May 19, 2020

Three Trends in Medicaid Utilization Management

When it comes to Medicaid utilization management, as with so many aspects of healthcare, it’s important to balance quality of care with long-term savings. Ideally, you want to align the right patients with the right care at the right time. Here are three trends in Medicaid utilization management which are helping states achieve that goal.

1. Medication assisted treatment

Medication assisted treatment (MAT) ensures that medication therapies — particularly those with high risk for abuse like opioids — are accompanied by behavioral therapy. These comprehensive programs treat the entire illness by supporting the physical and behavioral health of patients.

In the long run, MAT helps states save money by increasing treatment adherence and avoiding the ongoing expenses of addiction treatment. For example, without MAT, someone might take a two-week prescription of opioids, miss their refill, and experience life threatening symptoms of withdrawal.

With MAT, the patient would’ve had the support they needed to ensure they followed their treatment plan, avoiding the ongoing expense of addiction and improving their quality of life.

Given that the overall Medicaid spend on outpatient drugs is projected to increase faster than most other Medicaid services in the next 10 years, MAT is one of the key trends that can help states keep these costs under control.

2. Value-based care

With value-based care, the responsibility to control patient costs has been shifted to providers. Essentially, providers are incentivized to improve patient care while lowering costs.

In order to determine their metrics, providers have started collecting more patient data, helping them spot utilization trends such as:

  • Multiple visits to the same provider for a diagnosis that hasn’t changed
  • High or low cumulative number of services, prescriptions and admissions a patient has accessed
  • Patients accessing care from multiple providers for the same ailment

With this data, providers can determine which patients are at high risk for non-adherence or over/under utilizing services. By identifying these patients, healthcare networks can implement care strategies that not only reduce Medicaid spending, but also improve the quality of care that patients receive.

3. Holistic care

The trend of holistic care was born out of the observation that poor social determinants of health have often led to low adherence to treatment plans. Some of the key social determinants of health that influence Medicaid utilization management include:

  • Access to resources that are needed to meet daily needs, such as safe housing, food, etc.
  • Access to reliable transportation
  • Access to basic safety and social support resources

Without these resources, patients are much less likely to adhere to prescribed treatment plans, increasing Medicaid utilization over time. Assessments for social determinants of health can better identify these patients, and providers can work with them to enroll with a care coordinator or care management program.

This sort of wraparound care improves the wellbeing of the patient in multiple areas of their life, paying dividends in quality of life as well as Medicaid cost reduction.

Improving quality of care while reducing Medicaid spend

The key to Medicaid utilization management is ensuring that patients have the support and services they need to receive the highest quality care at the lowest cost.

By implementing medication assisted treatment, value-based care and holistic care, healthcare networks will be better equipped to increase treatment adherence and reduce the likelihood of over-utilization.

As healthcare becomes more data-driven, healthcare networks and providers need to track, analyze, and report on more data than ever before. Better Medicaid utilization management is just one reason why.

To learn more about Utilization Management, please visit here.

U3GM Blog Post Comments

Related Content

| May 19, 2020

Three Strategies to Improve Long-Term Services and Support Quality

More than 12 million individuals currently use Medicaid long-term services and support programs (LTSS). That number is only expected to increase as America’s aging... Read More
| June 4, 2020

The Evolution of Healthcare: 340B Drug Pricing and Medicaid

Since its inception in 1992, the 340B Drug Pricing Program has vastly altered the pharmacy management landscape within Medicaid agencies across the United States. The... Read More

Subscribe to email updates