Health Care Reform calls for a huge expansion of the Medicaid program in 2014. Over the past two decades, Medicaid spending has grown by 450%. At the same time, state budgets for Medicaid have remained flat or decreased.
As the largest health care insurer in the nation, Medicaid costs topped $466 billion in 2011, for approximately 60 million beneficiaries. Health reform expansion will add 16 million enrollees, mostly in private plans, bringing the total number of Medicaid beneficiaries nationwide to about 65 million and raising the stakes for controlling costs. States will continue to look for ways to better manage Medicaid programs, improve outcomes and control costs, and are relying more on health plans to manage their Medicaid patients.
States are turning to MCOs to provide care for more medically complex, older, disabled – and expensive – populations with the goal of improving their health status through an integrated system that coordinates care and promotes wellness. Beneficiaries with mental health or substance abuse diagnoses are at 30% to 50% higher risk for chronic illness than those without behavioral health issues.
Focusing on prevention and providing alternatives to high cost services and settings while maintaining quality are among the objectives of all managed care organizations — and particularly the focus of Medicaid MCOs. Monitoring and managing patients in an outpatient setting rather than an acute care setting will be required to meet new payment models.
The value of managed care results from providing the right amount of health care, at the right time, in the right setting. Focusing on wellness/prevention and providing alternatives to high cost services and settings, while maintaining quality are among the objectives of all managed care organizations — and particularly the focus of Medicaid MCOs.
Analytic tools are needed to manage Medicaid beneficiaries and will be a key element to success to providing value to States that need to make their health care programs more efficient and effective. Predictive and clinical analytics will be an essential tool to create targeted programs for Medicaid MCOs to help identify high-risk members, track healthcare metrics against benchmarks and provide care managers with access to current clinical and financial data.
Elsevier/MEDai’s advanced analytics capabilities allows Medicaid MCOs to be better positioned to support State Medicaid objectives of decreasing administrative and medical costs, providing high quality care coordination to Medicaid beneficiaries and maintaining overall program integrity.
Managed Medicaid solutions enable effective decision-making delivered through advanced analytics by providing the tools for:
- Management of High Risk Populations, particularly dual diagnoses beneficiaries (exponentially more risk and cost)
- Collaboration of Care that is Critical to Cost Reduction and Better Outcomes for Beneficiaries
- Identification of High Performing Providers
- Program Integrity
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