Population-based approach

We commend the Department of Community Health for taking a population-based approach to improving the health of Georgia’s Medicaid members. We are especially encouraged by the Department’s commitment to engaging with the care management organizations (CMOs) to monitor and improve racial health disparities among Medicaid members. This commitment is a strong first step, and we believe DCH could go even farther to address and improve health disparities in these three ways:

Planning for Healthy Babies

Planning for Healthy Babies (P4HB) is an important program to improve maternal and infant outcomes and address health disparities, but it serves only a small population of women in Georgia. One of the reasons P4HB is so successful is the targeted outreach efforts to women in areas with poor infant health outcomes. DCH should take a similar approach for all Medicaid eligible populations. By focusing CMO and DCH outreach efforts on areas of the state with poor health outcomes and high Medicaid-eligible populations, they may be able to make a similar impact on health disparities for a larger population.

Meaningful engagement with Medicaid members

To successfully reduce health disparities, we advise DCH and the CMOs to work closely and meaningfully with Medicaid members and community members from the populations experiencing the greatest health burdens to craft impactful strategies tailored to a specific group. There are great opportunities to close racial health gaps among Georgia’s Black & Hispanic communities especially. Georgia has the 2nd largest Black/African American population in the U.S.(The Office of Minority Health, 2021), and 15% of Black Georgians are uninsured (KFF, 2020). Georgia also has the 9th largest Hispanic/Latino population in the U.S., and 47% of Georgia Hispanics are uninsured (The Office of Minority Health, 2021). Black and Hispanic Georgians suffer from chronic and infectious diseases, including COVID-19, at rates higher than those of white Georgians CDC, 2021) and have shorter life expectancies ( The Office of Minority Health, 2021).

Unique barriers (including language, systemic inequities to build wealth, available pathways to coverage, immigration status, social discrimination, and more) block these groups from equitable health status and outcomes. These complex and long-standing barriers to health can only be overcome with meaningful, sustained engagement with members of these and similar groups. Based on GHF’s observations, the infrastructure that DCH and CMOs have for engaging members falls short of what is needed. (GHF humbly offers its assistance to all interested parties re-thinking engagement strategies and programs.)

Beyond language and cultural competency

The Quality Strategy points to translation and language services and cultural competency as strategies to reduce health disparities. These are important components, but they are not sufficient on their own. We encourage DCH to explore additional interventions that better address the root causes of disparities. These interventions could include maximizing the roles of the state’s community health workers (CHWs) and peer support coaches; and incentivizing CMOs to operate robust wrap-around service programs to address housing, food, transportation, and economic needs of members. Numerous studies have shown that CHWs and peer support coaches can play meaningful roles in improving health outcomes, lowering health spending, and reducing health disparities (Chan, 2021).

Another solution to reducing health disparities is to ensure every Georgian has a pathway to health coverage. Medicaid expansion would go farther than the proposed Pathways 1115 waiver towards accomplishing this. Several studies have shown that full expansion of

Medicaid (up to 138% FPL) narrowed disparities in health outcomes for Black and Hispanic individuals, particularly related to infant and maternal health (KFF, 2020). While this decision does not lay with the Department of Community Health, your leaders and staff are trusted and important messengers to state lawmakers about how such a move could improve the health of Georgians.

Behavioral health

We were encouraged to see the Quality Strategy call out behavioral health as an area of focus. Data before and during the pandemic supports that behavioral health needs are growing across the population, and there is no doubt that this holds true for Medicaid members.

However, the measures for Goal 1.5 predominantly address mental health (increase screening for depression among adults and adolescents), while largely ignoring substance use. We know that youth substance use is a risk factor for other issues, including school absenteeism, depression, and committing acts of violence. Data show that Georgia youth are experimenting with drugs and alcohol at younger ages (SAMSA, 2019). Therefore, DCH could significantly impact the behavioral health outcomes of young members by adding measures related to substance use screenings and referral to treatment services. To increase screening for substance-use disorders among youth, DCH could leverage CHIP funds for Health Service Initiatives. Utilizing these funds would provide sustainable funding for school-based or population-based services to address substance use.

Access to care via telemedicine

The increased utilization of telemedicine during COVID-19 has proven it is an important method of care for Georgia consumers, including Medicaid members. For that reason, we are pleased to see it identified in the Quality Strategy. However, telemedicine cannot overcome all access challenges because many Medicaid members live in areas with limited internet connectivity, especially those who live in communities of color and rural communities. We encourage DCH to look for additional methods to increase access to care, including addressing transportation gaps.

Notably, the Quality Strategy does not mention the Non-Emergency Medical Transportation benefit for Medicaid enrollees. In our experience, many enrollees do not know about the NEMT benefit and therefore do not make use of it. Additionally, at times NEMT is unreliable and unprepared to meet members’ transportation needs (i.e., sending a regular van to pick up a member who needs a wheelchair-ready van or sending transportation that cannot accommodate a child’s sibling). DCH could increase access to care by promoting the benefit to more beneficiaries and investing in improvements to the program.

Measurement, evaluation, and enforcement

GHF applauds the strong evaluation and enforcement measures included in the Quality Strategy. The inclusion of the value-based purchasing program in the GF 360º program and the intermediate sanctions policy offer strong accountability measures for Georgia’s CMOs.

We were further pleased to see multiple measures of network adequacy, including appointment availability, incorporated into the Quality Strategy. GHF views appointment availability and travel time/distance as perhaps the most accurate measures of network adequacy in terms of increasing access to care. We encourage DCH to hold these measures above other measures like provider member ratios. To meaningfully ensure network adequacy for Medicaid members, we encourage DCH to adopt more robust enforcement measures for these requirements. Specifically, DCH could leverage intermediate sanctions against CMOs with provider directories that are out-of-date or otherwise inaccurate. Requiring CMOs to maintain up-to-date and accurate provider directories will help ensure Medicaid enrollees can receive timely care and avoid costs associated with unknowingly utilizing out-of-network providers.