Medicaid Makeover – 5 Steps to Success

First of all, I wouldn’t dare write about something called “Medicaid Makeover” if I didn’t believe it was possible to actually change and improve this very necessary program. Let’s not spend the time debating the worthiness or usefulness of the Medicaid program – it goes without saying that there is a population in our country that needs help with healthcare and there is a program designed to help them. Now it’s our job as healthcare professionals to find a way to improve and streamline that program, in every State.Impossible, you ask? He’s dreaming, you say? Well, I’ve been accused of worse. But here goes.

There are some basic changes that I believe need to be brought to the top of the healthcare food chain if we are truly going to change the Medicaid program:

1. Every Medicaid program needs a qualified and efficient “Care Coordination Team” who functions 24X7 and acts to both (1) triage the patients when they get sick and (2) manage the population “Prospectively” using up to the minute, real time predictive and historical data. This team functions to remove the physician from the burden of the “management” of the patient’s care and instead uses the physician efficiently to provide the right level of care. One of the problems in Medicaid today is that the patients are often left “rudderless” – physicians simply do not have the time nor capacity to manage this population and in other cases the care teams do not have the right information with which to do their jobs efficiently. Access to data, both prospective and retrospective, is critical for these care teams if they are to truly intervene and prevent the onset of disease. The Care Coordination Teams and the physicians acting as a team, can and will make the right decisions for the patient, but neither can do it by themselves. It must be done as a well-coordinated team of caregivers. The underlying premise is that every State needs a fully-functioning and well-equipped Care Coordination Team dedicated to this population and engaged with the physicians. The team needs to be comprised of (1) Care Coordinators, (2) Health Coaches and (3) Case Managers.

2. The Care Coordination Team needs Mental Health counselors and therapists on staff – or at least rapid access to these specialists. So many of the issues in the Medicaid population are related to Mental Health that without properly trained counselors and therapists, many of the problems with the patients become compounded and are promoted to more serious issues. The Mental Health counselors and therapists need to be trained on not only depression but also bi-polar disorder, PTSD, anxiety and drug dependence at a minimum.

3. Medicaid programs need to staff and provide for their own hospital-based care units, or “Outpatient Care Units (OCUs).” Too much of the Medicaid population habitually uses the hospital as their primary care provider. This creates an enormous cost overrun for the States because the hospitals can’t ethically turn these patients away and the resulting cost of care is often 500% or more higher than it would have been at a primary care unit. Instead, under this program, the Medicaid patients who appear at the hospital for non-traumatic encounters would be brought to an OCU triage office located in the hospital and staffed by a qualified medical team who is present 24X7. The OCU triage unit would make the determination of the necessity of care and if found that the patient could be treated at an OCU more effectively and timely, the unit would transport (in a well-equipped van) the patient to the OCU. This change alone, if implemented, would help reduce the State’s Medicaid budgets significantly.

4. All Medicaid patients need to be screened for a number of clinical risk factors yearly. This data creates the predictive information that can be used “Prospectively” by the Care Coordination Teams to manage the population and prevent the onset of chronic illnesses. Appropriate preventive counseling and care should come out of the team’s approach to managing the patient with the goal of preventing the onset of diabetes, COPD, heart disease and other debilitating factors. The hand off from wellness screening is preventive care and counseling. To the extent that the patients will participate, States need to offer unlimited and free counseling sessions for weight loss, smoking cessation, pregnancy counseling and other services that are ultimately designed to help the patient manage him or herself. Obviously not every patient will comply with this kind of preventive care approach but if any segment embraces it that will lead to cost savings and further reinforce the effectiveness of such a program.

5. The wellness screening data needs to include socioeconomic factors. We partner with a company who specializes in the data capture and management of socioeconomic data from the Medicaid population. That company is called “Healthify” (web:, Twitter: @healthify) and they have achieved a high degree of success with some major urban clients to deploy their specialized intake system. The underlying support for such a program is that it is inherently obvious that if a patient is not getting food at home or is suffering abuse, their healthcare issues will be materially affected in so many ways. It is important (read: imperative) that Care Coordination Teams tasked with managing this population be given the entire set of data, both clinical and socioeconomic, to support their decision making process. WellTrackONE and Healthify are partnering together to create a “superset” of data intake questions that will be used in the wellness screening programs of the Medicaid population. Taken together, the results will be a significant amount of “Prospective” data that can be used by the Care Coordination Teams to efficiently manage the patient.

No single person or organization can change Medicaid in total overnight. It does require a change of methodology, however. The 5-step action items described above are a first layer in transforming Medicaid but not inclusive of all of the changes needed. However, progress is measured incrementally, and we believe the 5-steps listed above are the key starting points needed to provide a “Medicaid Makeover.”

WellTrackONE and Healthify will be proposing a demonstration project to a number of State HHS agencies as well as some well-respected MCOs to show how an implementation of our 5-step process can and will lead to a cost reduction and quality improvement in the Medicaid population.

Reference material:

1. Care Coordination in Medicaid (
2. Care Coordination and cost savings in Medicaid (
2. High substance abuse and mental health issues in Medicaid (

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