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Volume 13 Number 62 News: Medicaid States are trying new approaches that give them greater control over both the cost and quality of care for their most expensive Medicaid beneficiaries, according to a March report by the Center for Health Care Strategies. Fifteen percent of Medicaid beneficiaries, most of who are identified as aged, blind and disabled (ABD) or Supplemental Security Income (SSI) beneficiaries, account for more than 75 percent of Medicaid expenditures, and a majority of those ABD/SSI beneficiaries receive care through traditional fee-for-service (FFS) arrangements, according to the report. However, states have found that the "fragmented, uncoordinated, and often difficult to navigate" system is unable to provide comprehensive quality care while controlling costs, according to the report,Purchasing Strategies To Improve Care Management for Complex Populations: A National Scan of State Purchasers. States have responded by designing systems that go beyond purely FFS or full-risk managed care models, particularly because many states lack the resources to implement the latter. Instead, the new systems emphasize case management and use new financing structures, according to the report. "Aligning incentives and building accountability are important considerations in these models since they do not have the same clinical and financial 'levers' as fully capitated models," report authors Melanie Bella, Chad Shearer, Karen Llanos, and Stephen A. Somers said. CHCS is a nonprofit health policy resource center focused on improving the quality and cost-effectiveness of publicly-financed health care. A policy brief, Medicaid Best Buys: Improving Care Management for High-Need, High-Cost Beneficiaries provides an overview of what states should consider when designing new programs, based on the state scan report. Management Programs The 12 states reviewed for the report have implemented a variety of care management programs based on their target population, state capacity, provider availability, and other factors. Examples of their care management approaches include the medical home, disease management, and chronic care management models. Some states have broadened their disease management approaches to provide more comprehensive care to those with chronic conditions, while others have combined multiple programs to create a system that is responsive to high-risk beneficiaries, according to the report. It added that among those common elements is an effort to create "medical homes" focused on "strengthening the relationship between primary care physicians and their patients." In order to further improve their programs, states have also begun offering financial incentives for the use of health information technology, offering training opportunities to providers, and giving greater outcome and cost feedback to providers. Financing Strategies Most of the provider reimbursements plans the states have put in place are based on existing FFS structures, with additional per-member per-month payments for care management services. Some states have recognized that traditional PMPM payments are insufficient, though, and are providing additional payments until the system can be restructured to recognize the additional costs associated with high-need beneficiaries. For services provided by contractors, some states also are withholding payments if certain quality or financial targets are not met, while others are providing additional payments for spending reductions. States also are beginning to adopt quality measures or design new ones, especially for determining the success of care management. Other Considerations The report suggests states consider tools such as prior authorization, concurrent review, and discharge planning in order to further enhance their care management programs. States also should consider how much influence care management contractors can have if they do not build or modify provider networks and allow contractors sufficient flexibility to focus on the highest-risk beneficiaries. "The more flexibility a contractor has in tailoring interventions, the more the state can hold it accountable for developing holistic, patient-based plans of care," the report said.
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