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Integrating Managed Care and Medicaid
Alexandria—In 2013, state and local Medicaid spending increased 5.9% and federal Medicaid spending increased 6.2%, with a total increase of 6.1% in Medicaid expenditures. Fifty-five percent of Medicaid beneficiaries were in comprehensive managed care organizations (MCOs) in 2012, and in the light of recent Medicaid expansion, MCOs are essential to streamlining care.
James Golden, PhD, director, division of managed care plans, Center for Medicaid and Children’s Health Insurance Program Services, Centers for Medicare & Medicaid Services (CMS), gave the keynote address at the LSMMC meeting regarding this growing population and its implications. At CMS, Dr. Golden ensures that all Medicaid managed care programs are accessible and provide renowned care to members by developing and managing federal policy. Dr. Golden addressed the obstacles Medicaid enrollees face, the goals of CMS, and the ways stakeholders can work together to achieve them.
The number of people enrolling in Medicaid is increasing, with the current total reaching approximately 17 million. Per updated requirements under the Patient Protection and Affordable Care Act, more individuals qualify for Medicaid, including older adults, disabled individuals, and those with behavioral needs. There has also been a spike in demand due to the large aging population who are becoming eligible for long-term service and sup- port (LTSS).
For most Medicaid beneficiaries, MCOs are crucial to ensuring proper care. “Managed care has a wider view of the [healthcare] system than any of the individual components,” said Dr. Golden. As of 2012, 75% of Medicaid beneficiaries received services through a MCO, and 55% of Medicaid beneficia- ries were in comprehensive risk-based MCOs. This accounted for $116 billion in spending in 2012 US dollars.
Dr. Golden said the access to care goal is to “ensure managed care enrollees have timely access to integrated, high- quality care,” which he acknowledged is lacking. He referenced a report by the Office of Inspector General (OIG) that determined the accuracy of 1800 primary care physicians (PCPs) and specialists on provider directories. The OIG cold-called physicians’ offices listed as in-network providers and attempted to schedule an appointment. The report found that approximately 35% of providers could not be found at the location listed as their address, while 8% were not participating in the healthcare plan that they were indicated for and another 8% were not accepting new patients. Of the providers who offered routine, nonurgent appointments, the median wait time was 2 weeks—an average wait time of 9.9 days for a PCP appointment and 19.5 days for a specialist appointment.
Upon discovering this information, OIG urged CMS to partner with states to correct oversights such as those found in the report. OIG requested 3 steps be taken: (1) CMS work with states to assess the number of network providers offering timely appointments and improve the accuracy of healthcare plan information; (2) ensure healthcare plans’ networks are adequate and meet Medicaid managed care enrollee needs; and (3) ensure healthcare plans com- ply with existing state standards and evaluate whether additional standards are necessary.
Dr. Golden acknowledged that the report points to care gaps. He said CMS, state Medicaid directors, and stakeholders must improve coordina- tion for Medicaid beneficiaries. “Put all stakeholders around the table,” said Dr. Golden. Although he admitted that this may be difficult because there are multiple definitions of care coordination, Dr. Golden suggested stakeholders adopt the National Quality Forum’s (NQF’s) definition of care coordination, noting, “the deliberate synchronization of activities and information to improve health outcomes by ensuring that care recipients’ and families’ needs and preferences for healthcare and community services are met over time.”
In order to guarantee that quality care is provided, adequate measurement systems must be in place. Dr. Golden referenced some ideal tools, including Consumer Assessment of Healthcare Providers and Systems surveys, Healthcare Effectiveness Data and Information Set, Adult Core Set, and Child Core Set.
Medicaid beneficiaries should have timely access to care, and Dr. Golden suggested cap surveys or using the secret shopper method to ensure beneficiaries can make appointments and see a physician in a timely manner. “[We] do not have good proactive measures,” he said.
To fulfill the goal of quality care, a few improvements must be made.
While Medicaid recently expand to include new populations, Dr. Golden said, “[There is] still work to be done, especially for different populations coming in—particularly behavioral health.” Dr. Golden also mentioned “measures [taken by CMS and its stakeholders] must be more meaningful to enrollees.”
Dr. Golden referenced NQF’s 4 recommendations for quick and deliber- ate action to fill performance measure gaps and improve the solidarity of the healthcare system (Table).
Quality management systems should be implemented in LTSS as well, according to the presentation. Standards and processes should ensure that adequate safeguards are in place, members are receiving quality services and outcomes associated with that, data are collected regularly, and evidence-based practices are adopted.
Dr. Golden stressed the importance of integrating Medicaid and managed care to improve access to care. “Medicaid is a major and growing aspect to healthcare,” said Dr. Golden.—Melissa D. Cooper
