Safety Net in Greater Cleveland Demonstrates What Is Possible with Medicaid Expansion

07 May 2014
The expansion of Medicaid in Ohio was far from certain on February 5, 2013, when CMS granted a waiver that enabled Ohio to move up to 30,000 uninsured adults living in Cuyahoga County into a new health care coverage program called Care Plus. Three safety-net members of Better Health Greater Cleveland viewed the waiver as a testing ground for hoped-for statewide Medicaid expansion, which Ohio’s Governor Kasich ultimately approved in October.
The anchor organization for Care Plus was the county-owned MetroHealth System, Ohio’s largest safety-net provider and Better Health’s administrative home base. MetroHealth was joined in the program by Neighborhood Family Practice and Care Alliance, both Federally Qualified Health Centers and longstanding Better Health members. Together, the three organizations enrolled 28,294 uninsured patients between February and December 31, 2013. As Care Plus patients migrate to Medicaid later this spring, Better Health’s Data Center has been invited to assist MetroHealth in examining whether the program had achieved its goals, including better access, better care, better outcomes, and lower costs than those that CMS estimated as “budget neutral.”
As a measure of access, Better Health’s Data Center documented region-wide changes in the number of residents who were uninsured vs. insured by Medicaid, including Care Plus, in 2013 as compared to 2012. To examine care and outcomes, the Data Center focused
on changes in achievement on its standards for Care Plus patients with diabetes and hypertension seen at MetroHealth in both 2012 and 2013. To be more confident that the results of Care Plus patients were not simply due to trends in Better Health’s quality measures, MetroHealth’s Care Plus patients’ results were compared to those of MetroHealth patients who remained uninsured in both years. Data for region wide utilization and costs, including those incurred for care at unaffiliated health care organizations, were provided by MetroHealth, which served as the CMSsupported payer for Care Plus. The early results are far better than most observers expected—on all fronts.
Among Care Plus patients with diabetes, standards for care improved 9 percentage points (relative improvement 18 percent), and standards for outcomes improved 7 points (relative improvement 28 percent). While some measures improved more than others, improvements were noted on virtually all individual standards. Care Plus patients with hypertension showed modest improvements in good blood pressure control (3 points or 5.5 percent relative improvement) that were associated with an increased proportion of patients on two or more blood pressure medications. According to Better Health’s Data Center Director Thomas Love, PhD, “The year-to-year improvements for diabetes patients are unprecedented in Better Health’s history of public reporting. They are especially remarkable because the Care Plus patients were only enrolled for an average of nine months in 2013 and were more disadvantaged than other uninsured patients in 2012.”
Equally remarkable results on selected utilization measures and total costs of care, including region-wide data on all Care Plus enrollees, were reported. In contrast to other recent data from Oregon that reported a 40 percent increase in Emergency Department (ED) use associated with Medicaid expansion, ED use by Care Plus declined by at least 60 percent from 2012 to 2013—a decrease that was associated with a 50 percent increase in use of primary care services during the same time period. And, despite these counterbalancing forms of utilization, total costs of care among Care Plus patients were approximately 25 percent lower per enrollee per month than CMS’ “cost-neutral” estimates for these patients. When summarized across all enrollees, MetroHealth estimates total costs of services that are approximately $50 million lower than those CMS projected.
According to Better Health’s President Dr. Randy Cebul, “We probably should have expected improvements here in spite of some other evidence that led us to be a bit more pessimistic. All of the sites participating in Care Plus are in EMR-facilitated safety net organizations with longstanding commitments to disadvantaged populations that have highest-level national recognition for patient-centered care.
Patients were not randomly assigned at all—they were recruited and supported by nurse care coordinators partly funded by CMS. And perhaps just as important, MetroHealth felt at financial risk if it exceeded the CMS cost-neutrality requirements, and this was a strong
incentive that was felt throughout the system.” 
As far as improved access is concerned, the numbers tell the story. The more than 28,000 newly insured patients represented approximately 39 percent of Medicaid-eligible adults who were uninsured in Cuyahoga County during 2013. From MetroHealth’s reports of utilization, the 50 percent increase in use of primary care and 60 percent decline in emergency department use in 2013 are patterns consistent with better access to care. And from patient stories and evidence from the Oregon experiment, we expect that the newly insured sense much greater financial security, especially financial burdens related to medical costs.
Better Health believes that the Care Plus story describes a “secret sauce” that has several definable ingredients and that it is a recipe worth testing as Medicaid expands in states across the country.