Arizona Governor Doug Ducey carved out a place for mobile health in his plan for the state's new Medicaid plan this week, but some critics think the initiative could miss the mark for a low-income population less likely to have smartphones.
Arizona's Medicaid system, the Arizona Healthcare Cost Containment System (AHCCCS), is a managed care system that operates on a special waiver from the federal government. That waiver is set to expire next September, and Ducey is using that expiration as an opportunity to make changes to the system that he hopes will cut costs by empowering Medicaid users and helping them get back to work. The changes, a plan called "Choice, Accountability, Responsibility and Engagement" (CARE), include health savings accounts, strategic co-pays, and wellness incentives for Medicaid enrollees.
"This new plan gives Arizonans the tools to manage their own healthcare, rewards personal responsibility, and gives you, the patient, the freedom to decide where to spend your dollars," Ducey said in an announcement. "CARE also promotes wellness, reduces waste, uses technology to improve quality, and streamlines services."
The plan also includes references to mobile health tools, although the specific details are still unclear. In a section of the CARE fact sheet labeled "Electronic Communication: Apps, Texts, and More!", the governor's office explains that Medicaid enrollees will be able to "avoid an emergency room visit by using an app to look up your primary care doctor or find an urgent care near you, manage chronic illnesses or conduct your own health screenings using an app, receive text alerts for an appointment reminder or managing medication, and manage your account online, including annual renewals, address or income changes or use a chat feature to ask questions instead of waiting on hold or in long lines."
It sounds like a good use of technology to improve communication and cut costs, but a response piece in Modern Healthcare questions whether a smartphone-based approach to serving low income individuals makes sense, citing among other things the failure of a similar attempt by the state of Michigan. There, only 1,500 of the state's two million residents are active users of the app.
It's hard to say how the measures will play out in Arizona. The realities of low income smartphone use are nuanced. A recent report from the Pew Research Center showed that 50 percent of people making less than $30,000 a year have a smartphone -- the lowest percentage of any income group. On the other hand, 13 percent of people making less than $30,000 a year are "smartphone dependent" -- their smartphone is their only option for getting online -- compared to 7 percent of Americans overall. For those users, smartphone-based options for health management seem like a no-brainer.
If Arizona can deliver on apps that are well designed and user-friendly, there's no reason to assume their program will suffer the same fate as Michigan's. In addition, as Modern Healthcare points out, text message interventions, which are also part of Ducey's plan, are on surer ground. We've written about a few promising texting interventions with Medicaid populations in the past, one from HealthCrowd in New York and another from MemoText in Washington, DC.
“Over 80 percent of the population we intervened on had a mobile phone,” Neng “Bing” Doh, HealthCrowd’s CEO and cofounder, told MobiHealthNews in a 2014 interview. “Historically, a lot of Medicaid plans have had the preconception that because their members were lower income, that they didn’t have mobile phones. Another preconception is that people don’t want to pay for these messages or [that they] find them intrusive. We absolutely debunked that as well. Our response rate was anywhere from 30 to 60 percent and our opt out rate was really really low; it was 3.7 percent.”