Managed Care continues to expand into the Ohio Medicaid system. This should not be a surprise to anyone at this point. It appears that by 2018, we could have more than 95% of Ohioans, who receive the Medicaid benefit, getting their access through a Managed Care Organization (MCO). What I am witnessing now, however, surprises me a little. Providers are in a race to find the system, the fix, the specific tools, or magic spell that will transform their non-profit or for-profit agency into a company able to work in a Managed Care Environment. Executive Director’s seem to be like that person trying to build more muscle, or lose those extra pounds. They just need to find the newly discovered “thing”, buy it, use it, and they will be transformed. I am sure it will have a nice trademarked name, or be from some exotic place, like anywhere other than Ohio.
Everyone needs to get a grip. Yes, things are changing, and you will not be able to run your programs and agencies the same way. That’s because Ohio is not going to run their programs the same way either, and that has less to do with MCOs and more to do with what Ohio Medicaid wants and how it wants to accomplish it.
Here’s what I know. In 2008, with the help and support of an owner who liked to take chances with my ideas, I opened up my first behavioral health clinic. As one of two, very, part time clinicians, we ran groups and provided individual treatment. In the first six months, prior to CARF accreditation, we served a total of six adolescents. Humble beginnings to say the least.
When I left that same company at the end of 2014, as COO, the behavioral health company I helped start was serving close to 3,000 people across multiple clinic locations. How did we go from serving six adolescents, to almost 3,000 in less than 7 years? One of the strategies focused on engaging Managed Care Organizations.
Managed Care: Four Areas of Focus
There were four basic categories that you have to focus your attention and build your organizational practices around as Ohio transitions the oversight of their Medicaid program, away from our public institutions and into MCOs.
As you think about MCO’s being the new contracting entity, the first question you should ask yourself is, “Do I know anyone at the MCO?”. I have had several conversations with different Executive Directors over the years asking me about MCOs and what my thoughts were about their function and usefulness etc…I then would ask them a question in turn regarding who they knew or worked with at the MCOs. Inevitably, the answer was muted silence. I know a few people within managed care organizations, and I respect them as professionals. They have solid experiences in the provider world, they are smart, and they understand what the state of Ohio is asking of them as an organization. If you currently do not have an avenue open to be able to ask questions directly, or be available to problem solve with the MCOs, both their struggles and yours, then you have a lot of work ahead of you before the end of next year. You want to create easy and simple pathways of communication between your organizations and those being asked to be a significant partner in behavioral health transformation.
The next question you need to ask is, “How much does your service cost?”. In working with managed care entities directly, starting about 2012, it was imperative to understand our costs for each service we were providing. We had to align our program and fiscal models to work together, and then be able to tweak service and deliverables based on reimbursement. If you don’t understand whether or not your program and fiscal models are aligned, you will have significant struggles in a managed care world. You must be able to dial up or down services and overhead based on contracts and deliverables.
As mental health professionals we all know there is a lot that gets accomplished through treatment. Some of what gets accomplished is more measurable than other aspects, but in the end we all understand that it’s not as simple as cause and effect. Both therapist and patient will work hard to accomplish a positive outcome, that is subjective and relevant to the person, their journey and their supports. However, you cannot lose focus on what your payer wants to see as an outcome as well. Yes, we can complain about the outcomes, and argue that its unfair and as behavioral health providers we have less to do with variable “x”, and how do you measure things anyway,…Whether the system we are about to engage with is sophisticated enough to reliably measure the right things or not, you have a choice to improve that system through advocacy and outreach, or ignore it. Currently the state of Ohio’s, carved out, behavioral health system does not track outcomes at a state level. They track claims. I think moving toward an outcome based system is better than a claims based system. What I find bizarre is that, as a provider system, we tend to blame these rigid, non-important outcomes on the MCOs. Look at the contracts. MCOs, like all of us will be soon, are managing towards the expectation of the payer. Change the expectations of the payer if you want change.
The final area of focus is Action. Talk is cheap people. If everything I have stated above makes sense, the next question is whether you have the people, the culture, the technical knowledge, or the leadership in place to execute on these focus areas? Talking about managed care coming into our “carved out” system has been going on publicly for a little over two years now. If you keep talking about the focus areas above, but do nothing to implement, or change your people, culture, technical skill, or leadership within your agency, you have will nothing. It is time to be bolder, more innovative, and more focused than before. Start with the four areas of focus in this post and I think you will find that you will have success.