Wednesday, June 1, 2016

MDRP 2016: Final Agenda Available!

Medicaid Drug Rebate Program
September 20-22, 2016 | Chicago, IL
Download the final agenda: 

Now in its 21st year, IIR's MDRP Summit ( has continued to be THE authoritative MDRP Event for Everything Government Pricing, Rebates and Regulation. MDRP provides unparalleled access to the government regulators creating the rules, the industry leaders interpreting them, and the pharmaceutical executives implementing them.

Don't miss out on your opportunity to benchmark best practices and gain solutions to overcome new operational challenges brought on by AMP Final Rule, 340B, Medicaid Expansion, Class of Trade, Fair Market Value, FSS, VA, OIG, and other critical government programs.

Why should you attend MDRP?

• AMP Final Rule Implementation
• 120+ Speakers
• 6 Keynote Presentations
• 340B Guidance Updates

• State Dispute Resolution Meetings
• New Executive Leadership Boardroom
• Town Hall between Manufacturers and States

• 14+ Federal and State Agencies
• 600+ MDRP Executives
• 20+ States
• 30+ Solution Providers

Access the final agenda:

$400 savings ends Friday, July 1st! Click here to register:

Tuesday, May 24, 2016

How to Demonstrate the Efficiency of New Technology to Patients

Technology can be very confusing, especially if it isn't something you wouldn't normally interact with. While most medical technology can seem mundane to doctors, it is elaborate, complex and sometimes scary to patients. This isn't because they are techno-phobic; it is often just because they don't understand.

Introducing new technology to individual patients can be very difficult, especially if you aren't sure how to explain the benefits of using it. Use this quick guide to learn more about how to incorporate technology into your practice and make patients more aware of how things can help them. 

Explaining Change

Technology is improving at a rapid rate and it affects everything that we do. The medical field is no exception, with technology revolutionizing the industry even more. With all of the technology in the medical field, it isn't uncommon for patients to have to undergo new procedures or screenings.

If you need to introduce your patient to a new routine, start by explaining the reason for the change. You don't have to go into too many details. For example, if the screening would better help you understand the vitamin levels in a patient, say so. Explain that the new method is more efficient and tell them how it directly benefits them to use the technology. This will make them more apt to agree to use the new test or device.

Keep in mind that most patients won't understand complex medical jargon. For example, if you are trying to tell them the importance of using a vendor neutral archive, you can't just recite a dictionary explanation. You need to explain that the technology stores images and documents so that other machines can quickly access it. 

Show Examples

While you can't always show specific examples of tests, you can show a diagram that does. Even showing a cartoon drawing of a completed test can give the patient a little clarity. The more detailed the example is, the easier it will be to convey your message. People respond to visuals and can gain a lot of insight just by looking at a picture.

If you are trying to prove that a new method is more efficient than an old one, show the patient results. Even if it is your first time using the technology, you should be able to produce results of previous tests or information from the company showing how much it can help. 

Create a Video

Sometimes, new technology becomes widespread very quickly. To keep from having to explain yourself and the reasons for the change over and over again, try making a video to show your patients. During the video, you can:

• Explain how the technology works
• Why you are choosing this method
• How this method benefits the patient
• Go over statistics and proof that the method works
• Show a visual demonstration of the entire process.

The great thing about using video to demonstrate the effectiveness of medical technology is that it can be viewed at any time. You can send the patient home with a copy or ask them to watch it online before their visit. This helps to save you time and improves the efficiency of your office.

Be Personal and Relate to the Patient

Regardless of what method you use to explain how efficient your medical technology is, you need to be able to relate it to the patient. When patients enter a medical office, they want to know what the fastest and most efficient way to get healed is. If you don't clearly convey that the technology is helping the patient, they might not want to use it.

Demonstrating the efficiency of new technology doesn't have to be difficult. 

About the author: Greg Dastrup is a world traveler and professional writer with a passion for learning new languages. He’s spent most of his career consulting for businesses in North America. You can follow Greg here.

Friday, May 20, 2016

With Some Flexibility, Medicaid’s Future Seems Bright in a Polarized America

By Rene Macapinlac

Medicaid reform is as contentious as the upcoming presidential election. Critics abound questioning the expansion’s impact on state budgets and Medicaid’s effectiveness in delivering quality care.

What will happen to Obamacare soon after Obama leaves office? Will states reject Medicaid expansion? Len M. Nichols, director of the Center for Health Policy Research and Ethics (CHPRE) and a professor of health policy at George Mason University, believes that will not be the case. 

Nichols is confident that states will see expansion for what it is -- good for the budget, and good for the health of their residents. 

Waivers, including section 1332 of the Affordable Care Act (ACA), will play a key role to states that have yet to expand Medicaid. Section 1332 of the ACA allows a state to apply for a waiver to opt out of certain portions of the ACA in order to engage in innovative strategies for providing access to high quality, affordable health insurance. It gives states the latitude to pursue their own kind of health reform.

Although it will not be until January 2017 until the first of these waivers can be filed, states are beginning to see the potential for designing a health care program that will work specifically for their state. They may modify the rules governing covered benefits and subsidies, or make changes to the requirement for maintaining minimum essential coverage.

Some states are also now beginning to implement innovative programs reforming how care is delivered and paid for.  Part of the broader Section 1115 Waiver programs, the Delivery System Reform Incentive Payment (DSRIP) provides states with significant funding that can be used to support hospitals and other providers in changing how they provide care to Medicaid beneficiaries.

Under DSRIP initiatives, funds to providers are tied to meeting performance milestones or metrics.  DSRIP waivers generally focus on infrastructure development and system redesign, and clinical outcome improvements and population-focused improvements. Funding for DSRIP initiatives varies across states, but it can be significant.  

In the days ahead, there will be negotiations between states and the federal government over policy and budget. Some states have become so politically polarized to the point that anything linked to Obamacare has been deemed ineffective by some residents. But there are facts to support the case for Medicaid expansion. 

A recent study found that in states that expanded Medicaid, insurance coverage increased for low-income adults. The study, published by the Annals of Internal Medicine, also found better healthcare usage and diagnosis rates for chronic diseases.

Nichols believes it is not impossible to find a common ground on the issue of Medicaid expansion. It will no doubt take a lot of effort, but it can be done. After all, history has shown us that despite contentious politics, we have always been able to make programs work.

Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.

Medicaid Directors and the Brand New Challenges They Face

By Rene Macapinlac

The most recent State Medicaid Operations Survey, conducted by the National Association of Medicaid Directors (NAMD), shows just how the Medicaid program has changed and will continue to change rapidly in the days ahead.

Topping the list of major Medicaid innovations is payment and delivery system reform. Agencies are moving toward performance-based reimbursement models both within traditional fee-for-service care delivery and managed care. Directors face challenges with staffing, data and systems infrastructure, budgets, and procurement processes.

Difficulties in recruiting and retaining staff are pushing directors to internally shift existing staff resources and step up initiatives for acquiring new skill sets.  On top of the challenges with limited staffing and resources, the directors must deal with higher expectations, increased public visibility, and greater accountability.

Medicaid today has become a complex program covering a wide range of services requiring a broad scope of operational functions. These operational functions often involve contractors, making day-to-day management even more complex. Contractor involvement varies by state, with some agencies contracting key functions while others only do back-office functions.

Despite the persistent and increasing job challenges, Medicaid directors remain committed to building new capabilities in order to meet the needs of more than 72 million Americans. They are implementing new or expanded program integrity activities - conducting various audits, enhancing data resources and analytical tools, strengthening program policies and procedures, and coordinating with other entities.

Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.

Thursday, May 19, 2016

Using Technological Advancements to Improve Health Care Delivery

By Rene Macapinlac

Through the years, technology has played a vital role in improving the delivery of health. During day one of the Medicaid Managed Care Congress, the subject of technology often came up in discussing efforts to move beyond Medicaid and provide higher quality care.

Telecommunication technology or telehealth has become one of the main tools for health plans and providers to improve care and outcomes. Video conferencing is being used by patients and doctors for real-time consultations and discussions. Electronic devices available for transmitting patient health information to doctors and other health care providers. Pre-recorded videos and digital images of x-rays can now be electronically transmitted between primary care providers and specialists.

Mobile applications are increasingly being used for health services, information and education.

Underserved populations can be reached through targeted text messages to promote healthy practices, and through public alerts to inform them about disease outbreaks.

Technology has also played a vital role in data-gathering and building metrics to better measure patient outcomes and member engagement. It is a key component in the development of state-led payment and service delivery innovations.

Patient-Centered Medical Home (PCMH), the model of care for transforming the delivery of comprehensive primary care is leaning on technology -- email, video chat and mobile apps -- to help patients stay on top of their health and get health care when they need it.

The Children’s Community Health Plan uses claims-based technology to detect women at risk for delivering a child with neonatal abstinence syndrome (NAS). The number of cases of infants with NAS has increased with the rise in substance use disorder. Once algorithms identify at-risk women, they are provided with educational materials and their care providers are notified.

When it comes to diabetes management, Cigna-HealthSpring is using cellular technology (along with nurse visits) to help its members with uncontrolled diabetes. They give these members information on self-management and monitoring.

These are just some of the ways technology is changing the Medicaid managed care industry. Although implementation comes with issues and challenges to be hurdled, there is no question that all of these technological advancements have been improving outcomes and mitigating rising health care costs.

Technological innovations support the provisions of the Affordable Care Act by providing educational materials and opportunities for patients to care for themselves better. Furthermore they provide opportunities for doctors and other providers to intervene with a patient early on when the health condition is still easily treatable.

Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.

How Community Advocacy Improves Health and Outcomes

By Rene Macapinlac

Access to primary care is important, but there are other factors outside of the doctor’s office that determine one’s health. To help its member lead healthier lives, health plans should focus on advocacy and community-based programs.

Speaking to attendees of the Medicaid Managed Care Congress in Baltimore, Carol Steckel, senior director of public policy at WellCare, emphasized how identifying community-based solutions help improve health outcomes of their members and ultimately lower overall cost of care.

At WellCare, Steckel said they examine the health and welfare in the populations they serve. Using that data, they are able to identify the gaps in the network of social services. Where needed they link their members to such services as housing assistance, employment services, food banks and education support. They also improve quality of life for residents by providing transportation for seniors and people with disabilities so that they could go to medical appointments, day programs and shop for groceries.

Linking members with the community and social services improves health outcomes and ultimately lowers overall cost of care.

Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.

Tuesday, May 10, 2016

Medicaid Expansion Boosts Insurance Coverage, Use of Healthcare Services

- By Rene Macapinlac

Critics of Medicaid expansion have voiced out several reasons why states should not expand the program. Aside from concerns that it will burden the state budgets, they question Medicaid’s effectiveness in providing quality care. 

Now there are solid facts to support the case for Medicaid expansion.

A recent study found that in states that expanded Medicaid under the Affordable Care Act, insurance coverage increased for low-income adults. The study, published by the Annals of Internal Medicine, also found better healthcare usage and diagnosis rates for chronic diseases.

Researchers at the University of Michigan and the University of California-Los Angeles analyzed data from the National Health Interview Survey between 2010 and 2014. They compared the changes in outcomes among adults (ages 19 to 64, with family incomes 138 percent below the federal poverty level) in the 26 states that expanded Medicaid in 2014 with outcomes for adults in states that did not enact Medicaid expansion.

Among other factors, the researchers looked into coverage improvements compared to the previous year, doctor visits, hospitalizations and emergency department visits.

Here are some of the study’s key findings:

• In states that expanded Medicaid, insurance coverage increased 7.4 percent and Medicaid coverage increased 10.5 percent compared to non-expansion states.

• States that expanded Medicaid saw an increase in adults reporting an overnight hospital stay (2.4 percent), or visit to a physician (6.6 percent) in 2014, compared to non-expansion states.

• In states the expanded Medicaid, the rate of diabetes diagnoses increased (5.2 percent) as well as cholesterol diagnoses (5.7 percent).

It’s important to note that there were limitations to this study. Researchers only looked at the experiences of low-income adults during the first year of enactment of Medicaid expansion. They were not able to definitively rule out other factors unrelated to Medicaid expansion that may have influenced the results.

Although the study showed low-income adults were more likely to go to a physician or hospital, it was not able to determine improvement in the adults’ health because of the limited available data.

The researchers, however, have no doubt that greater use of health services could pay off in the future. They pointed out in the study that increased detection of chronic health conditions under Medicaid expansion could have important implications for both population health and national spending on health care “if it leads to improved management and control of these conditions." Since states began Medical expansion in 2014, Medicaid enrollment has gone up to more than 70 million people.

Monitoring these trends over time will be critically important for Medicaid managed care professionals as they prepare to adapt to changes, particularly when it comes to the people now gaining Medicaid coverage. Under the Affordable Care Act, states are now using Medicaid managed care plans to cover beneficiaries in rural areas, those with complex and chronic conditions, and many new enrollees. It will be interesting to see in the coming months how access to providers will be affected - as enrollment goes up and the number of uninsured people go down.

About the author:

Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.

Tuesday, May 3, 2016

3 Medicaid Mega-Reg Provisions Take Center Stage

In reporting the announcement of new rules updating managed care in Medicaid and the Children’s Health Insurance Program (CHIP), the media focused on three key provisions.

On April 25, the Centers for Medicaid and Medicare Services (CMS) finally released the rules aimed at overhauling Medicaid and Children's Health Insurance Program (CHIP) managed care plans. The new rules set the standards for modernizing the entire Medicaid managed care delivery system. This happens to be the first update to managed care regulations in more than a decade.

The lengthy ruling - more than 1,400 pages long - was broken down by the media. ManagedCareBiz, which keeps track of how the media reports on managed care issues, found that of all the provisions of the new regulation, the news media highlighted these three items:

- The new rules will establish a Medicaid managed care quality rating system to assist Medicaid recipients in picking a plan.

- The new rules will set a minimum medical loss ratio (MLR) of 85 percent for Medicaid. This means that profits of insurers will be limited as plans will spend a minimum of 85 percent of their intake on medical expenses rather than on administrative expenses.

- The new rules will require states to guarantee access to doctors and hospitals. The standards will include “time and distance” maximums to ensure physicians are not too far from the plan members.

News reports pointed out that the provision on quality ratings will have the most impact to the public as it will give consumers more information about the health plans available. It is comparable to the existing Medicare Advantage star rating system, which goes to show that the CMS is bringing Medicaid managed care in the same direction as Medicare Advantage.

Consumer advocates have been pushing the government for many years to come up with stricter standards for managed care plans. They believe that these plans have often favored profits over patients.

Other provisions of the new managed care rules for Medicaid and CHIP include:

- Requiring plans to regularly update directories of doctors and hospitals. (According to Kaiser Health News, a 2014 investigation by the Department of Health and Human Services’ inspector general found that half the doctors listed in official insurer directories weren’t taking new Medicaid patients.

- Pushing plans to better detect and prevent fraud by providers, including mandatory reporting of suspected abuse to the states.

- Making it easier for states to offer managed-care plans incentives to improve clinical outcomes, reduce costs and share patient information among hospitals and doctors.

The new regulation will be implemented in phases over the next three years, starting July 1, 2017. The CMS recognizes this as a major step forward in the administration’s efforts to strengthen Medicaid as well as CHIP which offers low-cost coverage to children in some families that don’t qualify for Medicaid.

With all of these changes happening, there is no better time to discuss and dissect Medicare managed care than today. If consumers have much of their attention on these three key takeaways, particularly the Medicaid managed care quality rating system, what are industry professionals focusing on? It will be interesting to see which provisions of the new Medicaid managed care regulation stand out for health care executives and other managed care professionals.

About the author:

Rene Macapinlac is the Director of Operations at ManagedCareBiz, an online resource for managed care professionals who need to stay up-to-date on industry news, analysis and commentary.

Wednesday, April 27, 2016

The Medicaid Managed Care Regulation is here!

Since the last major updates to Medicaid Managed Care regulation in 2003, Medicaid and managed care have both evolved dramatically. After years of waiting, CMS released the long-awaited final Medicaid Managed Care 'Mega-Reg' Rule. For those of you who would like to review it immediately, it is available here. As you know, this draft regulation will govern the activities of states and plans participating in the Medicaid and CHIP programs going forward. The time to plan has ended! It is “Game Time”!

IIR's Medicaid Managed Care Congress will be your first opportunity to dissect the implications of the Mega Reg and its impact on your daily operations and overall bottom line from thought leaders in the space including ACAP, Mostly Medicaid, and more.


Medicaid Managed Care Congress (MMCC 2016)
Marriott Harbor Inn
Baltimore, MD
May 18-20

MMCC’s Mega Reg Pre-Conference symposium will address and break down the rule, and analyze and interpret its effect with like-minded individuals and organizations. Key topics will include:

• Require transparency and fairness between plans and states in rate-setting
• Encourage efficient, realistic use of limited resources;
• Hold fee-for-service programs to the same standard as managed care;
• Set standards for network adequacy which reflect local conditions as they exist;
• Provide for realistic implementation timeframes for both plans and states;
• Promote the movement to value-based payment strategies; and
• Provide for comprehensive, accurate and fair quality reporting and standards.

Click here to download the full MMCC 2016 brochure

Below is a preview of the sessions in the Mega-Reg symposium:


Jennifer Babcock, Vice President for Medicaid Policy and Director of Strategic Operations Association for Community Affiliated Plans (ACAP)



Clay Farris, Senior Healthcare Executive
Mostly Medicaid


Deborah Kilstein, Vice President, Quality Management and Operational Support
Association for Community Affiliated Plans (ACAP)



Larry Heyeck, Deputy Director for Legal Services State of New Mexico


Amy Thomas, Assistant Director of Plan Support
Association for Community Affiliated Plans (ACAP)

Have a comment? Share your thoughts in the comments section or follow us on Twitter: @healthcarebiz and #MMCC16

Tuesday, April 19, 2016

Medicaid Managed Care Congress: Q/A with Carol Steckel (WellCare Health Plans)

Medicaid Managed Care Congress
With the Medicaid Managed Care Congress (MMCC 2016) right around the corner (May 18-20, 2016) we have reached out with the Q/A to one of the keynote speakers Carol Steckel, MPH Sr. Director,  Alliance Development, WellCare Health Plans, Inc.

What do you think will be the major implications of the Mega-Reg?

- Mega-Reg has the potential to strengthen the states’ ability to use managed care to promote innovative and cost effective methods of delivering quality care to Medicaid and CHIP beneficiaries.

What do you wish someone would have told you before joining Medicaid/healthcare industry?

- Navigating such a complex system can pose challenges and the system routinely and frequently changes. These challenges are offset by the knowledge that the work you are doing is improving the lives of the people we serve.  

What upcoming major trends are you excited about?

- There is great opportunity for states and managed care organizations to work together to empower people to take control of their health. I am most excited about the linkages we are developing between physical health, behavioral health, and social determinants of health.

What is the secret to success in your opinion?

- Working hard to be part of the communities where our members live helps us bring together the resources needed to serve the most vulnerable populations. Our members often face challenges in life beyond their health. By connecting them to needed social and community services, we seek to improve their ability to take control of their health by addressing their overall needs. We also strive to engage them in needed preventive health services to ensure they are getting the right care at the right time at the right place.

For MMCC, what do you hope to learn more about / who do you want to hear from?

- Providing care to vulnerable populations often involves going the extra mile to find and engage members where they live, whether that is in their homes, in a shelter or under a bridge – none of which is possible without collaboration across sectors at the local level. Learning more about the efforts of community organizations working to support the social safety net can help MCOs identify and address care gaps that may be barriers to health. 

Do you have any best practices of success stories you’d like to share? If so, please elaborate.

Medicaid Managed Care Congress presenter's logo - WellCare Health Plans- WellCare uses a coordinated care approach designed to ensure all of our members receive the unique services and supports they need to achieve and maintain the best health outcomes possible. This is based on our belief that a healthy community is one where social safety net providers and community-based organizations are thriving and supporting the needs of its citizens. We identify care gaps, which occur when the social safety net is stretched too thin. We partner with community groups to address these needs, and close the care gaps. We also work with academic partners to evaluate the programs to quantify the results in terms of cost savings, increased access to health case, and other benefits to the public health system. This approach allows us to deliver on our mission of enhancing our members’ health and quality of life and strengthening the communities we serve. 

Carol Steckel will also be presenting at the MMCC 2016 with a case study "Community advocacy, health connections model" which will cover three important questions:

- How to link a member to a community and/or social service?
- How to support the community in developing needed services?
- How to measure the impact of the program on our members?

To learn more about Carol Steckel's case study or to see who else will be presenting at the Medicaid Managed Care Congress download the brochure here

Have a comment? Share your thoughts in the comments section or follow us on Twitter: @healthcarebiz and #MMCC16