As more states begin to take on newly eligible Medicaid populations, there are a number of lessons that can be learned from health systems that have already begun managing these patients. These lessons include:
- Not taking on too many recipients at one time without understanding the costs
- Not taking on a large value-based population without prior managed care experience
- Creating financial incentives to build a provider network so there is sufficient access to care for this population
- Providing adequate technology and connectivity to measure utilization and outcomes
- Coordinating outreach services between providers and institutions
- Using telemedicine to facilitate care
It should also be recognized that all institutions within a state will not be equally prepared to manage the newly eligible population due to organizational, information technology, and provider network constraints. Some of this depends on whether organizations have developed an ACO or ACO-type structure to manage other commercial or Medicare populations because these infrastructures can be modified to manage Medicaid patients as well.
Key questions healthcare systems should ask themselves include:
- Is the organization’s leadership prepared to make the necessary investments to address the unique needs of this population, including time and financial resources?
- Is the provider network sufficient to support this population? Typically this population has significant psycho-social, economic, and logistical issues that challenge care delivery capabilities.
- Are the key payers aligned with the interests of the hospitals and ambulatory providers? Are they willing to fund the development of care delivery models and share in financial savings if improvements are accomplished?
- Is there sufficient technology in place to integrate clinical data among providers and track individuals across a continuum of care? Typically this includes integrated EMRs, data registries and warehousing, and health information exchanges (HIEs) across areas within the state.
- What quality metrics are put in place to monitor patient outcomes?
- Are there care management programs in place to manage patients across the continuum with a focus on preventative and post acute care, behavioral health issues, and other psycho-social needs?
Once this assessment has been completed, health systems can determine the priority of key capabilities that should be implemented and what their optimal role should be in serving the Medicaid population. It takes significant time and resources to build value-based patient care models. Most important is the amount of cultural change that is needed among all stakeholders to make this initiative successful.
Taking on the challenges of health management for this population is not for the risk averse, but it may be a necessary skill for many health systems as Medicaid expands and grows in importance as a major segment of the market.
Dr. Faber is a vice president with The Camden Group. As a physician executive, he specializes in the development of accountable care organizations and clinically integrated networks, physician engagement, and health information technology. Prior to joining The Camden Group, Dr. Faber served as Senior Vice President of the Rochester General Health System in New York, where he guided the development of the system’s clinical integration program and assisted more than 150 providers at 44 sites through the conversion process from paper records to an electronic health records system. He may be reached at email@example.com or 312-775-1703.
Ms. Wardrop is a vice president with The Camden Group. She has over 30 years of experience working in the healthcare provider sector. She has worked with a wide range of hospitals, healthcare systems, and independent and employed physician groups. Her key areas of expertise include strategic planning, medical staff development, physician recruitment and employment, electronic health record selections, hospital/physician integration, and population health. With a diverse background in hospital and physician arenas, Ms. Wardrop has in-depth knowledge of the political and economic factors and implementation processes that determine the success of strategic and operational turnaround initiatives. She may be reached at firstname.lastname@example.org or 312-775-1714.