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5 Data Challenges Impacting Managed Care Plans

Managed Care Plans

Previously, I analyzed the major players in the HHP. This post outlines the 5 challenges impacting managed care plans.

Naturally, measuring the success of the Health Home Program is critical. Each state’s Health Home Authority has designed quality measures, as well as reports for utilization and operations of the program. But some of the requirements laid out by states could pose real data-related challenges for payers. To prove HHP is successful, data that is not typically collected by payers may be required. These elements factor into communications, eligibility, risk determination, and reporting.

Here are 5 key data and reporting elements that will challenge participating payers.

1. Timely Data

Under HHP, managed care plans are responsible for timely and structured communication between the plan and its providers. This may require inbound and outbound data flows that will need to be incorporated into data warehouses, reporting layers, and operational systems. For example, if a patient went to the emergency room (ER) or was admitted to the hospital, the provider caring for her under HHP should be alerted.

While some of this information is available through claims, there is often a lack of timeliness in reporting due to claim lag, which diminishes the effectiveness of an intervention. Payers need to find creative ways, in this example, to identify and communicate ER visits and in-patient admissions to providers in order to be more effective and timely. One solution is using pre-authorizations to notify providers of possible in-patient stays. Another is creating a communication channel between commonly used emergency departments and acute care hospitals to alert payers and providers of HHP member activity.

2. Collecting New Data Elements

If a state’s reporting requires data elements that are specific to HHP – such as the number of people having health action plans created, or the number of case managers available for each HHP network provider – payers have to implement new data flows with the providers in their network. The implementation and operations of these new processes contribute to improved outcomes, but also have a cost in time and resources.

3. Mental Health Data Access

The main tenet of HHP is a “whole person” approach, which in many cases includes behavioral health services. In some states, mental health services for Medicaid recipients are provided by county- or state-run providers, and are essentially carved out from the payer. To facilitate the coordination of care, payers have to open up a data exchange from the county/state and ensure that HHP case managers have access to it and incorporate that data for holistic care.

4. Social Determinants of Health Data

Data associated with social determinants of health (SDoH) play a critical role in identifying members with the highest risk. Payers should consider these factors in determining who will benefit most from additional services through HHP.

The challenge for both payers and providers is to collect and disseminate this information in a timely, effective, and secure fashion, while ensuring its value outweighs the cost. However, data elements related to SDoH – such as access to housing, level of personal safety and availability of healthy food – are generally not collected by payers, and are just starting to be collected by providers.

5. Clinical Outcomes Reporting

Some states have created reporting requirements that measure clinical outcomes. If the targeted condition requires clinical measurements or screenings, which are not typically included in medical claims, payers will have to set up new data interfaces into a care management or similar system, or encourage providers to use CPT Category II codes that have results embedded in them.

This guide provides an overview of the Health Home Program and presents five common challenges payers will face when creating a successful program. To learn more, you can click here or submit the form below.

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Laura Herlands

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