Public Employees Health Program A Division of Utah Retirement System

PROPOSAL Value-Based Payment Pilot Programs

Number 19071

From:

Table of Contents Page Letter of Transmittal 1 Executive Summary 2 Firm Qualification and Personnel 2 Detailed Discussion 3 Scope of Services / Work Plan 5 Fees / Pricing 7 Schedule & Project Requirements 8 Security & Access Control 8 Data Exchange / Reporting 8 Questionnaire 9 RPF Legal Requirements Checklist 13

Letter of Transmittal

Coba Health, LLC was created in 2014 as Independent Surgeon Specialists, LLC, and the name was changed in 2016 to Coba Health. It is privately owned and has no debt or litigation, mergers, etc. The mission of Coba Health is: “To improve quality of healthcare while lowering costs in a transparent environment. To work with complete integrity in serving patients as if they were our own family.” Authorized Representatives of Coba Health: Leland Jacobson, CEO lee@cobahealth.com 801-358-7766 (primary contact) Keith Jacobson, CFO keith@cobahealth.com 801-400-5027 Mailing Address: Coba Health 5513 W. 11000 N. #206 Highland, UT 84003 Coba Health serves clients in 46 states. Over 1,000,000 members have access to our program. We are providing surgical services each day to members all over the country. Utah is our home and the birthplace of Coba Health. We would be delighted to provide a platform for employees of the State of Utah and their family members to allow a higher quality of care and savings to the PEHP plan.

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Executive Summary

Coba Health provides a group of over 1,200 surgery centers and hospitals located across the US, and top tier, fellowship trained, board certified surgeons from many specialties to provide surgical services for our clients. We provide over 75 elective surgical procedures in inpatient and outpatient settings. Our approach to patient care is simple, and patient centered. Each patient is assigned a Patient Manager to assist them in navigating through the complex world of healthcare. Patients know ahead of time what their treatment plan involves and have a resource to answer questions that arise throughout their episode of care. We do offer a great variety of surgeries, most commonly, orthopedics, spine, general, ENT, colonoscopy, etc. Please see Addendum A for a list of common procedures and CPT codes. Coba Health does not work with patients who are considered “high risk.” These patients are better served on their traditional health plan. We do not provide all surgical services, including, but not limited to: cancer treatment, organ transplant, cardiac surgery, obstetrics. Coba Health maintains a goal of 30-50% savings off of the traditional “discount” networks. We refer to our surgical offering as an “episode of care” which includes pre-op surgeon visits, surgical facility fees, surgeon and assistant fees, anesthesia charges, implant cost, inpatient stay as needed, and post-op surgeon visits. All these charges are rolled into one “bundled” claim. Before surgery, we will provide an estimated cost for the episode of care so that the payer knows up front what to expect. A single page claim is sent either on paper or electronically detailing procedure codes and providers and a single amount to pay, simplifying the process from several claims to process, down to one single claim. Patients are never balance billed. We ask that all providers send bills to Coba Health directly.

Firm Qualification and Personnel Coba Health has provided surgical services domestically and internationally for nearly six years. We have provided services in 46 states domestically including in Utah. We have refined processes that are patient focused and make every effort to expedite necessary care with the highest quality providers available. Out patient satisfaction is at 97% highly satisfied and would refer a family member to Coba Health.

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We work with a number of self-funded companies in Utah including, but not limited to: Traco, Beehive Telephone, Lee’s Marketplace, ICON Health & Fitness, Juniper Systems, Kier Construction, etc… Financially, Coba Health is privately owned and free of debt. We do not owe any unpaid taxes or bills and are not involved in any legal actions against us. We have a credit line established of $100M if needed for infrastructure and provider payments. Currently, we have 10 employees and a team of contracted Patient Managers.

Detailed Discussion Coba Health proposes to provide surgical services for PEHP Members. Providing surgeons are board certified, fellowship trained, and are vetted through quality metrics including: overall complications, infection rates, patient satisfaction, re-admittances, and clinical outcomes. Facilities are AAAHC, AAAASF, or JCAHO accredited, and are held to the highest standards of care. We propose that participants needing surgery be directed to one of our Patient Managers who will take basic patient information, answer questions, and give the patient options for providers located close to their home. They will then schedule the patient with a selected provider for a pre-op office visit. Once the patient has met with the selected surgeon and if surgery is deemed necessary, the patient will be scheduled for surgery in one of our contracted facilities where that surgeon has privileges. The surgeon’s office will provide all necessary instructions to the patient. The Patient Manager assigned to each patient is also available to answer questions the patient may have. At that point, Coba Health will send a report to PEHP detailing the patient, provider, procedure CPT codes and cost estimate. Following the surgery, the patient uses their PEHP plan to purchase prescriptions, DME, etc… A claim is then sent out from Coba which includes all charges in a bundled form. These charges include: All surgeon fees, facility fees, anesthesia fees, implant charges, pre-op and post-op surgeon office visits. Coba Health expects payment within 30 days of claim submission and will send a reminder if payment is not received within that time frame. The patient is scheduled for post-op visit(s) with the surgeon, and the Patient Manager contacts the patient for a follow-up call and satisfaction survey. The primary goal of Coba Health is to improve quality of care. We accomplish this by allowing top tier contracted surgeons to practice medicine according to the best available methods. They are able to dictate care 100% without the oversight of insurance dictating treatment protocols. We put the patient first. We will not cut corners or sacrifice quality of care in any circumstance to reduce costs. Our secondary goal is to save the plan money. Generally, the plan will save 30-60% off of a typical “discount” network. In addition to savings, the bundled claim greatly simplifies the billing process and makes it much more efficient.

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Coba Health has been in business for nearly six years now. We have grown rapidly and now over 1,000,000 people have access to our plan through their employers or other groups. We are providing services all across the US and continue to build our provider group so that services are close to home for our members. Our goal is to have a member scheduled with a surgeon specialist for a consult within 48 hours of their initial request. The founder and CEO of Coba Health is Lee Jacobson. Lee has worked for nearly 30 years in the surgical arena in a number of capacities. His education was at BYU and University of Utah in medical anthropology. He worked at St. Marks Hospital as a surgical assistant for 3 years and then was hired by Johnson & Johnson’s orthopedic division as a manager for the Utah area where he was responsible for surgeon training and support, hospital contracting, and billing. After 17 years with J&J he worked as a consultant to Surgical Support Systems and Omni Orthopedics and was heavily involved in bringing robotic surgery for total knee replacement to Utah. He has always been an innovator and proponent of simplifying and creating transparency around the cost while improving quality of care. Coba Health is the result of that vision. Keith Jacobson, CFO of Coba Health, has worked in a variety of systems management and finance for companies such as Covey, NuSkin, Links Consulting, and M5 Partners Keith is responsible for the financial well- being of Coba Health and brings a wealth of experience in building systems of operation and funding. Keith’s education was in business administration at Utah Valley University. He is an expert in contracting and negociations, bringing Coba Health to an expanded footprint across the US. Keith has been with Coba for 5 years. Craig Weston, COO. Craig completed his education at the University of Utah and has worked at various companies helping to create systems of efficiency and simplicity. He worked extensively with the 2002 Utah Winter Olympics committee, and has also worked for AMICO, and Financially Fit. Craig is a people person who is skilled at finding inefficiencies and fixing them. He has been key to helping Coba Health create a user friendly, simple system of operation. Jennie Day, Patient Manager and Billing Manager. Jennie has worked for 25 years in the world of patient relations, claims processing, coding, and billing. She has worked for Sutter Health, Utah Physicians Care System, and Revenue Cycle Services. Jennie manages our Patient Managers and is exceptional at claims, coding and billing.

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Scope of Services / Work Plan Coba Health provides surgical services for employees and their family members needing elective surgery. We provide Patient Managers who guide the member through the process, helping to find the right provider for their needs and schedule visits with that provider as necessary. We have 13 contracted facilities in Utah and over 1,200 contracted facilities nationwide. We are able to serve employees who are traveling or otherwise live outside of Utah. Please see Addendum B which lists our contracted facilities in Utah. The target subset of patients are those needing elective surgery who are otherwise healthy. Reimbursement is included in our bundled fee. Coba Health pays all providers we contract with and add a small fee to each surgery. Claim payments are expected within 30 days of claim submission and will send a reminder if payment is not received within that timeframe. We expect all patients to do very well. However, we recognize the inherent risks associated with surgery. We guarantee that the surgery will be performed properly, with the highest standard of care. Individual patients vary in their recovery and outcome, but we provide them with the best-case scenario for complete recovery, including the latest available technologies and treatment processes available. Bundled payments have become the gold standard for value based care. We offer predictable, transparent pricing for all procedures prior to the surgery being performed. A comparison to other pricing MUST include everything on out bundle, ie; all surgeon office fees and operative fees, all facility fees, all anesthesia fees, and implant costs. Only then can a fair comparison be made.

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The plan of operation is as follows and can be altered as needed for PEHP needs. 1. The patient initiates a request for surgical care through HR or PEHP. 2. The patient OR PEHP contacts Coba Health directly by phone or email with the request. 3. A patient Manager is assigned to the patient. 4. The patient is contacted by the Patient Manager and a Patient Voucher is completed. See Addendum C for a sample Patient Voucher. 5. The patient is given options of surgeons in their area and is scheduled with one of their choosing for a pre-op office consult. 6. The patient goes for the pre-op consult to the surgeon’s office. IF surgery is deemed necessary and the patient wishes, they are scheduled for surgery at a facility where the surgeon has privileges and Coba is contracted. 7. Coba communicates the date of surgery, facility, procedure, CPT codes and estimated cost to PEHP. 8. The patient has surgery and a single, bundled claim is sent to PEHP. 9. At this point, the patient uses their PEHP plan card for prescriptions, DME, physical therapy, etc… 10. The patient has a post-op appointment(s) with the surgeon to track progress. 11. Coba Patient Manager contacts the patient by phone approximately 2 weeks post-op to make sure they are doing well and to do a patient satisfaction survey. 12. Claim is paid to Coba Health by PEHP within 30 days of claim submission. 13. Coba follows up with the patient at 2 weeks, 6 months and 1 year and documents outcomes and patient satisfaction. This allows us to quantify outcomes and patient satisfaction in a true value-based offering. Potential Problems: Unexpected findings during surgery requiring additional procedures:

• Coba Health anticipates this in their estimate and will not increase charges. Patient experiences complications following surgery, ie; pain, bleeding, DVT, etc...

• Facility is authorized to treat the complication with whatever means necessary. This is all covered in the estimate given by Coba Health. In the event that the patient needs to be transferred to another facility, the PEHP plan would then be responsible for further care at that facility. In this event, PEHP would be contacted by Coba Health immediately.

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Patient is home following surgery and has complications:

• For pain, swelling, bleeding, the patient has contact information to reach the surgeon’s office during and after hours.

• For true emergencies, ie; difficulty breathing, loss of consciousness, chest pain, patient is to call 911 as in any emergency situation.

Unanticipated problems:

• Coba Health is committed to providing solutions to problems as they arise to the best of our ability. We will manage these on a case by case basis in a way that is fair to the patient and to the PEHP plan. Our goal is patient satisfaction and savings to the plan and we will work to accomplish that even to our own financial disadvantage if problems arise.

Tentative Schedule for Implementation Coba Health has systems in place now. However, in order to facilitate a smooth transition and make sure both teams from PEHP and Coba Health are able to integrate systems of operation effectively, we propose the following implementation schedule: September 2019: Send 5 PEHP patients through Coba Health and evaluate systems. October 2019: Send 15 PEHP patients through Coba Health and refine systems. November 2019: Send 30+ PEHP patients through Coba Health and solidify systems. At the end of each month, we would propose a meeting with key employees of PEHP and Coba Health to evaluate and refine operation systems. At that time, a report of estimated savings as well as early patient satisfaction surveys would be shared.

Fees / Pricing

Coba Health will not charge a PEPM or PMPM for services rendered to PEHP for this pilot period. A list of estimated pricing is included for our most common procedures. Please see Addendum A. Upon approval, a full list of estimated pricing will be provided for most of our procedures including CPT codes. Anticipated costs include employee awareness through internal marketing and training to make employees aware of the Coba Health option, printed or digital materials to support this effort, and personnel to carry out patient awareness. We anticipate minimal expense.

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Schedule and Project Requirements Coba Health has systems in place now. However, in order to facilitate a smooth transition and make sure both teams from PEHP and Coba Health are able to integrate systems of operation effectively, we propose the following implementation schedule: September 2019: Send 5 PEHP patients through Coba Health and evaluate systems. October 2019: Send 15 PEHP patients through Coba Health and refine systems. November 2019: Send 30+ PEHP patients through Coba Health and solidify systems. At the end of each month, we would propose a meeting with key employees of PEHP and Coba Health to evaluate and refine operation systems. At that time, a report of estimated savings as well as early patient satisfaction surveys would be shared.

Security and Access Control

Coba Health utilizes a number of platforms for communication, document transmittal, data storage, and disposal. Most communications are done via encrypted email on the gmail platform with Microsoft encryption. We never share PHI via text of voice messaging. All patients are required to sign a HIPPA release with Coba Health. No documents are left face-up in a workspace. Secure, compliant data storage is included in our EHR systems: Kareo and Cassio Intake. We hire a commercial shredding company to come and shred documents on a monthly basis.

Data Exchange / Reporting

Coba Health utilizes Microsoft Office, Excel, PDF, Word exclusively as formats for data exchange. We are vigilant about the HIPPA requirements and continuously remind employees of the importance of safeguarding patient information.

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Questionnaire

A. General 1. Please provide the location of your organization's office.

2000 Ashton Blvd. Suite 120, Lehi UT 84043 2. Please provide us with a background on your education and work

experience. Schooling at BYU and University of Utah in Medical Anthropology, 29 years in surgical services including contracting, surgical assisting, surgeon training, provider accreditation, billing, etc…

3. Please provide the name, address, and telephone number of the person(s) responsible for responding to this RFP. Lee Jacobson 801-358-7766 (cell)

4. Please provide the name, address and telephone number of the chief decision-maker in your organization who has oversight responsibility for your proposal. Lee Jacobson, CEO

2000 Ashton Blvd, Suite 120 Lehi, UT 84043 801-358-7766 lee@cobahealth.com

B. Qualifications

1. Please provide references for three current customers (similar in size and nature to PEHP, if possible) who utilize the services you are proposing. Advanced Medical Pricing Solutions (AMPS), Beehive Telephone (Tooele), Kier Construction (Ogden)

2. Please outline your expertise in this service and how long you have provided this service to patients? We have experience with over 20,000 surgical procedures and have been providing the current services to patients for 6 years.

C Service

1. Please disclose the location of the office that has responsibility for servicing the patients. 2000 Ashton Blvd. Suite 120 Lehi, UT 84043

2. Who will have the responsibility for direct contact with PEHP? Please provide a biographical sketch including address.

Lee Jacobson, CEO, Lee has worked for nearly 30 years in the surgical arena in a number of capacities. His education was at BYU and University of Utah in medical anthropology. He worked at St. Marks Hospital as a surgical assistant for 3 years and then was hired by Johnson & Johnson’s orthopedic division as a manager for the Utah area where he was responsible for surgeon training and support, hospital contracting, and billing.

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Craig Weston, COO Craig attended University of Utah and has worked

extensively as a consultant to various companies including AMICO, and Financially Fit to build and streamline processes and efficiencies.

2000 Ashton Blvd. Suite 120 Lehi, UT 84043 3. Will this person be available for periodic meetings with PEHP?

YES

D. Claim System 1. What method(s) do you utilize to transmit claims? Generally we

use a clearinghouse of our clients’ choosing. 2. Are you able to transmit claims via PEHP’s preferred ANSI 5010 837

format? Yes 3. Are you willing and able to submit all claims electronically through Utah

Health Information Network (UHIN - www.uhin.org)? Yes

E. Product Offering & Service Area 1. Please describe your service offering. Highest quality surgical

services with concierge service and discounts of 30-60%.

2. Please describe the expected outcomes patients should obtain from your service and how you plan to achieve those outcomes. Patients should expect excellent outcomes utilizing Coba Health group of fellowship trained, board certified specialists who are vetted according to complications, infection rates, cost, readmission rates, and overall patient satisfaction. 97% of our patients would refer a family member to Coba Health. We track outcomes through re-engaging patients at 2 weeks, 6 months, and 1 year post-op.

3. Please describe what participation requirements you have from the

member and from PEHP as part of your service offering. Coba Health contracts with high quality surgeons and facilities throughout Utah and the US. In order to utilize our services, a member must use a provider within our group. They must sign customary HIPPA and consent documents prior to service.

4. Please describe how the proposed reimbursement offering aligns

incentives between the payer, provider, and member/patient. Coba Health incentivizes payers through bundled discounts, and simplicity of billing. We incentivize surgeons by paying them more than they usually collect and by paying very quickly. Most of our clients who are self-funded companies incentivize members/employees by offering a zero out of pocket for the patient. This is accomplished by listing Coba Health as “paid 100%” on the plan document.

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5. Describe any warranties or guarantees you provide for your services.

Coba Health will cover complications that occur before the patient has been sent home from the surgical facility. Facility is authorized to treat the complication with whatever means necessary. This is all covered in the estimate given by Coba Health. In the event that the patient needs to be transferred to another facility, the PEHP plan would then be responsible for further care at that facility. In this event, PEHP would be contacted by Coba Health immediately.

6. Please describe any limitations our members may have in accessing

the service (e.g. – hours of services are limited or if specific health care conditions disqualify them). Because of our bundled, transparent pricing, we are only able to provide elective surgeries for healthy paitents. Conditions that MAY disqualify a patient include; diabetes, heart disease, kidney disease, obesity, etc… In our model, we strive to maintain very predictable outcomes. Patients with significant co-morbidities are a much higher risk for complications.

7. Describe the methods you will use to measure outcomes for the

services provided. Will you provide reports to PEHP on these measures? The patient meets with the operating surgeon at 2 weeks, 6 months, and 1 year post-op. This is all included in our service. The surgeon evaluates their progress and reports it to Coba Health. We also conduct patient surveys at 2 weeks, 6 months, and 1 year post-op. We are happy to share the data with PEHP for their members.

8. Describe how you track member satisfaction with your services. We

conduct patient surveys at 2 weeks, 6 months, and 1 year post-op. We are happy to share the data with PEHP for their members.

9. Describe the steps taken by your organization to ensure HIPAA

regulations are enforced. Coba Health employs the use of an HER system and uses stringent guidelines for data transmission, using encrypted email and data transmission.

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10. Describe the process a member would go through to access your service, starting with how they would contact you through how a claim would be sent to PEHP for the service.

The plan of operation is as follows and can be altered as needed for PEHP needs. 1. The patient initiates a request for surgical care through HR or PEHP. 2. The patient OR PEHP contacts Coba Health directly by phone or email with the request. 3. A patient Manager is assigned to the patient. 4. The patient is contacted by the Patient Manager and a Patient Voucher is completed. See Addendum C for a sample Patient Voucher. 5. The patient is given options of surgeons in their area and is scheduled with one of their choosing for a pre-op office consult. 6. The patient goes for the pre-op consult to the surgeon’s office. IF surgery is deemed necessary and the patient wishes, they are scheduled for surgery at a facility where the surgeon has privileges and Coba is contracted. 7. Coba communicates the date of surgery, facility, procedure, CPT codes and estimated cost to PEHP. 8. The patient has surgery and a single, bundled claim is sent to PEHP. 9. At this point, the patient uses their PEHP plan card for prescriptions, DME, physical therapy, etc… 10. The patient has a post-op appointment(s) with the surgeon to track progress. 11. Coba Patient Manager contacts the patient by phone approximately 2 weeks post-op to make sure they are doing well and to do a patient satisfaction survey. 12. Claim is paid to Coba Health by PEHP within 30 days of claim submission.

13. Coba follows up with the patient at 2 weeks, 6 months and 1 year and documents outcomes and patient satisfaction. This allows us to quantify outcomes and patient satisfaction in a true value-based offering.

11. Describe any regular reports you would provide PEHP. Please provide samples

of each report. Reports would be made monthly or quarterly according to PEHP’s direction. They could include estimated cost savings, patient satisfaction, and patient outcomes data. Samples are not available.

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RFP Legal Requirements Checklist PEHP will require the successful bidder to agree to the following terms and conditions prior to entering into a binding agreement. Please indicate whether or not your company will agree to the following: 1. Term & Termination. Company will agree to the term specified in the RFP with a

90-day termination provision.

Yes___X__ No_____

Explanation ____________________________________________________

2. Privacy. Company will sign a PEHP Business Associate Agreement and PEHP Non-Disclosure Agreement, as required.

Yes___X__ No_____

Explanation ____________________________________________________

3. Confidentiality. Company will agree to abide by the confidentiality requirements of

PEHP under Utah Code Ann. § 49-11-618, HIPAA, and other Board rules or resolutions.

Yes__X___ No_____

Explanation ____________________________________________________

4. Indemnification. Company will agree to indemnify PEHP from any and all costs, losses, or damages arising out of the bidder’s or their subcontractor’s acts and omissions. Company agrees that PEHP is unable to indemnify Company in any way.

Yes__X___ No_____

Explanation ____________________________________________________

5. Insurance. Company will agree to carry insurance coverage for its potential liabilities and provide evidence of such insurance upon request.

Yes___X__ No_____

Explanation ____________________________________________________

6. Dispute Resolution. Company will agree that this RFP and any contract or agreement resulting from the RFP, and any dispute arising therefrom, will be governed by the laws of the state of Utah, regardless of conflicts of laws principles, and that disputes will be heard by the courts in Salt Lake City, Utah.

Yes__X___ No_____

Explanation ____________________________________________________ 13

7. Inspection/Audit. Company agrees that PEHP shall have the right to inspect and/or audit the work and the processes used by the Company.

Yes__X___ No_____

Explanation ____________________________________________________

8. Conflicts of Interest. Company agrees that it has no conflict of interest in this proposal except as has been disclosed in writing in the proposal and that it will abide by PEHP’s conflicts of interest rules.

Yes__X___ No_____

Explanation ____________________________________________________

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Addendum A

Coba Health Pricing -- Common Procedures

Procedure Description CPT Code Estimated Price

ACL Repair 29888 $11,990.00

Knee Scope 29876 $7,390.00

Knee Scope w/ Menisectomy 29880, 29881 $9,390.00

Arthroscopic Rotator Cuff Repair 29827 $11,970.00

Open Rotator Cuff Repair 23420 $9,790.00

Total Knee Arthroplasty 27447 $24,875.00

Total Hip Arthroplasty 27130 $24,875.00

Total Shoulder Arthroplasty 23470 $22,800.00

Reverse Shoulder Arthroplasty 23472 $26,875.00

ACDF 22551, 22845, 22851 $21,490.00

Lumbar Discectomy 6.03 $18,990.00

Lumbar Fusion single Level 22612 $36,990.00

Lap Chole 47564 $18,990.00

Inguinal Hernia Repair 49525 $8,990.00

Lap Hernia Repair 49650 $11,880.00

Lap Hysterestomy 58550 $17,400.00

Vag Hysterectomy 58150 $13,550.00

Colonoscopy w/ Biopsy 45378 $2,800.00

*Prices include all surgeon fees, facility fees, anesthesia fees, and implant charges.

Addendum B

Utah Area Coba Health Contracted Facilities

St. George Surgery Center St. George, UT Grove Creek Surgery Center Pleasant Grove, UT Mountain Point Medical Center Lehi, UT Lone Peak Hospital Draper, UT Jordan Valley Hospital South Jordan, UT Cottonwood Surgery Center Murray, UT Salt Lake Regional Medical Center Salt Lake City, UT University Medical Center Salt Lake City, UT Davis Hospital Layton, UT South Ogden Surgery Center Ogden, UT Mount Ogden Surgery Center Ogden, UT Advanced Surgery Center of Northern Utah Logan, UT Franklin County Medical Center Preston, ID

Addendum C

PROCEDURE AUTHORIZATION – VOUCHER

PATIENT INFORMATION Date Of Service: Faclitlity Name: Status: Address: Members First Name: City: Members Last Name: State: Members Phione number: Zip Code: Member Email: Facilities Phone: Group Name: Facilities TIN: Address: State: City: Zip Code: DISCRIPTION: Generated on:

DATE OF CONSULTATION: Prepaired By:

DATE OF PROCEDURE: Email

Address: CPT CODE: Phone Number:

DIAGNOSIS CODE: Note: All Bills come to COBA HEALTH; 5513 W 11000 N Highland, Utah 84003 Phone Number (801)358-7766 TIN: 47-1770736