The Menges Group is regularly enlisted to conduct unbiased quantitative and qualitative analyses and prepare reports about topics of health policy interest.
Utah’s Medicaid program contracts with four Accountable Care Organizations (ACOs) to coordinate care for most of the state’s Medicaid enrollees. This October 2024 report examines the fiscal and programmatic impacts that transitioning to a prescription drug carve-out model, where the pharmacy benefit would be managed under a single-payer system using the fee-for-service payment methodology, would have on Utah’s Medicaid program. Our key recommendations include preserving the current pharmacy carve-in model, piloting a hybrid Preferred Drug List that allows the Utah Department of Health and Human Services and the ACOs to jointly guide utilization towards the most cost-effective drugs for specified drug classes, and exploring potential revisions to supplemental rebates collection and capitation rates for the pharmacy benefit.
This report explores the fiscal and programmatic impacts that a switch to a prescription drug carve-out model, where the pharmacy benefit would be managed under a single-payer system within Medicaid using the fee-for-service payment methodology, would have on Virginia’s Medicaid program (Cardinal Care). Our key recommendations for the Medicaid program include preserving the current pharmacy carve-in, preserving the common core formulary (i.e., the preferred drug list), enhancing reimbursements to critical access pharmacies, increasing MCO policymaking representation, and exploring potential revisions to capitation rates for the pharmacy component.
This report explores which prescription drug model is best suited for Washington’s Apple Health (Medicaid) program: the current carve-in prescription drug model, under which managed care organizations (MCOs) pay for members’ prescriptions, or a carve out model, where prescriptions are managed by a separate company using a fee-for service (FFS) payment mechanism. Our overall recommendation is that Washington should preserve the carve-in pharmacy model for the Medicaid program
This report was enlisted by the Pennsylvania Homecare Association to evaluate the need for enhancing Pennsylvania’s Medicaid Private Duty Nursing (PDN) payment rates. Through a mixture of quantitative analyses and real-life patient examples, this report highlights the anticipated benefits this PDN rate increase is projected to yield.
This report was commissioned by the Home Care and Hospice Association of Colorado. The report derives the Medicaid payment rate increase needed to attract adequate private duty nursing (PDN) service capacity in Colorado. We’ve estimated the cost to the Medicaid agency these rate increases will create — including the rate increase and the enhanced PDN capacity the higher payments can be expected to yield. The report also estimates the offsetting Medicaid savings that the increased PDN support can be expected to create via shortening and preventing hospitalizations.
This report describes trends in opioid and medication-assisted treatment (MAT) prescription drug usage in Medicaid, put together for a presentation at a recent opioid conference.
The Elevance Health Public Policy Institute engaged and worked with us to assess the degree to which quality scores on pharmacy-related measures were affected by the state’s Medicaid managed care program design features. The key issue assessed was whether quality scores were better in states where the prescription drug benefit was “carved-in” rather than “carved-out.” We created 34 group comparisons between the two settings, and consistently found the Medicaid MCO quality scores to be superior in the carve-in setting. This finding occurred across years, across a wide set of behavioral health and physical health HEDIS measures, and in different regions of the country.
Building upon our 2014 report titled Prescription Drug Adherence in Medicaid Managed Care, this report provides updated analyses performed on medication adherence, assesses the impacts of Medicaid expansion and the COVID-19 pandemic on medication adherence, and offers recommendations for further improvement to Medicaid medication access and adherence.
States that employ Medicaid managed care organizations (MCOs) to pay for prescription drugs outperform states that rely on the fee-for-service (FFS) setting to control drug costs. Despite larger rebates in FFS, MCOs’ effective strategies to encourage…
The purpose of this study is to assess the impacts of Kentucky’s Medicaid managed care program. The key components of this assessment include:
• Cost impacts of the Medicaid managed care program across the past two decades
• Performance on key quality measures
• Opioid and medication-assisted treatment (MAT) prescription drug usage trends
• Kentucky’s recent experience with COVID-19 vaccinations
• Minimum contract requirements for managed care organizations (MCOs) to participate in Kentucky’s Medicaid program
• Competitive procurement dynamics