Medicaid Monday: Medicaid Managed Care Works

Complete Coverage
By: TAHP | Tuesday, April 6, 2021

May 17, 2021

By: Jamie Dudensing

Over the past 20 years, Texas has transformed an outdated Medicaid system that provided fragmented care into a modern, patient-centered health insurance program providing more than 4 million Texans with the coverage and care they need.

How did Texas do it? We did it through managed care.

Unlike the previous fee-for-service model, managed care focuses on prevention, wellness, and care coordination. Health plans are incentivized to keep Texans on Medicaid healthy and encourage them to access preventive care and live healthier lives.

Millions of Texans, including children, pregnant moms, older Texans, and Texans with disabilities, have seen improved health outcomes, and Texas taxpayers have saved more than $5 billion since 2009. Managed care significantly reduced hospital stays for expensive chronic diseases like asthma and diabetes by 35%. It also reduced ER visits in STAR Kids by 6% in the first year of the program.

Managed care works just like your insurance. Every month, Texas pays a health care premium to the managed care plans for each person they cover. Medicaid health plans use that premium to cover medical expenses and prescription drugs, coordinate complex health care, and help Texans with Medicaid coverage lead healthy, active lives and live independently in their own homes and communities.

Managed Care and Care Coordination

Today’s Texas Medicaid is more than health care coverage—it connects Texans to the personalized care and support they need to stay healthy and live the fullest lives possible while creating efficiencies that benefit everyone.

One of the most important and unique aspects of Medicaid managed care is care coordination. Medicaid managed care gives Texans with complex medical needs access to caring health plan nurses who provide one-on-one support and walk families through the complicated health care system. These amazing nurses and care coordinators go above and beyond to ensure that the families have the care and support they need—services that go beyond the walls of a doctor’s office, including transportation arrangement, meal coordination, help navigating challenges in schools, and employment assistance.

Managed Care and Access

Like private health insurance, Texas Medicaid managed care organizations establish a network of providers. As a result, Medicaid managed care allows Texans on Medicaid to access and choose from a variety of doctors and hospitals in their area. Since the implementation of managed care Texans have seen increased access to care.

Currently, more than 80% of all Texas doctors are currently in Medicaid managed care plan networks and Texas Medicaid patients have better access to primary care than the general population. All Texas MCOs exceed state and national standards of having two primary care providers willing to take new patients for more than 90% of enrollees.

Satisfaction with care covered by Texas MCOs continues to exceed national rates. Access to urgent care, specialist appointments, and routine care in the Texas MCOs STAR Kids program also exceeds national rates.

Prior to Medicaid managed care, less than 15% of women received timely prenatal care. Today, 90% of expecting mothers in Medicaid receive timely prenatal care, resulting in healthier babies and mothers.

Managed Care and Prescriptions

Prior to prescription drugs being managed by Medicaid managed care plans, costs were out of control for Texas taxpayers. Drug costs had almost doubled from 2001 to 2011, growing more than 6.5% on average each year. As a result of Medicaid managed care, Texas Medicaid prescription drug cost growth dropped by 50% and is now three times better than the national average.

Medicaid health plans have prescription drug coverage programs in place that reduce opioid abuse and deaths, emergency room visits, and unnecessary hospitalization for kids with asthma. In fact, Medicaid managed care has reduced hospital stays for asthma and diabetes in Texas, chronic diseases that are typically expensive to treat, by more than 35% through better coordination of care and prescription drugs. One Medicaid plan in Texas successfully reduced the use of the Houston Cocktail, a dangerous and deadly mix of drugs including Viocodin, Xanen, and Soma.

Managed Care for the Future

While managed care has transformed most of Medicaid by achieving better results for clients and saving taxpayers money, there is still room for improvement. One of the best ways to improve the program is to continue to advance pay for quality programs and fully move away from a fee-for-service program by integrating additional services into managed care to ensure better coordination.

For more resources and to learn more about managed care and how it helps make Texas healthier, check out our Medicaid policy page

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