Regardless of continued instability and federal funding threats to the nation’s Medicaid program, new investments in preventative care and public health have shown promise and can be models to improve outcomes and reduce costs in New Jersey’s system.
A growing number of programs, big and small, are showing how a focus on keeping people healthy and better coordinating their care can pay off with better outcomes and economic savings. Panelists at NJ Spotlight’s “Future of Medicaid in New Jersey” conference last Thursday agreed there are many of opportunities for improving the state’s safety-net system, which now ensures one in five residents.
The challenge, panelists said, was to sustain and expand these efforts, and they urged the next New Jersey governor, who will be elected in November to replace Gov. Chris Christie, to encourage these reforms, while also bracing for potential funding shortfalls and major program changes.
“I’ve worked in many, many states. New Jersey has a great program,” said Erhardt Preitauer, senior vice-president for government programs at Horizon Blue Cross Blue Shield and chair of the Medicaid Health Plans of America, a national advocacy group. “It’s never ever perfect, there’s always opportunity to move forward, but New Jersey has a wonderful foundation from a Medicaid perspective.”
1.8 million enrolled
Some 1.8 million Garden State residents are now insured through Medicaid – 1.1 million through plans provided by Horizon — which costs more than $14.6 billion annually, most covered by the federal government. While New Jersey’s cost per enrollee is among the lowest nationwide, the program has expanded in size, adding more than 500,000 members through the federal Affordable Care Act. But funding for Medicaid continues to be under attack on federal — and sometimes state — level.
“Medicaid plays a critical role in our healthcare system,” explained Heather Howard, a Princeton University lecturer and former state health commissioner, who kicked off the conference — and not just as an insurance policy for those it protects. “That’s important enough in itself, but it’s important for the healthcare infrastructure of our state and our safety-net systems,” she added, stressing the critical role Medicaid payments play in supporting medical clinics, hospitals, and nursing homes.
The program is particularly important for children, Howard noted, covering one in three kids in the state, half of all low-income children, and 42 percent of Garden State births. A second panel at the conference focused on maternal healthcare, examined how the state can improve birth outcomes to improve lives and save costs long-term; while New Jersey is making progress in some areas, it still reports a high number of unnecessary C-sections, problems connecting women with early prenatal care, and significant disparities among racial groups.
“We are not doing as well as we could and a lot of it is access to care, and not getting these (pregnant) women into care early,” explained Dr. Nicole Lamborne, director of women’s health for Virtua Health System. “The earlier we can intervene and make differences in these moms’ lives, it makes a lifelong difference for the baby.”
State Sen. Joseph Vitale (D-Middlesex), the longtime health committee chairman, explored the recent history of Medicaid’s expansion in New Jersey, dating back to his creation of the KidCare pilot program in 1998, and the state’s culture of strong patient and consumer protections.
Vitale and others agreed federal support for the program — through the ACA as well as funding for the Children’s Health Insurance Program (which enabled KidCare) and for federally qualified health centers, which treat many Medicaid patients – was critical to its sustainability.
“Any change in resources from Washington will have a significant impact on our state budget and our ability to make up the difference (in funding),” Vitale said. “It’s critical for the next governor to prepare for what could be a worst-case scenario and work backwards from there.”
Panelists also discussed cost drivers, including the opioid epidemic and the growing need for long-term care. While only six percent of the Medicaid population is in nursing homes or other residential care, long-term care absorbs 42 percent of the cost; one in five seniors will at some point depend on Medicaid.
“The question of sustainability, of how we spend our money wisely, is certainly front and center not only for our elders as they need the system, but that pressure puts strain on the system for everyone else,” said Evelyn Liebman, director of advocacy for AARP New Jersey, which was a sponsor of the conference.
Individuals with disabilities
The program also plays a critical role for individuals with disabilities, explained Joseph Young, executive director of Disability Rights New Jersey, since it now pays for a range of homecare and support services, in addition to medical care. While two out of five disabled individuals reportedly receive Medicaid, Young said some 90 percent of those with serious life-long disabilities depend on the program to help them meet daily needs.
Young said he encounters plenty of clients who face problems with their Medicaid benefits — including denials by managed-care companies — and not everyone in the community is receiving the same level of services. But gone are the days when bankruptcy was the only option for disabled citizens with high medical costs, he said.
“Virtually nobody in New Jersey at the moment with a long-term chronic disability gets nothing,” he said, “and there aren’t people at home anymore waiting seven or eight years from when they graduate from high school to be integrated back into the community.”
Medicaid pays for certain nonmedical programs and support services in an effort to help members move from institutions to community-based care, which most people consider preferable.
Speakers also touched on systemic shifts, like the move toward value-based care and integration of physical and behavioral health, models that Preitauer said have become critical to Horizon’s work and are starting to have an impact. That said, New Jersey’s Medicaid physician-reimbursement rate is among the nation’s lowest, Howard said, making it difficult to attract providers to the program.
Rachel Cahill, senior healthcare program officer with the Nicholson Foundation, was among those who stressed the need for more detailed data that could reveal county-level healthcare patterns — without personal information. Information like this would help programs target reform efforts where they are needed most.
Matthew D’Oria, chief transformation officer with the New Jersey Health Care Quality Institute — another conference sponsor — noted that at least a third of all healthcare is considered unnecessary, and weeding out those excess treatments provides a huge opportunity for savings. “There are ways of getting at that that we haven’t fully embraced,” he said.
With support from Nicholson, NJHCQI produced a detailed plan, “Medicaid 2.0: A Blueprint for the Future,” released in March, that outlines dozens of steps designed to help the state improve its system; among the recommendations is creating an “office of healthcare transformation” at the governor’s office level, something D’Oria said should be a priority for the next administration.
“We try and identify areas where there are opportunities to make systems change and to make change that is sustainable,” Cahill said; Nicholson also operates a “Medicaid academy” at which New Jersey officials can learn best practices from other states. “That’s really where we are trying to leverage our funding values,” she said.
Speakers on the maternity panel also revealed how sharing best-practice strategies — like steps to reduce unnecessary C-sections, which involve more risks than vaginal births — has helped hospital systems improve birth outcomes, despite the current challenges. But there remains room for improvement, particularly among black and Hispanic women, who have been less able to connect with quality prenatal care.
“When you put up the economic disparity, it generally tells the story more than anything else,” noted Linda Schwimmer, president and CEO of the Healthcare Quality Institute. “But we can do a better job of zeroing in on where the needs are,” she added, underscoring the necessity of better data.
Suzanne Spernal, the clinical director of obstetric services at Monmouth Medical Center, a member of the RWJ/Barnabas Health network — which also sponsored the conference — stressed that other factors, like access to transportation and child care, can play a huge role in maternal health. “There are a lot of social determinants of health that impact woman getting the kind of care they need,” she said.
Spernal, Lamborne, and others stressed the need to find ways to effectively communicate with their patients – instead of lecturing them on proper care — and connect them with accessible community care.
Colleen Nelson, vice president of the Children and Family Health Institute at the Visiting Nurse Association Health Group, described how her team has been creative in how it reaches and helps new moms. Providers from her team conducted home visits to ensure one newborn would be safe coming home from the hospital and treated another woman in jail when she was arrested shortly after giving birth.
“Culture plays a huge role in maternal child health, more so than in other healthcare issues,” explained Robyn D’Oria, CEO of the Central Jersey Family Health Consortium. “Culture is very much embedded into all that we do and the decisions that woman and families make as related to maternal health.”