Hospitals need to prepare for Medicare’s expected site-neutral payment program. Billions are at stake.
The biggest problem is that they underestimate how tough it is to compete with established insurance carriers.
Planning carefully for this competition “can help determine whether it’s best to enter as an independent plan, partner with an established entity that brings the right capabilities, or to take delegated risk from a health plan for an attributed population.”
Further, “to maximize the benefits, providers need to know exactly what patients are attributed to the plan—and fiercely manage each and every individual accordingly. For the sickest and riskiest patients, that means delivering care differently—more targeted and coordinated across points of care—to drive savings in a major way.”
“Most provider-turned-health plans are at least somewhat well-positioned to improve the quality and reduce the cost of patient care across a network if incentives are appropriately aligned; this of course is fundamental to running a profitable plan.”
“The best plans go to great lengths to learn and document every last issue about their patients to get this right, and then receive higher payments from CMS for those riskier patients.”
• Ensure that community health assessments include specific attention to behavioral illness.
• Review and evaluate the organization’s behavioral plan in light of identified community needs, patient needs and available community resources.
• Use a comprehensive financial and operational assessment to evaluate the benefits and value of behavioral health services to all operational components of the hospital.
• Encourage and participate in developing a community-wide plan for people with behavioral health disorders and in coordinating community agencies that address behavioral health needs.
• Work with community agencies and with state and local governments to ensure that patients are treated in the most appropriate setting so that the hospital’s backstop role is appropriately limited.
• Create a formal plan that clearly defines the hospital’s role and its established relationships for behavioral health with other providers, practitioners, and government and community agencies.
• Clearly communicate to public and private payers the costs required to care for behavioral health patients and the cost to society of not treating those patients.
“Card-sharpers by Candlelight,” by Feliks Peczarski.
“But in an exclusive analysis of state and federal data, Reuters found that more than one in five of the thousands of doctors and other healthcare providers in the U.S. prohibited {for various infractions] from billing Medicare are still able to bill state Medicaid programs.”
With millions of patients newly covered by Medicaid under the ACA, and wild differences in the program’s oversight between states, it’s hard to see how this problem won’t get worse.
“Of the other respondents, 16 percent said they are using data in strategic decision making, 28 percent are relying on data warehouses to track key performance indicators and 24 percent are using data marts.”
In other words, the care-improving and money-saving and -making potential of data analytics in healthcare has barely been scratched.
By PHIL GALEWITZ, for Kaiser Health News
CMG Editor’s note: State officials trying to bring Medicaid costs under control would do well to read this.
When Bruce Hodgins went to the doctor for a checkup in Sioux City, Iowa, he was asked to complete a lengthy survey to gauge his health risks. In return for filling it out, he saved a $10 monthly premium for his Medicaid coverage.
In Las Cruces, N.M., Isabel Juarez had her eyes tested, her teeth cleaned and recorded how many steps she walked with a pedometer. In exchange, she received a $100 gift card from Medicaid to help her buy healthcare products including mouthwash, vitamins, soap and toothpaste.
Taking a cue from workplace wellness programs, Iowa and New Mexico are among more than a dozen states offering incentives to Medicaid beneficiaries to get them to make healthier decisions — and potentially save money for the state-federal health insurance program for the poor. The stakes are huge because Medicaid enrollees are more likely to engage in unhealthy practices, such as smoking, and are less likely to get preventive care, studies show.
For years, private employers and insurers have used incentives to spur employees and members to quit smoking, lose weight and get prenatal care, although the record of those programs for changing long-term behavior is mixed, studies show. “Financial incentives are effective at improving healthy behaviors, though the effect of incentives may decrease over time,” said a report last year by the Center for Healthcare Strategies, a research group based in Hamilton, N.J.
Another analysis published this month in the journal Preventive Medicine, which looked at 34 studies, found that workplace and other incentives can change health behaviors in the short term, but the effects dissipated once the incentives were taken away.
The Affordable Care Act is behind the latest push of wellness incentives in Medicaid. Besides Iowa and New Mexico, several other states that have expanded Medicaid under the health law have incorporated such incentives, including Indiana, Pennsylvania, New Hampshire and Michigan. Montana, which is about to become the 29th state to extend Medicaid, also plans to include such incentives.
“People are looking for some creative ways to pass Medicaid expansion and incentivizing healthy behaviors is pretty palatable to both conservatives and liberals,” said Maia Crawford, program officer of the Center for Healthcare Strategies. “It’s a potential win-win because of the potential for cost savings and health improvement.”
But getting them to participate in incentive programs can be challenging. For example, an Idaho program that offered a $100 voucher to entice Medicaid recipients to lose weight or quit smoking attracted less than 2 percent of eligible adults after two years.
Among the biggest obstacles is simply getting the word out to enrollees, Crawford said. But there are other issues, too: Poor people are less likely to understand how the incentives work and to face transportation and other barriers to get to doctor appointments or educational classes that are part of the program.
‘Long Way To Go’ To Learn What Works
Little is actually known about what types of incentives get people’s attention or help change their behavior, said Jean Abraham, associate professor of health policy and management at the University of Minnesota. It’s not clear, for instance, whether rewards are more effective in prodding people to take a concrete step, such as getting a colonoscopy or a mammogram, rather than in changing long-term behaviors, such as smoking. “We have a long way to go to understand what’s most effective,” she said.
The health law sought to get answers to some of those questions by including $85 million to test incentives in 10 state Medicaid programs.
States started the studies in 2012 and 2013 and some are struggling to get participants. Connecticut, for instance, has enrolled only half of the 6,000 people it sought for a smoking cessation program. The program pays Medicaid recipients as much as $350 in gift cards over a year for participating in smoking cessation counseling, using a counseling phone line and having a Breathalyzer test showing that they haven’t recently smoked. The $10 million, three-year study will compare that group’s health costs against those of a control group of Medicaid recipients who smoke but received no help.
Other states that received funding are California, Hawaii, Minnesota, New York, Nevada, New Hampshire, Montana, Texas and Wisconsin.
Separate from the health law, one of the largest incentives program is New Mexico Medicaid’s Centennial Rewards, which gives most of the state’s 600,000 recipients the chance to earn points to buy healthcare items.
They gain points each time they engage in a healthy behavior, such as getting a checkup or seeing a dentist. So far, only about 45,000 have registered and only half of those have redeemed points for gift cards.
New Mexico officials say they are not disappointed. “It is not only a new program for us, but a new concept for most Medicaid programs,” said Medicaid spokesman Matt Kennicott.
‘I’ve Never Felt This Good’
Juarez, 57, of Las Cruces, said the program has motivated her to walk every day at the mall where she works as a hair stylist and helped bring down her blood sugar levels.
“I’ve never felt this good,” she said. “This program motivates me to do more — it’s not so much the money as it’s the improvement in my body.”
Charles Milligan, who until last month was senior vice president of Presbyterian Health Plan in New Mexico, another Medicaid plan, said he’s seen an increase in members seeking preventive care, such as diabetes screenings and prenatal care. “The rewards program helps us engage with our members,” he said. Still, only about 30,000 of their 200,000 members have registered for it.
Iowa has also faced challenges getting Medicaid enrollees to complete the wellness exam and health risk assessment survey — even though some will have to pay a $5 or $10 monthly Medicaid premium if they don’t. About 19,500 of the state’s 125,000 enrollees have faced the potential penalty. Of those, about a third completed the wellness exam and assessment.
“The goal is to get people involved and to take a more active role in their own health and we are impressed with what we have achieved,” said Andria Seip, Iowa Medicaid’s Affordable Care Act policy manager.
Hodgins, who enrolled in Iowa Medicaid in January, said he’s glad his community health center advised him about the wellness exam and health survey —not because it saved him money but because he found out that he had high cholesterol and blood sugar, which he’s now working to bring under control.
“I’ve been blessed with decent health for 57 years,” said Hodgins, who recently started a delivery company and doesn’t mind the state prodding him to get examined. “I have to be responsible for my own health. That’s my obligation.”
