Of all the health organizations working as Medicaid managed care plans, some provider-based plans are seeing financial gains, sometimes in places where traditional Medicaid HMOs are not.
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 nonprofit insurers, Medicaid plans run by health systems like Gundersen, Presbyterian and University of Pittsburgh Medical Center 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.
Presbyterian Health Plan, the insurance arm of the eight-hospital, 100-plus clinic Presbyterian Healthcare Services in New Mexico, has posted gains for the last three years, according to Milliman data.
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. Presbyterian's 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.
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.
In Pennsylvania, where the average underwriting profit ratio among eight Medicaid plans was just 0.1 percent last year, the University of Pittsburgh Medical Center's Health Plan 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. It also has a roving fleet of mobile health and dental clinics, and will step in to help with transportation.
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 taping the strengths of integrated care has helped UPMC pull out gains for the last three years as other plans have posted losses, Lovelace said it isn't immune to challenges other Medicaid plans have seen, like churn, or changing eligibility of beneficiaries, and volatile drug prices.
Lovelace said UPMC isn't immune to challenges other Medicaid plans have seen, like churn or changing eligibility of beneficiaries and volatile drug prices. But, taping the strengths of integrated care has been a win for the organization and will help the organization make headway on the equally large challenge of helping members prevent or improve chronic health conditions.