Abstract
The following Issue Brief examines Medicaid managed care in Ohio with a focus on the essential elements which currently define the program, the recent efforts to utilize contracting to advance value-based reimbursement, as well as some opportunities to innovate for the future. This brief will not address MyCare Ohio as the issues, conditions and populations between MyCare and Ohio’s traditional program differ greatly and thus this piece cannot adequately provide meaningful comparative analysis.
Key Takeaways
Ohio’s Medicaid program is privatized, with managed care acting as the steward for Ohio’s efforts to achieve value
A number of programs have been developed, with some success, to increase quality and outcomes through managed care
Ohio has the opportunity to build on this value through increasing transparency and addressing social determinants of health
Insights Results
Overview of brief
Overall, this brief examines Medicaid managed care in Ohio with a focus on the essential elements that define the program. In Ohio, private payers act as the steward for Ohio’s efforts to achieve value. In addition, a number of programs have been developed, with some success, to increase quality and outcomes through managed care. Currently, Ohio has the opportunity to build on this value through increasing transparency and addressing social determinants of health
Outside of waivers, there are policies the Ohio Department of Medicaid (ODM) could consider as ways to increase accountability for plans and providers to address social determinants as a cost-saving measure: 1) Require plans to provide incentives to providers who screen for non-medical problems (e.g., CA is considering including screening for Adverse Childhood Experiences in Early Periodic Screening Diagnosis and Treatment); 2) Allow non-traditional services to count toward the medical loss ratio under the “in lieu of” standard (e.g., home visitation for a prenatal visit in lieu of an office visit); and 3) Develop metrics built on transitions of care across clinical and non-clinical settings (e.g., develop a metric on referrals to specific community-based services and tie to pay-for-performance)
While there are some successes to be had in the innovations over the last few years, more can be done particularly in the areas of social determinants and transparency. Contracts with managed care organizations should be designed in such a way that we maximize their value to create an efficient and effective delivery system
Ohio legislature should entrust ODM with the complicated, ever-evolving work that only an executive function could offer. If anything, the General Assembly should focus on MCOs and providers that directly receive Medicaid funds
Key takeaways/implications
If it’s known that costs are the result of a combination of social determinants and price, then systems should be engineered to address social determinants and price. Managed care, with its ability to see across systems and case manage enrollees, may currently be in the best position, to navigate the non-clinical factors that affect outcomes. This management should be done in collaboration with, even at the direction of, community-based organizations that manage the most complex patients with the highest needs. Similarly, providers must be held to a higher standard of care which is simultaneously agnostic to the source of patient coverage while considering the ways in which their choices affect cost, particularly when patients are unable to address their most basic of needs
