This blog post was originally written by Sarah C. Threnhauser and published on OpenMinds.com.
For the past couple years, our team has tracked the intersection of managed care and Medicaid services for consumers with an intellectual/developmental disabilities (I/DD). At last count, 50% of Medicaid consumers with I/DD receive their health and behavioral health benefits through Medicaid health plans and 15% of those consumers have their LTSS services delivered via managed care models (see State Medicaid Programs With MLTSS: The 2016 OPEN MINDS Update, What Are The Major Provisions Of The 2016 CMS Medicaid Managed Care Final Rule?: An OPEN MINDS Market Intelligence Report, and VBR & I/DD-The Wave Begins).
So, what does that mean for specialty provider organizations serving the I/DD population? That was the topic of The 2019 OPEN MINDS Strategy & Innovation Institute session, “Preparing I/DD & Other Long-Term Care Organizations For Managed Care – Implications For Consumers, Health Plans, & The Rest Of Us” featuring Ravi Ganesan, President & CEO, Core Solutions, Inc.; Tonya Copeland, Vice President, IDD Services & Employment & Community First CHOICES, UnitedHealthcare; Patrick Maynard, Ph.D., Chief Executive Officer, I Am Boundless, Inc.; and Prasad Thottempudi, MS, Managing Director, Deloitte Consulting; moderated by OPEN MINDS Senior Associate, Ray Wolfe, J.D.
The message of the day? For executives of provider organizations serving the I/DD population, this shift to managed care is fundamentally remaking the traditional business model. In states with this shift, new administrative infrastructure, technology functionality, service system model, and marketing approaches are needed. For those executives, the task is to “recognize, strategize, and adapt.” Mr. Ganesan explained:
We are going through big changes. It’s either an opportunity, or it’s fear of the unknown. If you sit back and think, we used to institutionalize people and now we are talking about putting the person in the middle. If you think about the next 10 years, I think we should see an opportunity for impact and the people we serve will be better off for it.
The roundtable discussion covered a lot of ground – from the payer, health plan, and provider organization perspective. I found five key takeaways for successfully building a strategy for success in the changing market:
Develop a strategy that can manage uncertainty – Like a lot of health care initiatives, the shift to managed care in I/DD services has come in waves, and often with very little certainty. Many provider organizations will have to make forward-looking decisions when they can’t see exactly what the future will look like. The potential for change is there, but until the contracts are signed, it hard to know what to prepare for. Mr. Ganesan explained:
Imagine if you tell a six-year old, this is your gift, but you can’t open it for three or five years. We know this shift to managed care is going to happen, but we don’t know how it’s going to impact us. There is a lot of uncertainty. One thought, get rid of all the noise and focus on developing a strategy for uncertainty.
Invest in technology infrastructure – The move to managed care has put increasing pressure on provider organization to collect, manage, share, and analyze data for population health management and value-based contracts. And if that doesn’t sound like enough, there is also an expectation that provider organizations offer consumer portal functionality and monitor staff improvement. Under managed care arrangements, provider organizations are expected to have these technology functions mastered and for those organizations with these investments, you’ll like need to make improvements. Dr. Maynard explained:
The infrastructure and systems to do performance-based outcomes in managed care is a challenge. It’s very expensive and takes a lot of time and capacity. This is where we get into scale and conversion. Size matters. I don’t see how organizations that are $15 million and under, will have the capacity to purchase and implement the systems they need. Organizations need to look at ways to come together to share resources.
Adjust revenue cycle management practice – Provider organizations must be able to provide detailed documentation of services provided, as well as accurate claims. The old fee-for-service (FFS) billing skills are of no use in a managed care environment. Preparing may mean training, it may mean outsourcing, or it may mean completely replacing your current system and staff. Ms. Copeland noted:
Having been on the provider side, I have helped a provider organization transition to the managed care system. I see are two challenges: claims processing and learning how to manage the billing processing. Organizations must have the ability to understand and manage the process. The other is the credentialing process. That can be challenging if you haven’t gone through it.
Invest in the future – In very few cases is the move to managed care an all or nothing scenario. Organizations will have to figure out how to operate in the FFS and managed care world at the same time. Even after the switch to managed care occurs, there will likely be a steady stream of changes from the state, the health plans, etc. Provider organizations are going to have to have to figure out how to keep track of these changes and know when to make changes. Mr. Thottempudi explained:
When you look at the administration aspects, the day-to-day operations have a significant shift. For example, the quality measures. How do you deliver FFS plus managed care, and keep it on track? And, the regulations are evolving daily in managed care. As the new rules and regulations come out, provider organizations have the challenge of keeping up and managing the day-to-day activities.
Adjust organizational culture – The good news is that many staff will continue to do their jobs and to attempt to do those jobs better. The bad news is, those jobs may change dramatically with the adoption of managed care. Leadership must help the staff make that adjustment by shifting the entire organizational culture. A concerted effort at staff education, and preparing everyone for this change, is mandatory for success. Ms. Copeland noted:
One of the most important things any organization can have is the ability to lead that organization through the change with a positive attitude. If they’re exhibiting the stress, that will trickle down to the employees. Yes, it can be challenging, but we have to say we will overcome it and make it through.
For more, elite members of the OPEN MINDS Circle can check out the OPEN MINDS web-based readiness self-assessment, Value-Based Reimbursement Readiness Assessment, focused on the organizational and technical competencies provider organizations need to be successful with value-based reimbursement. For more on adapting to new payments models, check out these resources in the OPEN MINDS Circle Library:
And join me on September 9 at The 2019 OPEN MINDS Executive Leadership Retreat, and the session “Aligning Non-Profit Health & Human Service Boards For Sustainability With The New Market Landscape: An OPEN MINDS Seminar On Governance Issues In The Time Of Changing Reimbursement Models & Charitable Care Rules.”