Five Questions With: Alison L. Croke

Alison L. Croke is vice president, Medicaid-Medicare integration, at Neighborhood Health Plan of Rhode Island. / COURTESY NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND
Alison L. Croke is vice president, Medicaid-Medicare integration, at Neighborhood Health Plan of Rhode Island. / COURTESY NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND

Alison L. Croke is vice president, Medicaid-Medicare integration, at Neighborhood Health Plan of Rhode Island. Prior to her current role, she worked with the Rhode Island Executive Office of Health and Human Services for approximately 10 years, where she helped to create new managed-care programs for Medicaid clients, including RIte Smiles, Rhody HealthPartners and Rhody Health Options.

Before joining EOHHS, Croke worked as a senior project manager at Neighborhood and at the Center for Health Care Strategies in Princeton, N.J., on several Robert Wood Johnson Foundation-funded national programs focused on developing health care delivery systems for vulnerable populations.
Croke holds an undergraduate degree in biological sciences from the University of Vermont and a master’s degree in health administration from the Medical College of Virginia, Virginia Commonwealth University. She spoke recently with Providence Business News about an agreement among Neighborhood, EOHHS and the Centers for Medicare & Medicaid Services to more efficiently serve Neighborhood members who are eligible for both Medicaid and Medicare services.

PBN: Can you describe the terms and conditions of the three-way contract among Neighborhood, the Rhode Island Executive Office of Health and Human Services and the federal Centers for Medicare & Medicaid Services; how will this agreement benefit some of Neighborhood’s most vulnerable members? Is this a natural evolution of Neighborhood’s growth since the enactment of the Affordable Care Act?

CROKE: The overall goal of Neighborhood’s new program, INTEGRITY, is to remove the many inefficiencies from a complicated system and, in doing so, improve the care that our members receive while saving taxpayer dollars. So, to that point, the three-way contract includes a variety of federal and state requirements, and specifies exactly how our care management teams will operate. For example, our care managers will be required to conduct health risk assessments with INTEGRITY members within specific timelines. Next, care managers must develop personalized care plans based on those assessments; the care plans must be shared with and agreed upon by the members themselves and any family members they request.

- Advertisement -

The contract, which also contains new language explaining beneficiary protections, establishes requirements for our call center and our network. For example, Neighborhood will be required to extend the hours of operation of our call center for this population and address members’ concerns in an expedited timeframe. Another key component of the contract focuses on what we call our “measures to collect.” In essence, this means we will be continuously evaluating the quality of the program and Neighborhood’s ability to serve this vulnerable population.

From our perspective, this is very much a natural evolution. We have been serving people with disabilities since 2009, and this program helps us serve the only remaining “unmanaged” group of Medicaid beneficiaries – the “dual-eligibles.”

PBN: If approximately 30,000 Rhode Islanders are dually eligible for both Medicare and Medicaid services, why are only 10,000 to 14,000 of them expected to enroll in INTEGRITY under this contract? Are only dually eligible individuals already enrolled in Neighborhood eligible to participate in INTEGRITY or any dually eligible Rhode Island resident?

CROKE: Any fully dual-eligible person in Rhode Island may choose to participate in INTEGRITY.
Of the approximately 30,000 dually eligible individuals in Rhode Island right now, about 21,000 of them are already Neighborhood members being served under our plan called UNITY. As part of the sign-up process, most current UNITY members will be passively enrolled into INTEGRITY. But since the core of INTEGRITY involves putting members’ wishes first, some may choose not to join. Our enrollment estimates assume some of the current UNITY members may opt out of INTEGRITY. Even so, INTEGRITY will remain an option for them going forward. We also anticipate the benefits of the plan will attract more members in the coming years.

The other group of potential members is the “opt-in” group. These are individuals who are currently in Medicaid fee-for-service coverage and have other supplemental plans. Using criteria established by the state, enrollment in INTEGRITY will also be open to this population.

PBN: How do you expect this coordinated care system to rein in costs and improve patient outcomes; what are the metrics established for cost savings and improved outcomes and how will it strengthen Neighborhood, if at all?

CROKE: This coordinated care system (Phase 2 of the Integrated Care Initiative) will build on the successes from Phase 1. During the first two years of this program, Neighborhood conducted almost 40,000 assessments of people eligible for both Medicaid and Medicare. When appropriate, we assigned an interdisciplinary care team tailored to the person. Neighborhood then leveraged the member’s team with a customized blend of services and supports that enables each member to receive the care that matters most to him or her, be it housing, food security or even socialization. The convergence of these services helps to support the member in the right setting, whether it is remaining in or transferring to a nursing home or a community setting. That’s where we can make a big impact – allowing the member to live independently (but with appropriate services) and most cost-effectively in his or her preferred choice. In the first two years of Phase 1, although overall membership rose, we helped to reduce the number of people living in nursing homes by 12 percent. Visits to emergency departments fell by 11 percent and hospitalizations and re-hospitalizations fell by 6 percent and 9 percent, respectively.

With INTEGRITY, these achievements will grow as we manage the Medicare benefit along with the Medicaid benefit. Integrating the two programs will allow for better alignment of financial incentives. In years two and three of the program, we will look into alternative payment models and shared savings plans. We will continue to collaborate with our vast network of providers to find innovative and cost-effective ways of serving our members. Neighborhood is also excited about starting the process of designing new clinical programs in partnership with our network providers to meet the unique needs of INTEGRITY members – integrating behavioral health care with primary care, offering a nurse practitioner rounding program with nursing homes and providing additional caregiver support benefits, for example.

PBN: What lessons has Neighborhood learned from Rhody Health Options, part of the first phase of EOHHS’ Integrated Care Initiative, that will inform the implementation and outcomes of INTEGRITY?

CROKE: Delivering the best health care to people such as those who fall into the dually eligible category has a great deal to do with recognizing what we typically call the “social determinants” of health. People are only able to take the best care of their health needs once their other concerns are addressed; if one of our members is about to get evicted, cannot afford groceries or does not have access to transportation, it’s not reasonable to expect the individual to prioritize making regular doctor’s appointments. Neighborhood has decades of experience in advocating for such populations, and that includes the members in Rhody Health Options, also known as our UNITY plan. Our care management teams spend countless hours connecting members to social services in the community – programs like Meals on Wheels for food, The RIde for transportation and various community and senior centers throughout Rhode Island that help with bills, meals and basic socialization – that can address those social determinants of health. Without exception, taking care of those needs allows our members to focus on their personal health. That same level of care will be offered to members enrolled in INTEGRITY.

PBN: What will success look like within the first six months and the first year of INTEGRITY; will this system be replicable by other insurers?

CROKE: During INTEGRITY’s first months, we will measure its success in a number of ways. As mentioned earlier, Neighborhood’s members have the ability to opt out of INTEGRITY; two metrics we will therefore look at are the opt-out rates (which we hope will remain as low as possible) and the opt-in rates (which we hope start – and remain – relatively high). We will also track our outreach to our members, making sure we are keeping them informed of their options and explaining how they can best take advantage of everything INTEGRITY has to offer. A low number of grievances filed by our members will also tell us that INTEGRITY is working well. CMS has also contracted with a leading research institute to do a national evaluation of the program, which will give us context and perspective on INTEGRITY’s successes.

Rhode Island will be the 13th state to participate in the demonstration; so, in that sense, it is already replicable. As we incorporate INTEGRITY into the overall Rhode Island healthcare landscape, we hope that it will encourage innovation across the health care spectrum.

No posts to display