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Clear language and human-centered design can help Medicaid enrollees keep their coverage

A Medicaid form with "Approved" stamped on it.Michigan’s expanded Medicaid program, the Healthy Michigan Plan (HMP), has provided health insurance coverage to hundreds of thousands of Michiganders since its launch in April 2014. However, in 2019, the state passed a work requirements bill, which introduced more steps needed to retain HMP coverage. The bill asked HMP enrollees to report a minimum of 80 hours of work per month to keep their insurance benefits. Consequently, to reduce the number of people who might lose coverage due to lack of reporting their hours, MDHHS developed a robust communication strategy. Their strategy used input from users, and applied a human-centered design. The Center for Health and Research Transformation (CHRT) at the University of Michigan evaluated this work. Results from the evaluation are published in this month’s JAMA Health Forum.

The CHRT team led 11 focus groups and fielded a survey to collect data from community health navigators, who help enrollees complete the paperwork needed to obtain and maintain coverage. Navigators reported that many of the steps taken by the state to improve the implementation of the bill for those on HMP insurance were helpful.  

While Medicaid communications are traditionally text heavy and technical, MDHHS used simplified language, streamlined the format, and employed attention-grabbing colors and icons in letters to beneficiaries. 

Findings

“MDHHS worked with external communication experts and this novel approach had a very positive impact,” said Patrick Kelly, lead author of the evaluation, who completed the survey while serving on CHRT’s research and evaluation team. “Respondents reported that traditional Medicaid form letters may get lost in the shuffle and be challenging for beneficiaries to understand…With the revamped letters, it appeared that beneficiaries’ attention was drawn to the envelopes. Many even brought the letters with them when meeting with navigators to discuss next steps.” 

While navigators reported overall improvements from traditional Medicaid communications, they were concerned that the policy itself was very complex to understand, and therefore to apply. This included some challenges regarding the communication around exemptions and concerns about internet, telephone, computer, and language barriers. 

Research shows that administrative burdens can lessen the utility of public health programs. The state of Michigan took steps to shift the administrative burden from individual beneficiaries by using administrative data where possible to automatically exempt and deem people in compliance with the policy. “This is a great improvement for the enrollees who are not always in a position to handle administrative requirements,” said Kelly.

In spite of these efforts, had Michigan continued to enforce the policy, it would have revoked health insurance coverage from about 80,000 enrollees.

Conclusions

Public agencies could apply this study’s results to other public benefit programs and policies. This would improve implementation and ensure that everyone can receive their authorized benefits.

“As the federal public health emergency will soon end and many individuals will need to re-apply to maintain Medicaid coverage, state Medicaid agencies can learn from Michigan’s experience by using enhanced human-centered design approaches to communicating with beneficiaries,” says Dr. Renu Tipirneni, a widely regarded expert on the impact of health reform policies and programs on low socioeconomic status, aging, and other vulnerable populations, and on delivery of care in the health care safety net.

 

Cited article:
Kelly RP, Marcu G, Hardin A, Iovan S, Tipirneni R. Health Navigator Perspectives on Implementation of Healthy Michigan Plan Work Requirements. JAMA Health Forum. 2022;3(6):e221502. doi:10.1001/jamahealthforum.2022.1502

Michigan Physician Survey: Primary care physician perspectives and practice trends

A physician, such as the physicians surveyed in Michigan for this research, sits across from a male patient in dark clothes.CHRT has been surveying primary care physicians (PCPs) in Michigan since 2012—tracking key trends in practice patterns, capacity, payer mix and care team composition. Our 2019 Michigan Physician Survey also asked physicians about care continuity and Medicaid work requirements legislation.

PCPs are a key component of a successful, high quality healthcare system. As the baby-boomer generation ages and the needs of this cohort increase, there is ongoing concern about how well the health care workforce can meet the increasing demands of an older and presumably sicker population.

Additionally, primary care is on the front lines of improving care delivery, such as increasing care management for complex cases, integration of behavioral health care and identifying and addressing social determinants of health.

Key findings of our 2019 Michigan Physician Survey include:

  • Primary care capacity in Michigan is good today, but there is some evidence it may decrease in the future. Capacity to accept new patients is high and has increased across all payer types since 2016. Almost two-thirds (62%) of PCPs indicated capacity for new Medicaid patients and over 80 percent reported capacity for Medicare and privately insured patients. However, 45% of PCPs indicate they intend to stop practicing medicine within the next 10 years— raising important questions about new PCPs or other practitioners in the training pipeline, and the need to continue tracking capacity over the next decade.
  • PCPs report more multi-disciplinary care team members than in 2016. Practices with a relatively higher volume of Medicaid patients were almost twice as likely to have Community Health Workers (CHW) and co-located psychiatrists on the care team. And, for the most part, hospitals and groups practices were more likely to have support staff, such as care managers and nurse practitioners, than single physician practices.
  • High deductibles and other cost issues threaten continuity of care. PCPs see cost and insurance-related issues as the biggest barriers to maintaining continuity of care with their patients; along with lack of transportation and limited health literacy.
  • The majority of PCPs are concerned about the impact Medicaid work requirements may have on care continuity and the complexity of the certification process. They are more evenly split in their opinions about how the new Medicaid work requirements could change the number of Medicaid patients in their practices, whether they would need to hire more staff, and the ethical issues of determining if someone is able-bodied.

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