High-performing health plans are critical to the success of efforts to align Medicare and Medicaid services, including the capitated financial alignment demonstrations as well as Dual Eligible Special Needs Plans. Yet, there is little consensus about what makes an integrated health plan high-performing. To explore this issue, The Commonwealth Fund supported the creation of PRIDE (PRomoting Integrated Care for Dual Eligibles), which is bringing together leading health care organizations to identify and advance strategies for providing high-quality and cost-effective care for Medicare-Medicaid enrollees and other high-need populations.
This brief, written by Penny Hollander Feldman of the VNSNY Research Center for the PRIDE project, describes a framework outlining the characteristics of high-performing health plans. While the framework is intended as a guide rather than a set of formal criteria, it can help states and health plans establish the elements essential to successfully providing coordinated, person-centered, integrated care that meets the needs of individuals with complex needs.
The seven organizations participating in PRIDE all have significant experience in serving Medicare-Medicaid enrollees and other high-need populations. PRIDE Profiles, developed by CHCS, provide a summary of each member organization, including the status of Medicare-Medicaid integration activities and key program design strategies that are helping these organizations to effectively meet enrollee needs. Future briefs will share the PRIDE project’s results as the members refine and build on what it means to be a high-performing health plan.