Community First Health Plans: Keeping the Focus
Insurance
Written by Amanda Gaines   
Monday, 01 October 2007
Community First Health Plans: Keeping the Focus - Health Executive - RedCoat Publishing
Charles Kight explains how this regional HMO keeps its finger on the pulse of South Texas healthcare.

When Community First Health Plans celebrated its 10-year anniversary in 2005, things looked rosy. The San Antonio-based not-for-profit HMO had been growing at a steady rate, and its Medicaid book of business, which is still its largest account, was taking off. Then, in the first quarter of 2006, the state’s decision to shut down a competing primary care case management model of coverage changed everything.

Community First Health Plans: Keeping the Focus - Health Executive - RedCoat Publishing
Charles Kight, President and CEO
Community First gained roughly 15,000 new members from the legislative change, which should have been good news for a company looking to maintain steady growth. However, a large percentage of those new members were pregnant women, which in turn brought a higher number of premature and complex newborns.

“Complex newborns are typically assigned to an NICU (neonatal intensive care unit), which is a very expensive course of care,” said Charles Kight, president and CEO of Community First. “The change caused us to reassess how we deal with complex newborns and to look for innovative ways to handle those cases, not only with metrics to track the volume of those particular cases but also with what we could do in outreach and case management to moderate our underwriting risk.”

Kight understands premature births are a national maternal health issue but, as the company name suggests, his focus was on his community first. The company started small, hiring another case manager in its health services management division to better handle the increased volumes of NICU admissions. Community First then engaged a company, through its reinsurance carrier, that specializes in case management and bill audit review for NICU patients.

“We also had started a pay-for-improvement project through which we incentivize our OB offices to encourage their pregnant patients to respond to a survey we send when we’re notified by the state of a new and pregnant Medicaid member,” said Kight, with a goal of identifying high-risk pregnancies and enrolling those members into the company’s case management program, Healthy Expectations. “We’ve also worked with hospitals to develop metrics for determining the acuity of those patients as it relates to the course of their inpatient care.”

Patients in the NICU are categorized into four levels, from highest to lowest acuity, relating the profile of the infant back to the appropriate revenue code level. Community First case managers talk with case managers at the hospital to assign an appropriate level given the clinical facts, and the hospital is then obligated to bill at the agreed level. As the clinical level of the baby improves, the levels should also step down.

“We found a number of babies were discharged from the NICU at the highest level, which does not make sense,” the CEO said. “The infants’ health should improve to eventually require a lower number of nursing hours before being discharged.”

Since implementing these changes, Community First has seen its Medicaid product come closer to breaking even. Kight admits the struggle in the first and second quarters of ’06 were due to substantial losses in Medicaid, primarily attributed to spikes in NICU utilization. “We’re closer to premiums completely covering medical expenses than we were in ’06, and those are the best results,” he said.

Beyond the numbers
Although numbers may seem like the biggest proponent for Community First changing its Medicaid policies, nothing could be further from the truth. Of course, as with any company, sound finances are imperative, but the company’s continued commitment to stay focused solely on its region enables the kind of attention to detail not inherent to larger, national providers. “We stay in close contact with issues as they develop,” said Kight. “Right now we have a focused effort on early childhood health.”

A number of years ago, the state of Texas was taken to court because its Medicaid Program’s well-child checkup policies were not as successful as they should have been. For example, under the plan, children two years and older are allocated an annual checkup, but only about 60% of the children were receiving their age-appropriate checkups. The litigation caused the state legislature to allocate money to improve the Medicaid physician fee schedule, incentivizing physicians to contact young mothers to bring their children in for exams and immunizations. Community First spent many months preparing for the new Medicaid contract, which went into effect September 1, and is currently focused on encouraging its members, especially the young moms, to take their children in for exams.

“We’re studying what other states and health plans have done to improve those compliance rates, but it’s not always about the numbers,” said Kight. “It’s about members educating members, encouraging them, and incentivizing them to take their children in for regular checkups.”

System migration
In the past two years, Community First has also made a significant adjustment to its IT capabilities by migrating from Pennsylvania-based management software company Amisys’ original transaction processing system, which resided on a Hewlett Packard box, to Amisys Advance, which functions in a Unix environment. Because of Community First’s continuous product diversification, including ASO (administrative services only) work, Medicaid, and CHIP (Children’s Health Insurance Plan), Kight willingly switched platforms with Amisys, despite the amount of work it caused his company. Community First has had to rewrite its surround code and retrain the staff working with the Amisys product daily, adding and deleting members, paying claims, handling medical management, and loading all network providers. “Amisys is the heart and soul of our IT infrastructure, and this past year we’ve worked on this migration effort,” said Kight. “The new system will go live in October.”

Amisys Advance is a Windows-based program, which gives Community First’s employees easier desktop navigation and the ability to add new modules as the company’s product lines grow. “We’re looking at a new member service module, and we’re looking to procure a new medical management system that will interface with Amisys Advance,” Kight said. “This new IT platform will give us the opportunity to access many of the newer technologies available in our industry.”

 
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