Why managed Medicaid/Medicare health plans need analytics to improve outcomes

By Mary Lou Mangan-Lamb 

Managed care organizations that provide healthcare services to Medicare/Medicaid members are dedicated to improving the health and wellness of these underserved populations, especially those living in rural areas.  

With this patient- and member-centric mission, health plans are continually under pressure to improve the quality of care, grow access to healthcare services, and boost chronic care programs. To be successful with these programs, health plans must use data analytics to monitor healthcare access and outcomes success, all while monitoring expenditures to help ensure new healthcare services for the underserved can be rolled out. 

Health plans, however, face several obstacles to offering current or future healthcare programs for Medicare and Medicaid members.  

Among the most significant issues: 

• Swelling enrollment 
• Aging population 
• Increasing number of chronic conditions 
• Access to healthcare services 
• Quality of care 
• Addressing preventable emergency department visits 

Nevertheless, health plans with Medicare/Medicaid lines of business are expected to help ensure members receive the care they need when they need it. Health plans want to improve the health of members while concurrently reviewing clinical and claims information to verify the care received works.  

The pandemic and analytics 

Nearly every corner of healthcare has been and continues to be impacted by the coronavirus pandemic. Medicaid spending throughout 2020 increased, surpassing 2019, as organizations addressed pandemic-related costs and services.  

“In federal fiscal year 2020 (FFY 2020), federal Medicaid outlays totaled $458 billion and grew at a rate of 12.0% compared to 5.2% in FFY 2019. This increase in the rate of annual outlays was largely attributable to accelerated outlay growth in the second half of the fiscal year reflecting the onset of the pandemic…,” according to KFF.  

The increase in spending linked to the pandemic likely will continue for two or more quarters. Medicaid enrollments, caused by widespread pandemic-related layoffs, are expected to continue to grow even as the economy recovers. Health plans must understand not only the fiscal impact of the pandemic but the clinical side as well to ensure members use resources efficiently and that Medicaid dollars have the most impact as possible. 

The pandemic has increased the need for interoperability between different data systems to allow health plans to monitor testing, positive cases, hospital length of stay, treatments and mortality rates related to the coronavirus. The best way to accomplish interoperability in practice is through an analytics dashboard used to aggregate data from multiple sources while allowing users to drill down to the member level. 

Analytics reveals answers 

Health plans with Medicare/Medicaid lines want accurate information available quickly to internal users who use the data in their everyday jobs to make fiscal, operational and programmatic decisions. To make this possible, health plans are moving toward self-service analytics that employ claims and clinical data and allows users to extract information when it’s needed. 

The best way to access this information and, more importantly, understand it, is with data analytics. In 2021 and beyond, access to this data is more important than ever as funding agencies and state legislatures ask health plans to prove what works and want to measure performance. 

As health plan analytics users delve into and understand data sources and metrics, they can present better programmatic options to decision-makers and make decisions to positively impact members more quickly and effectively.  

Health plans can use the information to: 

• View member treatment costs and utilization 
• Provide analytics to providers at the point of care 
• Show Medicare/Medicaid reimbursements are in line with market reimbursement rates 
• Measure how programs support member health and wellness 
• Move toward improved member outcomes 
• Seek insights into how and where Medicare/Medicaid dollars will make the most impact 
• Work closely with providers to get a holistic view of member health and quality of care 

While the information health plans seek seems simple enough—understanding the impact of healthcare programs on members can be extremely difficult without the right tools.  

Analytics use cases 

During the pandemic, telehealth use surged as health plans needed to find a better way to track and respond to member gaps in care. In the use cases below, I’ll briefly explore telehealth and gaps in care for health plans providing Medicare/Medicaid services. 

Telehealth grew significantly during the pandemic and likely will remain as an alternative to in-person care visits. Analytics solutions can track visits and help health plans understand the success of the programs. Specifically, analytics can help health plans understand: 

• When underserved members need extra assistance getting access to care 
• The best way to determine optimal primary care assignments 
• Ways to improve access to healthcare specialists 
• How to create better member access to preventative care, including dental access and diabetic treatments 
• Which rural Medicare/Medicaid populations may need more help controlling chronic conditions 

Gaps in care identification and understanding are critical to helping health plans make decisions for future member care. Analytics not only can identify and prioritize gaps in care, but also it can bubble up high-risk members or delinquent patient care. All of these can help health plans ensure Medicare/Medicaid members receive the right care, at the right place, at the right time. In addition, health plans can use the information to roll out preventive services before it becomes a gap.  

Analytics gives health plans with Medicare/Medicaid populations the ability to combine quality, cost, utilization management, enrollment and eligibility into a 360-degree member view.  These deeper insights help health plans devise new and improve existing healthcare services offered to Medicare/Medicaid members.