Policy Analysis Paper Module 6 Assignment

Policy Analysis Paper

This assignment is a policy analysis of local, state, or federal health policy.

1. Select a state health policy reform innovation
2. Discuss the rationale for the policy, how it was adopted (e.g., federal waivers, passage by
   state legislature), the funding structure, and (to the extent statistical data are available) its
   impact. ethical outcome based on evidence.
3. Examples of state innovations include Maryland’s hospital rate setting, Vermont’s single payer system, and Massachusetts’ health reforms

Policy Analysis Submission Requirements:
The policy analysis paper is to be clear and concise and students will lose points for improper grammar, punctuation and misspelling.
The paper is to be formatted per current APA style, 5-7 pages in length, excluding the title,
abstract and references page.
Incorporate a minimum of 5 current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.
Journal articles and books should be referenced according to current APA style.
Complete and submit the assignment by 11:59 PM ET Sunday.

SAMPLE POLICY ANALYSIS PAPER

Statewide Medicaid Managed Care Program

Among the latest health policy reform innovations in Florida is the implementation of the SMMC, or the Statewide Medicaid Managed Care Program. This program was started to enhance care coordination and care quality for Medicaid beneficiaries and control costs (Symum & Zayas-Castro, 2021). One of the key elements of the program is managed care organizations (MCOs). Medicaid beneficiaries through the SMMC program are enrolled in managed care plans, which are managed by different private insurance companies. Such MCOs are designated to organize and manage service delivery to those in their care. The other aspect is joint care (Chen et al., 2023). One of the goals of the SMMC program is to enhance the cooperation of healthcare providers and guarantee that beneficiaries get the appropriate services. MCOs are charged with handling referrals and transfers of care from one healthcare setting to another or between specialists (Chen et al., 2023).

The last element is prevention and wellness. The program is designed to reduce the occurrence of illness and the need for costly medical services through preventive care and wellness. MCOs may offer incentives to their beneficiaries in order to help them engage in preventive services involving screening and immunization. The other component is the provider network. MCOs establish their provider network, which consists of primary care doctors, specialists, hospitals, and other healthcare providers (Chen et al., 2023). The beneficiaries are typically advised to make use of the services offered by their MCO within the network of their MCO for effective care management and continuity. The next component is to add quality measures and performance indicators.

The SMMC program imparts quality measures and performance metrics that are used to monitor the quality of care provided by MCOs. These actions could be measured by patient satisfaction surveys, clinical outcome measures, and adherence to evidence-based approaches. Additionally, cost-cutting is also a significant issue (Symum & Zayas-Castro, 2021). By using Medicaid-managed care plans, SMMC’s objective in this way is to control cost growth while preserving or even improving the quality of care. MCOs obtain financial incentives when the care provided is economical and the resources are administered in a manner that is highly efficient.

Rationale for the Program

SMMC’s rationale lies in its ability to combine various advantages that overcome the challenges of the Medicaid system but also lead to better quality and productivity of healthcare delivery. First, SMMC targets the increasing fiscal burden on the state’s Medicaid program (Franco Montoya et al., 2020). Similarly, in many states, Florida struggles with rising healthcare costs due to the influences of population growth, escalating medical expenses, and the prevalence of chronic diseases. The state aims to control Medicaid costs through the transition of beneficiaries to managed care plans, which include mechanisms such as capitated payments to MCOs and the implementation of cost containment measures (Park, 2021). This replacement of the fee-for-service system by managed care systems helps the sustainability of the Medicaid program by making the budget predictable and cost management effective.

Additionally, the SMMC plan is based on the necessity of providing security of care and quality to Medicaid recipients. In the past, Florida’s Medicaid delivery has been a fragmented process, thus leading to inefficiencies, impaired care transitions, and disparities in healthcare outcomes (Park, 2021). Through the managed care plans, the program assigns beneficiaries to MCOs that are responsible for managing all healthcare services provided to the enrollees. The integrated approach seeks to simplify service delivery, limit superfluous services, and support the continuation of care for people with multiple medical conditions.

Furthermore, the SMMC program places considerable emphasis on prevention and wellness, which is closely linked to the transition to value-based care and population health management (Park, 2021). The objective of the policy is to encourage MCOs to invest in preventive services, health promotion initiatives, and chronic disease management programs so that costly acute interventions will be mitigated while the long-term health of Medicaid beneficiaries will be improved (Franco Montoya et al., 2020).

Its Adoption

The SMMC program in Florida meant several procedures, such as passing state legislation and getting federal waivers allowing managed care changes within the Medicaid program. The initial step towards the policy’s adoption is legislative action. The first step towards the implementation of the SMMC program included legislation by the Florida Legislature. In 2011, the Medicaid Reform Bill (House Bill 7107) was passed by the Legislature (FLSenate.gov, n.d.). This law established the statutory framework for the transition from the statewide Medicaid program to the managed care system. It commissioned the AHCA to bring about the changes in managed care and also supervise the procurement of managed care plans that would serve Medicaid beneficiaries (FLSenate.gov, n.d.).

The second was federal waivers. Alongside the state-level legislation, applying the SMMC program required the approval of the federal government in the form of waivers from the Centers for Medicare and Medicaid Services (CMS). Florida was granted these waivers so that it could reform its Medicaid program through managed care and, at the same time, deviate from certain federally mandated requirements (Frimpong et al., 2021). Florida in particular obtained mandatory managed care statewide waivers under Section 1915(b) and demonstration projects under Section 1115 of the Social Security Act to test innovative ways of providing and financing Medicaid services.

The fourth step is the procurement stage. After getting the required legislative and waiver approvals, the AHCA kicked off the procurement process to select managed care organizations (MCOs) to take part in the SMMC program. This procedure included providing RFPs to the interested, qualified MCOs to submit their proposals for being able to serve Medicaid beneficiaries in Florida. MCOs were rated based on criteria such as sufficiency of provider network, quality of care, financial stability, and experience working with the Medicaid population. Implementation and enrollment are the last steps of the procedure (Frimpong et al., 2021).

Following the conclusion of the procurement process, AHCA commenced with the phase’s implementation of the SMMC program, where individuals were progressively transitioned into the managed care plans based on geographical areas. Beneficiaries were provided information regarding their options and were encouraged to choose a plan that would fit their healthcare needs. The people who didn’t choose a plan were automatically assigned to one by the AHCA.

The Funding Structures

The funding for Florida’s SMMC program is mainly through federal and state contributions. These contributions are channeled toward capitation payments to MCOs in charge of managing healthcare services for Medicaid recipients. While the SMMC program is run by the federal government, the majority of the funding is provided through Medicaid matching funds, as outlined in the Medicaid State Plan (Frimpong et al., 2021). These funds are allocated to Florida according to a federal matching rate that is determined by the FMAP (Federal Medical Assistance Percentage), which is computed annually and differs from state to state. The feds reimburse state governments for the portion of Medicaid spending they incur, including payments to MCOs for the services they provide to Medicaid enrollees.

On the state level, Florida generates its proportion of Medicaid financing to cover the SMMC program. The funding for this program may come from general revenue, dedicated healthcare taxes, and other sources specific to the state (FLSenate.gov, n.d.). The state’s financial participation is vital for covering those expenses in Medicaid that are not paid for by federal matching funds and for the future of the program. The funding model follows a capitated payment method in which MCOs are paid a fixed amount per month on the basis of who is enrolled in the plan and not for the services that are actually used (FLSenate.gov, n.d.). These capitation payments are set up to promote cost efficiency among MCOs while providing excellent healthcare services to the enrollees. Further, the SMMC program can have performance-based incentives and quality withholding payments to make MCOs meet the required performance and quality measures.

Its Impact

Florida’s SMMC has displayed impressive results since its startup. The statistics demonstrate the increased care coordination and the transition to preventive services for the Medicaid beneficiaries. Managed care systems have improved management of chronic conditions and shared interventions, thus contributing to better care outcomes. In addition to cost-containment, SMMC has demonstrated effectiveness through capitated payments to MCOs and clause utilization management strategies (Chen et al., 2023). Nevertheless, inequities are still a concern, such as inequalities in healthcare services between groups that are underprivileged and in remote areas.

There are some providers who have raised concerns about low reimbursement rates, as it may limit their involvement and, as a result, diminish the accessibility of services for beneficiaries. Apart from that, administrative difficulties resulting from program necessity have been reported by both providers and MCO as well, which may adversely affect care delivery efficiency. SMMC has made notable accomplishments; therefore, appraisal and adjustment have to be carried out to resolve these issues and improve the impact on healthcare delivery and outcomes for Medicaid beneficiaries throughout Florida (Chen et al., 2023).

Ethical Outcomes

The ethical aspects of SMMC are varied and complicated. On the other hand, the purpose of the program is to help Medicaid beneficiaries get access to health care services and get necessary care in accordance with beneficence and justice principles. Through its preemptive and coordinated care, SMMC aims to improve the well-being of the vulnerable and address health inequalities (Chen et al., 2023). Besides, the ethical questions are related to the issue of a balance between the effects of cost-saving measures and the quality of healthcare service delivery. The present-day contractual arrangement known as capitated payment to the MCOs often results in cost-saving measures. They can cause a loss of quality patient care or reduced service availability.

The ethics of financial considerations are challenged by the question of whether such considerations should take a higher priority over patient needs (Franco Montoya et al., 2020). Lastly, there are health care access discrepancies and quality disparities, including for marginalized communities, resulting in issues of fairness and distributive justice for the SMMC program. To tackle the gaps in health care, it is necessary to strive for not only equitable access to care but also to remove barriers in the process for people who are left behind.

Conclusion

Last but not least, SMMC proves Florida’s dedication to high-quality healthcare for Medicaid members. The strategy demonstrates the advantage of being concentrated on the management of care, usage of preventive services, and control of costs through the improvement of the quality and efficiency of care. Nonetheless, the problems regarding healthcare inequitable access, reimbursements, and administrative tasks still exist, so the evaluation and improvement of the system are obligatory. These issues demand that the healthcare system be based on beneficence, justice, and equity. Hence, a healthy population of Medicaid beneficiaries can be expected as a result of the implementation of the SMMC program in Florida, which is based on patient-focused care and equal access to services. Collaboration among policymakers, healthcare providers, managed care organizations, and community stakeholders will be one of the key elements for improving and maintaining the positive outcomes of Florida’s Medicaid program.

References

Chen, A. Y., Opper, I. M., Dick, A. W., Stein, B. D., & Kranz, A. M. (2023). Pediatric oral health services in Medicaid managed care and fee for service. The American Journal Of Managed Care, 29(2), 104–108. https://doi.org/10.37765/ajmc.2023.89319

FLSenate.gov. (n.d). CS/HB 7107: Medicaid Managed Care. https://www.flsenate.gov/Session/Bill/2011/7107

Franco Montoya, D., Chehal, P. K., & Adams, E. K. (2020). Medicaid managed care’s effects on costs, access, and quality: an update. Annual Review of Public Health, 41, 537-549. https://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-040119-094345

Frimpong, E. Y., Ferdousi, W., Rowan, G. A., & Radigan, M. (2021). Impact of the 1115 behavioral health Medicaid waiver on adult Medicaid beneficiaries in New York State. Health Services Research, 56(4), 677–690. https://doi.org/10.1111/1475-6773.13657

Park, J. (2021). Medicaid managed care enrollments and potentially preventable admissions: an analysis of adult Medicaid recipients in Florida. International Journal of Healthcare Management, 14(3), 771-780. https://www.tandfonline.com/doi/abs/10.1080/20479700.2019.1692994

Symum, H., & Zayas-Castro, J. (2022, May). Impact of Statewide Mandatory Medicaid Managed Care (SMMC) programs on hospital obstetric outcomes. In Healthcare (Vol. 10, No. 5, p. 874). MDPI. https://www.mdpi.com/2227-9032/10/5/874