Pain points keeping execs of safety net health plans up at night

Data, quality, specialty drug costs and social determinants of health are the pain points that are keeping executives at nonprofit safety net health plans up at night, according to a recent survey jointly commissioned by Health Integrated and the Association for Community Affiliated Plans (ACAP).

Access to and optimization of data and analytics rose to the top for the second straight year and continues to be a major area of need as plans work to most effectively deploy resources to grow and manage their populations.

ACAP member health plans were invited by email to participate in an online survey between November and December 31, 2014. Respondents represented 26 unique ACAP member plans.

Lovelace“Quality metrics, such as HEDIS and STAR ratings, are an increased concern for all plans and challenges with specialty drug costs emerged this year,” said John Lovelace, president, UPMC for You and president, Government Programs and Individual Advantage UPMC Health Plan. “Far and away, housing is the biggest social determinant of health followed by food/nutrition.

“As health plans are held more accountable for outcomes, it’s critical that we take a 360-degree approach in supporting the needs of our members. Identifying and addressing medical and biopsychosocial factors can significantly impact an individual’s overall health,” said Lovelace.

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The survey confirms that data is playing a bigger role in how health plans manage their populations. With multiple data sources available from claims feeds to electronic medical records to information from patients themselves, isolating and analyzing the most useful data points is critical, according to the survey.

The cost and appropriate management of specialty drugs was another area of concern identified in the survey. Medical conditions impacted by specialty drugs include ailments more commonly seen in vulnerable populations such as hepatitis C and pulmonary hypertension. Pricey specialty drugs accounted for more than 31 cents of every dollar spent on prescriptions last year even though they represented only 1% of all U.S. prescriptions filled, according to pharmacy benefit manager Express Scripts. This creates a growing challenge for health plans as they try to determine new ways to manage costs while delivering quality care.

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For plans serving dual-eligible members, individuals covered by both Medicare and Medicaid, challenges in meeting regulatory compliance requirements are giving way to longer-term viability concerns such as driving higher Star ratings while appropriately managing costs. Dual eligible beneficiaries are among the sickest and poorest individuals covered by either Medicare or Medicaid and account for a significant portion of costs for both programs.

Another finding was around the importance of addressing the social determinants of health. By far the biggest social determinant reported was housing, followed by food and nutrition. To aid in these areas ACAP plans have developed special programs such as the UPMC for You "shelter plus care" program in Pennsylvania. The program provides stable housing to homeless members who have a history of avoidable yet repeated ER, inpatient, and skilled nursing facility use in efforts to break the cycle and provide what's needed most, housing. Another example includes CareOregon's Food Rx pilot project which provides vouchers to members who don't get enough food or don't have access to healthy food items. The vouchers can be used at the My Street Grocery trolley which travels to three local clinics where CareOregon members are served. These and other programs provide additional support to address the psychological, social, and economic factors that can significantly impact an individual's overall health and well-being.

A new level of thinking and innovation is required of health plan leadership, Lovelace explained.

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“The role of the health plan is evolving,” Lovelace said. “High-touch, member-centric initiatives paired with active medical management integrated with timely, accurate and actionable data are required. The need for this is heightened, especially at the member level and with vulnerable populations that are the hardest to reach and account for significant costs.”

Margaret Murray, chief executive officer of ACAP agrees, "We see a major shift in how plans are managing their members in today's healthcare climate. Serving the members most in need is not always an easy task, and optimizing data can help health plans direct the right resources to the right members at the right time."

The survey is administered annually to ACAP member plans and this is the third year it has been conducted. The purpose is to better understand the evolving needs and challenges faced by health plans serving vulnerable populations who are enrolled in Medicaid, Medicare Advantage and Children's Health Insurance Programs (CHIP). The results serve as a collective knowledge base for developing strategies and services to help plan members achieve Triple Aim outcomes while meeting quality, compliance and financial goals.