Medicaid Health Plan Leader Interview

John Lovelace

President, UPMC for You 
President, Government Programs and Individual Advantage Products


  • The Interview
  • Bio

Interview with John Lovelace


Q1: Looking back on the last 90 days, what issues have you been focused on the most? Do you think your peers (leaders in other MCOs) have been focused on similar issues?

Focus the last 90 days

We have spent a lot of time working for rate adequacy in Medicaid. Our major buyer is the state of Pennsylvania. The state has a number of strategic initiatives they want MCOs to help them achieve. Like many states, they are working to move forward with value-based payments to Medicaid providers. We are working to achieve rate levels that will achieve these aspirational goals. You also have to identify the right outcomes that make sense to match up with value-based payments. One recent example is our work on c-section rates. 

We’ve also been busy delivering on a wide range of contracts we have with the state, including DSNP and LTSS programs. Our LTSS rollout began January of this year, and next January we will be statewide. It already has 74,000 members.

Based on discussions with my peers in other MCOs, we all have the same focus issues: payments, rates and outcomes.

Progress on impacting social determinants of health

I have spent the past several years working on ways to address social issues that drive healthcare outcomes (SODH). The discussion has moved forward significantly in the last 5 years. We started talking about it in housing 10 years ago. And Centene recently announced an entire center focused on social determinants. It is now widely recognized now that there are a lot of things that can be done about it:

  • People are building referral networks. Screening for needs is critical, and we are learning that its easier when screener thinks there is some sort of solution.
  • We are starting to have conversations about using social determinants data for structuring payments accordingly.
  • We are making progress working with PCPs and FQHCs. Working to resource community health workers has been a big focus. And adding social workers to our strategy has been a big step.

With all the recent progress in things we can do to address these needs, there has not been much progress is seeing how the economics of all these things we think will impact social determinants interact. Our starting point- housing- does have good data on how housing costs impact medical spend. The main example, and the one with the most clarity, is homelessness.

For those beginning to think about how they want to impact social determinants in the populations they serve, I’d say there are 3 things to do:

  • ID what issues and needs are to be screened for
  • Determine how to explain the business case for items you can do something about
  • Explore where you have partnerships to help impact social determinants in a meaningful way

This really is the next big wave in Medicaid managed care. Everyone is going to be doing it, and the procurements reflect that. Look at the recent NC managed care RFP and its focus on social determinants. And the next Medicaid procurement here in PA is expected to have requirements related to data systems and accounting for health outcomes related to social determinants.

Q2: Looking ahead for the next 90 days, what do you think the most pressing issues will be?

Several things come to mind, and a lot of them have to do with behavioral health services: 

  • I think we will see more focus on accomplishing meaningful integration on impacts of physical health on behavioral health (and vice versa). Think about what we are seeing in some efforts in duals programs now.
  • There will also be an increased focus on outcomes for treatment of substance abuse disorders. As death rates increase, we will see more focus on what to do about this. Restricting supply by itself doesn’t fix the problem. You may just be pushing the problem to a place you don't see it anymore. The annual death rate from opioids is already shocking, and its expected to be at the same level for the next 10 years based on an article I read recently. Along these lines there are groups like the Shatterproof Coalition. This is a group founded by wealthy person whose son died of overdose after many attempts at rehab. Their mission is to work with payers to create evidence-based models for substance abuse treatment. All of this is part of a discussion about belief-based programs vs. evidence-based-medicine. We’ve had the former in things like AA and NA for decades. While it works for a lot of people, it also doesn’t work for a lot of other people. Other models are untested in terms of evidence, too. There is no evidence that 28-day rehab works. The main idea of this coalition is to create evidence that helps payers to implement different models.  Getting 40 big payers to change provider behavior is easier than getting 10,000 providers to change.
  • I think we will also see new focus on the impacts of value-based care. Where it take us by focusing on paying for success is a worry. One of the unintended consequences in pay for performance is taking only easier people. How do we account for this? What if people are treatment resistant, or not motivated to change? How do we account for those people that won’t be welcomed in value-based payment models by providers who want to shed risk?

Q3: What advice would you give to your peers about managing vendor partner relationships?

  • The first thing is to ask potential vendors is what peer reviewed evidence they have to support that what they are proposing is effective or what the impact is. What you normally get is carefully cultivated samples that are more like published commercials vs. evidence-based medicine. Vendors will pick and choose from successes and put those as their pitch. Don't rely only on the vendor to tell you the great stuff.
  • Be careful to quantify expected outcomes for what cost. Avoid a strategy to just try things and see what happens. You want clear, quantified goals like “reducing ED visits for CHF by 20%.” You also want to have a structured period of study and agree at the beginning what the goals and study methods are.
  • Explore vendor arrangements where they share some risk as part of the arrangement. Value-based payment models can apply to vendors, too. What’s the consequence if we don't achieve expected results? You don’t want to leave room for finger pointing at the end. You want to make the rules clear at beginning, so you don't argue over what went wrong.

I’ll give a somewhat hypothetical example to help illustrate all this:

We were in discussions with a care management vendor for help with high risk patients in Pennsylvania. This particular vendor had had success in other sectors.

We were able to talk with other MCOs who had worked with them. We learned the vendor was good at ABC, didn’t know what D was, and E-G was a complete revelation to them. They had no experience with patients with SMI. Turns out their success was very specific elderly ladies with early stage dementia who lived in independent living.

All the details are twisted up a bit to be discrete about who the vendor was, but you get the idea.

The moral of that story is to talk to your colleagues in other MCOs. Groups like ACAP are good for those discussions, because you’re not really in a group of competing MCOs.

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