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Maximize Value August 18, 2015

Managed Medicaid: Purpose-Build Your Care Management Offering

Partner, Health and Life Sciences, Oliver Wyman

The Medicaid market is growing rapidly: In 2006, it accounted for 10 percent of health plan revenue; in 2012 this grew to 18 percent, a number that is expected to continue to increase. Medicaid has always been a difficult market, managed at the state level, heavily (and confusingly) regulated, and designed to serve an exceptionally diverse population. Below, and in a new report, Oliver Wyman Principal Parie Garg explains how to succeed in managed Medicaid by understanding the nuances – a lot of nuances:

An effective care management (CM) program is the cornerstone of a successful Managed Medicaid offering. But this is an area where plans should ignore conventional wisdom. The individuals covered by Medicaid are so different from the commercially covered population that it makes little sense to attempt to address their needs by simply redesigning an existing CM program. Plans should go back to the drawing board and create a Medicaid-specific CM program, following these principles:

  • Design for Medicaid, not around it. Design the program considering the needs of the Medicaid population. Go beyond immediate healthcare needs and incorporate other aspects of life that can have a substantial impact on an individual’s use of healthcare resources: employment assistance, living conditions, social support, and others. It isn’t a question of how to “add” these services on top of existing ones, but rather how you incorporate them into the daily activities of your care programs.
  • Assess, assess, assess. The care plan assessment is an extraordinarily important part of the CM process. It serves to provide a true picture of an individual’s needs (within and outside the healthcare arena) and informs how much and what types of services the person needs and the plan will pay for. It can also be a way to identify if the individual qualifies for additional services or reimbursements from the State. MCOs that build a thoughtful assessment tool are able to manage their costs and reimbursements better while ensuring members are receiving the services that they need.
  • Go beyond the nurse. Medicaid CM programs need a host of services that supplement and complement medical care. In our experience, the most successful programs employ multidisciplinary teams that include social workers, respite support, home health aides, nutritionists, and providers supporting activities of daily living (ADLs), among others.
  • Put a face with a name. Establish a field force capable of forming personal connections with individuals. Many of the highest-cost Medicaid beneficiaries have living situations that contribute to poor health outcomes: lack of permanent housing, poor ventilation, inadequate heating and cooling. With personal connections and first-hand interactions your team can provide relevant coaching and connect people to appropriate services to put them on a path to success. These interactions are the difference between checking the box that a call was completed and making a difference in someone’s health and life.
  • Use the community. Strong connections with the community you serve will bolster the CM program, providing additional reach in unexpected places. Successful Medicaid plans achieve their success through care managers who use churches, community centers, and homeless shelters to locate hard-to-find members or to make a difference in their care. The community is where your members live their lives. To manage their health, your team needs to be there too.

Medicaid – a $125 billion market that promises to be one of the fastest-growing segments of healthcare for the foreseeable future – is an important business opportunity. But it is also an immense opportunity to meaningfully impact lives by connecting beneficiaries to community resources to help get them back on their feet, providing them confidence to overcome substance abuse issues, or checking in on an expectant mother to make sure she is equipped to care for herself and her baby. It is an inspiring opportunity for health plans to improve lives and communities.

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