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Value-based care models can help close care gaps for Medicaid beneficiaries


But providers need to understand, address patients’ social health determinants

As the world emerges from the COVID-19 pandemic, food insecurity persists, many people remain unhoused, and families continue to struggle with access to quality health care. The health care industry has been forced to take a hard look at existing health inequities in the United States—particularly in overlooked and marginalized communities and for those on Medicaid—and make changes to lower the cost of health care while improving the overall health of underserved populations.

Value-based care is a health care delivery model that compensates providers based on patient health outcomes rather than the current fee-for-service model driven by service volume. By incentivizing providers to focus on preventive care, care coordination, and managing chronic conditions, value-based care can help improve the overall health of their patient panel, thus lowering the cost of care by reducing the need for hospitalizations and emergency department visits. Additionally, value-based care can improve access to care for Medicaid beneficiaries by ensuring they receive the proper care at the right time, in the right place.

While value-based care is particularly well suited for providers serving Medicaid patients, its use does present challenges, particularly for independent primary care practices in low-income communities. Medicaid is less lucrative, is difficult to administer, and health literacy issues often persist.

For primary care providers looking for a value-based care partner, choosing one with experience handling the challenges specific to Medicaid is critical. In addition, partners must understand how to work with Medicaid populations while addressing social determinants of health (SDoH).

SDoH encompasses the environmental conditions in which individuals are born, grow, learn, work, play, and age, and can significantly impact a broad range of health outcomes, functional abilities, and quality-of-life risks. All of these can significantly impact health outcomes. To provide appropriate care, primary care providers need to learn the challenges their patients face and connect them with organizations that can help them address those challenges. SDoH such as access to education, housing, and healthy food, all significantly impact health outcomes.

In addition to SDoH, health equity and cultural competence are critical to creating positive health outcomes for cultural groups. That means primary care providers need to embed cultural beliefs into their point of care to improve the health outcomes of all their patients.

While most providers know culture's role in patient satisfaction, prescription adherence and interacting with the health care system, they need tools to embed cultural beliefs in their point-of-care practices. Cultural competence training equips providers with a deeper understanding of the communities’ values and traditions, benefiting the patient, provider, and health care system.

The Centers for Medicare and Medicaid Services has set a goal of enrolling all Medicare and most Medicaid beneficiaries in accountable, value-based care programs by 2030. As a result, the vast majority of Medicaid payments are expected to be aligned with value-based care models by 2030, which means providers will need to adopt a new set of business capabilities.

By focusing on preventive care, care coordination, and managing chronic conditions in a culturally competent manner, value-based care can improve the overall health of Medicaid patients, ultimately helping to lower the overall cost of health care.

Hugh Lytle is founder and CEO of Equality Health

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Peter H. Reilly, HUB International: ©HUB International