Back on the road to Medicaid managed care

seniors (2)During the 2015 legislative session, lawmakers passed HB 1566, which requires the Oklahoma Health Care Authority (OHCA) to solicit requests for proposals for care coordination models for Oklahomans on Medicaid who are aged, blind, or have a disability. OHCA has initiated a nearly 18-month process of gathering facts, community input, demonstration proposals, model selection, and requests for proposals. Here’s how it will work:

What is HB 1566?

 Simply put, HB 1566 requires OHCA, which administers Medicaid in Oklahoma, to initiate requests for proposals for care coordination models for the state’s aged, blind, and disabled SoonerCare population. Although a managed care system may not be the outcome, the bill’s authors say it’s what they had in mind. ​In this model of health care, treatments are coordinated through the oversight of a primary care physician or team, which provides referrals if patients need a specialist. 

This sounds familiar. Have we done this before?

Sort of, yes. In 1996, OHCA instituted a Medicaid managed care program in Tulsa, Oklahoma City, and Lawton (a study had found that fully-capitated managed care outside the state’s urban centers was not feasible). Following nearly a decade of provider dropouts and double-digit rate increases, OHCA concluded that it could provide care more efficiently at lower cost, and terminated the program in 2004.

Via Pacific Health Policy Group

Why focus on the ABD population this time?

Oklahomans who are aged, blind, or have a disability (ABD) constitute a relatively small portion of the state’s SoonerCare beneficiaries (178,025 people, or 14.6 percent of enrollees), but are responsible for a disproportionate amount of state Medicaid spending (46.4 percent). Legislators who supported HB 1566 believe that there are potential cost savings to be found by instituting a managed care system. 

What are the important characteristics of ABDs?

As of 2007, 70 percent of Oklahomans on SoonerCare who were aged, blind, or had a disability had three or more chronic conditions – for example, simultaneous hypertension, dementia, and epilepsy. Broadly speaking, the three most common chronic conditions this group has are cardiovascular, psychiatric, and conditions of the central nervous system. Slightly more than 51,000 are aged, while the remaining 126,000 are blind or have a disability (there’s some overlap between those groups, as well). Fewer than 20,000 reside in nursing homes: most receive care in home- and community-based settings.  

Because the needs of this group are so medically complex, very small changes in access to care can have a significant impact on their health. Even under the current system, many Oklahomans with disabilities don’t have access to all needed care: for example, as of June, the waiting list for Oklahomans with developmental disabilities to receive some services was 9 years long, with more than 7,000 people in line.

What’s happened so far?

Since the bill was signed earlier this summer, OHCA has been active in laying the framework for the request for proposals. In June, OHCA put out a request for information regarding the capabilities of care coordination models and managers. Respondents were also invited to present their proposed models, and those presentations, with audio, are available here. The 23 responses, which discussed which populations would be covered, how payment would work, and quality and outcome measurement, have been condensed and are available here. In broad strokes, three primary models were presented:

  • Capitated (risk) plan – a care management organization is paid a fixed rate per member per month, regardless of whether the member seeks services over that period. 
  • Managed fee-for-service/Administrative Service Organization performing care coordination – Members would have a care manager but would otherwise continue to receive services as in the current system; OHCA would pay for care coordination and retain any resultant savings.
  • Local, community-based provider organizations – OHCA would contract with local organizations serving members in a defined area of the state (one plan, for example, was suggested by the McAlester Regional Health Group).

In August, the Health Care Authority announced that Pacific Health Policy Group (PHPG) had been named as the development consultant throughout the process. PHPG has worked with OHCA on a variety of projects since 1994. PHPG’s director, Andrew Cohen, has been brought on board to advise the Health Care Authority and coordinate with stakeholders.

What happens next?

Following discussion and input at the stakeholder meeting on October 13, the model selection will be finalized by the November meeting. Regional stakeholder meetings will be held throughout the state Sept. 28 – Oct 1 (exact locations and dates TBD).

Winter meetings will concern development of the request for proposals, with draft language submitted to the federal government in March. The request for proposals will be released in June, with answers from bidders due in August.

Because this change affects a medically-fragile, complex population, OHCA particularly interested in making sure that stakeholder feedback and comments are central to developing a care coordination model. As such, the stakeholder meeting schedule and relevant documents are on a single centralized page at the OHCA website, and they encourage interested parties to sign up to receive email updates and meeting notifications. Although the RFP development process is fairly lengthy, many of the foundational elements will be finalized within the next few months. As such, interested organizations and individuals should be involved as early as possible.

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Carly Putnam joined OK Policy in 2013. As Policy Director, she supervises policy research and strategy. She previously worked as an OK Policy intern, and she was OK Policy's health care policy analyst through July 2020. She graduated from the University of Tulsa in 2013. As a student, she was a participant in the National Education for Women (N.E.W.) Leadership Institute and interned with Planned Parenthood. Carly is a graduate of the Oklahoma Center for Nonprofits Nonprofit Management Certification; the Oklahoma Developmental Disabilities Council’s Partners in Policymaking; The Mine, a social entrepreneurship fellowship in Tulsa; and Leadership Tulsa Class 62. She currently serves on the boards of Restore Hope Ministries and The Arc of Oklahoma. In her free time, she enjoys reading, cooking, and doing battle with her hundred year-old house.

3 thoughts on “Back on the road to Medicaid managed care

  1. The moral hazard is obvious. The advantag waiver program does this and is successful. Ohca has 6% admin cost. If the savings at 90 million as proposed the admin rate will be 2%. Private health insurance pays at least 60% more than Medicaid for hospital care. To squeeze a savings assumes ohca is incompetent or the client will have to forego services. The contract needs to protect the clients.

  2. Being disabled, I have to have my PCP refer me any time I need to see a specialist. Soonercare is already an HMO and has been since it was implemented. I am epileptic with high blood pressure and chronic pain in my back, hips, knees and legs. I also suffer with rheumatoid arthritis. I am allowed six prescriptions a month but I am supposed to be taking more than that. So many times I have to do without my meds. If other insurance companies limited the number of prescriptions allowed, I think the cost of the drugs needed would come down and then people would be able to afford what their insurance didn’t cover.

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