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Health Plan Leaders Reveal Top Challenges With Managing Vulnerable Populations

by Health Integrated | Apr 02, 2015
Health plan leaders reveal top challenges with managing vulnerable populations, including optimizing data and analytics, specialty drug costs, quality metrics and health determinants. The results are published in the Health Integrated and ACAP Annual Health Plan Survey.

Health Integrated, the leader in Precision Empowered Care Management, released the results today of an annual health plan survey jointly commissioned with the Association for Community Affiliated Plans (ACAP), a national trade association representing not-for-profit safety net health plans. The survey is administered annually to ACAP member plans to better understand the evolving needs and challenges faced by health plans serving vulnerable populations who are enrolled in Medicaid, Medicare Advantage and Children’s Health Insurance Programs. Collectively, ACAP-member safety net health plans serve more than 11 million people across the United States.

Chief executive officers, chief medical officers and medical directors from nearly half of the ACAP health plans completed the survey and ranked the main areas of importance to their organizations as well as their top challenges. While the top challenges varied by size of plan (based on number of lives covered), several areas consistently ranked high across the board including:

  • Access to and optimization of data and analytics
  • Specialty drug costs and management
  • Quality metrics (HEDIS and Star ratings)
  • Addressing behavioral and social determinants of health

The results were corroborated by a strategic advisory board composed of leaders representing the ACAP plans. The survey and strategic advisory board are both part of a strategic alliance formed between Health Integrated and ACAP to support safety net plans. After three highly productive years, the organizations recently renewed the alliance for an additional three years.

For the second straight year, access to data and analytics was a primary concern for plans of all sizes. “The survey confirms that data is playing a bigger role in how health plans manage their populations. With multiple data sources available from claims feeds to electronic medical records to information from patients themselves, isolating and analyzing the most useful data points is critical,” said Sam Toney, MD, chief medical officer and executive vice president of clinical integrity at Health Integrated.

Margaret Murray, chief executive officer of ACAP agrees, “We see a major shift in how plans are managing their members in today’s health care climate. Serving the members most in need is not always an easy task, and optimizing data can help health plans direct the right resources to the right members at the right time.”

The cost and appropriate management of specialty drugs was another area of concern identified in the survey. Medical conditions impacted by specialty drugs include ailments more commonly seen in vulnerable populations such as hepatitis C and pulmonary hypertension. Pricey specialty drugs accounted for more than 31 cents of every dollar spent on prescriptions last year even though they represented only 1 percent of all U.S. prescriptions filled, according to Express Scripts, a leading pharmacy benefit manager. This creates a growing challenge for health plans as they try to determine new ways to manage costs while delivering quality care.

For plans serving dual-eligible members, individuals covered by both Medicare and Medicaid, challenges in meeting regulatory compliance requirements are giving way to such longer-term viability concerns as driving higher Star ratings while appropriately managing costs. Dual-eligible beneficiaries are among the sickest and poorest individuals covered by either Medicare or Medicaid and account for a significant portion of costs for both programs.

Another finding was around the importance of addressing the social determinants of health. By far the biggest social determinant reported was housing, followed by food and nutrition. To aid in these areas, ACAP plans have developed special programs such as the UPMC for You “shelter plus care” program in Pennsylvania. The program provides stable housing to homeless members who have a history of avoidable yet repeated ER, inpatient and skilled nursing facility use in efforts to break the cycle and provide what’s needed most – housing. Another example includes CareOregon’s Food Rx pilot project which provides vouchers to members who don’t get enough food or don’t have access to healthy food items. The vouchers can be used at the My Street Grocery trolley which travels to three local clinics where CareOregon members are served. These and other programs provide additional support to address the psychological, social and economic factors that can significantly impact an individual’s overall health and well-being.

John Lovelace, president of UPMC for You, said, “We feel strongly that the role of the health plan has changed and we are leading the charge. As plans are being held more accountable for outcomes, we need to take the lead in bringing all services together to fully support our members. You can’t have healthier members without addressing all of their medical, social, economic and behavioral needs.”

“The results of the survey have shown us that plans are focused on outcomes and that addressing all of the contributing factors is key in doing so,” said Dr. Toney. “This is the reason we developed our Precision Empowered Care Management model combining actionable big data with our Dynamic Somato-Social Theory to address the biopsychosocial drivers impacting outcomes.” By identifying and addressing the root causes of utilization at the member level, Health Integrated has enabled safety net plans to enhance quality and increase compliance, while reducing medical costs.

About the Association for Community Affiliated Plans
The Association for Community Affiliated Plans is a national trade association representing 58 nonprofit safety net health plans in 24 states. ACAP’s mission is to strengthen not-for-profit safety net health plans in their work to improve the health of lower income and vulnerable populations. Collectively, ACAP plans serve more than 11 million enrollees, representing more than 50 percent of individuals enrolled in Medicaid-focused health plans. For more information, visit


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