Medicaid Managed Care Plans and Access to Care: Results from the Kaiser Family Foundation 2017 Survey of Medicaid Managed Care Plans

Discussion

Managed care plans are on the front lines of efforts to facilitate access to care for Medicaid enrollees. In this role, plans both work directly with providers and enrollees and also undertake efforts to facilitate connections between providers and enrollees. While many of these activities stem from contract provisions between states and plans, others are plan-initiated. For example, less than half of states using comprehensive managed care require plans to conduct strategies to address social determinants of health, and several states report¹ that their MCOs provide enhanced services beyond those contractually required.

Survey results indicate that plans serving Medicaid enrollees are typically focused on serving the low-income population and have extensive experience in this market. This focus and experience may explain high rates of plan activity to address non-medical (social) barriers to health common among the Medicaid population, such as inadequate housing and food insecurity. In addition, many plans are serving high-risk or high-need populations and have developed screening or other programs to identify and engage these groups.

Many plan efforts to address issues in member access — whether they are focused on provider network adequacy, access outcomes, or efforts to integrate care — use provider payment as an incentive. Payment can be a powerful tool and, in most cases, is at the discretion of plans. Survey findings show that plans are developing APMs to provide incentives for providers to modify practices to provide high-quality, easily-accessed, and low-cost care. Though APMs with low provider risk (such as pay-for-performance) are most common, plans may be turning their focus to investment in total cost of care/shared savings (and risk) models such as ACOs or global payment models. Take-up of these models may vary by provider market characteristics and provider readiness to make organizational changes. In addition, there may be limits to plans’ ability to create payment incentives within the capitation payments that they receive from states. Currently, evidence of the effects of ACOs, episode-based payments, and global budget models on spending and quality of care is limited. States and MCOs will monitor current and future evaluations of the effectiveness of these models, especially for the Medicaid population specifically, as Medicaid beneficiaries tend to have complex medical and social needs that may differ from other payers’ patient populations. Many responding plans also reported using non-payment methods, such as incentives geared directly to enrollees (through healthy behavior programs) or steps to ease administrative burden on providers, in their efforts to facilitate access to care.

Survey results also provide a window into the current state of service integration and the shift to patient-centered care. Plans reported relatively high rates of carving in long-term services and supports (LTSS) and behavioral health services to their contracts, which aligns with other survey results indicating plans’ efforts to pursue co-located behavioral and physical health care providers or to establish integrated care coordination teams. However, despite a majority of plans reporting that their state contract included a broad range of services such as prescription drugs, NEMT, and substance use disorder services, many plans reported subcontracting for these services, which may run counter to integration goals.

Several survey findings point to external forces that pose a challenge to plans’ ability to facilitate access. Most notably, plans reported high rates of difficulty in recruitment for some specialties and listed provider supply as a leading challenge. Provider supply (especially among psychiatrists²) is a challenge for all payers, including private insurers and Medicare. While payment is one tool to address provider network issues, it can be limited if the market simply does not include sufficient providers. Regulation³ of network adequacy reflect this challenge and may allow states to exempt certain specialties from network adequacy requirements;⁴ however, enrollee need for these services remains. Many plans are turning to telehealth as an option, although plans are bound by state rules regarding telemedicine. Another external force affecting plans is Medicaid eligibility, as enrollee tenure in plans aligns with Medicaid eligibility rules. Longer plan enrollment may facilitate successful patient-provider relationships and allow for plans to reap the benefits of initiatives whose effects are not immediate. However, recently proposed policies, such as waiver provisions that allow disenrollment or lock-out periods for failure to comply with new rules, could exacerbate enrollee churn. A final area of external forces affecting plans’ ability to ensure access is proposed policy change to Medicaid financing or use of Medicaid waivers. Though plans are likely to remain in the Medicaid market even if the ACA is repealed, plans expressed high rates of concern about the implications of proposed changes, such as waivers or per capita caps, for enrollee access to care. Most plans reported that they would consider policy changes that could impede access (e.g., payment cuts or utilization control) if faced with lower capitation payments under Medicaid reform.

The 2016 Medicaid managed care regulations⁵ include new federal requirements for how states operate their Medicaid managed care programs. For example, the managed care regulations strengthen network adequacy requirements, such as time and distance standards, and clarify states’ authority to require MCOs to implement value-based purchasing or participate in delivery system reforms. The managed care final rule also broadens federal standards for care coordination to include coordination between settings, with services provided outside the plan, and with community and social support providers. In light of the surveyed plans’ reported difficulty recruiting certain providers, such as specialists and subspecialists, the 2016 regulations could increase pressure on plans to focus energy in this area. Additional CMS resources that guide plans on compliance with the regulations also place considerable emphasis on provider networks and access standards.⁶ Plans are moving ahead with actions to come into compliance with the regulations, despite federal signals that they will revisit the regulations.

While MCOs in this survey have long experience serving Medicaid enrollees, they face an uncertain future as they navigate how to move forward with new initiatives in the context of potential budget cuts, waivers, and changes to federal regulations. This survey was in the field between April and September 2017, when the fate of specific legislative efforts to repeal and replace the ACA and to restructure federal Medicaid financing was unknown. As 2018 begins, there is a focus on administrative actions using Medicaid Section 1115 demonstration waivers, state actions on Medicaid expansion, and other federal health care priorities. Medicaid in 2018 is also likely to continue to be part of both federal and state budget deliberations. Key findings from our survey illustrate that plans are active in many areas, including pursuing strategies to improve access to care, implementing payment and delivery system reform models, developing linkages to non-medical social services, and coming into compliance with the Medicaid managed care rule. Plans are moving forward in these areas despite a broader environment of uncertainty, driven by federal proposals to restructure Medicaid financing and repeal the ACA as well as administrative actions such as the approval of the first work requirements in Medicaid. Findings from our survey of Medicaid managed care plans can provide important context for ongoing Medicaid policy discussions and debates involving legislative and administrative action, as plans represent an important stakeholder in the Medicaid program.