Getting to the “Win3” – How Managed Care Plans Can Develop High-Value Partnerships
Note: Different states have different terms for Medicaid Managed Care Plans, such as Managed Care Organizations (MCOs) or Prepaid Health Plans (PHPs). For consistency, we use the Managed Care Plan (MCP) terminology in this blog instead of MCO or PHP.
By Rebecca Gerr
Reflecting on a teammate’s recent call with a community-based organization (CBO) and a managed care plan (MCP), I was struck by one participant’s observation that this call was different – namely, that the focus was to develop what the Quantified Ventures team refers to as a true win-win-win (win3) solution by aligning parties on shared impact objectives.
In a win3 model, a high-impact service:
Supports the patient/member;
Generates quantifiable value for the MCP; and
Appropriately compensates the CBO partner for its mission and work, with a funding mechanism that sustainably supports ongoing operations.
Across the country, QV builds such purposeful win3 partnerships between MCPs and CBOs that deliver high-impact programs supported by revenue streams that enable sustained operations, program enhancements, and growth.
Through our work, we have found that while some elements are common across all solutions, there are core features that differentiate win3 solutions:
Maximize MCP value
Produce high-impact member outcomes
Provide adequate, sustainable revenue for CBO
Getting to the win3 requires both MCPs and CBOs – who are accustomed to uneven and sometimes challenging, negotiations – to come to the table ready to work creatively and collaboratively toward mutually beneficial member health outcomes. In this framework, sustainability, often a long-term goal for the partnership, instead becomes a central tenet from the outset.
There is no better active testbed for this work than California, where the Department of Health Care Services (DHCS) implemented CalAIM (California Advancing and Innovating Medi-Cal), a California Medicaid (Medi-Cal) initiative to promote equitable, coordinated, and person-centered care. The CalAIM framework incentivizes MCPs to address members’ health related social needs (HRSN) through a suite of services including Enhanced Care Management (ECM) and Community Supports (called “in lieu of services” or ILOS in other states) that plans are encouraged to offer their members.
In the CalAIM framework, getting to the win3 requires a solution to create beneficial results for the member, CBO, and MCP (alone and often in coordination with other plans), while meeting the state’s rigorous requirements. And this in turn relies on aligned objectives, operations, and outcomes across all partners.
Based on Quantified Ventures’ work with MCPs of all shapes and sizes across the country, we have identified 4 criteria that are essential for win3 partnership success.
1. Find a mission-aligned partner
Local California CBOs are best positioned – and encouraged by the state – to provide Community Supports for Medi-Cal members. For MCPs, a successful CBO partner is trusted by the local community, provides a high value service to the member – and for the payer – and is willing to move beyond its traditional service delivery method (i.e., innovate) to address whole-person needs.
QV has fine-tuned a process for working with MCPS to identify, engage, and assess candidate CBO partners. Through our work, we have found that an open-minded and outcomes-oriented philosophy - along with a willingness to enhance existing program models, data collection, reporting capabilities, and payment structures - is a key feature of successful CBO and MCP partnerships.
2. Update your partnership framework
Both MCOs and CBOs must rethink and often update the way they engage with one another – shifting away from a narrow transactional mindset and toward a more aligned partnership. To best support forward-thinking CBOs, MCPs should recognize the value of the partner’s approach and demonstrate a willingness to adapt its own processes accordingly. MCPs often need to develop new operational and contracting competencies to get to the financial model that can support CBO work. CBOs similarly need to develop program models that meet member needs and state requirements, enhance data capture infrastructure, and adjust to MCP partnership requirements.
Recognizing this need, California developed a technical assistance (TA) marketplace to provide state-subsidized services to enable CBOs, providers, counties, and tribes to build their capacity and infrastructure to meet the opportunity. (Quantified Ventures is one of a select group of California TA marketplace vendors).
3. Anchor the solution in impact
Centering value as the dominant goal requires an openness to completely reexamine the program at all levels, such as the way services are delivered (and by whom), the services themselves, and the data systems / operations used to track outcomes. Producing a win3 solution often means that a CBO needs to update or augment its program model to generate the specific value proposition that is of interest to a payer. So long as the work is still mission-consistent and organizationally aligned, CBOs need to be open to modifying what they do and how they do it and commit to tracking (or building the capacity to track) progress toward the agreed upon value metrics.
In California, some CBOs are thinking beyond offering single community supports, and instead leveraging their expertise working with California’s populations of focus to develop (or partner to offer) a more holistic suite of services to address MCP member whole-person needs. This approach benefits the provider, generates a wider base of potential revenue streams, and enables cost-sharing across a larger suite of programs. Importantly, this strategy also supports MCPs looking to fill multiple Community Support gaps and members who can access comprehensive services.
In speaking with some of these innovative providers, we have learned that they are considering developing Community Supports that rely on similar service infrastructure – such as expanding a recuperative care facility to also offer short-term post hospitalization stays – by assessing shared staffing and enhanced information / data tracking systems.
4. Make payment sustainable and aligned with member health and wellbeing outcomes
High impact models require predictable, adequate, and sustained revenue to operate effectively, yet providers nationwide report that current funding models are wholly inadequate and often require raising philanthropic and other grant dollars to maintain operations.
Recognizing that providers require support to adequately meet Medi-Cal members’ needs – and the state’s stringent requirements – California developed a multi-pronged approach to help CBOs and MCPs build the foundation for their partnerships.
DHCS received federal authorization to spend $1.44 billion on the “Providing Access and Transforming Health” (PATH) program. PATH includes varied initiatives such as the PATH technical assistance marketplace for Community Supports and Enhanced Care Management providers, funding to support capacity and infrastructure, and funding for organizations interested in supporting the justice-involved populations.
The state allocated an additional $1.5 billion in incentive payment program (IPP) funding to support CalAIM implementation, with a notable focus on building capacity for Community Supports and Enhanced Care Management implementation. MCPs have provided IPP funding grants to CBOs to support their transition to delivering CalAIM services.
Though critical, these funding streams are insufficient in that they are designed to support start-up costs and program implementation and do not fully cover the cost of ongoing program operations. For this reason, in addition to reviewing reimbursement rates, some forward-thinking MCPs have begun to develop value-based contracts with Community Supports and Enhanced Care Management providers. Though initial contracts have focused on process measures, innovative MCP and CBO partnerships are looking to link payment to outcomes for a set of mutually agreed upon, beneficial member outcomes. For MCPs, this can also strengthen IPP reporting responses, by aligning CBO incentives with MCP reporting requirements, such as reducing unnecessary emergency department utilization.
At Quantified Ventures, we have found that linking payment to value aligns incentives between MCPs and CBOs - producing positive results for both sides, as well as the client member. MCPs receive quantifiable value from the provider services. CBOs find that the additional revenue earned by continuing to provide high quality services allows them to further improve their operations and services. And members receive sustained, high-quality services that better address their holistic health needs.
By designing a reimbursement model where the MCP pays the CBO for the value delivered by the service (often with pay-for-performance incentives) we help deliver better member health outcomes while achieving MCP and CBO financial goals.
Want to discuss how we can work together to build a win3 solution for your organization? Email me at rgerr@quantifiedventures.com. Interested in learning more about how QV supports CalAIM implementation? Email CalAIM@quantifiedventures.com.