By:
Mary Mosquera, Senior Editor
New York, North Carolina and Texas are examples of how states take different paths to expand and improve Medicaid managed care, including medical home models, new services and health plan competition. Regardless of the tools, managed care is fast approaching as the primary method to deliver health care to low income populations.
New York has the largest Medicaid program in the country based on its annual budget of $53 billion and serves 5 million New Yorkers, about 25 percent of the state’s population, according to Jason Helgerson, Medicaid director in the Office of Health Insurance Programs, New York State Department of Health.
The state has gravitated to managed care on a voluntary basis but left individuals with complex and chronic conditions in its fee-for-service program, “sort of a halfway point to real managed care for the entire population but not going into those higher cost areas. That has changed in the last few months,” he said at a recent briefing sponsored by the Kaiser Family Foundation.
A Medicaid redesign team in New York “put the state on a three-year glide path to get out of fee-for-service in our state,” Helgerson said
New York wants to expand the mandatory managed care umbrella to the dual eligible population, who drive 36 percent of the total Medicaid budget, to bring them into integrated and coordinated care. “We have a number of small programs, but they haven’t grown to sufficient size yet,” he said. The state has also mandated that managed long-term care will take effect in April 2012.
New York has 820,000 Medicaid patients in medical homes and pays a bonus to physicians who meet National Committee for Quality Assurance (NCQA) accreditation standards. Most of those patients are in low-income health plans. “We’re gearing up for the move which includes identifying very specific performance measures that we’re going to hold plans accountable for,” Helgerson said. "We’re now looking at outcomes of those members to see if that extra payment of millions of dollars is seeing a return on investment."
To use managed care effectively, states have “to structure the contractual relationship, provide the right financial incentives and have the right checks in the system to ensure getting the outcomes you want,” Helgerson said.
Elsewhere, North Carolina has expanded its pioneering Community Care of North Carolina (CCNC) Medicaid medical home model across all the state’s 100 counties and serves 1 million Medicaid recipients. CCNC, established as a not-for-profit organization, has 14 provider networks that develop care management and coordination practices, and an informatics center to collect and analyze claims data for quality purposes.
North Carolina plans to add incentive-based upon metrics to further drive quality, said Dr. Craigan Gray, director, medical assistance division, North Carolina Department of Health and Human Services. For example, pharmacy services will fill more generic prescriptions based on tiered reimbursement. CCNC has also added a pregnancy medical home model, with measures to improve clinical outcomes.
“We’ll pay the obstetrician a little more. It’s data and claims driven, and there is surveillance through in-office chart review to make sure they meet the quality outcome metrics,” he said.
“But that does not measure the collateral benefit that we receive from this program from getting healthier kids and avoiding the later costs that Medicaid would undoubtedly bear from being very low birth weight,” Gray said.
The medical home model in North Carolina has demonstrated enough cost savings and quality improvements to attract the attention outside of Medicaid of several large employers within the state. These organizations, including the manager of North Carolina’s health plan for state workers, Blue Cross and Blue Shield, have engaged CCNC as an option to their health coverage. The overwhelming majority of primary care providers in North Carolina participate in CCNC.
“This is truly engaging the power of the Medicaid program to improve the standard of care across the state,” Gray said.
Texas plans to grow its STAR Medicaid managed care program throughout the state by March 2012 from just large metropolitan areas, in part to be prepared for the anticipated spike in individuals eligible for Medicaid under health reform.
Medicaid growth in general is outpacing infrastructure, and states are going to have to respond, said Joe Vesowate, deputy director of managed care operations, Medicaid and CHIP divisions, Texas Health and Human Services Commission.
Care coordination is a cornerstone, along with adding services to support that, such as a pharmacy benefit.
In March 2012, Texas Medicaid will add a managed care dental program for its children’s insurance program and expand to most parts of the state its STAR Plus managed care program for acute and long-term services for the disabled and chronically ill.
A critical characteristic underlying the expansion of managed care and controlling costs is Texas’ competitive procurement for healthcare services. ”The key is having these competitive relationships, good business environment and the right number of managed care organizations for the capacity,” Vesowate said.
