We’ve seen an increase in Medicaid and Medicare consumers in specialty health plans during the last decade—”vertical” plans organized for consumers with specific needs. There are now more than 700,000 Medicaid beneficiaries in these plans (see The Medicaid Vertical Carve-Out Landscape: The 2019 OPEN MINDS Update). And in the Medicare market, there are 2.5 million Medicare beneficiaries served by SNPs, 12.3% of the total 20.4 million Medicare Advantage enrollees (see Medicare Specialty Vertical Carve-Out Plans: The 2018 OPEN MINDS Medicare SNP Market Share Report).
During the recent 2020 OPEN MINDS Performance Management Institute, we had a chance to learn some of the challenges – and best practices – for making these plans work from two executives who are in the middle of the action. In their opening keynote, New Models For Complex Consumers: The Role Of Vertical/Specialty Consumer Health Plans, John Selig, vice president, Public Sector, Optum, and Julia Brillhart, RN, MSN, national vice president, Operations, Magellan Complete Care, illustrated the challenges needed to make this relatively new model work. Optum conducts independent assessments used by the Arkansas Shared Savings Entity (PASSE) program, a specialty plan for consumers with serious mental illness (SMI) and intellectual/developmental disabilities (I/DD) (see Which State Had The Greatest Change In Medicaid Managed Care? What Is Coming In 2019?). Magellan is managing a specialty health plan for consumers with an SMI in three regions in Florida.
Arkansas set up the Provider-Led Arkansas Shared Savings Entities (PASSE) to manage benefits for about 40,000 individuals with an SMI or I/DD diagnosis (see Arkansas Medicaid To Launch Full-Risk Phase Of Medicaid Shared Savings Program In March 2019). The entities are at full financial risk for acute care, behavioral health, pharmacy, and support services, receiving a capitated (per member per month) payment. By regulation, the PASSEs are a collaboration between a group of provider organizations and a managed care organization – and must be at least 51% provider owned.
A unique feature of the Arkansas program is using an independent assessment to evaluate program participants and set rates. In Arkansas, Optum was awarded a contract for that role (see Arkansas Seeks Independent Assessments And Transformation Support Services) and has completed more than 80,000 assessments. There are three tiers for behavioral health assessments: Tier 1 (lowest) includes counseling level services, Tier 2 (intermediate) for rehabilitation services, Tier 3 is (highest) for intensive-level services. For I/DD, there are two tiers that stratify consumers by need for institutional-level care that might require 24/7 paid supports.
The independent assessments and PASSEs faced stumbling blocks early in the process. “Beneficiaries were wary, some providers were resistant, referrals were problematic, the assessment tool algorithm required adjustment, assessors needed additional training, and provider business flow was disrupted,” he explained. There were also payment issues. In fact, almost a year elapsed before PASSE claims payment problems were resolved, noted executives from Arkansas who were in attendance and participated in the program. The number of PASSEs went from five to three, which was attributed to concerns about having enough members assigned, managing complex data and operational systems as well as financial risks. “A year in, the situation is much-improved,” said Mr. Selig. “Consumers and providers are more comfortable with the process, and the state is saving money and collecting valuable data.”
In Florida, Magellan Complete Care (MCC) of Florida started initial rollout as the specialty plan for individuals with SMI in 2014 (see Magellan Complete Care Florida Medicaid Contract Goes Live) and was rebid in 2015 (see Florida Seeks Medicaid HMO Reform And Capitated Health Plan Services). Members for the integrated managed care program designed by the Agency for Health Care Administration for individuals with SMI and mandated by the state legislature are assigned using an algorithm based on two years of utilization history, diagnostic data, and pharmacy data. There are currently 18,300 members enrolled in the program, which covers physician visits, hospital care, prescribed drugs, mental health care, and transportation.
Challenges faced by specialty health plans include finding shared goals with consumers, providers, and care teams, the ability to create a realistic picture of success, as well as these issues outlined by Ms. Brillhart:
- Multiple funding sources for behavioral health programs can lead to duplication and fragmentation of services – jails, school systems, crisis system, housing, child welfare
- Limitations on addiction treatment information being shared, due to confusion over 42 CFR Part 2 and state laws
- Shortage of behavioral health care professionals, particularly in underserved areas
- Stigma of enrolling in and carrying a membership card for a health plan dedicated to SMI
- Concerns at the medical professional level about working with individuals living with SMI
- Member churn poses a challenge to care continuity
- Establishing quality metric and outcome improvement measures, baselines, and benchmarks based on special populations
Recommendations from executives working to improve working relationships with specialty health plans: Consumer engagement is critical to success, new models of collaboration are required, social service supports are critical to the well-being of all consumers with chronic conditions, and a systematic approach to braiding multiple funding streams is key. I walked away with one common belief from these two experts: There is no “magic bullet.” Assuring the well-being of consumers with complex needs takes a good plan, hard work, and a willingness to recognize what doesn’t work, retool, and keep moving forward.
For more information on vertical specialty consumer health plans’ integrated models, check out these resources in the OPEN MINDS Industry Library:
- Specialty Health Plans On The Increase In Medicaid
- The Medicaid Vertical Carve-Out Model Comes To I/DD
- Will Health Plan Backward Integration ‘Remake’ Specialty Care?
- The Medicaid Vertical Carve-Out Landscape: The 2019 OPEN MINDS Update
- The Health Plans Have It!
- Health Plan Marketing Strategy – Reading The State-Specific Market Landscape
- The Changing Face Of Integration
- Medicare Specialty Vertical Carve-Out Plans: The 2018 OPEN MINDS Medicare SNP Market Share Report
- The Medicaid Care Coordination Models Driving Strategy In Your State
- Health Homes, Specialty Health Plans, CCBHCs. Oh My!
And for more, join us June 1 at The 2020 I/DD Executive Summit: Strategies For The Future, featuring Ken Anderson, Senior Associate, OPEN MINDS and Drew Di Giovanni, Senior Associate, OPEN MINDS; and facilitated by OPEN MINDS Senior Associate Ray Wolfe, J.D.