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Dual Eligible and Medicaid Managed Care Contracting

State of Affairs

Jeffrey Katz, MD, ACEPPhysicians’ Housecalls

HBPC Practitioner View/No Disclosures

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Dual Eligible patients mostly found at home

Medicaid MCO members wander:◦ Medicaid Neighborhoods◦ Do not prioritize health issues or provider

encounter◦ free government cell phones, ◦ relatives and friends addresses, ◦ cold calls, ER, pharmacy, hospital addresses

Member Location

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Find common ground, talk up not down

Demonstrate trust with follow up and follow through

Address changes in address and phone number each visit

Maintain Contact/Build Trust

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What diagnosis contributed to last ER/Hosp admission and what were triggers?

Did social/home chaos contribute to non-compliance/lack of focus?

Did untreated psychiatric/substance abusecontribute to non compliance?

Clinical Challenges

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Utilize Case Managers and Social Services for transportation, Meals on Wheels, PCA

Speak to other prior community providersincluding methadone/subox providers

Access to Regional Health Information Exchanges (“RHIOs” – CRISP in Maryland/DC),

Curaspan, Patient 360

Care Coordination

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Medicaid MCO members medically sicker and on steeper decline slope

Diabetes, COPD, CHF, HIV, Hep. C, Bipolar, Schizophrenia, Major Depression, GSW paraplegia, Wounds

Coordinate Care or fail

Common Conditions

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All MCO’s focus on cost containment so ER/Hospital utilization, specialists, skilled RN, etc.

Network and build relationships in your community, at hospital fundraisers, state medical society meetings, where-ever possible

Know your worth and articulate what you can do for the MCO to contribute to cost containment and care

MCO will pay 100% ( not 80%), on time, and a premium for accurately valued/priced services, but

Be ready to be graded on performance.

Financial Issues and Lessons Learned

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Ask for 6 month trial to demonstrate impact on cost reduction, care management,

All MCO’s rank members by relative illness burden, ER/admission risk, then group in manageability and severity groups.

Reference Academy or Scientific studies if no practice data specific to you

Talk the Talk

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Build relationship with MCO Operations department

Ask for; ◦ ER/Inpatient PMPM costs, ◦ Run Rate and ◦ VBP completion rate as a historical method to

track impact and practice improvement, (use 6 month intervals for review)

Data Mining

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Price your services with your costs and your competition in mind

MCO’s will value one stop shop to avoid members enrolling in multiple programs

Transitional Care programs and ACO’s as emerging opportunities

Be ready for all Patients with all possible diagnoses, and,

From all Payers, patients may not be homebound, just◦ frequently admitted and/or ◦ may not have existing PCP relationship.

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