Managed Care Organizations: An Emerging Opportunity for HI Professionals

This article is part of a series detailing the opportunities and entry into a nontraditional health information management sector: managed care organizations (MCOs). The series starts with a big-picture approach, understanding the impact of MCOs on the modern healthcare environment. The series will then go into the direct connections between MCO operations and the health information professional’s skill set. Lastly, it will end with how to transition and the professional benefits.

The modern and evolving holistic healthcare environment has increasing focus on the “Triple Aim”: improving the individual experience of care, improving the health of populations, and reducing the per capital costs of care for populations.

What this equates to is rapid evolvement of nontraditional healthcare services, services focused on the person and populations outside the provider episode of care. At the center of all this are managed care organizations (MCOs)—with a crucial element in that they are serving the most unserved and vulnerable populations of the country (Medicaid and Medicare). MCOs are a crucial part of the Triple Aim and the healthcare system, but they have one of the smallest percentages of our AHIMA member workforce.

As experts in our professional domains, we know there are many other parties that are relying on and creating health information.

As consumers, we know the disconnect between healthcare entities, which is both provider-to- payer and provider-to-provider. As community members, we know there is much more that goes into well-being than clinical care.

Studies estimate that clinical care only accounts for 20 percent of the impact on health outcomes; the rest is social determinants of health (SDOH). These are all matters that health information (HI) professionals are equipped to address but can’t if we don’t have presence where needed. This is a pivotal opportunity to elevate our profession and AHIMA members’ careers.

MCOs As ‘Change Agents’

Reach and impact alone makes the MCO space a focal point. Large managed care organizations coordinate care and enable well-being for tens of millions of members per year nationwide, which positions MCOs to be the impact catalyst on population health, value-based care, health equity, and health literacy.

These are all things coordinated and most impactful outside of the provider space. Value-based care has not only seen substantial increases in adoption but is being pushed by the government.

A study by Health Care Payment Learning & Action Network in partner with AHIP (America’s Health Insurance Plans) has seen over 20 percent of payments move away from fee-for-service between 2016 to 2021. Additionally, the Centers for Medicare & Medicaid Services (CMS) has set a goal to have all Medicare beneficiaries enrolled in value-based care models by the year 2030. It is a transformational point in our healthcare system evolvement, and MCOs are the change agents.

MCOs alone are not the answer to healthcare’s problems, but they are a vital piece of the puzzle. Multisector collaboration is needed to complete the puzzle with their individual data and information pieces. MCOs fill large gaps of the puzzle with their data on medication adherence through prescription fill/not filled claims, individual SDOH through Medicaid and Medicare applications and screening, provider visits outside the primary’s network through claims, needed preventive visits through care coordination, and more.

They also have the infrastructure and experience to detect and act on data indicators to prevent unnecessary health issues and emergency visits. This is especially significant for older adults, those with cultural/language barriers, and those with personal economic instability.

Understanding the Value of MCOs

In order for all this data to work toward a whole-person approach, it must be able to be shared accurately and timely. This is a challenge between provider-to-provider, and provider-to-payer.

What is equally important and historically omitted from data exchange regulations is sharing from payer-to-payer and payer-to-consumer, though that is changing. CMS and the Office of the National Coordinator for Health Information Technology (ONC) having been working on rules that outline requirements for the sharing of health information and data, efforts that HI professionals have been engrossed with and leading on the provider and health information exchange (HIE) sectors. Complete data sets, coupled with the ability of AHIMA health information stewards, creates a tipping point opportunity.

HI professionals and payers need to work together. Each is putting forth their best to serve their patients/members and community. The larger issue at hand is that a lack of coordinated effort is missing. For their part, MCOs utilize clinical associations’ standards care guidelines to drive decisions.

MCOs are so much more than a claims payer; they are a lifeline for their members and community populations; wellness centers, food delivery, mobile dental clinics, care coordination, pregnancy programs, education and art, vaccines provided in the community, housing, free diapers, etc. Where the provider business is to detect and treat sickness (often associated with SDOH), MCOs are in the business of wellness and enablement.

They are also a resource to providers, many of whom are outside of large healthcare systems, and therefore without an abundance of resources and services for vulnerable and remote populations.

Financial ability alone contests the rhetoric. MCOs are not tax-exempt entities with donors and substantial cash streams. In fact, every MCO operates under a medical loss ratio that strictly depicts how much of capitation and revenue can be spent on administrative functions versus direct member expenses as well as a profit threshold, amount with excess being returned to the government. When an MCO is serving the amount of members and providers they do, with depicted cash spends, the first and foremost priority and consideration are the members, providers, and communities.

Much of the frustration felt by providers and HI professionals in the provider settings stems from the lack of understanding of the payer side. AHIMA representation in the payer space will bridge the gap and foster the cohesion.

Stephen A. Young, RHIA, MBA, MSS, is director of records management organization for the enterprise risk management division of the AmeriHealth Caritas Family of Companies.

Statements of law, fact and views expressed are those of the author individually and are not the opinion or position of AmeriHealth Caritas Family of Companies, its parent organizations or its affiliates. The AmeriHealth Caritas Family of Companies does not endorse or approve, and assumes no responsibility for, the content, accuracy or completeness of the information presented.