The incoming presidential administration will likely implement significant changes to Medicaid eligibility criteria and coverage duration. Public statements and planning documentation propose introducing work requirements, more stringent eligibility redeterminations, and potentially other changes to Medicaid coverage – shifts that could create a more complex environment for managed care organizations, primary care providers (PCPs), and patients receiving Medicaid.
Our team has proactively identified several key ways that Waymark can help patients, as well as their providers and health plans, as they navigate these changes.
Anticipating Eligibility and Coverage Changes
At Waymark, we work with health plans to improve eligibility navigation and identify, track, and assist patients through increasingly complex requirements when facing the risk of coverage loss. This proactive approach can enable early interventions and provide targeted support. Similarly, our evidence-based protocols help us assess factors that might exempt patients from work requirements and improves the likelihood of application success.
Patients receiving Medicaid benefits have shared that Waymark care team members have helped them access job training, education and employment opportunities. Waymark has also intentionally expanded our outreach programs to help patients navigate the benefits renewal or redetermination process to maintain continuous coverage. We continue our care coordination efforts to ensure continuity of care during coverage transitions, based on our protocols for handoffs between providers and care management teams when coverage status changes.
Enabling Cost Reduction Through ED and Hospital Visit Avoidance
With the potential implementation of more stringent Medicaid spending targets, states and health plans will face increased pressure to reduce the overall cost of care. This pressure may translate into a heightened focus on reducing emergency department (ED) utilization and hospital admissions where possible, and calls for an equally heightened focus on rising-risk populations whose adverse health events could be avoided with adequate and timely access to primary care.
Waymark will continue to focus on conditions that frequently lead to avoidable ED visits and hospitalizations, such as diabetes, heart failure, and COPD. We continue to tailor plans for identified rising-risk utilizers of ED and hospital services by incorporating social determinants of health (SDOH) into our interventions. We are also constantly monitoring how those SDOH factors change in tandem with underlying economic and social forces, community organization capacity, and possible shifts in federal and/or state funding streams and policies.
Supporting Positive Maternal Health Outcomes
The potential changes to reproductive health services under the new administration have already led to increased attention on maternal morbidity and mortality rates. States and health plans are likely to be held responsible for these outcomes despite potentially reduced resources.
Waymark deploys targeted interventions for members of populations at the highest risk for adverse outcomes, including those with co-morbid hypertension (pre-eclampsia), diabetes, mental health conditions (across the mild to severe spectrum, and including psychotic disorders across all axes), and/or substance use conditions.
Waymark’s care teams have already integrated behavioral health care into our maternal care protocols and will continue to do so while also calibrating our data-powered solutions to support these efforts. We will also continue to support comprehensive prenatal and postnatal care that goes beyond traditional medical care to address social and behavioral factors affecting maternal health.
Managing Vaccination Rates and Infectious Disease Risk
Anticipated changes to Department of Health and Human Services policies may affect vaccination programs, potentially leading to increased risk of pertussis, measles, and other vaccine-preventable communicable diseases. Targeting vaccination tracking and reminder systems in our care management platform helps us ensure that eligible patients remain up-to-date on all immunizations. These systems allow for the incorporation of HEDIS vaccination gaps (CIS), ingestion of data from state vaccination databases, and targeted outreach to under-vaccinated populations.
Waymark tests data-driven educational campaigns that support well-child visits, and those campaigns can also be leveraged to combat vaccine hesitancy, given our understanding of our specific patient populations and their unique concerns and barriers to vaccination. We continue to conduct targeted outreach to under-vaccinated populations, typically via combinations of phone, SMS, and in-person outreach. Vaccine counseling is integrated into our pharmacy counseling visits, with our care teams trained in effective communication strategies to address vaccine hesitancy.
Delivering Behavioral Health Interventions Under Capitation
Potential reductions in Medicaid coverage and rates for fee-for-service behavioral health services may create increased challenges for access and the receipt of care. This is another case to be made for providers and health systems leveraging community-based care teams; integrated behavioral health care as part of these programs has been demonstrated to positively impact communities.
Waymark continues to offer behavioral health counseling via licensed therapists, employing screening and early intervention protocols for mental health and substance use conditions, incorporating insights from diverse data sources into our rising-risk algorithms to enable proactive engagement. We’re focused on increasing access to care through telehealth options for behavioral health services, which are facilitated through community health workers (CHWs) and delivered by our licensed therapists to the most vulnerable populations we serve.
As the Medicaid landscape evolves, it’s essential that the organizations responsible for providing high-quality, timely care to patients receiving Medicaid work collaboratively to navigate these forthcoming changes. By leveraging existing strengths in each of these areas, we can support patients, partners, and programs in navigating challenges while improving health outcomes and reducing overall healthcare costs.
