Managed Care: 3 Considerations When Expanding Services

The push towards outcome-driven health care, which intensified after the Affordable Care Act came into force five years ago, has prompted several managed care organizations to step up their efforts to deliver more value to members while keeping costs in check.

Among the more important shifts has been the emphasis on preventive medicine and services that can help identify and address health problems early, reducing the need for more costly treatments and interventions that can lead to long recovery periods and inconvenience patients. In fact, 80% of health plan executives say they are promoting value-based care through an increased focus on social determinants of health, including where people live and work. Their efforts include expanding outreach programs within their communities and some organizations have invested in medical vans to go around neighborhoods and provide services, like flu shots or blood pressure tests, for free, sometimes even to non-members.

Health plans have also begun partnering with providers in more formal ways, including establishing distinctly branded care access through joint venture partnerships with clinics and hospitals in more vulnerable communities where patients might not have previously had access to an insurance product.

Process Might Increase Liability

While outreach programs can be beneficial for patients, providers, and the overall health care system, a number of challenges must be addressed. Although liability risks — for example, bodily injury — are highly concerning, insurance coverage traditionally purchased by managed care organizations may not cover these new services.

Managed care entities that are expanding their services should consider the following actions:

  1. Establish the exact nature of any new services your organization is providing. Any outreach programs should be clearly defined and the new services carefully determined. Any health professionals taking part in these programs should understand their roles and abide by clear policies on what they can do.
  2. Exert caution when embarking on new collaborations. Some managed care companies are working with other health care providers to deliver community-based services. Businesses discuss new care delivery models with their brokers, including sharing descriptions of the job functions of those delivering expanded services — for example, what type of medical training is required to fill the role — and addressing the minimum state medical malpractice requirements for medical services.
  3. Ensure appropriate insurance coverage. Some managed care organizations have extended their community services without expanding their insurance coverage, leaving them potentially unprotected from lawsuits and other risks. Talk to your broker about any changes, including new services, and work on expanding coverage where needed. Gaps in traditional managed care policies can be addressed with a managed care wraparound product, which provides protection for hands-on health care services in addition to traditional professional services liability. It is also important to make sure other organizations you are working with have the right coverage.

Expanding services and increasing community outreach can provide value to patients, but managed care organizations must make sure they account for potentially greater risk, and ensure that their coverage addresses these new perils.