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Managed Care Partners - Riding the (Medicaid) wave

Managed Care Partners Fall 2010

Riding the (Medicaid) wave

Date: October 31, 2010

Marc Engelhart, Edward Kumian, Robert R. Neall, Victoria Fretwell and Kathy Pettway
Among those working to keep Priority Partners on target are administration management team members, from left, Marc Engelhart, Edward Kumian, Robert R. Neall, Victoria Fretwell and Kathy Pettway.

Reading tea leaves. Trying to paint a merry-go-round while it’s running. Drinking water out of a fire hose. The metaphors Robert “Bobby” Neall uses in describing how best to care for people newly eligible for Medicaid say it all.

Neall heads Priority Partners, Hopkins’ Medicaid managed-care program. As a CEO caught between a pinched economy and an untested national health care plan, he makes no secret that it’s not the easiest time for this line of work. “Trying to put together a wholesome health care program out of the public Medicaid purse is always going to be a struggle,” he says. But now, as one of only two statewide MCOs in Maryland, Priority Partners is being tested as never before in its 14 year history.

The program, however, has weathered earlier storms—another metaphor for handling the so-called cost bubble that inevitably accompanies a large influx of new patients—and come out stronger. And as Neall and colleague Victoria Fretwell, who heads marketing and communications for Johns Hopkins HealthCare, search out more ways to adapt, it’s clear that Priority Partners aims to keep on keeping on without compromising the mission.

The pressure today comes not so much from the national Affordable Care Act now starting to trickle into practice as from the expanded eligibility for Medicaid that the Maryland General Assembly approved in 2007. That vote increased Medicaid entry by raising the traditional cutoff of 40 percent of the federal poverty level to 116 percent. “The result,” Neall explains, “is that since 2008, we’ve been accepting large numbers of new members from across the state and we’re doing this during a period of fiscal austerity.”

Practically, that’s translated to 60,000 new Priority Partners members in the last 18 months. Because of the new guidelines, most are the adult working poor. “Many haven’t seen a doctor in years,” Neall says, “and they come with pent-up needs,” including chronic problems like high blood pressure, diabetes and dental disease. And there’s a financial jar: With the swell in 2009, Priority Partners had to absorb $20 million in unprecedented losses to maintain care. Half of that loss was as revenue taken back by a financially strapped state.

“It’s hard to get your head around,” Fretwell says. “We hold weekly meetings to see how the membership is going, discuss the state of medical costs and debate if what we’re seeing is a blip or a trend.”

But because Priority Partners is already responding to present statewide changes, Neall says, “we may have taken our medicine early,” before that part of the new federal law—which bumps eligibility to 133 percent of the federal poverty level—takes effect. And the program may be well-placed to roll with the times because of where it stands and what it’s willing to try.

“In the last few years, Priority Partners has functioned very, very well,” he explains. “We pay our bills faster; we pay more accurately; our quality scores are good; we don’t nickel-and-dime providers with irrelevant red tape. We also have a very strong provider network and have worked hard to expand it.”

“It’s fair to say that we’re nimble,” agrees Fretwell. “We’re constantly looking at practices we have in place.” A good example, she says, is Opportunity Reports (OR), a new program now in pilot-testing. “OR pulls data from our claims and encounters with members to let us pinpoint problem areas. Then we sit down with our providers and brainstorm ways to improve. That lets us tell a large provider, say, in Harford County: You’re doing a fabulous job with immunizations but 38 percent of your diabetic patients haven’t had an eye exam. And perhaps the provider tells us there was no one free to set up preventive appointments. We could fix that and head off serious illness and its expense.”

“In short,” says Neall, “we’re doing everything we can.”