A survey of Medicaid managed care organizations (MCOs) found that key barriers to increasing value-based purchasing arrangements continue to be providers’ readiness and willingness to participate in alternative payment models as well as their limited information technology capabilities.
The newly released Institute for Medicaid Innovation’s annual 2020 survey reflects 2019 data from Medicaid MCOs, representing 67 percent of all covered lives in Medicaid managed care across 37 states. IMI’s goal is to equip Medicaid stakeholders with the information needed to accurately articulate the national narrative about Medicaid managed care.
Approximately 93 percent of all Medicaid MCO respondents used an alternative payment model, or value-based purchasing arrangement, with 100 percent of medium (i.e., 250,001 to 1 million covered lives) and large (over 1 million covered lives) health plans reporting engagement in 2019. Half of the health plans implemented value-based purchasing arrangements with primary care providers while very few established similar arrangements with behavioral health providers, dentists, home and community-based service providers, and long-term care facilities, the report found.
An increase in establishing VBP arrangements with dentists was seen from 2017 to 2019, while a decrease was seen in implementation of arrangements with home and community-based services providers, long-term care facilities, and orthopedics. Furthermore, 43 percent of health plans indicated that the percentage of payments to hospitals through alternative mechanisms was less than 15 percent.
Another key issue the survey identified was behavioral/physical health integration. In 2019, 73 percent of health plan respondents indicated being at risk for behavioral health services for their Medicaid members. Medicaid MCOs reported operational, network, and policy barriers when integrating behavioral and physical health. The majority of health plans indicated that fragmentation in program funding and contracting for physical and behavioral health services (92 percent), provider capacity to provide integrated physical and behavioral health at point of care (92 percent), and access to data between care management and behavioral health teams (67 percent) were common barriers to care.
IMI hosted a webinar on Dec. 8 to discuss the survey results. Dianne Hasselman, M.S.P.H., deputy executive director of the National Association of Medicaid Directors, said state Medicaid directors have given a tremendous amount of thought to how to fix foundational cracks in Medicaid that have been laid bare through COVID-19.
Even though the data in the survey is from 2019, there are several “through lines,” Hasselman said, that might help Medicaid directors fix foundational cracks. Pointing to the data about provider reluctance to participate in value-based purchasing arrangements, she noted that during the pandemic, providers who were reimbursed only by fee-for-service were ravaged, while states were able to offer monthly retainer payment support to help other providers through that time. “I hope that changes the psyche of those providers to move away from fee for service to value-based payment. We have to double-down on that moving forward.”
“What kills me is that we haven’t figured out how to solve behavioral health integration,” said Wendy Morriarty, M.P.H., R.N., vice president and chief medical officer for Horizon Blue Cross Blue Shield of New Jersey. “We need to solve that. We are getting closer, but for some reason we are still struggling there and the report validates that and it makes me crazy.”
Morriarty added that there are some inherent structural challenges around deploying upside and downside risk models in Medicaid. Rules and regulations around dual-eligible patients and how federally qualified health centers operate add levels of complexity, she said.
Social determinants
In 2019, all the respondents indicated that they offer targeted social determinants of health (SDOH) programs. The most common populations that were targeted for SDOH programs were homeless/housing insecure (87 percent), people who were pregnant (73 percent), and adults with serious mental illness (67 percent). IMI noted that the survey findings highlighted that plans used multiple SDOH screening tools and not just one, across all Medicaid MCO respondents. Half of the health plans indicated utilizing an internally developed or adapted tool, with 13 percent not using any tool.
Nicole Truhe, M.P.A., senior director of policy, Medicaid, for UnitedHealthcare Community & State, said health plans are evolving from just screening for social determinants to creating referrals and then closing the loop to ensure access to services. “We are seeing an increase in partnerships with nonmedical entities,” she said. “I hope we will see new ways that health plans can support the capacity of community-based organizations to provide social needs resources.”
This year’s survey added a section on sexual and gender minority health. The survey findings showed that in 2019, 60 percent of Medicaid MCO respondents indicated that they offered targeted programs to address sexual and gender minority health, while 20 percent were considering offering targeted programs for their members. Next year’s survey will add questions about COVID-19, telehealth, health equity and structural racism.
Although the pandemic intensified them, disparities in health outcomes have always been there. More than other organizations, Medicaid health plans focus on these issues, said Morriarty. “We were doing SDOH before it was cool,” she said. “But when we combine the activities we have been doing and pull the data on outcomes, we see maternal health outcome disparities in every state. We can talk about what a great job we are doing, but we are not yet moving the needle there. I would love for us to put a stake in the ground and say we are going to make a difference there.”
