This document discusses how Medicaid and public health resources can work together to improve health outcomes, particularly for patients with asthma. It provides examples of tobacco cessation programs and a pediatric asthma pilot program in Massachusetts that utilized community health workers and environmental modifications to reduce emergency department visits and hospitalizations. The document emphasizes challenges around agency silos at both the state and federal levels but outlines various mechanisms Medicaid has to support innovation, including waivers, new ACA authorities, and partnerships with other organizations. It argues Medicaid must be a partner in prevention efforts.

1. Medicaid and Public Health:
Focus on Asthma
Stephen Cha, MD, MHS
Chief Medical Officer
Center for Medicaid and CHIP Services
Centers for Medicare & Medicaid Services
June 13, 2013

2. Medicaid and CHIP
• The Center for Medicaid and CHIP Services is the nation’s
largest insurer: almost 60 million rely on Medicaid and CHIP
• 40% of births
• One of every four children
• Joint state-federal program
2

3. Medicaid Moving Forward
• The Center for Medicaid and CHIP Services is working to
propel positive change forward to achieve: improved health
of populations, improved experience of care, and
reduced trends in cost
• Goal is comprehensive, integrated patient-centered care and
financing that supports these goals
• Encourage and support our partners in this effort by clarifying
policy and providing support

4. Case study: Assessment and plan
52 year old male
• Asthma: Maximal meds already, still with ED visits, needs
environmental modification
• Diabetes: Meds, counsel on weight and diet
• Hypertension: Meds, counsel on weight and diet
• Obesity: Counsel on weight and diet
• Tobacco: Refer quitline, pt still precontemplative
• History of opiate addiction: S/p treatment, in counseling,
concerned now that discharged to community
• Depression: Meds, therapy at community center
• Unstable housing: In housing now

5. Where can public health and prevention
resources improve this patient’s health?
52 year old male
• Asthma: Maximal meds already, still with ED visits, needs
environmental modification
• Diabetes: Meds, counsel on weight and diet
• Hypertension: Meds, counsel on weight and diet
• Obesity: Counsel on weight and diet
• Tobacco: Refer quitline, pt still precontemplative
• History of opiate addiction: S/p treatment, in counseling,
concerned now that discharged to community
• Depression: Meds, therapy at community center
• Unstable housing: In housing now

6. Problem list for
Medicaid and public health together
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•
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•
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Asthma
Diabetes
Hypertension
Obesity
Tobacco
History of opiate addiction
Depression
Unstable housing

7. Support Best Practices
• Driving question: How are our policies supporting or hindering
the best practices on the ground to achieve three part aim?
• Strive for seamless set of services across silos– which entity is
best situated to most efficiently and effectively achieve our
goals?
• Medicaid must be a partner in prevention

8. Challenges
• Silos:
• State level: Medicaid vs public health vs mental health vs
chronic disease vs substance abuse vs perinatal
• Federal level: Disparate agencies and strategies
• Legal/regulatory (i.e., other licensed personnel)
• Need for partnerships
• Challenges in heading into 2014

9. Lots of mechanisms exist to support
Medicaid innovation
1. State plan amendments/waivers
–Broad systems reform under 1115: CA, MA, TX, OR
–Targeted delivery reforms under waivers: asthma, interconception, LTC
–Integrated Care Models (MN)
1. New authorities under Affordable Care Act
–Medicaid Quality Measurement Program, health homes, HIT
–Adult Quality grants
–Others: healthcare acquired conditions, tobacco cessation, prevention, etc.
- Section 4106: 1% bump for USPSTF validated services
- Section 4004: Education and outreach on prevention, especially obesity
1. Collaboration with Center for Medicare and Medicaid Innovation (CMMI), Medicare-Medicaid
Coordination Office (MMCO)
–CMMI: State Innovation Models, Strong Start, CPCi, FQHC, chronic disease prevention
incentives, emergency psychiatric demonstrations, Innovation challenge grants
–MMCO: Financial alignment models
1. Other departmental collaborations: National Quality Strategy, MHI, tobacco

10. Two case study areas for
improving public health via
Medicaid
• Tobacco
• Pediatric asthma

11. Tobacco
• Quitlines
• Pregnant women
• Coverage policies

12. Massachusetts Pediatric Asthma Pilot
Program
• Goal
– Improve health outcomes, reduce asthma-related emergency department
utilization and asthma-related hospitalizations, and reduce associated
Medicaid costs for children with high-risk asthma.
• Strategy
– Preventative care using CHWs, care teams, and recognition of environmental
factors, measured by cost savings and service utilization measures.
– PMPM payment
• Focus on preventative care
– Utilization of non-traditional workers for preventative care
• HEPA filters for vacuum cleaners
• CHWs for home visits and care coordination
– Explicit measurement of cost-shifting vs. cost reduction and effect/interaction
of pilot with other state initiatives
• Practices are eligible for up to $10,000 in
infrastructure payments related to this initiative (may
not be implemented)

13. Massachusetts Pediatric Asthma Pilot
Program
• Reporting Quality to the State
– Progress measured by cost savings and service utilization
• Post-intervention data compared to baseline numbers
– Reduction of ED visits and hospitalizations is primary focus
• CHIPRA measure on annual asthma-related emergency room visits is
required
• State Quality Reporting to CMS
– State must provide status updates on a quarterly basis including
payment, service, and outcome records

14. Summary:
Medicaid on the road to reform
• CMS stands ready to partner with states, providers, and
stakeholders to accelerate our path to achieve better health,
better care and lower costs
• Multiple pathways to reform
• Driving question should not be our authorities, but the strength
of evidence and appropriateness of intervention

15. Questions?