Modernizing Managed Care in Medicaid and CHIP to Improve the Quality and Value of Health Care

by | Aug 28, 2015 | Choosing Health Equity

In June, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update the managed care regulatory structure for both Medicaid and the Children’s Health Insurance Program – marking the first time managed care rules will be substantially revised in more than a decade. Now, with approximately seven in ten Medicaid beneficiaries enrolled in Medicaid managed care organizations (MCOs), the program has an important opportunity to transform how MCOs deliver care to help meet the goals of the Triple Aim – improved patient experience of care, improved quality, and lower costs.

Modernizing managed care in Medicaid and CHIP can improve care for some of our nation’s most vulnerable patients, which is critically important. But it can do even more than that: Success in the Medicaid managed care program can help propel transformation across the health care system, strengthening access to comprehensive, coordinated, patient- and family-centered care for everyone.

The proposed rule for managed care in Medicaid is complex – you can find our detailed comments here – but it’s worth highlighting a few key provisions and some of the changes we recommended be incorporated into the final rule:

  • CMS’ strong emphasis on quality measurement in Medicaid managed care will help ensure accountability for quality care and improved health outcomes while improving care for Medicaid enrollees. Under the proposed rule, states would be required to develop and implement comprehensive quality strategy plans with involvement from beneficiaries and other stakeholders. We urged CMS to take its commitment to quality improvement further by encouraging states to capture and use patient-reported data, through patient reported outcomes measures and patient experience measures.
  • Several provisions in the new rule would allow managed care organizations to test and implement innovative value-based payment models that tie reimbursement to quality and value, rather than to volume. Transitioning toward value-based payment can play an important role in delivering on the goals of the Triple Aim.
  • We support, and see tremendous value in, provisions that would require that each enrollee have a dedicated care coordinator, and that MCO care coordination teams take a multi-disciplinary approach to health and integrate community resources – including community-based organizations, community health workers, mental health peer wellness specialists and non-clinical social supports – into their networks and care coordination teams.
  • Also key to care coordination and the delivery of patient- and family-centered care is the use of health information technology and shared care planning, which can do a lot to facilitate meaningful patient engagement and ensure that beneficiaries get the right care, in the right place, at the right time.

The proposed rule touches on many other important issues, including benefit design, choice of family planning methods, network adequacy, beneficiary protections, and anti-discrimination protections. You can read the National Partnership’s comments on all of these issues here.

Throughout its history, Medicaid has transformed access to care for low-income individuals and families, including children, parents, pregnant women, seniors and people with disabilities. Modernizing Medicaid managed care and holding it accountable for enhanced benefit design, care delivery, and payment requirements is an important step toward ensuring that Medicaid delivers high-quality, high-value, person-centered care to all beneficiaries.

The final rule for Medicaid managed care is likely to be released sometime this fall.