As Medicaid Changes Loom, Healthcare Leaders Call for Greater Coordination and Innovation

At Health Evolution Connect, leaders from Penn Medicine and Independence Health Group discussed the challenges facing Medicaid and the need for stronger partnerships, better data sharing and new approaches to caring for patients with complex needs.

As significant changes to Medicaid eligibility and coverage take effect, healthcare organizations are preparing for potential disruptions that could extend well beyond health plans and government programs.

Patients and families, hospitals, physicians, community organizations and other stakeholders will all be affected, particularly those caring for people with complex medical and social needs.

That was the focus of a recent Health Evolution Connect discussion, “Medicaid on the Line: Commitments, Not Commentary,” moderated by ConcertoCare CEO, Dr. Julian Harris, and featuring Kelly Munson, President & CEO of Independence Health Group, Inc., which includes AmeriHealth Caritas, and Kevin Mahoney, CEO of Penn Medicine, University of Pennsylvania Health System.

The discussion focused on what organizations are seeing in Philadelphia, how health plans and providers can work together during a period of significant change, and where technology and new models of collaboration could help maintain continuity of coverage and care.

Preparing for Medicaid changes

Munson emphasized the need for healthcare organizations to prepare now for the changes ahead.

With leadership experience spanning health plans and work with state and federal officials, Munson has a broad view of the challenges created when Medicaid policy changes affect patients, providers and plans simultaneously.

The changes could create additional complexity for patients who move between coverage arrangements or providers, as well as for organizations responsible for ensuring that care continues without interruption.

The challenge is particularly significant for people with multiple chronic conditions, who may rely on several physicians, medications, social services and care management programs.

“Preparation” therefore means more than understanding changes in eligibility rules. It also means ensuring that organizations can communicate with one another when a patient’s coverage, provider relationships or care needs change.

The interoperability challenge

One of the more significant opportunities discussed during the session was the potential role of artificial intelligence in improving interoperability.

Healthcare organizations have spent years working to connect information across different systems. Yet important data remains fragmented among counties, states, federal agencies, health plans, providers and community organizations.

Munson highlighted the opportunity for innovators to use AI to help build the “data pipes” needed to connect those systems and improve continuity of both coverage and care.

The potential application goes beyond automating administrative work or generating clinical documentation. Better connected data could allow organizations to identify changes in coverage, clinical risk or social circumstances more quickly and coordinate responses across organizational boundaries.

For patients with complex conditions, those connections can be particularly important.

Consider a patient with congestive heart failure and diabetes who requires insulin. That individual might interact with a primary care physician, cardiologist, endocrinologist, pharmacist, health plan care manager and home-based or community care team.

Each organization may have critical information about the patient, but that information is not always available to the others.

A change in insurance coverage could affect access to insulin or another medication. A hospitalization could occur without the outpatient care team receiving timely information about the patient’s discharge. A medication change by one physician may not be immediately visible to another.

No individual organization necessarily caused the problem. The larger issue is that the healthcare system often remains fragmented around a patient whose needs are not.

Better interoperability could allow the organizations involved in a patient’s care to identify risks earlier, coordinate interventions and potentially prevent avoidable emergency department visits and hospitalizations.

Partnerships beyond traditional boundaries

The discussion also highlighted examples of partnerships between health plans and providers.

Munson pointed to the relationship between Penn and IBX and its contribution to AmeriHealth Caritas’ quality performance in D-SNP and Medicaid.

Mahoney discussed Penn’s recently announced ASC partnership, which is focused on broader market affordability.

The examples reflect a growing recognition that some of healthcare’s most difficult challenges cannot be addressed by a single institution.

Health plans may bring data, financing and population-level incentives. Health systems and physicians bring clinical expertise. Community organizations often bring trusted relationships with patients and local knowledge. Technology companies can provide tools and infrastructure that connect the different participants.

The challenge is creating partnerships that operate consistently rather than only in response to individual crises.

Putting the patient at the center

The conversation also reflected a broader shift in how healthcare organizations are thinking about complex patients.

People living with multiple chronic conditions do not experience healthcare according to the organizational boundaries that define the industry. A patient with heart failure and diabetes may simultaneously need primary care, specialty care, medication management, behavioral health support and assistance with social needs.

For such patients, continuity is not simply an administrative goal. It is an important component of effective care.

That has implications for how organizations design care models.

Rather than adding another layer of technology or another program around an already fragmented system, healthcare organizations have an opportunity to use data and technology to better coordinate the people and resources already involved in a patient’s care.

ConcertoCare, which focuses on patients with complex medical and social needs, sees this challenge particularly clearly. Its model emphasizes more proactive and coordinated care for patients who often interact with multiple parts of the healthcare system.

A moment for action

The Medicaid changes ahead will create challenges for organizations across the healthcare ecosystem. But the disruption also presents an opportunity to rethink longstanding approaches to collaboration, technology and care delivery.

The central question is whether the healthcare system can move beyond commentary about fragmentation and begin building the infrastructure and partnerships needed to address it.

That will require health plans, providers, government agencies, community organizations and technology companies to work across traditional boundaries.

It will also require a shift in perspective: from asking which organization owns a particular problem to asking which organizations need to work together to solve it.

The Medicaid landscape may be changing. The larger opportunity may be to use that change to build a healthcare system that is more connected, more responsive and better able to maintain continuity for the patients who need it most.

As the discussion at Health Evolution Connect made clear, the question facing healthcare leaders is increasingly not what any one organization can accomplish on its own.

It is what can be accomplished together that none could accomplish alone.