This week we are running a series examining the increasing role providers are playing in government programs. Our government programs experts examine the trends, opportunities, and challenges associated with providers taking on increasing risk in Medicare and Medicaid programs. Oliver Wyman Partner Melinda Durr, with Principal Parie Garg and Engagement Manager Greg Berger, kicks off the series with a look at best-practice strategies providers should utilize to manage Medicare and Medicaid populations and with an overview infographic spotlighting how innovative programs are doing across the country:
Providers are playing an increasingly important role in government programs. These range from active participation in the government marketplace by launching Medicare Advantage and Managed Medicaid products to indirect effects through quality programs that are (to a large extent) controlled by providers.
Given the population dynamics across Medicare and Medicaid and the ongoing provider-member relationship, it makes perfect sense that providers should play a large part in managing these populations. They are diverse and complex, follow the 80-20 rule, and require an understanding beyond healthcare needs that deeply ingrained community providers can deliver.
However, despite the similarities, there are several differences between these two populations that make the keys to success slightly different.
Keys to Success: Medicaid
- Focus on the social determinants of health: It is estimated that for Medicaid populations, social determinants of health can drive as much as 60 percent of the total healthcare cost. Any provider taking on management of Medicaid will need to consider needs beyond healthcare. For example, might a patient need their ceiling tiles replaced to mitigate asthma attacks? Is the living situation hygienic? Is the patient in transitional housing? Does he or she have a place to be discharged?
- Develop a strong field force: While providers certainly serve to uncover needs beyond healthcare, a strong field force is the only way to truly assess Medicaid needs and identify the social determinants of health. Further, unlike the Medicare population, this population can be extraordinarily difficult to reach – how do you contact someone who doesn’t have a phone or a permanent address? A field force with deep community connections can overcome some of these challenges. We have even seen examples where doctors serve as a field force to provide care visits to homeless individuals.
- Enable behavioral health capabilities: The most expensive Medicaid patients tend to be the ER superutilizers, who ping-pong in and out of the ER as much as five to eight times a year. Often these patients suffer from severe behavioral health or substance abuse challenges. Managing these expensive individuals virtually demands a well-developed behavioral health/substance abuse offering.
Keys to Success: Medicare
- Focus on strong documentation: The Centers for Medicare & Medicaid Services (CMS) uses medical record review to validate Stars and Risk Adjustment data for Medicare Advantage members. As a result, optimization of these programs relies on medical record documentation and diagnosis coding. Ensuring documentation is accurate and represents the patient’s clinical conditions and health status is critical. In addition to supporting these programs, accurate capture of clinical conditions also allows providers to understand patient needs and ensure delivery of holistic care that supports a strong physician-member relationship.
- Seek additional administrative support: Many Stars and Risk Adjustment activities live beyond the day-to-day delivery of care and can involve ensuring patients are scheduled for office visits, identifying gaps in care prior to appointments, and capturing supporting codes during the visit. Coordination of these administrative activities and clinical interventions can be challenging without proper resourcing (clinicians to capture conditions and co-morbidities; office staff and coders to translate conditions into accurate codes; technology and tools to ensure efficiency and accuracy of coding and documentation) or processes dedicated to this area (compliance plans, regular monitoring, chart reviews).
- Extend your reach beyond the office walls: While the average MA and Medicaid member may vary, the value realized through extending the provider’s reach beyond the office remains consistent across both populations. The MA population has a high incidence of chronic conditions that are exacerbated as these members age. Increasingly, adult children and other caregivers play a critical role in managing MA members and require increased access, information, and support. Providers will continue to play the primary role in supporting seniors; and to do so, will need to expand their reach through feet-on-the-street resources and technology that drives more consistent engagement and coordinated management of MA members.
We believe that providers that bear risk can have a strong impact on these high-need, high-cost populations - and also that they have the chops to turn the market on its ear by serving their communities while bearing risk.
Learn more about these trends from the infographic below and the subsequent posts in our ongoing "Risk-Ready Providers" series: