CMS Seeks Input On Innovative Payment, Delivery Models It Can Test in Medicaid Managed Care

CMS is seeking stakeholders' advice on whether the agency should test Medicaid managed care reforms in the areas of pharmacy and medication management, value-based insurance design, telehealth, hospice care, long term services and supports, network design, behavioral health, and provider incentive arrangements like accountable care organizations in order to potentially reduce costs while improving quality of care.

The agency's innovation center says in a broader request for information issued Thursday (Oct. 2) that fiscal pressure and market developments have led health plans to increasingly come up with innovations in care delivery, plan design, beneficiary and provider incentives and network design. Although these innovations have proven successful, their adoption in the range of CMS stand-alone programs -- such as Medicaid managed care, Medicare Advantage, Medicaid Prescription Drug Plans -- that use health plans as delivery systems has been limited, CMS says.

“Testing models of these types of innovations will require collaboration with health plans, states, and other stakeholders,” CMS says. “These models will complement the Innovation Center's existing portfolio of models that use innovative methods of payment to improve health care quality and reduce costs.”

The RFI notes that Medicaid has a long history of using managed care for large segments of beneficiaries in the state and federal health care program for low-income families and individuals. Nearly three-quarters of beneficiaries are in a managed care program, with 51 percent enrolled in comprehensive full-risk plans, and many states that have expanded Medicaid under the Affordable Care Act have chosen to use managed care as the primary delivery system, CMS notes.

In the section of the RFI dealing with Medicaid managed care CMS asks states to describe successful models states are using to implement incentives for plans in promoting value-based purchasing, such as withholds and other financial incentives in their contracts with managed care plans.

The National Association of Medicaid Directors has been pressing CMS to give states flexibility to customize innovation models in their contracts with managed care plans, as the agency works for the first time since 2002 to update its Medicaid managed care regulations. States often use withholding practices, such as not enrolling beneficiaries in plans or removing beneficiaries from plans, in order to ensure contract compliance on the part of Medicaid managed care plans.

The RFI also asks stakeholders to describe successful state efforts to promote alignment of provider incentives and quality metrics across managed care plans.

Medicaid Health Plans of America director of federal policy Amy Ingham said the RFI is a positive opportunity for managed care plans to highlight work they are doing to improve quality of care while controlling costs and innovative programs they have developed.

“Some of the unique programs the health plans have in individual markets they serve in, or across states -- some of the plans that serve in multiple markets or multiple states, have in place to serve the population enrolled are remarkable,” Ingham said. “This is an opportunity for us to highlight to CMS what some of those programs look like and what some of the successes have already been.”

She noted that Medicaid managed care plans already work with the CMS' innovation center on a number of test models, including the dual-eligibles demonstration.

Ingham said it will also give Medicaid managed care plans the chance to let CMS know what particular areas should be focused on in innovation model tests. Ingham said she thinks one of the areas plans would like to focus on is integrating behavioral health and physical health, though she can't speak for member plans and how they'll individually respond.

“That's been a huge focus for our health plans for a long time,” she said. “There's a pretty broad understanding that physical health impacts mental health, mental health effects physical health. There needs to be a more integrated approach.”

The National Governors Association recently announced that it is starting a year-long initiative in Alabama, Nevada and Washington state to look at how to make broader, system-wide applications for innovations happening in those states' Medicaid programs. Washington state and Nevada are looking at models for integrating behavioral and physical health delivery.

The agency has given interested parties until Nov. 3 to submit comments and ideas on the RFI. -- Todd Allen Wilson (twilson@iwpnews.com)