Managed Care in 2020 and Beyond: The Decade for Integrated, Individualized Care

February 20, 2020

Cardinal Innovations Healthcare is the largest specialty health plan in the country, insuring more than 850,000 North Carolinians with complex needs. Using a community-based model of care management, Cardinal Innovations has led the way in developing services, processes and solutions that improve the lives of our members and their families. Recognized for operational excellence, innovative solutions and superior outcomes for members, accuracy and speed of payments to providers, and cost-effective funds management, Cardinal Innovations is a leading healthcare company in the United States.

Dietrick Williams is the Chief Operations Officer at Cardinal Innovations Healthcare (full bio at the end).

Meaningful efforts in managed care programs over the past decade have led to improved care delivery across the country. Advancements include the development of accountable care organizations (ACOs) and the implementation of the Affordable Care Act (ACA). Specifically, successful ACOs have empowered providers to focus on care quality over cost, helping to improve member engagement and outcomes while impacting costs at the same time.

Meanwhile, through the implementation of Healthcare Exchanges, the ACA has given more individuals access to care and has improved insurance coverage choices. It’s paved the way for greater consumerism in healthcare, with health exchanges simplifying how members compare and buy insurance plans. Plus, as Medicaid expansion has spread across states, health plans have been compelled to evaluate their benefits, products and programs to build more consumer-friendly offerings.

These are good things. Today, consumers have more healthcare options and more control over them. Managed care has evolved into a more holistic part of the consumers’ world. It’s no longer just about copays, deductibles, and premiums, but has become part the overall quality of life for individuals and families.

As we move into the new decade, members ideally will start to be able to tailor their healthcare with the same flexibility and ease with which they now purchase auto insurance. The care they receive should be whole-person centered, holistic, and integrated, accommodating the full range of their clinical, behavioral, social, and spiritual health needs.

But first, there are key challenges that we’ll need to address. Among the biggest hurdles are creating effective care delivery models and developing effective partnerships with key stakeholders. That’s because there is no 1-size-fits-all solution in managed care. Nuances abound — across markets, regions, cultural competencies, geographies, and member populations — and each factor plays into how well any system can deliver care.

Going forward, there are significant opportunities to develop more effective managed care delivery models for more Americans. A critical first step? Recognizing that everyone’s healthcare requirements are different, especially those with complex care needs.

Understanding the member population

For any state, county, community, or catchment area, figuring out the right managed care approach requires a deep understanding of the member population being served. That includes recognizing that what works in California, the Midwest, or rural North Carolina will look different elsewhere based on the unique healthcare needs of those citizens. Managed care organizations must look at the social determinants of health (SDOH) that factor into well-being, as well as the cultural disparities within race, religion and age before deciding on delivery system models and improvements.

In doing so, we’re navigating a significant shift. Instead of asking, “How do we pay for care?” the question is becoming, “What does our community need to live and remain healthy?” Addressing clinical, behavioral and SDOH needs may be new territory for some communities, but it’s an essential part of the conversation.

For example, helping an individual manage a condition such as diabetes is more effective if the provider understands that the member’s medication compliance may be impacted by their schizophrenia, further compounded by inadequate housing or food. By addressing those issues in their entirety, there’s a greater chance of successfully controlling the member’s diabetes.

Likewise, transportation is a big factor in the successful care of many members. A program initiated in Stokes County, North Carolina, for example, connects member engagement teams with community boards and service organizations to improve access to care for many individuals within the community. Working together, these organizations provide transportation for members to get to and from their doctor’s appointments, obtain their prescriptions, and the like. More programs like this are needed.

Building effective partnerships

The Stokes County example illustrates the power of effective partnerships. But bringing the right stakeholders to the table, involving them in decision-making and ensuring they work well together can be a hurdle. We know from historical managed care efforts that stakeholders don’t want care models forced upon them, and that managed care plans cannot create full-scale success on their own.

Instead, organizations must seek to involve the populations they are attempting to serve, as well as the individuals and organizations who currently care for them. Again, the “whole person” methodology is the key trend driving us forward.

For instance: for a managed care organization serving a foster care population, an effective care model will include partnerships with families, guardians, social services, HHS, and the school system.

An example of this type of working partnership comes from an Enhanced Crisis Response program piloted in Mecklenburg and Cabarrus County, North Carolina. The program aims to help youth returning home from the hospital and prevent the need for residential inpatient care through the use of community-based treatment and supports. In 1 case, coordination across the hospital, payer, social services, and the member and family helped ensure 1 troubled teen received the treatment needed within the community, while enabling the entire family to begin healing from years of trauma. In this case, the coordination extended beyond the state, with the youth being placed temporarily at home with their grandmother and the North Carolina clinician working within that community to surround them with appropriate care and services needed and ensure the kinship placement was solid.

The key, of course, is that everyone involved in taking care of a foster child has a say, helping understand and shape what those members need. From there, a consensus around program evolution can be achieved by measuring member outcomes based on managed care principles and sharing those results with partners.

Evolving how we measure success

Many organizations acknowledge the need to evolve how they measure managed care success. It’s an effort that requires collective input from providers, state agencies, community organizations, regulators, members, and families all working in recognition that existing measurements are insufficient — especially for more complex member populations.

Updated outcomes measurements are especially important for populations such as those with behavioral health or intellectual and developmental disabilities. These members often require non-traditional healthcare services for which clinical measures simply don’t apply. Their outcomes aren’t based on being cured of a disease or on controlling a specific aspect of health. Instead, more relevant personal outcome measures and indicators might include SDOH factors such as food security or independent living arrangements. For these members, we need to be able to measure success based on their ability to self-manage and be active participants in their communities.

Using resources to connect the continuum

Many organizations also are looking at how to put technology to work effectively. Telemedicine technologies, for example, hold increasing promise to break down barriers, expand care access and deliver more convenient services for members. Likewise, there’s growing interest in exploring new care delivery mechanisms that leverage social media to positively influence behaviors by taking advantage of the direct contact it offers with consumers and providers. Making way for new technologies on the horizon — including artificial intelligence, robotics and more — may prove beneficial to the health of everyone.

Ultimately, however, the trends taking hold in this new decade will continue to focus on more connected, convenient options for members as consumers. Managed care models must continue striving toward improved access to care, engaging members in both their treatments and their wellness to drive better outcomes while reducing associated costs.

Bio

Dietrick Williams joined Cardinal Innovations Healthcare as Chief Operations Officer in spring 2019. He has worked in the health plan/payer industry for over 20 years and has experience with a vast array of health plan operations that includes leading core operation teams including billing and enrollment, claims, contact centers, and grievances and appeals. He’s also supported network builds for service area expansion, clinical and non-clinical operating models and implemented large government sponsored programs including Medicaid managed care, Medicare and most recently the Affordable Care Act (ACA), Healthcare Exchange product. Williams holds Bachelor of Arts and Master of Science degrees in Health Service Administration from Florida International University in Miami. He is a former member of the Institute for Diversity in Health Management and the National Association of Health Service Executives.