An Overview of Medicaid Incentives for the Prevention of Chronic Diseases (MIPCD) Grants
Status of MIPCD Programs to Date
The interim national evaluation of MIPCD programs, submitted by the Secretary of the Department of Health and Human Services to Congress in November 2013, provided an overview of the status of MIPCD programs and enrollment to date. States faced unforeseen challenges in the implementation process, which led to the delayed implementation of most programs. As a result, most states had been enrolling participants only for a short period of time before the interim evaluation and were below their beneficiary enrollment targets. As of August 31, 2013, Texas was the only state that had met its enrollment target of 1,250 beneficiaries. Due to the lack of evidence available at the time of the interim evaluation, no recommendation was made for or against extending the programs beyond January 2016.1
Certain challenges were common among states implementing MIPCD programs. These challenges included:
- Administrative delays and working through state bureaucracies (e.g. contracting limitations, releasing Requests for Proposals and securing contracts, creating and submitting materials to multiple institutional review boards, and trying to hire staff)
- Provider engagement and participation, for reasons such as administrative burdens associated with program oversight and data collection, agreeing to program requirements, incorporating the program into providers’ daily workflows, lack of funding to encourage provider participation, and the inclusion of some services (such as YMCA diabetes prevention classes) in the program that are not covered by Medicaid
- Provider management and oversight (especially in large states with a high number of providers participating in Medicaid, or where providers may be geographically dispersed over large distances)
- Participant identification (e.g. identifying eligible participants for the program due to lack of target population data or being uncertain whether individuals who meet the program criteria are eligible for or enrolled in Medicaid)
- Managing patient incentives (e.g. technical barriers and difficulty with vendor procurement for offering cash in the form of debit cards)
- Community perceptions of participants (particularly perceptions of participants with mental health conditions when attending community events such as Weight Watchers meetings or YMCA classes).
As a result of these challenges, states have adapted many elements of their MIPCD programs, including:
- Timelines (most states delayed implementation dates and some states modified the implementation of programs, scaling them down or staggering their roll-out)
- Beneficiary recruitment and enrollment (e.g. adopting new recruiting tools, reducing enrollment targets, changing the screening and enrollment process, expanding the target population)
- Beneficiary incentives (e.g. changes to the incentive size, type, or distribution to maximize their effectiveness)
- Provider recruitment, training, and incentives (e.g. adjusting provider training and reimbursement, or the type of provider recruited, in an effort to recruit more providers)
- Evaluation design (e.g. amending the evaluation design or selecting a new design)
The challenges faced, and changes made to MIPCD programs, have led states to learn a variety of lessons to date. Common lessons learned include:
- Flexibility: Have the ability to adapt to challenges as they arise.
- Problem-solving: Anticipate potential issues and develop alternative plans and options when things to not go as planned.
- Political support: Have high-level champions in state government to help minimize bureaucratic obstacles and establish stakeholder relations.
- Project oversight: Adequately plan program implementation, hire a capable program manager, and implement comprehensive project management systems and infrastructure.
- Collaborative partnerships: Develop partnerships during the planning phase and nurture those relationships (e.g. with local mental health authorities, care coordinators, advocacy groups, Department of Social and Health Services board members).
- Ongoing communication: Communicate frequently and in-person to build relationships with partners and providers.
- Trained providers: Determine whether there is a sufficient number of providers with the training, capacity, and practice protocols to provide the service that the state is incentivizing.
- Cultural and linguistic awareness: Incorporate translated materials into the program and include interpreters and bilingual health coaches at the clinics/project site locations.2
The Secretary of the Department of Health and Human Services will submit a final national evaluation to Congress on the MIPCD programs no later than July 1, 2016. The final report should describe the effect of the initiatives on the use of health care services by Medicaid beneficiaries, the extent to which special populations (including adults with disabilities, adults with chronic illnesses, and children with special health care needs) are able to participate in the program, the level of satisfaction of Medicaid beneficiaries with the accessibility and quality of health care services provided through the program, and the administrative costs incurred by state agencies administering the program.3
Going forward, more evidence is needed on the effect of beneficiary incentive programs in Medicaid on health care utilization, health outcomes, and costs. Once programs are further underway and more participants are enrolled, the final evaluation of the MIPCD program will likely be able to incorporate more evidence on these programs. The evaluation will also incorporate a recommendation on whether to extend federal funding of these initiatives past January 2016. The existence of, or lack of, federal funding could greatly influence whether MIPCD grantee states (as well as other states with beneficiary incentives in Medicaid) continue their incentive programs.
Beyond the MIPCD program, other states are incorporating beneficiary incentives into their Medicaid programs as part of Medicaid expansion waivers. Michigan and Iowa have approved Section 1115 demonstration waivers and Indiana and Pennsylvania have Section 1115 waivers pending approval with the Centers for Medicare and Medicaid Services (CMS) for alternative Medicaid expansion plans that include healthy behavior incentives.4 Iowa and Michigan received approval, and Pennsylvania is seeking approval, to charge premiums to certain Medicaid beneficiaries, but allow premiums and copays to be reduced for beneficiaries who comply with specified healthy behaviors, such as completing physicals and/or health risk assessments. Indiana’s waiver proposal (HIP 2.0) builds on the state’s existing Healthy Indiana Plan (HIP), a pre-ACA Medicaid expansion program for adults that includes health savings accounts to which the state and individual contribute. The program offers enhanced account roll-overs to beneficiaries who complete appropriate preventive services.5 In general, pre-ACA Medicaid beneficiary incentive programs and MIPCD programs tend to offer extra rewards (such as cash, gift certificates, etc.) that go beyond the traditional Medicaid parameters. States that are incorporating healthy behavior incentives into their Medicaid expansion waivers under the ACA, however, are tying healthy behaviors to reduced or waived premiums and cost-sharing that are otherwise required. Overall, the Medicaid expansion waiver documents contain few details about the healthy behavior programs, and states are expected to develop the specific protocols for CMS approval.
Medicaid programs could encounter unique challenges in implementing healthy behavior incentives compared to private insurance programs that cover people at higher incomes. Low-income individuals face a range of economic and social barriers in their everyday lives that may make it difficult for them to participate in Medicaid incentive programs. For example, low-income populations may have difficulty affording transportation or child care to get to doctor appointments, educational classes, or weight loss programs. They may have insufficient access to phones or computers to call helplines or use web-based programs, or have difficulty affording health activities that may not be covered by Medicaid, but which would help them to achieve their health goals and earn financial incentives. Additionally, private insurance programs are likely to offer greater financial incentives, which could influence more substantial behavior change. Going forward, it will be important to monitor healthy behavior programs’ effects on Medicaid beneficiaries’ access to care, health care utilization, health outcomes, and costs, given the interest in this topic among MIPCD states and other non-MIPCD states.