What policymakers can learn from Medicaid managed care innovations

September 15, 2015 | By Leslie Small

States that want their programs to better serve the growing ranks of Medicaid enrollees should look to some of the innovative solutions employed by Medicaid managed care organizations (MCOs), according to a new white paper from the Anthem Public Policy Institute.

Medicaid currently serves 70 million individuals in the United States, and as cash-strapped states try to cut costs and improve care quality for their programs' enrollees, they are increasingly turning to managed care models. In fact, about 74 percent of Medicaid enrollees are part of an MCO, FierceHealthPayer has reported.

This is good news, as research shows that Medicaid MCOs typically outperform Medicaid fee-for-service plans on key clinical quality metrics, the paper states. The government also applies more rigorous access-related standards to Medicaid MCOs than it does to Medicare or commercial plans. This means, however, that the traditional measures of network adequacy aren't enough to truly assess how well plans serve their members.

Thus, MCOs have come up with strategies to maintain strong relationships with providers and enhance their provider networks. Here's an overview of the three main initiatives that the paper highlights:

Innovative use of technology. Telehealth holds "much promise" to expand healthcare access, especially given provider shortages in underserved geographic areas and in certain disciplines, such as psychiatry or specialty practices. Many MCOs also have developed outreach strategies that use mobile technology educate members on chronic conditions, to send screening reminders and even consult with members who fail to file critical prescriptions.

Care delivery and payment reforms. Like other health plans, Medicaid has been fundamentally transformed by the rise of patient-centered medical homes, care coordination models, data-driven population health management efforts, accountable care organizations and the shift from volume-based to value-based payment models. And many MCOs have led the way with these new models; in one example, the Gateway Health Plan of Pennsylvania continuously reviews member data in order to send alerts to its care management team to arrange preventive care for members who are overdue for such services.

Support of non-traditional providers. Some Medicaid plans solve provider shortages and care access gaps by allowing physician assistants, nurse practitioners and advanced-practice nurses to be credentialed as primary care providers. Medication therapy management programs, meanwhile, feature pharmacists working closely with other members of the care team to achieve the best results from patients' medication therapy. Finally, many Medicaid plans have integrated retail clinics into their provider networks to offer their members convenient care alternatives.

"We believe these innovative strategies being adopted by MCOs should be part of the dialogue with state and federal policymakers, Jennifer Kowalski, vice president of the Anthem Public Policy Institute, said in announcement, adding that "the examples in this paper illustrate an opportunity to broaden the dialog around network adequacy, especially with the delivery system rapidly moving from volume-to-value-based care."

To learn more:
- here's the paper
- read the announcement