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Managed Care Organizations Need Critical Data to Thrive

Public & Private Payers


National health spending in the United States is projected to grow at an average rate of 5.5 percent per year from 2017 through 2026, reaching $5.7 trillion by 2026. While rising prices of medical goods and services and greater disposable personal income are partially to blame, increasing Medicaid costs are also a leading contributor.

As of July 2018, 34 states adopted a Medicaid Expansion program to bring new healthcare coverage options to low-income families. In response to this increase in Medicaid enrollment - and the correlated increase in costs that comes with it - states have continued to express interest in contracting with managed care organizations (MCOs) to help them deliver healthcare services to Medicaid beneficiaries.

Partnering with Providers on Clinical and Financial Health of Members

Arrangements between MCOs and states are increasingly risk-based, as MCOs control healthcare spending by trying to improve health plan performance, care quality, and overall outcomes. While the specific initiatives implemented by individual states under these contracts vary, the overall goals of MCOs are universal: Reduce unnecessary use of services and costs, focus on preventive care and early intervention, and provide quality care coordination and care management.

The push toward value-based care has amplified the need to achieve these goals, with MCOs looking to better understand the patient holistically: clinical, behavioral, social, and financial factors can all inform health and care. Traditionally, MCOs have worked solely with claims information, or the billable interactions between insured patients and a healthcare delivery system, to aid their strategies. Now, MCOs must expand their view, and overall understanding, of the patient by taking advantage of the clinical information residing in the patient health record.

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