Anthem's James Holland Talks Medicaid Partnerships


An executive view on medicaid partnership growth.

James Holland

4 min read

What is driving the deluge of payer-provider Medicaid partnerships?

James Holland: Medicaid payer-provider partnerships are growing for two primary reasons. First, state customers are demanding improved collaboration between insurers and providers to drive better health outcomes for Medicaid consumers. This can manifest in the form of increased requirements for value-based reimbursement, state Medicaid contracts geared toward payer-provider joint ventures, or other requirements that encourage partnerships. Second, both payers and providers now realize straight fee-for-service healthcare delivery doesn’t provide the effective outcomes payer-provider collaboration can deliver. This is particularly relevant to Medicaid; reimbursement is low, while performance expectations are high — there is not a lot of room for gaps in execution.

How do these partnerships compare to Medicare Advantage or Commercial products?

JA: Medicaid – a more complex product than Medicare or commercial products – is a state-managed health program with different requirements between states, and different requirements from Medicare and commercial programs. However, the ultimate objectives of the programs are fundamentally the same — to increase access to high quality care with improved health outcomes at a lower cost.

As an example, ensuring high care quality is a critical element of partnerships across Medicaid, Medicare, and commercial programs. In commercial programs, quality may be defined by a few predetermined performance metrics, such as the flu immunization rate, emergency room utilization rate, or consumer satisfaction. In Medicare programs, quality is typically assessed through Medicare STAR performance which is a combination of Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures. In Medicaid, states typically include all HEDIS and CAHPS measures, as well as custom measurements designed to meet state health policy objectives. These custom measures, which may change from year to year, can further vary by Medicaid eligibility category, such as Temporary Assistance for Needy Families (TANF), Children’s Health Insurance Program (CHIP), Supplemental Security Income (SSI), or long-term services and supports (LTSS). This can lead to challenges across these areas in tracking and reporting quality performance. 

Effective care coordination and case management are critical to deliver better outcomes, especially with higher risk patients. For these programs to be effective, a managed care organization must contact consumers and drive meaningful conversations about how engagement leads to behavioral changes. The healthcare provider is often in the best position to influence consumers to change behavior and take control of their health.

How is Amerigroup working to advance these types of Medicaid partnerships?

JA: We partner with providers in states where there is an existing Medicaid program opportunity. We also work with providers to propose innovative pilot programs and serve populations not currently benefiting from a managed system of care. While creating full health plan partnerships with providers where both parties share risk and responsibilities, we aim to build fully collaborative, transparent partnerships that serve government sponsored health programs. As of 2018, Anthem has eight publicly announced Medicaid alliances.

How do you see the role of the partnerships evolving as providers get more comfortable with taking on Medicaid risk?

JA: Once provider-owned health plans realize through a partnership, they not only survive, but thrive, and often become profitable for the first time on risk-based payments, they embrace alliance partnerships. We have a partner health plan that has operated in the Medicaid space in the same region for years. We joined them to create a plan in which they will expand their footprint to a large rural region where their health system does not have a significant presence. The alliance offers innovation and growth opportunities that better position them to deliver quality healthcare services for the consumers in the area. 

We envision partnerships becoming more digitally driven than before. For instance, Anthem’s Live Health Online expands innovative service programs to bring care access to consumers and patients in rural areas. In contrast, provider health plans are not necessarily able to independently invest in a program that grants consumers online access to physical and behavioral health providers through their computer or smartphone. Hence, this digital shift is bringing more care to more patients.

We also see more of our partners building alternative payment models for their physician networks, including tools to facilitate physicians and behavioral health providers. This enables providers to partner more effectively, in alignment with the state’s APM goals, while improving consumers’ health outcomes. 

  • James Holland