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.

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.

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.

Details:

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:

MEGA REG SYMPOSIUM OPENING REMARKS

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

NETWORK ADEQUACY

CHALLENGES IN RATE-SETTING 

Clay Farris, Senior Healthcare Executive
Mostly Medicaid

QUALITY

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

MEDICAL LOSS RATIOS, RISK CORRIDORS, AND OTHER MMC FINANCING ISSUES

CHANGING THE FACE OF MEDICAID: PROGRAM INTEGRITY REQUIREMENTS FOR MEDICAID MANAGED CARE 

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

ALIGNMENT AND COORDINATION AMONG PUBLIC COVERAGE PROGRAMS, INCLUDING MEDICAID, MEDICARE, MARKETPLACES

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

Download the full MMCC 2016 brochure here

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

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

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.

- 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

The Implications of the Mega-Reg on the Medicaid Managed Care Industry: 2016 & Beyond

2016 is a year of transformation for the healthcare ecosystem - over the past year we’ve seen the implementation of major ACA provisions, delivery system reforms, payment reforms, and states pursuing better value. There’s been a recent shift away from taking a budget-driven approach, and is now driven by the desire to improve quality and outcomes. The implications will be huge and will go beyond Medicaid. 

We’ve had a short Q/A with Jennifer Babcock, Vice President for Medicaid Policy and Director of Strategic Operations, Association for Community Affiliated Plans (ACAP), who will also be chairing and presenting at the Medicaid Managed Care Congress in May. 

What upcoming major trends are you excited about? 

Medicaid is undeniably undergoing a great deal of change right now, and there are many advancing trends keeping all Medicaid policy analysts on our toes. One of the most exciting, from my perspective, is efforts by Medicaid health plans to impact social determinants of health and to integrate within the health plan help for people to get jobs, housing, nutritional support, even support as they leave the criminal justice system. A substantial number of ACAP member plans are doing important work in these areas, as described in a fact sheet we produced in 2014. Efforts by health plans to impact social determinants underscore that 
our collective goal is to improve the health and well-being of people covered in Medicaid.

Secondly, I’m excited to learn about efforts by plans, states, and providers to look at improving quality of health at the population level. Again, these efforts offer a great opportunity to improve the health of the entire nation, given how expansive a coverage program Medicaid is. 

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

If finalized the way we at ACAP hope, the Mega Reg will erase any lingering questions about the crucial role MCOs play in Medicaid, leading the way to greater emphasis on the partnership between states and plans. I hope, for example, that CMS will require transparency between states and plans in general, and in particular with regard to the rate-setting process to ensure that all rates are set and approved in a timely and comprehensible manner. Also, I would like to see CMS move toward payment and coverage models that use MCOs to promote population health. Lastly, I would like to see movement toward standardized quality measurement that allows us to learn what Medicaid pays for, not just in MMC, but FFS as well.

Do you have any best practices of success stories you’d like to share? 

My colleagues at ACAP worked with a subset of ACAP plans last year on a substance use disorder collaborative, which resulted in this toolkit, which is available publicly for other health plans to use. This toolkit provides best practices for plans working with individuals impacted with SUD, including opioid addiction. It’s an example of how effectively and quickly Medicaid MCOs can respond to a significant population health problem. We are very proud of these plans’ efforts. 

For MMCC, what do you hope to learn more about? 

I am looking forward to hearing from the real experts about quality in Medicaid managed care and Medicaid. I am anxious to gain insights about how best to coordinate and standardize the myriad quality measurement and reporting efforts so that we can get on with the business of using results to improve care for people, and to improve Medicaid overall, and CHIP as well. While it’s fascinating to see the efforts many states are making to report on the adult and pediatric core measures sets (the CMS 2015 Annual Report on the Quality of Care for Adults in Medicaid and 2015 Annual Report on the Quality of Care for Children in Medicaid and CHIP were released in February of this year), I feel strongly that we all can do more to ensure that quality of care for Medicaid and CHIP enrollees is measured, reported, and improved.

Learn about the implications of the new regulations and beyond by joining the Medicaid Managed Care Congress (MMCC) in Baltimore, MD (May 18-20, 2016.) For more information about MMCC 2016 visit the website here.

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

Four Major Managed Care Industry Concerns by Jennifer Babcock (ACAP)

The managed care landscape is evolving with the elections around the corner and the Mega-Reg stipulated to release. There is a lot going on in the industry. Read about the four major concerns of the industry by Jennifer Babcock, Vice President for Medicaid Policy and Director of Strategic Operations, Association for Community Affiliated Plans (ACAP):


1.    ACAP’s member plans are very innovative and nimble Safety Net Health Plans that have demonstrated a clear dedication to their enrollees, their communities and to safety net providers. Some Safety Net Health Plans have participated in Medicaid in their states for decades. The move toward consolidation in the industry poses a threat to this commitment, so one of ACAP’s primary goals is to provide support for and create efficiencies for these plans.

2.   The continued lack of an Affordable Care Act Medicaid expansion in many states has produced a drastically inequitable coverage system with multiple negative impacts on people, providers, and states alike. I’m heartened, though, to see the efforts our members and many others are making in those states to encourage governors and state legislatures to expand.

3.   Despite progress, it is still so difficult for people to access all the services they need to thrive, including not only health services, but services addressing social determinants of health as well. Many ACAP health plan members have moved boldly into this area by providing linkages to housing, nutrition, and employment services. CMS has provided leadership in this area as well – one example is last year’s guidance related to how Medicaid programs can fund housing activities.

4.   The continued fragmentation of coverage and care complicates health care for families. Many of the families our plans serve are split between Medicaid, CHIP, Marketplace coverage, and Medicare. Certainly, plans can and do make the choice to operate in all of these programs to address overlap for families, but participation by plans in multiple programs is not a sure thing, and it is not an easy lift, particularly for Safety Net Health Plans. There aren’t always clear incentives for them to do so, which can mean that single families can have to manage two or more sources of coverage, networks, and so on. CMS’ efforts to align requirements across programs is appropriate and useful, although more work needs to be done in this area. Ultimately, enrollee families will benefit.



Hear more from Jennifer Babcock as she will be chairing and presenting at the Medicaid Managed Care Congress (MMCC) 2016, Baltimore, MD with the session "Dive Deep into the Implications of the Mega-Reg"

Download the brochure to see the most up-to-date agenda for the MMCC here.

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