We spoke with Shannon McMahon (the MD Medicaid Director) about all the exciting things going on in Maryland Medicaid programs.
February 2017 Medicaid State Spotlight: Maryland
Category: Amazing Free Content
Medicaid Industry Who’s Who Series: Jennifer Sweet
Join Jennifer Sweet April 17-18 in Chicago to hear from policy insiders, MCO leaders and state officials who will provide a clearer picture of the future of Medicaid expansion and financial alignment, as well as proposed Medicaid regulations! Register using code HMP139 for a 15% discount at https://goo.gl/9ISGFT.
Medicaid Who’s Who: Jennifer Sweet – Medicaid Segment Lead for Florida Blue
1. What segment of the industry are you currently involved?
A: I am on the payer & managed care side of the industry. I am working in Florida where the Medicaid population is largely managed by MCOs.
2. What is your current position and with what organization?
A: I am the Medicaid Segment Lead for Florida Blue.
3. How many years have you been in the Medicaid industry?
A: For about a decade, and before that, in commercial health insurance.
4. What is your focus/passion? (Industry related or not)
A: In terms of work, I am committed to doing things “right” for this population – and that entails everything from delivery of quality and appropriate services to the people who need these services to being an effective steward of taxpayer funds and a good partner to our state Agency. We are all on the same side, serving our communities, is how I see it. Personally, outside of work, I love to travel and experience other cultures, languages and architecture.
5. What is the top item on your “bucket list?”
A: I work with a not-for-profit, the Lyceum Fellowship, that awards travel grants to talented students of architecture. My goal is to ensure this organization is funded and managed such that it survives long after I do.
6. What do you enjoy doing most with your personal time?
A: I appreciate finding spaces of quiet down time on the weekend to simply read, walk my dog, hang with family and friends.
7. Who is your favorite historical figure and why?
A: I enjoy reading both history and biography so picking a favorite is hard. I enjoy learning what motivated the person who has a significant accomplishment, and where he or she drew the strength to fight for the accomplishment. Abraham Lincoln is a prime example. But brave, grand acts are interesting to read about in much lesser known characters as well. It’s also interesting to get a glimpse of how others think and frame the questions of their time. Ruth Bader Ginsburg and Oprah Winfrey come to mind as I say that, or Margaret Thatcher.
8. What is your favorite junk food?
A: Popcorn, specifically, hot air popped with butter and salt. Always has been my favorite, I was never a chips-cheetos-fritos kind of kid.
9. Of what accomplishment are you most proud?
A: I am very proud of my son and my family but I don’t consider them an “accomplishment” per se. So I’d have to say that there isn’t a single grand accomplishment but rather, all the wins along the way – whether in education, business, hobbies, love – they all add up to a core accomplishment that is my life. I am happy with it.
10. For what one thing do you wish you could get a mulligan?
A: I don’t want a mulligan so much as a repeat performance of some great moments in my life. The times when things fell short, well, they are what they are and they are behind me now.
11. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?
A: Knowing that the changes ahead (at both state and federal levels) are likely to be significant & fundamental, any list has to include effectively planning the response to those changes. But in the meantime, I’d say:
- Align payers and providers through appropriate contracting that establishes partnerships as a means of improving not only the lives our members/patients and our respective businesses, but to contribute to improvements in the very fractured US health care marketplace.
- Improve the whole world of data in Medicaid – as in: capturing more accurately the services we deliver, communicating this effectively to others (e.g., providers, the state Agency), and advancing the way we use this data in search of more effective, efficient management of care.
- Make space to be innovative, to find solutions that move us forward – not easy to do in the din of everyday operations and life.
Clay’s Weekly Medicaid RoundUp: Week of February 20th, 2017
Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2lRoz5n
Or you can click the one for optimist readers – http://bit.ly/2lRbJno
THE WHEAT STATE TILTS AT WINDMILLS- Either KS and ME know something we don’t, or these 2 states are about to get approval for Medicaid expansion in the era of Trump. ME got it on the ballot and KS reps just passed it in their house. Or maybe lefty reps in both states are play-acting to look good for their base since Dems in generally are licking wounds right now? You decide. News and Weather at 10.
HEART OF DIXIE WANTS CAID FOR CONS- Err, sorry I meant to say “justice-involved.” Please don’t take away my snowflake card. Senator Cam Ward wants Alabama to get some help from the federalis to cover inmate costs. If his bill goes through, the feds (that translates to “taxpayers in other states”) will pay 70% of the costs of healthcare for Bama’s bad guys.
CONTINUED CHAOS IN UNHINGED WHITE HOUSE WITH DARK VISION OF AMERICA. DOOM! DOOM! DOOM! RUSSIANS! RESIST! Actually, yet another logical, calculated appointment was made to President Trump’s team this week. Brian Blase just joined the staff. Blase is a PhD economist who spent time as a Senate staffer and has been very open about his criticism of current Medicaid financing shenanigans. Couple this with the appointment of Price to DHS and Veerma to CMS- Mr. Trump is not joking about transforming Caid. The Resistance will have to do better than misbehaving at town halls and worshipping Michael Moore if they want to effectively shape what’s coming.
BEAVER STATE SEES DROP IN ENROLLMENT– There’s been about an 11% drop in Oregon Caid enrollment comparing Jan 17 to Mar 16. This translates into 133,000 less managed care members, which = 133k x 12 x the average cap rate less money for the MCOs (CCOs) in Oregon (I do fancy Medicaid math, you should sign a consulting agreement and pay me to do fancy Medicaid math for you. I also put most of my internal thought processes in parentheses [rarely in brackets] {and never in whatever these things are}). That’s a lot less cash the MCOs (CCOs) have to operate and will probably lead to some sort of horse-trading required come rate-setting time.
MOLINA POSTS NY CAID LOSS; RECENT SIGNALS OF EXITING EXCHANGES- Revenues for Molina in NY dropped $185M YOY, resulting in an overall $192M Q4 loss. The main culprit? Having to pay $322M into a risk adjustment pool that then got redistributed to other MCOs who showed higher risk memberships. Molina has also recently begun socializing the idea of it pulling an Aetna and exiting the exchanges.
XEROX (OLD ACS) ASKS JUDGE TO LIMIT THE PAIN IN THE LONESTAR STATE- The flailing MMIS giant has alleged that the state is using “a web of lawsuits” to jack up potential settlements related to that whole debacle over prior auth for orthodontics services for TX Medicaid bennies. Xerox wants to be able to designate the dentists involved as responsible 3rd parties. TX wants to be able to sue Xerox AND the dentists separately. The suit currently rings up at about $1B in potential payouts.
FARRIS’S FANTASTIC FRAUD FOLLIES– None this week dear readers. I hear you collectively, depressively sighing. But remember- I gave you an entire Roundup of Fraud Follies like 2 weeks ago. Remember that. Hold it close.
That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (its spring. You know its spring.) and keep running the race (you know who you are).
****
FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Uba ya aiko Ɗan ya ceci duniya
Medicaid Industry Who’s Who Series – Dr. James Bush
Dr. James Bush is the featured panelist for the upcoming Wyoming State Medicaid Spotlight Webinar on March 6th. RESERVE your seat today!
Medicaid Who’s Who: Dr. James Hall – Chief Medical Officer, Wyoming Medicaid
1. What is your current position and with what organization?
A: Wyoming Medicaid Medical Director
2. How many years have you been in the Medicaid industry?
A: 10 years
3. What is your focus/passion? (Industry related or not)
A: Quality improvement
4. What is the top item on your “bucket list?”
A: A smooth transition to high-value care and revitalized primary care.
5. What do you enjoy doing most with your personal time?
A: Travel, hunting and music.
6. Who is your favorite historical figure and why?
A: Marcus Tullius Cicero. Defender of the Roman Republic.
7. What is your favorite junk food?
A: Pizza
8. Of what accomplishment are you most proud?
A: 37 years of marriage and two great children.
9. For what one thing do you wish you could get a mulligan?
A: Some ill-chosen business partners.
10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?
A: What will stay or go from the ACA, the transition to High value high quality care, and the evolution of HIE.
To ensure that you’re in the loop on all things Mostly Medicaid, be sure to sign up to receive our free newsletter, join the discussion on LinkedIn and check out tons of great content at www.mostlymedicaid.com.
Clay’s Weekly Medicaid RoundUp: Week of February 6th, 2017
Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2lygShv
Or you can click the Special Valentine’s Day treat for optimist readers – http://bit.ly/2lyalTX
It’s been a while my dearest readers. As is our custom when returning from hiatus, let’s begin with the normal ending segment…
FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Maria Navarro and Judith Bench of Orlando are charged with using their special needs school to bill 21,000 bogus Medicaid therapy claims. They billed for 8 hours a day but only had staff to provide 2. Taxpayer tab – $4.5M. Pedro Garcia of Mission, TX was charged this week with submitting Medicaid claims for dead people – to the tune of $300k. John Holland of Miami was CEO of Portneuf Medical Center when he (allegedly) took bribes that facilitated $12M of Medicaid fraud. He plead not guilty this week. Michael Johnston of Broadheadsville, PA got sentenced for pilfering $100k from Medicaid using bogus mental health services claims. Mr. Johnston took the cash and used it cover trips to Jamaica. Stephen Monaco (awesome name), a podiatrist from Haverton, PA was sentenced this week for stealing $4.9M from Medicaid, Medicare and other payers. Dr. Monaco would barter opioids with patients in exchange for them letting him shoot painful (but unnecessary) injections into their feet. Eduard Zavalunov of NYC became the 9th fraudster to plead guilty in a multi-clinic racket that bribed Medicare and Medicaid bennies (with cash) to undergo unnecessary tests. Taxpayer tab – $70M. Shalonda Suggs of Oklahoma City pled guilty this week to a $200k mental health services not provided scheme. Julia Faigel of Boston, MA was ordered to pay $475k for Medicaid dental fraud. She had TWENTY ONE corporations she used to rob the taxpayers. Robert Windsor of Cumming, GA pled guilty this week of bilking GA Medicaid, KY Medicaid, Tricare and FEHBP (the healthcare federal employees get) for more than $20M. His gig? Medically unnecessary balance tests, electromyography (whatever the heck that is) and qualitative drug screens. IPC – a hospital staffing firm that provides doc labor, also goes by Team Health if you are googling for it- will cough up $60M for defrauding Medicaid and Medicare via upcoding. Dr. Oughatiyan was the whistleblower and he will get $11.4M. Bernard Greenspan of Newark, NJ got $200k in bribes for his role in a $200M fraud scheme. He’s pleading innocent (he’s also 80 years old), but 2 dozen other docs have pled out on this scheme which involved Biodiagnostic Lab Services bribing docs for referalls to Medicare and Medicaid. And now, drum roll (we have a lot of contestants this week!)… Mr. Windsor you win this week’s award for your tenacity and not settling for ripping off just one Medicaid program. Indeed – stealing from both GA and KY sets you apart. I hope you stashed some cigarette money someplace, so you can barter in the slammer.
Sadly, I was able to fill an entire Roundup with fraud follies (with a total of about $384M stolen by my rough count). I could do this each and every week (but that would be boring). And I left out several big ones this week, too. Nothing to see here, move along. Regardless of whether we repeal, replace or repair there will always be this wonderful gravy train for fraudsters. As I pay my taxes in the next month or so, I know that makes me feel good. How about you?
That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (I swear we never have winter anymore here in AL. Must be global warming, or maybe the Russians?) and keep running the race (you know who you are).
****
FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Papa a voye Pitit la pou konsève pou mond lan
Clay’s Weekly Medicaid RoundUp: Week of January 9th, 2017
Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2irmSci
Or you can click the one for optimist readers – http://bit.ly/2irnjDt
WAIT A MINUTE- WHO’S SURPRISED AT THE CURRENT ACA REPEAL EFFORTS? It’s been hated by millions since day 1 (and loved by millions, especially on the left), the GOP has introduced 60+ repeal bills over the last 7 years – and now everyone is floored that one of the first things the Right does once it regains control is renew repeal efforts? The Senate took step 1 of a 10-step procedure to repeal ACA early Thursday morning. Here’s the best guide I have seen so far – http://read.bi/2ipCPji
THE LAND OF OPPORTUNITY STATE PUTS APPLICATION BACKLOG TO REST- AR brought in about 250 temp workers, but they got it done. Back in June there were 100,000 “pieces of paperwork” overdue, including 34,000 or so apps that were 45 days old. At year end (just a few weeks ago – weird), there were no overdue apps. Hey AR – can you send those temp workers over to KS?
SOONER STATE MCD NEEDS ANOTHER $200M TO KEEP THE LIGHTS ON- My crystal ball says they will get it. Just look at last year- when the overall OK budget was $1.3B short, OK Mcd got $1B (which was an increase over the previous year). You silly lawmakers need to just submit to the Mcd dominance of your budgets and move on.
MAGNOLIA STATE NEEDS ANOTHER $75M NEXT YEAR- Backers of the bump point to cuts in prior years, as well as a recent $58M cut in September that addressed lower-than-expected state revenues. It is interesting that the request for more money is happening when MS enrollment is decreasing.
KUDOS TO HPP ON THE KEYSTONE WIN- Health Plan Partners was awarded new membership in PA this week. The award will expand the HPP PA footprint into 13 more counties, home to nearly 500,000 Mcd members. Congrats HPP!
THE COPPER STATE ANTI-EXPANSION LAWSUIT MOVES FORWARD- Its only been four years of spending money on the 300,000 new bennies, but the AZ Court of Appeals has scheduled the hearing challenging whether the way the Good Guvn’r Brewer unilaterally expanded was legal in the first place.
FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. Family Care Nursing (such a wholesome name!) of Meriden, CT settled this week for $5.3M related to billing for 60 day assessments knowing it was not an RN doing the work. Aretha Derrico was arrested for billing Mcd for $57,000 of home health services not provided in Havana, FL. Randy Crowell of Henderson, NV plead guilty to a $100M Rx reverse-diversion scheme last week. Mr. Henderson had an impressive range – from Utah to NY. How did he do it? He was a licensed wholesale rx distributor, of course. Still wondering what “reverse-diversion” means (I made that up, I think)? Instead of the pills going from legit sources to the black market, Mr. Henderson acquired pills in the black market and sold them to pharmacies. Sort of like money laundering, but with oxycontin. Although the specific hit to Mcd is not enumerated, I am more than impressed with this one. There are wonderful details like the use of lighter fluid to remove labels from bottles. Mr. Henderson – you win this week’s award! I would be interested in acquiring the movie rights to your story, when you get out of the slammer.
That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (or stay inside and order your pepper seeds. They will need 30 days to germinate, and then that’s March and you want them strong when you put them out in May, right?) and keep running the race (you know who you are).
****
FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Pitā sēva dha varlḍa dīkarānī
Medicaid News Roundtable: December 2016
Great Medicaid news show with Barb Witte, Kris Vilamaa of Germane Health and Bruce Greenstein of Quartet Health
Medicaid Industry Who’s Who Series: Shannon McMahon
Medicaid Who’s Who: Shannon M. McMahon– Deputy Secretary, Health Care Financing with Maryland Department of Health and Mental Hygiene
Shannon M. McMahon, MPA, was appointed the Deputy Secretary of Health Care Financing at the Maryland Department of Health and Mental Hygiene in February, 2015. In this role, she is responsible for the operation of the state’s Medicaid program, which serves over 1.2 million Marylanders.
Previously, Ms. McMahon was the Director of Coverage and Access at the Center for Health Care Strategies (CHCS) where she lead Medicaid eligibility, benefit design and purchasing implementation efforts and learning collaboratives for states and the federal government. Prior to CHCS, she worked in executive and management-level roles in Minnesota Medicaid, most recently as the Chief Administrative Officer, where she oversaw finance and operations for Minnesota’s three public health care programs.
Ms. McMahon also spent several years working on health policy issues as a non-partisan analyst at the Department of Legislative Services in Annapolis and also held the position of senior budget and policy adviser to the Secretary and Principal Deputy Secretary of Maryland’s Department of Health and Mental Hygiene.
Ms. McMahon has a bachelor’s degree in justice from American University, Washington, D.C. and a master’s degree in public administration from Northeastern University, Boston, Massachusetts where she was a recipient of a full tuition public policy fellowship. She is a member of the board of directors of the National Association of Medicaid Directors.
Shannon McMahon is the featured panelist in the upcoming State Spotlight Webinar on Feb. 6th at 2pm EST. Learn more and register for free here.
1. What is your current position and with what organization?
Deputy Secretary, Maryland Department of Health and Mental Hygiene/Medicaid Director
2. How many years have you been in the Medicaid industry?
I’ve been working in health care policy/operations and consulting for 19 years; my focus has always been on the public sector, and Medicaid in particular.
3. What is your focus/passion? (Industry related or not)
My passion is making the government side of health care (enrollment, access) more person-centric. I love Lean and business process re-design.
4. What is the top item on your “bucket list?”
Snuba the great barrier reef
5. What do you enjoy doing most with your personal time?
International travel with my family; I think that foreign travel is the greatest gift you can give kids, as it imparts two key business and life skills: organization and resilience.
6. Who is your favorite historical figure and why?
Eleanor Roosevelt; I’ve always admired her commitment to public service and her ability to problem solve in the most politically charged environments.
7. What is your favorite junk food?
Snickers
8. Of what accomplishment are you most proud?
The recent Section 1115 waiver that we secured for Maryland Medicaid is a very big step to begin addressing the social determinants of health at the local level while also expanding access to substance use disorder services in the State. The partnership forged between the State and local governments, as well as the support from the provider and advocacy community made it possible. The amazing team in Maryland Medicaid worked hand and glove with our federal CMS counterparts to get ‘er done.
9. For what one thing do you wish you could get a mulligan?
I have a knack for calling people by the wrong name, and have done so with some pretty senior people in both government and the provider community.
10. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?
In Maryland, we are coming off the recognition of the 50th anniversary of Medicaid in 2016. Our two big focuses for the next six months are
(1) Implementing the SUD expansion under the 1115 waiver which includes a physical health-behavioral health integration component;
(2) Developing a new payment and delivery system for individuals dually eligible for Medicare and Medicaid.
(3) Potential changes to the ACA will be of particular interest to Maryland as well, and as a member of the NAMD board, I have had the opportunity to engage with the key executive and legislative branch leaders on potential changes.
Clay’s Weekly Medicaid RoundUp: Week of January 2nd, 2017
Soundtrack for today’s RoundUp pessimist readers- https://www.youtube.com/watch?v=9jK-NcRmVcw
Or you can click the one for optimist readers – https://www.youtube.com/watch?v=cYrUW68kggg
BONUS Optimist Song: https://www.youtube.com/watch?v=btPJPFnesV4
SOMEBODY TELL THE GOOD GUVN’R HE’S WEARING LAST YEAR’S FASHIONS: Perhaps the protracted battle with the outgoing Guvn’r has left NC Good Guvn’r Roy Cooper a little confused. He is talking about expanding Mcd in the Tarheel State, seemingly unaware that expansion is yesterday’s news. He promised to submit a state plan amendment by this Friday to expand under ACA rules, which have to be approved by CMS. This is either a PR stunt only, or the new Guvn’r is more clueless than the average bear.
NOW THERE’S AN IDEA: AK ASKS TO KEEP ACA CASH FLOWING BUT WANTS MORE CONTROL ON LIMITING ELIGIBILITY THAN ALLOWED BY MASTERS IN THE DISRICT (CAN I USE 2 COLONS IN A HEADLINE?): The Good Guvn’r Hutchinson has been in talks with the new cabinet members about letting AR tighten eligibility requirements for its expansion bennies. He may end up getting what he’s been begging CMS for for years after all. Amazing the difference a new king (er, President) makes.
AND SO IT BEGINS- One half of the country seems to be moving into the next phase of grief. The denial phase was like watching a train wreck- fascinating (Stein’s stratagem and the attempts at electoral mutiny), terrifying (Fake News pots calling kettles black) and pitiable (b-b-but the Russians did it!) all at the same time. We are now witnessing the negotiation and acceptance phases best I can tell. I now see Op Eds discussing how block grants may not be that bad (as long as its tied to healthcare inflation) and detailed analysis of the expected GOP battle plans to repeal the sacred cow of ACA (as opposed to the previous stance of “but they can’t do that).
KS ELIGIBILITY APPS: STILL LATE- 2 years and counting for the backlog. State officials did get it down to 1,400 or so in September (from a high of 15,000), but its climbing again. The latest number is 2,247 apps at least 45 days old.
MCO TIDBITS: Item 1) WellCare completed its acquisition of Care1st of AZ this week, adding 115,000 lives to the ledger. Item 2) Iowa newspapers are now reporting they have obtained secret documents showing MCOs calling the Iowa program “drastically underfunded” and a “catastrophic experience.” Sensing that these documents reveal a disconnect between what is being said publicly and privately, Mr. Pin Ochio has stepped in with new evidence that Oceania hacked the Iowa Medicaid agency. He insists we ignore the contents of the documents and focus on the manner of their discovery.
FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award. There’s actually just one this week: Abe Freund, operator of Acacia Mental Health Clinic, LLC in Milwaulkee has been charged by the feds with stealing as much as $7M from Medicaid. Acacia was billing $474 for drug tests that should have been paid at $20. At the end of the feeding frenzy, 99% of all Wisconsin substance abuse counseling payments were going to Acacia. Acacia payments surged from $300k to $3M over a few years. Lesson learned (?)- when you see 99% of your SA payments going to one provider that’s grown tenfold in a few years, maybe you should have something in place to stop paying that provider number before it gets to that point?
That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (enjoy the snow! One Yankees nuisance is a Southerners magical experience) and keep running the race (you know who you are).
****
FULL, FREE newsletter: http://eepurl.com/ep81Y . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: o Patéras ésteile ton Yió gia na sósei ton kósmo
Medicaid Industry Who’s Who Series: Sheila Wilson
Medicaid Who’s Who: Sheila Wilson, BSN, RN, CCM – Director of Care Management, Medicaid with Priority Health
Sheila is a Registered Nurse with over 31 years’ experience in both clinical and managed care environments. She has extensive experience in case management, and is especially knowledgeable about the challenges facing the Medicaid population. Currently Sheila serves as the Director of Care Management for Medicaid at Priority Health, a Michigan based company serving HMO, PPO, Medicare and Medicaid members across the State of Michigan. Her responsibilities include the development, implementation and administration of programs to achieve medical cost goals for the Medicaid Business Unit. She directly oversees case and disease management, as well as medical utilization operations. Sheila and her team recently received two prestigious Pinnacle Awards from the Michigan Association of Health Plans for work done to incorporate children with special health care needs into managed care, and for spearheading a pilot project with the use of a medical mobile application for children with asthma.
Sheila obtained her Bachelor of Science degree in Nursing from Alverno College, and has held her Certification in Case Management (CCM) since 1994. She has completed the first year of a 2 year Executive MBA Program with Grand Valley State University. She currently lives in Grand Rapids, Michigan with her husband Bill and daughter Ashley.
At the Medicaid Innovations Conference, where Clay Farris of Mostly Medicaid is the Event Chairperson, Sheila Wilson is presenting the following case study:
Taking a Multidisciplinary Approach to Care Management and Delivery: Creating Provider, Health System, and Community Partnerships
Priority Health created the Medically Complex Children’s Program to improve the member experience. A team of Pediatricians, Care Managers, Community Health Workers, Nurses and Specialists within the Academic General Pediatric Residency Clinic (part of the Spectrum Health System), coordinate care for members and aid with basic needs like food, housing, clothing, medication management and transportation. One of our most vulnerable members, a child whose family was new to the United States, arrived to the hospital with acute liver failure and needed a transplant. His parents lacked the resources that the child needed for proper care, so he was enrolled in the Medically Complex Children’s Program. After he was enrolled, a complex care plan was created with input from all team members, including the member and family. The care team assigned to his case helped plan, anticipate his needs between appointments, provide ongoing reinforcement of the care plan and minimize unnecessary Emergency Department visits. The program focuses on one patient, one family, one care plan and one care team to create a better member experience and better health outcomes!
You can learn more about this topic and the rest of the agenda at http://www.medicaidinnovations.com/
1. Which segment of the Industry are you currently involved?
I am currently working within the Medicaid Program at Priority Health. Priority Health is one of 11 Managed Medicaid Health Plans here in the state of Michigan.
2. What is your current position and with what organization?
I am the Director of Care Management for the Medicaid Program here at Priority Health.
3. How many years have you been in the Medicaid industry?
I have been working within the Medicaid Care Management Field since 2002.
4. What is your focus/passion? (Industry related or not)
I have a passion and commitment to the underserved in the counties in which I live and work. Understanding the barriers and challenges to obtaining the needed health and social services by segments of our population who are often overlooked and disenfranchised is a core element of my being. I believe that we each can impact the trajectory of another person’s life through the hard work and examples that we set for each other.
5. What is the top item on your “bucket list?”
I actually have two items that occupy the top spot. I would love to have the ability to go to Washington, meet with our Legislators and discuss some of the current issues facing our Country and our State today. My minor in college was Political Science, so I have a strong interest in our political system. On a more personal note, I would love to travel the country, visiting small towns and big cities along the way. I particularly enjoy the coastal areas and would love to spend some time sailing with my family.
6. What do you enjoy doing most with your personal time?
I love spending time with my 3 grandchildren. Time stops whenever they are around. I love curling up with a good book in front of the fireplace during the cold winter months and tending to my garden during the summer months.
7. Who is your favorite historical figure and why?
I would love to meet both Hillary Clinton and Michelle Obama. I think they are both brilliant women who believe in the strength and tenacity of all women.
8. What is your favorite junk food?
I love vanilla frosted unfilled long johns. My father use to get them for me when I was a little girl and I’ve loved them ever since.
9. Of what accomplishment are you most proud?
I am almost finished with my Executive MBA Program. I was able to do this while caring for my 89yr old mother, my husband and 16 yr. old daughter as well as working full time as the Clinical Lead for our Medicaid Product. So many times, I doubted my ability to do it all and yet have somehow managed to meet the needs of my family and myself, both professionally and personally.
10. For what one thing do you wish you could get a mulligan?
Very early in my career, I was given the opportunity to attend an OB GYN Nurse Practioner Training Program at virtually no cost to myself. I turned down that offer. I often wonder how different my life would have been had I decided to take advantage of that opportunity.
11. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months?
- With the change of leadership in Washington, I am concerned about the future of Medicaid in general and of Medicaid Expansion more specifically.
- Pharmacy cost trends are rising at an unsustainable rate. There is very little that Care Management can do to impact this as it is largely a pricing/contracting issue.
- Payment for Health Care is moving away from a Fee-For-Service Reimbursement Model to a Value Based Reimbursement Model. I worry that our Provider Partners are not moving as quickly to meet the rapid changes that are State is requiring of its Medicaid Health Plans.