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Delivering Value with Medicaid Managed Care


How MCOs are delivering value to Medicaid populations.

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Today, one in five Americans and more than half of America’s children depend on Medicaid, the largest source of public health coverage in the nation.

In many states, Medicaid spending has become the second largest budget item, eclipsing all but education costs. In 2016, Medicaid accounted for 17.1% of state budgets, up from 14.3% in 2007, and there are no signs of those costs abating. In 2018, growth in state spending on Medicaid was up almost 5% from the previous year.

As state governments look for innovative ways to serve growing Medicaid populations, many are increasingly turning to managed care organizations (MCOs) to administer the program and cover the associated costs of delivering care. Currently, 40 states and the District of Columbia contract with MCOs to provide Medicaid managed care services (North Carolina, the 40th state, is expected to launch its managed care program on Nov. 1, 2019).

A holistic approach to care

When it comes to serving low-income, vulnerable populations, MCOs must go beyond just providing access to needed medical, behavioral and pharmacy care. It’s estimated medical care accounts for only 10% to 20% of health outcomes. The rest can be attributed to “social determinants of health” like where you live, what you eat, how secure you feel, and how connected you are to those around you

For example, homelessness, food insecurity, and inadequate transportation are just some of the issues facing today’s Medicaid populations. To overcome these barriers, support for members must go beyond the walls of the doctor’s office and address the realities they face in their homes and communities.

Meeting members where they are

One way MCOs are making healthcare more accessible and effective for Medicaid members is by personalizing the care management system. At WellCare, for example, care managers engage with certain members face-to-face, meeting them where they live to gain a fuller understanding of their health and life circumstances.

Those interactions also help develop a trusting relationship with the member, often a critical factor in gaining their cooperation and commitment to their medical care. Care managers collaborate with doctors, pharmacists, and other healthcare providers to coordinate care while working with social service agencies to address social determinants of health that may be preventing them from accessing healthcare services such as lack of employment or education, child care, or transportation.

Related: How Medicaid Expansion Impacts Cardiovascular Health

Take for example WellCare member Brandi Logan. Brandi is deaf and lacked a support system to help her care for her son Dylan who was experiencing developmental delays. After visiting Brandi in her home, her care manager created a plan and worked to help Brandi pay medical bills, access transportation to appointments, and manage daily tasks. Dylan was enrolled in school and received the therapy he needed to thrive.

The data speak more broadly to the success of this approach. WellCare Medicaid members who received this type of field-based care management experienced a 26% decrease in hospital admissions, a 23% decrease in hospital readmissions, and a 20% decrease in emergency room utilization.

Addressing social determinants of health

Because social determinants of health disproportionately affect the Medicaid population, Medicaid MCOs are on the frontlines of this issue and, in response, are creating solutions that help members receive the social services they need to remove barriers to good health.

One such program is WellCare’s Community Connections Help Line, a toll-free line that connects both members and non-members to local, community-based resources that offer services such as food, transportation, housing, education, and utilities assistance. Since its inception, the Help Line, which has a database of more than 300,000 social service support resources, has provided nearly half a million referrals to those in need.

And, what’s more, these programs work: showing positive cost and health outcomes for those who access services. A study conducted with the University of South Florida found those who accessed services through WellCare’s Help Line experienced a nearly 10% reduction in healthcare costs. Further, compared to demographically similar members, those with social barriers removed through the help line were nearly five times more likely to schedule and attend a visit with their primary care doctor; 2.4 times more likely to improve body mass index (BMI); and 1.5 times more likely to comply with diabetes treatment.

Combatting the opioid epidemic

Today’s Medicaid MCOs are also on the front lines of the opioid crisis. It is estimated Medicaid covers about 30% of Americans with an opioid use disorder, and according to one study, the medical costs of Medicaid patients diagnosed with opioid abuse or dependence are almost three times that of patients without the diagnosis.

To address the epidemic and its associated health and financial costs, WellCare has implemented a number of successful programs and policies to help curb opioid misuse and abuse. For example, in Kentucky, WellCare leveraged a pharmacy management program to curb opioid misuse and abuse by identifying approximately 1,300 members at risk based on criteria such as prescription dispensing, prescription refills, pharmacy use and emergency department utilization. At-risk members were connected to one pharmacy, one healthcare provider and a care manager specialized in substance abuse treatment. As a result of the program, opioid dispensing dropped by 55%.         

Medicaid managed care delivers value both to states and to beneficiaries. In addition to quality outcomes, the Menges Group estimates MCOs delivered nationwide savings of $7.1 billion in 2016 and are projected to save $94 billion over the next 10 years.

And, most importantly, for states whose Medicaid populations have a host of needs, managed care continues to make important inroads to help its members live better, healthier lives.

Kelly Munson is executive vice president of Medicaid for WellCare Health Plans.

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