How Are States Addressing Primary Care Quality in Medicaid Managed Care?
As states have sought greater quality, efficiency, and value in Medicaid, many have turned to comprehensive managed care plans to organize, deliver, and manage health care. In 2016, more than two-thirds of Medicaid beneficiaries nationally were enrolled in managed care. Given that strong primary care is critical to achieving a high-performing health system, it’s instructive to examine how primary care is addressed in states’ Medicaid managed care quality-improvement strategies.
Federal Medicaid law requires state managed care plans to offer Medicaid beneficiaries access to primary care. States that contract with comprehensive managed care organizations (MCOs) must base their approach on written quality assessment and improvement strategies that, among other matters, address how they will use managed care to support and strengthen primary care.
In the fall of 2018, we reviewed online state Medicaid quality strategies to better understand their primary care–related goals, expectations, and priorities. Out of 39 states using MCOs, 36 made their strategies available online.1 While written online strategies are a requirement, states may use other approaches to strategic development of managed care systems such as listening sessions, stakeholder meetings, and discussions with experts.
This post outlines the key themes that emerged from our review. Two technical appendix tables — one organized by state, and the other by topical issue and cutting across all states — provide readers with the actual, detailed language contained in the state strategies. This level of information should prove useful in helping state officials and others who seek in-depth information about the specifics of state strategies and how they compare, while also being useful to state program administrators as they consider ways to update their strategy plans.
Primary care improvement is a critical state focus. Consistent with federal policies, all posted strategies contain a primary care focus, although the nature and specifics of this focus vary by state (see Appendix Table 1). Some states emphasize quantifiable access goals related to network panel size, travel times, appointment waiting times, and specific areas for capacity improvement. Other states combine these goals with broader aims such as lifting overall performance on health outcomes measures. Certain states emphasize distinct subpopulations as a priority, such as infants (Illinois), adolescents (New York and Nevada), and children in foster care (Virginia). Others set priority for certain services such as oral health (Virginia). Numerous states aim for more robust primary care capacity through health homes (Rhode Island) as a key feature of their primary care networks.
State quality strategies incorporate social determinants and advanced care coordination. Three-quarters of the state strategies explicitly plan to use managed care as a means of identifying and addressing underlying social determinants of health, such as housing or transportation needs. Kansas, Michigan, Nebraska, Ohio, Rhode Island, and Virginia offer notable examples of how states are using health risk assessment and care coordination to address such needs (see Appendix Table 2). Among the 36 states, 34 place strategic priority on coordinating across health and social services for high-risk populations, such as frequent emergency department users, patients discharged from the hospital and in need of extended care, and patients with behavioral and psychosocial needs. Indeed, care coordination for complex patients emerges as a pressing service delivery issue for states. California offers an innovative example of a care management strategic aim that spans physical, behavioral, and oral health.
Patient engagement and cultural competence are common areas of emphasis. Most states identify greater patient/family/caregiver engagement as a priority. Developing plans that offer care and support patients and families in a culturally competent fashion is a goal of nearly every state. Of note is Florida‘s plan for a multilingual family engagement program focusing on oral health in children. Indiana, whose federally approved Medicaid demonstration uses cost-sharing to incentivize preventive care, describes its plan for Medicaid managed care organization–operated kiosks in certain retail stores to offer health risk assessments, as part of an effort to motivate to patients to play a more active role in their care. As New York moves slowly toward managed care for people with developmental disabilities, it emphasizes the use of managed care to help people develop greater self-care capacity with activities of daily living.
Half of all states include explicit primary care payment reform strategies. Compared to health care access or care integration, for example, fewer state quality strategies discuss their payment reform plans; about half do so. This is not surprising as payment reform is technically complex; furthermore, private managed care companies are engaged in a competitive market activity and states may prefer to state their aims broadly while giving competitors the flexibility to test specific approaches without specifying any particular model in public policy.
But some states offer more detail and transparency regarding the models they intend to test as a strategy for aligning payment and quality. Colorado indicates its intent to move toward a single primary care payment model, while other states, such as Florida, indicate that they will preserve MCOs’ ability to use their own customized approach rather than a standardized model. Michigan, Ohio, and Texas describe various value-based payment options with the goal of moving a certain percentage of all payments under one of these options. Under its delivery system reform incentive program (DSRIP), Massachusetts describes the primary care payment reform initiative that is a central feature of the demonstration. Of special interest may be Minnesota’s payment reform model, which attempts to align incentives around quality, efficiency, and population health equity.
Where Medicaid is concerned, the road to primary care delivery and payment reform runs through managed care. States’ quality strategies show the breadth and ambition of the quality goals they have set. How states might use payment reform as a tool for achieving these goals is a strategic question that carries implications for the relationship that states choose to maintain with participating MCOs. As we proceed with an in-depth review of Medicaid managed care contracts, we will learn more about how states translate these goals into their agreements with health plans.