Medicaid managed care: Lessons to take home
Compete or become indispensable niche provider
As Medicaid programs address pressure to convert to managed care, some revamp themselves into models of efficiency and excellence from which any women’s health facility could learn a thing or two. Others opt out of direct care but not to vanish. Instead, they make themselves indispensable by shoring up private-sector providers who take care of Medicaid patients. Changes like the ones described in this story make it worth your time to take a fresh look at your local Medicaid program. You might learn how to upgrade your client satisfaction ratings, or you might discover extra patient care resources for no cost at all.
When New Jersey state officials pressured their Medicaid-funded providers to switch to a managed care model, the providers had to compete with other plans in the market, or Medicaid recipients would go somewhere else. The Medicaid clinics knew the state program would contract with more cost-efficient providers on a moment’s notice.
"We’re not the only game in town anymore for our patients," says Elaine Bronner, MSN, RN, C, ANP, former director of ambulatory women’s health services at the University of Medicine and Dentistry of New Jersey-University Hospital in Newark. Providers say Medicaid patients are attractive as other managed care populations.
"Medicaid dollars are green money just like that of any other insurance plan," Bronner notes, "and if we wanted to keep our patients, we had to change our ways."
Changes occurred on three fronts:
1. Patient satisfaction surveys told Bronner and associates that waiting to see the doctor was the biggest complaint. The no-show rate was 40% for block appointments at 9 a.m. and 1 p.m. One month into the new program, no-shows dropped to 19%. (The flow of clients through the center is pictured in the diagram, "Triage Process for Women’s Health Center," p. 157.)
2. If staff ownership isn’t a priority through- out the process, it won’t work, Bronner says. Ownership required participation in the planning, from receptionists to physicians. It started four months before the patients noticed any differences at all.
Extra resources to enhance patient care served as incentives that cinched staff cooperation. Social workers came in as case managers, and extra midwives and nurse practitioners were hired.
3. The third change component involved computer systems and equipment. Patient appointments and records were computerized. Relocating an ultrasound machine and a lab to the women’s building cost $200,000 and nets annual savings of $500,000. The efficiency of having ultrasound and lab services in the building reduced patients’ exam room time from 60 to 41 minutes, which resulted in the savings.
Looking back on the project, Bronner suggests, "Make sure all the pieces are in place before you make a change like we did. Having the electronic system up and running is especially important."
When Medicaid in Colorado allowed women to get their prenatal care from any provider who would accept Medicaid reimbursement, the Tri-County Health Department in Englewood phased out its network of prenatal clinics.
"We saw it coming," says Maggie Gier, RNC, MS, associate director of nursing. "We said Maybe the health department doesn’t need to be in this business.’" Instead, Tri-County officials devised a plan to deploy their resources where they would make the best impact.
To that end, Gier and staff promoted the "Prenatal Plus" program and comprehensive family planning services among women’s centers and other private sector providers who accept Medicaid reimbursement. Prenatal Plus is a consumer education and case management package designed to ensure better birth outcomes for Medicaid patients. (For program details and information about the availability of this federally sponsored service in your state, see "Medicaid prenatal care nets good birth outcomes," p. 158.)
Tri-County’s family planning program, also federally funded, is available to all women. Fees are income-adjusted from nothing up to $67 for a Pap smear and annual exam. Other services include counseling and referral for termination of pregnancy and birth control or sexually transmitted disease medications for one-third retail cost.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content