Medicaid Managed Care Organizations Research Articles

Housing support a high priority in New Jersey Medicaid waiver renewal

An approved five‐year renewal of New Jersey's Section 1115 Medicaid demonstration initiative will enhance the state's efforts to address the health‐related social needs of beneficiaries, including those with mental illness. The Medicaid waiver program will allow for coverage of housing services, such as transitional housing support for individuals experiencing homelessness, and will strengthen requirements for Medicaid managed care organizations (MCOs) to employ dedicated housing specialists and to track beneficiaries' progress toward housing stability.

Flip the Pharmacy’s impact on comprehensive medication management performance

BackgroundClinically integrated networks of community pharmacies are expanding partnerships with health care payers for sustainable provision of patient care services. The Pennsylvania Pharmacists Care Network (PPCN), a part of CPESN USA, launched its first payer program in 2017 with a Medicaid managed care organization for comprehensive medication management (CMM). Some PPCN pharmacy teams have participated in Flip the Pharmacy, a national practice transformation initiative. ObjectivesThis study aimed to determine whether pharmacy participation in Flip the Pharmacy was associated with a greater rate of CMM encounters than in nonparticipating pharmacies within a statewide clinically integrated network. MethodsThis project was a retrospective quantitative study. CMM encounter data including total number of encounters and total number of eligible members were extracted from monthly reports. Generalized estimating equations were used to assess the association between Flip the Pharmacy participation and CMM encounter rates. ResultsOf 103 pharmacies that participated in the CMM program in 2019 and 2020, 77.7% of pharmacies (n = 80) were included in analyses. Of these, 31.3% (n = 25) participated in Flip the Pharmacy. Overall, 80 pharmacies documented 8460 patient encounters through the CMM program. On average, pharmacies participating in Flip the Pharmacy recorded 1.67 times the rate of encounters compared with non-Flip the Pharmacy pharmacies (95% CI 1.10–2.54), controlling for single versus multiple pharmacy sites and weekend hours. On average, pharmacies participating in Flip the Pharmacy recorded 1.18 times the rate of initial encounters (95% CI 0.84–1.59) and 2.06 times the rate of follow-up encounters (95% CI 1.22–3.48) compared with non-Flip the Pharmacy pharmacies. ConclusionParticipation in Flip the Pharmacy in Pennsylvania was associated with greater engagement and completion of encounters within a payer program for CMM. Continued practice transformation efforts are needed to ensure the sustainability of community pharmacy practice as it continues to expand into payment for patient care services.

Advancing health equity through partnerships of state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations.

Reducing health inequities in marginalized populations, including people with Medicaid insurance, requires care transformation to address medical and social needs that is supported and incentivized by tailored payment methods. Collaboration across health care stakeholders is essential to overcome health system fragmentation and implement sustainable reform in the United States (U.S.). This paper explores how multi-stakeholder teams operationalized the Roadmap to Advance Health Equity model during early stages of their journey to (a) build cultures of equity and (b) integrate health equity into care transformation and payment reform initiatives. Advancing Health Equity: Leading Care, Payment, and Systems Transformation is a national program in the U.S. funded by the Robert Wood Johnson Foundation that brings together multi-stakeholder teams to design and implement initiatives to advance health equity. Each team consisted of representatives from state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations in seven U.S. states. Between June and September 2021, semi-structured interviews were conducted with representatives (n = 23) from all seven teams about experiences implementing the Roadmap to Advance Health Equity model with technical assistance from Advancing Health Equity. Facilitators of building cultures of equity included (1) build upon preexisting intra-organizational cultures of equity, (2) recruit and promote diverse staff and build an inclusive culture, and (3) train staff on health equity and anti-racism. Teams faced challenges building inter-organizational cultures of equity. Facilitators of identifying a health equity focus area and its root causes included (1) use data to identify a health equity focus and (2) overcome stakeholder assumptions about inequities. Facilitators of implementing care transformation and payment reform included (1) partner with Medicaid members and individual providers and (2) support and incentivize equitable care and outcomes with payment. Facilitators of sustainability planning included (1) identify evidence of improved health equity focus and (2) maintain relationships among stakeholders. Teams faced challenges determining the role of the state Medicaid agency. Multi-stakeholder teams shared practical strategies for implementing the Roadmap to Advance Health Equity that can inform future efforts to build intra- and inter-organizational cultures of equity and integrate health equity into care delivery and payment systems.

Proposed Social Drivers Of Health Bonds Offer Promising Improvements But Face Many Challenges To Implementation.

Social drivers of health (SDH) bonds have been proposed as a way of incentivizing investment in SDH interventions by Medicaid managed care organizations. The success of SDH bonds is predicated on the acceptance of shared responsibilities and resources for corporate and public-sector stakeholders. Underwritten against a Medicaid managed care organization's financial strength and promise to pay, SDH bond proceeds would support social services and investments in interventions that may mitigate social drivers that lead to poor health outcomes, which would in turn lower health care costs for low-to-moderate-income populations in communities of need. This systematic public health approach would tie together community-level benefits with the shared cost of care of participating managed care organizations. The Community Reinvestment Act model allows for innovation to meet business needs of health organizations, and cooperative competition can facilitate needed technology improvements for community-based social service organizations.

Proposing An Innovative Bond To Increase Investments In Social Drivers Of Health Interventions In Medicaid Managed Care.

Interventions to address social drivers of health (SDH), such as food insecurity, transportation, and housing, can reduce future health care costs but require up-front investment. Although Medicaid managed care organizations have incentives to reduce costs, volatile enrollment patterns and coverage changes may prevent them from realizing the full benefits of their SDH investments. This phenomenon results in the "wrong-pocket problem," in which managed care organizations underinvest in SDH interventions because they cannot capture the full benefit. We propose a financial innovation, an SDH bond, to increase investments in SDH interventions. Issued by multiple managed care organizations in a Medicaid coverage region, the bond would raise immediate funds for SDH interventions that are coordinated across the organizations and delivered to all enrollees of the region. As the benefits of SDH interventions accrue and cost savings are realized, the amount managed care organizations must pay back to bond holders adjusts according to enrollment, addressing the wrong-pocket problem.

COVID-19 and MCO-community partnerships to address enrollee social needs.

Many Medicaid managed care organizations (MCOs) now screen enrollees and connect them to community-based organizations (CBOs) to address unmet social needs. COVID-19 has significantly disrupted health care delivery and overall economic activity in the United States. We examined how partnerships between Medicaid MCOs and CBOs to address social determinants of health have been affected by the pandemic. Guided by questions and recruitment strategies developed with our stakeholder advisory board, we conducted 26 interviews with representatives from all 6 of Kentucky's Medicaid MCOs. In-depth, structured interviews for data collection and iterative content analyses to identify themes. Several themes emerged, including substantial increases in enrollees' unmet needs and the demand to find new ways to be responsive, changing funding patterns, disruptions to and evolving modes of communication, and shifting partner relationships. In virtually all areas of impact, COVID-19 has been associated with both negative and positive change. Unmet social needs associated with the pandemic placed tremendous strain on CBOs, limiting their capacity to sustain some programs and partnerships. Isolation associated with COVID-19 also had wide-ranging effects on service delivery, communication with enrollees and partners, and the ability to maintain relationships. Nonetheless, the pandemic also had some silver linings, including additional resources and flexibility for addressing unmet needs. Federal and state agencies, along with MCO leaders, should carefully evaluate what innovations have been particularly effective during the pandemic and craft new flexibilities into their policies, procedures, and regulations.

The effects of behavioral health integration in Medicaid managed care on access to mental health and primary care services-Evidence from early adopters.

To evaluate the impacts of a transition to an "integrated managed care" model, wherein Medicaid managed care organizations moved from a "carve-out" model to a "carve-in" model integrating the financing of behavioral and physical health care. Medicaid claims data from Washington State, 2014-2019, supplemented with structured interviews with key stakeholders. This mixed-methods study used difference-in-differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve-out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions. Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach. The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%-2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness. Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards "carve-in" models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care.

Community health worker team integration in Medicaid managed care: Insights from a national study.

Community health workers (CHWs) have historically worked in community-based settings. Medicaid managed care organizations (MCOs) are integrating CHWs into their teams, largely to support social determinants of health. Little is known about how teams are structured in these environments or how CHWs and their supervisors perceive CHW roles in MCOs. In 2021, two CHW professional associations and a university partnered to conduct a national cross-sectional survey of CHWs working with MCOs. A total of 146 CHWs representing 29 states and 55 supervisors working in 34 states completed the survey. Although two-thirds of supervisors said only a high school diploma or equivalent was required for hiring, over half of CHWs reported having a bachelors or graduate degree. The majority of CHWs (72.6%) and employers (80%) said CHWs receive training in core competencies. Under half of CHWs reported working with a registered nurse (RN) (45.8%) or social worker (43.8%), and about a third work with a behavioral health (36.3%) or primary care provider (33.6%). Among supervisors, 70.9% identified social workers as CHWs' team members and over half indicated CHW work with RNs (56.4%), behavioral health (54.5%) and primary care providers (52.7%). Over half of CHWs (52.1%) and roughly two thirds (63.6%) of supervisors indicated that CHWs use electronic health records. Roughly 85% of CHWs make referrals and roughly three quarters conduct social screenings. Around half of CHWs said they assist with care planning (54.1%), conduct health screenings (52.1%) or participate in case reviews (49.3%). About three quarters of CHWs (75.3%) and over two thirds of supervisors (67.3%) believed that CHWs are utilized to their full potential. Under three quarters of CHWs (72.6%) and over half of supervisors (54.4%) believe CHWs are equitably compensated for their work. Overall, CHWs roles in MCOs appear to focus on supporting clinical care and making referrals for social issues, rather than addressing community-level concerns. Health plans should ensure that CHWs have the professional freedom to develop community-based solutions to common social needs. MCOs should also ensure that CHWs receive equitable compensation and ensure that CHWs have opportunities for promotion.

Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care

Medicaid is a key policy lever to improve opioid use disorder treatment, covering approximately 40% of Americans with opioid use disorder. Although approximately 70% of Medicaid beneficiaries are enrolled in comprehensive managed care organization (MCO) plans, little is known about coverage and prior authorization (PA) policies for medications for opioid use disorder (MOUD) in these plans. To compare coverage and PA policies for buprenorphine, methadone, and injectable naltrexone across Medicaid MCO plans and fee-for-service (FFS) programs and across states. This cross-sectional study analyzed MOUD data from 266 Medicaid MCO plans and FFS programs in 38 states and the District of Columbia in 2018. For each medication, the percentages of MCO plans and FFS programs that covered the medication without PA, covered the medication with PA, and did not cover the medication were calculated, as were the percentages of MCO, FFS, and all (MCO and FFS) beneficiaries who were covered with no PA, covered with PA, and not covered. In addition, MCO plan coverage and PA policies were mapped by state. Analyses were conducted from January 1 through May 31, 2022. Coverage and PA policies were compared for MOUD in 266 MCO plans and 39 FFS programs, representing approximately 70 million Medicaid beneficiaries. Overall, FFS programs had more generous MOUD coverage than MCO plans. However, a higher percentage of FFS programs imposed PA for the 3 medications (47.0%) than did MCOs (35.9%). Furthermore, although most Medicaid beneficiaries were enrolled in a plan that covered MOUD, 53.2% of all MCO- and FFS-enrolled beneficiaries were subject to PA. Results also showed wide state variation in MCO plan coverage and PA policies for MOUD and the percentage of Medicaid beneficiaries subject to PA. This cross-sectional study found variation in MOUD coverage and PA policies across Medicaid MCO plans and FFS programs and across states. Thus, Medicaid beneficiaries' access to MOUD may be heavily influenced by their state of residency and the Medicaid plan in which they are enrolled. Left unaddressed, PA policies are likely to remain a barrier to MOUD access in the nation's Medicaid programs.

Hospital-initiated Extended-release Injectable Buprenorphine Using a Novel Reallocation Initiative From an Outpatient Addiction Medicine Clinic.

Novel strategies for initiation and continuation of buprenorphine are critical, especially during a pandemic when traditional opioid use disorder treatment pathways may be disrupted. We describe an innovative outpatient to inpatient reallocation initiative for extended-release buprenorphine (XR-BUP) designed to repurpose an expensive medication for use in hospitalized patients facing treatment barriers upon discharge and pilot the feasibility of XR-BUP use in the inpatient setting. We collaborated with our institution's inpatient pharmacy and a New Jersey Medicaid managed care organization to create an alternate pathway to make XR-BUP available to hospitalized patients insured by the same payor. In this process, XR-BUP doses were deidentified and transferred to the inpatient controlled substance inventory for administration to hospitalized patients at no charge by our Addiction Medicine Consult Service after a period of sublingual buprenorphine stabilization. Our reallocation pathway bypassed several existing XR-BUP regulatory barriers to allow for inpatient administration. To date, we have transferred approximately 85 XR-BUP 300 mg doses to the inpatient controlled substance inventory. This equates to a cost savings of nearly $145,000. Reallocation of XR-BUP from an outpatient to inpatient setting increased postdischarge buprenorphine treatment access while also reducing health care costs by repurposing an expensive medication that would otherwise go to waste. Use of reallocated XR-BUP in the inpatient setting may pave the way for addition of XR-BUP to the hospital's formulary to minimize treatment gaps after discharge.

Medicaid expansion, managed care plan composition, and enrollee experience.

To examine changes in plan composition and enrollee experience associated with Medicaid expansion among Medicaid managed care organization (MCO) enrollees. Using 2012-2018 Adult Medicaid Consumer Assessment of Healthcare Providers and Systems surveys, we estimated changes in MCO enrollee characteristics and 4 outcomes: having access to needed care, having a personal doctor, having timely access to a checkup, and having timely access to specialty care. We estimated multivariable linear probability models comparing pre- vs postexpansion changes in expansion vs nonexpansion states. The postexpansion period was modeled as an event-study regression to account for changes over time. The coefficient of interest was a Medicaid expansion-by-year term. Medicaid expansion was associated with statistically significant decreases in the proportion of female enrollees (-8.4 percentage points [PP]; P < .01) and increases in the proportion of enrollees who were aged 55 to 64 years (6.8 PP; P < .01) and were non-Hispanic White (4.4 PP; P < .01). Relative to enrollees in nonexpansion states, MCO enrollees in expansion states were significantly less likely to report access to a personal doctor (-1.6 PP; 95% CI, -3.0 to -0.1 PP) and less likely to report timely access to specialty care (-2.1 PP; 95% CI, -3.4 to -0.8 PP; P < .01) in the first year after expansion. Differences were not statistically significant by the second year post expansion. There were not significant changes in the other 2 outcomes. State policy makers may need to account for the role that Medicaid expansion may have in changing Medicaid MCO enrollee composition to prevent unfair penalization on performance metrics.

Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid.

Understanding the extent to which beneficiaries can "realize" access to reported provider networks is imperative in mental health care, where there are significant unmet needs. We compared listings of providers in network directories against provider networks empirically constructed from administrative claims among members who were ages sixty-four and younger and enrolled in Oregon's Medicaid managed care organizations between January1 and December31, 2018. "In-network" providers were those with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a given health plan. They included primary care providers, specialty mental health prescribers, and nonprescribing mental health clinicians. Overall, 58.2percent of network directory listings were "phantom" providers who did not see Medicaid patients, including 67.4percent of mental health prescribers, 59.0percent of mental health nonprescribers, and 54.0percent of primary care providers. Significant discrepancies between the providers listed in directories and those whom enrollees can access suggest that provider network monitoring and enforcement may fall short if based on directory information.

State Expectations and Medicaid Managed Care Organizations' Efforts to Address the Social Needs of Medicaid Enrollees.

Existing work on states' efforts to address the social needs of Medicaid enrollees indicate the implementation of several state-level strategies to move Medicaid Managed Care Organizations (MMCOs) toward the provision of whole-person care. However, less is known about how these expectations drive MMCOs' SDOH efforts. To address this gap, we interviewed representatives of eight MMCOs (N=28) and 12 state Medicaid offices (N=17). Participants described varying state-implemented instruments for encouraging an SDOH-focus among MMCOs, including both coercive (e.g., contractual mandates) and subtle approaches (e.g., request for proposal process and performance measurement expectations). However, regardless of states' expectations, MMCOs, driven by organizational and industry-related factors, recognized the importance of addressing SDOH as part of a holistic approach to health care. Collectively, regulatory pressures, organizational strategy, and market forces influenced MMCOs' efforts to address SDOH leading to a normalization of their role in addressing members' social needs within a medical paradigm.

COVID-19 and social determinants of health: Medicaid managed care organizations' experiences with addressing member social needs.

BackgroundThe significant adverse social and economic impact of the COVID-19 pandemic has cast broader light on the importance of addressing social determinants of health (SDOH). Medicaid Managed Care Organizations (MMCOs) have increasingly taken on a leadership role in integrating medical and social services for Medicaid members. However, the experiences of MMCOs in addressing member social needs during the pandemic has not yet been examined.AimThe purpose of this study was to describe MMCOs’ experiences with addressing the social needs of Medicaid members during the COVID-19 pandemic.MethodsThe study was a qualitative study using data from 28 semi-structured interviews with representatives from 14 MMCOs, including state-specific markets of eight national and regional managed care organizations. Data were analyzed using thematic analysis.ResultsFour themes emerged: the impact of the pandemic, SDOH response efforts, an expanding definition of SDOH, and managed care beyond COVID-19. Specifically, participants discussed the impact of the pandemic on enrollees, communities, and healthcare delivery, and detailed their evolving efforts to address member nonmedical needs during the pandemic. They reported an increased demand for social services coupled with a significant retraction of community social service resources. To address these emerging social service gaps, participants described mounting a prompt and adaptable response that was facilitated by strong existing relationships with community partners.ConclusionAmong MMCOs, the COVID-19 pandemic has emphasized the importance of addressing member social needs, and the need for broader consideration of what constitutes SDOH from a healthcare delivery standpoint.

Anticipated efficiencies, real costs: Medicaid managed care organizations and the pharmacy benefit.

The Affordable Care Act led an additional 15 states to begin contracting with comprehensive, risk-based managed care organizations (MCOs) to administer pharmacy benefits for Medicaid beneficiaries between 2010 and 2017. Reasons for this shift included concerns about administering complex benefits for an influx of new beneficiaries, assumptions about the cost-saving potential of privately run managed care, and a desire for budget predictability. As drug prices increased during the past decade, the way that state pharmacy benefits were administered via MCOs affected the ability of states to meet the needs of their Medicaid beneficiaries. Here, we review the advantages and limitations of 2 strategies that give states more centralized control over management of the pharmacy benefit: excluding the pharmacy benefit from MCO contracts and aligning preferred drug lists across beneficiary types. We propose that centralizing utilization management tools, aligning incentives for managed care payers with the needs of patients and Medicaid programs, and the ability to implement formulary exclusions may enable states to achieve savings and better meet the needs of beneficiaries. DISCLOSURES: No funding supported the writing of this Viewpoints article. Kesselheim is supported by grants from Arnold Ventures. Bendicksen has nothing to disclose.

Assessment of Handicapping Labio-Lingual Deviation index scoring methods and their effect on orthodontic treatment coverage by Medicaid.

The purpose of this study was to assess the validity and reliability of Handicapping Labio-Lingual Deviation index (HLDI) scoring methods as calculated by digital models (DM) and visual inspection (VI) and their agreement to either meet or fail to meet the Medicaid coverage threshold. An additional objective was to assess the agreement with Medicaid managed care organizations (MCO) coverage decisions. The study included the orthodontic records of 401 patients who applied for Medicaid coverage. Two methods were used to calculate HLDI scores: (1) Measurements derived from DMs using OrthoCAD software; and (2) VI of intraoral photographs. The levels of agreement between the two methods and the Medicaid coverage decision by a MCO were evaluated. The study results show a high level of agreement between the two HLDI calculation methods, DM and VI evaluation methods(Cramer's V=0.812). The agreement on coverage decisions (eligible/not eligible) between VI methods and the official MCO decision was Cramer's V=0.318. The agreement on coverage decisions between the DM method and the official MCO decision was Cramer's V=0.318. MCO assessment results of the patients using HLDI showed low agreement with the results obtained by DM and VI scoring methods used in this study. The Illinois Medicaid system is apparently using unknown factors other than the HLDI score when determining when approving or disapproving orthodontic coverage. MCO decisions on eligibility for orthodontic treatment coverage were not consistent with patients' treatment needs.

Cost and Utilization Impacts of a Medicaid Managed Care Organization's Behavioral Health Wraparound Program.

Wraparound programs that provide comprehensive evidence-based outpatient treatment, transportation, social services, and housing supports have shown promise for improving clinical behavioral health-related outcomes to reduce the need for institutionalized care; however, the majority of evidence is based on wraparound programs for children. This study examined the impact of a wraparound program for adult Medicaid managed care organization members with serious mental health or substance use disorders on health care costs and utilization. This retrospective observational study used 2013-2018 claims data collected from a large Medicaid managed care organization operating in multiple states. We used an intention-to-treat difference-in-difference study design to examine the association of the wraparound with costs and utilization. Adult Medicaid members with an emergency department (ED) or inpatient visit for a behavioral health condition (index visit) were eligible for the study. Outcomes included all-cause and behavioral health-related costs and utilization during follow-up after the index visit's admission date. Outcomes were calculated overall, as well as separately by inpatient, ED, and outpatient/wraparound settings. We found that during the first post-admission month, the wraparound program was associated with 27.6 percentage points (PP) and 27.2 PP reductions in the number of behavioral health-related inpatient nights and costs, respectively. However, during subsequent months (median follow-up ranging from 7 to 10months) there were no associations with per-member-per-month total all-cause or behavioral health-related costs. Nonetheless, the wraparound program was associated with 12.3 PP reduction in all-cause cost during the entire study period among a subset of members who were high cost at the baseline. Reduced hospital utilization and costs during the first month of wraparound services were fully counteracted by outpatient, housing, and other wraparound services costs during the following months. This indicates the importance of proper payment arrangements with value-based contracting or performance targets with wraparound services providers to align the objective of reducing inpatient use. Future wraparound programs may consider a more focused recruitment from high-cost members with complex care needs. However, our estimates were conservative given that it's from a single Medicaid managed care organization's perspective and some benefit from investing in addressing social needs may be realized in longer term (beyond our study period). States' Medicaid programs may consider the longer-term cost and broader, societal benefit of wraparound investment.

Mental health service utilization review patterns in a Medicaid managed care program.

The current study investigated mental health utilization review (UR) clinical service authorization requests, denials, and reasons for denial in a statewide Medicaid managed care organization (MMCO) program. Retrospective analysis of utilization review data reported by MMCOs in New York State. Data from the utilization review practices of 15 MMCOs were collected and analyzed for calendar years 2017 and 2018. The data reported are specific to mental health services and include the number of authorization requests, number of clinical denials, and the reasons specified for each denial. Analyses were undertaken to determine the UR denial rates and most common reasons for denials. A total of 264,901 requests for inpatient mental health service authorizations and 53,687 requests for outpatient mental health service authorizations were made in 2017 and 2018. Of these, 1.5% of inpatient authorization requests and 0.4% of outpatient authorization requests were denied for reasons related to medical necessity. The most common reason for inpatient mental health service denials was that the patient no longer met the standard for the requested level of care. Low UR denial rates warrant further examination of the relationship between UR and both quality of care and patient outcomes in mental health care. With the substantial resources spent on UR, findings could point to areas of potential reforms to the system that may minimize these costs and improve care for patients with mental illness.

Navigating the Intersection of PrEP and Medicaid.

The proposed national PrEP program would serve people who are uninsured as well as those enrolled in Medicaid. In this article, the authors propose a set of recommendations for the proposed program's implementers as well as state Medicaid agencies and Medicaid managed care organizations to ensure PrEP access for people enrolled in Medicaid, addressing gaps without undermining the important role of the Medicaid program in covering and promoting PrEP.

The implementation of opioid prescribing report cards in Medicaid managed care: a community quality collaborative

Philadelphia, Pennsylvania, is an urban epicenter of the opioid epidemic, and inappropriate opioid prescribing remains a top concern. To help address this issue, the Philadelphia Medicaid Opioid Prescribing Initiative, a type of community quality collaborative, mailed thousands of local Medicaid providers an individualized prescribing report card in 2017 and 2018. The report card featured details of providers' opioid prescribing, including peer comparison measures and inappropriate prescribing measures like concomitant opioid and benzodiazepine prescribing. This case study describes the unique process of developing and distributing the opioid prescribing report cards, with a particular focus on the role of Medicaid managed care organizations. Using Medicaid pharmacy claims, the extensive variation in prescribing measures within and across specialties is also illustrated. The report card's implementation points to the potential value of collaborations between public health departments and Medicaid managed care organizations and can provide insight for other locally grown policies.