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Now is the Time to Modernize Communication in the Medicaid Program

By ABNER MASON

What do television shows 60 Minutes, Roseanne, Designing Women, and Murder, She Wrote all have in common? They were top 10 prime time shows in the 1991 – 92 season according to Nielson Media research. Obviously, what Americans want to watch has changed in 34 years. The decline in market share the major networks – ABC, CBS, and NBC – have experienced, and the dramatic growth of streaming services proves the point. It makes sense to let people watch what they want to watch on the device of their choice, and use new technologies like streaming services to access the shows they want to watch.  It would be foolish for us to insist that Americans watch only shows from the legacy networks on traditional TVs. But this is basically what we are doing now when we force Medicaid Managed Care Plans (Plans) to comply with a 1991 Federal Law when they communicate with Medicaid recipients.

Here’s the problem. Federal legislation called the Telephone Consumer Protection Act (TCPA), enacted in 1991, makes it very difficult for States and Plans to use text messaging to communicate with their members, even though texting is the primary, and preferred mode of communication for all Americans including Medicaid recipients. TCPA requires a State or Plan sending a text to have permission from the person receiving the text before the text is sent. Violations of TCPA result in significant financial penalties for each infraction, and penalties are tripled if the sender knowingly sent the text without consent.

Medicaid recipients are typically assigned to Plans, they do not choose their Plan, and as a result, in light of TCPA, and potentially enormous financial penalties being assessed, plans have taken the position that they do not have consent from recipients to text them. And that is the problem.

Texting is the way most Americans communicate today. Other modalities like US mail (called snail mail for a reason), phone calls (who answers calls anymore?), and email (likely to go without a response for days or weeks) are dramatically less effective. Because they are low income, many Medicaid recipients often do not have a landline, or a laptop. They rely on their mobile phone for all their communication, including healthcare related communication. Texting is their preferred, and often only way of communicating.

As Founder and CEO for SameSky Health, I spent over a decade working with Plans to help them engage their members and navigate them into healthcare at the right time and the right place. Again and again, we found when we could maneuver around the outdated restrictions TCPA placed on Plans, we got higher engagement which translated into more well child visits, more breast cancer screenings, more diabetes (a1c) screenings, and so on. Using modern tools of communication is a way of meeting people where they are. It builds trust and leads to better health outcomes. But sadly, because of TCPA, we were not able to text members in most instances.

What has been a significant problem will be made exponentially worse when Federal Work Requirements are implemented as now seems likely. A Federal Medicaid Work requirement will dramatically increase the need to modernize how States and Plans communicate with Medicaid recipients. Compliance with TCPA is standing in the way of this modernization. And if it is not fixed, many, many people will lose their Medicaid benefits for purely procedural reasons.

To improve health outcomes, allow efficient communication to verify work status,  and provide twice yearly redetermination information, States and Plans must be exempted from the outdated provisions of TCPA. Senate action on, and final passage of the Reconciliation legislation offers the best opportunity to get an exemption from TCPA passed and signed into law.

The time to act is now.

So lets focus on (1) getting the exemption language in the Senate version of the Reconciliation legislation, (2) working with HHS and CMS to ensure post legislation guidance directs States and Plans to include texting as a best practice when implementing work requirement programs and communicating with recipients more generally, and (3) implementing a media strategy to build support for using modern technology to create easier more efficient ways for Medicaid recipients to comply with the new work requirements.

We have two months – June and July – to get action on an exemption in the Senate, and the remainder of the year to influence Administration guidance on work requirement programs.

Medicaid beneficiaries will be the biggest winners if we succeed because an exemption is a key strategy to reduce unnecessary loss of Medicaid benefits.

What can you do? Call your Senator and ask them to support modernizing how States and Plans communicate with Medicaid recipients. And please share this blog post with your network.

Abner Mason is Chief Strategy and Transformation Officer for GroundGame Health. He serves on the Board for Manifest MedEx, California’s largest health information exchange, is Vice-Chair of the Board for the California Black Health Network, and is a member of the National Commission on Climate and Workforce Health. Here are are just some of articles and interviews he has published over the past 10 years pushing for States and Plans to be able to text Medicaid recipients. 

It’s “Slack for Health Care”- athenaText

 

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By now it’s not a secret that EMRs are “records” and yet we’ve been trying to cram communication functions down their throat. Meanwhile the hottest tools in enterprise tech are souped up versions of AIM (remember that, you AOL fans?)– with companies like Slack & HipChat providing group-based instant messaging and changing the way teams work. As health care becomes a team sport, you’re going to see many approaches from the major EMR vendors and new entrants in the coming months to fix the communication problem. And yes at Health 2.0 this Fall I’ll be running a full panel on the topic that the Clinical User Experience Sucks–how do we fix it?

This week athenahealth, one of the few big cloud-based players in EMR-land introduced athenaText. (Don’t bother asking why there are no caps in the company name yet the simple word “text” gets a capital T in the middle of the product name! It’s as you’d expect an instant message product (rather than SMS one) but with some differences. For a start it integrates direct into the athenaClincals EMR, but it also pulls in both drug info and physician contacts from the Epocrates product that athenahealth owns (and which has several hundred thousand physicians on it). The goal is to spread the product virally (think Skype or Slack). But first things first. What is it and how does it work? I spoke with VP of UX at athenahealth, Abbe Don, to find out more and to get a demo, which you can see below.

Why Texting Patients Works: The Health Belief Model

With the rise of cell phone usage, smart and otherwise, many health care providers, researchers and entrepreneurs alike have assumed that this ubiquitous technology can be used to improve health and wellbeing. Entrepreneurs have led the charge and so the common catch phrase “there’s an app for that” underscores the fact that nearly 17, 000 health related apps are available either for free or a small charge for Android or Apple users.  Young people in the US are perhaps the best targets of our mhealth efforts because they are eager users of mobile technology. However two questions arise naturally: 1) does data show that these apps lead to improved outcomes? 2) is there a theory of how we might use cell phones to improve health outcomes?

In a series of studies, we found that simply responding to text messages over a 3-month period led to improved quality of life and pulmonary function in pediatric asthma patients. In both studies, the researchers randomly assigned 30 asthmatic children, 10 to 17 years old, into three groups – a control group that did not receive any SMS messages; a group that received text messages on alternate days and a group that received texts every day. The children that received messages everyday between two scheduled appointments had the improved psychological and physical outcomes. Thus, our data does indicate that cell phones can be used effectively to improve health outcomes.

Perhaps more compelling is that we may have evidence of a possible mechanism that can lead to improved outcomes. The Health Belief Model is a cognitive theory of behavior change that espouses the notion that a critical pillar of behavior modification is that the individual must make the connection between the severity of the symptoms and the disease itself. In the case of asthmatic patients, we found that many times they attributed their symptoms to other causes. For example, they would say that they couldn’t exercise in the afternoon because they had a heavy lunch or that they couldn’t sleep the night before because they had seen a movie that had made them anxious— rather than attributing these symptoms (inability to exercise or sleep) to their asthma. The Health Belief Model also places value on acquiring knowledge about the disease. Thus, we sent patients texts messages that either asked about symptoms they had experienced or about asthma myths. Thus, our studies also indicate that improving symptom awareness and knowledge about their disease led them to have better medication adherence which in turn led to improved health outcomes.

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