Medicaid Population

Medicaid is arguably the most unique and complicated health insurance program in existence.

In all states and territories, Medicaid plays a critical role in providing health coverage for children, low-income families, people who are pregnant, elderly people with disabilities, and others with specific health needs. Medicaid eligibility standards and benefits vary significantly from state to state and are designed to cover our communities' most vulnerable people.

Care providers face some of their greatest challenges with Medicaid enrollees, who may have chronic, complex conditions and health needs related to social drivers. As doctors and hospitals face their own economic pressures, it can be difficult to fund adequate resources for managing all patients' whole health. Medicaid enrollees who experience poverty or are elderly or disabled — or all three — are more likely to need comprehensive care management and coordination that require an investment of time and resources. These dynamics make it especially important to ensure that the incentives, and support, for care providers to manage whole health are clear and sustainable.

Our Approach: Care Provider Quality Incentives

At Elevance Health, our Medicaid affiliated health plans are privileged to serve more than 10.5 million Americans in 25 states and Puerto Rico.2 In 2020, an estimated 42% of births were covered under Medicaid,3 and approximately 1 in 11 Medicaid births were among consumers enrolled in one of our affiliates' plans.4 When we talk about being a lifetime, trusted health partner, that means establishing a relationship of trust and reliability that can span a lifetime. Our affiliated health plans' local presence enables us to respond to local priorities and state requirements, while bringing our national scale and expertise to the table.

We work to identify and support quality care providers so that we can expand consumers' access to the best possible care, expand the reach of value-based programs, and advance population health management.

We believe that fee-for-service payment is incompatible with patient-centered care delivery because it does not drive sufficient accountability for appropriate care, cost, or utilization. Our value-based programs reward doctors, hospitals, and health systems for the quality and efficiency of care provided, measured by improved consumer health outcomes and reduced healthcare costs.

Our Provider Quality Incentive Program (PQIP) is the best example. It is a shared-savings program that rewards care providers for quality and cost-effective healthcare to patients covered by a Medicaid plan. Nearly 1 in 5 Medicaid consumers is assigned to a care provider participating in PQIP,5 which is a non-negotiated, upside-only program available to medical groups caring for 1,000 or more of our Medicaid consumers.

Our Progress

We have seen measurably improved clinical quality performance by PQIP-participating care providers. In 2021, these care providers scored significantly higher than their nonparticipating peers on a variety of quality measures. PQIP is successfully promoting better management of diabetes so that patients can avoid complications like heart disease, kidney failure, blindness, and amputations. It also promotes well-child visits that are crucial to ensuring children receive recommended immunizations and other preventive care.

Diabetes: HbA1c Testing: 1.7%

Diabetes: Eye Exam: 2.4%

Obesity Prevention: Weight Assessment: 11.4%

Weight Assessment and Counseling for Nutrition for Children and Adolescents: 14.9%

That performance translates to effective preventive care, as seen by avoided complications from chronic disease and avoidable illness, for patients who see PQIP-participating doctors.

Additionally, PQIP cost savings results show that quality care can also be lower in cost: Participating care providers save close to 6% in medical cost relative to their peers,6 delivering value to state government partners while rewarding care providers for the coordinated, prevention-oriented care they deliver to this vulnerable population.

Spotlight: Addressing Maternal Health Disparities in Medicaid Populations

We examined the use of and outcomes from doula services offered by our affiliated Medicaid managed care plans in three states: California, Florida, and New York. Doulas provide person-centered care to pregnant and postpartum people.

Our findings, included in the Addressing Maternal Health Disparities: Doula Access in Medicaid report, suggest that doulas offer a personalized and effective approach for improving delivery of culturally competent maternal healthcare and mitigating birth inequities, including:

  • Fewer inpatient hospital admissions during pregnancy.
  • Lower odds of Cesarean delivery.
  • Increased likelihood to attend the postnatal visit.
  • Lower odds of postpartum depression or anxiety.
  • Lower overall costs compared to pregnant people not using doulas.

Spotlight: Impacting ER Utilization in Medicaid Populations

In the U.S., emergency rooms (ERs) are visited more than 130 million times a year.7 Of those visits, certain patients might have chosen a different source of care had they known about other options.

Our affiliated health plans piloted a text-based patient outreach program that relies on a combination of data modeling, behavior science, and targeted outreach to help consumers know when to seek care at an ER or whether their concerns could be better addressed at an urgent care center, through an online visit, or at their doctor's office.

Our data model uses algorithms that combine historical data with sophisticated behavior science analysis to forecast which consumers are most likely to visit an ER soon to seek care for conditions that are not life-threatening. The first step in this clinically driven approach is comparison, followed by analysis which evaluates consumers based on traits and factors, and finally outreach. These outreach messages are brief and direct. They do not imply that the consumer made the wrong decision. Instead, the messages teach them about other options like urgent care, telemedicine, or seeing their own physician.

Our findings suggest that consumers who were presented with ER alternatives were more likely to use those alternatives if the need arose. We continue to research ways to encourage consumers to seek care in the most appropriate setting and to connect them with convenient alternatives to the ER.

Forward Together

Our success as a lifetime, trusted health partner has to begin with engaging our consumers and establishing a relationship of trust and reliability from the very beginning. By definition, Medicaid enrollees have relatively fewer resources. They also often face barriers to the care they need. Together, we and our care provider partners must address that lack of resources and barriers to care through comprehensive care management and coordination if we are to help these patients improve their whole health.

All of that informs our future-oriented work, which includes expanding access with remote and virtual options, using personalization to build trust, boosting care management and coordination for our enrollees' care providers, and streamlining authorizations and data sharing to ensure timelier access to care. A value-based care approach, therefore, is vital for the health and well-being of the most vulnerable people in our communities and those who care for them.

1 Centers for Medicare & Medicaid Services, National Health Expenditures 2020 Highlights (Accessed December 12, 2022): cms.gov/files/document/highlights.pdf. 2 Internal data (2022). 3 Kaiser Family Foundation, Births Financed by Medicaid: 2020 (Accessed December 2022): kff.org. 4 Elevance Health, Addressing Maternal Health Disparities: Doula Access in Medicaid (September 2022). 5 Internal data (2022). 6 Elevance Health PQIP evaluation (2022). 7 Centers for Disease Control and Prevention, National Center for Health Statistics, Emergency Department Visits (September 6, 2022): cdc.gov/nchs/fastats/emergency-department.htm.