private health plans faces the same obstacles as those Medicaid beneficiaries who receive benefits from state Medicaid agencies. Their demographics and socioeconomic pressures are the same, they just receive health insurance from a different source. 

There are many significant differences when we compare the privately insured to commercially-managed Medicaid populations.

Medicaid beneficiaries-whether receiving benefits through the state or from a commercial plan-typically live in medically underserved towns and cities, are poor and disadvantaged, and have complex health and social needs. "Medicaid-dominated plans are disproportionately concentrated in areas with greater concentrations of ethnic minorities, higher levels of poverty, and fewer health care resources," according to the 2000 Kaiser Commission on Medicaid and the Uninsured report.

  Medicaid beneficiaries are less likely to be employed (48% vs. 75%), have less than a high school degree (37% vs. 17%) and are more likely to have income less than the poverty level (62% vs. 22%) compared to people who have private insurance.

Medicaid at-large covers 45% of poor Americans

  low-income children and parents. Of those 59 million people, about two-thirds are members of an HMO or primary care case management program.

The 2000 Kaiser report confirmed that "...the costs of serving the Medicaid population are higher than the costs of serving the commercial populations because Medicaid enrollees are distinct from those groups both in terms of their medical needs and use of health care services, especially emergency room use."

Medicaid beneficiaries face more health and psycho-social issues than their counterparts at commercial health plans, making it more difficult for commercial health plans to help. With many Medicaid beneficiaries suffering from complex health-related issues – multiple, severe chronic diseases, mental health issues, barriers to care and lower education levels – commercial health plans just don't have the expertise or the capacity necessary to help members of this complex population improve their health. This can overwhelm health plans that don't recognize the differences between the groups. 

Because these differences do exist, care management programs that look at each participant as a "whole person" are critical. This approach considers many factors in addition to the chronic illness including: 

By looking at the barriers to care-everything from co-morbidities to difficulties accessing healthcare services-faced by Medicaid beneficiaries, care management program nurses can effect change by helping them deal with any and all challenges that they might have in meeting health goals. 

Because Medicaid beneficiaries have fewer options and less access when it comes to healthcare services, a 24/7 nurse advice line is crucial to help them achieve their goals. By ensuring that members can talk to a registered nurse whenever an acute health problem arises, the issue can be taken care of quickly. This can cut expensive emergency department visits.  

Effective outreach helps the success of a holistic care management program by ensuring that participants receive services in the way that's best for them. This could be through a face-to-face nurse visit, over the phone, online, or in the community through social or religious organizations. In addition, each form of outreach matches the education level of the beneficiary, ensuring that the information can be understood. 

A registered nurse is the point of contact for the Medicaid beneficiary and the beneficiary's provider, ensuring that both are engaged in the program. The goal is to build a cohesive, long-term relationship between the participant, physician and the nurse.  

There's always the question of how well care management programs work in different populations. Through our own programs, we've found that the use of certain healthcare services decreases dramatically through better self-management:

Commercial health plans must use many resources to achieve these results. Typically, the plan doesn't have these resources; it's simply not part of their expertise. Creating these programs from scratch-building the necessary technology infrastructure, and hiring and training nurses and other clinical staff to administer them-is a daunting and expensive task. 

It's clear that commercial health plan members and managed Medicaid populations 

 different. And a care management program that employs strategies and tactics proven to work with Medicaid beneficiaries can be an important part of an overall program to improve their health and wellness. 

Jim Hardy is Senior Vice President and General Manager at McKesson Health Solutions, a provider of care management services to commercial and government payors, and is the former Deputy Secretary for Medical Assistance Programs at the Pennsylvania Department of Public Welfare. 

 "Public and Private Health Insurance: Stacking Up the Costs," Health Affairs, 24 June 2008, Ku and Broaddus 

 The Characteristics and Roles of Medicaid-dominated Managed Care Plans, The Kaiser Commission on Medicaid and the Uninsured, 2000.  

 Medicaid: A Primer, pp. 5-6, The Kaiser Commission on Medicaid and the Uninsured, 2009 

 Medicaid: A Primer, p. 13, The Kaiser Commission on Medicaid and the Uninsured, 2009 

 The Kaiser Commission on Medicaid and the Uninsured, 2000.  

 McKesson Health Solutions Research Department. Emergency department visits decrease 6%; In-patient admission rates decrease 12%; Doctor's visits decrease 4%. The typical return on investment generated by these changes is 2.50:1. The decreases in utilization are an indication that chronic diseases are better managed by program participants. 

 Investing in Quality: Medicaid Opportunities for States, p. 3. National Conference of State Legislatures Summit, July 22, 2009. Melanie Bella, Senior Vice President, Center for Health Care Strategies.  

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