​In surveying how Medicaid managed care may evolve in the coming years, Jeff Myers, president and chief executive officer of the Medicaid Health Plans of America, tells Provider he sees even more populations served by long term and post-acute care (LT/PAC) providers coming under managed care, like the intellectual and developmental disabilities (ID/DD) segment.

Citing a PricewaterhouseCoopers report that showed 74 percent of Medicaid beneficiaries are in a full-risk managed care product, he says the prevalence of the health plans is not news.

“But, the big story underneath the story is that states are looking to put populations that have been traditionally carved out in fee-for-service models into full-risk contracts,” Myers says. “So, I think you are going to see over the next two to three years a significant increase in duals [dual eligibles] in full-risk contracts and a lot of MLTSS [Managed Long Term Services and Supports] services fall into full-risk contracts.”

Myers also foresees communities that have traditionally been in very fragmented designs for care move to a comprehensive model that is also capitated, which puts providers on the hook to provide better care or they face financial penalty.

“And, obviously that cuts both ways,” Myers says. “Plans are responsible for making quality happen, and providers—knowing the expertise they have—can start rethinking what it is they do to provide that quality. I really think you are going to see a massive change in the next three to five years as you see ID/DD adults and the aged poor move into full-risk models that traditionally they have not been in.”

On other Medicaid issues, Myers says even though the fiscal year 2019 budget released by President Trump recently is not a game changer, since presidents’ budgets in general are not likely to have a major impact on policy, the fact the president realized the extent of the opioid crisis “and has indicated a willingness to put billions of dollars behind coming to some solution is a good thing.”

A presidential budget is at least a signal of an administration’s priorities, he says, and the opioid example is a positive one for Medicaid health plans that would be used to address the crisis under comprehensive care models.

Legislative efforts are also heating up, with new plans being offered seemingly on a daily basis. One of the newest came on Feb. 27 when a group of eight senators released a bipartisan plan that would authorize some $1 billion in federal funding for addiction treatment and prevention and institute a three-day limit on opioid prescriptions for acute pain.

The legislation works off the Comprehensive Addiction and Recovery Act of 2016.

Even with the new focus on opioids on both ends of Pennsylvania Ave., Myers says much needs to be fleshed out in a government response plan since a key barrier to achieving success will be through providers, which are lacking in numbers right now.

“There are not enough providers out there to treat this addiction,” he says. “The government is going to have to think differently on how to address it and how you have health plans build networks to address these challenges.”

There will be a lot of discussion over the next couple of months about wrapping new opioid addiction dollars into a mechanism to allow states to increase Medicaid health plan rates to build out provider networks or create funds to supplement the cost of behavioral health.

On the flip side of the Trump budget, Myers says he was “not delighted to see the huge amounts of money that the administration thinks should be pulled out of the program.”

Speaking about the failed attempts in 2017 to revamp Medicaid funding as part of the doomed repeal of the Affordable Care Act (ACA), he says, “From our view, Congress has already gone through that, and the American people have spoken that it is not something they want to do. People feel it is an important entitlement and important access point to health care for the working poor.”

As an extension of that thought, Myers says the specific way the ACA repeal bills would have changed Medicaid funding by deploying block grants on federal outlays to the states is also a dead issue.

“Congress [in 2018] is not going to move to do this. It is a suboptimal way to address funding issues for Medicaid,” he says. Entitlement reform in general, be it Medicaid or Medicare, is an highly unlikely target this year, he says, but “smaller nibbles” are likely, via so-called 1115 waivers and work requirements favored by many Republicans.

The 1115 waiver process is a focal point of the administration’s Centers for Medicare & Medicaid Services as it promotes state “innovation” to bring ideas on what states may favor in terms of making Medicaid more efficient.