2018-06-27 National Governors Association

Medicaid and Complex Care

States continue to drive toward improving the health of their residents and, because health care costs are a large and growing component of state budgets, governors also are looking for long-term, transformational ways to improve the efficiency of their Medicaid programs. Generally, a small segment of the enrollee population account for large portion of states’ Medicaid expenditures. Those individuals with complex care needs, also known as “super-utilizers,” tend to have a history of chronic illness, multiple comorbidities, special needs and other non-clinical complications that may be related to unstable housing, employment, food and transportation and interaction with the criminal justice system. They often use emergency departments and inpatient services when home and community-based interventions could be employed with good outcomes and at lower costs. By appropriately redirecting state funds to address the comprehensive needs of people with complex care needs, states can rein in escalating costs and improve the quality of care delivered to high-risk and vulnerable Medicaid beneficiaries.

The NGA Center is currently working with nine states (AlaskaColoradoConnecticutKentuckyMichiganRhode IslandWest VirginiaWisconsin and Wyoming) over the course of 18 months in the second round of the Developing State-Level Capacity to Improve Health and Reduce Cost of Populations with Complex Care Needs Policy Academy. The first round finished in November 2014, with seven participating states (AlaskaColoradoKentuckyNew MexicoPuerto RicoWisconsin and West Virginia). Through this comprehensive technical assistance effort, NGA Center will assist states in identifying target complex care populations through data analytics; developing care delivery and payment models that incentivize best practices and provide return on investment through optimizing health and behavioral health care approaches; and adding wraparound services such as transportation and housing.