Posted on April 16, 2021April 16, 2021 by MM_ADMIN

Medicaid Concept: Medicaid Drug Discount Programs

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by Medicaid Drug Discount Programs?

One of the main ways that Medicaid agencies can control spending on drug benefits is by entering into rebate agreements with drug manufacturers. These rebate agreements offer Medicaid programs a discount on drug pricing in exchange for allowing drug manufacturers access to the very large markets of Medicaid membership. States can participate in the national Medicaid Drug Rebate Program (MDRP) and receive the discounts.

The other major drug discount program in the Medicaid space is the 340B program. This program allows “covered entities” to purchase drugs at a discount, and then resell those drugs at normal prices (thus keeping the difference).

What role does Medicaid play?

The national MDRP is managed by federal HHS. When states choose to participate, they must allow all drugs that have been negotiated at the federal level. States can also enter into “supplemental agreements” with manufacturers, which in effect provide preferential placement on a state’s drug formulary.

While the 340B program was designed to allow smaller hospitals and other providers to purchase drugs more cheaply, it has evolved into a way to generate increased revenues. States have noticed this and have begun to “take back” management of the drug benefit from health plans in order for the state to obtain these revenues.

Explore further

https://www.macpac.gov/wp-content/uploads/2018/05/340B-Drug-Pricing-Program-and-Medicaid-Drug-Rebate-Program-How-They-Interact.pdf

https://www.hrsa.gov/opa/index.html

https://www.americanactionforum.org/research/primer-the-medicaid-drug-rebate-program/

https://www.whistleblowerllc.com/medicaid-drug-rebate-program/

https://www.kff.org/medicaid/issue-brief/understanding-the-medicaid-prescription-drug-rebate-program/

https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/index.html

Posted on March 31, 2021March 31, 2021 by MM_ADMIN

Medicaid Concepts: Transportation as a Social Determinant of Health

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by transportation as a social determinant of health?

While most of the social determinants of health conversation focuses on various forms of food, clothing and shelter issues, lack of transportation is another area that is generally recognized as impacting healthcare. In places where public transportation is not available, the ability to get to health appointments can be especially limited. If a Medicaid member cannot actually get to the doctor’s appointment, then few of the benefits of proper care can be realized. According to a report from the American Hospital Association, more than 3.6M Americans do not get the care they need because they did have a way to get to their visit.

What role does Medicaid play?

Many Medicaid programs have operated optional non-emergency transportation (NET) programs for years. While these programs address the issue, there are long standing challenges with missed pickup appointments, overly complicated dispatch systems and legacy providers.

Several innovative Medicaid programs have emerged using rideshare vendors (like Uber and Lyft) to streamline the member experience and improve visit completion rates. Medicaid programs can partner with these vendors (or have their Medicaid managed care plans partner with them).

While these options can help meet gaps in urban environments, transportation challenges in rural areas for Medicaid members will likely require alternative solutions.

Explore further

https://nationalcenterformobilitymanagement.org/transportation-and-social-determinants-of-health-destinationss

https://www.aha.org/ahahret-guides/2017-11-15-social-determinants-health-series-transportation-and-role-hospitals

http://www.hpoe.org/resources/ahahret-guides/3078

http://www.hpoe.org/Reports-HPOE/2017/sdoh-transportation-role-of-hospitals.pdf

https://www.ruralhealthinfo.org/topics/transportation

https://populationhealth.humana.com/social-determinants-of-health/lack-of-transportation/

Posted on March 25, 2021March 25, 2021 by MM_ADMIN

Medicaid Concepts: Managed Long Term Services and Supports (MLTSS)

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by Managed Long Term Services and Supports (MLTSS)?

These are the services provided to Medicaid members in a managed care model. Because of the unique member needs, the focus on care coordination and management, and intense cost structure of this model many states have decided to use stand-alone managed care programs just for LTSS. The LTSS stands for long term services and supports. Add an “M” in front of it for “managed.”

CMS has encouraged states to use MLTSS models with an array of funding efforts and aspirational goals. These include the Money Follows the Person (MFP) inititiative and the Balancing Incentive Program (where states are encouraged to increase the percentage of LTSS provided in the home or community vs. in a facility). These efforts have paid off- 25 states operate an MLTSS program as of November 2020 (compared to only 8 states in 2004).

Medicaid programs spent $167B on LTSS in 2016.

map from MACPAC 2020
from CMS technical specifications for MLTSS measures 2017
from Mathematica report, 2018

What role does Medicaid play?

States design the features of their MLTSS programs and contract with managed care companies to deliver the services. They also set eligibility requirements for members, which can include both functional and financial criteria.

States also work with plans and actuaries to set rates for these services.

States also have to manage the quality reporting process for these services, using measures selected by CMS. These measures generally focus on ensuring needs assessments and care plan requirements are met.

Explore further

https://www.medicaid.gov/medicaid/managed-care/managed-long-term-services-and-supports/index.html

https://www.macpac.gov/subtopic/managed-long-term-services-and-supports

https://www.medicaid.gov/medicaid/downloads/final-eval-dsgn-mltss.pdf

https://www.medicaid.gov/medicaid/downloads/eval-dsgn-mltss.pdf

https://www.michigan.gov/mdhhs/0,5885,7-339-71547_4860_78446_78448-474121–,00.html

https://www.medicaid.gov/medicaid/downloads/mltss_assess_care_plan_tech_specs.pdf

https://www.nj.gov/humanservices/dmahs/home/mltss.html

https://www.macpac.gov/subtopic/eligibility-for-long-term-services-and-supports/

http://mltss.org/wp-content/uploads/2019/12/MLTSS-Profile-12-9-19.pdf

https://www.medicaidinnovation.org/_images/content/2019-IMI-MLTSS_in_Medicaid-Report.pdf

Posted on March 19, 2021March 19, 2021 by MM_ADMIN

Medicaid Concepts: Value-Based Payment Models

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by value-based payment?

Defining value-based care / payment remains one of the largest challenges in all of the healthcare space, and Medicaid is no different. While everyone agrees that the concept means something akin to “pay more for better outcomes,” providers and payers continue to struggle to arrive at agreement on definitions, how to adjust for population mix and what incentives actually work.

Some terms you may hear related to value-based payment include: shared savings, gain sharing, risk corridors, incentives, withholds and pay for performance.

A sub-industry of solution vendors leverages the focus on value-based payments to drive sales and growth. These range from care management companies and specialized provider groups that use HEDIS performance as core to their value proposition, all the way up to software companies that have emerged to help providers keep track of the complex set of requirements in their value based contracts.

On the Medicare side, CMS implemented several value based programs meant to change the way providers are paid (as part of ACA). The most recent ones were rolled out in 2019: Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).

What role does Medicaid play?

Medicaid programs have also invested significant effort in migrating from the legacy fee for service system to value-based payment models. Early efforts included health homes and patient-centered medical homes (PCMH).

More recent efforts have attempted to leverage managed care plans to hold providers accountable for quality. Most states use HEDIS-based incentive systems for managed care payments. Many states require health plans to place an increasing percentage of their provider payments in value-based contracts. In these arrangements, the Medicaid agency establishes benchmarks and contracts with an External Quality Review Organization (EQRO) to oversee the plan performance.

States also have implemented innovative solutions separate from their managed care arrangements. Tennessee has a mature episode-based payment program that rewards providers for better outcomes on comprehensive bundles.

A few states have attempted to use Medicaid Accountable Care Organizations (ACOs). Many states also participated in the CMS-funded State Innovation Models (SIM) program to pilot new ways to use value-based payment approaches.

Explore further

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs

https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/smd20004.pdf

https://medicaiddirectors.org/publications/medicaid-value-based-purchasing-what-is-it-why-does-it-matter/

https://www.chcs.org/resource/value-based-payments-in-medicaid-managed-care-an-overview-of-state-approaches/

https://www.medicaid.gov/resources-for-states/mac-learning-collaboratives/value-based-purchasing/index.html

https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-downloads/functional-areas/vbp-benchmarking-brief.pdf

https://www.ama-assn.org/system/files/2019-04/medicaid-value-based-care-models.pdf

https://hhs.texas.gov/about-hhs/process-improvement/improving-services-texans/medicaid-chip-quality-efficiency-improvement/value-based-care

https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/nursing/meetings/2018/nacnep-sept2018-CMS-Value-Based-Care.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing

Posted on March 12, 2021March 12, 2021 by MM_ADMIN

Medicaid Concepts: Telehealth

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by telehealth?

Telehealth (in any payer space) can mean a wide variety of healthcare services that are technology-enabled, including:

Remote patient monitoring
Messaging
Virtual provider visits

Until recent years, most telehealth services were delivered using a hub and spoke model, which essentially connected providers across locations for specialist consultations. In the traditional hub and spoke model, a patient still has to travel to a location for the telehealth visit. As smartphones and related applications have evolved, patients also want more ability to have services delivered virtually, and more options have emerged for members to stay at their home and receive telehealth services.

A large industry of solution vendors has emerged in recent years, and has been especially successful during the COVID pandemic. Significant investment dollars flow through to these vendors, and a corresponding increase in sales and marketing efforts has occurred.

What role does Medicaid play?

Medicaid programs have historically paid more for telehealth than other payers (or had more generous coverage). This is changing as other large payers (such as Medicare) have relaxed previous restrictions on telehealth coverage during the COVID pandemic. Each Medicaid program sets its own rules related to telehealth, and there are often state laws governing payments for telehealth. These laws usually focus on whether telehealth must be covered, and whether it must be paid for at rates similar to in person visits.

Some of the challenges Medicaid agencies face related to telehealth are:

Determining which services can be delivered virtually and still meet HEDIS quality standards (which are used in pay for performance models)

Determining which services can be delivered virtually and still meet HEDIS quality standards (which are used in pay for performance models)

Determining which services can be delivered virtually and still meet HEDIS quality standards (which are used in pay for performance models)

Determining which services can be delivered virtually and still meet HEDIS quality standards (which are used in pay for performance models)

Explore further

https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html

https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/medicare-and-medicaid-policies/

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth

https://www.hhs.gov/coronavirus/telehealth/index.html

https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit-supplement1.pdf

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

https://telehealth.hhs.gov/providers/billing-and-reimbursement/

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

https://www.dhs.wisconsin.gov/telehealth/index.htm

Posted on March 5, 2021March 5, 2021 by MM_ADMIN

Medicaid Concepts: Third Party Liability and Coordination of Benefits

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by Third Party Liability (TPL) and Coordination of Benefits (COB)?

Some Medicaid members can have multiple sources of health insurance coverage besides their Medicaid coverage. (One GAO report estimates that 14% of Medicaid members had additional third party coverage in 2012). When this occurs, Medicaid is supposed to be the “payer of last resort.” In practical terms, this means that all other forms of insurance coverage should pay their share of the costs of a member’s care before Medicaid begins to pay.

There are various other types of payers that are required to pay before Medicaid does, including:

Employer sponsored health insurance
Pharmacy benefit managers
Medicare
Court-ordered health coverage
Settlements from a liability insurer
Workers’ compensation
Long-term care insurance

What role does Medicaid play?

In order to ensure compliance with the legal requirement for Medicaid to pay last, states are required to “take all reasonable measures to ascertain the legal liability of third parties to pay for care and services that are available under the Medicaid state plan.” This means states must operate business functions dedicated to ensuring the total coverage picture for each Medicaid member is known and incorporated into payment systems.

The state activities to ensure this are collectively referred to as “coordination of benefits” (COB). At a high level COB involves data-matching and identifying other responsible payers. In states that have Medicaid Managed Care, Medicaid plans often are paid to execute COB activities on behalf of the state.

Explore further

https://www.medicaid.gov/medicaid/eligibility/coordination-of-benefits-third-party-liability/index.html

https://medicaid.georgia.gov/programs/third-party-liability

https://www.in.gov/medicaid/files/third%20party%20liability.pdf

https://www.macpac.gov/subtopic/third-party-liability/

Posted on February 25, 2021February 26, 2021 by MM_ADMIN

Medicaid Concepts: Electronic Visit Verification

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by electronic visit verification (EVV)?

Electronic visit verification (EVV) is a category of technologies and services used to validate that a visit actually occurred (usually in the member’s home). While EVV has been around for a long time, the 21st Century Cures Act made it mandatory for all state Medicaid programs by January 2020 for personal care services and January 2023 for home health services.

At a minimum, EVV systems must document:

Date of service
Location of service
Individual providing service
Type of service
Individual receiving service
Time the service begins and ends

What role does Medicaid play?

In addition to implementing required EVV systems, Medicaid agencies are in a unique position to leverage EVV data to improve member service provision. Medicaid agencies also play an important role in educating members on the benefits of EVV and reassuring those members that have privacy concerns related to GPS data tied to their home.

While EVV is primarily designed to prevent fraud in the Medicaid system, there are opportunities to use EVV data to improve care coordination and identify member quality gaps. The ability to use EVV to improve member outcomes is only beginning to be explored.

Explore further

https://www.medicaid.gov/federal-policy-guidance/downloads/cib080819-2.pdf https://www.medicaid.gov/sites/default/files/2019-12/evv-requirements-intensive.pdf

https://www.medicaid.gov/medicaid/data-systems/outcomes-based-certification/electronic-visit-verification-certification/index.html

https://medicaid.publicrep.org/feature/electronic-visit-verification-evv/

https://medicaid.ohio.gov/INITIATIVES/Electronic-Visit-Verification

https://medicaid.georgia.gov/programs/all-programs/georgia-electronic-visit-verification-evv

https://chfs.ky.gov/agencies/dms/dca/Pages/evv.aspx

https://dhhs.ne.gov/Documents/EVV%20October%20Slides.pdf

https://www.in.gov/medicaid/providers/1005.htm

Posted on February 21, 2021February 21, 2021 by MM_ADMIN

Medicaid Concepts: Member Engagement

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by member engagement?

With so much focus in the Medicaid space on improving health outcomes for the sickest, most vulnerable populations, the need to have the member engaged in their own health is clear. “Member engagement” is a broad term that includes a range of ideas: treatment compliance, emergency room avoidance, self-directed care, decision-making, health assessments, and member onboarding.

All efforts centered on member engagement are based on the idea that people will make better healthcare decisions when they are more engaged. One of the biggest obstacles to increasing member engagement today is the overload of information. It is increasingly difficult to get the member’s attention in an information-rich world of social media, email and entertainment.

Member engagement should not be confused with care management. Care management describes a model focused on care coordination, treatment pathways and targeting members with complex needs. While care management also relies on member engagement, the two terms are not synonymous.

What role does Medicaid play?

Over the past several decades, Medicaid agencies have worked to improve member-engagement. Many of the earlier efforts evolved out of the disease management programs of the late 1980s and 1990s. Newer efforts focus on maximizing the effectiveness of communications to members, targeting specific members to close quality gaps and aligning incentive programs to encourage healthy behaviors.

While much of the member engagement effort focuses on newer technology solutions (think smartphones or telehealth), there are still important functions related member engagement that happen in a call center, or when a member fills out a member satisfaction survey. Medicaid agencies, health plans, and providers all have opportunities to increase member engagement in a wide range of settings and thereby improve health outcomes.

Explore further

https://carenethealthcare.com/medicaid-member-engagement-strategies/

https://medcitynews.com/2018/09/here-are-some-high-impact-engagement-strategies-for-medicaid/?rf=1

https://www.chcs.org/media/PRIDE-Culture-of-Engagement-FINAL.pdf

https://healthpayerintelligence.com/news/how-to-improve-medicaid-member-engagement-care-coordination

https://www.colorado.gov/pacific/hcpf/performance-measurement-and-member-engagement

Posted on February 10, 2021February 10, 2021 by MM_ADMIN

Medicaid Concepts: Modularity

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by Modularity?

States spend billions of dollars each year on claims payment and related technology systems. These payments have traditionally gone to a handful of vendors able to build such large scale solutions.

It has proven difficult to flexibly evolve Medicaid technology systems when most functions reside in one solution. Over the past 20 years, CMS (which pays for the majority of the costs of these systems) has attempted to create positive disruption with an emphasis on modularity. In lay person’s terms, this means using a set of smaller modules that can work together to accomplish objectives instead of one monolithic system.

An entire industry has grown up around the concept of modularity, including both technology and consulting vendors.

To understand modularity, there are two related key terms:

MMIS– Medicaid Management Information Systems is the term used to talk about the technology systems needed to pay provider claims, conduct certain federally required functions (like fraud detection) and interface with other systems such as eligibility and enrollment. This term is defined in section 1903 of the Social Security Act. At the most simple level, states must have payment systems approved by CMS since CMS is paying so much of the costs of healthcare services.

MITA – The Medicaid Information Technology Architecture (MITA) initiative is sponsored by CMS and is designed to improve systems used in Medicaid programs. It has various goals and standards, and states have to report on their use of related principles in their system design.

One of the common concerns is perceived lack of precision in the definitions provided by CMS. Many stakeholders have called for CMS to identify a list of acceptable modules.

“A module is a packaged, functional business process or set of processes implemented through software, data, and interoperable interfaces that are enabled through design principles in which functions of a complex system are partitioned into discrete, scalable, reusable components. An MMIS module is a discrete piece (component) of software that can be used to implement an MMIS business area as defined in the Medicaid Enterprise Certification Toolkit (MECT)” – CMS State Medicaid Director Letter, August 16, 2016

What role does Medicaid play?

While CMS pays most of the costs of these systems, states procure them. As states update their MMIS systems, they have an opportunity to do a modular procurement. So far, states have typically sought to procure modules for claims payment, eligibility, drug management and electronic visit verification. In addition to modules, states also procure Systems Integrator (SI) contracts. SI vendors provide the overarching system needed to integrate modules together.

Explore further

https://www.medicaid.gov/medicaid/data-systems/medicaid-management-information-system/index.html

https://www.medicaid.gov/medicaid/data-systems/medicaid-information-technology-architecture/index.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidInfoTechArch/Downloads/mitaoverview.pdf

https://mmcp.health.maryland.gov/Documents/MMAC/2019/05_May/2019%20MMAC%20Summit_MMIS%20Transformation.pdf

https://doit.maryland.gov/contracts/Documents/catsPlus_torfp_status/M00B0600019-MHT-MMT-RFP.pdf

https://www.cns-inc.com/wp-content/uploads/2018/06/CNSI-Modularity-White-Paper-FINAL_0.pdf

https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/contracting/pre-solicitation-announcement.pdf

https://www.medicaid.gov/medicaid/data-systems/downloads/rfi-modular.pdf

https://www.medicaid.gov/medicaid/data-systems/medicaid-enterprise-certification-toolkit/index.html

https://downloads.conduent.com/content/usa/en/white-paper/defining-mmis-modularity.pdf

https://www.optum.com/content/dam/optum3/optum/en/resources/PDFs/optum-modularity-approach-for-hhs-medicaid.pdf

https://www.medicaid.gov/federal-policy-guidance/downloads/smd16010.pdf

https://www2.deloitte.com/us/en/pages/public-sector/solutions/medicaid-management-information-system-modernization.html

Posted on February 4, 2021February 4, 2021 by MM_ADMIN

Medicaid Concept: Loneliness as a Social Determinant of Health

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by loneliness as a social determinant of health?

While most of the social determinants of health conversation focuses on various forms of food, clothing and shelter issues, loneliness and isolation have also been shown to play a significant role in health outcomes. Recent studies suggest that loneliness can have as big an impact on health as smoking or obesity. Cigna has conducted extensive surveys with generational breakouts that show millennials and generation z are loneliest of all, and its affecting their health. NIH has also studied loneliness and social isolation in older Americans.

Loneliness acts as a fertilizer for other diseases. The biology of loneliness can accelerate the buildup of plaque in arteries, help cancer cells grow and spread, and promote inflammation in the brain leading to Alzheimer’s disease. Loneliness promotes several different types of wear and tear on the body.” – Steve Cole, UCLA

What role does Medicaid play?

Some states have launched programs to target loneliness specifically (Ohio‘s friendly caller program is one example). Medicare Advantage plans have also launched similar efforts during the COVID pandemic.