Medicaid Health Plans Save Millions by Moving from Auto-Assignment to Smart-Assignment
25 Julio 2024 - 10:00AM
Business Wire
Cave Consulting Group, Inc. (CCGroup) and healthcare researchers
(such as Yale University) performed studies that show a 350,000
member Medicaid health plan will save between $2 million and $15
million annually by moving from auto-assignment to
smart-assignment. Over a billion dollars are saved across all
Medicaid health plans.
Smart-assignment achieves savings as follows. About 35% of
Medicaid enrollees (20 million enrollees) do not elect a PCP upon
enrollment in a Medicaid health plan. “For these enrollees,
Medicaid health plans perform auto-assignment (randomly assign) to
a network PCP,” stated Dr. Douglas G. Cave, President/CEO of
CCGroup. “Auto-assignment is market inefficient because half of
these Medicaid enrollees are auto-assigned to inefficiently
practicing network PCPs.” An inefficient PCP is a provider that
delivers healthcare services at a higher cost-of-care with no
perceivable difference in quality or satisfaction.
Dr. Cave asserted, “Auto-assignment should stop, and
smart-assignment should immediately start.” Smart-assignment means
assigning Medicaid members only to efficiently practicing PCPs.
Efficient PCPs save money in three ways: PCPs patient treatment
costs are lower; PCPs refer less often to specialists; and when a
referral is necessary, PCPs can make referrals to more efficient
specialists that perform less extensive diagnostic tests and
therapies. Therefore, smart-assignment saves Medicaid health plans
well over a billion dollars annually.
What barriers exist for Medicaid health plans to implement
smart-assignment? “An initial barrier is that auto-assignment is
the status quo. Senior management is often unaware of the
significant savings associated with smart-assignment,” defined Dr.
Cave. With education, this barrier is overcome.
He continued, “Another barrier is that a Medicaid health plan
can only measure about 25% of individual PCP efficiency and
quality.” The reason is that one Medicaid health plan’s membership
does not generate enough claims data to build a sufficient volume
of medical condition episodes of care – needed for PCP efficiency
measurement. Successful smart-assignment programs require
measurement of at least 75% of individual PCP efficiency.
This barrier is overcome by working with CCGroup. “CCGroup
maintains one of the largest databases on physician cost and
quality measurement,” stated Yuri Alexandrian, Chief Operating
Officer of CCGroup. The database is known as the CCGroup-CMS
Innovator Project Database. Mr. Alexandrian explained, “Nationally,
we measure 75%-to-80% of all PCPs efficiency and quality. Using
this information, our Medicaid health plan clients successfully
implement smart-assignment, while preserving Medicaid member access
to care.”
Dr. Cave mentioned, “A final barrier is that PCP efficiency
needs to be accurately and reliably calculated. This is no easy
task, yet smart-assignment depends on accurate PCP efficiency
measurement. Fortunately, this barrier is not an issue. For several
decades, CCGroup has remained the market leader in accurately
measuring physician efficiency and quality.”
The foundation of CCGroup’s patented reliability is the use of
medical condition episodes and analysis of a relevant set of
medical conditions for PCPs. This marketbasket of medical condition
episodes is weighted together to determine overall efficiency
scores for each PCP.
About Cave Consulting Group, Inc. (CCGroup)
Cave Consulting Group, Inc. is a software and consulting firm
located in San Mateo, California. The company is focused on
improving the efficiency (cost-of-care) and effectiveness
(quality-of-care) of the healthcare delivery system. Senior
management of CCGroup has assessed the performance of physicians
and hospitals for over 32 years for health plans, health systems,
HMOs, physician groups, CINs, ACOs, TPAs, and employers.
View source
version on businesswire.com: https://www.businesswire.com/news/home/20240725419986/en/
Mr. Yuri Alexandrian, CCGroup 650-286-4100
yalexandrian@cavegroup.com