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Recently, the Centers for Medicare and Medicaid Services (CMS) released proposed changes for Medicaid and Children’s Health Insurance Program (CHIP) managed care programs. This is CMS’s first update to the Medicaid managed care organization (MCO) regulations in over a decade.

There have been many changes in the healthcare marketplace since the last MCO rule update in 2002. Specifically, the adoption and expansion of Managed Medicaid plans has skyrocketed, with more than 34 million Americans enrolled in a Medicaid MCO (a 10 percent increase since 1999). Helping to fuel that growth, the Affordable Care Act has mandated insurance coverage and created Health Insurance Marketplaces. Also of note, quality improvement programs such as Medicare’s Star Ratings have shown population level improvements to important outcomes, including medication adherence.

The CMS notice focuses on the areas of beneficiary experience, quality improvement, delivery system performance, and fiscal integrity. The alignment of the Medicaid programs with Medicare, Health Insurance Marketplace, and Commercial plans is a consistent theme throughout the notice. Below is a summary of these key focus areas, along with RxAnte’s perspective.

Quality Improvement

Summary: To further quality improvement and measurement, CMS has proposed developing a quality rating system for Medicaid and CHIP MCOs. Quality initiatives would focus on increasing transparency, aligning with other systems of care, and consumer and stakeholder engagement. Quality measurements would include disease states such as diabetes, asthma, depression, and blood pressure. Similar to other rating systems, preventive health and readmissions will become a focus for Medicaid plans.

RxAnte Perspective: Moving toward a more standardized set of quality measures is an important step that will both incentivize improved clinical outcomes and enable better benchmarking across health plans. Implementing quality improvement initiatives means more data collection, measurement, and reporting for Medicaid MCOs. CMS estimates the quality rating system would likely not be in effect for 3-5 years, however, it is important for plans to start focusing on these initiatives today. Early adopters will be well prepared when the changes take effect and more importantly, will benefit from improved quality in the short term with reduced medical costs and higher member satisfaction.

Delivery System Performance

Summary: The proposed rule includes several provisions to support delivery system reform efforts and initiatives that improve healthcare outcomes and beneficiary experience, while effectively managing costs. Some recommendations included adopting quality and outcome-based provider reimbursements, expanding patient-centered medical home initiatives, increasing efforts to reduce the number of low birth weight babies, and establishing minimum reimbursement standards to support timely access to care.

RxAnte Perspective: Delivery system reform has improved transparency and accelerated quality improvements within the Medicare and insurance marketplaces. CMS is looking to expand these same successes within the Medicaid sector. With increased focus on quality improvement and access to care – accurate measurement, education, and provider tools will be a key to success of these programs. Effective provider engagement programs will be crucial to performing well in these initiatives.

The proposed changes to the managed Medicaid rules show CMS is dedicated to modernize Medicaid and CHIP programs to strengthen the quality of care in a cost-effective manner. These changes would better align Medicaid with other health insurance programs such as Medicare and Health Insurance Marketplaces. CMS intends to focus on quality measurement, provider relations, and new payment models within the managed Medicaid market, and plans should to focus on these efforts sooner rather than later. With continued transparency from CMS and consideration of feedback from the market, these changes support the agency’s mission of better care, smarter spending, and healthier people.

About RxAnte

RxAnte is the leading platform for improving medication use and drug therapy outcomes through predictive analytics and targeted clinical programs. Its innovative analytics platform is transforming how organizations work with healthcare professionals, care management intervention providers, and patients to promote the safe and effective use of prescription medications. Created by experts in advanced analytics, medication adherence, health IT, and quality improvement, RxAnte offers patent-pending platforms that include predictive and decision analytics, advanced program evaluation methods, and an innovative platform for provider engagement.