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Top 4 mistakes Medicaid health plans make when vetting solution vendors

6-minute read

Many of our clients are Medicaid health plan operational teams that manage vendor relationships. The article below is based on our experience working with Medicaid health plans who have been able to optimize their vendor management processes.

Mistake 1: Failing to have a process for managing vendor sales meeting requests

Most Medicaid health plans describe their vendor management scenario as “deluged” with vendor meeting requests. When our plan clients quantify the time they spend on each vendor sales effort, they realize that all the meetings and followup meetings and related correspondence and efforts add up to many hundreds (and sometimes thousands) of health plan staff hours. While some Medicaid plans have begun to implement more policies to manage this process, most plans still have room to optimize the return on this significant time investment.

A defined vendor-engagement process is critical

Mistake 2: Not setting up expectations on the front end for how your vendor engagement process works

Communicate expectations to vendors from the very first meeting

Few vendors (especially new vendors) understand the way your plan prefers to manage procurement efforts. Each plan is different in how it prefers to engage with vendors. Some plans only meet with vendors related to a problem they are actively trying to pursue. Some only meet with vendors they have invited to respond to an RFP. Other plans meet with vendors at any time, to learn more about solutions or to get new ideas.

Once a vendor is engaged in a potential solution discussion, they will need to know what to expect in terms of different business units involved in the decision, information and data that will be needed to support the business case, what to expect in terms of acceptable pricing models and how long the overall process normally takes. Most vendors have no idea what to expect, and most plans do not communicate what to expect. Setting expectations from the start will go a long way to keep everyone aligned and making the best use of your precious time.

Mistake 3: Not right-sizing the proposed project to the problem and the vendor’s current scale

Sometime you need a solution to close HEDIS gaps for 100 members. Sometimes you need an overhaul of an entire process, or a brand new critical technology system. Rest assured, whatever the size of your problem, any solution vendor engaging you in a sales process wants to maximize the size and duration of the contract. If you do not set quantified scope parameters correctly, you will end up with a solution that either doesn’t go far enough or goes too far. Best practices include using a member-level target list (for interventions / gap closure based projects), starting with an initial pilot, and breaking any effort more than 60 days up into phases.

Always fit the size and complexity of the solution to the size and complexity of the problem

Mistake 4: Not checking references in depth

Invest time in longer discussions with vendor references

Vendors pitching you their solution will only show you their very best results. While this information is important, this should not be the only data you use to kick the tires of their capabilities. Ask for more than three references – this way you have a better chance of getting a broad perspective of what other plans have experienced with the vendor.

How You Can Address The Risks of Partnering with Solution Vendors in the Medicaid Space

In addition to your own research into potential vendor partnerd, there are a few key tactics that can help you overcome some of the common challenges in the space.

  1. Engage a consulting firm with deep expertise in the space, but that also has a practice area focused on assisting Medicaid health plans vet solution vendors. We provide this type of assistance to our health plan clients, and are happy to have a conversation anytime. If our services and expertise are a fit for your needs as you develop or execute your strategy, engaging with us is a simple process. If we are not the right fit, we are happy to make a referral to another firm who may be.
  2. Consider adding a Medicaid-specific, independent vendor review product to your toolkit. While there are multiple options for vendor reviews in the healthcare space, most are not independent evaluations (they receive their revenues from the vendors reviewed). If you are considering enhancing your vendor review process, an independent review tool is critical.

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What are the 4 critical risks of investing in the Health and Human Services (HHS) space?

6-minute read

Many of our clients are investment professionals working in the health and human services space (including the full spectrum from angel to VC to equity firms). The article below is based on our experience working with investors who have succeeded in this space.

Risk 1: Failing to understand that seeking revenues in the Health and Human Services (space) creates a new set of challenges for your portfolio companies

One of the worst mistakes investors new to the space can make is to assume that strategies rooted in the commercial payer or Medicare Advantage space can be simply pivoted into the Medicaid space. The mistake is understandable, because few portfolio companies understand this risk and they do not know to communicate it to their investment partners.

Risk 2: Underestimating the Learning Curve

Understanding that commercial and Medicare strategies need to be dramatically altered to work in Medicaid is the first step. The next risk is underestimating the learning curve for Medicaid. Each state operates its own Medicaid program, and most benefit, operational and procurement decisions are done independent from federal operations. We have a saying in our space: “If you have seen one Medicaid program, you’ve seen one Medicaid program.” Besides the policy differences across states, each state has its own agency and stakeholder environment, and navigating these is extremely complex for HHS veterans. Finally, the regulatory environment for this space evolves constantly, and in ways that greatly impact revenue projections. For those new to the space, critical mistakes and loss of time are guaranteed.

Risk 3: Miss the Unique Complexity of the HHS Sales Cycle for Your Portfolio Companies

Many investors rely on the relational nature of other verticals for confidence in sales revenues. While relationships play an important role in the HHS space, most contracting is done using a defined competitive procurement process. This applies to both state agency and health plan contracts (though less so in health plans). Because of the regulatory and bureaucratic components, the sales cycle for this space is much longer and much more unpredictable than in other verticals.

Risk 4: Differences in pricing models

The Medicaid space has two key components that drive unique pricing models: A focus on the rate-cell capitation payments to managed care plans, and long-standing efforts to implement value-based payment models.

Medicaid health plans are paid a per member per month (pmpm) fee by states to manage different populations (such as diabatics or pregnant mothers). All the costs for care and management of each member must be funded by those rates or the plan loses money. Each plan thus thinks of all vendor solution costs in terms of pmpm. This type of pricing is not the norm for most portfolio companies operating in the commercial space, and it may take a large effort to structure pricing models in a way that will succeed in the Medicaid space. Most portfolio companies price solutions at an aggregate level and do not have a way to assign costs at the plan member level.

The second challenging part of HHS pricing models is the focus on value-based payments. Most Medicaid state agencies and health plans are required to place an ever-increasing amount of their payments to providers in what is called a “value-based” arrangement. While precise definitions of these models remain elusive, the critical risk is not being able to clearly tie a portfolio company solution to specific member outcomes. Vendors should also be prepared with standard risk sharing arrangements to offer to prospects in the Medicaid space.

How You Can Address The Risks of Investing in the HHS Space

In addition to your own research into this vertical, there are a few key tactics that can help you overcome some of the common challenges in the space.

  1. Engage a consulting firm with deep expertise in the space, but that also has a practice area focused on assisting investment professionals. We provide this type of assistance to our investment clients, and are happy to have a conversation anytime. If our services and expertise are a fit for your needs as you develop or execute your strategy, engaging with us is a simple process. If we are not the right fit, we are happy to make a referral to another firm who may be.
  2. Consider adding a vertical-specific market intelligence product to your toolkit. While there are multiple options for general investing market intelligence in the healthcare space, if you are considering (or already executing) an investment thesis tied to HHS-vertical revenues, the more specific your research sources, the better.

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Medicaid Concepts: Electronic Visit Verification

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by electronic visit verification (EVV)?


Electronic visit verification (EVV) is a category of technologies and services used to validate that a visit actually occurred (usually in the member’s home). While EVV has been around for a long time, the 21st Century Cures Act made it mandatory for all state Medicaid programs by January 2020 for personal care services and January 2023 for home health services.

At a minimum, EVV systems must document:

  • Date of service
  • Location of service
  • Individual providing service
  • Type of service
  • Individual receiving service
  • Time the service begins and ends

What role does Medicaid play?


In addition to implementing required EVV systems, Medicaid agencies are in a unique position to leverage EVV data to improve member service provision. Medicaid agencies also play an important role in educating members on the benefits of EVV and reassuring those members that have privacy concerns related to GPS data tied to their home.

While EVV is primarily designed to prevent fraud in the Medicaid system, there are opportunities to use EVV data to improve care coordination and identify member quality gaps. The ability to use EVV to improve member outcomes is only beginning to be explored.

Explore further


https://www.medicaid.gov/federal-policy-guidance/downloads/cib080819-2.pdfhttps://www.medicaid.gov/sites/default/files/2019-12/evv-requirements-intensive.pdf

https://www.medicaid.gov/medicaid/data-systems/outcomes-based-certification/electronic-visit-verification-certification/index.html

https://medicaid.publicrep.org/feature/electronic-visit-verification-evv/

https://medicaid.ohio.gov/INITIATIVES/Electronic-Visit-Verification

https://medicaid.georgia.gov/programs/all-programs/georgia-electronic-visit-verification-evv

https://chfs.ky.gov/agencies/dms/dca/Pages/evv.aspx

https://dhhs.ne.gov/Documents/EVV%20October%20Slides.pdf

https://www.in.gov/medicaid/providers/1005.htm

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Medicaid Concepts: Member Engagement

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by member engagement?

With so much focus in the Medicaid space on improving health outcomes for the sickest, most vulnerable populations, the need to have the member engaged in their own health is clear. “Member engagement” is a broad term that includes a range of ideas: treatment compliance, emergency room avoidance, self-directed care, decision-making, health assessments, and member onboarding.

All efforts centered on member engagement are based on the idea that people will make better healthcare decisions when they are more engaged. One of the biggest obstacles to increasing member engagement today is the overload of information. It is increasingly difficult to get the member’s attention in an information-rich world of social media, email and entertainment.

Member engagement should not be confused with care management. Care management describes a model focused on care coordination, treatment pathways and targeting members with complex needs. While care management also relies on member engagement, the two terms are not synonymous.

What role does Medicaid play?

Over the past several decades, Medicaid agencies have worked to improve member-engagement. Many of the earlier efforts evolved out of the disease management programs of the late 1980s and 1990s. Newer efforts focus on maximizing the effectiveness of communications to members, targeting specific members to close quality gaps and aligning incentive programs to encourage healthy behaviors.

While much of the member engagement effort focuses on newer technology solutions (think smartphones or telehealth), there are still important functions related member engagement that happen in a call center, or when a member fills out a member satisfaction survey. Medicaid agencies, health plans, and providers all have opportunities to increase member engagement in a wide range of settings and thereby improve health outcomes.

Explore further

https://carenethealthcare.com/medicaid-member-engagement-strategies/

https://medcitynews.com/2018/09/here-are-some-high-impact-engagement-strategies-for-medicaid/?rf=1

https://www.chcs.org/media/PRIDE-Culture-of-Engagement-FINAL.pdf

https://healthpayerintelligence.com/news/how-to-improve-medicaid-member-engagement-care-coordination

https://www.colorado.gov/pacific/hcpf/performance-measurement-and-member-engagement