Elevance Health’s report indicates Medicaid managed care, administering health plans’ pharmacy benefits, yields superior outcomes. Menges Group’s analysis, using NCQA’s data from 2014-2022, compares 29 pharmacy-related HEDIS measures. Carve-in models outperform carve-outs by 65%, rising to 68% in regional assessments. Notably, 33 out of 34 comparisons favor carve-in settings. Findings stress the carve-in approach’s advantages in enhancing pharmacy-related quality outcomes, urging policymakers to consider this evidence.
The report by Elevance Health unveils the impact of Medicaid managed care organizations on pharmacy-related outcomes. Using comprehensive data analysis spanning eight years, The Menges Group evaluates the efficacy of carve-in and carve-out models. This research delves into 29 HEDIS measures, showcasing the dominance of carve-in models across behavioral and physical health aspects. These findings underscore the significance of managed care in achieving superior quality outcomes in pharmacy management, signifying a pivotal shift towards value-based healthcare models.
In a recent report by Elevance Health, it was revealed that states employing Medicaid managed care organizations to administer health plans’ pharmacy benefits exhibited superior pharmacy-related quality outcomes compared to those without such arrangements.
The investigation, conducted by The Menges Group, a prominent healthcare consulting organization, harnessed the National Committee for Quality Assurance (NCQA) Quality Compass data set spanning from 2014 to 2022. They analyzed the Healthcare Effectiveness Data and Information Set (HEDIS) data to scrutinize Medicaid managed care organization pharmacy-related quality outcomes.
A comparative analysis encompassing 29 pharmacy-related HEDIS measures was carried out between health plans in states where managed care organizations managed the pharmacy benefit (carve-in model) and those where managed care organizations were not responsible for this aspect (carve-out model).
Delving deeper into the findings, the study revealed that managed care organizations operating under the carve-in model showcased superior HEDIS scores in 65 percent of the quality performance evaluations when compared to those in carve-out states. This trend persisted even after eliminating age-related measures, remaining consistent at 65 percent.
Of the 29 HEDIS measures analyzed, 12 were focused on behavioral health, while 17 pertained to physical health. Impressively, the carve-in setting demonstrated enhanced performance in 67 percent of comparisons for behavioral health measures and nearly 63 percent for physical health measures. These results remained robust even after excluding age-related measures.
To mitigate regional disparities, researchers compared HEDIS scores in carve-out states with collective scores across managed care organizations in adjacent carve-in states. Across three regional analyses, the carve-in setting displayed a superior average HEDIS score in 68 percent of comparisons.
The comprehensive report encapsulated 34 sets of findings encompassing various comparative analyses. Astonishingly, in 33 out of 34 comparisons, managed care organizations operating under the pharmacy carve-in model consistently demonstrated higher HEDIS scores compared to their carve-out counterparts.
Researchers emphasized the conclusive nature of these findings, stating, “The pharmacy carve-in setting has yielded better performance than the carve-out setting across pharmacy-related quality measures where differences in prescription drug management can reasonably be expected to influence outcomes.” They urged policymakers to consider this evidence when deliberating on programmatic choices.
Medicaid managed care organizations function as an alternative to the traditional fee-for-service payment model. In this approach, states pay fixed monthly fees to managed care plans for each enrolled individual, granting beneficiaries access to the provider networks offered by these organizations.
Assessment of managed care organizations hinges on quality metrics and patient outcomes, aligning with the broader push towards value-based care. These organizations incentivize high-quality care, and the report’s findings affirm the potential of this model in fostering better outcomes, especially concerning the integration of pharmacy benefits.
Overall, Elevance Health’s report affirms that Medicaid managed care organizations effectively elevate pharmacy-related quality outcomes. The Menges Group’s extensive analysis unequivocally demonstrates the supremacy of the carve-in model over carve-outs, with consistent superior performance across measures. These compelling findings advocate for policymakers to consider the carve-in approach when shaping healthcare policies. The report signifies the pivotal role of managed care in advancing quality outcomes and calls for embracing this paradigm shift towards enhancing value-based care in healthcare delivery.
