Profile: Centene Corp (CNC.N)
11 Jul 2014
Centene Corporation is a multi-line healthcare enterprise, which provides programs and services to the number of under-insured and uninsured individuals. The Company provides member-focused services through locally based staff by assisting in accessing care, coordinating referrals to related health and social services and addressing member concerns and questions. It also provides education and outreach programs to inform and assist members in accessing appropriate healthcare services. It combines its decentralized local approach for care with a centralized infrastructure of support functions, such as finance, information systems and claims processing. The Company operates in two segments: Medicaid Managed Care and Specialty Services. In January 2014, the Company announced that it has completed the purchase of an interest in U.S. Medical Management, LLC. Effective March 27, 2014, Centene Corp acquired a 50% interest in Ribera Salud SA, and a 50:50 unit between Banco de Sabadell SA (Sabadell) and Bankia SA, from Bankia SA.
The Company’s Medicaid Managed Care segment provides Medicaid and Medicaid-related health plan coverage to individuals through government subsidized programs, including Medicaid, the State Children’s Health Insurance Program (CHIP), Foster Care, Medicare Special Needs Plans and the Supplemental Security Income Program, also known as the Aged, Blind or Disabled Program, or collectively ABD. As of December 31, 2011, Medicaid accounted for 74% of its at-risk membership, while CHIP (also including Foster Care) and ABD (also including Medicare) accounted for 12% and 12%, respectively. Other state programs in Massachusetts represent the remaining 2% at-risk membership. Its Specialty Services segment offers products for behavioral health, care management software, health insurance exchanges, individual health insurance, life and health management, long-term care programs, managed vision, telehealth services, and pharmacy benefits management to state programs, healthcare organizations, employer groups and other commercial organizations, as well as to its own subsidiaries. Its health plans in Arizona, operated by its long-term care company, and in Massachusetts, operated by its individual health insurance provider, are included in the Specialty Services segment.
Medicaid Managed Care
The Company’s information technology (IT) department has mapping/translation programs for loading membership and linking membership eligibility status to all of Centene’s subsystems. Its Centelligence is enterprise data warehouse system, which provides a seamless flow of data across its organization, enabling providers and case managers to access information, apply analytical insight and make informed decisions.
The Company prepares provider comparisons on a severity adjusted basis. It gathers utilization data from multiple sources, allowing for an integrated view of its members’ utilization of services. These sources include medical, vision, behavioral health claims and encounter data, pharmacy data, dental vendor claims, and authorization data from the authorization and case management system utilized by it to coordinate care. Its health plans provide the services, which include primary and specialty physician care, transportation assistance, inpatient and outpatient hospital care, vision care, emergency and urgent care, dental care, prenatal care, immunizations, laboratory and x-ray services, prescriptions and limited over-the-counter drugs, home health and durable medical equipment, therapies, behavioral health and substance abuse services, social work services, around-the-clock nurse advice line, and care coordination. Start Smart For Your Baby is its prenatal and infant health program designed to reduce the incidence of low birth weight babies, identify high risk pregnancies, Infant and Children program and prevent hospital admissions in the first year of life. The program includes risk assessments, education through face-to-face meetings and materials, behavior modification plans, assistance in selecting a physician for the infant and scheduling newborn follow-up visits. The program includes a Notification of Pregnancy process to identify pregnant women more quickly and enables it to help them gain access to prenatal medical care, give them education on their healthcare needs, assist with social needs and concerns, and coordinate referrals to appropriate specialists and the obstetrics (OB) case management program as needed. The Notification of Pregnancy also identifies women eligible for OB management program, or 17P Program, which aims to reduce the rate of recurrent preterm delivery and neonatal intensive care admissions through the use of Progesterone. In addition, Start Smart has also co-written a book for the first year of life with the American Academy of Pediatrics.
Connections Plus is a cell phone program developed for members who have limited or no access to a safe, reliable telephone. The program puts free, preprogrammed cell phones into the hands of eligible members. Members are identified through case management activities or through a referral. Connections Plus is available to members in all Centene health plans. This program has been expanded to service members with mental health issues, and specific diseases, including sickle cell. AT&T / WellDoc Program is a pilot program, through a partnership with AT&T. This program provides smart phones to a limited group of members with diabetes, giving them access to DiabetesManager, the enterprise mHealth solution from AT&T and WellDoc. DiabetesManager enables patients to manage their diabetes by offering real-time tips and advice based on their individual data. It not only tracks food consumption and blood sugar levels, but also allows members to take control of self-management of their Type II diabetes. MemberConnections is a community face-to-face outreach and education program designed to create a link between the member and the provider and identify risk elements to a member’s health, such as nutritional challenges and health education shortcomings. Its MemberConnections representatives make home visits, conduct educational programs and represent its health plans at community events, such as health fairs.
Health Initiatives for Children is aimed at educating child members on a range of health topics. Its health plans are reaching out directly to children with newsletters, contests and a series of children’s books, which have been sponsored by the Company. These books have focused on managing asthma, obesity prevention and healthy eating. The books educate children on the importance of living an active and healthy life. Health Passport is a patient-centric electronic community health record for foster care children. Health Passport collects patient demographic data, clinician visit records, dispensed medications, vital sign history, lab results, allergy charts, and immunization data. Providers can directly input additional or updated patient data and documentation into the Passport. All information is accessible anywhere, anytime to all authorized users, including health plan staff. The CentAccount Program offers members financial incentives for performing healthy behaviors. The incentives are delivered through a restricted-use MasterCard redeemable for health-related items only. This incentive-based approach increases the utilization of preventive services while strengthening the relationships between members and their primary care providers. The Asthma Management Program integrates a hands-on approach with an outreach methodology, which can be customized to suit the different age groups and populations it serves, which are affected by asthma. Nurtur Health, Inc., a wholly owned subsidiary of the Company, provides life, health and wellness programs, it provides proactive identification of members, stratification into appropriate levels of intervention, including home visits, culturally sensitive education, and robust outcome reporting. The program also includes care coordination to ensure patients have basic services, such as transportation to the doctor, electricity to power the nebulizer, and a clean, safe home environment. Fluvention is an outreach program aimed at educating members on preventing the transmission of the influenza virus by encouraging members to get influenza vaccines and take everyday precautions to prevent illness. It uses an integrated communications approach, including direct mail, phone calls, providing information through health plan Websites and posting information in provider offices. The health plans also conduct general community awareness through public service announcements on television and radio.
EPSDT Case Management is a preventive care program designed to educate its members on the benefits of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. Life and Health Management Programs are designed to help members understand their disease and treatment plan. These programs address medical conditions, which are common within the Medicaid population, such as asthma, diabetes and pregnancy. Its Specialty Services segment manages many of its life and health management programs. Its ABD program uses an assessment tool, which identifies barriers to care, unmet functional needs, available social supports and the existence of behavioral health conditions, which impede a member’s ability to maintain a proper health status. Care coordinators develop individual care plans with the member and healthcare providers ensuring the integration of behavioral, social and acute care services. These care plans, while specific to an ABD member, incorporate Condition Specific practices in collaboration with physician partners and community resources.
For each of the Company’s service areas, it establishes a provider network consisting of primary and specialty care physicians, hospitals and ancillary providers. As of December 31, 2011, the health plans it operated contracted with 32,824 primary care physicians, 97424 specialty care physicians and 1, 258 hospitals. Primary care physicians include family and general practitioners, pediatricians, internal medicine physicians and obstetricians and gynecologists. Specialty care physicians provide medical care to members upon referral by the primary care physicians. Specialty care physicians include orthopedic surgeons, cardiologists and otolaryngologists. It also provides education and outreach programs to inform and assist members in accessing appropriate healthcare services. Its health plans facilitate access to healthcare services for its members through contracts with its providers. Its contracts with primary and specialty care physicians and hospitals. It pays hospitals under a range of methods, including fee-for-services, per diems, diagnostic related grouping and case rates. It pays physicians under a fee-for-service, capitation arrangement, or risk-sharing arrangement. The services it provides to support physicians include customized utilization reports, case management support, and Web-based claims and eligibility resources. Customized utilization reports provide certain of its contracted physicians with information. Equivalency reports provide physicians with financial comparisons of capitated versus fee-for-service arrangements. Case management support helps the physician coordinate specialty care and ancillary services for patients with complex conditions and direct members to appropriate community resources to address both their health and socio-economic needs. Web-based claims and eligibility resources provide physicians with on-line access to perform claims and eligibility inquiries.
The Company’s specialty services are a component of its healthcare enterprise. Its specialty services are provided through the eight businesses, which include Behavioral Health, Individual and State Sponsored Health Insurance Exchanges, Life and Health Management, Long-term Care and Acute Care, Managed Vision, Telehealth Services, Pharmacy Benefits Management and Care Management Software. Cenpatico Behavioral Health (Cenpatico) manages behavioral healthcare for members through a contracted network of providers. Cenpatico works with providers to determine the services to help people overcome mental illness and lead productive lives. Its networks feature a range of services and levels of care to help people with mental illness reach their recovery and wellness goals. In addition, it operates school-based programs in Arizona, which focus on students with special needs and also provide speech and other therapy services.
Celtic Insurance Company (Celtic) is a nationwide healthcare provider licensed in 49 states offering health insurance to individual customers and their families. Sold online and through independent insurance agents nationwide, Celtic’s portfolio of major medical plans is designed to meet the needs of the uninsured at all budget. Celtic also offers a standalone guaranteed-issue medical conversion program to self-funded employer groups, stop-loss and fully-insured group carriers, managed care plans, and health maintenance organizations (HMO) reinsurers. Nurtur Health, Inc. (Nurtur) specializes in implementing life and health management programs. Health risk appraisals, biometric screenings, online and telephonic wellness programs, disease management and work-life/employee assistance services are areas of focus. Nurtur uses telephonic health and work/life balance coaching, in-home and online interaction and informatics processes to deliver clinical outcomes and overall healthcare cost.
Bridgeway Health Solutions (Bridgeway) provides long-term care services to the elderly and people with disabilities, which meet income and resources requirements. Acute care services include emergency and physician and hospitalization services, limited dental and rehabilitative services and other maternal and child health services. OptiCare administers routine and medical surgical eye care benefits through its own contracted national network of eye care providers. OptiCare clients include Medicaid, Medicare, and commercial health plans, as well as employer groups. OptiCare offers a range of plan designs to meet the individual needs of its clients and members. NurseWise and Nurse Response provide a toll-free nurse triage line around-the-clock. Its members call one number and reach bilingual customer service representatives and nursing staff who provide health education, triage advice and offer continuous access to health plan functions. In addition, its representatives verify eligibility, confirm primary care provider assignments and provide benefit and network referral coordination for members and providers after business hours. Its staff can arrange for urgent pharmacy refills, transportation and qualified behavioral health professionals for crisis stabilization assessments.
US Script offers progressive pharmacy benefits management services. Services include claims processing, pharmacy network management, benefit design consultation, drug utilization review, formulary and rebate management, specialty and mail order pharmacy services, and patient and physician intervention. Casenet, LLC (Casenet) is a software provider of care management solutions, which automate the clinical, administrative and technical components of care management programs. It maintains a controlling ownership interest in Casenet and is implementing this new software platform, which is available for sale to third parties.
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