HMPI’s response to the Oklahoma Health Care Authority’s Request for Public Feedback on Managed Care Organization program implementation
In mid June the Oklahoma Health Care Authority (OHCA) announced it would seek proposals from managed care organizations (MCOs) to improve health outcomes and access to care for Oklahoma’s Medicaid population in October of 2020. OHCA is in the process of developing the request for proposal, and in doing so requested public feedback on what considerations needed to be included in the proposal. HMPI took the opportunity to provide feedback, as there are many things to consider when switching the Medicaid population to MCOs. Below is a summary of HMPI’s feedback and our full comments can be accessed through the hyperlink.
Background on RPF Response: Commercial MCOs
Healthy Minds Policy Initiative offers this response to a Request for Public Feedback (RPF) by the Oklahoma Health Care Authority (OHCA) about a proposal to shift the SoonerCare (Medicaid) program to a comprehensive commercial managed care model. This is a broad summary of our feedback, and our complete feedback is available here.
What is a comprehensive managed care model?
Private insurance organizations would be hired by the State to act on the State’s behalf to issue insurance coverage to Medicaid enrollees under a value-based payment system intended to reduce overall costs to the State. In return for assuming the risk of insuring Oklahoma’s Medicaid population, these Managed Care Organizations (MCOs) would attempt to earn a profit by ensuring their State funding — overhead and a monthly payment per enrollee — exceeds the costs of providing care.
Can this model work in Oklahoma?
Our comments are not intended to represent a comprehensive analysis of this model’s viability in Oklahoma. However, we offer the following considerations relevant to the Request for Public Feedback:
- Small, high-risk populations are, in principle, financially unsustainable in a private insurer model. Because of its relatively small and unhealthy population, Oklahoma may be at greater risk of a general MCO collapse, as it experienced in the 1990s.
- With a small, higher-risk population, Oklahoma may not be able to support more than one or two commercial MCOs — a scenario that would reduce competition and create financial challenges for the State and treatment providers.
- Moving to a commercial MCO model is a high-stress, risky transition for providers already in financial difficulty. Doing so at the same time as asking providers to take more patients, with Medicaid expansion, would compound stress and risk provider closures.
Can this model work for mental health and addiction coverage?
- Commercial MCOs have historically struggled to deliver outcomes for special populations, such as serious mental illness and substance abuse, foster children and developmental disabilities. This can be attributed to:
- Inherent difficulty in managing complex needs in unfamiliar local systems;
- Unique challenges maintaining network adequacy for behavioral health providers whose workforce pools, geographic coverage and financial capabilities are already limited, and;
- Lack of understanding of or commitment to evidence-based care for more challenging populations, often due to treating mental health as a “secondary” benefit.
- Substance use providers are typically less financially stable than other providers and are the least-equipped to manage a transition from single-source, fee for service safety-net funding to the value-based expectations of multiple payers. Thus, they are an extreme risk of closure in a transition to a commercial MCO model without dedicated funding and support.
What should we consider about the current model?
Our RPF response is not intended to represent a thorough analysis of Medicaid management in Oklahoma. However, Oklahoma’s existing structure of Medicaid administration, managed directly and split between OHCA and ODMHSAS, has impressive financial and outcomes advantages that should not be ignored. We cite two examples, although there are many more:
- OHCA’s overall administrative burden of roughly four percent is far below the most successful commercial insurance organizations.
- Under the oversight of ODMHSAS, annual cost growth for Medicaid’s behavioral health line has been held virtually level with inflation for nearly a decade. Prior to ODMHSAS obtaining direct management of behavioral health Medicaid in 2012, these costs had increased 14 percent annually. This speaks to the wisdom of retaining behavioral health expertise in direct administration of Medicaid spending.
How can the State accomplish its goals?
In addressing each question raised in the State’s RPF, we offer suggestions that can be used to improve value-based care whether as part of a commercial MCO model or its current system. Our RPF response addresses issues such as:
Benefits
- How and when should OHCA transition aged, blind, and disabled (ABD) and other initially excluded individuals to managed care?
- What strategies would improve the integration of services (especially behavioral and physical health), including through provider communication, shared assessments and planning, and data sharing?
- How can MCOs improve access to evidence-based behavioral health care such as Screening, Brief Intervention and Referral to Treatment (SBIRT), medication-assisted treatment for opioid use disorder or Assertive Community Treatment?
Quality and Accountability
- What mechanisms should the state use to incentivize MCOs to improve member outcomes?
- What specific network development, care delivery, and care coordination approaches should MCOs be required to employ to better meet enrollees’ behavioral health needs?
Care management and coordination
- How should the state encourage or require consistency across MCOs in the utilization management process to reduce provider administrative burden?
- How can MCOs improve the management and coordination for members with chronic or complex health conditions?
Provider Payments and Services
- Should OHCA require MCOs to maintain a minimum level of reimbursement? How should this be accomplished? How should the state sustain provider compensation?
- What is appropriate for timely payment of claims?
- How can MCOs support primary care providers in caring for their patients? What infrastructure, programs, training or coaching would be useful?
Network Adequacy
- How should MCOs work with providers to ensure timely access to care standards are met?
- What are reasonable time and distance standards in Oklahoma by provider type?
