How One Health Plan Helps Others Achieve Scalability, Efficiencies

A health plan with solid roots in the south west United States is taking a unique approach to caring for its members by leveraging its knowledge and expertise in creating other health plans through scalability and efficiency. The health plan is leveraging its strategy, management, product design and administrative functions — all things it has done successfully in its own community — that can be shared and adapted by other health plans across the country.

The health plan will implement and standardize its population health platform in delivering Business Process Outsourcing (BPO) capabilities for the state’s Medicaid program and the affiliated health system’s commercial, Medicare and Medicaid lines of business.

The health plan has over 25 years of managed care experience through its affiliated integrated delivery system in partnering with providers who want to start or strengthen their own health plan. The health plan has worked with HighPoint since 2017, to provide leadership and support in the design, development, and deployment of its BPO services that are assisting the provider-owned health plan and accountable care organizations, core claims technologies (Health Rules Payer and Facets) and care management (ZeOmega Jiva).

The provider-health plan arrangement

According to a McKinsey & Company study, the evolution of provider-owned health plans gives health systems an opportunity to grow in their market. It’s research in the Market Evolution of Provider-led Health Plans report, shows that health systems need to consider different ways of understanding the consumer and the risks or benefits of such arrangements. Health plans need to understand where the potential for best growth opportunities lie, and rethinking the payer-provider interactions to take full advantage of integrated claims and clinical data.

In a provider-owned health plan, the purpose, value and culture are shared by the health system and health plan, and the good and bad of the bottom line, as well. Provider-owned health plans give providers access to the scale and efficiencies of the health plan’s operations, while allowing them to drive decisions for the members/patients they serve. Many of these provider-owned health plans are joint ventures between provider organizations and traditional health insurers.

The health plan, HighPoint partnership

The health plan’s success is best measured by its strong financial rating in a historically low-reimbursement healthcare environment, its leading quality results, and a deep knowledge of, and experience with, managing Medicaid and Medicare. Today, two-thirds of a health plan’s revenue is at-risk and its care model is continually improving to better serve its members.

In support of this mission, the health plan HighPoint partnered with is delivering BPO services in the most cost-effective and efficient way and demonstrating best practices with experience across its technology platform.

Managing state’s Medicaid plan

The BPO rollout began as part an off-shoot of the state’s Medicaid program. The health plan was one of four in the country given the opportunity to offer this program.

The first deployment of case management functionality occurred in October 2018, and the remaining functionality — disease management and population health management will be delivered this year. Once delivered, the health plan will be able to support the state’s Medicaid program mandates. The state Medicaid program is designed to keep residents in good health, through routine care, special needs reviews, and complex healthcare services.

The central United States’ health plan will then support 11 east coast health systems, under a joint partnership, as they work to serve the Medicaid population through a provider-owned health plan.

To manage multiple clients, HighPoint has worked closely with the executives at the health plan and ZeOmega to develop the architecture for its business needs. HighPoint has also developed clinical pathways, care and utilization management capabilities that will allow for NCQA alignment and compliance, including configuring member letters, care plans, claim system crosswalks, assessments and system testing, training documentation, train-the-trainer activities, and end user training.

In addition, HighPoint’s work includes claims, case, utilization and disease management, member and provider portal integration to Appeals & Grievances and document management.

Additional benefits

The health plan has served the state’s residents for over 100 years and continues to focus on the care of members with Medicaid since 1997.

This solution will provide members with these benefits, including:

  • Dental varnish for children between six months and three years of age
  • Physical and behavioral health benefits for members who qualify for Pregnancy Only Medicaid. This includes prescription drug coverage and routine dental care.
  • Traditional healer benefits covering provider services for counseling and healing rituals for Native American members

The health plan selected HighPoint because of its experience in the population health market — with more than 20 years of supporting and managing people, processes, and technology through similar endeavors. In addition to HighPoint’s experience in implementing ZeOmega Jiva solutions across multiple clients both large (Blues plans) and smaller health insurers.

To learn more about the HighPoint Population Health practice, please reach out to Chris McShanag, vice president, population health.