As payers on behalf of states and the federal government, Medicaid managed care organizations have the potential to drive reforms, and if they don't, they could be on the chopping block.
A majority of states are now using Medicaid managed care, many expecting savings for Medicaid budgets that have been starting to crowd out other funding priorities like education and transportation. But so far, innovation has been limited.
In at least four places, providers "do not generally perceive Medicaid managed care as a catalyst for delivery system reform," according to a study by Georgetown University researchers Laura Summer and Jack Hoadley.
Summer and Hoadley surveyed leaders and staff at health systems, primary care centers, behavioral health clinics, local health departments and a few health plans in Milwaukee, Oakland (California), Seattle and Washington D.C., places where a majority of low-income adults are covered through risk-based Medicaid managed care.
Providers in those localities aired a range of complaints that go beyond some of the traditional arguments the hospital and medical establishment has made against managed care, suggesting a need for health plans to adapt and change some of their strategies -- especially since some of the same problems may also present themselves in the new Medicare-Medicaid dual eligible demonstrations.
"Fragmented delivery systems, limits on the types of services for which managed care organizations are at risk, and the volatility in managed care markets all present challenges to improving care delivery" in Medicaid managed care, Summer and Hoadley found after speaking with 122 individuals and 40 organizations.
Providers in Milwaukee, Oakland, Seattle and the District told Summer and Hoadley that they tend to see MCOs "more as administrative entities than as innovators in delivery system reform," with one of the exceptions being community-based MCOs that work with safety-net providers.
Continuity concerns
The "most problematic factor" for providers, perhaps the one most inhibitin long-term reform, is volatility in the Medicaid managed care market, with three of the four communities Summer and Hoadley studied seeing turnover of managed care plans prior to or during the surveys last year.
This has "interrupted established patient–provider relationships, changed policies and procedures, and disrupted community-based efforts to improve service delivery" that in the worst cases could lead to adverse consequences.
In one community, new plan assignments threw off an emergency care reform program, where beneficiaries arriving at EDs without emergency issues were sent to their previously-identified community-based clinics. In some cases, patients arriving at the clinic with pressing but non-emergent needs learned that the clinic was no longer participating in their new plan's network.
Referrals have also been a problem. One clinic referral specialist told Summer and Hoadley that MCO networks are like "moving targets," with options for hospitals and specialists often in flux for Medicaid patients.
Care manager relationships
Similar to ACOs and dual-eligible demonstration programs, Medicaid managed care plans have been adopting care managers as points of contact and support for beneficiaries, but their effectiveness isn't yet clear -- and their perception, from the eyes of beneficiaries, may be short of meaningful.
One part of the problem, at least in the four communities Summer and Hoadley surveyed, is that MCO-based care managers have very little personal contact with enrollees aside from phone calls. Another part is that beneficiaries may not really think of care managers, or anyone affiliated with an insurance company for that matter, as a health resource, care provider or anything other than a payer.
As one clinic staffer told Summer and Hoadley: "The thing is, you can't just do case management if you are an HMO who no one even knows. People know their doctor but not who is paying the bills. It's hard for them to have an impact on people."
What states can do
Based on what the respondents said, and some evidence of what works, Summer and Hoadley argue that states, MCOs and providers could make a number of policy tweaks to incentivize the kind of changes that would offer better continuity and coordination of care.
To avoid volatility, like the two insurers that ended their contracts early in Seattle, states "could require that MCOs make long-term commitments to the program, discourage plan withdrawals by excluding reentry for a period of time, and minimize rounds of competition for new contracts," Summer and Hoadley argue.
To avoid disruption in care for beneficiaries, states could require MCOs to let beneficiaries keep primary care doctors with established relationships or honor prior-authorizations and prior-relationships for ongoing treatment.
With MCOs and providers both taking on more risk, states could also develop pay-for-performance programs that "credit MCOs for working with other community stakeholders to achieve improvements in service delivery."
As for what MCOs could do, Summer and Hoadley suggest contracting with local "trusted organizations" for care management, or having MCO-based care managers start making home- or office-based visited rather than just telephone calls.
MCOs could also reimburse group or home visits for certain patients, and help pay for supportive services like child care, transportation or interpreters, the researchers argue.