Consumers with the most complex health issues are being moved into managed care forms of service delivery. During the last decade, we have tracked this slow transition to managed care (see Enrollment Of The Medicaid I/DD Population In Managed Care For Acute Care Services: An OPEN MINDS Market Intelligence Report, The Future of Medicaid Managed Care: Building a Comprehensive Care Solution for the Complex Consumer Population) and it was the focus of the keynote session at The 2019 OPEN MINDS Executive Leadership Retreat with Michael J. Hammond, MSM, Optum’s Vice President for Product and Partnership Development. His overarching message: Improving outcomes and mitigating health care costs for complex populations requires “reimagining the local ecosystem.”
To succeed with any population that has complex needs, care teams must address the “whole person” and include person-centered solutions that involve complex ecosystem of supports. System design, said Mr. Hammond, include these core elements for a redesign regardless of the population:
- Stratification and triage by risk/need
- Integration of services with a designated care home and personalized care plan
- Consumer engagement and provider engagement strategies
- Information exchange among all stakeholders
- Performance measurement and accountability
- Financial incentives aligned with quality care and health outcomes
The difference in design from one population to the next is in the focus on performance and outcomes. For the population with intellectual and development disabilities, Optum focuses on a discrete measure set including service delivery and effectiveness (percentage of ISPs with needs that have progressed towards goals, goals met and unmet); choice and control (percentage of individuals informed of and opting to use self-direction), community inclusion (proportion of individuals who have and maintain an integrated, competitive job in the community) and percentage of assessed caregiver needs identified and addressed.
For the foster care population in managed care, the focus is slightly different. Performance measures include utilization (reduction in length of stay for inpatient hospitalizations and appropriate use of psychotropic medications); quality measures such as increased awareness and training for staff and providers related to the special needs of the foster care population and improved HEDIS measures; and consumer experience using net promoter scores.
For populations with serious mental illness, performance measures have a clinical focus (percentage of case with goals met, treatment adherence, medication adherence, and seven- and 30-day follow-up) and a cost focus (readmissions, inpatient utilization, and total cost of care).
The executive discussion following the keynote focused on what provider organization executives seek from health plans. Executives were looking to be led on whole-person care coordination for behavioral, medical, and social issues and said they’d be willing to accept a per-member-per-month payment as well as an upside and downside risk based on selected performance measures. A key issue was data sharing to manage performance. Provider organization executives talked about the need for real-time, bidirectional data sharing to determine the performance of the consumers they manage.
Mr. Hammond provided advice on the need to develop contracting expertise for emerging gainsharing and risk-sharing models. His checklist for contracting included specifying level of risk, population and service requirements; outlining performance metrics and data sharing arrangements; and reviewing consumer engagement and provider network terms.
To prepare your organization for managed care for complex populations, check out these resources in The OPEN MINDS Industry Resource Library:
- Enrollment Of The Medicaid I/DD Population In Managed Care For Acute Care Services: An OPEN MINDS Market Intelligence Report
- Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System
- Managed Care Competencies Assessment
- Building A Technology Infrastructure For Value-Based Care: Tech To Support Performance Management
- Tech Step #1: Getting The Data You Need
- The Essential Tech List For Value-Based Purchasing
- Tech Step #2: Using Data To Optimize Consumer Care Coordination & Population Health Management
- Structuring (& Budgeting For) Analytics
- Does Paying For Value ‘Work’?
- How Do We Automate Population Health Management?
To learn more about this topic, join us at The 2020 OPEN MINDS Performance Management Institute in Clearwater, Florida on February 13 for the session, “Population Health Management For The Complex Consumer Market: How To Utilize Data To Coordinate Services Across The Care Continuum” with James Stewart, President & CEO, Grafton Integrated Health Network &, Advisory Board Member, OPEN MINDS.