Electronic Health Reporter

By Michael Scarbrough, board member, AristaMD.

If it isn’t already clear, the headlines are signaling that the era of healthcare innovation is upon us and moving swiftly. Managed Medicaid plans could be losing out on millions of contracted lives (and money) by lagging in the adoption of digital telehealth resources to improve access to care and patient outcomes. Leveraging an eConsult solution is a proven way to increase access to high-quality care while lowering system cost, ensuring innovation scoring opportunities are not missed.

Innovation is the new constant

Although the pace of innovation in healthcare has traditionally been slow, organizations are increasingly seeking new ways to innovate in order to support value-based care models. Recent partnerships formed between Amazon, Berkshire Hathaway and JPMorgan Chase, CVS and Aetna, Cigna and Express Scripts, and so on strongly indicate that innovations rooted in providing better care for lower costs are paramount to the success and growth of healthcare.

Payers whose ongoing strategies are not placing precedence upon innovation will be left in the dust. Not only will this be costly for access and quality, it can jeopardize managed Medicaid payers’ chance of re-procuring and expanding contracts.

Managed Medicaid Plans must innovate to reach objectives

Managed Medicaid plans need innovations to improve the value and efficiency of healthcare provided. To ensure they’re getting the best value, state Medicaid programs re-procure contracts with managed care payer groups on a perpetual basis — sometimes as frequently as every three years. States use these periods as an opportunity to seek updated solutions to long-standing or emerging challenges, often assigning points to questions that speak to innovations in care delivery for Medicaid recipients.

Key Medicaid challenges

Barriers to care and access within Medicaid programs are often among the most important issues states and managed care plans are attempting to address. The Kaiser Family Foundation 2017 survey of Medicaid managed care plans reported high rates of difficulty in recruitment for some specialties and listed provider supply as a leading challenge.

Timely access to care is key to healthcare goals, as delays in accessing necessary care exacerbate health conditions, in turn leading to more costly treatment and poor outcomes. This lack of care access worsens a health crisis that could have been easily avoided with more proactive (and less expensive) care.

A key takeaway from 2018’s 11th annual Medicaid Managed Care Summit was that, “Reforming healthcare in the U.S. is not about spending more money, but about moving around the dollars that we’re already spending.” Adoption of eConsult platforms allows health plans to solidify their value-based initiatives and Medicaid payers to expand access to needed specialist services, bring new physician access points to urban and rural areas and leverage the latest in technology and sophisticated referral protocols to help meet members’ care needs.

How innovation can secure contracts

We can look at North Carolina’s August 2018 request for proposals as an example of how innovation is crucial to securing and expanding contracts. The proposal evaluation criteria included several measures related to telehealth. A few key examples below:

“Promote and monitor North Carolina’s Medicaid Managed Care sustainability by developing the processes, standards and data protocols needed to demonstrate good financial stewardship of limited resources and adherence to financial management objectives.”

“The PHP (prepaid health plan) shall provide services via telemedicine to Medicaid and NC Health Choice Members as an alternative service delivery model in compliance with all state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA) and record retention requirements. The services provided via telemedicine shall be provided in an amount, duration and scope no less than the amount, duration, and scope for the same services furnished to beneficiaries under the Medicaid Fee-for-Service program. 42 C.F.R. § 438.210(a)(2).”

“The PHP may use telemedicine as a tool for facilitating access to needed services in a clinically appropriate manner that are not available within the PHP’s network.”

“The PHP may use telemedicine as a tool for facilitating access to needed services in a clinically appropriate manner that are not available within the PHP’s network and in accordance with the PHP Telemedicine Coverage Policy.”

As many contracts are lost over matters of one or two points, innovation is a key category and can mean the difference between winning and losing a contract worth hundreds of millions of dollars. North Carolina’s RFP shows us the emphasis in which innovative solutions are expected.

Access is a top issue where states are seeking resources to improve. The adoption of an eConsult platform is the commitment to stewarding resources in order to achieve value-based goals that state Medicaid plans are looking for to best serve their patient populations. The time to innovate is now — and failing to stay ahead of the curve could cost plans millions.