Medicaid MCOs Hope for Expanded Access, Care Opportunities

This article is reprinted with AIS Health’s permission from the January 7, 2019, issue of Radar on Medicare Advantage.

Despite a recent federal court ruling creating some uncertainty about the future of Medicaid expansion, industry experts interviewed for AIS Health’s annual Outlook Survey express optimism about several recent developments that they believe will give way to better patient care going forward.

For one, November’s midterm election results may spell more Medicaid expansion, particularly in historically Republican-controlled states. Voters in three states approved measures to extend Medicaid coverage, and three Democratic governors unseated Republicans who did not support expansion, including newly sworn-in Maine Gov. Janet Mills (D) who just signed an executive order to expand Medicaid. At the same time, Democrats winning control of the House lessens the chance of Republicans making another stab at repealing and replacing the Affordable Care Act (ACA), which despite last month’s ruling by a federal judge in Texas remains the law of the land.

From a policy perspective, given that Congress is “fairly neutered in the split in the House and the Senate, then the bigger macro level, seismic changes like per capita caps are probably off the table vs. more under-the-radar, yet significant impacts you see from a regulatory and even judicial perspective,” predicts Alex Shekhdar, vice president of federal and state policy, Medicaid Health Plans of America (MHPA).

“In terms of patient engagement, payment reforms and so forth, the biggest tool that the administrator and the secretary have to effectuate the Medicaid programs is the 1115 waiver,” he says, referring to the demonstration waiver that states can use to make broad changes to their Medicaid programs or modifications that focus on a specific population or service over a five-year period. “And [CMS] has indicated that there is no stop and believes they have the legal authority to continue to push forward on the waivers.”

Moreover, with new waiver opportunities unveiled in November 2018 for states to address serious mental illness and serious emotional disturbance in adults, “that de facto implicates Medicaid managed care arrangements that exist [in states that seek waiver approval], whether it involves tweaking or securing new network providers, or in terms of making certain operational changes to existing contracts,” Shekhdar predicts.

“I think the tide has turned and the red states realize that Medicaid is an important part of the continuum of health care in the U.S.,” weighs in Jerry Vitti, CEO of Healthcare Financial, Inc., a Boston-based firm that specializes in enrolling the uninsured into health programs. “But I also see the potential for more work requirements, lockout periods and premiums, copayments, deductibles — all those conservative consumer-oriented elements — and I think there will be a continued push to get those approved” via 1115 waivers. As a result, Medicaid managed care organizations may see a “burst of enrollment” from expansion, followed by churn due to various requirements that make it difficult for people to maintain coverage, he predicts.

Meanwhile, states and plans are hoping for more leeway to address social determinants of health, adds Vitti. “I think there’s just more and more recognition and acceptance that social determinants of health play an outsized role in the health care of folks, especially in a high-risk population and the disabled,” he observes. “And so with more recognition, there’s more creativity in the marketplace now around how to address these. You’ve seen this from the Trump administration [in Medicare Advantage; see story, p. 1], so I would say more momentum toward funding housing, nutritious food and other social factors is where we’ll see further development.”

CMS Is Considering Social Determinants
While Medicaid doesn’t directly pay for housing and other social needs, HHS Sec. Alex Azar in public comments last fall hinted at a possible demonstration addressing social determinants through the Center for Medicare and Medicaid Innovation (CMMI). Given some of the work already being done by organizations like Intermountain Healthcare and UPMC Health Plan to address housing and other non-medical factors through local partnerships, CipherHealth’s Friso van Reesema says he is optimistic that CMS will “follow suit” and start reimbursing for those types of services.

“Housing, transportation, meals…those are the ones that have been more at the forefront, but [with growing adoption of] work requirements, beneficiaries could probably be working more and better if they had a childcare benefit,” adds van Reesema, who is vice president of business development with the New York-based patient engagement and care coordination health care IT company. “You can’t ask people to work without being able to support what’s happening at home.”

He continues, “It’s all about options. There are so many different pieces of this puzzle, like social isolation and behavioral health….I think it’s a sign of the times when we’re paying a certain amount for our taxes and we’re seeing that it’s not necessarily working. We have to put a little bit more toward engaging people in social services and working with community-based organizations to connect the dots that much better, to provide the right type of services to the people who need it the most, and be able to show the impact through data.”

Plans Follow Medicaid Buy-in Talks
On a more micro level, Shekhdar adds that MHPA is very interested in “seeing what happens with regards to the interface between 1332 waiver approvals and Medicaid and any kind of effect that might have, as well as conversations about Medicaid buy-in, which are being led by New Mexico.” Also known as State Innovation Waivers, states over a five-year period can use section 1332 waivers to pursue creative strategies for providing their residents with access to high quality, affordable health insurance while retaining the basic protections of the ACA, such as the “public option” New Mexico is exploring in addition to other policies.

“So those types of conversations are intriguing because Medicaid buy-in portends new opportunities for Medicaid managed care plans going forward as well as the insurers that play across both low-income products and Medicaid products. But the problem is it means different things to different people and takes different iterations, and what it looks like depends on what the state architecture is,” observes Shekhdar.

Contact van Reesema and Shekhdar via Joe Reblando at [email protected] or Vitti at [email protected].

Written by Lauren Flynn Kelly