Thursday, April 26, 2012

What should be the considerations for health plans in the Medicaid Space?

Recently MMCC supporter Nathan Goldstein of the Gorman Health Group sat down with our conference director Sarah Gordon to discuss dual eligibles, and some of the unique opportunities they create for Medicaid managed care health plans.

To read Nathan's entire transcript, download it here.

At MMCC this year, we will be hosting a full day symposium Monday, April 30 called, "Cost Containment Strategies for Dual Eligibles."  If you're interested in joining the full day symposium and the Medicaid Managed Care Congress this April 30-May 2, 2012 in Baltimore, mention code XP1726BLOG when you register to save 25% off the standard rate!

In this final installment, he answers the question:
If our health plan audience is looking ahead in the Medicaid space, what would you say to these plan executives who will be at our Conference in May? Are there any key planning considerations that you’d like to share with them?

Nathan: That’s a great question. There a couple of things. First of all, we’ve got to remember that these programs are going to be state-by-state. Last year, 2011, the Coordination Office awarded 15 states $1 million a piece to design person-centered approaches to coordinated care across primary, acute and behavioral health and long-term supports and services for duals. And what that means is that state-by-state you see different approaches. What I meant by the laboratory here. In Colorado, the proposal is to enroll duals into what’s called an ‘Accountable Care Collaborative’, which is sort of a hybrid medical home and ACO, which is a familiar term to our listeners I would imagine. And it would include involuntary enrollment of both Medicare Fee-for-Service and MA enrollees. 
It’s different elsewhere. New York is considering a range of options. State management of delivery and financing of a combined benefit package, managed long-term care, SNPs. In Oklahoma they are considering ACOs or state-operated network, an expansion of the PACE program. Tennessee is going to do it through TennCare and expand managed care services to include Medicare Parts A and B. So, the first thing these folks need to do is bring their head of Regulatory Affairs with them to the Conference. It’s worth paying for the extra seat. They are going to get so much knowledge that they can apply to their home situation, but recognizing that the home situation is going to be unique to that state. And that’s where it begins.
The other considerations, at least where the duals are concerned, would be as follows: One is that the model of care or the service model with which you approach these beneficiaries needs to be different. In case management (traditionally in managed care), you would have a case manager assigned to that very small proportion of beneficiaries (2-5% depending on the plan and the way they approach it) to be that advocate within the plan and that navigator to help the beneficiary navigate the system. Keep in mind that dual eligibles see an average of 10-12 different physicians, 30-40 office visits a year. It’s an extraordinary volume of clinical information to coordinate. Imagine being that beneficiary. Imagine when, as inevitably happens, a couple of those doctors tell you to do different things, things that contradict each other. How do you resolve that? Many of the beneficiaries don’t. So, it’s critical that traditionally you would have a case manager watching out for those beneficiaries. They weren’t necessarily duals. They were just your most vulnerable beneficiaries. We would make the argument that you need to take almost a case management approach and apply it to customer service where the duals are concerned. We actually recommended for many of our plan clients it’s a good fit for them in serving their Medicare Advantage population more generally. It is certainly true in the duals. The challenge, of course,is that, as we’ve stated, these can be very hard beneficiaries to get in touch with. Where do you send the mail to a transient beneficiary? As I said earlier, sometimes the cell phone is the best way to get in touch with them. Maybe you should offer a cell phone as part of your plan to all of your beneficiaries. Plans need to think outside of the box here and get involved in a different way in their beneficiaries life if they have any hope of succeeding here.
The first consideration is: “What’s going on in my state?” The second consideration is: “What kind of a service model can I offer my beneficiaries that can distinguish my plan and do so, of course, in a completely compliant way to attract beneficiaries (because you are going to voluntarily enroll into my plan in some cases or make me attractive to the state to be a qualified provider).” And how do I get on top of some of these difficult service issues?
The next two things are absolute must dos. The first is to take a look at how your provider network is contracted, both the rates and the incentives, the information that you share with the network, how you share it to them, and your use of field agents (are you sending in long faxes to these offices? Well, they are getting used to line bird cages; they aren’t getting read). Are you having face-to-face interaction with the big players in your provider network and compelling them and giving them better information with which to make better clinical decisions because ultimately they are the one in contact with the beneficiary, not us the payer? We can only give them information for them to make better decisions. We can’t force them to do anything. No bonus scheme in the world is going to do that.
The last consideration is really a financial one that ties back to care, which is risk adjustment. As I’ve said a number of times, these beneficiaries are terribly expensive. They are expensive because they are sick. In that they are sick they need our support, but we can’t do this purely out of the goodness of our heart without getting revenues to pay for all that care. Risk adjustment is the way the plans get the revenues to care for those beneficiaries.Your non risk-adjusted average beneficiary premium is around $800-$850 pmpm.. It’s a big range nationally, about $350 range between a high and a low. But, let’s say it’s 800 bucks. These beneficiaries can be as high as $3000 per member per month. But, if you don’t accurately report that risk score, how much money are you going to get? Well, in this example, you’ll get $800 or $850. So, you’ve got to risk adjustment right to get the payment right or else you’ll never fund those benefits that the beneficiaries are entitled to.
So, those are really the four considerations: what’s your state’s local market condition, what is your service model, what can you offer these beneficiaries that’s unique, risk adjustment. And then think about your provider network very carefully. You’re probably going to have to re-contract portions of it to make this all work.

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