Caresource scrutinized over late payments as new medicaid work arrives

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No taxpayer subsidies are involved. The government uses a similar approach with Medicare private insurance plans and the Medicare prescription drug benefit. Reed said regulations limit insurers ability to charge more to lower their risk, so the loss of these payments could make some of these insurance companies pull back or walk away altogether rather than risk big losses.

This especially will be felt by the insurers that sell plans for small groups. You just have too much risk. As of June, the rates were estimated to rise an average of 8. Many people qualify for subsidies that lower the final cost of these plans, but those who make too much to qualify have continued to see premiums soar. The Ohio Department of Insurance, which approves final premium rates for the marketplace plans, is evaluating what potential impacts there might be for plans sold on the exchange in , said spokesman Chris Brock.

Centers for Medicare and Medicaid Administrator Seema Verma said the Trump administration was disappointed by a New Mexico court ruling that questioned the workings of the risk program for insurers. Unable to totally repeal the law, the White House and the Republican-led Congress have taken a series of steps that make it harder for the ACA to work as intended. This flexibility allows plans to mitigate risks in paying for higher cost services by addressing other essential needs such as housing and transportation.

In addition to this flexibility, there are some required notifications that plans must have with their members e. For some populations, the state is more prescriptive about what is required of plans, including during transitions of care between settings and services, which are historically known as inefficient points in the delivery system. MCOs also have the ability to offer feedback on individual providers regarding their performances on evidence-based guidelines and quality metrics, some of which is mandated.

One example of this mandated provider interaction is tied to maternal mortality where the state requires additional payments to providers who convert 1 percent of Cesarean section rates to vaginal-based deliveries, which is a predictor in maternal and infant mortality. Claims data can be shared with contracted providers, but data, and reimbursement, may also be established with non-contracted providers if it allows patients to receive necessary services but does not always entail sharing discrete, outcome-related data.

Regarding the panel, the state mandates that there be a certain number of primary care providers PCP so that total capacity for a single PCP is no more than members.

The state ensures that this network of providers is meeting federal standards of adequacy and that enrollees are able to determine what providers are available. If an MCO fails to meet these standards, the state can impose sanctions. The remaining sections of the contract outline information relative to fraud, waste and abuse, financial performance including the medical loss ratio and quality.

In some respects, this measure can act as a proxy to determine if the utilization management efforts of an MCO are effective without compromising continuity of care.

Indeed, the state publishes information on this performance metric and others quarterly , with data on hearings, appeals, PAs, clean claims and complaints. It should be noted that plans were generally successful at processing claims within the state guidelines, with the average time ranging from 2. As this information has not been updated since the inclusion of behavioral health into managed care, this data will be important in evaluating how community-based behavioral health providers are faring under this system.

Early signs did show struggles for some MCOs, particularly CareSource, although current data indicates improvements have been made. Comparison as the basis of performance enables an evaluator to understand achievement in a realistic, applicable context. In a service-based industry like health care, however, comparison can be difficult because of the amount variability and the depth of inputs that can affect the outcomes of any given service for any given individual.

To this end, the population health model becomes the primary way health care is delivered by the state through its agreement with the plans and, consequently, the contracts between plans and providers. Population health has myriad definitions but, for this brief, population health will be defined by the health outcomes of a group of individuals, including the distribution of such outcomes within the group.

Since it is an entitlement designed as a public good effectuated through government, the role of the state is to balance the pressure to control costs with that of enabling service for eligible members of the public. To this end, ODM has established measures in its contract with managed care that try to create a basis of comparison, diminish the impact of chronic diseases on expenditures and account for the public health priorities of the state.

Risk, in insurance terms, is the likelihood of an insured service taking place. For this reason, in the context of population health, there are individuals who are lower risk less likely to receive a service and higher risk more likely to receive a service.

This stratification process must also include using a standardized risk assessment tool for the purposes of stratification within 90 days of enrollment. For each of these populations, the MCOs must outline specialized services and resources that align the stream with their associated level of risk. It is within this framework of population-aligned, risk-informed services that managed care has the highest potential for value creation.

Included in these specialized services and resources are requirements for care management, risk assessment, individualized care plans, staff availability and identification, routine communication requirements, transitions and technology which documents all of these pieces.

There are also requirements to work within specific projects of the state, including the Comprehensive Primary Care CPC initiative, behavioral health redesign, co-management of home and community-based waiver populations with waiver administrators, and case management of individuals leaving correctional facilities.

Plans also must engage in activities which utilize statistically-based quality improvement science and engage in activities, as directed by the state, to address health disparities tied to social or economic disadvantage. To understand how MCOs act as agents of ODM in effectuating population health, it may be worthwhile to focus on CPC and behavioral health redesign as outlined in the contract as examples. A second aspect of the payment model includes the opportunity to participate in shared savings for practices who meet population and performance qualifications.

This includes information sharing, the identification of needs, common case management and data regarding attribution and utilization. Unlike other parts of the managed care program in Ohio, this requirement to commonly case manage populations is unique. A Health Affairs national review of the model did not show many meaningful results in terms of outcomes or costs, though other analysis suggests that the project needed time to mature and that physicians were generally more satisfied and thought the CPC initiative made their work more productive.

It should be noted that this effort, known as Behavioral Health Care Coordination, is still being finalized as this paper is being published. With that said, the current requirements for this partnership contemplate coordinating with the primary care provider for the enrollee, participating in QBHE meetings as needed, notifying the QBHE of any critical transitions such as admission to an emergency room , closing gaps in care and other social needs, and providing technical support to QBHEs around data use.

While QBHEs have always played a role in case managing the needs of individuals with severe mental illness or substance use disorders, the community-based system has been disconnected from the traditional medical environment, and is also left out of electronic health record incentives and medical education payments for workforce development.

To this end, MCOs play a role not only in assisting QBHEs with connecting case management functions between QBHEs and other providers, but also are intended to compensate for this lack of capacity through contractual mandate. The state, pursuant to federal law, must have an independent evaluator examine how MCOs are performing relative to quality benchmarks but also develop individualized data around utilization, encounters, patient experience and case management.

In October , the state of Ohio issued a report on the P4P program. These measures were:. As mentioned earlier, P4P is based on a sliding scale, where the minimum payment is made at the 25 th percentile and the total bonus is earned once the 75 th percentile is exceeded. For the six P4P measures, a low of The state could increase or decrease the minimum and maximum percentiles for P4P.

It should also be noted that these are relative measures, meaning the percentile is based on national comparisons for any given measure, not that of a true rate of completion i. As mentioned previously, the state contracts with an independent evaluator to determine quality achievement.

This brief will not examine the CAHPS results of the MCOs as they are not tied to payment via P4P, but every plan was above the 25 th percentile for all measures, with the most common rating being above the 90 th percentile, indicating Ohio enrollees are generally satisfied with their plans and the associated contracted providers.

Reflecting on this data, it should be noted that no single plan met all minimum performance standards in Only the following measures, all of which are tied to pharmaceuticals, earned the highest ratings:.

However, as of April , the P4P program as a bonus structure was sunset and a withhold arrangement, wherein up to 2 percent of the total capitation awarded to plans will have to be earned back through the achievement of quality, was installed.

For those dollars that are not earned, a bonus pool is available to those plans which achieve above the 75 th percentile. As opposed to the previous P4P program, the quality measures in state fiscal years and will be tied to cardiovascular disease, diabetes, behavioral health and healthy children.

Since , ODM has built upon its initial contractual arrangement to tie more dollars to value and prescribe greater attention be paid to high-risk, high-cost Medicaid enrollees as well as performance improvement projects based on historical performance. OAHP claimed quality vastly improved. A report from the U. Given the high-level of concern from providers about payment, it makes sense that the dueling pressures of timely payment and adequate fraud protection require some level of contractual and procedural contemplation by the state.

To that end, there are some considerations the Ohio Department of Medicaid could take into account as it revisits its contract with MCOs through the rebidding process. According to national research, it takes an average of 17 years before evidence makes it into clinical practice. In other words, the process of implementing the best medicine possible is not always consistently and standardly communicated with clinicians, therefore leading the system to be defined by fragmentation.

In the context of Ohio Medicaid, many of the efforts over the last few years can be seen through the introduction of standardized, value-based concepts into clinical workflows. According to the data that is available, these efforts are having a positive impact on cost and quality, but not as much as they could.

The process of implementing the best medicine possible is not always consistently and standardly communicated with clinicians. Some of the current system may not be achieving its full potential because the arrangement of the delivery system information is asymmetric and asynchronous. Asymmetry is happening because the types of data that exist are disparate and not readily shared through a common tool in a broad way.

This means that the clinical information on any given patient is not always available to the person or persons responsible for delivering care. If some of the highest-value services come in the coordination beyond clinical spaces to non-clinical services, this is a significant continuity issue. In theory, a provider could reach out to an MCO or an MCO to a provider if there are gaps in care or if there are specific high-risk cases which need collaboration.

That said, there is no formal systemic tool or protocol to do this, so there is no overt incentive. Key in this conversation is the problem of asynchronous information exchange wherein the data that is exchanged, whether it is clinical or claim-based, does not always happen in a real-time manner, meaning care decisions may not be circumspect.

And while the CPC initiative promotes direct engagement between providers and payers, the state of Ohio could consider optimizing the specific case management engagement between the two groups for the highest risk populations.

Put simply, if they are not sharing information, the state could make them. It will be worthwhile to see how the withheld arrangement compels MCOs to think differently about the ways in which they collaborate with providers. Perhaps this sort of tool can be equally shared with providers, allowing MCOs to automatically adjust their contracted rates with providers relative to measures tied to quality.

In other words, MCOs and providers should share the penalty. Beyond this, the state could consider doing more to enable better information exchange between plans and providers. While Ohio has previously contemplated transparency laws, those were focused on patients, the least empowered actors in the commercial process of health care. While some may say that is the exact logic and thus the basis for such regulation, it has actually been shown to increase utilization and costs, which is the opposite of the desired effect.

Additionally, the state could develop a comprehensive, comparable all-payer claims database APCD or electronic clinical quality measures eCQMs which include medical claims, pharmacy claims, dental claims and eligibility and provider files collected from private and public payers.

Importantly, data on quality achievement, while publicly reported for payers, is not reported for providers in Medicaid. Even in the context of payers, it is confusing and technical. If Ohio continues the general structure of HEDIS, it should review which measures are included and to what degree they are achieved. For public health crises like these , Ohio could make the P4P incentive or withhold more significant for a period of time to concentrate on the issue through that measure and consider tailoring any given measure to the needs of a given geography.

While a number of the interventions were outside of the program increasing public transit funding as a way to address transportation issues for beneficiaries , a number were also possible through intentional Medicaid policy design. Many of these interventions, borrowing from other states, relied on the use of demonstration waivers to address these issues. Outside of waivers, though, there are policies the Ohio Department of Medicaid could consider as ways to increase accountability for plans and providers to address social determinants as a cost-saving measure.

Referencing 42 CFR , there are a number of provisions which enable states to better engineer their payments towards social determinants through managed care: [42]. Require plans to provide incentives to providers who screen for non-medical problems. Develop metrics built on transitions of care across clinical and non-clinical settings. As was mentioned in an earlier section of this brief, MCOs have their rates risk-adjusted so that payment accounts for the potential intensiveness of need.

In Massachusetts, the state added social determinants to this rate calculation process, creating a natural incentive for plans and providers to document these needs as they affect final reimbursement. Finally, Ohio could consider evolving beyond managed care into something wholly separate with accountable care organizations. Accountable care organizations are groups of doctors, hospitals and other providers who come together voluntarily to give coordinated care. With ACOs, what the state would be doing is essentially opening up the market to new entrants.

This could, in effect, allow for some innovative arrangement to come into the picture, though a few things should probably be kept in mind during design. For one, community organizations would have to be included. In some states, like North Carolina , ACOs must contract with community organizations and sub-contract the case management to these local organizations.

If, for example, someone has an intense behavioral health need and they rely on services from that provider more regularly than they do their primary care physician or MCO, the behavioral health provider leads the case management efforts. Additionally, these arrangements must be full risk, especially for providers. The reality in American medicine is that price is what is driving up cost and providers at least their employers are responsible for this problem, not patients.

Lastly, whatever the arrangement, it must put patients at the center of its design. Any organization operating as an ACO must be responsive to the needs of patients and patients should have decision-making authority in the organization. Whatever delivery model is enacted through policy, there are the commonly shared values of a better experience for patients and clinicians, lower costs and increased quality.

Given the difficulty in transforming this complex system, particularly in a program with the depth and breadth of Medicaid, reforms, understandably, take time. It is with this in mind that an examination of the data is necessary and the data tells us we are, slowly, improving.

While there are some successes to be had in the innovations over the last few years , more can be done particularly in the areas of social determinants and transparency. Contracts with managed care organizations, which receive billions of taxpayer dollars, should be designed in such a way that we maximize their value to create an efficient and effective delivery system.

It is for this reason that, while the legislature should demand transparency from the Ohio Department of Medicaid, it should entrust ODM with the complicated, ever-evolving work that only an executive function could offer. If we know, empirically, that costs are the result of a combination of social determinants and price, then our system should be engineered to address social determinants and price.

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States were previously not allowed to tie Medicaid eligibility to work requirements, but the Trump administration opened the door to let states add such requirements. The health insurance program for low income Ohioans — jointly funded by the state and federal government — covers about 3 million residents, with about , covered through Medicaid expansion.

The state reported that about 95 percent would be exempted from the requirement for those covered by Medicaid expansion to either have a job for at least 20 hours per week, be looking for work, or attending school or job training. Critics have said more people would likely lose coverage than the state estimates, pointing to the higher than predicted number of residents who lost SNAP benefits when Ohio created work requirements.

The decision could be a setback for the Ohio Department of Medicaid, which is waiting on federal permission to add job requirements for those covered through the expansion of Medicaid through the Affordable Care Act. We hope the Kentucky decision is appealed, and we expect that it will be. Kentucky was the first state in the country to get that permission, and the new rules were scheduled to take effect Sunday in a northern Kentucky suburb of Cincinnati.

Boasberg blocked the rules because it said the Trump administration never adequately considered whether the changes would comply with the central tenet of Medicaid: Providing health care for its citizens. Department of Health and Human Services so the process could be restarted. The state should abandon its effort to create work requirements, she said. The process for getting approval for work requirements likely will be slowed by the ruling, according to Rea S.

Hederman, vice president of policy for The Buckeye Institute, an Ohio free-market think tank. The Buckeye Institute voiced support for the requirements during the public comment phase of the approval process.

Ohio re-worked all the billing codes and upgraded the information technology requirements for providers. Some delayed payments can be blamed on those changes. Still, some worry that payment problems could put undue financial strain on smaller behavioral health providers. MORE: Did drug distributors contribute to opioid crisis? Yes, says local exec. Susan Bichsel, chief executive of Jewish Family Service Association of Cleveland, said her agency has had similar problems with CareSource failing to promptly pay Medicaid claims for services such as home health care.

The backlog has since been cut in half. CareSource said as of today, Jewish Family Services has 60 outstanding claims. Bichsel said she had to hire three additional people in her finance department to deal with the rejected claims and make appeals to CareSource.

Who has staff for that? Measures to protect There will also be measures to protect providers as the plan rolls out. In Other News. About the Authors. Laura A. Kaitlin R Schroeder. All Rights Reserved. Learn about Careers at Cox Enterprises.

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We hope the Kentucky decision is appealed, and we expect that it will be. Kentucky was the first state in the country to get that permission, and the new rules were scheduled to take effect Sunday in a northern Kentucky suburb of Cincinnati. Boasberg blocked the rules because it said the Trump administration never adequately considered whether the changes would comply with the central tenet of Medicaid: Providing health care for its citizens. Department of Health and Human Services so the process could be restarted.

The state should abandon its effort to create work requirements, she said. The process for getting approval for work requirements likely will be slowed by the ruling, according to Rea S. Hederman, vice president of policy for The Buckeye Institute, an Ohio free-market think tank. The Buckeye Institute voiced support for the requirements during the public comment phase of the approval process.

The judge wants more detailed information from the Administration on how these waivers meet the goals of the Medicaid program. Ohio says yes. Loren Anthes, Medicaid researcher with Cleveland-based Centers for Community Solutions, has said the changes would add costly red tape to oversee the requirements and would also create uncessesary barriers to health care.

MORE: Ohio Medicaid overhauling how it pays for addiction, mental health care The process for getting approval for work requirements likely will be slowed by the ruling, according to Rea S. Ohio says yes Loren Anthes, Medicaid researcher with Cleveland-based Centers for Community Solutions, has said the changes would add costly red tape to oversee the requirements and would also create uncessesary barriers to health care.

The growing company is headquartered downtown and just completed construction on a second office to house about employees. The redesign of how Ohio Medicaid pays for behavioral health was several years in the making as part of a broader plan to integrate behavioral health care with other types of health care.

Corcoran and Criss said in their letter sent April 19 that both of their departments have heard concerns and the departments are focusing on how to address challenges related to the system changes. MORE: State's record for enforcing insurance mandate quest ioned. In Other News. About the Author Kaitlin R Schroeder. All Rights Reserved. Learn about Careers at Cox Enterprises.

Back to Top. Thirty-nine area residents are among Ohio consumers who filed complaints with Ohio Attorney General Dave Yost about problems with residential solar energy systems installed by Pink Energy, formerly known as Power Home Solar, a North Carolina company that closed and filed for bankruptcy in October.