Post on 13-Jul-2020
Community-Based Organization Engagement with a Managed Care OrganizationSept. 20, 2018
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PCA-1-012081-08272018_08312018 © 2018 United HealthCare Services, Inc.
The Managed Care Perspective
Why collaborate with a Community-Based Organization (CBO)?
• Regulatory compliance
• Public/member health initiatives
• Community partnership
• Medical cost and utilization controls
• Alignment with similar initiatives (health homes)
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Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
PCA-1-012081-08272018_08312018 © 2018 United HealthCare Services, Inc.
Regulatory Requirements: The New York Medicaid Landscape
Delivery System Reform Incentive Payment Program (DSRIP) and
Value- Based Contracting (VBC) fundamentally changed the Medicaid
business.
• As of Jan. 2018, value-based payment (VBP) contractors in a Level 2 or 3
arrangement must contract with at least one Tier 1 CBO.
• Language describing this standard must be included in the contract
submission to count as an “on-menu” VBP arrangement.
• This doesn’t prevent VBP contractors from including Tier 2 and 3 CBOs in
an arrangement to address one or more social determinants of health – in
fact, this is actually encouraged.
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Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
PCA-1-012081-08272018_08312018 © 2018 United HealthCare Services, Inc.
Value-Based Contracting: Where to start?
How is my CBO classified?
• Tier 1: Non-profit, non-Medicaid billing, community-based social and
human service organizations
• Tier 2: Non-profit, Medicaid billing, non-clinical service providers
• Tier 3: Non-profit, Medicaid billing, clinical and clinical support service
providers. Licensed by the New York State Department of Health, New
York State Office of Mental Health, New York State Office for Persons with
Developmental Disabilities, or New York State Office of Alcoholism and
Substance Abuse Services
Is my organization in the Department of Health Directory?
• Take the survey on the Department of Health website:
https://www.surveymonkey.com/r/SDH-CBO
• The survey allows you to indicate your CBO’s service area and services
provided.
o MCOs use the CBO list when planning for CBO inclusion in VBC.
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Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
PCA-1-012081-08272018_08312018 © 2018 United HealthCare Services, Inc.
Value-Based Contracting: Where to start?
Know your Value Proposition
• What unique skills or strong relationships can my organization bring to
the table?
• What social determinants of health does my organization address?
• How does the population that we serve align with the MCO’s population?
• What geography do we serve?
• Is the CBO prepared to accept and share data? (performance data,
member health data, etc.)
• Does your organization have the ability to take additional referrals?
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Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
PCA-1-012081-08272018_08312018 © 2018 United HealthCare Services, Inc.
Considerations
• MCO Strategy: What is driving the MCO/CBO collaboration?
• MCO Size: Does the MCO operate on a smaller, local scale; or larger global
scale?
• MCO Footprint/Market Share: What presence does the MCO have in a
particular geography?
• MCO/Provider Collaboration/Contracts in Place: Can the CBO
collaborate with care providers who already have key relationships with the
MCO?
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Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
PCA-1-012081-08272018_08312018 © 2018 United HealthCare Services, Inc.
Case Study: Care Provider Collaboration
UnitedHealthcare Level II contract with large primary care health
system in New York City:
• The health system contracted with the CBO.
• The health system/CBO contract was incorporated formally in to the
MCO/health system VBC arrangement.
• The following components were called out in the contract:
- Health system strategy
- Social determinants to be addressed and CBO’s assistance with them
- Target patient population
- Service delivery
- Project scope
- Geographic location
- Needs assessment
- Targeting and evaluation
- Implementation and timeline
- Project funding
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Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
PCA-1-012081-08272018_08312018 © 2018 United HealthCare Services, Inc.
Direct MCO Engagement with a CBO
Our existing relationships with CBOs:
• Collaborations to ensure continuity of coverage
• Collaborations to provide health education and engagement opportunities
such as health fairs
• Collaborations to share limited data to allow the health plan to locate
members who may be homeless and/or lost to care
• Expansions of existing relationships to provide direct interventions
addressing a social determinant of health.
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Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
PCA-1-012081-08272018_08312018 © 2018 United HealthCare Services, Inc.
Going Forward
• Expanding the conversation around the MCO/care provider/CBO
collaboration
• Thinking outside the box
• Sustaining beyond Delivery System Reform Incentive Payment
(DSRIP)
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Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
PCA-1-012081-08272018_08312018 © 2018 United HealthCare Services, Inc.
Questions?
Thank you!
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S E P T E M B E R 2 0 , 2 0 1 8
D O R E L L A W A L T E R S
D I R E C T O R O F E X T E R N A L P R O G R A M A F F A I R S
CBOs: Key Considerations on
Relationships with Managed Care
Organizations
G O D ’ S L O V E W E D E L I V E R
01 Mission in Action
02 Value Based Payment Opportunity
03 Partnerships are key
04 Contracting
05 Lessons Learned
.
Contents
1 2
Mission in ActionA b o u t G o d ’ s L o v e W e D e l i v e r
G O D ’ S L O V E W E D E L I V E R
Our Mission
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• God’s Love We Deliver, a nonsectarian organization, is the New York
metropolitan area’s leading provider of life-sustaining meals and nutritional
counseling for people living with severe illnesses
• We prepare and deliver nutritious, high-quality meals to people who, because
of their illness, are unable to shop or cook meals for themselves
• We provide illness-specific nutrition education and counseling to our clients,
and all meals are individually tailored for each client by one of our Registered
Dietician Nutritionists
Clients 7,000+ served annually including clients, children and caregivers
Bronx Westchester
CountyHudson
County, NJQueens
Manhattan
Brooklyn
Staten IslandNassau
County
Long Island
G O D ’ S L O V E W E D E L I V E R
Our medically tailored meals are cooked in our state of the art commercial
kitchen in SoHo (NYC).
All meals are low-sodium and are freshly cooked with no preservatives,
starters or fillers, and are flash frozen to optimize nutritional value and
quality.
We customize meals by addressing a combination of restrictions, resulting
in almost infinite meal variety for members.
Meal restrictions include:
• Pork, Beef, Fish and Vegetarian
• Sugar, Fat and Dairy
• Renal, Minced and Pureed
• Acid/Bland and Fiber/Gas
Our Meals
1 5
G O D ’ S L O V E W E D E L I V E R
What We Do What Members Do
1 6
Value Based Payment Opportunity
G O D ’ S L O V E W E D E L I V E R
• Paying for VALUE over VOLUME of healthcare services
• Different levels for this type of arrangement, called Tiers
• NYSDOH Goal: 80% of all Mainstream Medicaid payment in VBP by 2020
• Requirement from NYSDOH: As of January 1, any Tier 2 or higher VBP arrangement must involve:
• One Tier One Community Based Organization
• One Social Determinants of Health project
God’s Love fulfills both requirements
1 8 8 8
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Value Based Payment Contracting Requirement
New York State Department of Health (NYSDOH)
Managed Long Term Care Growth
3,081
9,397
24,76751,780
57,871
66,80194,131
121,767
150,901
201,506
231,359
263,121
312,543
366,467
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
Mea
ls p
er F
Y
G O D ’ S L O V E W E D E L I V E R
1. Leverage your history in the community
2. Speak to your core competencies
3. Know the research in your field
4. Leverage client and provider feedback
5. Have your data and report on your
historical impact
6. Anticipate the MCO’s goals/concerns
and then ask them to clarify
7. Know the metrics/goals the other party
needs to meet
8. Know the research in your field
9. Craft a convincing narrative about how
your services will help accomplish
these metrics
10. After your SWOT analysis, present your
“Return on Investment” for the MCO
2 0
Community Based Organizations
You’re Fabulous, Say So!
Partnerships are key
G O D ’ S L O V E W E D E L I V E R
1. Be clear on the intention of your partnership
2. Establish clear parameters and expectations
3. Make sure to clarify decision points
• Agree on acronyms
• Be clear on how each organization works
• Confirm how members will be referred and
enrolled
• Establish clear communication lines
4. Determine key stakeholders early on
5. Establish communication structure and
timelines
6. Screening for SDOH
• Track what the patient needs and report on
it!
• Share findings with each other, consistently
• Make sure the MCO can keep track of what
you do and what you’ve reported
7. Billing and reimbursement timelines
8. Refine, review, implement and then do it again
2 2
Partnership considerations
G O D ’ S L O V E W E D E L I V E R
• DSRIP Performing Provider Systems
• Hospitals
• Managed Care Organizations
• Integrated Primary Care
• Independent Practice Association
• Accountable Care Organizations
• And more!
2 3
Partnerships
What’s Possible?
If Managed Care
Organizations haven’t
reached out, you need to
pursue them!
G O D ’ S L O V E W E D E L I V E R
• Anticipate the
MCO needing
help
completing
the template
• Consider your
target
populations
• Consider
evaluation
methods
2 4
Plan for the submission
SDOH
G O D ’ S L O V E W E D E L I V E R
1. What preconceived notions the
MCO/contractor may have about your services?
2. What services will you offer and what’s the
price point?
3. How will you serve the MCO’s members?
4. What will be the members experience? Is
there a time limit on services?
5. How would you have to change your program to
meet contract requirements?
6. What are the pros and cons of flexibility?
7. How would you manage the new flexibility?
8. Who on your staff is involved in making
flexibility a success?
2 5
CBO Operations Considerations
Consider…
Contracting
G O D ’ S L O V E W E D E L I V E R
• Which populations will you serve?
• Ask the MCO who they need help with!
• Diagnoses: HARP, Cancer, Asthma, etc
• What metric (s) do you want to influence?
• Re-hospitalizations
• New Admissions
• Potentially Preventable Emergency Room Visits
(PPVs),
• Prevention Quality Indicators– Adult (PQIs),
• Prevention Quality Indicators– Pediatric (PDIs).
• What services will you provide?
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Populations and Services
G O D ’ S L O V E W E D E L I V E R
1. Know what you can do going in:
• Are you looking for a smaller project with
option to grow? Or can you handle a bigger
scale?
• Do you have the ability to invest in new staff,
technology, data collection, etc.?
• Do you have the ability to deliver on ALL
aspects of contract? (reporting, health
screening, MIAs, and so much more)
2. Hire appropriate legal counsel
3. Start the conversation – formal or informal –
and then follow up
4. Be beyond responsive!
5. Are you willing to use other funding streams
to supplement the contracting arrangement
or do you expect direct payment through a
contract for services?
6. Even with direct contracting, do you have the
resources to cover your costs if there is a lag
in payment?
7. Know how much of your cost you are willing to
absorb should payment be predicated on
outcomes
8. What determines walking away?
2 8
Contracting Negotiations
G O D ’ S L O V E W E D E L I V E R
• Communication is key!
• Build “buy in” constantly
• Responsiveness and timeliness
• Keep the MCO informed of engagement
opportunities
• Branding, volunteering, etc.
• Stay connected and engaged
• Meet in person, email updates, etc..
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The room where it happens!
G O D ’ S L O V E W E D E L I V E R
1. What data do you have/need to deliver
service?
2. What data do you have/need to show
outcomes?
3. What data does the healthcare entity
have/need?
4. How will you exchange this data adhering to
patient privacy laws?
5. How will you get outcomes data back?
6. Are there pro bono resources that can help
you add capacity?
3 0
Data and IT
Ask Yourself…
G O D ’ S L O V E W E D E L I V E R
• Added/Changed Program Services
• Nutrition modification
• Allow health plan to authorize 1 – 21 meals a week
• New Delivery Options
• Aligned with Home Health Aide hours
• Flexibility in delivery days
• Expanded geography (to cover 2 very large suburban counties)
• Enhanced Customer Service
• Streamlined Authorization Process
• Ongoing education sessions for referral staff
• Open Houses/webinars
• Daily notification of MIAs
• Collaboration on providing care
3 1
Flexibility Example:
Community Partners Program
Lessons Learned
G O D ’ S L O V E W E D E L I V E R
• Stay up to date on healthcare and its affect on
your patients
• Consider how you tell your story to a new
person, and make them fall in love with your
CBO
• Assess your data protections and strengthen
accordingly
• Get comfortable asking for what you need
• Consider collaborations to have an impact
3 3
Think Differently
G O D ’ S L O V E W E D E L I V E R
1. Consider cultures and language
2. Make sure to clarify decision points
• Be clear on how each organization works
• Establish clear communication lines
3. Determine key stakeholders
4. Get buy in from champions
5. Track your discussions
6. Confirm contacts for contracting and
implementation
7. Engaged leadership in both organizations
will move the work faster!
8. Discuss and consider priorities in advance
9. Get clear on how the project will be done
3 4
Lessons Learned
G O D ’ S L O V E W E D E L I V E R
TRACKING
SERVICES
Confirm populations to be
served and services to be
reported on, consider data
sharing
COLLABORATION
Make sure that both
decision makers and line
staff are all on the same
page for both
organizations
REPORTING
Establish reporting needs:
Medicaid Numbers, etc.
BRANDING
Establish early on how you
will showcase the
partnership
RESEARCH
Stay tuned to research
and work with the MCO on
quality and impact
reporting and publishing
COMMUNICATION
Stay in contact with each other,
lots of check-ins and emails.
Confirm a meeting structure to
modify accordingly
PAYMENT & B ILL ING
Determine how you will bill
and get reimbursed
M EDICAL INSIGHTS
Stay in touch on any
health discoveries with the
patient
3 5
Checklist
Keep this in mind
Questions?
G O D ’ S L O V E W E D E L I V E R
God’s Love We Deliver
166 Avenue of the Americas
New York, NY 10013
Godslovewedeliver.org
Dorella Walters
Senior Director of External Program Affairs
dwalters@glwd.org
212.294.8123
Alissa Wassung
Director of Policy & Planning
awassung@glwd.org
212.294.8171
Contacts
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P R E S E N T A T I O N T I T L E 3 7
Thank You