Health Policy and Law student Lisa Hurtado returns to complete her Capstone Project and her last requirement in order to receive her master’s degree after moving to Texas to pursue a Career Opportunity she couldn’t say “No” to. Read about her career journey, and all the exciting things happening in Texas between Managed Medicaid Health Plans and Nursing Facility Providers focused on best serving “high medical need individuals” on Medicaid.
When Lisa Hurtado applied to the Health Policy and Law Program she was working as an Outreach Program Coordinator in Cardiovascular and Renal Services at Sharp Memorial Hospital. When she began the program fall of 2008, she had started a new position as Network Manager for United Behavioral Health. While still taking classes in August 2011, Lisa changed jobs again to become Managing Director for Managed Care Relationships for Kindred Healthcare’s Hospital & Nursing Divisions. It became clear to Lisa that employers valued the skills she was obtaining in her master’s degree program and felt she was qualified to take on these new roles.
After completing all her coursework with just her Capstone Project left, another great job opportunity came her way as Manager of Provider Contracts for Molina Healthcare in Texas and off she went in August 2012.
Fast forward to winter quarter 2016, and Lisa feels that she can now manage both her current position as Contract Manager II for Molina Healthcare, and complete her Capstone Project so that she can finally finish her master’s degree.
A little history on what is happening in Texas: in the past, skilled nursing facilities billed claims for patients on Medicaid and/or Medicare directly to the state (state government) or Medicare (the federal government) for reimbursement. Many large states, like Texas, with high Medicaid populations living in skilled nursing facilities decided to carve-in this population of beneficiaries into managed care plans. This was to take effect on 9/1/2014 in Texas. During this complex transition for Nursing Facility Providers, beneficiaries and their family members, many hurdles were encountered and concerns arose. While addressing these concerns and working through them in partnership with the MCO’s and providers, the state of Texas delayed the launch of the initiative until 3/01/2015 and mandated that the MCO’s utilize a singular contract template to contract with Nursing Facility Providers. This minimized the variation in contract language that the Providers needed to review during the contracting phase of this initiative, but required quite a bit of re-work on behalf of the MCO’s since there were 1300 + facilities across Texas prior to the new implementation date of 03/01/2015, and that number was growing. The Managed Medicaid Health Plan choices in Texas are Molina (officially Molina Healthcare of Texas) where Lisa works, United Healthcare, Amerigroup, CIGNA (CIGNA Health Spring in Texas), and Superior Health Plan (Centene).
As of 3/1/2015 in Texas, nursing facilities no longer bill the state, but bill the healthcare plans for reimbursement. The healthcare plans receive a premium from the state for each enrolled Medicaid beneficiary. Healthcare plans must pay Medicaid clean claims within ten calendar days.
Case Managers from each health plan are actively involved in managing their members care and partner with contracted nursing facility staff to ensure the needs of the member are met and facilitate member satisfaction. The state and federal government (Medicaid and Medicare) continue to highlight the focus on quality of care outcomes and the value of care among this high need, high cost population of beneficiaries. In support of this, Molina Healthcare of Texas began a pay for performance program for contracted and qualified nursing facilities that kicked off on March 1, 2015 coinciding with the state nursing facility initiative. In addition to Molina’s quality program, this year Nursing Facilities can choose to apply, and if approved participate in a Quality Incentive Payment Program (QIPP). The program is designed to incentivize nursing facilities to improve quality and innovation in the delivery of care, including focus on the creation of an environment of home and community within a facility.
The owners of these long term care facilities change frequently. This is driven in part by requirements to be aligned with an Acute Care Hospital System in order to participate in Nursing Facility Quality Programs. With each change of ownership, new paperwork must be filed at the state and federal level and new contracts signed between the nursing facility and the healthcare plan. Lisa’s job entails explaining and negotiating contract terms with nursing center executive leadership and building a foundational relationship between organizations that can be leveraged across departments ranging from contracting, claims, provider services, case management, utilization management and executive leadership.
One more challenge that Lisa faces is that her colleagues and leadership team turnover on a regular basis. With all that is going on in healthcare today, there are plenty of opportunities as well as the continued stress of operating under all the new rules and regulations and political maneuverings. Experienced leaders can choose to use their professional network to move on or be enticed to pursue new and exciting positions frequently.
As Lisa embarks on completing her master’s degree in Health Policy and Law, she envisions a future for herself working in some capacity to ensure that high medical need individuals and the elderly of our country receive the respect and quality of care they deserve as age and health issues impact their independence; that they may live and thrive in a setting of care that honors the dignity and spirit of each unique individual.