Keeping Up With Changes in Medicaid

As of November 2018, Medicaid is the largest healthcare program in the United States, covering 1 in 5 Americans, and over two-thirds of beneficiaries are enrolled in private managed care plans.

Alongside this trend are shifts in care delivery under Medicaid, as well as challenges and solutions being posed by value-based care models, all of which were discussed during a session at the National Association of Managed Care Physicians 2019 Fall Managed Care Forum being held October 10-11 in Las Vegas, Nevada.

Cindy Garvin, CCM, CPM, CPHQ, senior manager of population health practice at Change Healthcare Consulting, opened up the session by outlining new trends being seen in how care is being delivered under Medicaid, including driving member engagement, supporting population health, dependence on technology, risk sharing, and managed care.

At the same time, there are various trends impacting the Medicaid population, including the following:

• Medicaid budgets are stressed, which is leading states to expand managed care as a tool to contain expenses for subpopulations in fee-for-service programs
• Newly covered beneficiaries are relatively more affluent, creating new consumer demands on chief information officers to deliver mobile solutions
• Program integrity and compliance needs have compounded, pulling administrative dollars from other information technology investments
• Medicaid variations by state will continue to increase, reducing opportunities for information technology simplification across states
• Medicaid rules are converging with Medicare and the Affordable Care Act, increasing opportunities to standardize information technology between commercial lines and government programs

In addition to these trends, the growing prevalence of value-based models has made a wave in Medicaid, said Elaine Taverna, MHA, LBSW, vice president of risk adjustment at Henry Ford Health System, who outlined several challenges driven by these value-based models, and solutions for addressing them.

Provider network

Issue: Among Medicaid managed care organizations, there is a challenge of recruiting and retaining providers. The Health Resources Administration projects a shortage of more than 20,000 primary care physicians in 2020.

Solutions: According to Taverna, extending the provider network is an important strategy to combat shortages. This includes expanding practices to nurse practitioners and physicians. In order to recruit and retain providers, practices can offer payer-to-provider outreach, provider hotlines, administrative efficiencies that simplify the contractual relationship between years and provider, and financial incentives like a sign-on bonus or offering rates comparable to those in Medicare and commercial plans. Taverna also highlighted increased use of telemedicine.

Patient-centered medical home

Issue: There’s a provider eligibility issue as a result of certain credentialing and practice requirements.

Solution: Pay attention to the quality and care management requirements the state requires. According to Taverna, National Committee for Quality Assurance standards are a good place to start.

Issue: Implementing and maintaining these programs require additional resources, and meeting the requirements will impact payment.

Solution: Taverna recommends doing an analysis upfront to calculate what it will cost to run the program out of a certain number of clinics and determine if the financial impact of payments outweighs the cost of additional resources.

Accountable care organizations

Issue: The model requires broad affiliations and takes significant time and resources to develop, leaving a possibility for independent physicians to fall through the cracks.

Solution: According to Taverna, independent physicians should purposefully affiliate with the accountable care organization.

Pay-for-performance models

These models include shared savings programs and episode of care or bundled payments.

Issue: Metrics may not be tied to what is meaningful or achievable to a practice (for example: patient satisfaction).

Solution: Watch for metrics that are not meaningful or achievable, and engage with payers to mitigate the risk, said Taverna.

Issue: Performance is often impacted by upstream or downstream provider affiliations.

Solution: Taverna recommends being selective and only affiliating with providers who have similar performance incentives.