Applying A New Approach to
Managing Health Care Benefit
Costs
Community Health Networks

California Nonprofit Mutual Benefit Corporation

“Owned” by Member employers


Aligned interests with employer community
No provider, insurer, or MCO affiliation

No “ulterior” motives
Community Health Networks

Patient Centered Medical Home (PCMH)

Adherence to Evidence Based Protocols

Early intervention and screening

Culturally compatible outreach services

On-site pharmacies

Community based provider networks
Community Health Networks

Patient Centered Medical Home (PCMH)

Unique population health and utilization patterns

Unmanaged utilization patterns

35% of acute care physician visits occur through hospital
outpatient and emergency departments1

Clear need for a Primary Care patient system or structure
to provide early intervention and care management
services
1
Source: Health Affairs, September 7, 2010
Community Health Networks
Adherence to Evidence Based Quality Criteria
Source: Rand Corporation, New England Journal of Medicine
Community Health Networks

Patient Centered Medical Home (PCMH)

Identifiable physician or clinic relationship

Greater focus on prevention

Early identification and management of health problems

Compliance with Evidence Base Care Guidelines

Care management infrastructure and resources

Nurse Practitioners, Physician Assistants
Community Health Networks

Patient Centered Medical Home (PCMH)

PCMHs have quality improvement and quality assurance
components and monitor the quality of medical care they
provide

PCMHs significantly reduce emergency room visits and
hospitalizations

PCMHs are extremely effective at managing patients
with chronic conditions
Community Health Networks
Patient Centered Medical Home
Reduction in ER
Visits
Group Health Cooperative of Puget Sound (WA)
29%
Community Care of North Carolina (NC)
16%
HealthPartners Medical Group BestCare (MN)
39%
Genesee Health Plan HealthWorks (MI)
50%
John Hopkins Guided Care PCMH (MD)
15%
Source: University of California at San Francisco, Center for Excellence in Primary
Care, August, 2009
Community Health Networks
Patient Centered Medical Home
Reduction in
Hospitalizations
HealthPartners Medical Group BestCare (MN)
24%
Genesee Health Plan HealthWorks (MI)
15%
John Hopkins Guided Care PCMH (MD)
24%
Intermountain HealthCare Medical Group (UT)
10%
Geisenger Health System ProvenHealth (PA)
14%
Source: University of California at San Francisco, Center for Excellence in Primary
Care, August, 2009
Community Health Networks

Patient Centered Medical Home (PCMH)

“Quality of care, patient experiences, care
coordination, and access are demonstrably better.

Investments to strengthen primary care result within
a relatively short period of time in reductions in
emergency visits and inpatient hospitalizations that
produce savings in total costs.”1
1 Source:
University of California at San Francisco, Center for Excellence in
Primary Care, August, 2009
Community Health Networks

Patient Centered Medical Home (PCMH)

Value Based Purchasing:

“Increasing access to preventive and primary
care, and promoting better coordinated care and
care [delivered] in the right settings drives higher
quality care.”1
1
Source: Kathleen Sebelius, Secretary of Health and Human Services
Community Health Networks

Patient Centered Medical Home (PCMH)

Community Health Networks has partnered with
several community health organizations to
provide access to integrated primary care and
preventive services

National Health Services

Clinica Sierra Vista

Adventist Rural Health
Community Health Networks

Patient Centered Medical Home (PCMH)

National Health Services

Programs to provide a full range of primary and
preventive care services to serve rural hourly
worker population

10 clinics located throughout Kern County
Community Health Networks

Patient Centered Medical Home (PCMH)

Clinica Sierra Vista

Primary Care and Specialty programs including
child obesity, behavioral health, cancer detection,
and diabetes

14 clinics located throughout Kern County
Community Health Networks

Patient Centered Medical Home (PCMH)

Adventist Rural Health

Facilities provide primary care and specialty
medical services

17 clinic locations primarily in Northern parts of
the Central Valley.
Community Health Networks

Patient Centered Medical Home (PCMH)

Other Rural Health Clinic Partners

Delano Regional Medical Center

Kern Medical Center

Tulare District Hospital
Community Health Networks
Over 50 Clinic Locations Throughout
Southern and Central California
Community Health Networks

Adherence to Evidence Based Protocols

Prevalence of “gaps in care”

Only 45% of diabetic patients receive care that
complies with evidence-based protocols1

Only 54% of asthma patients receive care that
complies with evidence-based protocols1
1Source:
Rand Corporation, New England Journal of Medicine
Community Health Networks

Adherence to Evidence Based Protocols

Community Health Networks programs identify
these gaps in care through clinical programs
and data analytics

On-site preventive health screenings

Medical claims data

Prescription drug data

Eligibility files
Community Health Networks

Adherence to Evidence Based Protocols

Closing “gaps in care”

Gaps are closed through coordinated effort with
our Patient Centered Medical Home Programs

Outreach through face-to-face patient
advocacy programs

Disease-specific education programs
sponsored by health clinics
Community Health Networks

Adherence to Evidence Based Protocols

Care Gap Analysis and Clinical Intervention can
be implemented using:

CHN Network and PBM Program, or

Your current Network and PBM Program
Community Health Networks

Early intervention and screening programs

Current system and structures fail to adequately
address screening and early intervention

Only 55% of patients receive evidence-based
preventive care services1

Only 66% of patients receive appropriate
immunizations1

Only 18% of patients receive appropriate
counseling and education1
1Source:
Rand Corporation, New England Journal of Medicine
Community Health Networks

Early intervention and screening programs

Critical role of early identification and health
screening in managing population health and
health plan costs

Analysis of claims and population demographic
data, and

Work-site health screening through partnerships
with community stakeholders identify
opportunities for focused intervention
Community Health Networks

Culturally Compatible Outreach Services

Unique population characteristics give rise to
unique challenges

Perception regarding the role of health care

Lack of understanding of the health care system

Health care literacy deficit

Language barriers

Transportation issues
Community Health Networks

Culturally compatible outreach services

Outreach programs tailored to address
challenges

On-site health screenings and care gap analysis

Face-to-face Patient Advocacy

Transportation services

Targeted health care education programs

Multi-lingual services
Community Health Networks

On-Site Pharmacies

Key challenge to managing population health is
non-compliance with prescribed medication
regimes

Results in complications to chronic disease
states

Manageable chronic conditions become acute
episodes of care
Community Health Networks

On-Site Pharmacies

Community Health Networks on-site pharmacy
program includes pharmacy services through a
Federal program known as “340B”

Patients may fill and refill prescriptions at the
time and place of visit at qualifying clinics and
community pharmacies

Pricing for prescriptions drugs dispensed
through 340B pharmacies is 25% to 35% lower
than that available through most pharmacy
benefit manager programs
Community Health Networks

Community Based Provider Networks

Provider network tailored to meet the needs of
rural employers and their members

Focus on access to primary care services

Integration of specialty, ancillary and hospital
services with primary care

Core service area includes Kern, Tulare and
Kings counties

Full complement of facilities and services
Community Health Networks

Community Based Provider Networks

Provider network tailored to meet the needs of
rural employers and their members

25% to 35% greater Provider Network savings
compared to statewide plans1

Network access fees typically 50% lower
compared to statewide plans
1Based
upon repricing of $40 million in 2009-2010 paid claims
Community Health Networks
Patient Centered Medical Home
Program Description
Primary Care Services
Access to more than 50 Patient Centered
Medical Home clinics
Community Outreach Programs
Included with Patient Centered Medical
Home
Hands-On Clinical Management
Care Gap Analysis and Adherence to
Evidence Based Medicine Protocols
On-site Pharmacy Program
Access to preferred pricing at on-site and
community pharmacies
Available as an overlay to your current health care programs or in
conjunction with Community Health Provider Network
Community Health Networks
Comprehensive Provider Network
Program Description
Primary Care Clinics
Access to more than 50 primary care clinics
and more than 300 primary care
practitioners
Specialist Physicians
Access to more than 450 specialist
physicians
Ancillary Providers
Access to full complement of ancillary
providers
Hospitals
Access to hospitals in Kern, Tulare and
Kings counties
Available in conjunction with Patient Centered Medical Home
Community Health Networks

Next Steps

Needs Assessment and Review meeting with Employer,
Broker/Consultant and CHN

Typical follow-up items

Identification of disease state management opportunities

High level care gap analysis

Matching of CHN Programs with population needs

Claim network savings evaluation
Community Health Networks

For more information

Contact your Broker or Consultant

Contact Community Health Networks

Derek Tefft, Director of Operations

877-830-7470 or dtefft@centralcaliforniaehc.org