Care Coordination

Data sharing and staff contacts are the keys to improving collaboration between Medicaid managed care organizations and public health departments, according to California officials and plan staffers. Leaders from managed care plans say that close collaboration improves outcomes for high-needs populations who struggle with one or more social barriers to health.

“When you're looking at claims data, we're obviously not going to see a claim for homelessness. We’re not going to be able to capture that. But when we take our data and bump it against data that's available to some of the public health jurisdictions, and we find out that some of our members are facing housing instability, then that also gives us the ability to understand that maybe their health outcomes are directly being affected by these social determinants of health,” said Nishtha Patel, manager of care transformation at Inland Empire Health Plan (IEHP), during a March 21 Manatt LLP webinar. “No matter what we do intervention-wise, if we're not addressing those, their health outcomes are not ever going to improve.”

Artificial intelligence (AI), drug shortages and cell and gene therapies are just a few of the areas on which the FDA is focusing during a major reorganization. Those were some of the topics that FDA Commissioner Robert Califf, M.D., discussed with Mike Tuffin, president and CEO of AHIP, at the insurer trade group’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 12 through 14 in Baltimore.

When asked his vision for the FDA in 2024 and beyond, Califf responded that 2024 priorities were different because it’s an election year, and the agency’s priorities are “tied to the administration that’s in place.”

During a keynote session at the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum, health plan leaders offered sobering assessments about the state of health equity in the U.S. Still, they offered concrete steps their organizations have taken with community partners to address systemic inequalities.

“I would give us a grade of ‘C’ [on health equity]. Probably, before the murder of George Floyd, I would have given us a ‘D,’” said Karen Dale, market president and chief diversity, equity and inclusion officer at AmeriHealth Caritas. Floyd was killed by a white police officer during an arrest made outside a Minneapolis convenience store in May 2020, sparking nationwide protests over police brutality and racial inequality.

After circulating a discussion draft in the first half of 2023, Sen. Bill Cassidy, M.D. (R-La.) on March 14 released his long-awaited bipartisan bill aimed at improving coverage for Medicare-Medicaid dual eligibles. The Delivering Unified Access to Lifesaving Services Act of 2024 calls for comprehensive changes to the way states and plans currently deliver care to dual eligibles, who often have multiple chronic conditions and account for a disproportionate share of spending.

The bill was introduced by Cassidy and his cosponsors, Sens. Tom Carper (D-Del.), John Cornyn (R-Texas), Mark Warner (D-Va.), Tim Scott (R-S.C.) and Bob Menendez (D-N.J). It would, among other things, require all states to establish an “integrated health plan” for duals — either building off their own or existing options — and require managed care organizations to develop and update comprehensive care plans that include a designated care coordinator for each beneficiary. The legislation also includes “passive enrollment” of qualifying dual eligibles into such plans and continuity of care requirements. The legislation also seeks to expand access to Programs of All-Inclusive Care for the Elderly (PACE) to individuals aged 55 and older.

More than half — 52% — of adults covered by commercial insurance deal with social risk factors that can raise health care costs, according to a Feb. 20 white paper from UnitedHealth Group and the Health Action Council (HAC). UnitedHealth and HAC executives say that the report’s findings can help health plans and plan sponsors be more proactive in addressing social determinants of health (SDOH)-related needs in commercial populations.

Some SDOH challenges faced by the commercially insured population include social isolation and problems with finances, food, and housing, per the report. Twenty-six percent of the studied group faced one SDOH risk, 16% faced two SDOH risks and 10% faced three or more.

Recently it’s been difficult to underestimate artificial intelligence’s (AI) reach across health care entities such as specialty pharmacies, infusion providers and pharma companies. While AI has helped streamline many processes, its ultimate impact may be debatable at this point, and caution in certain areas is warranted, according to some industry experts.

“AI-enabled solutions have transformed the specialty pharmacy and home infusion industries,” contends Mesfin Tegenu, CEO and chairman of RxParadigm, Inc. He notes that AI’s subset of machine learning (ML) uses algorithms to find patterns and make predictions, leading to streamlined operations, better patient care and optimized resource allocations, all of which have the potential to result in cost savings.

Since integrating physical and behavioral health into its managed Medicaid program beginning in 2016, the state of Washington has not seen significant changes in utilization, quality measures or health outcomes, according to a recent JAMA Health Forum study. Experts tell AIS Health, a division of MMIT, that the study illustrates the challenges associated with integrating behavioral and physical health care that may not be fully apparent until the process begins.

K. John McConnell, Ph.D., the study’s lead author, tells AIS Health that Washington is just one of many states that in recent years have moved away from so-called carve-out models in Medicaid, where one health plan handles physical health and a separate behavioral health organization manages behavioral health. Most states now have carve-in designs where states contract with managed care organizations (MCOs) that are responsible for payment for all health care services for their members.

Numerous companies have developed health and well-being apps and programs, making it difficult sometimes for companies to assess them and choose which ones to offer their employees. With this problem in mind, UnitedHealthcare recently rolled out UHC Hub, a platform that helps self-insured employers select and purchase health and well-being programs.

The vendors participating in the UHC Hub include Teladoc Health, a leading telehealth company; Noom, a subscription-based app for weight management and healthier living; and Cleo, a company that offers support for parents and caregiving.

While pharma manufacturers for the most part are still adhering to their traditional business model, other entities in the drug channel are reorganizing, which will prompt drugmakers to be nimble as they adjust to the new reality. That’s one of the overarching themes moving into 2024 discussed during a recent webinar hosted by Adam J. Fein, Ph.D., CEO of Drug Channels Institute, which was recently acquired by HMP Global. In this second of a two-part series, AIS Health highlights the remaining industry trends projected by the longtime industry expert.

Managed care experts predict that 2024 will see further and deeper adoption of artificial intelligence (AI) across the health care sector despite emerging legal risk. Meanwhile, regulation of AI in health care is already underway, but mostly at the state level, with action in Congress stalled and the Biden administration taking an incremental approach.

Health insurers for years have put big data at the center of significant capital investments and operational changes, as major insurers have portrayed themselves as technology players with vast proprietary data sets. For many insurers, automation and algorithms are already intrinsic to claims processing, prior authorization, revenue cycle management and actuarial work. AI could make those insurance processes faster and cheaper.