2015-08-06-奥纬咨询-How_to_Succeed_in_Managed_Medicaid_6页_147kb

POINT OF VIEW: HOW TO SUCCEED IN MANAGED MEDICAID

• Welcome to the world of Managed Medicaid – not profit-free, not mysterious, not something to ignore. It is a crucial and growing part of healthcare, accounting for a significant portion of health plan revenue.
• Forget outdated views of Medicaid. It's complex (state-by-state rules), challenging (difficult to profit), but growing rapidly due to demographics, ACA, and economic factors.

1. UNDERSTAND THE POPULATION AND MARKET

• Complex Population: Medicaid beneficiaries are distinct from commercial populations, comprising low-risk groups (children, families) and high-risk, high-cost groups (Aged/Blind/Disabled, ID/DD, SCI/TBI).
• Deep Population Knowledge: Success requires understanding specific needs within these groups and appreciating the unique characteristics of each state's program, including eligibility, benefits, exclusions, and reimbursement mechanisms. Treat every state as a valued customer.
• Personas Are Crucial: Understand the nuances and potential overlaps in needs within and across different population segments.

2. BUILD A PURPOSE-BUILT CARE MANAGEMENT (CM) OFFERING

• Tailor, Don't Adapt: Design a CM program specifically for Medicaid, going beyond immediate medical needs to include vital social determinants like employment, housing, and social support.
• Do More Than Assess: Implement thorough, ongoing assessments to accurately understand individuals' true needs and qualify them for potential state-funded services. This improves cost management and member care.
• Multidisciplinary Teams: Employ diverse professionals (social workers, home health aides, respite, nutritionists, ADL support) to deliver comprehensive care.
• Personal Connections: Use a dedicated field force (face-with-a-name) to build trust, understand living situations, provide personalized coaching, and connect beneficiaries to necessary community resources.
• Leverage the Community: Utilize community networks (churches, shelters, community centers) to reach members and enhance CM effectiveness.

3. MANAGE REVENUE AND COSTS EFFECTIVELY

• Accurate Risk Assessment & Adjustments: Utilize state-specific risk adjustment programs diligently to ensure proper payments, manage variation, monitor population shifts, and meet regulatory requirements.
• Quality Focus: Improve care quality while driving down costs by tracking and improving quality metrics (though standards vary), especially for dual-eligible populations affecting Medicare Star ratings. Increasingly link quality scores to Medicaid reimbursement.
• Fraud, Waste & Abuse (FWA) Monitoring: Strong, relentless monitoring of provider billing and service delivery is crucial to combat widespread FWA, ensuring legitimate coverage and controlling costs.

4. CULTIVATE THE RIGHT ORGANIZATIONAL MINDSET

• Focus on the Person: Serve the end customer – the highest-need segment in healthcare. Embed this mission.
• Empower Staff: Enable employees to provide person-centered care, treating "the person" first, not just "the patient."
• Culture of Doing Right: Foster an environment where doing the right thing for Medicaid members is the core principle.

FINAL THOUGHT: Tapping into the $125 billion+ Medicaid market offers significant business potential and a powerful chance to positively impact lives through improved care coordination and resource access. Success hinges on strategic operational setup coupled with a genuine commitment to serving this unique population.