Leveraging Care Management Software for Medicaid

Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies

Medicaid Programs are in the spotlight as the United States moves forward with a myriad of health care reform initiatives. As a result, health plans and providers will need to utilize care management software and related health information technology (IT) systems to support the care coordination needs of underinsured and uninsured Americans.

With millions of individuals already receiving insurance coverage through Medicaid or the Children’s Health Insurance Program (CHIP), and 10 million-plus expected to join in the next few years, Medicaid is set to become an even bigger part of the case management industry, and in a broader sense, the health care delivery system.

Right now, the main driver of Medicaid growth is the Affordable Care Act (ACA). This has led state-based Medicaid programs to implement managed care systems and other integrated care techniques to not only improve outcomes for patients, but reduce costs within increasingly burdened budgets.

Medicaid Expansion
To understand case management’s unique impact on Medicaid, it’s important to examine who will be receiving new benefits as a result of the ACA. Because Medicaid and CHIP eligibility was skewed heavily toward covering children before the ACA, many newly eligible recipients will be adults, largely without dependent children. They will also be low-income people—138% of the federal poverty line is less than $27,000 for a family of three—who, in many cases, have not had health insurance before, but do not have significant health issues. Understanding this new population is key to grasping the key challenges and incredible opportunities case managers will face beginning next year.

Integrating Case Management
Because 5% of Medicaid patients account for more than 50% of health care costs, care management is central to improving clinical and financial outcomes. Care coordination is changing and care managers are essential to integrating and supporting these new populations through the continuum of care.

For example, state Medicaid programs are placing a greater emphasis on treating targeted, complex populations with co-morbidities rather than focusing simply on specific disease states. Parity laws are also helping to more fully integrate behavioral health and addiction programs with primary care. A broader array of integrated health care services is being offered, using multi-disciplinary teams to address an individual’s total health care needs. Care managers are a key component to providing these integrated services across the continuum of care.

IT Support
Without a doubt, care management IT systems must assume a central role to support Medicaid program sponsors, providers, individual beneficiaries and their families. As a result, the reliance on IT applications to support patient care will expand. Care managers must have access to IT systems that can provide key functions in support of Medicaid enrollees including: implementing risk-assessments that help create customized care treatment plans; promoting automated workflows and documentation; stratifying opportunities to identify and manage targeted populations; and tracking/reporting financial and clinical outcomes – among other capabilities. It will be nearly impossible to provide the reporting these programs require without the use of IT systems.

Final Thoughts
Medicaid programs across the country are changing rapidly to meet the demands of these new eligible populations, as well as the overall increase in both the size and requirements of the Medicaid system. IT innovation has become a necessity as Medicaid costs consume more and more of a state’s budget. Medicaid directors see care coordination and population management as effective ways to better serve both patients and taxpayers by reducing costs, while improving clinical outcomes. Health IT systems are an essential part of this strategy.