Managed Care Programs

Earlier today, #CMS issued a #Medicaid Final Rule codifying existential Quality, Access and Accountability requirements. Among other things, these new rules improve #AccessToCare and #HealthEquity by: ⏩ Creating a mandatory MCD Quality Ratings System (#QRS) containing 18 required #HEDIS & #CAHPS measures which mirrors #MedicareAdvantage & #Exchange #StarRatings programs and requires public display of ratings online  ⏩ Requiring 10- or 15-day maximum wait time standards for routine appts for OP MH/SUD, #primarycare, OB/GYN & 1 add’l state-chosen service ⏩ Requiring MLR reporting, and minimum 85% MLR if states set a minimum MLR target ⏩ Expanding/encouraging #VBP, #VBC and #APMs and codifies Provider Incentive requirements ⏩ Adding guardrails and clarity for use of ILOS, including enrollee rights/access and oversight (the MCD version of #SupplementalBenefits in #MA) ⏩ Codifying #QualityImprovement expense criteria  ⏩ Expanding/strengthening network adequacy and benefit/service availability requirements These rules require Medicaid MCOs to ensure actual access exists for the care and services beneficiaries are entitled to. Just as we've seen recently with CMS changes to #MA, #PartD and #Stars, today’s FR change the game. Especially in combination with the 2027/2030 #DSNP Alignment rules in the 2025 MA FinalRule, these new requirements represent the most change in MCD accountability in decades. Here are 3 practical things Medicaid plans can do immediately for success: 1️⃣ Identify a silo-buster. CMS is aligning programs to minimize burden. It will be hard, if not impossible, to be profitable and highly rated if MA and MCD use separate processes, vendors, provider incentives, etc. It will be even harder to pass along product-specific provider accountability via risk/VBC without cross-program synergy/alignment. #Silobust relentlessly! 2️⃣ Educate, re-educate, re-skill & up-skill. These 284 pages, combined with the 182 in this week’s Nondiscrimination FR and last month’s 1,327 page MA FR can’t be understood or operationalized in your team’s ‘spare time.’ Every person in every team needs to understand the #NewNeedsOfFederalFunding so daily decisions meet new regulatory requirements. 3️⃣ Know your communities, know your providers and know your members. #NextGen solutions in both MA and MCD will require us to know and understand the communities and patients we have the privilege of serving. CMS understands the seismic impact of these rules, and is giving multiple years to come into compliance with the #NewNeedsOfMedicaid. Adaptation will require every bit of the long runways, though it will be tempting to slow-roll transformation since the timeline is long. #WhatGotYouHereWontGetYouThere #Transformation > #TinyTweaks #LetsRoll ⭐ ⭐ ⭐ ⭐ ⭐

We solved half the problem & thought we bridged the gap. Ever worked on a solution that looked perfect on paper… but ended up creating more problems than it solved? That’s exactly what happened when I was called in to review a telehealth solution. It was well-designed, checked all the cybersecurity boxes, & allowed patients to consult doctors remotely. The project requirement was clear: enable remote consultations. And the solution delivered exactly that. But here’s the thing: While healthcare systems often operate in silos, patients experience their care as one continuous journey. And this solution missed critical parts of that journey: 🔸 No easy way to book follow-ups. Patients had to call, leading to missed care. 🔸 Medication collection still required hours of travel, making the platform’s convenience meaningless. 🔸 Administrative staff were overloaded, causing delays in care coordination. We solved one problem & unintentionally created three more. The solution was designed for the system’s convenience, not the patient’s journey. To shift the perspective, we expanded the conversation to include voices we hadn’t considered: 🔸 Pharmacists: To integrate medication delivery into the process 🔸 Community Health Workers: To provide local, hands-on support 🔸 Family Caregivers: To highlight logistical & emotional challenges at home 🔸 IT Teams: To automate follow-ups & reduce administrative burden 🔸 Local Transport Providers: To enable last-mile delivery of medications With these insights, we redesigned the solution into a comprehensive care experience: ✅ Patients could book follow-ups easily & get automated reminders ✅ Medications were delivered directly to their homes ✅ Caregivers & community workers ensured patients didn’t fall through the cracks I later learned that: 🔸 Missed follow-ups dropped by 40%. 🔸 Medication adherence & health outcomes improved significantly. The redesigned platform didn’t just connect patients to doctors, it completed the care journey. Next time you’re working on a solution, consider these points: 1️⃣ Patients see one journey While systems operate in silos, patients experience care as a unified process. 2️⃣ Identify all stakeholders Both direct & indirect voices like caregivers, pharmacists & community workers, are essential to closing gaps. 3️⃣ Design for continuity Address every touchpoint in the patient’s journey, ensuring nothing falls through the cracks. Have you worked on solutions where overlooked stakeholders made all the difference? What’s one gap you discovered that changed everything? #DigitalHealth #Innovation #HealthcareTransformation #PatientExperience #Collaboration 💡This post is part of 'Rethinking Digital Health Innovation' (RDHI), empowering professionals to transform digital health beyond IT and AI myths. 💡Find the ongoing series and resources on our companion website (URL in comments). 💡 Repost if this message resonates with you!

💡 Pretty ground breaking work in guiding population health care management through reinforcement learning (basically using longitudinal trajectories+ learning models) to support complex decision-making with and for patients. 🚨 Bottom line: SARSA-guided care management (CM) reduced acute care events by 12% points Sanjay Basu, MD, PhD Bhairavi Muralidharan Sadiq Y. P. JMIR Publications published on a state-action-reward-state-action (SARSA) reinforcement learning model that moves beyond traditional individual care manager experiential judgement to guide outreach of medically and socially complex patients. This tool learns from longitudinal trajectories to prevent adverse outcomes through recommender systems, provides suggestions of what interventions patients may need, and output can guide smarter judgement by CMers. Background: 💠 CM programs have notoriously been hard to evaluate reliably due to enormous variation in implemention, staffing, and training-- leaving the door open for missed identification of interventions or bias 💠 CMers are increasingly community health workers and unlicensed staff, and these programs have spread to support millions of Americans 💠 Most programs are implemented using locally created workflows based on clinical guidance and EHR documentation 💠 The more efficient CM outreach is in identifying the patients which will benefit from specific interventions, the greater the efficiency of staff deployment - less time prepping for outreach so staff can spend more time directly with patients (quality) and greater patient reach per staff (quantity). Here's how it worked, they: 💠 Evaluated 3175 Medicaid beneficiaries in CM programs across 2 states from 2023 to 2024 💠 Compared alternative approaches for recommending “next best step” interventions: the standard experience-based approach (status quo) and a state-action-reward-state-action (SARSA) reinforcement learning model 💠 The analysis of as robust and included: - Clinical impact metrics, - Counterfactual causal inference analyses to estimate reductions in acute care events - Assessed fairness across demographic subgroups - Performed qualitative chart reviews where the models differed Results: 💠 SARSA-guided CM reduced acute care events by 12% points compared to standard care management with a NNT 8.3 (95% CI 4.6-45.2) to prevent 1 acute event 💠 SARSA CM improved fairness across demographic groups, including gender (reduction 1.5%) and race and ethnicity (reduction 3.3%) 💠 Qualitatively, SARSA CM detected and recommended interventions for specific medical-social interactions (e.g. respiratory issues associated with poor housing quality, food insecurity for those with diabetes) Models like this have the potential to help care managers leap forward in becoming even more efficient in advocating for patients to receive needed services with better outcomes. #smarter #efficient #caremanagement #value #populationhealth #AI https://lnkd.in/g36B_Ztp

Every now and then a topic comes up that I happen to know a little bit about - like Medicaid Managed Care. Shares of Elevance (40% Medicaid) and Molina (mostly Medicaid) took a tumble today after Elevance announced higher medical costs mostly due to Medicaid. Medicaid plans - Elevance, United, Centene, and Molina - caught a break during the pandemic with elevated enrollment since beneficiaries did not need to show that they still qualified financially. However, about a year ago, redeterminations began, resulting in many losing eligibility. Health plans downplayed the losses, leading to rosy estimates of retention. Unfortunately, the loss of eligibility turned out to be worse than expected. Many healthy, low-cost members dropped off while sicker members remained, leading to lower premium revenues as medical costs stayed the same or increased, causing higher "loss ratios." Health plan premiums are currently set by the states, with premium increases lagging behind medical cost trends. It may take a couple of years for state actuaries to correctly set new rates, as actual medical costs are rising at double-digit rates. Health plans report that their target margins are 2-4% in Medicaid, but state actuaries usually set rates with an expectation of 2% margins. Margins much in excess of 2% are not sustainable, and as states face tough times financially, the actuaries target the lower end of the range. Things are getting tougher for health plans operating in the government sector. Fewer health plans achieved 4 STARS in Medicare, and NCQA ratings declined for Medicaid plans. Since these rankings affect quality bonuses, revenues will decline. The challenges ahead highlight the complexity and uncertainty in the Medicaid Managed Care landscape.

🚨 New CMS Final Rule: Medicaid & CHIP Managed Care 🚨 CMS released an important update with the "Medicaid Program; Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality Final Rule." 📜 It’s been packed month for health care regs - but don't let this one pass you by... I’m especially keen to see the new efforts to impact access to care. 🏥 I'll share more insights on the national Quality Rating for Medicaid and CHIP soon. 🌟 What impacts do you foresee from these changes to Medicaid? Let's discuss! Summary Highlights: Appointment Accessibility: 🕒 New standards reduce wait times to 15 business days for routine care and 10 for mental health services. Quality Assurance: 🔍 States are required to conduct secret shopper surveys and annual enrollee experience surveys. Public Transparency: 🌐 States must maintain a single, accessible web page with managed care plan details. State Directed Payments (SDPs): 💸 Simplified rules for value-based purchasing, including non-network providers. Provider Payment Levels: 💰 Caps ensure payments for certain services do not exceed average commercial rates. External Quality Review (EQR): 📊 Increased public engagement and use of accreditation reviews. Medicaid and CHIP Quality Rating System (MAC QRS): 📈 A new framework for beneficiaries to compare and select plans. Check out the full details here: https://lnkd.in/e5BhCtRr #Medicaid #CHIP #HealthcarePolicy #CMS #ManagedCare

ABA spending in Medicaid grew 421% from 2021 to 2025. The number of children actually receiving it grew 67%. That gap is exactly the kind of signal that calls for stronger oversight, and CMS released a new State Medicaid and CHIP ABA Toolkit (link in comments) this week aimed at doing just that. A few things worth flagging: 1) The toolkit covers clinical standards, benefit design, payment methodology, provider enrollment and credentialing, utilization management, and program integrity, plus a self-assessment checklist for states 2) CMS was explicit that this is not a benefit cut: no new federal requirements, no reduction to EPSDT obligations, no single treatment approach mandated 3) The goal is stewardship, not restriction: helping states, MCOs, and providers build the guardrails that let this benefit keep growing responsibly From where I sit, this is a welcome development. A benefit that scales this quickly needs oversight infrastructure to scale with it, and a toolkit that gives states, health plans, and providers a shared framework for utilization management and payment integrity is a meaningful step in that direction, one worth building into FY27 rate and trend conversations now.

At Pair Team, we've spent the last several years on the ground helping to implement California’s bold vision for Medi-Cal transformation. Last week, we submitted recommendations to the state for the next phase of this transformation. Drawing on our experience delivering Enhanced Care Management (ECM) to more than 15,000 Medi-Cal members across 14 health plans and 100+ community-based organizations— and achieving large improvements in health and healthcare utilization— we shared our appreciation for the California Department of Health Care Services's leadership and our ideas for strengthening the program going forward. Our recommendations focus on three big opportunities. 🔹 Assure that ECM providers effectively steward resources by: - Promoting sharing of claims data between managed care plans (MCPs) and ECM providers - Adopting payment models that reflect member complexity, need and outcomes - Aligning ECM and Dual Eligible Special Needs Plan (D-SNP) efforts and creating incentives for ECM providers to enroll patients into D-SNPs 🔹 Strengthen the ECM ecosystem and delivery infrastructure by: - Standardizing and scaling MCP infrastructure as enrollment grows - Encouraging hospitals to enroll eligible patients into ECM, either through their own programs or an ECM-provider partner - Recognizing both in-person and virtual engagement as effective modalities of care delivery - Investing in community care hubs to expand CBO participation 🔹 Prepare for the future of AI and H.R. 1 by: - Creating an AI Center of Excellence within DHCS - Supporting providers and CBOs in deploying safe, effective AI tools - Using AI-powered agents to help members meet new federal community engagement requirements and avoid coverage losses We’re encouraged by the progress we've made in California through CalAIM — including reductions in ED and inpatient utilization, improved chronic disease outcomes, and meaningful cost savings — and we believe the next phase can achieve even more. We’re grateful for the opportunity to partner with DHCS, health plans, counties, and community-based organizations to build a more integrated, person-centered, and sustainable Medi-Cal program and look forward to future collaboration. 👉 Read our full recommendations here: https://lnkd.in/gm9g2Yit

IT/OT integration is how you de-risk growth.     If the top floor can’t see the shop floor in real time, quality slips, downtime grows, and batch release slows. In our world of compliance and complex supplier networks, blind spots turn into audit findings and missed delivery windows.     Here’s the core move I see working. Combine the real and digital worlds across product and production so horizontal data flows become routine. Think engineering models, test results, materials, building processes, automation code, and performance data moving between teams. Then connect the vertical path. Executives, planners, and operators sharing the same context so decisions line up with actual conditions. That’s where you get predictive maintenance instead of unplanned stops, data‑centric supply chain adjustments instead of last‑minute expedites, energy transparency that feeds credible sustainability metrics, and stronger cybersecurity plans that account for both IT and OT exposure.     Pharma adds constraints, but the pattern still holds. IoT devices can read modern and legacy equipment, extending the digital thread into your supplier ecosystem so logistics, production timing, and potential disruptions show up early. A closed loop between development, production, and optimization tightens traceability and speeds corrective action. Digital twins let engineering teams iterate quickly on both process and line design without risking validated operations.     Pick one high‑stakes decision and wire it end to end. For many, that’s batch release. Map the horizontal data you need across quality tests, materials, and line performance. Then build the vertical connection so insights reach the teams that plan, schedule, and approve. Keep the scope small, include cybersecurity from day one, and define the single source of truth for that decision. When it works, scale to the next decision. 

Stafford Beer, the famous systems thinker, noted that "the purpose of any system is what it does"—meaning if the system isn't delivering what’s needed, it’s not the people's fault but a flaw in the system's design. #Health and #care are riddled with silos and fragmentation. Specialists, services, and apps address isolated parts of our bodies, but no one looks after us as whole persons, within the context of our lives. As society ages and grows sicker, we find ourselves bouncing between disconnected specialists, clinics, and "pathways," often unaware of our histories or other care we're receiving. Integrated Care has long been discussed but rarely delivered. The "sausage machine" model of #healthcare inherited from industry keeps optimising parts, not wholes. Demand rises, resources are strained, and waiting lists grow. Integrated Care Systems (ICSs) were conceived as a new model to bring together health and care into a more holistic approach, supporting wellness, early intervention, and person-centred care for disease or infirmity. For an #ICS to be more than a rebranded silo collection, it must serve as a system-level convener of integrated support, fostering collaboration across health, social care, local councils, communities, VCS, and industry partners. How do we shift from siloed services to holistic support that centres on people’s needs and lived experiences? And how can we view this challenge through a life course lens—Start Well, Live Well, Age Well, and Die Well? Transforming silos into systems requires a shared vision for the future and a collective journey to reach it. One that recognises that it is the relationship BETWEEN the parts that creates a strong and effective system. I’ve been honoured to work with Suffolk and NE Essex (#SNEE) ICS on their breakthrough “Future Shift” programme https://shorturl.at/RCKBM. This unique 3 Horizons programme has united leaders across the ICS to reimagine a future holistic SNEE system and the journey to get there, built on a shared identity and a "Can Do Health & Care" ethos. Stepping back to view the national landscape, we need more of this visionary, systems-based approach—not just additional funding to sustain outdated methods—if we are to build the future health system that we all need and deserve. For the Imperial Programme that develops these ideas further see here: https://shorturl.at/3nsa1 #nhs #socialcare #communitycare #healthpolicy