Assuring adequate revenue for a duals care coordination program is critical to its success, says Julie Faulhaber, Health Care Services Corporation’s (HCSC) vice president of enterprise. Being sure that care planning and risk assessment components adequately and appropriately document the concerns of the individuals will help health organizations to bypass this potential roadblock.
The first big roadblock to consider is when programs are not integrated and how that impacts members’ plans and regulators. For example, we have a dual eligible special needs plan (SNP) in New Mexico. It is not a fully integrated dual eligible SNP. We also have Centennial care riding side by side. That is great because members can be enrolled in similar programs, so that is much more of a benefit than having people in FFS Medicare.
However, it still means members have two ID cards, two sets of member materials, and often three places to call Medicare and Medicaid. Then you add in the waiver services the person qualifies for. Being able to figure out different appeals, grievance processes and more is a big quality issue to members struggling with their health issues.
Integration is a key piece for the member perspective, as well as from a plan’s perspective. It is expensive to operate these programs and to coordinate when you don’t have all of the pieces in your control. That impacts the regulators as well. One way to overcome this is to focus on the win-win opportunities for integration.
Another roadblock is unrealistic regulator expectations. When regulators set up programs, they read about clinical best practices, and that is what they want to use as standards. They often do not take into account the actual realities and expertise brought by managed care. It is important to encourage those regulators to look at realistic situations. It is also important to be persistent in addressing these issues with facts and other best practice examples that could be brought in lieu of what they have in place.
A third roadblock is low revenue, or low risk adjustment. Risk adjustments are so important with the dual eligible population. Having a financial team look at that before you enroll in or begin a program is crucial.
People with disabilities, and especially those with primary behavioral health concerns, score low in many models. Be aware of that as you review models employed by states. Even in Medicare models, these individuals tend to score a little low.
To assure adequate revenue for the program, be sure that your care planning and risk assessment components adequately and appropriately document the concerns your individuals have.
Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population describes HCSC’s innovative tactics to engage this largely older adult and disabled population in population health management with support from a range of community partners and services.