Model community health program can reduce Medicaid MCO costs

by Richard Frye, Ph.D.
Thursday, January 8, 1998

Managed care organizations with growing numbers of Medicaid recipients are increasingly interested in effective prevention programs to modify unhealthy lifestyle practices of at-risk enrollees in order to control costs. Among the barriers to effective preventive care for Medicaid recipients are illiteracy, limited access to health services, poor nutrition, transient lifestyles, and no telephone. When MCOs intervene against these barriers, they foster improved patient health and thereby reduce costs.

One preventive health program, which enlists community workers to modify the lifestyles of hard-to-reach, chronically ill Medicaid beneficiaries, has managed to reduce emergency room and hospitalization use and significantly lowered costs.

The Community Health Worker Outreach Program, one of four initiatives of the Enhancing Neighborhood Action By Local Empowerment project, housed at the University of Maryland at Baltimore, achieved a 27% reduction in Medicaid costs over the past three years. That amounts to an average annual savings of $11,000 per patient, according to Donald Fedder, M.D., program director of ENABLE.

The program trains workers recruited from two largely African American neighborhoods in west Baltimore to serve some 300 middle-aged and older Medicaid beneficiaries with chronic illnesses. The recruits have to be supervised closely because they often have suspect work ethics, says Fedder. But the community workers relate well to the patients, who are typically suspicious of medical personnel.

"The big problem in health care," contends Fedder, "is we speak in tongues." Fedder shared with The Health Care News Server a recent experience with his own physician, in which he was handed a sheaf of papers with no further instructions as a prescription for reducing his cholesterol level.

Fedder, whose background is in behavioral change, believes that physicians ultimately have little effect on patients' unhealthy habits. The seven minutes patients spend on average in their encounters with physicians, he says, ultimately "mean nothing." Environment and heredity have a larger influence on behavior, he observes, but "lifestyle is half of the game." It takes a peer to influence change. That is why the program recruits workers from local communities.

A University of Maryland professor, Fedder called upon Maslow's theory of personality to account for the program's interventionist model. In this view, he muses, low-income, Medicaid patients would not feel higher-level needs until basic physiological and security needs have been fulfilled. It is for this reason that community health workers operate first to satisfy patients' lower-level needs. But thereafter Maslow's humanism gives way to the program's behaviorism. If illness can be attributed to unhealthy lifestyle practices, then the workers optimize health outcomes and costs by eliminating barriers to effective patient treatment.

The typical community health worker requires up to seven visits to gain the patient's confidence, says Fedder. "This is a secondary-prevention program. Patients suffer from hypertension, congestive heart failure, diabetes. The community workers can prevent a lot of exacerbation."

One way to counter the difficulty that medically-underserved, low-income populations have in accessing health care services is to arrange for the services to come to them. In a sense, preventive care for Medicaid beneficiaries has never been more complex. Workers assist patients with diabetic finger sticks, blood-glucose recording, diabetic foot inspections, diet modification, referrals. Whatever it takes. "A lot is intuitive," Fedder maintains. "They become pretty good street psychiatrists." But their primary role, he emphasizes, is to ensure that patients adhere to whatever therapy regimen has been prescribed by their physician. They provide a combination case worker, social services function. "It's not magic," he says. "I can tell you that it does work."

Community health workers undergo a three- to six-week training session, during which a variety of health care professionals, including physicians, nurses, and psychologists, allow them to understand the basics of the disease. "That kind of networking is essential," maintains Fedder. Each worker is assigned 30 patients, but workers do not operate independent of the program. "They have got to have support," he says. The program supervisor, who is trained in psychology, makes daily contact with the workers. Patient visitations are closely monitored. In addition, every other week workers come in for direct discussions with the supervisor. CHWOP was instituted seven years ago, in response to the query by a high-ranking medical official, what's wrong with Medicaid beneficiaries? Why can't they learn? The remark did not surprise Fedder. "Managed care organizations have no experience with high-risk patients--and they are scared to death." But, he insists, "anyone can be helped. This model will work for them."

"I look at the patient as the primary care provider," Fedder explains. It's not hard to diagnose illness, but it's hard to prevent it when you are confronted with dire social circumstance. The fact is, he adds, "these people don't trust health care organizations. They have been experimented on, used as guinea pigs. We deserve this."

ENABLE is funded primarily through a grant from AmeriCorps, which provides 3 of the 4.5 million dollar budget for each three-year cycle. The grant stipulates, however, that the balance must be met through matching funds from local sources. In spite of the CHWOP program's documented record of success, Fedder struggles each cycle to raise the difference. "This is also a jobs program," he points out. "The cost is relatively small. We should not have to look." Fedder is anxious to see the model instituted elsewhere; in fact, he is promoting a "gainshare" arrangement. "I don't see any downside."

According to Fedder, although all CHWOP patients are Medicaid beneficiaries, not all require the services of the program. "The program is geared for the high-risk, high-cost user," he says, "who doesn't know how to get around the system.

"I really see them [the community health workers] as ombudsmen for patients," says Fedder, who insists the objective of the program is to help patients to become self-sufficient. "We are trying to get people to understand that they can take care of themselves."