Partnering for Success: How Great Collaborations
CAN Produce Quality Results
© BHM Healthcare Solutions 2013
Presentation Overview
Opening Warm Up Exercise
The Great Potential for Change & The Current Problems With Our
Healthcare System
Why MCO Provider Partnership is the Answer
Break
Barriers and Opportunities
Steps to Foster Great Provider/MCO Collaboration
© BHM Healthcare Solutions 2013
Presentation Objectives
• The goal of today’s presentation is not merely to speak to you,
the audience, but to create a dynamic environment where
learning and collaboration can flourish
• Throughout this presentation we will be stopping periodically to
take part in some group exercises and activities
• Each of these activities has been created with the goals of
gaining insight into the MCO/provider perspective, create an
environment of learning where you can begin to understand the
steps needed to foster dynamic collaboration, and help to
identify barriers to collaboration that exist in the system
• Of course we will talk a little….but not too much….let’s get
started!
© BHM Healthcare Solutions 2013
Group Introduction
• Let’s take a moment to get to know one another
What is your name?
Are you a provider, MCO, or other?
If you had to describe healthcare today in one
word, what would that word be?
© BHM Healthcare Solutions 2013
Group Introduction
What did we learn?
© BHM Healthcare Solutions 2013
Group Introduction
• Now that we have had a chance to learn a bit more about
one another, let’s talk a bit about why we are all here
Because healthcare in this
nation is changing and we
are part of the change
Because we need to create
goal alignment so that we
can all work together for
future success
© BHM Healthcare Solutions 2013
Because we understand
that there are challenges in
today’s dynamic healthcare
environment and we are
committed to overcoming
these obstacles
THE GREAT POTENTIAL FOR
CHANGE & THE PROBLEMS
WITH OUR CURRENT
HEALTHCARE SYSTEM
© BHM Healthcare Solutions 2013
The Great Potential for Change
• Never before in the U.S. healthcare industry has there
been such an atmosphere of change, or such an
opportunity to improve the healthcare system
• Industry movements such as healthcare reform, the
creation of MCOs/ACOs, expanded healthcare coverage,
integrated care, and innovative pilots taking place
nationwide hope to accomplish the following goals:
Improve care
outcomes
Remove
barriers to
treatment
Align
payments with
quality
© BHM Healthcare Solutions 2013
Decrease cost
of provision of
care
The Great Potential for Change
• Every individual in this
room, as part of the
healthcare industry,
plays an important part
in the success of this
change, and the
accomplishment of
these goals
© BHM Healthcare Solutions 2013
The Great Potential for Change
• Whether a Managed Care
Organization (MCO)
associate, or a provider
partnered with an MCO,
each of you has the
potential to impact the
delivery of healthcare for
todays consumers and
contribute to realizing the
goals of change and
reform – but this cannot be
accomplished alone
© BHM Healthcare Solutions 2013
The Great Potential for Change
• To create the most impact,
and to truly realize the
potential of improved care
which is more cost
effective, it is critical for
providers and MCOs to
facilitate collaboration,
innovation,
communication, and
meaningful partnerships to
drive this change
Communication
Meaningful
partnerships
© BHM Healthcare Solutions 2013
Innovation
Collaboration
Is it That Easy?
• …..But the traditional perspective of MCOs and providers as
adversaries can inhibit this collaboration
• Today we will focus on why the current healthcare system does
not work, why MCOs have the greatest potential for realizing the
goals of reform, and how providers as true partners are
essential to this success
• We will examine the traditional adversarial viewpoints of
providers vs. MCOs, and examine how we can create a culture
of collaboration and respect through realizing that we are all
driving toward a singular goal
• Finally we will examine how some innovative programs which
create meaningful provider/MCO partnerships have shown that
permanent, positive change can take place in healthcare
© BHM Healthcare Solutions 2013
The Problems with Healthcare
Segmented
noncoordinated
care
Volume not
value
emphasis
Lack of
access to
providers
Underinsured
or non insured
Misaligned
payment
incentives
Unsustainable
cost
Poor
Outcomes
© BHM Healthcare Solutions 2013
Unsustainable Cost
The United States spends
more per capita on
healthcare than any other
country
• Per capita spend in the U.S. is over $8k compared with
spend in France, the second highest spend, which is
just over $5K
• U.S. spends nearly double the average ($3,923) than 15
other healthcare countries
In addition, the healthcare
spending growth rate in the
United States is one of the
highest in the world and is
rising far faster than overall
economic growth
• Healthcare spend was 9% of the GDP in 1980, and
more than 16% of GDP in 2008
• This 7% point increase is one of the highest of any
developed country
Despite this, the United
States does not achieve
better outcomes for many
important health measures
• The World Health Organization ranks the U.S.
Healthcare system 37th in the world out of 191
countries, and the U.S. has one of the lowest rankings
of any developed country
© BHM Healthcare Solutions 2013
Unsustainable Cost
© BHM Healthcare Solutions 2013
Unsustainable Cost
• Total Health Expenditure per Capita and GDP per Capita,
US and Selected Countries, 2008
© BHM Healthcare Solutions 2013
Unsustainable Cost
• Growth in Total Health Expenditure Per Capita, U.S. and
Selected Countries, 1970-2008
© BHM Healthcare Solutions 2013
Unsustainable Cost
• Total Health Expenditure as a Share of GDP, U.S. and
Selected Countries, 2008
© BHM Healthcare Solutions 2013
Poor Outcomes
•
Despite a significant healthcare spend the U.S. has low life
expectancy rates, the world’s highest obesity rates, and premature
birth and mortality rates for infants which are significantly higher than
their counterparts
© BHM Healthcare Solutions 2013
Poor Outcomes
© BHM Healthcare Solutions 2013
Poor Outcomes
© BHM Healthcare Solutions 2013
Poor Outcomes
© BHM Healthcare Solutions 2013
Lack of Care Coordination
• Besides high cost and poor quality outcomes, lack of care
coordination remains an obstacle to effective care in the
U.S. healthcare system which is often fragmented in
nature
• At the illness level, the Institute of Medicine studies show
that within any given hospital many medical errors result
because of lack of effective data sharing and coordination
• At the patient level, the average Medicare beneficiary sees
two physicians and five specialists per year – those with a
chronic illness see an average of thirteen physicians per
year
© BHM Healthcare Solutions 2013
Lack of Care Coordination
No Coordination
Coordinated Care
• Results in poor outcomes
• Drives up admin and overall
healthcare costs
• Greatly increases the risk of
medical errors
• Decreases treatment
adherence
• Is a substantial
mental/behavioral health
barrier
• Results in better outcomes
• Decreases overall
healthcare spend
• Increases treatment
adherence and improves
patient satisfaction
• Reduces risk of errors
• Creates a comprehensive
plan to treat the whole
patient
© BHM Healthcare Solutions 2013
Misaligned Payment Incentives
• Adding to the challenges of the current healthcare system
is the misalignment of payment incentives which are
present in the fee-for-service (FFS) system
More services
Less coordination
Stifles innovation
Only pays for
selected services not email, group
visits, phone calls
Incentives for
duplication
Few incentives for
prevention
No link to quality
Incentives to
increase high profit
services/patients
and avoid low
profit
© BHM Healthcare Solutions 2013
Volume not Value Based
•
•
The need to address payment misalignment has resulted in the shift toward
value rather than volume based care
Examples of value based care include both bundled payments and capitated
payments, as well as programs which reward and penalize organizations
financially through payment increases and decreases based on performance
Provision of
care which
produces
optimal
outcomes
Provision of
optimal
outcomes in
the most cost
effective way
possible
Provision of
optimal
outcomes
while ensuring
highest levels
of patient
satisfaction
© BHM Healthcare Solutions 2013
Value based
care which
provides the
right care at
the right time,
in the right
setting
Lack of Provider Access
• Provider access continues to plague many consumers
• Lack of available providers in rural areas
• Lack of available providers due to physician shortage
• Lack of available providers for some specialties (such as
psychiatry)
• Lack of access can also be attributed to other obstacles
•
•
•
•
Lack of knowledge on how to navigate the healthcare system
Lack of appropriate coverage
Delays in receiving appropriate care
Inability to gain access to preventative services
© BHM Healthcare Solutions 2013
Lack of Provider Access
• Impacts of lack of access:
Overall physical,
social, and
mental health
status
Prevention of
disease and
disability
Detection and
treatment of
health conditions
Preventable
death
Life expectancy
Quality of life
• Barriers to accessing healthcare leads to:
Unmet health
needs
Delays in
receiving
appropriate care
Inability to get
preventive
services
Hospitalizations
which could have
been prevented
© BHM Healthcare Solutions 2013
Escalated
medical costs
Poor quality
outcomes
Underinsured or Non-Insured
• Until recently the U.S. was the only developed nation
which did not provide healthcare coverage for its citizens
• The Affordable Care Act promises to change this, by
providing healthcare coverage to individuals which meet
minimum standards
• Many more people will become Medicaid/Medicare eligible
• Those who are not will be able to purchase insurance through
exchanges which offer a subsidy to offset cost making insurance
more affordable
Now is the time to work on perfecting the healthcare delivery system before
more global changes take place, and the volume of covered lives greatly
increases under ACA
© BHM Healthcare Solutions 2013
Uninsured or Non-Insured
© BHM Healthcare Solutions 2013
Uninsured or Non-Insured
© BHM Healthcare Solutions 2013
Underinsured or Non-Insured
•
•
•
In a report released by the North Carolina Institute of Medicine, based on
census information the following is the volume of uninsured individuals in the
state of North Carolina
Group
Number of Uninsured
Children (0-18 yrs)
214,000
Adults (19-64)
1,314,000
Total
1,562,000
In certain counties the rate of uninsured is considered “high” and represents
8.8% to more than 10% of the total population. These counties include;
Alamance, Chatham, Duplin, Durham, Edgecombe, Forsyth, Greene, Halifax,
Hertford, Hoke, Lee, Lenoir, Mecklenburg, Montgomery, Robeson, Sampson,
Swain, Tyrell, Vance, Warren, Washington, and Wayne
Early Health Insurance Exchange reports indicate that 90% of those gaining
coverage are Medicaid eligible, even without expansion this constitutes a
significant amount of newly covered…..are you prepared for the volume?
© BHM Healthcare Solutions 2013
The Outlook is Not Dismal
• Healthcare reform is taking place on both the State and
Federal level and we are part of the movement
• Specific reforms and legislation have been created to
address each and every one of todays healthcare
obstacles
• Despite other delivery methods, the Managed Care
Organization – Provider Partnership has the greatest
potential to bring about real and lasting change
• Our industry is dynamic, it is an imperative that we begin
nurturing collaboration and fostering partnerships now in
order to serve the needs of our state’s healthcare
consumers
© BHM Healthcare Solutions 2013
MCO Provider Partnership
Addresses Healthcare Challenge
Unsustainable Cost
• Addressed by Per Member Per Month Payments which
drive healthcare cost efficiency
Misaligned Payments
• Creation of value metrics, and quality measurements
and monitoring
Uninsured
• Responsive assistance to population at the provider
level that helps individuals navigate care system
Volume vs. Value
• Transition from volume based fee for service to value
emphasis to provider best outcomes
Non-coordinated care
• Dedicated care coordinators and case managers that
assist consumers in getting coordinated effective care
Lack of Access
• Responsive provider network which meets required
access to care requirements
© BHM Healthcare Solutions 2013
Your Mission
To work to drive
healthcare change for
the consumer
To do your part in
creating a healthcare
system that is cost
effective and
sustainable
To dedicate yourself to
the fight for a better
healthcare system that
works for all of us
To believe that through
partnership and
collaboration we can
make a difference in the
lives of the consumer
© BHM Healthcare Solutions 2013
To realize that change
can only be brought
about if we are all
partners working toward
a common goal
In Case You Not Inspired Yet…A
Quick Motivational Speech
© BHM Healthcare Solutions 2013
MCO PROVIDER
PARTNERSHIPS: VEHICLE
FOR DYNAMIC CHANGE
© BHM Healthcare Solutions 2013
Why MCOs Are the Answer
• States, providers, and
MCOs working together to
provide Medicaid services
have a proven track record
nationally of improving
care coordination,
enhancing consumer
satisfaction, promoting
cost effective services,
and controlling health care
costs
Improving
care
coordination
Enhancing
consumer
satisfaction
Promoting
cost
effective
services
Controlling
health care
costs
© BHM Healthcare Solutions 2013
Why MCOs Are the Answer
• The MCO model is the only model which simultaneously
offers the opportunity of providing high quality patient
centered care, while still allowing for budgetary
predictability and full accountability
• Other pilot models (ACOs, health homes, and patient
centered medical homes) improve integration of care, but
do so in a fee for service environment
• Only MCOs offer the full continuum of integration and the
highest potential for cost savings
• Additionally, MCOs models have far surpassed other
models in terms of the capability to have systematic quality
measurements implemented
© BHM Healthcare Solutions 2013
Why MCOs are the Answer
• In the past 15yrs Managed Care has become the
predominant form of healthcare in the United States
• All states except Alaska and Wyoming have all or a portion
of their Medicaid population enrolled in a Managed Care
Organization
• Between 1991 and 2005 Medicaid Managed Care
Enrollment grew by more than 900%
• More than 27 million Medicaid eligible consumers are
currently enrolled in a Managed Care Organization
• 20 out of 25 states participating in the Duals Alignment
Demonstration program have opted for the capitated
model over fee for service
© BHM Healthcare Solutions 2013
The Future of Healthcare
Reform
© BHM Healthcare Solutions 2013
How Dramatic Will the Change
Be?
•
“The transformation dynamic is
provocative, characterized by both
the challenges related to an
unprecedented competitive
landscape and the fact that the
regulatory environment at all levels
will only grow more difficult to
anticipate and
manage….organizations
demonstrating the ability to drive
savings through the ecosystem
while raising quality should be able
to position themselves for a
significant “commission” on those
results”
- Ed Giniat, National Sector Leader,
Healthcare & Pharmaceuticals
© BHM Healthcare Solutions 2013
The Future of Healthcare
Reform
How we Pay for Care
How Care is Organized
How Care is Delivered
•
•
•
•
•
•
•
•
•
•
• Center for Medicare/Medicaid
Innovation
• Comparative effectiveness
• Care teams across multiple sites of
service
• Electronic Health Records
• Care Transitions
• Improved Dual Eligible Coordination
Payment reductions
Bundled payments
Shared savings
Value-based payment
Independent payment advisory
board
Accountable Care Organizations
Medical Homes
Managed Care Organizations
Episodes of care
Health Insurance Exchange
© BHM Healthcare Solutions 2013
Managed Care In North Carolina
© BHM Healthcare Solutions 2013
Changes Still to Come
•
Affordable Care Act (ACA) is a law created in 2010 that strives to
make preventative care – including family planning and related
services - more accessible and affordable for Americans by expanding
Medicaid Coverage and creating new Affordable Insurance
Exchanges. It consists of three separate pieces of legislation:
The Patient
Protection and
Affordable Care
Act; and
•
•
The Health Care
and Education
Reconciliation
Act; and
Taxpayer Relief
Act of 2012
This Law will continue to greatly impact the healthcare industry
including providers, MCOs and consumers in the years to come
While some provisions of the law have already taken effect, many
more provisions will be implemented in the coming years with large
changes anticipated beginning Jan. 2014.
© BHM Healthcare Solutions 2013
45
Changes Still to Come
• There are currently 1.5 Million uninsured individuals in the
state of North Carolina who will soon be flowing into the
healthcare delivery system – not including the
underinsured – many of which will be Medicaid recipients
• Estimates indicate that 24.3% of individuals in the state, at
a minimum, will be covered once healthcare reform is fully
implemented in 2019
• Expenditures are expected to increase by as much as
49.7% - not including co-morbid medical conditions that
exist in the Medicaid populations with mental illness
© BHM Healthcare Solutions 2013
Changes Still to Come
© BHM Healthcare Solutions 2013
Changes Still to Come
• Medicaid members with behavioral health disorders are
expected to account for approximately 31.9% of the
expected increase in total Medicaid expenditures
© BHM Healthcare Solutions 2013
Changes Still to Come
2010
Expansion of
Medicaid Rebate
Reduction of
Medicare Retiree
Drug Subsidy
established
2011
Coverage for
preventative and
in-home services
Significant rebates
to close doughnut
hole
2012
MLRs take effect
ACO shared savings
with CMS
Reduced rebates for
Medicare Advantage
W2 reporting for
health coverage
Industry fees begin for
pharmaceuticals
Quality Based
Reimbursement
2013
2014
Higher Medicare
tax on high income
individuals
Health Insurance
Exchanges
Expansion of
bundled payments Rating rules
© BHM Healthcare Solutions 2013
implemented
Coverage mandates
and subsidies
Medicaid expansion
Health Insurance
Industry fees begin
The Potential of Managed Care:
Care Coordination
• One of the largest benefits of MCO organization is the
requirements imposed on each MCO to provide provider
networks which consist of the right types, and sufficient
numbers of providers to allow for optimal consumer access
to services
• Care Coordination if a fundamental part of this care and
results historically in lower rates of inpatient utilization, ER
utilization, and all cause readmissions relative to FFS
members
• MCO consumer satisfaction ratings are superior to those
of FFS models, as well as HMO models nationally, with
satisfaction ratings 8% higher than other delivery models
on average – attributed directly to coordination of care
© BHM Healthcare Solutions 2013
The Potential of Managed Care
• This underscores an important point:
MCOs are dependent upon the providers in
their network to fulfill their mission in relation to
access of care and care coordination.
© BHM Healthcare Solutions 2013
The Potential of Managed Care:
Quality
• MCOs must adhere to some of the most rigid quality and
performance measurements in the industry. This provides
accountability for care being provided and allows us to
work toward the value/cost balance that we are striving for.
Accreditation
Requirements
(NCQA, URAC)
HEDIS
Measures
External Quality
Review
CAHPS metrics
Patient
Satisfaction
Surveys
© BHM Healthcare Solutions 2013
Ongoing PIP
and QI projects
Provider
Satisfaction
Surveys
The Potential of Managed Care:
Cost Control
• According to a 2012 study, Managed Care hospital
readmission rates were 22% lower than traditional FFS
• An analysis of 24 separate state Managed Care programs
showed savings of up to 22% compared to traditional FFS
Cost savings generated
via a steady PMPM
contract
States afforded
budgetary predictability
to provide population
care
© BHM Healthcare Solutions 2013
MCO absorbs costs of
extreme illness and
injury
The Potential of Managed Care:
Cost Control
•
•
…..However, the goal here is not just to reign in costs, but to do so
without impacting the quality of care – in fact the goal is to improve the
quality of care via optimized outcomes
The MCO accomplished this, in partnership with the provider via the
following:
Ensuring timely
access
Ensuring high
quality care (that
which is medically
necessary)
Emphasizing
prevention rather
than treatment
Maintaining
consumer access
to broad provider
network
© BHM Healthcare Solutions 2013
The Potential of Managed Care
vs. Other Delivery Systems
•
•
While ACOs and PCMHs offer integration capability, they lack proven
demonstrated capability in quality measurements
ACOs can only impact those providers participating with the ACO –
they cannot impact the large swaths of the population that MCOs
impact, and they often do not coordinate care outside of the ACO
Only MCOs offer full
continuum of
integration
MCO impact larger
number of
consumers
MCOs have tighter
state mandated
financial control =
cost savings
© BHM Healthcare Solutions 2013
MCOs have proven
record of measuring
quality and impacting
outcomes
Ok, Let’s Summarize
•
•
•
•
We know that there is a problem with the current healthcare system
We know that healthcare has significant system barriers
We know that MCOs working with providers can address these
healthcare issues – in fact MCOs have more potential than any other
healthcare model to bring about positive change
We understand that partnership between MCOs and Providers is
critical
….But how do we get there, and how do we
create great collaborations between groups
which often have opposing viewpoints?
•
This will be our focus during part two of this presentation, after a brief
break
© BHM Healthcare Solutions 2013
BARRIERS AND
OPPORTUNITIES
© BHM Healthcare Solutions 2013
Partnership Cannot Work
Without MCOs and Providers
• The goals of healthcare
reform cannot be
accomplished without
MCOs and Providers
• MCOs and Providers are
equal in terms of
importance in realizing the
goals of healthcare reform,
and success of both
parties is interdependent
MCOs must have
an appropriate
provider network
which can ensure
access to timely
high quality care
© BHM Healthcare Solutions 2013
Providers are
dependent upon
the MCO
relationship for the
volume of
Medicaid/Medicare
patients treated by
their practice
Understanding the Other Side
• Sage words from Anna North, Contract Manager,
Eastpointe
This is the direction that NC
has decided to pursue
This has to be successful;
consequences of failure do
not benefit the State,
providers, or the LMEs
To be successful we have
to navigate the obvious
conflicts and maintain
productive relationships
Relationships are better
built before the crisis
© BHM Healthcare Solutions 2013
Managed Care Responsibilities
• Monitor and coordinate care through the entire range of
services (primary care through tertiary)
• Emphasize prevention and health education as part of
population health management
• Encourages the provision of care in the most appropriate
setting and by the most appropriate provider
• Ex. Outpatient clinics vs. inpatient setting, PC provider vs.
specialist
• Promotes cost effective care through aligned incentives
• Capitation of providers, cost sharing by consumers, etc.
© BHM Healthcare Solutions 2013
Managed Care Strategies
• Managed care has undergone significant shifts in how it
works to accomplish goals of cost effective quality care
Early Managed Care Strategies
New Managed Care Strategies
• Restrictive pre-authorization
• Disease management
• Aligning incentives
• Prevention
• Consumer education
© BHM Healthcare Solutions 2013
NC Specific Managed Care
Strategies
Care Coordination
Flexible Rate Setting
Limitation of Provider Network
Utilization Management
Re-investment of savings to expand services
Utilization of data to manage the system
Focus on consumer outcomes (Provider Report Card)
© BHM Healthcare Solutions 2013
Mechanisms to Achieve Savings
• Improving access to preventive and primary health care
though standards for hours of operation, availability, and
acceptance of new patients
• Investment in enrollee outreach and education to promote
utilization of preventive services and health behaviors
• Provision of medical home to an individual and utilizing
MD expertise to refer patients to appropriate care setting
• Individualized case management and disease
management services
• Utilizing lower cost services when available and clinical
appropriate
• Conducting provider profiling and enhancing provider
accountability for quality and cost
© BHM Healthcare Solutions 2013
Cost Savings Opportunities
• Structural challenges of coordinating care and controlling
costs inhibit savings in a FFS environment
• Unstructured system
• Incentives to provide as many services as possible
• Little motivation to manage mix and volume of services effectively
• Managed Care eliminates this problem by creating a single
system which coordinates the financing and delivery of
healthcare
• Incentives to coordinate care
• Reduction of cost of inpatient and other expensive health care
services
• Alignment of “right care, right setting, right time” theory
• Enables data flow for population health management
© BHM Healthcare Solutions 2013
Cost Savings
• Structural changes
centered around the
expansion of managed
care have been the
major transformative
force in health markets
in recent years and
have played a major
role in restraining
growth in health
spending
© BHM Healthcare Solutions 2013
Cost Savings
• US consumers have not yet understood the effects of
unrestrained spending on medical treatment – 62% of
respondents in a survey indicated that health plans should
pay for medical treatment even if the cost was $1M per
person
• Providers are accustomed to the autonomy in the fee for
service model, and may find it challenging to deal with
restrained resources
• Purchasers will need to explore innovative ways to deliver
cost effective care, and must ensure that quality is not
sacrificed in order to retain provider and consumer buy in
© BHM Healthcare Solutions 2013
Provider Cost Challenge
• When managed care processes are overlaid on an already
complex reimbursement system the following challenges
arise:
Multiple authorization
procedures without
consistency
Disjointed
collaboration between
providers and other
providers both in and
out of MCO network
Complex revenue
stream being
generated from
multiple sources
Reimbursement rates
and protocol which
vary significantly by
payer
© BHM Healthcare Solutions 2013
Quality of Care
•
•
•
14 of 20 studies analyzed by Miller & Luft indicate that the quality of
care provided by MCOs is either greater than or equal to the level of
care in the FFS environment
MCO enrollees receive more preventative tests, examinations, and
health promotion services than their FFS counterparts
Vulnerable populations, such as children have seen excellent results
in MCO environments
• 40% greater number of routine screenings than FFS counterparts
• 50% more office visits than FFS counterparts
•
Managed Care has proven effective in reducing unnecessary
overutilization of services
• FFS patients 2.3 times more likely to have coronary bypass surgery;
mortality rates is 1.5 times greater than MCO counterparts
© BHM Healthcare Solutions 2013
Population Health Management
• Managed Care chronic care management/population
health management programs are gaining recognition in
providing high quality and comprehensive care for difficult
chronic conditions at reasonable costs
• Managed care has driven innovation in terms of the
chronically ill, which particular success for the following
conditions:
Mental
health
Diabetes
Chronic
renal
disease
Lower back
pain
Spinal cord
injury
© BHM Healthcare Solutions 2013
Asthma
MANAGED CARE SUCCESS
STORIES
© BHM Healthcare Solutions 2013
Managed Care Success Stories
•
Arizona
• In a one year period
Arizona’s capitated MCO
program realized a cost
savings of $52 million
dollars, a 19% savings over
what FFS costs were
estimated to have been
without managed care
• Medicaid expenditure growth
rate decreased from 9.9% to
6.8% over an eight year
period
• Large scale savings have
allowed the state to finance
large scale enrollment
growth for both Mental
Health and acute programs
© BHM Healthcare Solutions 2013
Managed Care Success Stories
• Wisconsin
• Wisconsin’s mandatory MCO enrollment for AFDC qualified
members resulting in a cost savings of 10.7% over what costs
would have been in a FFS environment based on historic rates
• ER visits were dramatically reduced through a program that
provided a 24 hour nurse line available to all MCO members
• Additional strategies utilized include:
Concurrent
review
Coordination of
long term
services
Chronic disease
management
Prior
authorization for
certain services
Discharge
planning
Prescription
drug
management
© BHM Healthcare Solutions 2013
Managed Care Success Stories
• Kentucky
•
•
•
•
Program operates in states largest urban area
SSI populated accounted for 25%-34% of enrollment
53% to 61% of program savings were attributed to this population
Program has demonstrated favorable performance with respect to
quality of care and access to services
Passport Health Plan, a Kentucky MCO scored above the National
Commission of Quality Assurance Quality Compass mean
© BHM Healthcare Solutions 2013
Managed Care Success Stories
• Ohio
• Medicaid managed care program, PremierCare, saved $26.4
million dollars for a savings of 2.2% versus what costs would have
been under FFS in a single year
• Savings are attributed to a 27% decrease in PMPM costs for
inpatient hospital services
• Groups who account for significant spend are targeted with
innovative prevention strategies
© BHM Healthcare Solutions 2013
Managed Care Success Stories
• Texas
• Texas created an independent assessment of its MCO and 1115
waiver programs called STAR+PLUS, the findings of this
assessment revealed:
Savings achieved
in MCO programs
has grown
annually
Enrollee
satisfaction for
MCOs was
equivalent to FFS
• Inpatient stays have been lowered by 28%
• Community based adult day care services utilization has increased
by 38%
• Personal assistant services have increased by 32%
© BHM Healthcare Solutions 2013
STEPS TO FOSTER GREAT
PROVIDER MCO
COLLABORATIONS
© BHM Healthcare Solutions 2013
General Keys for Collaboration
• Create meaningful contacts between organizations and
open dialogue
• Providers should know who key contacts are within primary
departments of the MCO
• MCOs should have C-Suite level provider contacts that they reach
out to on a regularly occurring basis
Understand how your MCO
is structured
Know who contacts are for
care coordination, billing,
etc.
© BHM Healthcare Solutions 2013
General Keys for Collaboration
• Understand the MCOs future strategies and goals for
providers
• What initiatives are in place now
• What is mandated by the MCO contract
• When will significant shifts take place or roll out
• Create a collaboration time line so that you can get ahead
of key initiatives and plan for meaningful exchange will
before deadlines hit
• Develop a strong relationship with the MCOs medical
director, this is your primary liaison for clinical issues and
the Medical Director can serve as a voice for the provider
community at internal meetings
© BHM Healthcare Solutions 2013
General Keys for Collaboration
• Get involved with Committees and Associations – MCOs
have a large number of committees which are open to
input from providers
• Providers who have strong relationships with other
providers may consider establishing their own sub groups
and associations to work with the MCO
• Seek to involve yourself in community associations and
committees to align provider concerns with consumer
concerns and collaborate with the MCO at the community
level
© BHM Healthcare Solutions 2013
General Keys for Collaboration
• Know where to find resources and updates, and take
advantage of them
Providers
MCOs
Know the provider manual
Ensure that all provider information is
current
Know where updates are posted for
providers
Develop an effective strategy to reach out
to the providers in your network
Take advantage of MCO trainings and
resources
Make resources readily available online
Learn how to navigate the MCO website
and call lines
Provide trainings and special sessions
centered around common provider issues
© BHM Healthcare Solutions 2013
General Keys for Collaboration
• Know the details of where provider feedback is needed,
and where MCOs are most receptive to input
Provider
Councils &
Associations
Clinical
Advisory
CFAC
QM
Committees
© BHM Healthcare Solutions 2013
Collaborations in Quality
• Some of the greatest collaborations between providers
and MCOs have occurred when alignment of MCO and
Provider Quality Improvement initiatives occurred
• What are your MCOs current Quality Improvement Projects?
• Is there a way that your practice can align these QI goals
internally?
• When you both work toward a common goal it creates a win win for
both organizations
• Work together to track the data and outcomes
Example: MCOs QIP involves making sure that patient follow up occurs in a
timely manner post discharge. Hospital aligns goal of discharge follow up
internally. MCO care coordinators reach out to patients, Hospital provides
timely report of discharges and contact information. Provider notifies MCO
care coordinator of any missed appointments
© BHM Healthcare Solutions 2013
Collaborations Based on Patient
Populations
• A small percentage of patients
account for a large portion of the
healthcare cost
• Work together to target these
patient populations
• Emphasize population health
management, get informed and
educate others
• MCOs are always looking for
innovative ideas on how to impact
quality and cost – share with them
your ideas and make the case for
why this is valuable
© BHM Healthcare Solutions 2013
IT and Data Sharing
Collaborations
• Create dedicated IT and reporting collaborative work
groups between providers and MCOs
Providers
Understand what is required from a data and
reporting perspective
MCOs
Host data and reporting collaborative
sessions for your providers
Make the case for managing care and
patients via data
Know what data systems the MCO utilizes
Educate providers on what IT systems you
use, and any integrations with other systems
you have already established
Understand how EHRs will be used in your
practice and take MCO data sharing into
consideration during implementation
Ensure that when it comes to data and
reporting you communicate clearly what you
need from providers
© BHM Healthcare Solutions 2013
Cost Based Collaborations
• Explore what other regions are doing to keep costs low
and quality high – create a micro-pilot with select providers
which mimics this approach
• Once the micro-pilot has been perfected roll this out with
additional providers in your network
• Look for provider success stories, or if you are a provider
and have a success story share it with your MCO
• Highlight what successful providers are doing, and push
this information out across your network so that others can
replicate the success
© BHM Healthcare Solutions 2013
Provider-Provider Partnerships
• MCOs can encourage or recommend partnerships
between providers in their network who may be
unconnected
• Providers should seek to develop strong partnerships with
other providers to impact greater cost savings and quality
benefits
• Consider expansion opportunities which could serve the
population at large
• Create innovative programs around specific diseases
• Engage in prevention and education initiatives with
multiple providers and the MCO working together for
maximum impact
© BHM Healthcare Solutions 2013
What to Remember
• Providers and MCOs are in this together and the success
of everyone involved will be dictated by how well these
parties can collaborate to meet the needs of a new
healthcare environment
• Emphasis should be on value, and population health
• Data and reporting are critical to success, those who do
not master this are doomed to failure
There is before us today a great opportunity to revolutionize the delivery of
health care and provide consumers with lower cost high quality care.
Whether we fail or succeed will be determined by the extent to which we
work together. Collaboration can produce great results!
© BHM Healthcare Solutions 2013
Question and Answer Session
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© BHM Healthcare Solutions 2013