The Brave New World Of SMI Population Management – New Care Coordination Model, New Financing Model

Executive Briefing | by | February 16, 2015


Monica E. Oss
Monica E. Oss

Over the past two years, there has been lots of discussion about “integration” and we have covered the emerging range of integrated care coordination models – the growth of Medicare SNPs (see Medicare Advantage Enrollment Up 9% Between 2011 & 2012), the emergence of Medicaid managed care plans for LTSS services and the dual eligible population (see 47 States To Expand Medicaid LTSS In 2015), and accountable care organization (ACO) and medical home constructs within health plans (see CMS ACO Outcomes Data Identifies Highest-Performing ACOs and Medicaid Accountable Care Organizations: Program Characteristics In Leading-Edge States). What these changing models share is the move to coordinate consumer care not by the type of clinical problem, but by the type of specific consumers and consumer needs – the transformation of a horizontal care management system to a vertical care management model.

Manuel Arisso, JD, LHRM

What does the new “vertical HMO” concept for SMI consumers look like in practice? We got the answer to that question during the keynote address at the 2015 OPEN MINDS Performance Management Institute, The Challenges & Opportunities Of Moving To Integrated Care Management, by Manuel Arisso, JD, LHRM, CEO of Magellan Complete Care of Florida. Magellan’s initiative in Florida is one of two national initiatives (the other in Maricopa County in Arizona – see Mercy Maricopa Integrated Care Launches Arizona Regional Behavioral Health Authority Contract and Mercy Maricopa Offers Medicaid Beneficiaries With SMI Four Integrated Care Options) where behavioral health care management programs has expanded to include management (and financial risk) for medical, pharmaceutical, dental, and other benefits. (To review our coverage of the Magellan initiative in Florida, check out Magellan Health Services Chooses Casenet To Support Magellan Complete Care, Magellan Complete Care Florida Medicaid Contract Goes Live, and Magellan Complete Care Of Florida Reports SMI Specialty Plan Enrollment At 26,500) If this concept is successful, it will likely change the U.S. health care delivery system map in some very fundamental ways.

In Mr. Arisso’s presentation, I was struck by two fundamental changes – one in the operationalization of care coordination and the other in financing. Mr. Arisso referred to the Magellan care coordination model as its “secret sauce.” The model is an approach with four areas of focus – health promotion, disease management, care management, and utilization management – and has eight key players:

  1. Integrated Care Case Manager (CM) – A registered nurse or a licensed mental health professional who works with the treating providers and other members of the team, and puts together a care plan. They also keep track of how things are going for members with complex situations.
  2. Health Guide – A professional that helps the member make their way through the health care system. The Health Guide helps to make and keep doctor appointments, and coordinates with community agencies and other resources.
  3. Primary Behavioral Health Professional – A mental health professional who co-leads the Care Coordination team and is responsible for overall clinical direction when primary diagnosis is a serious mental illness.
  4. Primary Medical Professional – A medical professional who co-leads the Care Coordination team and is responsible for overall clinical direction.
  5. Pharmacist – A pharmacist who reviews medications used, as needed.
  6. Peer Support Specialist – A professional who provides emotional support and to give hope for the future.
  7. Wellness Specialist – A professional who helps members develop skills in self-management of chronic medical conditions and healthy lifestyles.
  8. Care Workers – A professional who locates other community services for members and arranges access to care.
  9. Family member Caregivers Or Representatives – Non-professional individuals who help with a member’s care, are also included in the team.
mcc-member-network

This team has (to me) a surprising intensity of real time contact. In addition, the care coordination efforts are supported by technology – most members have a cell phone and text messaging is a commonly used mode of communication. While this may sound like “overkill”, the investment in care coordination has a substantial return-on-investment (ROI) potential when you consider that 2,000 members of the fee-for-service (FFS) Medicaid population in Florida used $200 million in total benefits (health, behavioral health, pharmacy, and related health care expenses).

The other area of innovation is in the financing models. Mr. Arisso gave an example of Magellan establishing a global capitation model, where a primary care provider organization and a behavioral health provider organization will share a capitation rate for outpatient services – and share with Magellan in the savings on the use of inpatient costs. This is a model, along with others, that will offer great opportunity for payer/provider collaboration, for incentivizing meaningful integration of care coordination between primary care and behavioral health, and for facilitating the use of innovative practices (including technology) in serving consumers.

Will this model become the norm for population health management for the SMI population?  We’ll know more in the next year – and we’ll bring you the developments as they occur. If you couldn’t join us in Florida, follow us on Twitter @openmindscircle with the official institute hashtag #OMPerformance; and check out pictures live from the event on our Facebook page.


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