This edition explores the dynamics of optimal coordinated care, in relation to governmental policies/actions and MCO operational activities. There are several combinations of ways that optimal care coordination programs are not yet being achieved. The construct described may be useful in identifying how a given program can be modified to better yield an optimal setting for facilitating access to needed care, ensuring that the services rendered are as cost-effective as possible, and helping covered populations maintain and improve their health status over the course of their daily lives. The years ahead create exciting opportunities to widen and strengthen partnerships between state and federal governments and the MCO industry in the Medicaid and Medicare arena.
This report assesses Medicaid MCO quality scores as published annually by NCQA. One of the report’s key findings is that there does not appear to be any relationship between Medicaid MCOs’ enrollment levels and their quality scores. Another is that high-scoring plans are disproportionately concentrated in certain states – with these patterns often recurring (with different health plans in these same states) with regard to quality scores in the Medicare and private insurance sectors. This leads us to conclude that some geographic areas are more conducive to high scores than others – and that MCOs making the same efforts in quality would likely obtain very different quality scores based on the market area in which they operate. Our report also identifies the Medicaid MCOs with both large enrollment and high quality scores, the MCOs that stand out most favorably relative to average scores within their state, and the NCQA-accredited MCOs achieving the greatest improvements in their quality scores between 2010 and 2013.
The Association for Community Affiliated Plans (ACAP) enlisted The Menges Group to prepare a report on the ways in which state Medicaid agencies have opted to regulate Medicaid MCO PDL content. Most states afford MCOs wide latitude in establishing their PDLs. Conversely, a few states require MCOs to use the statewide Medicaid fee-for-service PDL, and a few others have taken a middle ground regulatory position. The paper emphasizes that utilizing the lowest-cost, clinically effective medication is one of the most important avenues available to achieve Medicaid savings, and concludes that wide MCO latitude over PDL content is the most appropriate policy.