Research Paper Example on Medicaid Managed Care Plans

Published: 2021-07-09 14:19:46
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George Washington University
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Research paper
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In July 2016, approximately two-thirds of the Medicaid beneficiaries had already been enrolled into at least one of the three managed care programs. Since 2011, Illinois launched the initiative to migrate the Medicaid beneficiaries to the managed care organization system. Initially, the integration did not progress smoothly due to the patients, healthcare providers and doctors expressing concern and confusion in the policy shift. However, in February 2016 the Illinois Department of Healthcare and Family Services (HFS) released the request for proposal aimed at restructuring the states Medicaid Managed Care Organization system (MCOs). Currently, Illinois has some contracts which contain different MCOs thereby promoting high enrollment rates onto the Integrated Care Program. According to Mulvany, 2016, the new procurement by the Illinois Department of Healthcare and Family Services will replace the current MCO contracts that have several termination dates.

Presently, roughly two million of the three million one hundred thousand Medicaid enrollees in Illinois have been integrated into the States managed care system. Representing about sixty-five percent of the entire Medicaid population within Illinois. The Illinois Department of Healthcare and Family Services upholds the objective of expanding the services delivered by the Illinois managed care system on the enrollee type and geographical basis. In an attempt to cover the one hundred and two counties within Illinois from the current thirty counties that are covered with about eighty percent of the probable population that is eligible for the Medicaid care services. At the moment twelve Managed Care Organization systems in the Illinois managed care system offer medical services to the states residents. Despite the Request for proposal setting the limitation on the contracts, the state Seeks to award between four to seven recipients there has been a gradual enrollment increment over the previous years. For instance, the MCO health plan assessment of the March 2015 enrollment depicts the overall enrollment total being one million 9 hundred and eighty-three thousand six hundred and twenty-seven (Zweig, 2015). Moreover, the Illinois Medicaid aims at also integrating the rural beneficiaries into the new managed care system. Besides, enabling the clients to change their existing providers to challenges experienced by the enrollees for the necessary access to the pharmacist may be quite difficult.

As per Macfarlane, 2015, the data from the Medicaid Managed Care Data Collection System in 2015 and 2016 depicts a twenty-four percent increase in the comprehensive MCOS in the Medicaid enrollment. Subsequently, the comprehensive MCOs covers most of the Medicaid benefits inclusive of the primary, specialty and acute care. Additionally, in eighteen states almost seventy-five percent of the Medicaid recipients enrolled in any of the Managed care programs were in the comprehensive MCOs. The actual number of states with more than seventy-five percent increased to one-third of the total states. Consequently, the shift is due to the decrease in the Primary care case management programs. On the other hand, the states enrolled significant population groups into the 2016 Comprehensive MCO programs to include the blind, aged, disabled adults and children. Finally, approximately five million low-income grownups were catered for by the ACA Medicaid as they were enrolled into the MCO programs.

According to Budryk, 2015, the Illinois Medicaid program endorsed a strategic based on the great risk managed care. Therefore the Care Coordination Entities for seniors, Children with Special Needs, Managed Care Organizations and Adults under the Affordable Care Act developed as collaborations to enhance the services offered to the beneficiaries. Thus the Illinois Department of Healthcare and Family Services initiated the following healthcare programs: Family Health Program, Medicare Medicaid Alignment Initiative and Integrated Care Program while upholding the Primary Care Case Management program in the non-mandatory regions of Illinois. Subsequently, the managed care models enable the Department to accomplish its objectives of testing the inventive healthcare coordination models. The department implemented the Managed Care Organization Systems and Primary Care Case Management to improve the living standards as well as the health care of the Persons with Disabilities and the senior citizens within Illinois jurisdiction. Hence the integrated healthcare system unifies one's physicians, nursing homes, hospitals and other specialists as an integral part of the healthcare team. As a result, the care is well organized in relation based on the patients needs providing an improved health outcome and a coordinated medical approach. Therefore the integrated care lays emphasis on the factors which can affect an individuals well-being and health as well as lay a strategic plan in place to manage their medical needs including social, physical and behavioral needs (Brennan, Conway & Tavenner, 2014). As a result, the Integrated Care Program serves Seniors and Persons with Disabilities in the Medicaid program in The Greater Chicago Region, the Quad Cities Region, Central Illinois Region, Metro East region and Rockford Region. Every health plan is associated with a multidisciplinary integrated healthcare team for the enrollees who are recognized as individuals requiring the care management system. Therefore the integrated healthcare teams comprise of the non-clinical and clinical staff members whose professional experience and skills support and complement each other to oversee the enrollee's needs.

The participation of the Managed Care Organizations in the departments Family Health Plan, Medicare-Medicaid Alignment Initiative and Integrated Care Program, a demonstration is often reimbursed on the capitation basis. Furthermore, the Illinois Department of Healthcare and Family Services establishes the MCO rates from the enrollment data, the experience gained from healthcare plan claims and the free-for-service claims (Macfarlane, 2015). Under the Integrated Care Program, the Managed Care Organizations are compensated based a capitation basis for the Medicaid services offered inclusive of the physician care, laboratory, substance abuse, hospitalization among other services. The capitation rate is usually paid based on the six different population rate cells that are derived from the different types of enrollees, for example, the HCBS waivers enrollees, community residents, and nursing facility residents. Quality healthcare is safeguarded by the Illinois Department of Healthcare and Family Services through the contractually pay-for-performance measures that incentivize the expenditure on the care producing healthy life outcomes. Therefore the payments are withheld when the Managed Care Organization systems are not spent as per their capitation payments linked to care which should produce quality outcomes. Consequently, an eighty-eight percent medical loss ratio depicts the revenue percentage from the contract which should be spent on the medical services to the enrollees. Likewise, a portion of the capitation rate funds the incentive pool with approximately one percent in the first measurement year to about a two percent in the third measurement year (Oberlander & Laugesen, 2015). Therefore, an assessment of every plans previous year performance acts as the baseline to that particular measurement year. However, when the preceding years performance is below the initial baseline, the initial baseline will remain as the baseline.

 

 

References

Brennan, N., Conway, P. H., & Tavenner, M. (2014). The Medicare physician-data releasecontext and rationale. New England Journal of Medicine, 371(2), 99-101.

Budryk, Z. (2015). 5 changes to help medicare ACOs thrive. Newton: Questex Media GroupLLC.

Macfarlane, M. A. (2015). Sustainable competitive advantage for accountable careorganizations. Journal of Healthcare Management, 59(4), 263-271.

Mulvany, C. (2016). MACRA the medicare physician payment system continues to evolve.Healthcare Financial Management, 70(2), 32-35.

Oberlander, J., & Laugesen, M. J. (2015). Leap of faithmedicare's new physician paymentsystem. New England Journal of Medicine, 373(13), 1185-1187.

Zweig, D. (2015). Early results from medicaid ACO programs show promise. Newton:Questex Media Group LLC.

 

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