Managed care has become the prevailing method for states to deliver healthcare to Medicaid beneficiaries, but states may not have the capacity to handle the spike in enrollment that is anticipated from health reform in 2014.
Two-thirds of low income individuals who receive Medicaid are enrolled in comprehensive managed care programs, including risk-based managed care organizations (MCO) and primary care case management programs.
This was among the key findings of a survey released Sept. 13 by the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured (KCMU). The survey describes state Medicaid managed care programs, their diversity and how states monitor access and quality.
Only three states, Alaska, Wyoming and New Hampshire, did not have any managed care programs as of October 2010 when the survey was conducted, according to the report. By the number of individuals covered by Medicaid, 50 percent are in MCOs, 16 percent in primary care case management programs and 34 percent in traditional fee-for-service programs.
Almost two-thirds of those enrolled in Medicaid MCOs are in plans that serve Medicaid enrollees primarily or exclusively, according to the survey. Beneficiaries in MCOs are evenly split between for-profit and non-profit plans.
“We see the prospect for an accelerated amount of activity in managed care in Medicaid because state budget and fiscal pressures are expected to continue. State Medicaid programs are looking more to including populations that are more vulnerable into managed care,” said Vernon Smith, managing principal at Health Management Associates, which prepared the survey with Kaiser.
And the prospect looms for a large expansion of individuals on Medicaid under health reform, he added.
Increasingly, states are incorporating quality metrics in their managed care programs to improve outcomes, measure performance and reduce costs, with “care management replacing the words managed care,” said Diane Rowland, executive director for the Kaiser Commission on Medicaid and the Uninsured, at a briefing announcing the survey, “A Profile of Medicaid Managed Care Programs in 2010: Findings from a 50-State Survey.”
States are beginning to turn to managed care, including integrating care coordination and care management, for their Medicaid population with more complex needs, in addition to most children, pregnant women, and parents, she said.
A majority of states reported that, for at least one Medicaid managed care program and/or geographic area, they now require enrollment in managed care for populations such as disabled children receiving Supplemental Security Income (SSI) and seniors. Half of states report some enrollment of those who are dually eligible for Medicaid and Medicare in managed care.
States rely on managed care to serve their Medicaid populations because of lean budgets and the desire to improve service delivery and payment systems. But only about half of states with MCOs say that their plans have or could develop enough capacity to absorb the spike in Medicaid enrollment that is anticipated under the health reform law, according to the survey.
One approach that North Carolina is taking to expand capacity is to make better use of available resources, including the patient, to manage chronic conditions, said Dr. Craigan Gray, director of the medical assistance division in North Carolina’s Department of Health and Human Services.
“We’re also looking at other models of care, such as changing the paradigm that happens in the primary care office, like group visits and putting telemedicine in place to manage those with chronic illnesses,” he said.
A pilot in Rowan County has reduced emergency room visits among a test population with diabetes and congestive heart failure by almost 48 percent. It’s also a teaching tool, Gray said.
“We are finding, fixing and educating the population to be able to manage their chronic disease better. It’s one way we will reduce the chatter coming through the primary care offices for management of chronic disease,” he said.