In California and in many states, the health plans bear the ultimate responsibility to safeguard the care standards and monitor the claims payment capability and financial solvency of risk-bearing medical groups. Health plans bear a compliance responsibility when contracting with downstream providers. Enforcement of existing requirements is likely a better starting place. However, are new regulatory oversight standards necessary? As regulators contemplate additional, new bold actions, it is imperative to consider that increasing oversight increases cost and shrinks the already tight margins of the Medi-Cal managed care dollar going to providers. There has been much speculation around whether and to what extent California’s regulators will address delegation oversight by health plans, spurred on by the experience of the prominent group and its MSO.
Here we share our thoughts and examine three issues of concern: (1) the need for health plan oversight, (2) how to enable successful governance between a risk-bearing medical group and their MSOs and (3) policy concerns related to offering “narrow networks” based on, among other factors, economic profiling. The recent high profile collapse of one of the nation’s more prominent risk-bearing medical group and its affiliated MSO highlights a number of potential operational, financial and regulatory dilemmas that must be carefully managed in the relationship between an MSO and one or more medical groups. Risk-bearing medical groups and IPAs turn to captive or separate Management Services Organizations (MSOs) to provide many of the functions to arrange for the delivery of high-quality care services. These “pioneer” providers practiced population health management before it gained industry currency and have utilized outcomes-based payment to incentivize provider innovation for decades.
State Medicaid and Other Waiver Programs.Managed Services Organization (MSO) Development and Optimization.Care Management Assessment, Optimization and Implementation.Quality and Provider Performance Improvement.Primary Care Provider Network Empanelment Assessment and Optimization.Post-Acute Network Assessment and Optimization.Managed Care Contract Revenue Optimization.Managed Care / Risk Readiness Gap Assessment.
Value-based and Risk Transfer Payment Arrangements.