For the first time since 2002, the Centers for Medicare & Medicaid Services (CMS) has proposed changes to the Medicaid regulations (Mega-Reg) that are designed to align the rules governing Medicaid managed care with other sources of coverage (e.g. Qualified Health Plans, Medicare Advantage plans and Exchanges). CMS wants high performing health plans in the Medicaid program and they want to align quality standards across Medicaid, Medicare and the Marketplace (Exchanges). The comment period ended July 27, 2015 and the final rule is expected to be published soon.
To achieve this, CMS would establish a new section that requires a quality strategy for a state’s entire Medicaid program with minimum standards that align with the Medicare and Marketplace quality rating systems. As part of the Mega-Reg, Health plans would be required to achieve accreditation and post their overall quality score. This improves transparency and gives beneficiaries the opportunity to consider quality when selecting a health plan. States would also use this data when evaluating a health plan’s performance, establishing quality improvement goals and when performing oversight of health plans.
…health plans will achieve a rating similar to the Medicare five-star rating system or the quality performance rating in the Marketplace.
The proposed quality rating system would include measurement components similar to Medicare and Marketplace programs and health plans will achieve a rating similar to the Medicare five-star rating system or the quality performance rating in the Marketplace. CMS announced the final domains and measures that will be used to beta test the quality ratings under three summary indicators: (1) Clinical Quality Management; (2) Member Experience; and (3) Plan Efficiency, Affordability and Management. Under these summary indicators is a set of eight domains and then each domain has a set of performance measures, that all together create a rating that consumers can use when deciding on a health plan.
Mega-Reg May Require Implementing or Enhancing MTM Programs
As the healthcare system moves to value-based purchasing and risk sharing with a more intense focus on quality improvement, the need for innovative solutions grows. Providers at risk are interested more than ever on how to optimize drug therapy to control overall healthcare spend. Integrating pharmacists into the chronic care management teams by ways of medication therapy management (MTM) programs will improve outcomes, drive quality improvement and improve plan efficiency. Several states already have MTM programs in place for Medicaid, but the new Medicaid quality review system could expand the number of programs or drive enhancements to existing programs.
Several states already have MTM programs in place for Medicaid, but the new Medicaid quality review system could expand the number of programs or drive enhancements to existing programs.
MTM is provided through various channels including community pharmacies, health plans, independent practitioners, PCMHs, ACOs and long-term care. The best MTM systems enforce standard data elements and are interoperable with other systems to maximize total medical management. The best MTM processes include a standardized approach to review and evaluate the data to to identify and resolve drug therapy issues.
Regardless of the MTM channel, engaging the patient or caregiver is a cornerstone in the success of the program. Successful programs include creative methods for outreach and patient commitment to participate. At the end of the day, the best drug therapy is the one that the patient adheres to. MTM programs have been successful in improving adherence, reducing inappropriate or excessive use, and in resolving drug therapy issues. All of this leads to improved clinical quality and reduction in total healthcare costs.
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Leslie Lotano-Saba has more than 30 years of pharmacy experience in senior level leadership roles with health plans, long-term care, PBMs and mail order, with a focus on government programs. She is recognized for developing practical strategies that decrease costs and increase revenue without compromising quality. In May 2015, Leslie established her own consulting firm, Saba and Associates, LLC, to apply her extensive industry knowledge and expertise toward simplifying complex pharmacy programs and improving performance.
Leslie holds a Bachelor’s of Pharmacy from Albany College of Pharmacy and a MS in Healthcare Administration from Union College and attended the Wharton School Executive Management Program for Pharmacy Leaders. She is a member of WBL, AMCP and ACHE.