Printer-friendly format

Keith Gaither, TennCare Acting Chief of Networks

TennCare officials hope that what’s already working in Middle Tennessee will work just as well in East and West Tennessee.

In January, the TennCare Bureau released a request for proposals (RFP) for health plans to assume full financial risk and serve Medicaid-eligible patients in the two regions. Just as in Middle Tennessee, two MCOs (managed care organizations) will get the job, with TennCare Select, an MCO administered for the state by BlueCross BlueShield of Tennessee, as a backup.

RFP responses are due March 6, and the state is scheduled to announce the bid winners on April 22. West Tennessee residents should receive care under the new system on Nov. 1 and East Tennessee residents on Jan. 1, 2009.

On April 1, 2007, AmeriChoice TennCare Health Plan and AMERIGROUP Community Care in Tennessee began offering services to Middle Tennessee residents. The two plans won the first-time competitive bid process, which required integration of both physical and behavioral health services.

“In general, I think things are going very well in Middle Tennessee,” said Keith Gaither, TennCare acting chief of networks. “We are hearing that the integration model is working, which is one of our main goals. I’m very pleased to hear that.” He added that “it just makes sense” to have one plan meeting both the physical and behavioral needs of an enrollee.

Both Middle Tennessee plans boast sufficient networks of doctors and other providers. “There are a few stragglers who are still signing up, but in general, we have a good panel of doctors and hospitals in Middle Tennessee,” Gaither said. The experience in Middle Tennessee has proven that two plans are enough, offering competition and choice and a sufficient number of enrollees for each plan. “We wanted to have enough size involved in terms of number of lives to attract large, financially backed companies. You get a better economy scale when you get a larger plan, which can handle the ups and downs,” he said.

Gaither said he expects all the plans involved with TennCare now to submit RFP responses, as well as at least four companies with no history in the state. Including TennCare Select, four plans serve West Tennessee and four serve East Tennessee under an “administrative services only” arrangement. MCOs submit invoices for services rendered to enrollees and receive a fixed administrative fee. Under the new model at work in Middle Tennessee, the MCOs assume the financial risk and are paid set monthly rates, or capitated payments, to manage and deliver care.

“With the plan at full risk, there are a couple of things that will happen,” Gaither explained. “One, we will have a more predictable budget. We will know how much we would spend on a Medicaid child under 1. We know what that capitation rate is going to be, so it becomes easier for us to predict what our budget will look like. We just have to monitor our enrollment. Two, in the long run, when the plans are at-risk with more of a focus on managing care and disease-management programs, I think we’ll see that utilization will be more appropriately aligned with the means of the enrollee.” Some TennCare recipients pay co-pays or premiums, depending on the plan and their income.

A few changes have been made in the new RFP as compared with the Middle Tennessee RFP. For one, responders are required to complete what are called “contact memorandums” — proof that the bidder has already contacted a specified number of providers and “actively engaged in discussions with them,” according to one of the RFP documents. “The state expects that this process will contribute to the proposer’s understanding of the unique service delivery system and enrollee population in each region.”

Said Gaither about this new requirement, “It gets that conversation started. I think that’s going to help encourage network development. It also gives some providers a chance to give them some input before the proposals are even delivered, a chance to tell their view of what things are like in their region, which would be helpful.”

Another change is something TennCare is offering bidders: background on each region, including demographics, and a list of current providers in each region. “East and West Tennessee are very different,” Gaither said. “We want someone who understands that region and what those needs are. Every region of the state is different, and different kinds of people live in different areas, and the geography is different. The providers are very different in each region. The more they know about what they’re bidding on, we’ll all be better off in the end.”

While some states have introduced managed-care strategies for certain populations, Tennessee is the only state with all of its membership enrolled in managed care. Tennessee is also breaking new ground by dividing the state into three regions and by introducing the contact memorandums.

“We try to be ahead of the curve and try to be innovative and improve constantly,” Gaither said.



February 2008

Tags:

None

Login and voice your opinion!