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The right model for Oklahoma

A Look At The Numbers provides information on how managed care organizations (MCOs) will partner with Oklahoma to provide care for a growing Medicaid population.

Medicaid managed care enables Oklahoma to deliver higher quality care and improved health outcomes for Medicaid recipients, while managing healthcare costs.

The care people need, when they need it. That is the model of managed care.

Medicaid in Oklahoma

Oklahoma’s Medicaid program, SoonerCare, provides healthcare to many individuals facing economic and social barriers to help improve their health and well-being.

893,000

Oklahomans currently enrolled in SoonerCare1

This number is expected to grow by as much as 250,000 people with SoonerCare’s expansion, including nearly 50,000 who have lost coverage as a result of unemployment over the past year.2

Higher quality care

Improving population health

The managed care model is based on the delivery of quality care that provides services that are medically necessary for people when they need them. MCOs empower members to engage with their own healthcare, providing education around and support for preventive services. This engagement with preventive services is particularly critical in Oklahoma.

See how OK stats compare to national medians.

In Oklahoma, an estimated 43% of drug overdose deaths in 2018 involved opioids.3 MCOs can play a central role in driving positive health outcomes across states, in particular, helping address the opioid epidemic by working with providers around prescribing practices and instituting checks to curb the abuse of opioids among Medicaid enrollees. MCOs also integrate behavioral and physical health considerations to better monitor all aspects of patients’ health.

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21%

of deliveries in Oklahoma included timely postpartum care, compared to the national median of 61%4

The right partnership for Oklahoma

SoonerCare can be at its best in partnership with MCOs, which can provide budget predictability and help Oklahoma deliver healthcare in new ways.

Standards of care

How MCOs are held accountable

Unlike the fee-for-service approach, the managed care model is measured against specific quality standards by federal and state governments. MCOs are accredited and regularly reviewed using up to 69 quality measures by the National Committee on Quality Assurance (NCQA) as well as by state agencies.

Performance measures set by states ensure that MCOs deliver consistent, high-quality care that is aligned with state strategies to improve population health, while also providing competition and choice for recipients.

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69

quality measures that MCOs are accountable for annually5

Managing costs and risks

Delivering transparency and predictability

Oklahoma needs a way to plan and manage its budget, while ensuring that a growing number of Medicaid recipients get the quality healthcare they deserve.

The managed care model delivered nationwide Medicaid savings of $7.1 billion in 2016.6 Had remaining fee-for-service expenditures nationwide been transitioned to the managed care model during 2017, an additional $5 billion would have been saved.6

Preventing fraud, waste, and abuse in Medicaid is a top priority, and managed care organizations have shown they can help. In 2019, the managed care model had a national Medicaid improper payment rate of 0.12%, compared to the fee for service model rate of 16.3%.7 With states facing unprecedented care and economic pressures in the midst of a pandemic, the managed care model delivers critically needed stability to millions and strengthens our country’s Medicaid health safety net.

With managed care, states pay a fixed, per-member, per-month rate, which allows them to budget with transparency and predictability. In the event that costs of care exceed the agreed funding amount, MCOs assume full financial responsibility for any overages. This structure incentivizes MCOs to improve population health—through care coordination, preventive services and other measures—which keeps the focus on the quality and value of care. This approach is particularly vital in Oklahoma, which ranks 49th among states in avoidable hospital use and cost.8

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$7.1B

in nationwide Medicaid savings in 20166

Provider experience

Helping states help providers

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Through Medicaid managed care, providers benefit as well. MCOs use value-based payment models that incentivize, empower, and reward providers for the quality of care.

MCOs also help maintain strong provider networks and offer clinical support, continuing education, and technological innovations that enable providers, especially rural providers, to deliver higher quality care.

Due to the flexibility of the managed care approach, MCOs can provide relief payments to support providers in times of crisis. During COVID-19, MCOs are providing advanced payments to providers (separate from the CMS payment program) and advocating for additional federal action that can ensure critical support to providers during this pandemic.9

Patient experience

Partnerships to address social determinants

By coordinating care, managed care organizations can help treat the whole person, serving as the glue that binds community resources with a unified health strategy, integrating physical and mental health services.

MCOs’ social determinants initiatives are widespread and address numerous aspects of health, with 77% of MCOs reporting housing activities, 73% reporting nutrition activities, and 51% reporting education activities that aid the Medicaid population.10

The managed care model, unlike the fee-for-service approach, is built to bring together disparate parts of the delivery system. MCOs are incentivized to partner with community groups to address social determinants of health, which can have a significant impact on the health of Oklahomans.

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73%

of MCOs reporting nutrition activities 10