Management Care Re-Procurement Presents Opportunities for Service Enhancement and Innovation: OhioGuidestone’s Managed Care RFI Response
The Institute of Family and Community Impact (IFCI) is an initiative connected to OhioGuidestone. Founded in 1864 as the German Methodist Orphan Asylum, OhioGuidestone has been serving children and families in Ohio for over 150 years. Their continuum of services includes mental health services, out-of-home programs, early childhood programs, parenting services, employment programs, family counseling programs, and juvenile justice services.
As the state’s largest provider of community-based mental health services, OhioGuidestone was pleased to have the recent opportunity to provide comments to the Ohio Department of Medicaid (ODM) in advance of the re-procurement of the state’s Medicaid managed care organization (MCO) contracts. The organization’s experience in serving approximately 30,000 Medicaid-eligible individuals each year provides unique insights into the health care needs of MCO members.
Responses to select items from the Request for Information, issued by ODM, are summarized below. Both OhioGuidestone and IFCI will continue to advocate for the health care needs of the many individuals we serve across the state, and hope that re-procurement will result in service enhancement and innovation, to the benefit of all Ohioans.
“While there have been challenges in navigating changes to the system since Behavioral Health Redesign, we recognize the immense opportunities for innovation and collaboration in service delivery provided by the managed care organizations,” says Dr. Ben Kearney, Executive Vice President at OhioGuidestone and IFCI Fellow. “For example, payment innovation that would better address the social determinants of health could yield huge results. In addition, advances in technology will allow MCOs and providers to leverage data to enhance quality and access and ultimately improve people’s lives.
“It’s true that there are still kinks to work out, including issues related to timely payment and communication. However, if all stakeholders can work together to proactively improve the system, the possibilities are endless. We appreciate the state’s willingness to hear directly from providers and consumers on their experiences to inform this process.”
A lack of basic needs, especially transportation, is a significant barrier for many in accessing health care.
Transportation is a consistent barrier. This includes a lack of transportation and unavailability of public transit options, in addition to unreliable or inaccessible transportation provided through MCOs. Improved access to reliable transportation options would improve access to care.
In addition, a lack of access to basic needs, such as food and housing, are significant barriers to accessing care, and this holds especially true for mental health services. Individuals who are not able to access sufficient food or who lack safe and affordable housing often lack the time and cognitive bandwidth to fully engage in mental health services or other related supports. In light of this reality, our providers often spend significant amounts of time assisting individuals and families to overcome these barriers, and this time is not always fully reimbursed within the existing system.
Providing avenues for reimbursement of services related to the social determinants of health would allow providers to better support individuals to resolve these problems and focus more fully on their health and wellness. More specifically, integrating a screening mechanism to assess barriers and challenges around social determinants of health upon enrollment will allow needs to be identified swiftly and provide a more holistic picture of the individuals. Improved data sharing would allow providers to access this information in advance of the onset of services, allowing us to be more responsive to client needs.
Toxic stress and trauma can act as barriers to care.
Individuals who have experienced trauma may have a greater hesitance to engage in traditional health care. Avoidance is common among individuals who have been exposed to trauma and toxic stress, and, in particular, these individuals will often avoid disclosing their experiences and symptoms. This can interfere with one’s willingness and ability to access health care. As trauma and toxic stress are linked with negative long-term health outcomes, this can have significant implications over the lifespan.
ODM and MCOs can seek to address this through multiple means, including requiring training for network providers on understanding trauma and toxic stress, and their implications for health care access, as well as providing tools for engaging these individuals most effectively. As a result, individuals with exposure to trauma can build increased positive associations with health care providers and institutions over time, to increase their willingness to engage.
In order to identify trauma exposure early and facilitate connections to trauma-informed services, a trauma screening protocol should be developed for MCO members, either at the time of enrollment or in the context of well-child visits, to reduce this barrier to care.
Home-based services play an important role; engagement can be increased by meeting individuals where they are.
At times, life circumstances or other issues interfere with one’s ability to follow through with initial appointments to start services. It often is the first appointment that is the hardest to complete. Home-based assessment services play an important role here, as they decrease cancellations and no-shows. MCOs should incentivize providers who conduct assessments in-home as they offer an alternative to enrollees who struggle to keep office-based appointments.
In addition, MCOs and ODM should promote the use of mobile access to services: for example, mobile mammography buses, mobile medication assisted treatment, or other mobile clinics, in addition to telehealth. Contracts should support the co-location of services, including co-locating adult and pediatric services but also co-locating social determinants of health and mental health and substance use treatment services onsite with primary care/physical health to reduce travel time and other barriers for consumers and promote coordination and collaboration.
Improvements are needed around data sharing, for both providers and consumers.
Improvements could be made in the publicly available information on MCO performance metrics, in an easily accessible manner for both consumers and providers. Individuals also should have access to information on providers and the quality and accessibility of their services via a publicly available “report card.” This would allow for consumers to make more informed choices about services.
Consumers should have open and accessible access to their records, in order to be informed on the status of their health. Allowing consumers easier access to their records will help improve accuracy and transparency, and empower individuals to be more involved in their health care. Patient portals that act as repositories for records across providers could be beneficial to consumers in managing their health care and also could act as a means to share information from doctors or other helping professionals. Providers should be compensated for time spent helping individuals access and utilize their health data.
Data sharing needs significant improvement to allow providers to best meet the needs of enrollees and collaborate effectively with other providers. Our ability to access information swiftly and easily on our clientele is paramount to quality of care. We have the following recommendations:
- The creation of a state-level system/open health information exchange that would allow providers to share information to promote continuity of care. A common platform is critical, as are common rules around data collection and formatting.
- Data sharing supports better continuity of care. The contracts should build in incentives for providers and MCOs to support continuity of care and relationship building/coordination among providers.
- Providers need better access to market data relative to their array of services. This is essential to identify gaps in the marketplace and estimate client volume and subsequent staffing needs. Currently, no platform exists to access timely information on the health care market. A statewide system with information provided by MCOs could be a tremendous help to build services in shortage areas and help providers more efficiently deliver services to those in need.
Workforce development is essential to enhance access to care.
State and federal policy reforms to support loan forgiveness would be a significant step in addressing workforce shortages across the state in key areas. In addition, rate increases or other financial incentives that would support increased wages would similarly improve recruitment and retention challenges. Creative solutions such as tax abatements and housing credits also could be considered to attract and retain talent at the state level.
Workforce pipelines should be developed and supported by the state and MCOs to build early exposure to health care fields among Ohio youth and create pathways into key areas. In addition, Ohio should better leverage and advertise existing programs such as the Health Service Corps.
Ohio also should consider strategies that support assisting work-required Medicaid recipients to join the health care field; creating an accessible and flexible program that could offer pathways to these positions could support the state’s efforts to promote work among the Medicaid population while also addressing workforce shortages.
Prevention and coordination are critical elements to an improved delivery system.
Increased coverage of prevention services would promote upstream approaches that could be of great value to enrollees and reduce costs long-term. This could include coverage for school-based prevention programming as well as other office- and home-based prevention programming.
Care coordination tasks such as scheduling meetings with providers and collecting necessary records often are not reimbursable in the current system. The state/MCOs should develop a mechanism to reimburse for these services and/or otherwise incentivize providers for this work.
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