Helping States Target Interventions to Medicaid Patients Who Need Help the Most

    • October 10, 2012

While our health care system undergoes rapid changes in these fiscally challenging times, health care providers and federal and state agencies are tasked with seemingly conflicting challenges: improving the quality of patient care while constraining or reducing costs.

“Medicaid agencies are really faced with dual challenges right now,” Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program alumna Lindsey Leininger, PhD, MA, says. “As more people enter the system under health reform, cost-effective targeting is going to be crucial to Medicaid’s ability to implement and execute innovative programs.”

Like other states, Wisconsin is expecting more enrollees under health reform, so targeting intensive care management innovations makes fiscal sense, Leininger says. She began studying the state’s health care system as a Health & Society Scholar from 2008 to 2010. Under a new grant from The State Health Access Reform Evaluation (SHARE) program, Leininger, an assistant professor at the University of Illinois at Chicago School of Public Health, will help Wisconsin officials establish a new risk assessment tool designed to facilitate effective targeting.

SHARE is an RWJF program that supports rigorous research on health reform issues at the state level, with a focus on implementation of the Affordable Care Act (ACA) and other efforts designed to increase coverage and access. Leininger’s project will use self-reported health measures from Wisconsin Medicaid applicants to predict future health care utilization and costs, allowing the state to better target and design its program.

Getting the Right Benefits to the Right Populations

In 2008, Wisconsin expanded its Medicaid program to cover thousands of residents who were previously uninsured or paying premiums for private sector coverage they could not afford. All children under age 19, parents and caretaker relatives with family incomes below the Federal Poverty Level, and low-income pregnant women were among those who benefited from the “BadgerCare” expansion.

A second component of the reform effort was launched in the summer of 2009: an eligibility expansion to low-income childless adults—a population that will gain Medicaid eligibility on a national scale under the ACA.  As part of the expansion, Wisconsin required childless adult applicants to fill out a self-reported health questionnaire upon enrollment. With the SHARE funding, Leininger and her research team will use the health measures reported by childless adults to build a clinical prediction tool that signals which enrollees are most at risk for high expenditures and high emergency department utilization.

With that information and utilization patterns from the enrollees’ first year in the program, the state can better predict which participants will need or could benefit from services like case management, care coordination, and medical homes.

If we can segment this population into different risk categories, we can better, and more cost-effectively, target our interventions,” she explains. “We’re hoping this will produce a product that Wisconsin and other Medicaid agencies can use to identify populations for innovative care delivery design. We want to create a statistical tool to help states choose the right populations for the right care delivery innovations.”

Leininger says her work with the Wisconsin Medicaid agency as a Health & Society Scholar helped build a relationship that will continue as she completes research for her SHARE grant. “We really work collaboratively with agency officials to figure out what questions are important to them, set a research agenda, and disseminate our findings.”

“Our hope is that the team’s research will save the state money and result in better care outcomes for the populations Medicaid serves,” Leininger adds.

Health & Society Scholars Program a “Genesis”

“The research I did as a Health & Society Scholar was the genesis for the SHARE-funded project,” Leininger says. The data her team collected from Wisconsin’s Medicaid agency and other programs created “a rich resource” that she is now using in her new evaluation of the program.

“RWJF has been so crucial to our team being able to produce all the research we’ve had on the Wisconsin program,” Leininger adds. “Through support from both of these programs, the Foundation has allowed us to leverage the data resources and the relationship we’ve built with Medicaid agency officials to create a tremendous body of knowledge about health care reform.”

Learn more about the RWJF Health & Society Scholars program.
Learn more about The State Health Access Reform Evaluation (SHARE) program.
For an overview of RWJF scholar and fellow opportunities, visit www.RWJFLeaders.org.