Analysis: The more things change, the more they remain the same – Managed Care for Medicaid (Expansion, this time) in Oklahoma
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Published: 10-May-2021

Pat McGuigan 

Oklahoma City – When voters decided narrowly, but clearly, to expand Oklahoma’s Medicaid system to new populations, they also infused new urgency into a long-standing debate. 
Namely, how to improve health care outcomes in the most vulnerable populations.

Things have changed only a little, since I dove into the Managed Care issue back in February 2018. 
The Oklahoma Health Care Authority (OHCA) operates the Medicaid system, which has run on a fee-for-service basis. 
When a provider performs a service they send a bill to OHCA and get a check in the mail. The costs of delivering care have grown over time, and there have been only a few tools available to Oklahoma to control cost growth – even as health outcomes remained less than desirable. 
Despite continual spending increases, Oklahoma has not received hoped-for return (in the form of improved quality, outcomes or access) on that long-standing investment.

The system already siphons critical funding that might go to other state programs. Do we really believe there has been enough accountability within the current system serving 1 million Oklahomans, a quarter of all state residents? (When the Oklahoma Health Care Authority, a few years back, ran out of money to treat the flu epidemic, it was proof that the current system has not equipped well enough to handle this sort of stress.)

Can Oklahoma do better? 

A 2018 study from the Oklahoma Association of Health Plans (OAHP) asserted that modernizing Medicaid could prevent these types of scenarios from happening in the future while serving to modernize the health care delivery system. 
Entering contracts for a Managed Care system, the state can pay one lump sum to managed care organizations, or MCOs. 

With voters having decided the issue expansion, implementing Managed Care provides Oklahoma with the ability to at least manage the growth of Medicaid spending, improve health outcomes, increase access and drive innovation to create a truly modernized Medicaid program.

Kaitlyn Finley, the Oklahoma Council of Public Affairs (OCPA) analyst I’ve cited previously, had another fine essay last week, entitled “Oklahoma House seeks to grow state health agency.” 
She was digging into the Marcus McEntire proposal (Senate Bill 131) that would create a new chunk of bureaucracy within OHCA to invent what already exists: Managed Care models. 

Stick with me on this. She wrote, “The number of Oklahoma Medicaid enrollees has grown significantly relative to the general state population over the past two decades, leading to a sharp increase in expenditures.
“With expansion coming down the pike, this would be the worst time to throw hundreds of millions of dollars towards the Oklahoma Health Care Authority to implement managed care. They do not have the time, infrastructure, or incentives to implement managed care effectively or efficiently.”
Taking her ever-measured approach, she pondered the recent effort to spike the chief executive’s considered program to implement the voter’s will between now and the fall, when Medicaid Expansion must take effect. She concluded:  “Instead of further growing government and reinventing the managed-care wheel, the legislature should reject [Senate Bill 131] and adopt Gov. Stitt’s plan to manage Medicaid costs.”

Back to the future, y’all  

Haley Faulkenberry, executive director of the OAHP, in a straight-forward commentary for The Oklahoman on Sunday, April 30, pointed out, “Medicaid managed care is a well-established and highly successful model that’s already been adopted by 40 U.S. states. These states partner with managed care organizations (MCOs) to administer Medicaid benefits because it’s the only model with the structure, tools and resources needed to address today’s complex health care needs.”

She observes, “Health care is about more than just seeing a doctor when you feel sick — everything from where you live to what you eat can have a significant effect on your long-term health and wellbeing. What’s called the fee-for-service model, the current model for administering Medicaid in Oklahoma, brings a short-term fix to these types of issues.
“This model sees each doctor visit and test ordered as a separate event, often measuring a patient’s experience by the number of services rendered. The model wasn’t created to look at health issues holistically and does not have the infrastructure or the right incentives to proactively identify and improve health outcomes at the community level.

“The Medicaid managed care model is instead built for health outcomes — focused on the unique needs of individuals and communities. MCOs take the time and resources to invest and address local health care needs.”
Continuing the Faulkenberry narrative: “MCOs can deploy locally based staff who visit every county and community to understand population health, and work with local organizations to identify where certain types of care or social services are needed most. MCOs can provide not only immediate value to patients but they also invest in measures, such as community support services, that can improve health outcomes over the long term.

“MCOs also invest in resources for providers. MCOs in Oklahoma will have dedicated provider support staff working alongside providers all across the state. This team will help doctors and hospitals manage the billing and claims processes, provide training and continued education opportunities, and share critical data and insights about the health of their patients. The state would not be able to hire and adequately manage this type of support team on its own.” 

Faulkenberry noted: “Administrative costs in Medicaid managed care also support the coordination efforts necessary to make Medicaid work better for everyone in Oklahoma. An effective program to improve health outcomes for the Medicaid population and ensure Oklahoma spends its health dollars wisely, requires a strong administrative function that allows for oversight and investment in key areas.
“Managed care organizations bring the technology, innovation and expertise of the private sector and will partner closely with Oklahoma to build the more modern Medicaid program we need. Oklahoma has been ranked in the bottom of health outcomes for far too long. It’s time to deliver a modern health system that is proven and is successfully advancing health outcomes in other states across the nation.”

If it’s true that even when things change, they sort of remain the same, keep in mind how we began this humble series reporting and analyzing on the governor’s plant to implement Managed Care of Medicaid Expansion.

Managed Care and Lives Saved

Both Ray Carter of the Center for Independent Journalism and this writer have pointed out – not ad nauseam, but consistently – the pragmatic side of at least seeking to slow the growth of already-surging Medicaid expenditures, where and when possible. 
But here’s the deal: Managed Care in general and the system in Florida specifically can point to good results for patients. In March, I pointed to a then-new peer-review study that found strongly positive results in combating COVID deaths for a sample of nearly 39,000 Floridians in a Managed Care program.

The analysis cited, from the American Journal of Managed Care found that Cano Health’s “population health management program reduced COVID-19 mortality by 60 percent, compared to a mirror group of Florida patients.”
That “retrospective cohort study” included 38,193 MCPs (Managed Care Patients) in the Sunshine State who were monitored, the AJMC report said, “for COVID-19 incidence, hospitalization, and mortality.” That cohort was “compared with a mirror group from the state of Florida.”

The abstract summary of reported results were striking: “The mean (SD) age among the MCPs was 67.9 (15.2) years, and 60 [percent] were female. Older age and hypertension were the most important factors in predicting COVID-19. Obesity, chronic kidney disease (CKD), and congestive heart failure (CHF) were linked to higher rates of hospitalizations. Patients prescribed off-label outpatient medications had 73 [percent] lower likelihood of hospitalization (P<.05). Compared with the mirror group, MCPs had 60 [percent] lower COVID-19 mortality (P<.05).”


A trio of reporters for Read Frontier (April 30) marched through some of the point/counter-points of the Managed Care debate. 
In the wrap-up of that “fact check” exercise, they reported, “Under federal law, OHCA as a state agency has restraints on which services it can pay for. Managed care companies, in contrast, have the flexibility to pay for a wider variety of preventive care treatments.”

Note: This is part of a continuing series of analyses on the debate over Managed Care of Medicaid Expansion in Oklahoma. Pat McGuigan is editor of The City Sentinel newspaper and founder of CapitolBeatOK.com, an online news service. 

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