CMS Proposed Rule Aims to Modernize Managed Care for Medicaid and CHIP and Improve Quality

On May 26, 2015, the Centers for Medicare and Medicaid Services (CMS) announced a proposed rule intended to modernize Medicaid and Children’s Health Insurance Program (CHIP) managed care regulations — the first major update in more than a decade — and enhance the quality of care delivered to beneficiaries.

According to a CMS alert, the rule would improve beneficiary communications and access, provide new program integrity tools, support state efforts to deliver higher quality, cost-effective care, and better align Medicaid and CHIP managed care rules and practices with other sources of health insurance coverage.

CMS proposes to modernize Medicaid managed care regulations by:

  • Supporting states’ efforts to encourage delivery system reform initiatives within managed care programs that aim to improve health care outcomes and beneficiary experience while controlling costs
  • Strengthening the quality of care provided to beneficiaries by strengthening transparency and measurement, establishing a quality rating system, and broadening state quality strategies and consumer and stakeholder engagement
  • Improving consumer experience in the areas of enrollment, communications, care coordination, and the availability and accessibility of covered services;
  • Implementing best practices identified in existing managed long term services and supports programs
  • Aligning Medicaid managed care policies to a much greater extent with those of Medicare Advantage and the private market
  • Strengthening the fiscal and programmatic integrity of Medicaid managed care programs and rate setting
  • Aligning the CHIP managed care regulations with many of the proposed revisions to the Medicaid managed care rules strengthen quality and access in CHIP managed care programs.

The deadline to submit comments is July 27.

This is another example of the federal government moving toward value-based care. Earlier this year, the U.S. Department of Health and Human Services announced goals and a timeline to shift Medicare reimbursement toward paying providers based on quality of the care they give their patients, rather than quantity.

Many physicians — regardless of practice type, setting, specialty, or geographic location — are filled with uncertainty with a multitude of changes to the health care delivery system. It will take investments of your time, energy, money, and the learning of new skills sets to be successful in value-based delivery.

How can you get prepared and make sure you’re ahead of the curve in the volume to value transition?

Through a series of six online, on-demand courses and live workshops, the Pennsylvania Medical Society (PAMED) is offering CME to ensure Pennsylvania physicians and their health care teams have the skills necessary to succeed in the transition to value-based delivery systems. Learn more about this series and register.

This series is facilitated by PAMED member Ray Fabius, MD, a nationally renowned expert in quality and population health.

What launched Dr. Fabius into action in his own practice?

“During my days as a practicing pediatrician in Philadelphia, I was shocked when a medical director from a health plan came to my office and was able to tell me more about my practice than I knew,” said Dr. Fabius. “He had information that compared my performance on quality and on utilization, and even information regarding my patient satisfaction. I never again wanted to have someone else know more about my practice than I did.”

Hear more from Dr. Fabius.