David Jordan, President and CEO, United Methodist Health Ministry Fund
Katie Schoenhoff, Vice President of Programs, United Methodist Health Ministry Fund
Donna Cohen Ross, Owner, DCR Initiatives, LLC

This article originally appeared in Grantmakers in Health as part of its “Views from the Field” series on Dec. 9, 2024.

Medicaid managed care contracts are a powerful tool for change; philanthropy has a role to play

As a foundation, the mission of the United Methodist Health Ministry Fund (the “Health Fund”) is to improve the health of all Kansans. Our success, in large measure, depends on investments we make in advancing positive policy and systems changes that affect the state and communities. So, with large numbers of the state’s most vulnerable people relying on Medicaid for health coverage and care, we focus on leveraging the opportunities this program offers to sustain improved health outcomes and make progress on health equity.  

Today, as we enter a time of increased social and political uncertainty, with Medicaid’s structure and finances under threat, such efforts are more crucial than ever: philanthropic organizations like ours must continue to move forward, as well as act to preserve and protect the significant policy gains achieved over time.

This View from the Field describes how the Health Fund, working along with numerous stakeholders throughout Kansas, went “all in” on a multi-year effort, beginning in 2021, to shape the reprocurement of our state’s Medicaid managed care contracts for KanCare, the state’s Medicaid delivery system. This key process establishes and amplifies the state’s  health care priorities for the next several years and defines the expectations it holds for all managed care companies that wish to deliver care to Medicaid enrollees.  By getting involved at the earliest point in the process – as the state’s Request for Proposals was being developed – we had a better chance of assuring that the resulting contracts would align with what we have learned from the research, innovation, and experience at the core of our grantmaking.

Sharpening our focus

KanCare plays an integral role in the health of many of the most vulnerable people in our state, serving more than 415,000 Kansans—the majority of whom are children. The program also serves pregnant women, parents, people with disabilities, and the elderly.

The Kansas Department of Health and Environment contracts with three private managed care organizations (MCOs) to deliver care to KanCare enrollees. With these contracts scheduled for rebid in 2023-24, we thoroughly invested ourselves in the reprocurement process.

We wanted the state to prioritize people in its Request for Proposals (RFP), challenging bidders to describe the distinguishing approaches they would employ to improve Kansans’ health. The process presented a chance to increase access to care and address the social drivers of health—non-medical needs, such as nutritious food, safe housing, and educational and employment opportunities. In doing so, we could reduce health disparities and advance health equity.

We advocated that the agency prioritize enhancing KanCare enrollees’ experience and satisfaction with both the insurers and health system, as we firmly believe the Medicaid program should focus on improving how the patient interacts with the program to encourage more eligible users to participate.

As we developed our strategy, we sharpened our vision for how KanCare could best serve its enrollees and providers. Our work focused on developing robust, evidence-backed comments on the RFP and encouraging fellow foundations to join us and the many other stakeholders participating in the process.

Our colleagues at REACH Healthcare Foundation and Health Forward Foundation convened an event attended by state policymakers, which created an opportunity for partners and grantees to share concerns and identify priorities. The Kansas Health Institute developed a report from this stakeholder meeting, which became a valuable tool for the state and our efforts.

We also utilized other resources that became instrumental in helping shape our comments. With support from The Commonwealth Fund, Medicaid experts at George Washington University and elsewhere built a searchable database drawn from over 40 current Medicaid managed care contracts. This enabled us to illustrate our comments with specific language collected from states already implementing the practices we were counting on KanCare to adopt. In addition, resources from the Center for Health Care Strategies, Bailit Health, and State Health and Value Strategies were helpful in informing our approach and comments.

Crafting strategic feedback

We submitted four sets of comments addressing specific areas of concern, making the case that:

• the reprocurement process should reflect the expressed needs and interests of the people Medicaid serves, stress accountability, improve oversight and require community reinvestment;
• contracts address the need to enhance the rural health workforce;
• expectations for high quality maternal and child health are featured prominently; and
• pre-conception care and Medicaid’s family planning benefit plays helps to shore up the health status of people of childbearing age, leading to improved health for the next generation.

We proposed that the state include a set of required questions for bidders in these four high-priority areas:

• Advancing equity, such as, “How will you ensure that providers and enrollees are full partners in addressing health care disparities?”
• Expanding workforce capacity, such as, “How will you deploy community health workers to ensure that KanCare enrollees have sufficient access?”
• Improving maternal health, such as, “How will you ensure a two-generation approach to care, including screening and treatment for caregiver depression?”
• Addressing social drivers of health, such as, “How will you form meaningful partnerships with community organizations to address social drivers of health?”

We also called for greater accountability, transparency, and oversight of the MCOs. We wanted to see clear goals, benchmarks, and expectations outlined in the RFP and the state’s intention to enforce them. By leveraging data-reporting requirements, we made the case that the state could better hold MCOs accountable for adhering to the contract’s terms.

We offered strategic methods for how the state could incentivize and reward bidders for putting forth their best ideas, as well as for performance after winning the contract.

We advocated for a required performance improvement plan to ensure the MCOs continuously improved their quality and performance throughout the duration of the contract. We also suggested using a public-facing dashboard for tracking their performance, which would increase transparency in the process.

And, given that these high-value contracts were worth nearly $4 billion the last time they were awarded, we pushed for a meaningful community reinvestment requirement to help ensure that the communities served by winning MCOs also benefit.

Lastly, we sought to expand the provider network to include more types of providers, such as community health workers, in-home therapists, and doulas, all of which would greatly benefit our state’s rural communities.

Taking action

Throughout the process, we took an active role in promoting and attending public meetings, coordinated closely with other advocacy organizations, and submitted detailed feedback to the state while encouraging others to do the same. We offered to meet with any prospective bidders to share our thoughts, while maintaining neutrality and never endorsing any organization.

We took these efforts to the media, publishing an opinion article in the Kansas Reflector to help emphasize the importance of providing feedback to the state during this process.

“The state has an opportunity to improve the health and experience of enrollees,” we said in the piece. “With new MCO contracts, Kansas can do more than in the past to advance health equity, support children’s health and development, narrow health disparities, and ensure critical community linkages and supports for enrollees.”

Making gains; protecting wins

Based on stakeholder feedback, the state revised its procurement process to prioritize the people enrolling in KanCare. This was the cornerstone of our advocacy, and we viewed it as a significant win.

Key changes included:

• Incorporating questions that aligned with the key themes we advocated, such as requiring bidders to describe how they will address workforce development challenges, meet maternal and infant health care needs, and identify and address the social determinants of health.
• Requiring MCOs to employ a health equity director or manager.
• Requiring care coordinators to educate enrollees about postpartum coverage and ensure quality care.
• Improving access to interpretation services for enrollees with limited English proficiency.
• Adding new requirements for closed-loop referrals to ensure enrollees are successfully linked to benefits they need.

And one of the additions we are most pleased about, is the requirement that MCOs invest 3 percent of annual after-tax profits back into the communities they serve.

They must work with state and community stakeholders to identify priority areas, as well as submit an annual reinvestment plan for state approval.

Of all the changes implemented, we believe this new requirement could have the greatest positive impact. It will strongly benefit the health of our state’s communities, and we anticipate it also will fuel programs that are of great value to KanCare enrollees but do not have the sustainable financing they need to survive long term. Kansas is ahead of the game here, as we’re one of a relatively small but growing number of states to have included a reinvestment requirement.

By focusing on the contracting process, we also were able to protect gains we had already made for KanCare enrollees, thereby cementing the future of the recently enacted extension of postpartum coverage from 60 days to one year.  Another example is our multi-year effort to persuade the Kansas Department of Health and Environment to cover services delivered by community health workers under Medicaid.

Lessons learned

Engaging in administrative advocacy of any nature takes time. As we reflect on the journey, we would encourage foundations to:

1. Start early by talking with state leaders about the process and weigh in on early parts of the process— including the RFP process to select the writer for the MCO proposal.
2. Stay the course. Administrative advocacy requires patience and flexibility. Also recognize that stakeholder partners may be unfamiliar in dealing with administrative processes and will need extra support.
3. Utilize all available tools. Engaging in direct administrative advocacy may not be part of your strategy. However, there are multiple ways foundations can engage in administrative advocacy—convening stakeholders, funding research, supporting communications plans, and providing funding for partners on the ground.

Finally, it is important to recognize that in a process like contract reprocurement, there is not a true finish line. While the RFP and contracts may have been improved, there will continue to be a need for advocacy to improve the program to better serve the residents of your state. Foundations are in a unique position to play both a direct role in the procurement process and support partners to advocate for improved state benefit programs.

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