Of all the health organizations working as Medicaid managed care plans, a good number of provider-based plans are thriving, sometimes in places where traditional Medicaid HMOs are not.
After many Medicaid health plans in the 35 with managed care programs took fairly significant financial hits in 2011 and 2012, aggregate performance rebounded a fair bit in 2013, according research by Milliman.
While provider-based Medicaid plans are about as likely to come out in the black as insurer-only plans – with about 60 percent of both types posting a financial gain last year, according to Milliman – provider-based health plans may have some advantages as states tweak or overhaul their Medicaid programs in pursuit of savings and benefit improvement.
Exposed to the same risk as Medicaid plans sponsored by for-profit and non-profit insurers, Medicaid plans run by health systems like Gundersen, Presbyterian and UPMC are trying to bring the benefits of integrated delivery networks to a program that has traditionally struggled to offer well-coordinated services for beneficiaries while challenging the finances of providers and managed care insurers alike.
As Karla Lord, the director of business operations for Gundersen Health Plan in Wisconsin, said, there can be "easier collaboration and fewer barriers because the provider and health plan are owned by the same parent company."
Granted, Gundersen and other providers plying the integrated provider-payer model have had their financial disappointments – Gunderson, for instance, posted losses in 2011 and 2012 before a gain last year – but some have made some headway.
In Massachusetts, according to the Milliman study, only two of the five Medicaid plans posted a financial gain last year -- Boston Medical Center Health Plan and Neighborhood Health Plan, the insurance arm of Partners HealthCare. Boston Medical Center's plan has posted a gain for the last three year's running, the only Massachusetts Medicaid plan to do so, according to Milliman data.
Across the country, in New Mexico, only one of the four Medicaid plans turned a gain last year -- Presbyterian Health Plan, the insurance arm of the eight-hospital, 100-plus clinic Presbyterian Healthcare Services.
The other three posted losses, including the Lovelace Health System's plan, which was recently sold to Health Care Services Corporation -- and on average, the plans took an underwriting loss of 3.5 percent.
Presbyterian was the only one in the state to come ahead in the last three years, according to Milliman data. Presbyterian Healthcare Services' leaders think they've found good ways to adapt to policy and reimbursement changes over the years while leveraging an extensive network for patient care.
Presbyterian's 30-year-old health plan is the only insurer that has operated continuously in Medicaid since managed care's inception in New Mexico in 1997, said Charles Milligan, Presbyterian's senior vice president for enterprise government programs.
Now covering 185,000 Medicaid members, about 35 percent of the state's managed care population, Presbyterian Health Plan was able to "weather a lot of the recession" and has adapted to "different policy initiatives from some administrations over the years," said Milligan. Benefit mandates for Medicaid have shifted along with Governors, and currently Presbyterian is embarking on changes to participate in the next redesign of the New Mexico Medicaid, Centennial Care, which will see all Medicaid benefits covered by the health plan.
IDNs and 'anywhere care'
Pennsylvania is another state where Medicaid plans do not uniformly see gains or losses and where policies are in flux (the Governor is seeking a federal waiver to subsidized private exchange health plans for residents who would qualify for expanded eligibility under the Affordable Care Act).
In Pennsylvania, the average underwriting profit ratio among eight Medicaid plans was just 0.1 percent last year, and only three came out in the black -- University of Pittsburgh Medical Center's plan, Health Partners Plan, which is sponsored by a group of seven Philadelphia area hospitals, and Aetna's Coventry subsidiary.
Pennsylvania's other provider-sponsored Medicaid plan, from Geisinger Health System, posted a loss in 2013, although that was the organization's first year running a Medicaid plan. UPMC Health Plan, operating in Medicaid since 1997, was the only Medicaid plan to post a financial gain in all of the last three years, according to Milliman data.
Covering most of western Pennsylvania's Medicaid beneficiaries, about 260,000 individuals, UPMC Health Plan has been putting its parent organization's integrated delivery network and technology initiatives to work in an attempt to understand beneficiaries' needs and meet them across a number of channels, said John Lovelace, the health plan's president of government programs.
In part to try to avoid ER trips for non-emergent care, UPMC Health Plan pitches "anywhere care" to Medicaid beneficiaries, as it does for commercial members, Lovelace said. There are UPMC's walk-in clinics, free-use of online video and telephone consults, a 24/7 nurse advice line, and a number of home- and community-based services.
UPMC Health Plan has a roving fleet of mobile health and dental clinics, and will step in to help with transportation. "It works sometimes, but not others," Lovelace said of Medicaid-covered transportation, which plans aren't responsible for in Pennsylvania. "So sometimes we send them a ride or help them with reimbursement if their family takes them."
The organization is also contracting with the state to do home assessments for Medicaid beneficiaries to spot and try to remedy problems like mold, leaky roofs, dust, rugs or smoking that can trigger health conditions like asthma.
While eking out gains for the last three years as other plans have posted losses, UPMC Health Plan has not been immune to challenges other Medicaid plans have seen, like churn, or changing eligibility, of beneficiaries, and volatile drug prices.
"We had a good year," Lovelace said of 2013, "but we're all kind of taken back on the Sovaldi front. We'll have a pretty not so good this year, in part because of Hepatitis C drugs and drugs costs generally. Sovaldi so far this year has cost $13 million and we didn't plan for that."