Managed Care Rediscovered | MedPage Today

For two years, the healthcare system has expanded its long-standing shortcomings by tackling depleted resources and previously unimaginable challenges. Hospital income plummeted, “burnout” and resignations between medical professionals surged, and the health of the population was compromised. However, even in the face of overwhelming obstacles, “American ingenuity” has not diminished.

The authors of a recent article state that while the industry’s profitability over the next few years is uncertain, there are significant opportunities and urgent needs for healthcare innovation. They also describe new business models that show real potential in providing higher quality, more accessible care at lower cost. A new and innovative model that is producing better returns for payers to provide better service to individuals with complex medical needs (ie, chronic illnesses and long-term conditions that require continuous management). A model that incorporates care provision and advanced analysis. The authors suggest that Medicaid is one of the segments that offers growth potential in this area.

If this sounds vaguely familiar, there is good reason. At the core of these innovations are, in fact, next-generation managed care models that are strategically deployed in regions that are likely to have the greatest positive impact on the individual.

The pandemic has already accelerated a substantial shift from hospital-based care delivery to outpatient and telemedicine applications, forcing a focus on the healthcare system. The new and diverse business models of the healthcare system not only improve profitability, but also provide care in better settings and improve care coordination while maintaining or enhancing the quality of service.

Pennsylvania has a long-standing reputation for implementing innovative business models. For example, the University of Pittsburgh Health Center and Gaisinger Health are nationally recognized for demonstrating how the healthcare system can help both patients and profits by entering the insurance business. In addition, payers in the southeastern part of the state helped pioneer Medicaid manage in the mid-1980s.

Here in Philadelphia, new integration models are being introduced in real time. A few months ago, Thomas Jefferson University announced the completion of a long-term plan purchase from Health Partners Plans, Inc., a non-profit managed managed care plan. With this acquisition, Jefferson is in the growth ranks of an integrative medicine system that owns hospitals, hires doctors and operates insurance companies that pay for medical care. The focus of the healthcare system was not on entering the commercial health insurance market, but on the Medicaid and Medicare plans of health partners servicing poor areas of the city.

My colleague and former Jefferson CEO, Dr. Stephen Clasco, MBA, was the driving force behind this approach and many other innovative approaches. He manages health insurance dollars as a means of reducing wasted spending, eliminating fragmentation of health insurance payers and healthcare providers, and most importantly, enabling new interventions. I saw. For example, enabling broadband and telemedicine services can reduce hospitalization for beneficiaries of Medicaid with chronic illness.

We’ve come a long way since the 1980s, when managed care was suspected. We have seen the concept of health and value-based care for the population built into Medicare and Medicaid. We are better adapted to the social determinants of health and are more aware of the need to recognize and eliminate inequality. The next-generation managed care model is not yesterday’s HMO. These are very likely to be part of the solution to a problem in the medical system.