7 Ways Medicaid MCOs Can Optimize Their Provider Networks


Now more than ever, Medicaid MCOs need the right providers in their network.

Parie Garg and Sarah Cohan

6 min read

With deep budget cuts looming, managing and building the right provider network for Medicaid will be more important than ever. Successfully caring for Medicaid members requires compassionate, thoughtfully tailored interactions with providers and with the plan – and one of the best places a plan can start is by designing the right network with well-suited providers.

Oliver Wyman has identified seven ways that Medicaid MCOs can build a high-performing Medicaid network.

1. Concentrate on Medicaid-heavy practices

Practice makes perfect. Providers who see a high volume of Medicaid patients are best positioned to care for them successfully. For a Medicaid patient, “buying Glucerna” as part of a treatment plan is not an option, when that $10 can mean milk for their children for two weeks. Practices where just 5 percent of the panel is comprised of Medicaid simply don’t understand these issues the way Medicaid-centric practices do; and MCOs are better off steering Medicaid patients towards those practices with the right experience.

2. Include behavioral health

We’ve all heard the phrase “mind over matter.” So why does a patient’s mental health specialist sometimes fail to work together with their physician to ensure whole-person wellness? Keeping a patient with schizophrenia on their diabetes medication could be near impossible without integrating their behavioral health and physical health care. Use of navigators to bring the two sides together and encourage patient engagement is one way that Medicaid managed care programs are beginning to bridge the gap.

3. Integrate social support services

Oftentimes with Medicaid patients, social factors make the difference between a successful health outcome and non-compliance. An endocrinologist talking to her patient about proper insulin usage may not think to ask whether he has stable housing with a refrigerator to store the medication safely. Organizations such as Health Leads are working to make social determinants of health a standard part of patient care, and Medicaid MCOs should take notice and partner with similar organizations to provide a well-rounded network of services.

4. Provide accessibility and convenience

Medicaid members are increasingly behaving like consumers, not patients, of healthcare; and so they expect to see providers where and when it is convenient. In a recent study by Oliver Wyman and Robert Wood Johnson Foundation, accessibility and convenience factors such as online appointment booking and expanded hours were rated as a top priority by vulnerable populations. MCOs building a Medicaid network should focus on providers offering these convenience factors.

5. Drive member engagement through the provider community

Member engagement is incredibly difficult in the Medicaid population, and working through their providers is key to building trust. If providers aren’t trained in the nuances of Medicaid care, they will fail to win trust, and that will lead to non-compliance. MCOs can help by working with providers to hold trainings on respect and cultural sensitivity, hiring from members’ communities, and offering compassionate interpretation services.

6. Conduct ongoing performance management

Medicaid patients can be among the costliest if not well managed, and they often have chronic conditions that require close monitoring. Data collection and analysis should be done regularly on the member population and their providers to allow timely intervention. Member analytics can identify concentrations of spend that can be better managed, and predictive modeling can identify members at risk for expensive episodes. Meanwhile, provider analytics can identify outliers in quality or utilization that can be improved by performance management. For instance, an MCO that identifies physicians who inappropriately prescribe more opioids than their peers will be better-positioned to serve this population.

7. Align payment models

MCOs can support providers through value-based payments and through joint investment in resources geared towards the Medicaid population (such as case management). As an example, a large regional health plan partnered with several provider groups, who committed to moving to full risk over the next seven years. The health plan funded case management resources for the first few years, then transitioned to partial funding, handing over full funding responsibility to the providers in later years.

Clearly, there is more to Medicaid network management beyond just creating narrow networks. Medicaid members deserve a custom-built program that suits their needs, not a repurposed commercial network with a few add-ons. MCOs looking to win in Medicaid should create a network that will serve this population with knowledge of and compassion for their complex needs.