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Opinion: Managed care for Missouri’s most vulnerable


When I first heard rumblings about expanding the use of Medicaid managed care, I was doubtful. After all, how could a fixed per-participant amount be good for our Medicaid population that has the highest needs? After careful research, I believe that a well-structured program, implemented carefully and with significant stakeholder input, would be good for individuals in Missouri with long-term care needs.

As mandated by the Centers for Medicare & Medicaid Services (CMS), state Medicaid programs must cover services provided in nursing facilities and home health services (typically nursing services). Missouri also has a number of waivers that allow it to provide Home and Community Based Services (HCBS) and provide services to individuals who have intellectual or developmental disabilities (I/DD). These populations are currently on the fee-for-service model, where the state pays providers for each encounter with the health care system. According to a 2019 report, services rendered under a fee-for-service model made up two-thirds of Medicaid spending.

Most other Medicaid participants are on a managed care model. Under the managed care model, MO HealthNet pays the managed care companies a per-member per-month fee, and the managed care companies utilize these fees to pay health care providers.

Managed Long Term Supports and Services (MLTSS) is a managed care program for people with the highest level of medical need. MLTSS serves people with ongoing care needs and can do so while improving the quality of care. As of November 2020, 25 states utilize MLTSS programs. Moving some individuals who receive Medicaid under a fee-for-services model to MLTSS has the potential to save Missouri a significant amount of taxpayer dollars.

MLTSS also provides opportunities for better care. Depending on how the contract between the state and the managed care provider is structured, the MLTSS contract can provide value-based payment models, better family caregiver supports, targeted supports addressing the social determinants of health, improved pharmacy management, and other innovations.

While I hear “Medicaid Reform” as an option for saving money in a year when we are expanding Medicaid, I do not believe MLTSS is a reform that should come this year. CMS has laid out guidelines for moving to an MLTSS model, which include careful planning, stakeholder engagement, support for beneficiaries, and alignment of payment structures, among other recommendations. This planning process is a lengthy process, and I believe that even trying to implement this in FY 2023 would be a stretch.

Missouri is due for reforms to its Medicaid system. There are ways to reduce costs while improving the health of our poorest residents. MLTSS is a potential reform that warrants careful consideration.