Medicaid Prescription Drug Management: Quality Scores Compared Across Different Approaches
States that employ managed care organizations (MCOs) to manage the Medicaid prescription drug benefit collectively exhibit higher scores on pharmacy-related clinical quality measures than states that rely on the fee-for-service (FFS) program to administer the benefit.
States have increasingly implemented capitation contracting with managed care organizations (MCOs) in seeking greater access, cost containment, and quality outcomes and accountability in their Medicaid programs. Prior research has confirmed that states can achieve the greatest savings through MCOs’ management of the drug benefit when compared to a FFS model.
This analysis highlights the clinical value that MCOs can also deliver when administering the prescription drug benefit in state Medicaid programs as part of their integrated system of care coordination. Large-scale comparisons of HEDIS quality scores were made between the MCO and FFS settings, with each of these considering a broad set of relevant measures and reporting years. In 97 percent of these instances, the fully MCO-managed model outperformed the FFS model.
Related Public Policy Research
Outcomes in Medicaid Members Engaged in Health Plan, PBM, and Community Pharmacy Collaboration
Results from a value-based collaboration between a health plan, pharmacy benefit manager, and independent community pharmacies demonstrate these arrangements can improve outcomes for Medicaid members with higher healthcare needs.
PBM and Community Pharmacy Partnerships Can Improve Medicaid Outcomes
Individuals’ visits to community pharmacies outnumber visits to other healthcare provider types by nearly 2:1. Value-based care arrangements between pharmacy benefit managers (PBMs) and independent community pharmacies, where enhanced services are performed, can improve outcomes for individuals at higher risk for poor health outcomes.
There is a growing understanding of the clinical roles that pharmacies and pharmacists can play, beyond medication dispensing and adherence, such as medication adjustment, vaccination, and outcomes monitoring. Value-based payment (VBP) in pharmacy has the potential to recognize the contributions pharmacies and pharmacists can offer to improve patient outcomes and reduce costs.
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