Your Primer to Healthcare Mergers and Acquisitions

5 Provider Strategies For Confronting The End Of I/DD Carve-Outs As We Know Them

Jul 31, 2018

by Rachel Boynton

by Rachel Boynton

Volume 5 Issue 16, July 31, 2018 

There is no faster evolving healthcare area than the Medicaid-funded Long Term Care Support Services (LTSS) marketplace. The combination of reimbursement pressure, limited state budgets, and the movement to bring LTSS services under the direct administration of health plans (“carve ins”) is challenging many traditional I/DD providers. The rapid proliferation of health plans and Managed Care Organizations (MCOs) into the LTSS is forcing I/DD providers to understandably rethink their long-term vision.

With the inevitability of the health plan expansion into LTSS services the question for providers is simple: How do you best prepare to succeed in this new “carve in” environment?

Know where your marketplace is headed– Many states are in the midst of planning and implementation of I/DD carve ins with varying degrees of provider and stakeholder input. The key for providers is not only giving input, but clearly understanding the specific requirements of Medicaid and the state for the individual MCOs. These requirements will shape health plan behavior and are worth reviewing so individual providers understand where the MCO will focus in contracting relationships.

Share your vision and incorporate stakeholder input – As a provider begins to articulate a vision and plan for the new LTSS environment, reaching out to stakeholders is essential. They have invaluable input and including them in your efforts strengthens your organization. MCOs typically respect organizations that can demonstrate they have strong stakeholder support.

Align your internal efforts – One of the biggest challenges for an I/DD provider can be confusion in the ranks about how to interact consistently with a new funding entity like an MCO. Provider leadership can strengthen their position with a health plan when they can demonstrate that they are well organized from top to bottom. Seeing this an MCO anticipates their mission will be easier to fulfill, including the timely delivery of high quality services.

Access and utilize data – Many I/DD providers have inadequate technology for tracking data, especially related to client outcomes. In dealing with MCOs that often have relatively sophisticated IT capability this is one of the biggest areas for a competitive advantage.

Make your data visible to MCOs – With the ability to track important outcome and quality data the next step is for I/DD providers to synthesize information so that it can be shared with an MCO. Many health plans are venturing into the I/DD market with a multitude of questions about how to capture useful data in a new service population. If you make a presentable effort that you can share with a health plan you have a better chance of building a relationship with them.

For many providers the natural reaction is to “fear the unknown” of health plan expansion into the previously sacrosanct world of I/DD services. In fact, the opposite tact makes sense – health plans are not enemies but the evolution of healthcare service management. Clearly understanding their mission and responding in kind is the best path for provider and stakeholder success in the coming decades.

Rachel Boynton

Rachel Boynton CM&AA

Managing Director

As Co-Founder of LifeShare, a multi-state human services and healthcare organization, Rachel has a unique background of over 20 years of successful operational and executive experience, in addition to an MBA in Healthcare Management. She began her professional life as a home care provider, an experience that created the foundation for the innovative quality and success of LifeShare, while also changing her life. At LifeShare, she managed their Operations (Adult Day/Residential; Child Therapeutic Foster Care; HCBS; Child Therapeutic Day/Diversion Services, and Educational Programming), Finance, HR and Quality Assurance (facilitating COA accreditation and policy/procedure implementation). After selling LifeShare to Centene, Rachel remained during the transition of management and helped to provide outcome measurements and COA compliance reporting. At VERTESS she is a Managing Director providing M+A advisor and consultant services, specifically in the I/DD, behavioral health and related healthcare markets, where systems are rapidly evolving, and providers are striving to adapt strategically to diverse challenges.

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