Oregon offers lessons in serving new Medicaid patients

For new Medicaid enrollees in Oregon, the first visit with their doctor in some ways is like a first date.

When Dr. Christina Milano, a family physician and assistant professor at the Oregon Health & Science University, has her initial visit with a patient who signed up for the state's expanded Medicaid program, she doesn't do a formal medical evaluation. Instead, she uses the visit as a chance for her and the patient to get to know each other. For her, the meeting helps her form an individualized care plan. For patients, it gives them a chance to decide if they want her to be their doctor.

But it's not just her that patients have to decide about. It's her whole staff, because Milano is part of a patient-centered medical home team that will be working with the patients to manage their health. So that first visit includes a tour to give patients the chance to meet the nurses and other professional staff. “We make a huge effort to underscore the relationship aspect from the very beginning,” Milano said.

Many of these patients have never had health insurance or a regular caregiver and they don't necessarily know how to use the healthcare system effectively. Milano wants to is build a strong bond with new patients to help them stay healthy, use the system properly and avoid unnecessary use of the hospital emergency department, which traditionally has been a primary source of care for uninsured Americans. Primary-care providers throughout the country will face the same challenge with millions of Americans newly enrolled in expanded Medicaid programs under the Patient Protection and Affordable Care Act.

A recent study of Oregon Medicaid patients published in Health Affairs found that a lack of relationship-building between beneficiaries and physicians—not trouble finding a primary-care physician—was the key reason enrollees overused the ED. The researchers found that 40% sought care infrequently because they said they were confused about their benefits, faced access barriers, had negative interactions with providers, or felt that care was unnecessary. Most of those studied said they experienced substantial improvement to their healthcare after months or years of working closely with a provider.

“Patients who had a bad experience were sometimes reticent to use care, which decreased the value of coverage,” said the study's lead author, Heidi Allen, an assistant professor of social work at Columbia University. “Patients did the best when they felt in partnership with a provider, that they were working together toward shared goals.” That was particularly true for people with complex health issues.

In 2012, the CMS awarded Oregon $1.9 billion to transform its Medicaid program by establishing regional coordinated-care organizations using the medical home model. Oregon has to produce significant savings or it will face a big loss in federal Medicaid funding. Before the CMS waiver, researchers found that new Medicaid patients in Oregon used the ED 40% more than the control group of people who were uninsured, with most of those ED visits being unnecessary.

A substantial amount of research shows that the medical home model helps reduce unnecessary ED visits for low-income beneficiaries, said Melinda Abrams, vice president for delivery system reform at the Commonwealth Fund. Last month, Oregon Medicaid officials released data showing that ED visits by Medicaid beneficiaries in the new coordinated-care organizations decreased 13% in the first nine months of 2013 compared with the same period in 2011.

Providers and health plans say it's critical to give new Medicaid enrollees a full orientation about their benefits and how to use the healthcare system, and quickly connect them with their provider.

Kaiser Permanente Health Plan of the Northwest, which serves nearly 12,000 Medicaid beneficiaries in Oregon, uses non-clinician staffers called navigators who reach out to beneficiaries by phone within a month of their enrollment. The navigators orient them to Kaiser and its benefits, informing them how to use the 24-hour nurse advice hotline and urgent-care centers. They help the new members fill out a short health screen to identify their health needs. The navigators may schedule the member's first appointment with a primary-care doctor whose practice will serve as their medical home.

Using navigators to connect members quickly with primary care and chronic-care management is crucial and is likely to reduce ED use, said Lynn Barker, director of Medicaid and Charitable Programs at the health plan. But there are still lots of unknowns, such as whether no shows for appointments will be a significant problem.

Experts hope other states learn from the medical home strategy Oregon has used for getting new Medicaid enrollees into a managed, relationship-based healthcare program. Just giving people insurance without guiding them through the system is reckless, said Marc Williams, a spokesman for Colorado's Department of Health Care Policy and Financing, which is using the medical home model. “It's like giving a 16-year-old the keys to a new Ferrari and they don't have a driver's license,” he said.

Follow Virgil Dickson on Twitter: @MHVDickson