A Year of Milestones

Oct 6th, 2010 | by OurHealthCareSource.com

This year has marked a series of milestone anniversaries for many of our nation’s most well known public programs. Programs that have become synonymous with stability, security and health care. They are: Social Security, Medicare and Medicaid. And, let’s not forget one of the most significant pieces of legislation our nation has seen in the last 20 years – the Americans with Disabilities Act (ADA).

You may be wondering why a large health plan like CareSource would care about the ADA or public programs in general. It’s actually pretty simple. It’s because each of our members is touched by at least one of these programs every day. Moreover, our members have tenaciously navigated the pitfalls of bureaucracy to secure and retain a benefit that is fundamental to their sheer existence. And, a good portion of them are just beginning to realize the opportunities that now lay before them as a result of the ADA (which, by the way, strives to remove significant barriers for individuals with disabilities. More on this later.)

Social Security – Celebrating 75 Years of Security
Despite being well past the age where most Americans can begin to receive benefits, the Social Security program is still viewed as one of the most important programs in our country. In fact, according to the AARP, nine out of ten adults held this view consistently in 1995, 2005 and 2010. Social Security underscores the importance of many of the values we advocate for today – independence, safety and financial peace of mind. As technology and innovation allow us to live longer, these values will remain essential to a more secure and productive tomorrow.

Medicare and Medicaid Turn 45
When Lyndon B. Johnson signed Medicare and Medicaid into law in 1965, do you think he ever dreamed it would result in health coverage for more than 100 million Americans just 45 short years later?

It’s a dream that many of us are proud to fathom. It’s a fiscal challenge we’d like to forget. But without these two programs, America would be a very different place. While not necessarily perfect, these programs have driven us as a society to build a health care system that allows us to live longer, employ millions of Americans and provide the strength a nation needs to forge ahead. Yes, some might agree that we have lost our footing along the way, but the passage of the Patient Protection and Affordable Care Act will be a milestone that will be celebrated just four short years from now.

ADA Celebrates 20 Years
July 26, 2010 marked the 20th anniversary of this historic legislation enacted to break down barriers in housing, the workplace, schools, malls, telecommunications and public transportation for people with disabilities. Despite its worthwhile advancements, leading advocates realize there is still much more work to be done. Our nation has focused heavily on supporting disabilities financially and medically, but not really as much on merging these ideals in a way that fosters inclusion and independence.

As we reflect on the needs of the more than 65,000 members with disabilities we serve in Ohio and Michigan, it is with great humility that we continue our advocacy to extend our reach to cover more individuals with disabilities. Doing so will ensure that they receive health care in a way that is person-centered, comprehensive, coordinated and in a setting where they can thrive and succeed.

Charting New Milestones
As a non-profit health plan, we recognize the foundation these programs have established for the current generation and for generations to come. The programs mentioned above as well as countless others have truly inspired the advent of companies like ours that are adamantly focused on supporting the underserved. In this commemorative year, we want to take this opportunity to honor each person who works tirelessly every day to help our nation’s most vulnerable reach their next important milestone. Happy Anniversary!

Turning Downside Upside Down

Apr 20th, 2010 | by OurHealthCareSource.com

The passing of health care reform means a lot of good things for underserved populations throughout our country – most notably, an increase in both Medicaid eligibility and Medicaid reimbursement rates for primary care providers in the next few years.

But with every up side – our most vulnerable population being taken care of as an upside in this case – there is always a downside. And unfortunately, providers see the increase in Medicaid eligibility as potentially having a downside impact on their businesses. It’s not because doctors don’t want to help those that can’t afford care. Doctors have consistently absorbed the costs of seeing economically-challenged patients, whether the patient is on Medicaid or not. The downside, to put it bluntly, is about reimbursement rates.

The Downside Dissected
Currently, doctors simply do not get reimbursed as much for services rendered to a Medicaid patient. State Medicaid programs, out of fiscal necessity, have negotiated lower rates with providers and hospitals than commercial insurance plans offer because of the scarce resources available to fund public health programs. And as a Medicaid managed care plan, we aren’t in a position to provide the same level of reimbursement to doctors that commercial plans can offer because our revenue is based on the Medicaid fee schedule. We already allocate over 90 percent of our revenue to medical care and keep our administrative costs around five percent and it still only pays providers about 85 percent what Medicare pays.

But that doesn’t mean there aren’t other ways for Medicaid managed care plans to help doctors see the value in dealing with Medicaid patients and plans. Some states embrace Medicaid managed care over fee-for-service because Medicaid plans have the flexibility to create services and programs specifically designed to help doctors better engage with his or her Medicaid patients– something fee-for-service simply can’t accomplish.

At CareSource, we have been working closely with our provider networks in Ohio and Michigan to reduce administrative barriers and bring the added-value services providers need to better engage with our members. And paying over 95% of our clean claims quickly is a key focus because we recognize that providers rely on us to keep their doors open.
But we have introduced other programs too…

Health Care Home – A Pilot Program on the Rise
We are piloting a program called Health Care Home. This program truly bridges the gap between the patient, the practice, and the health plan. We offer a unique set of services to assist the practice, the patient and their family. For example, we assign a case manager to work with each practice, sharing data, clinical information, immediate access to after-hours nurse triage information, and assistance with office resources. We can assist physicians by identifying areas of need and cooperatively enhance practice capabilities. Health Care Home also allows for outcome-based reimbursements beyond negotiated Medicaid reimbursements to incent providers to prioritize Medicaid patients.

Putting Technology to Work
In addition, we have created similar online administrative tools to those that commercial plans offer to their provider networks. This includes online preauthorization forms, online claims submission and tracking. Unlike commercial plans, we initiated the availability of online member profiles. The CareSource Member Profiles give providers a detailed medical history of their CareSource patients – a typically elusive piece of information since Medicaid patients tend to access the health care system in spontaneous and unpredictable ways.

A Resource for Your Patients During Off Hours
We also have in-house 24-hour nurse and triage call centers that have been URAC Accredited for our members. This benefits providers because obviously their offices are not open 24-hours a day. “CareSource 24” – as we call it – provides a resource for members who face medical issues when their primary care provider’s office is closed. The goal is to provide comprehensive and coordinated services, 24 hours a day, 7 days a week. Our focus is to make sure services are available whenever they are needed.

Combating the ‘No Show’ Issue
Because Medicaid plans work with many families who may not have access to reliable transportation, we offer transportation as a covered service. Providers can take more comfort in knowing that their Medicaid patients will have a greater likelihood of showing up for appointments because plans like CareSource offer this benefit in a way that is more accessible to its members than the fee-for-service system. A simple call to our member services line puts them in touch with our transportation vendor. In addition, CareSource case managers provide direct education to members about the importance of keeping their appointments and the impact no-shows have on a doctor’s office. Another way to break down barriers that preclude access and make a provider’s job a little easier.

Growing in the New Era of Health Care
The important point to this article is this – Medicaid will always guarantee providers some form of reimbursement for the medically necessary services they render to eligible members. But plans like ours prioritize the development of resources that help providers in ways that don’t cost them more money and potentially save them administrative costs – online tools, call centers, integrated support services like case management, transportation…these are the services that, when absent, can make serving Medicaid patients more expensive for a provider. But programs like these are at the foundation of our business as we continue to grow in this new era of health care.

Providers reading this article – What would make dealing with Medicaid plans like ours more appealing? What can be done to make the relationship better given the constraints of reimbursement levels?