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.
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.
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:
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.
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:
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.
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.
Since 1985, KEPRO has helped more than 20 million members lead healthier lives through clinical expertise, integrity and compassion. KEPRO was founded by physicians and clinical expertise is at the core of our organization.