Latest / Becker’s Payer Issues Podcast / HR1 Effects and How Organizations Can Prepare for Them

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HR1 Effects and How Organizations Can Prepare for Them · Becker’s Payer Issues Podcast

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  Hi, everyone. This is Lucas Voss with Becker's
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  Healthcare. Thanks so much for tuning in to
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  the Becker's Healthcare podcast series. So great to
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  have you. Today, we're talking about h r
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  one effects and how organizations
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  can prepare
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  for them. And joining me for today's discussion,
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  so great to have him, is Trey Sutton.
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  He's the CEO and cofounder of Sift. Well,
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  Trey, thanks so much for being here today.
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  Great to have you. Thanks for having me.
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  Great to be with you. And for those
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  that might not know you yet, at least,
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  could you just share a little bit about
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  yourself,
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  your background, and CIFWell?
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  Yeah. Of course. Yeah. So been in around
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  health care on and off for twenty five
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  years.
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  You know, I come to the HR one
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  conversation
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  with a lot of, passion and and kind
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  of interest in in the topic.
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  I spent a few years as chief financial
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  officer of Medicaid in North Carolina and then
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  was also, CEO of a community health plan
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  with about a million lives that mostly was
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  Medicaid. And so, you know, as I look
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  across what's happening right now from a regulatory
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  perspective, it's pretty concerning, specifically the implications of
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  HR one and folks losing coverage.
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  At CifWell,
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  the way to to kinda think about us
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  for the listeners that are, managed care folks
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  is we're almost like the best medical medical
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  economic shop you can build, combined with some
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  clinical operators all inside of a project management
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  office. So we generally fall under the category
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  of predictive analytics,
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  but there's, the we really like to see
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  it through. And in the context of HR
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  one, you know, we're helping plans right now
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  identify exactly who's gonna lose coverage and how
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  to engage those individuals.
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  Trey, so good to have you. Thanks for
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  being here. I I wanna level set our
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  conversation
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  just a little bit for our listeners.
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  The federal COVID nineteen public health emergency unwinding
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  disenrolled roughly twenty
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  five million people nationally
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  with some of the procedural disenrollment
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  rates right around that thirty percent mark,
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  again, in hard hit states, which certainly differs.
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  HR one brings now a different
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  set of disruptions that I wanna talk to
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  you about. Again, we talk about work requirements,
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  six month redeterminations,
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  immigrant eligibility
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  restrictions. Right? That adds a whole another level
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  of complications
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  there. But, again, that administrative
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  churn risk
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  still seems familiar for a lot of organizations.
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  Right now, what should health plans be carrying
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  forward from the unwinding
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  experience, and where does that analogy breakdown?
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  Yeah. Of course. I mean, I you know,
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  there there are a lot of similarities, particularly
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  on the administrative, you know, part of redetermination.
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  I think, you know, as I think about
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  this in the context of the public health
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  emergency online and few things come to mind.
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  One is, you know, folks developed a lot
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  of channel strategies to engage their members, make
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  them aware of the risk of losing coverage
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  when we were going through the public health
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  emergency online. And so I think thinking about
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  channel strategies to to connect with members, I
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  think about,
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  throughput, just like where are those members?
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  Do I have the right sets of resources?
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  Does the state have the right set resources
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  to to manage that throughput or or additional
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  volume
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  as a function of six month redetermination.
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  And then relationships,
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  you know, we know that, a lot of
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  individuals that are covered by Medicaid, there's a
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  level of distrust deservedly so
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  with the health care system overall, but they
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  do tend to trust their, faith based organizations,
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  their community based organizations. And so how do
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  you think about leveraging those relationships that you
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  established during the unwind and
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  and and leverage those for communication purposes, building
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  awareness
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  importance of completing paperwork and all the rest
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  of it as we as we enter it.
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  So those would be the things that I
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  would I would say carry forward.
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  The, you know, the parts that are gonna
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  be very different is, you know, this is
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  almost like everything everywhere all at once. You
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  know, it's not just redetermination.
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  We've got, you know, further constraints going in
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  around SNAP, utility assistance, housing assistance, cash benefit.
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  And so this is only one piece of
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  everything that's happening right now, and and it's
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  pretty concerning. So,
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  but I do think there's an opportunity for
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  folks to get it organized and and execute.
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  Yeah. I love that you mentioned the trust
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  piece. And and depending on where you are,
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  right, it just depends. It's the resources, the
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  state resources. It's the community in and of
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  itself.
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  It's very individual down to, as you started
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  your answer, the channel strategies. Right? It it
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  just depends on
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  where you are. Again, that impact is not
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  uniform.
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  It depends on who your members are, where
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  they live, what we've just established. Right?
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  What does it actually take to move from
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  we know this is coming. Right? Okay. We
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  have mandates that need to get taken care
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  of to we know which specific members are
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  at risk and how to actually then reach
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  them.
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  Yeah. I mean, what I'm gonna describe next
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  sounds simple, but it's it's not simple. I
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  I think two things, and then you gotta
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  put them together. First is you gotta know
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  your members at scale. And what I mean
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  by that is,
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  what what groups do they fall in? Medically
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  fragile, medically exempt? Are they med are they
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  Medicaid expansion population?
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  Where are they? How do you connect with
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  those individuals? What are the
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  what are the communication channels? I mean, we're
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  we're pulling forward information, like, where somebody's likely
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  to see an advertisement. Is it in an
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  airport? Is it at a discount warehouse store?
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  What types of radio stations are they listening
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  to? And so I think, again, it sounds
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  simple,
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  but get to know your members.
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  Number two is get to know the new
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  regs. And and what I mean by that
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  is pulling HR one apart and understanding what
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  that means at the local level for your
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  individuals. And then what you gotta do is
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  you gotta put those two puzzle pieces together.
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  If you understand the rules and you understand
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  your members,
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  and then you can start to use channel
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  strategies, including the community based organizations I talked
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  about a a minute ago. But it's super
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  important that you understand those two pieces and
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  then fit it together.
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  Yeah. And I wanna come back to
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  the knowing your regs piece that you've just
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  touched on because, again, we know that with
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  six month redeterminations,
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  they are going to be in effect January
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  2027.
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  Work requirements are kicking in at December
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  2026.
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  Right? So
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  we know this is happening. It's coming,
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  but that preparation window is really, really short
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  when you're looking at those dates. For health
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  plan leaders that are listening today, what are
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  some of the most important things they should
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  be doing right now
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  and certainly in the next ninety days?
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  And, again, what does this look like at
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  scale? What does should or what should their
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  readiness plan look like at this stage?
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  Yeah. You know, when I think about good
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  readiness at this stage, it it covers a
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  lot of the things that that that I've
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  said already, which is knowing your members, knowing
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  the regs, fitting those pieces together, understanding what
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  what channel strategies
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  and relationships you can leverage.
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  I mean, good readiness for me looks like
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  getting a plan in place and understanding
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  who is gonna be involved in ensuring that
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  folks stay covered.
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  And if you're a health plan leader, it's
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  not just your internal teams. You need to
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  look across the net the ecosystem and understand
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  who else is gonna be involved in processing
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  that redetermination
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  paperwork. In North Carolina,
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  where, you know, I was on the agency
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  side at Medicaid and then was on the
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  plan side. And so I've got a very
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  detailed understanding of how that's processed in North
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  Carolina. And the way that we do that
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  is county DSS offices. You know, folks come
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  in, provide their paperwork, fill out the application,
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  then it's processed. That's the type of information
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  that plan leaders need to understand today. Not
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  only who is gonna be involved internally
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  on making sure that folks stay covered, but
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  also looking outside the organization
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  and what is the capacity for my partners
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  on the state side
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  in order to process what effectively will be
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  twice as many applications
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  a year, at least for the Medicaid expansion
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  population.
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  Yeah. So good plans in place.
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  Knowledge in this instance certainly
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  is truly power. Trey, it's so great to
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  have you on, so great to have you.
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  What's that one final takeaway for our audience
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  that you want them to walk away with?
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  Yeah. I mean, for for the health plan
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  leaders out there, I would say get organized
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  and execute. This is really important.
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  We all have an opportunity. Anybody that's involved
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  in the Medicaid population has a real opportunity
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  to make sure folks stay covered, stay healthier,
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  live more meaningful lives. It it is our
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  job as health plan leaders. And so the
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  takeaway, I would say, is is you've got
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  an opportunity to to make a difference, a
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  real difference in this instance.
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  And then lastly, there are also opportunities for
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  advocacy.
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  Specific example is when we say, medically fragile
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  substance use disorders falls under that, what does
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  that mean somebody's
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  checked themselves into inpatient detox? Does it mean
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  they've gone to an AA meeting? Does it
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  mean that they've gotten a DUI?
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  So I think there's a lot of ambiguity
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  yet to be defined, and that's where I
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  think a lot of health plan leaders have
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  have an opportunity today. So I don't say
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  get out there and advocate.
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  Trey, again, thank you so much for your
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  time and insights today. So great to have
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  you. Awesome. Thank you. And we also want
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  to thank our podcast sponsor, SiftWell. You can
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  tune in to more podcasts from Becker's Healthcare
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  by visiting our podcast page at beckershospitalreview.com.