A Managed Care Organization for the Entire Family
PPC to Advicare: Making the
Transition
Presented to: Office of Rural Health
July 23, 2013
Medicaid Update
Company Structure
Organizational Chart
Board of Directors
May/June, 2013
Ken Meinke
CFO
Harold Moore
CIO, Information Services
Clara Figueroa
Administrative. Assistant
Gerald Harmon, MD
Medical Director
Mikki Barrett, BSN, RN
Director, Care Management
Bea Prashad, RN, BSN,
MBA, CNOR
Team Leader, Care
Management
1.Donna Steele, LPN,
2.Rhonda Dowie, RN
Case/Disease Management
Deryl Macaulay, RN
Utilization Management
LaTasha Bomer, LMSW
Social Work
Kisha Price
Director, Claims and
Provider Data Management
1.Sherrie Marrapode
2.Dilsa Bailey
3.Raquel Soto
Provider Credentialing
1.Nikki Moore
2.Shanitha Robinson
3.Yvonne Bishop
Claims Service Center
Patrick Caster
President
Cesar D. Martinez, MBA, MPA
Executive Director, Advicare
CEO, PPC Health Plan Management
Kathryn Gailey, JD, MPH
Compliance Officer
Dell Jeter
Director, Network Management
Kisha Price
Director, Customer Service
Mary Wasden, MBA
Manager/Team Leader,
Provider Relations
Flavia Figueroa
Team Leader,
Customer Service
1.Kelli Williamson
2.Joan Reeves
3.Jeanne Watson
4.Pam Boyd
5.Jodi Key
6.Wendy McCrea
7.Neshelle Miller
8.Pat Rubio
Provider Relations
Representatives
Tandi Card, JD
Director, Compliance
and Human Resources
Toni Hunter
Manager, Training
and Human Resources
1.Karen Cantrell
2.Yesenia Perez
3.Ruto Soto
4.Charlene Carter
Customer Service
Representatives
Open
Appeals & Grievance
Coordinator
Joe Lowry, CPA
VP, Finance, Administration
Open
Quality Management
Open
Associate Medical Director
2
Medicaid Update
DHHS / Medicaid Update
Medicaid Update
Data Source: SCDHHS, July 2012
3
Medicaid Update
236,000
ACA Expansion
Potential New Membership
170,000 205,000
Eligible Under Current
Medicaid Rules
Will Enroll In
Medicaid Managed Care
Per Individual Mandate
Data Source: SCDHHS and Milliam, July 2012
4
Medicaid Update
SCDHHS meets promise to insure more poor
children through ‘Express Lane’ eligibility
Posted Thu, 10/04/2012 - 10:22
COLUMBIA, S.C.— Approximately 65,000 children who
are currently eligible for South Carolina’s Medicaid program
but are not signed up will be enrolled and immediately able to
receive services through a coordinated care health plan, the
South Carolina Department of Health Human Services
(SCDHHS) announced Thursday.
Data Source: SCDHHS, October 2012
5
Company Update
Company Overview
and Update
Company Update - Goals
1) Accessible, comprehensive, family centered, coordinated care.
2) Provide a medical home with a primary care provider 
manage the patient’s health care,

perform primary and preventive care services,

arrange for any additional needed care, and,
Connecting
Patients to their
 focus on the physician-patient relationship.
Medical Home
3) Patient access to a “live voice” 24 hours a day, 7 days a week to ensure appropriate
care.
4) Patient education regarding preventive and primary health care, utilization of the
medical home and appropriate use of the emergency room.
7
20,225
Members Statewide
July Effectives
Company Update -Membership and Outreach
No Complaints to Medicaid – Mar ‘11 to Current
18,000
16,542
16,149
15,595
14,883 15,006
14,474
14,476
14,435
13,562 13,600
13,299
EQRO Audit
92%
16,000
14,000
12,293 12,548
11,735
12,000
SCDOI: Approves
HMO License
10,709
9,519
10,000
8,651
8,000
Readiness
6,000Review 87%
6,294
5,384
Approved in
46th County
CMS Approves Model of
Care/Ops Manual for 3 Years
SRHS Acquisition
of PPC
4,250
4,000
3,268
2,341
2,000
1,098
319
-
Start-Up
8
20,225
Members Statewide
Jul 1 Effectives
Service Area - Driven by Provider Network
Primary Care
Contracted
Family/General Practice
Internal Medicine
Pediatrics
PCP Total
Speciality
Contracted
Allergy and Immunology
Anesthesiology
Audiology
Cardiology
Chiropractor
Dermatology
Durable Medical Equipment
Emergency Medical
Endocrinology and Metab
ENT/Oto-laryngology
Gastroenterology
General Surgery
Gynecology, OB/GYN
Hematology/Oncology
Home Health
Infectious Diseases
Infusion Therapy**
Laboratory Services
Licensed Independent Social Workers
Licensed Marriage & Family Therapist
Licensed Professional Counselor
Neonatology
Nephrology
Neurology
Neurosurgery
Oncology - Medical, Surgical
Oncology - Rad/Rad Oncology
Ophthalmology
60
106
2
129
19
12
103
83
10
26
60
48
173
60
17
15
17
15
6
3
16
104
29
22
24
88
Specialist Total
TOTAL PROVIDERS
674
291
574
1,539
Speciality
Optometry
Orthopedic
Orthopedic Surgery
Orthotics/Prosthetics
Otorhinolaryngology
Pediatrics, Cardiology
Pharmacies*
Physiatry, Rehab Medicine
Plastic Surgery
Podiatry
Private Occupational Therapy
Private Physical Therapy
Private Speech Therapy
Psychiatry
Psychologist
Pulmonology
Radiology, Diagnostic
RHC's/FQHC's
Rheumatology
Surgery--Cardiovascular
Surgery--General
Surgery--Neurological
Surgery--Pediatric
Surgery--Plastic
Surgery--Thoracic
Urology
Vascular Surgery
Contracted
61
5
83
43
9
3
1,306
8
11
24
25
79
43
132
2
68
99
64
16
5
51
3
9
5
22
1
3,424
4,963
2
Tenet
Hospital Contracting
As of 07/09/2013
Phase 4
HCA
Phase 3
Phase 2
Phase 1
Tenet
4
Innovation in Care Coordination
Innovation in Care Coordination:
System Features and Sample Screen
Shots of Web Based System Available
to Providers and PPC Staff
CLOUD SYSTEM
1. NCQA HEDIS &
P4P Certified
Innovation in Care Coordination
1) Care Coordination and Case Management.
2) Disease Management
Care
Management
3) Pharmacy Management
4) Service Referral Management
Use of Evidence-based
Clinical Practice
Guidelines and Protocols:
National Guidelines
Clearinghouse™ (NGC)
www.guideline.gov.
5) Tracking of services provided to members
Quality
Management
Customer
Service
6) Oversight and Clinical Risk Identification
7) Outcomes measurement and data feedback
System integrates
Interqual Medical
Guidelines
8) Member Enrollment, Education and Outreach
9) Provider Contracting, Education and training on evidence-based medicine
10) Performance tracking & reporting (financial, medical, quality & enrollment)
Medical
Economics
11) Distribution of care coordination fee to participating physicians
12) Shared Savings for Participating Providers – No Downside Risk
18
PIPs
NCQA QI Format
Innovation in Care Coordination – 2012 PIPs
PIP
Goal
Results
1. Maternity Initiative (SBIRT)
Improve Quality &
Lower Mater./NICU Cost
1. Decreased Costs in
‘12 by $3.50pmpm
2. Prenatal & Postpartum
Care HEDIS ~ 90%
percentile; State is < 25%
2. Child Immunizations
(EPSDT/Well-Child)
75th Percentile of HEDIS
Over 4K Outreach - Led
~ 40% Improvement Over
Baseline (CY 2011)
3. Pediatric Asthma
Decrease Asthma Admits
Admits / 1,000 dropped to
2.8 from 9.3 in ‘12 over ‘11
4. Member Recertification
At or Better than
5% Disenrollment
Disenrollment Rate
dropped to 8% from 11%
19
Risk Level
Improvement
Innovation in Care Coordination – Risk Profile
Membership Profile - As of 1Q2012
Sex
Female
Male
No-Level
Level 1
Level 2
Level 3
All Others
DM Candiates
CM Candidates
Complex CM Candidates
Low Risk Risk Score 2.0 thru 4.99 Risk Score 5.0 thru 9.99 Risk Score 10 or Greater
5,730
657
81
122
4,817
227
39
63
TOTAL
10,547
884
120
185
Percent
90%
8%
1%
2%
Total
Membership
6,590
5,146
11,736
100%
Membership Profile - As of 1Q2013
Membership by Sex and Risk Level
Membership as of March 2013
No-Level
Level 1
Level 2
Level 3
Total
All Others
DM Candidates
CM Candidates
Complex CM Candidates Membership
Sex
Low Risk Risk Score 2.0 thru 4.99 Risk Score 5.0 thru 9.99 Risk Score 10 or Greater
Female
7,807
1,268
211
29
9,315
Male
6,561
562
162
35
7,320
Total
Percent
14,368
86.37%
1,830
11.00%
373
2.24%
64
0.38%
16,635
100.00%
20
Innovation in Care Coordination
Provider Monthly Panel for Patients to PCPs with Risk Score
PCP Panel Group Report
Month of Enrollment
Group Name:
Mar, 2011
Family Medicine Center
Group Number:
GP1234
Total Members:
3
Per Member Case Management Fee:
$
2.50
Total Case Management Fee:
$
7.50
Risk Score: A measure of the members' severity / illness burden based on claims history. The mean Risk score across the population is 1.0. The
.
higher the score above the mean the higher the severity / illness burden of the member.
Medicaid ID#
Plan Begin
Date
DOE JOE
1234567891
3/1/2011
DOE JOE JR
1234568667
DOE JANE
1234569444
Member Name - Last, First
Phone
Number
Sex
Age
Risk
123 First Street, Irmo, SC 29063
8031234567
M
44
1.02
3/1/2011
321 Main Street, Irmo, SC 29063
8032224567
M
3
0.75
3/1/2011
777 Second Ave, Irmo, SC 29063
8031234444
F
26
2.51
Member Address
PPC shares with its PCPs a monthly panel report with the patient risk score for
each member assigned to the PCP. This allows the PCP and PPC to target the
most severely ill members and those that are predicted to have high risk burdens.
21
Innovation in Care Coordination
Innovative Technology : Identify HEDIS / Care Gaps and High Utilizers
“Point and Click”
Identify All Quality
Measures and Members
Non-Compliant with
HEDIS
“Point and Click”
Identify All ER Utilizers
and Patients with High
Service Utilization
22
Innovation in Care Coordination
Innovative Technology : 360 Degree View of Info on Enrollees
“Point and Click”
Care Plans with Problems,
Goals, Interventions
“Point and Click” Enrollee Info at Finger-Tips for Providers and PPC Staff
Full Glance of Enrollee, Clinical Profile, Medical Records, Conditions, Self Reported
Info, Vitals, Notes, Quality History, Quality Management, Quality Measures,
Care Management, Assessments, ER Visits, Hospital Admission
23
Innovation in Care Coordination
Innovative Technology : Clinical Profile and Predictive Model on Members
“Point and Click”
“Point and Click”
“Point and Click”
“Point and Click”
Predicts Probability of
Hospital Admission
Predicts Cost for Next
12 Months
Total Current Costs
Of Patients
List Chronic Conditions
On Patients
“Point and
Click”
Tells You If
Condition
Is Being Treated
24
Innovation In Care
By end of 2012 launch PPC/MedHOK system via
provider portal to select IPAs/groups to enhance
care coordination.
Every Member in the programs gets a full
Comprehensive Patient Clinical Profile Report.
This Comprehensive Patient Clinical Profile Report
will / can be shared with other providers and will
help the patients’ PCP provide the capability to target
individual members for inclusion in care
management programs.
Because our system uses predictive modeling, our
reporting content leverages the predictive modeling
methodology and care opportunities to support high
risk member identification, provider effectiveness
reporting, and patient risk profiles.
Advicare Risk Adjusts All Members and Performs Predictive Modeling
25
SCDHHS Quality Initiatives
• Patient Centered Medical Homes (PCMH)
– NCQA Application Phase ($0.50)
– NCQA Level I ($1.00)
– NCQA Level II ($1.50)
– NCQA Level III ($2.00)
• Centering Program
• Nurse Family Partnership
• Screening Brief Intervention & Referral to
Treatment (SBIRT)
Wrap Around Payments
• Advicare has been
working with SCDHHS
and SCDHHS is
committed to making
wrap payments in a
timely manner.
• Advicare is committed
to ensuring that all
encounter data is
submitted to the state
in a timely manner. We
are also committed to
working with the clinics
to ensure our patients
get the best quality of
care.
Website : www.AdvicareHealth.com
1.
2.
3.
4.
5.
6.
7.
8.
On-Line PCP Directory
Provider Manual
Clinical Guidelines
Clinical Action Plans
Drug Look-Up
Pharmacy Look-Up
Download Forms
Member Benefit
Information
9. Member Enrollment
10. Receive News &
Updates
26