How Medicaid Managed Care Health Plans Can Align with Ohio’s Next Generation Managed Care Program

The new Next Generation Medicaid Program in Ohio looks to close health equity and care gaps, like transportation, with an elevated focus on the individual and not the business of managed care. Learn more about the needed shift in Ohio.

Providing health coverage to more than 3 million people in Ohio, the Ohio Department of Medicaid (ODM) has recently redesigned its state healthcare program. Initiated as a waiver in 1978, the Ohio managed care Medicaid program historically operated under a business-oriented model that was established to improve access, quality, and continuity of care while reducing Medicaid spending. After finding that more than 90% of all the state’s Medicaid beneficiaries are in managed care arrangements, the department knew it was time to change its approach.

Using a population health model, Ohio launched the Next Generation Program in February 2023, marking the first significant structural change of the state’s Medicaid program since 2005. Grounded in population health’s wellness and prevention-based framework, the Next Generation program is, “focused on the individual, not the business of managed care.”

Removing Barriers to Care Using Population Health Models

Health plans that follow a population health model are steadily increasing in popularity across the United States, in large part because of the 2016 Medicare Access and CHIP Reauthorization Act (MACRA) which supports a transition from a fee-for-service reimbursement model to a value-based system. Population health and value-based care models shift the paradigm from volume of services provided to quality and value of care.

This makes the population health model—which is focused on illness or disease prevention to improve health outcomes and healthcare lower costs—well suited to eliminate healthcare disparities and address the individual, not the business. To effectively target pertinent barriers to care, the framework relies heavily on population data and effective analysis for trends in a population’s health, quality, and care costs. Additionally, this data needs to be shared and exchanged between state agencies like ODM, clinicians, health plans, and other partners.

Once at-risk member subgroups are identified, intervention services and preventative plans can be developed specific to the unique care barriers or social determinants of health (SDoH). Health plans can leverage a similar process and incorporate preventative plans into Medicaid benefit packages.

Introducing the Next Generation Medicaid Program

The Next Generation Program was developed to improve healthcare quality and Medicaid program outcomes across Ohio. The program was constructed using statewide survey findings with over 1,000 unique insights from residents, providers, advocates, and associations. The program is founded in and outlined by five core goals and is designed to leverage best practices in the context of family and community in multiple domains.

- Improve wellness and health outcomes

- Emphasize a personalized care experience

- Support providers in better patient care

- Improve care for children and adults with complex needs

- Increase program transparency and accountability

For more on the five goals of the Next Generation Medicaid Program:

The program strives to bridge the gap in healthcare in underserved communities by aligning benefit packages and enhanced services with identified SDoH and care obstacles. Enhanced services are often preventative in nature which can empower members to overcome barriers to care. Using a population health model that’s focused on disease prevention, the Next Generation program seeks out the root cause of healthcare issues at the beginning. The intended result: reduced healthcare costs, improved care quality, and increased member engagement.

Opportunities to Reduce Inequities and Improve Health

Why is data so important to the Next Generation Program? Frequently, updated data identifies which barriers to care are high-acuity and acts as a benchmark to measure the progress of proactive efforts. Certain data shows areas that Ohio can improve.

According to the 2023 Health Value Dashboard report, poor air quality, food insecurity, and transportation accessibility were identified as SDoH affecting Ohioans. When looking at the wider spectrum of SDoH needs, managed care plans should look to align their benefit packages with areas that have a high impact on health outcomes. For example, Ohio was nationally ranked 50th for toxic pollutants, 41st for outdoor air quality, and 47th for children in smoking households, and 40th for food insecurity. Medicaid benefits should equip high-risk populations with services that address harmful environmental conditions such as extending respiratory care and free meal delivery.

Furthermore, transportation accessibility can close gaps in inequities and improve health value in the state, which is calculated as a composite measure of population health outcomes and healthcare spending. Within Ohio’s Health Value Dashboard rankings, there are outcomes that don’t appear to be transportation-related; but in reality, access to reliable transportation plays an active part in beneficiaries receiving preventative care. When looking at preventative outcomes that could be directly benefitted by transportation, Ohio ranked 41 or lower in:

- Colon and rectal cancer early-stage diagnosis

- Heart failure admissions (among Ohio Medicare beneficiaries)

- Potentially avoidable emergency department visits

- Primary care physicians

Transportation is not only a way to get from ‘here to there’ – it’s a vehicle for maintaining good health. Often, members getting to their doctor appointments and picking up prescriptions at the pharmacy are considered routine aspects of a healthcare journey. Without reliable transportation to their preventative care appointments, health outcomes can get worse.

On a national scale, barriers to NEMT are highly prevalent, resulting in 25%-50% of missed medical appointments and causing over three million individuals to forego or delay medical care annually. Meanwhile, NEMT is an indispensable benefit that can drive meaningful change in achieving health equity and reduce costs. As of 2022, non-emergency medical transportation (NEMT) benefits resulted in a positive return on investment of over $40 million monthly per 30,000 Medicaid beneficiaries.

Individualization: The Key to Health Equity

Many will be watching ODM’s Next Generation Managed Care Program and how the model can make progress on Medicaid’s overall population health and health value metrics. Adopting the population health model into Medicaid programs and addressing SDoH, like transportation, is critical for achieving improved health outcomes—and the equitable distribution of those health outcomes—to vulnerable populations. The journey to reaching care equity is an uphill battle, but supporting individualized healthcare models and member services is ultimately what moves the needle in delivering high-quality care.

At SafeRide, we know that every person is unique in their healthcare journey and that it’s important to individualize managed care benefits and resources. We are proud to have designed a platform that addresses the individual by incorporating member-centric design principles every step of the way. State Medicaid programs like Ohio’s Next Generation Program are a step in the right direction to lead with more person-centered efforts designed to eliminate disparities in healthcare access and outcomes. SafeRide shares the same vision: an equitable healthcare system that’s without roadblocks so anyone, anywhere has access to care.

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