A lot happens in Medicaid in 30 days. We cover it all in 60 minutes with our distinguished panel this month.
2018 September Medicaid News Roundtable
Author: Sarai McDowell
2018 August Medicaid News Roundtable
A lot happens in Medicaid in 30 days. We cover it all in 60 minutes with our distinguished panel this month.
Medicaid Who’s Who Interview: Thomas Kaye
Tom Kaye is an incredibly knowledgeable pharmacy executive. Check out his LinkedIn profile.
1. Which segment of the industry are you currently involved?
A: As healthcare is very broad, I have been very fortunate to participate in many sectors. I have for the last 25 years focused on Medicaid fee for service and managed Medicaid under 1115b and 1915b waivers, commercial and Medicare part D, SNP and a few other venues. My most current assignments has been work with several of the national top 5 insurance companies with focus on their movement into Medicaid managed care. Medicaid managed care involves states filing of waivers with CMS for state participation as an experiential program to reduce state Medicaid costs. New to the market for Medicaid are the commercial power houses insurers eager to join the ranks. My past experience has also contained hospital, ancillary infusion services, compounding, new drug development, sales and marketing for pharmaceutical with PBM services
2. How many years have you been in the Medicaid industry?
A: Over 25 years
3. What is your focus/passion? (Industry related or not)
A: Focus Currently my ability to assist with consultative effort for changing the velocity of pharmacy expense to plans and stakeholders. Minimally , cost avoidance with existing tools and emerging tools are offered to lower costs of claims / benefits. I find that most cost reduction exist as incremental efforts, common sense issues. The low hanging fruit as some mention, is generally picked already and there may be no gain in cost reductions utilizing this approach.
4. What is the top item on your “bucket list?”
A: Bucket list flows over the top currently, but the top would be a train voyage stating in Canada, traversing though the great wood lands, valleys, national parks, upper north country of America and ending in southern California after 10 days. The train has crystal glass roofs, great food and sleeping accommodations.
5. What do you enjoy doing most with your personal time?
A: I enjoy wood working and engineering as a DIY “MAKER” The lack of intensity and the pleasures of wood are very rewarding and often humbling.
6. Who is your favorite historical figure and why?
A: I would choose Nikola Tesla, inventive, problem solver, and futurist.
7. What is your favorite junk food?
A: Fried pork skins, love the crunch and salt, not much flavor; might be similar to rice cakes. Pork skins go better with beer.
8. Of what accomplishment are you most proud?
A: Raising a family of three children and maintaining marriage to the same woman for 47 years. Having successfully raised the children who are married with 5 grand kids.
9. For what one thing do you wish you could get a mulligan?
A: Redo’s are always hard, but I would take one for the multiple moves of family around the country for job opportunities. This was disruptive for the kids.
10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?
1. Financially, plans are being asked as are providers to take less in compensation due to the ever-rising costs of care and supplies. This is NOT sustainable for more than 3 years due to the drag it will place on GDP and tax burdens of the people. We have been witnessing to the failure of the most recent design of healthcare modeling, costs and untruths. Yes the likely hood of a new program will evolve, but with this come more regulations and restrictions that take provider time from patientsThere likely will be a deployment of new benefits which involve personal responsibility from the members. Plans WILL move from a Risk corridor arrangement as currently set, to an admirative services only payment process such as we have with various Medicare programs. Single payer may still be living
2. Infrastructure and telecommunications will need to be harmonized. Some relaxation as to HIPAA regulations will be needed to allow more robust communications with all stakeholders and data sharing for measurements. Today we see a quagmire of efforts to use mobile devices, electronic communications etc. This is a great idea ; however we have the highest costing patients (members over 50 YO) bucking the improvements and struggling with new forms of communications. The demographic is not willing to adopt many of the new areas of communication based on lack of understanding, fear and frustration. It will take a few years for this to subside.
Look for adoption and proliferation of IT super hubs and servers that embrace block-chain type transactional information. The use of similar hubs and techniques such as with twitter, Facebook to improved communications to patients, providers and payment process. Legislation will be offered to embrace much more for IT compatibility across all systems. Increased transparency to cost of services will evolve though IT systems to align awareness of true prices instead of predatory pricing we see today with many oncology and transplant medications. The increased use of real time data for “Value based” care will be coming along.
3. Science never stands still. The ethical issues growing out of research is complex and often too perplexing for the human mind to cope with. Improved understanding of the elements of humans will be pushed to the front of research. Payment for research will need to be allowed.
Look to see within the next 5 years and maybe sooner a better understanding of pathophysiology of human disease- gene sequences and informative attributes of cause and effect. Phage deployment and advanced nanobots with Crispr/Cas9 and newer versions of gene manipulations are moving at light speed to approved therapy. The possible end of a PCP visit other than the patient attending a diagnostic session to take samples for a gene related medication to be made as personal medications. The market disruption may be phenomenal as we know it today. Curative actions/steps may out pace chronic treatments with current consumption of marginal medications. The mere removal of chronic conditions such as diabetes, COPD, arthritis, cardio vascular issues would be very disruptive regarding payment, profits and how payments are to be arranged?
July 2018 Medicaid Star Search
Want to find out about what innovative companies are doing in the Medicaid space, but don’t want to sit through boring demos? On this episode of Medicaid Star Search, we talked to i2i, Smart Policy Works, and Medical Advantage Group.
Medicaid Who’s Who Interview: Bill Lucia
Bill Lucia has decades of experience in the healthcare system industry, specifically in the IT area. Check out his LinkedIn profile.
1. Which segment of the industry are you currently involved?
A: My company, HMS, is a healthcare IT organization that works with multiple Medicaid stakeholders including more than 300 Medicaid payers, 45 Medicaid agencies, at-risk providers and Medicaid recipients to assure the financial integrity of Medicaid and assist our clients in understanding and managing their members.
2. How many years have you been in the Medicaid industry?
A: I actually started at HMS working with safety net providers who were heavily dependent on Medicaid, 21 years ago.
3. What is your focus/passion? (Industry related or not)
A: My true north and passion is to help make our healthcare more efficient and effective so that everyone can lead healthier lives, not worrying about the cost of healthcare or deciding between healthcare services and putting food on the table.
4. What is the top item on your “bucket list?”
A: I have two — first I’d like to open a shelter for abandoned and abused animals. Its at crisis proportions in our nation and we just don’t do enough. And yes this ties to health because pets can be great emotional support for the chronically ill and disabled. My second is to retire and spend half of my time in Italy living “La Dolce Vita”.
5. What do you enjoy doing most with your personal time?
A: Even though I travel all the time for business, I still love to travel the world and explore other cultures. I’ve visited over 20 countries but have many more to see.
6. Who is your favorite historical figure and why?
A: Leonardo da Vinci is one of my favorite historical figures. He is best known as the artist who created the Mona Lisa and the Last Supper, but he was a true renaissance man as he was also an architect, musician, engineer, scientist and inventor. Da Vinci was ahead of his time and sketched the first parachute, helicopter, motor car and other inventions that are essesntial to modern day life. His story inspires me to be creative and innovate.
7. What is your favorite junk food?
A: Ok, two…dark chocolate with nuts (which is not junk food, it’s good for you!) and piza (it’s in my blood).
8. Of what accomplishment are you most proud?
A: Leading HMS’s growth from a small services vendor in one line of business to one of the Top 25 healthcare IT companies in th U.S. and focused on a very critical mission of making the healthcare system more effective. We’ve built a “want to” versus “have to” culture at HMS because all of our employees know the value we bring.
9. For what one thing do you wish you could get a mulligan?
A: Ah only one? Well personally, it would be that I wasn’t in town when my Beagle passed away. Holding an animal during it’s last breaths reminds you how fragile life can be and being abe to thank them for unconditional love.
10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?
A: Well, in no specific order… First, we have to aggressively attack the Opioid crisis, which disproportionately impacts the Medicaid program. Advanced analytics exist to help us do this and crack down on prescribers but also be more predictive about addiciton.
Second, we have to share more data across the healthcare system and across the entire Medicaid program. HMS recently developed a risk intelligence tool, ELLI, that does just that and enables Medicaid Managed Care plans to understand their member at enrollment, accelerating care management, avoiding costly ER visits and better engaging the member by understanding social determinants of health.
Third, we have to be careful about policy changes to Medicaid under the auspices of reform or revoking the Affordable Care Act. States need both flexibility in how to manage their programs but assurances that changes to the federal/state partnership are very carefully thought through to avoid disruption to the members, their families and providers.
Menges Group 5 Slides Series for June & July 2018
The Menges Group puts out these great analyses and insights each month. And is kind enough to let us repost them for the MM audience. Check out themengesgroup.com to learn more about the work they do.
Attached are the June & July 2018 edition of our 5 Slide Series. Both of these editions draw upon datasets we have developed and regularly update. Our June 2018 edition summarizes the recent financial performance and quality performance for Georgia’s Medicaid health plans, as an example of the information we often provide our clients using these datasets. Our July 2018 edition conveys summary data regarding the Medicaid MCO industry’s overall financial performance during CY2016 and CY2017.
Medicaid Who’s Who Interview: Friso van Reesema
Where passion for serving others and career meet, there lies Friso van Reesema. Check out his LinkedIn profile.
1. Which segment of the industry are you currently involved?
A: I’m predominantly involved in supporting community-based Medicaid managed care plans and FQHCs. I support both the payer and provider partner on communicating with vulnerable Medicaid beneficiaries including Duals, CHIP and MLTSS.
2. How many years have you been in the Medicaid industry?
A: My support for Medicaid beneficiaries officially started in 2012, with patient education and engaging vulnerable populations with communications and technology, as well as joining a non-profit Board for health equity. At CipherHealth, I’m continuing in the journey with a strong focus on Medicaid Managed Care Organizations. The passion that these clinical and non-clinical teams have for supporting the vulnerable is commendable. It’s a privilege to arm these teams with tools to improve the quality of their lives from a whole-person perspective. Great progress over the past 6 years!
3. What is your focus/passion? (Industry related or not)
A: Serving others, especially those with fewer means, is an innate passion that my grandfather passed along to me. He served on the Red Cross in the Netherlands and engaged the royal family in this global organization for disaster relief. Those genes made it to my mom and now to me. I’m passionate about education; whether it’s listening to the homeless or members of a local Boys and Girls Club to understand how to support them with education, insights and guidance. Being at the intersection of patient and provider communication is awesome. Bridging the health literacy and time scarcity gap supports both parties. It’s in my nature to help out.
4. What is the top item on your “bucket list?”
A: Speak 8 languages and travel to all 7 continents with my wife and two boys! This way we can order fresh, nutritious and local food in the local language to avoid ordering cow’s tongue. I’d like to do more with my cultural anthropology and public health master degrees by diving deeper into cultural competency in population health communications and tying them to social determinants that I identify from traveling and research to support local health plan outreach, assessments and care coordination.
5. What do you enjoy doing most with your personal time?
A: Keeping the adrenaline and competitive juices flowing by playing tennis in a men’s league is fun and healthy for me, but I really enjoy being on and in the water with my family either sailing or watching them tube and yell with excitement.
6. Who is your favorite historical figure and why?
A: A favorite and lesser known historical, yet current, leader of deconstructing racial disparities and bias is Archbishop Desmund Tutu of South Africa. Tutu is a favorite, because I met him through my grandfather while they were actively supporting South African public health initiatives including sexual assault, HIV prevention, childhood vaccines, etc. Besides bringing back great memories of working with my family, Tutu has an amazing humour and smile that wins over even those jealous of his power as former Archbishop of Cape Town, helping to dismantle apartheid with Nelson Mandela. He received the Noble Peace Prize and is beyond modest about his accomplishments. He’s a ‘must-meet-and-have-dinner-with’ type of legend.
7. What is your favorite junk food?
A: Deep fried ‘bitterballen’ from Holland with mustard sometimes tops Garden Catering’s Chicken Nuggets and cones.
8. Of what accomplishment are you most proud?
A: My two boys and wife are proud of my role in the community. I’m also jazzed by reactions from family and friends around a 5K Mud Run getting local, vulnerable and affluent families together in a muddy course to raise money for our local Boys and Girls Club, which started with 40 participants six years ago and now is maxed out at 800 runners and walkers raising over $175,000 per year for the prominent safety net community program and facility.
Professionally, I’m proud of my longstanding friendships with healthcare executives I’ve partnered with to achieve stretch goals supporting corporate strategy. One such relationship is with Cindy Hallam, when we empowered providers and members with shared decision making for chronic low back pain in Louisiana. The plan won an important State bid beating out National payers with a competitive advantage in provider engagement and involving people in their treatment options around chronic low back pain.
In my previous role educating providers on pain management and anesthesia, I am proud as a CT citizen for empowering community health clinic teams with educational lunch scenarios around how to identify and manage aberrant opioid seeking behaviors. After 3 months of education and empowerment, a local retail pharmacy was held up for oxycontin, because of the reduction in prescribing, which improved provider satisfaction and the State budget.
9. For what one thing do you wish you could get a mulligan?
A: As a golfer, I take my fair share of mulligans or provisionals. Live is too short for regrets. I have made plenty of less than perfect career and personal decisions that I learn from, remind myself and share with others, which often produces a laugh. Being Dutch, transparency sometimes results in “foot in mouth” syndrome. Life without apologies would leave me mute.
10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?
A:
- Support Medicaid recipients with a hybrid Medicaid/exchange product that makes financial sense for them and their family including the impact of work requirements for the potential to graduate to an exchange product for the family. Use incentives just like in the commercial market to change health behaviors!
- Medicaid programs and waivers to improve housing stability with incentives for beneficiaries, government, Medicaid MCOs and health systems, as well as the life sciences is paramount for emergency department diversion and reducing unnecessary medical expenditures.
- Collaborate more with community-based organizations and social services to optimize resources and exchange data on activities and clinical + non-clinical information to identify opportunities to support beneficiaries and those that manage their health and wellbeing.
2018 July Medicaid News Roundtable
A lot happens in Medicaid in 30 days. We cover it all in 60 minutes with our distinguished panel this month being Jerry Dubberly, Rob Damler, Virgil Dickson, and Jeff Myers.
2018 July Medicaid State Spotlight: Kansas
We talked all things Kansas Medicaid with Jon Hamdorf, Kansas Medicaid Director.
Medicaid Who’s Who Interview: Cindy Becker
Cindy has decades of involvement in the Medicaid industry. Check out her LinkedIn profile.
1. Which segment of the industry are you currently involved?
A: Most recently, I’ve worked with behavioral health expansion, integration with physical health, and community engagement. However, I’ve been involved with Medicaid policy, funding, and implementation throughout my career.
2. How many years have you been in the Medicaid industry?
A: I’ve worked at both the state and local levels for more than 25 years. During this time, I held senior executive positions at the state’s Medicaid agency, one of the largest metropolitan counties, and Managed Care Organizations. I’ve also been intimately involved with health reform in Oregon from drafting legislation to transforming service delivery to engaging diverse communities.
3. What is your focus/passion? (Industry related or not)
A: I’m solutions-focused and passionate about creating high performing systems through effective policy analysis, planning, communications, metrics, and relationships. Figuring out how to make things work is the ultimate challenge, particularly when working in the Medicaid space! I’m also a big believer in process improvement and especially like Peter Drucker’s quote: “There is surely nothing quite so useless as doing with great efficiency what should not be done at all.”
4. What is the top item on your “bucket list?”
A: I would love to go on a photographic safari.
5. What do you enjoy doing most with your personal time?
A: I enjoy painting and crafts, probably because they have a beginning, middle, and end (unlike much of the work in the health arena).
6. Who is your favorite historical figure and why?
A: Golda Meier – I admire her leadership, tenacity, non-traditional approach and her many accomplishments. She was a force to be reckoned with who worked relentlessly to achieve her goals.
7. What is your favorite junk food?
A: Donuts!
8. Of what accomplishment are you most proud?
A: Early on in my last position, the communities I worked with identified a major gap in services for children and youth. I’m very of proud of bringing public and private sector stakeholders together to create–and fund–community mental health crisis services for children and drop-in services for transition-aged youth experiencing behavioral health issues.
9. For what one thing do you wish you could get a mulligan?
A: Years ago, I was involved in a major agency reorganization which didn’t go smoothly. One of the main reasons was the director’s negative feelings towards middle management, feeling they were the cause of the agency’s problems. While I supported that approach at the time, it was a great lesson learned as I went on to leadership positions. In fact, successfully working with middle management became a critical component in subsequent change initiatives that I lead.
10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?
A:
a. Tracking and strategizing any federal health reform changes to the ACA — everyone is waiting for the next shoe to drop.
b. Engaging non-traditional partners and communities to:
- Expand and integrate behavioral health and physical health services
- Focus on social determinants, specifically housing and food insecurity
- Increase health equity among marginalized populations.