Track C Dividers - FRA, LLC - Financial Conferences · PDF fileTrack C Strategies for...

Track C

Strategies for Successfully Contracting with Medicare Advantage Plans

Dhyan D. Lal, Vice President, Network Strategy and Contracting ‐ Payer Strategy Group | Pacific

Northwest Region

CATHOLIC HEALTH INITIATIVES

Stephanie W. Schreiber, Shareholder

BUCHANAN INGERSOLL & ROONEY PC

Robert Ramsey, III, Shareholder

BUCHANAN INGERSOLL & ROONEY PC

Dhyan D. Lal Regional Vice President of Payer Strategy & Operations Pacific Northwest Region Dhyan Lal serves CHI Franciscan Health as the Regional Vice President of Payer Strategy & Operations for the Pacific Northwest region. Mr. Lal is a seasoned healthcare professional with an extensive and diverse background. His career highlights include senior management positions at Tenet Healthcare, Vice President of Operations for a multi-specialty medical group in Southern California, and most recently he was the Director of Payer Contracting for Providence Health & Services, Washington/Montana Regions and Swedish Health System.

He was a member of the Insurance Reform Advisory Group as part of the Joint Select Committee on Health Reform for the State of Washington. Dhyan Lal served as a member of the Washington State Health Exchange Advisory Committee from 2012 – 2015.

Mr. Lal received his Bachelor of Science degree in Health Administration from California State University, Northridge and holds a Master’s degree in Business Administration from Saint Mary’s College of California.

Practices

Industries

Affiliations

Adjunct Professor, University of Pittsburgh School of Law Allegheny County Bar Association

Civic & Charitable

Board member, Life'sWork Board member, The Center for Victims

Education

University of Pittsburgh School of Law, J.D., magna cum laude, 1998, Order of the Coif; Managing Editor of the Law Review

Health Care

Mergers & Acquisitions

Health Care Transactions

Health Care Joint Ventures

Nonprofit Organizations

Cybersecurity & Data Protection

Health Care

Mergers & Acquisitions

Health Care Transactions

Health Care Joint Ventures

Nonprofit Organizations

Cybersecurity & Data Protection

Stephanie Winer Schreiber is a corporate and health care attorney who provides businesses, non-profit organizations and healthcare entities with sound, efficient and practical advice. She actively engages with her clients to identify and implement solutions to complex legal and business issues.

Stephanie focuses her practice on substantial merger and acquisition transactions, joint ventures, general corporate matters, corporate reorganizations, governance issues and compliance and regulatory matters. Within the healthcare arena, in addition to her extensive experience in mergers and acquisitions, Stephanie actively assists clients in structuring complex joint venture transactions, negotiating provider and professional services agreements, organizing health information exchanges, handling medical staff disputes, tackling privacy concerns, including those under HIPAA and HITECH and satisfying healthcare licensing obligations. Within the corporate and non-profit arenas, Stephanie assists clients with corporate reorganizations, venture fund transactions, drafting commercial contracts, negotiating and drafting operating agreements, shareholders agreements and other corporate governance documents, as well as other corporate matters. Stephanie is an adjunct professor at the University of Pittsburgh School of Law, where she teaches courses in Business Planning and Healthcare Business Transactions. She is also a frequent lecturer for, among other organizations, the Pennsylvania Bar Institute and Healthcare Education Associates, speaking on such topics as Healthcare Mergers and Acquisitions, Shareholder Agreements, LLC Agreements, HIPAA matters, HITECH, Fiduciary Duty, Damages in Commercial Contracts and Negotiating Quality Provisions in Provider Agreements. Stephanie also serves as co-chair of the firm’s Pro-Bono Committee. Stephanie focuses her pro-bono activities on the provision of services to small start-up non-profit organizations. Prior to attending law school, Stephanie served her community as a social worker, working with abused and neglected children, victims of sexual assault and juvenile offenders.

Events

Shareholder [email protected]

T:412 392 2148 | F:412 562 1041 Pittsburgh

Stephanie Winer Schreiber

Kent State University, B.A., Social Work, 1980

Admissions

Pennsylvania

News & Media

12/3/2015 "The Basics of a VC Term Sheet" Presenter, Innovation Works & the Institute for Entrepreneurial Excellence

5/14/2015 - 5/15/2015 2015 Network Building & Contracting Forum Healthcare Education Association

4/29/2015 Understanding Damages & Indemnities in Commercial Contracts

10/16/2014 Preparing PA LLC Documents Pennsylvania Bar Institute

6/25/2014 The Shareholder Agreement: Valuable guidance if you draft, negotiate, interpret and implement these agreements Pennsylvania Bar Institute CLE

6/19/2014 Provider Contracts and Quality Measurement

4/9/2014 - 4/10/2014 Pennsylvania Council of Children, Youth and Family Services 2014 Spring Conference

3/13/2014 - 3/14/2014 20th Annual Health Law Institute

2/10/2014 - 2/11/2014 Best Practices in Network Development & Contract Management Conference

10/8/2010 HITECH: The Ever-Evolving World of Data Security presenter, East Central Regional Annual Conference

© 2016 Buchanan Ingersoll & Rooney PC

2/11/2016

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1

Strategies for Successfully Contracting with Medicare Advantage Plans

March 2016RISE ‐ Annual Summit

Nashville, TN

Stephanie Winer Schreiber, Esq. – Buchanan Ingersoll Rooney Robert Ramsey, Esq. – Buchanan Ingersoll Rooney Dhyan Lal, MBA – CHI Franciscan Health

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Understanding the Nuances of At‐risk Contracts

• Full risk or shared risk arrangements are both dependent on increasing the RAF score through enhanced coding and documentation. Direct impact includes:– HCC drives an increased RAF (risk adjustment factor) score– An improvement in RAF equates to increased premium from CMS– The higher the premium, relative to medical expense, the lower the overall MLR (medical loss ratio).

• A lower MLR can result in increase cost savings or greater shared‐risk distribution to a provider.

• Unit price (CMS + rate paid to providers) can be counter‐effective in a risk arrangement.– A provider who takes risk needs to balance the price point for services and how it impacts the MLR. (Clinical risk vs. Insurance risk)

2/11/2016

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Examining Quality‐based Contracts

• Are additional specific quality measures necessary in a value based contracts (VBC)? Not necessarily…

– VBCs can and are primarily driven by the HCC/RAF

– HEDIS based quality measures that drive Star ratings can be built into separate incentive programs.

• Primary Care PMPY (per member per year) incentives based on # of HEDIS targets met.

– Value can be directly aligned with clinical programs and primary care initiatives

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Negotiating Essential Provisions in Quality Contracts

• Properly Defined Measurement Periods• Incorporation of Guidelines and Administrative Requirements outside of the Contract

• Tied Participation in Quality Agreements to other Agreements between the Parties

• Inclusion of Additional Requirements for Participation in Quality Contracts

• Program Administration Matters

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Negotiating Essential Provisions in Quality Contracts

• Termination Provisions in Quality Contracts• Effect of Participation• Evaluation Criteria• Indemnification Provisions• Ambiguous Provisions in Agreements• Transparency Initiatives Participation• Negotiations Regarding Use of Care Managers• Attribution/Enrollment Considerations

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Mitigating Part D risks

• Considerations to take into account in order to properly price a Medicare Part D product:– All the recent transparency (e.g., Medicare Compare)– Recent mergers/acquisitions– Fast‐paced nature of a pharmacy benefit, – Recent specialty boom (e.g., Hep C), – Population segmentation (MAPD, PDP, Community Plan, D‐SNP, I‐SNP, Non‐Low Income, Low Income, “Non‐Spenders”, “Spenders”)

– Formulary considerations (e.g., lean, generic heavy, brand heavy, rebate focused, adherence focused)

– CMS Regulations (e.g., are they going to force future consolidations due to restrictive tests, such as OOPC)

“Part D is really a Pandora’s Box and is a very complicated product to price…” (per a Chief Actuary at Prominence Health)

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Part D, ‐cont.‐Health Plan Pricing Strategy

• Each carrier has its own strategies that widely affect pricing. Here are just some examples that creep into pricing:– A traded carrier that is vertically integrated and owns its own PBM (e.g., United) is going to price plans to make sure that PBM still looks good to Wall Street.

– A carrier that is vertically integrated, owns its own PBM, and has its own brick/mortar pharmacies (e.g., CVS), is going to price the plans specifically to get members into its stores.

– A carrier that is small, does not own its own PBM, and is not that sophisticated should price Medicare Part D plans as aggressively as possible to minimize buy‐downs and let the program’s Risk Corridor bail them out.

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Part D.‐cont‐Provider Taking Risk, Considerations

• Like the ACA Risk Corridor, the Part D Risk Corridor was supposed to have a life span of 3 years; 2017 will be the 11th year.

• Unlike the ACA Risk Corridor where the government is the big loser and might get stuck paying out huge sums of money, the Part D Risk Corridor is a possible money maker because big carriers make enough money to offset the losses.

• From the provider side, why wouldn’t you want a piece of that gain. It’s our doctors that are driving the plan’s profits generally on the drug side with their practice patterns and quality care…

• A plan might price aggressively with the intention of swelling membership for a potential future sale. And, the provider would have little insight to the plan.

2/11/2016

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Negotiating More Effectively by Better Understanding How Plans Develop Their Bids

• Key Considerations– What is the current performance of their Provider Network in a given pricing area.• Unit cost (rates paid to providers)• RAF scores of network providers• HEDIS performance (drives STAR rating)

– Consumer choice and plan design(Are consumers more interested in zero premium, or moderate‐to‐high premium with ‘richer’ benefits?)

– Part D pricing

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THANK YOU!

Track C

Case Study: How an ACO is Mitigated Risk Adjustment Challenges with Targeted Strategies

Murray Brozinsky, Chief Strategy Officer

TALIX

Francis Cheung ,Chief Information Officer

CRYSTAL RUN HEALTHCARE

Murray Brozinsky Chief Strategy Officer, Talix As chief strategy officer for Talix, Murray Brozinsky heads business and corporate development for the company. He has more than 20 years of experience founding, operating and advising high growth technology firms. Murray has spoken at numerous industry conferences on various health information technology topics and trends. He holds a B.S. in Finance and a B.A. in Philosophy from the University of Pennsylvania, an M.S. in Engineering from Northwestern University’s McCormick School of Engineering and Applied Science, as well as an M.B.A. from Northwestern University's Kellogg and McCormick schools. Murray also sits on the board and/or advisory board of numerous tech start‐ups.

Francis H. Cheung Chief Information Officer, Crystal Run Healthcare Francis H. Cheung is the Chief Information Officer at Crystal Run Healthcare. Mr. Cheung is a graduate of University of Wisconsin, Madison in Madison, Wisconsin where he earned his Bachelor and Master of Science in Industrial Engineering. Mr. Cheung is Lean Production Certified and his professional affiliations include membership to the College of Healthcare Information Management Executives (CHIME) and the Healthcare Information and Management Systems Society (HIMSS). Mr. Cheung joined Crystal Run Healthcare in April of 2015 with over 25 years of healthcare IT experience. In his role as Chief Information Officer at Crystal Run Healthcare, Mr. Cheung oversees information technology (IT) and business intelligence and leads the development of IT systems and infrastructure to support and promote Crystal Run’s integrated, value based model of care. Prior to joining Crystal Run Healthcare, Mr. Cheung spent four years with United Health Group’s Optum Collaborative Care where he held the title Vice President, Provider System Technology and led platform implementation for their accountable care organization (ACO). Prior to Optum, Mr. Cheung held the position of VP and CIO at Park Nicollet Health Services for nine years where he lead the implementation of the electronic record as well as other enterprise systems.

2/23/2016

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How an ACO is Mitigating Risk Adjustment Challenges with Targeted Strategies

Francis Cheung, Chief Information Officer, Crystal Run Healthcare

Murray Brozinsky, Chief Strategy Officer, Talix

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• Introduction and Background

• Crystal Run Healthcare: A Case Study

- Evolution

- Risk Adjustment Challenges

- Goals

- Strategies Implemented

- The Path Ahead

• Q&A

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Agenda

2/23/2016

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Proactively identify high-risk patients

More accurately predict costs and

determine reimbursement level

Optimize treatment planning and care

delivery

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Why Risk Adjustment Matters

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MSSP ACO Performance (2013-2014)

Significant Opportunity for Targeted Risk Adjustment Strategies

2/23/2016

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But They Require the Use of New Data & Technologies

Level 1Claims data onlyRules‐based

Level 2Claims + Structured Clinical data only

Rules‐based

Level 3Claims + Structured + Unstructured clinical data

NLP; Rules‐based

Level 4Claims + Structured + Unstructured clinical data

NLU; Taxonomy + Rules‐based

Technologies

Data

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About Crystal Run Healthcare

• Physician owned MSG in NY State, founded 1996

• 350+ providers, 30+ locations

• Joint Venture ASC, Urgent Care, Diagnostic Imaging, Sleep Center, High Complexity Lab, Pathology

• Early adopter EHR (NextGen®) 1999

• Accredited by Joint Commission 2006

• Level 3 NCQA PCMH Recognition since 2009

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2/23/2016

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Where is Crystal Run Healthcare?

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The Value Proposition

The Triple Aim

• Improve the health of the population

• Enhance the patient experience of care

• Reduce, or at least control, the per capita cost of care.

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Crystal Run Mission

“The mission of Crystal Run Healthcare is to improve the quality and availability of, and satisfaction with, health care services in the communities we serve. To accomplish this goal, the practice emphasizes both traditional medical excellence as well as responsiveness to consumer needs through service excellence and patient empowerment.”

2/23/2016

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Population Management Program at Crystal Run Health

Attributed Population(Base PMPM + Risk)

Risk Adjustments(Demographic + Clinical

Condition)

Attributed PopulationTarget PMPM

Actual Pop Health Costs(Paid Amount)

Quality Outcome

Shared Savings(Upside or Up/Down Sides)

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Population Management Program at Crystal Run Health

Attributed Population(Base PMPM + Risk)

Risk Adjustments(Demographic + Clinical

Condition)

Attributed PopulationTarget PMPM

Actual Pop Health Costs(Paid Amount)

Quality Outcome

Shared Savings(Upside or Up/Down Sides)

• Between 2013 and 2014• Rely on manual processes• Reduction in risk score compared to region• Financial Opportunity ~$4M• Did not have the detail data until 2015

• 2015• Developed interim processes• Used internal EDW and engaged Milliman • Established centralized coding department• Focused efforts

• Began vendor search

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2/23/2016

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Risk Adjustment System Requirements

Accurate coding according to true burden of illness

Input include prior history, Rx and Lab, Claims and unstructured

narratives such as H&P

Multi‐entity, multi‐plan, multi‐plan year, potential for multi‐risk scores

Intuitive and easy to use

Ability for machine learning / tuning

Report on provider performance

Integration with provider work flow

Modern technology platform

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Evolution of HCC at Crystal Run Health

Stage 1 : “Sticky Notes”

• MA review past clinical history

• Prepare stick notes based on schedule book

• IMO Coding Program

Stage 2: “Brute Force”

• Centralized coding department

• Gaps‐in‐care generated from EHR

• HCC codes based on patient history and current medication

• Based on daily appoint schedule or on‐demand

• PDF link within EHR

Stage 3: “Integration”

• Implement Coding InSight for MSSP patients

• Deep integration with NextGen

• Physician work flow simplification

• Expanded clinical taxonomy

• Timely performance reporting

Stage 4: “Multi‐plan”

• Add Crystal Run Health Plan

• Integrate into health plan operations

• Other risk stratification trials

Before 2014 and 15 Current Efforts Next

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2/23/2016

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Evolution of HCC at Crystal Run Health

Sticky Notes

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EHR Integration

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Provider Work Flow

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Provider Work Flow

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Natural Language Processing

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Work Flow Integrationa

EHR / Claim

s / HIE MIRTH

Integration

Payer Claims & Attribution

Provider Input to NextGen EHR

Clinical Rules

EDW

INPUTS

NLP

HealthTaxonomy

Risk Adjustment

Model

WORKFLOW INTERGRATION

SUSPECT IDENTIFICATION

ANALYTICS & REPORTING

Billing and Coding

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2/23/2016

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Accurate Coding Based on Clinical Taxonomy

INDUSTRY STANDARDS CALIBRATIONMost precise and comprehensive healthcare taxonomy for all healthcare segments mapping multiple industry standard terminologies including

• ICD‐9, ICD‐10• MESH, NCI THESAURUS, GENE ONTOLOGY, OMIM• SNOMED, LOINC, HCPCS, DRG• RXNORM, NDC

1+ MILLION CONCEPTS BASED ARCHITECTURE Concepts with many attributes including

• Synonyms, Abbreviations, Acronyms• Misspellings• Homonym Identification• Stemming Correction Lists

2+ MILLION SEMANTIC RELATIONSHIPS WITH RANKINGS Unique in the industry and include

• Disease to Drugs • Disease to Symptoms • Disease to Treatments • Disease to Diagnostic Procedures • And many others with Ranking strength

HISTORY OF THE TAXONOMY

Highly‐iterative effort over 15 years in development by a dedicated team of Medical Professionals and Data Scientists and tens of millions of R&D dollars in multiple implementations & domains. 3rd party verifications

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Timely Reporting

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Results

• 100% Provider engagement

• Improved suspect identification

• Point‐of‐care integration

• Prospective and retrospective review

• Monitor and analyze ongoing performance

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Next Steps

• Fine‐tuning to optimize precision / recall

• Implement at CRHP

• Measure coder productivity improvements

• Integrate into provider compensation matrix

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2/23/2016

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Summary

Think of RA as part of your broader mission and pop health goals

Empower internal champion(s) to drive the process

Choose a product that will enable accurate coding according to true illness

burden

Using technologies to leverage all data in the patient record (e.g. claims, prior

history, Rx, Lab, unstructured narratives)

Must be intuitive, easy‐to‐use and integrated into workflow

Look for robust and dynamic reporting & analytics for ongoing improvement

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Questions?

Thank You

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Track C

Managing the Impact of Patient Self‐Pay on EMR Processing

Jeannie Hennum, Senior Vice President

CIOX HEALTH

Tressa Lyon, RHIT, Health Information Manager

NORMAN REGIONAL HEALTH SYSTEM

Jeannie Hennum ‐ Senior Vice President of Sales at CIOX Health Jeannie is responsible for developing relationships between health plans and health care providers. She also is responsible for internal education as to the importance of why medical records are utilized by health plans for initiatives such as NCQA/HEDIS and CMS Medicare Advantage Risk Adjustment programs. Prior to joining CIOX Health, Jeannie worked at several healthcare information solutions companies providing consultative services to the Quality, Revenue Integrity and Claims Adjudication departments at many national, regional, and local health plans. In the course of her 23 years’ experience in working with health plans, Jeannie has served as a Regional Sales Director at Outcomes Health Information Solutions, the Vice President of Business Development at Health Solutions Plus, and as the President and Chief Executive Officer for Linnaeus, Inc. Jeannie is a former Board Member for the State University of New York Children’s Center at Cortland.

Tressa Lyon has been working for Norman Regional Health System for 13 years. Tressa was the HIM

supervisor for 6 years and for the past 3 years has been working as the HIM Manager. Tressa worked

many years as a certified nursing assistant where she gained her clinical back ground. She is actively

involved with OkHIMA serving as the OkHIMA annual conference vendor chair, Advocacy Manager and

education coordinator elect. Additionally, Tressa serves on several committees within her health

system.

3/4/2016

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Managing the Impact of Patient Self-Pay on EMR Processing

March 21, 2016

Tressa Lyon, RHIT, Health Information Manager, Normal Regional Health SystemJeannie Hennum, Senior Vice President, CIOX Health

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Topics

• Evaluating the Pros and Cons of Remote EMR Access

• How Patient Self-Pay Rules Impact EMR Processing

• A “Behind the Scenes” View of the EMR Chart Request Fulfillment Process

• Methods for Ensuring Providers, Plans & Patients are Protected

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The Pros and Cons of Remote EMR Access

Health Plan’s Perspective

• Pros:– Easier Access to Records

– Quicker Turnaround Time to Obtain Records

– Direct Oversight of Retrieval Team

• Cons:– Training on Many EMRs

– Constant IT Support

– Expense of Infrastructure

– Expense of Personnel

– Inability to Ensure Patient Self-Pay Authorization

Provider’s Perspective

• Pros:– Decreased Onsite Personnel

– Lower Cost to Produce Records

– Faster Turnaround Time

• Cons:– Training on EMRs

– Constant IT Support

– Expense of Infrastructure

– No Direct Oversight of Information Released

– Inability to Ensure Patient Self-Pay Authorization

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Patient Self-Pay Rules & EMR Processing

• The Rule: The Health Insurance Portability and Accountability Act (“HIPAA”) Omnibus rule (“Megarule”)

– Issued in January 2013– Significantly revised HIPAA by strengthening the privacy and

security rules designed to protect individual’s protected health information (“PHI”) and the national standards to secure the integrity of electronic PHI.

• The EHR: Covered Entities and Business Associates that use EHRs must be able to respond to patient requests to restrict the use or disclosure of PHI upon request.

• The Problem: This may pose a problem for those using EHRs since the patient request must be honored each and every time the healthcare provider accesses the patient’s PHI.

• The Example: A patient that exercises his or her right to restrict disclosure of mental health diagnosis or sexually transmitted disease diagnosis must be made known to the healthcare provider using the EHR.

• Considerations: – Automatic prompts within the EHR to remind healthcare providers to restrict

use and/or disclosure of a patient’s PHI might be needed to ensure that layers of protection are built into the EHR to adhere to this new Megarule requirement.

– In addition, secure log-in requirements might be needed to ensure restricted data within the EHR is not shared with others in accordance with the patient’s request to restrict his/her PHI.

The Megarule implemented many of the changes required by the Health Information Technology for Economic and Clinical Health Act (“HITECH Act”) which was enacted as part of the American Recovery and Reinvestment Act of 2009 (Pub.L. 111–5). The final Megarule was effective March 26, 2013 and compliance with the Megarule begins on September 23, 2013. The Megarule modifies the privacy standards located at 45 C.F.R. parts 160 and 164, subparts A and E (the "Privacy Rule"), the security standards located at 45 C.F.R. parts 160, 162 and 164, subpart C (the "Security Rule"), and enforcement standards located at 45 CFR part 160, subparts C, D, and E (the "Enforcement Rule").6 This article surveys the major areas where the Megarule has implications for the use of EHRs – the Privacy and Security Rules.http://www.americanbar.org/content/newsletter/publications/aba_health_esource_home/aba_health_law_esource_1305_barrett.html

3/4/2016

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• Before Processing (or remotely accessing a medical record): Self-pay status must be checked to determine if patient requested this information to be restricted from their health plan.

• Patient Restrictions: If a patient chooses NOT to file insurance on a particular date of service or other incident of care (typically called a “self-pay” encounter) and requests that information about that encounter not be disclosed to her/his insurer, the PHI must not be accessed/disclosed to the health insurer.

• How to Access the Restrictions: You must know where it is for paper and electronic records at each facility.

– Every facilities’ policy may be different , for example…• Flag System in EMR and/or MPI (Master Patient Index)

– Note that flags added at the MPI level may not cross to every source system (EMR) and may require a centralized validation point for the flag or marker where information is not authorized to be disclosed

• Form in patient medical record• Or, separate filing system

• Other Complications: – The patient must have paid for the entire visit in full, AND have requested the restriction for

the restriction to apply.– Further, while it may be paid in full by the patient, it may be contained within another service –

“bundled” service. Example, patient may have paid separately for a lab test while in the ER for a car accident.

Patient Restrictions: How to Process Requests

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• The standard is a “low probability of compromise” of the data, meaning that is more critical than ever that you remain vigilant to avoid breaches.

• If breach or even suspected breach occurs, immediately notify the party and document the details of the suspected breach.

• Fines range from $100 to $1,500,000

Business Associates Directly Liable for Breaches

3/4/2016

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Changes at Norman Regional Health System

• Process Changes:– Committee formed to ensure compliance

– Forms changed, new forms and policy/procedure created

– Created self-pay responsibility agreement

– Process for receipt of payment and process for no payment received

– Process for securing the medical record and ensuring compliance

– Audits performed to ensure compliance and provide education

In a Nutshell: The patient’s

medical record may not be released if

patient did not sign authorization

• Where do the requests go to within a health system?

Where in Norman are the Health Plan Requests?

Health Information Mgt

Quality & Compliance

Managed Care Department

Practice Sites

COO’s Office

Billing Dept

Risk ManagementHuman Resources

Revenue Integrity

3/4/2016

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• Processing workflow – once we get your requests…• Request is received & reviewed by staff member to determine type of audit • Request manually entered into disclosure tracking system• Request is manually entered into audit relief system• If multiple patients are on one list, that number of copies is made. Each patient is de-

identified except one. This allows the requests to be scanned to each chart and allows for a cover sheet when records are mailed.

• Records are printed & reviewed to ensure patient security• Records are mailed; depending on requestor, records are sent with tracking information• Closed out in disclosure tracking with:

– Number of pages sent– Date sent– Documents sent– Mode of delivery

• Records entered into audit relief system with– Date received – Who signed off – Tracking numbers– Notes– Records are tracked and monitored for denials

• NOTE: Process is electronic for connected health plans for HEDIS and Risk Adjustment

EMR Process – A Behind the Scenes View

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• Case Study: Requests Reported Missing…

• Resulted in determining the need for Centralization of the Request Intake Process & Delivery tracking

• Build or Buy?

• Used established relationship with Release of Information (ROI) vendor– Knowledge of Systems

– HIPAA Expertise

– HIPAA Accountability

– Electronic Relationships with over 140 health plans and vendors

PHI Protection for Plans, Providers & Patients:

3/4/2016

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Best Practices

• Integrated Technology – Health Plan Requests & Provider Processing Systems

• ROI Specialists Perform Patient Self-Pay Verification

• Improves Chart Collection: Speed, Quantity & Quality

• HITRUST Certified

Charts at Connected Provider Sites

Charts at All Other Sites

Call CenterVerification

Grouper

Health Plans

Chart Request Files

Health Plan Request Management System

Centralized Intake& QA

ChartsProcessed

Charts Delivered to sFTP1

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3

46 5

ROI Specialists

Connected Provider Personnel

All Other Sites

ROI Specialists or Connected Provider Personnel push button in Provider Processing System to download medical record requests

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Questions?

Tressa Lyon, RHIT, Health Information ManagerNorman Regional Health System

405-307-1362; [email protected]

Jeannie Hennum, Senior Vice PresidentCIOX Health

770-360-1870; [email protected]

Track C

Provider Perspective: Making the Payer‐Provider Connection – Improving Outcomes with Better

Communication and Collaboration

Michael Ruiz de Somocurcio, Vice President – Payer and Provider Collaboration

REGIONAL CANCER CARE ASSOCIATES LLC

Michael Ruiz de Somocurcio

Mr. Ruiz de Somocurcio is Vice President of Payer and Provider Collaboration for Regional Cancer Care Associates. RCCA is the largest independent oncology group in the Northeast with over 120 oncology providers located in New Jersey and Maryland. His responsibilities include health plan contracting, developing value based arrangements that includes bundles and episodes, identifying providers for clinical integration along with supporting growth strategies for entering additional markets. Prior to RCCA, he has spent over 15 years on the health plan side working for national, regional and start-up health plans. Most recently he served as COO of Amerigroup NJ, where he had responsibility for operations, network and marketing functions. Prior to that he served as VP of Network Strategy for Oscar Insurance Corporation, a start-up health plan based in New York City. He joined the team prior to launch and was a key member in developing the insurance arm of the organization and in gaining approval and licensure to expand into additional markets.

In his career, he has led and closed negotiations worth billions of dollars in medical spend; developed and created medical cost containment strategies saving millions of dollars; built narrow and tiered network products based on cost, quality or provider partnerships; and developed mutually beneficial provider engagement strategies that moved toward paying for value. He has spoken both locally and nationally.

DRAFT 3/14/2016

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Provider Perspective: Improving Outcomes with Better

Communication and Collaboration with Payers

Provider Perspective: Improving Outcomes with Better

Communication and Collaboration with Payers

ByMichael Ruiz de Somocurcio

VP, Payer and Provider Collaboration

Proprietary and Confidential

Regional Cancer Care Associates OverviewA Multi-State-Manager of Oncology Care

Founded in New Jersey in 2012 as a integrated oncology practice

Largest independent, physician led, oncology group in the northeast

Although independent, our physicians are the heads of oncology at majorhospitals in our area

30 locations in New Jersey, Maryland and Washington, D.C.

120 oncologists along with another 10 gyn-onc and breast surgeons and radoncologists

800+ personnel

RCCA physicians treats 43% of ALL Cancer in NJ

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DRAFT 3/14/2016

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Plan Programs

Horizon – currently running upside only bundles with a total cost of care budget

Hormone Only Breast bundle, Adjuvant Colon and Metastatic Lung

CIGNA – in their episode program for patients undergoing any type of chemo

Aetna – currently reviewing their oncology medical home program. Will be participating shortly

United Healthcare– in their 3 year episode pilot program with 4 other national practices. Initial 5 practice episode saved $33million compared to national averages

CMS Oncology Care Model – application in, announcements coming soon

3


Common Themes We Are Hearing From Our Health Plan Friends

1. Compliance with Evidence Based Clinical Guidelines/Pathways

2. ER utilization

3. IP admissions/readmissions/lengths of stay

4. Generic usage

5. Patient Education and Satisfaction

6. Enhanced patient access (24/7 with EMR)

7. Advanced Ancillary Utilization (specifically imaging and lab)

8. Transition of Care/Patient Navigation/Advanced Care Plans

9. End of Life Management/Palliative Care/Hospice Use

10.Total Cost of Care

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DRAFT 3/14/2016

3


Oncology Costs

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What’s driving cost increases and why are the plans and other providers approaching us?

Highest cost category isn’t cancer alone. It’s a diabetic, COPD or CHF patient who develops cancer

– When an ACO or PCMH receives their total cost of care data, this category is highest– Multiple chronic conditions requires clinical collaboration among providers

Increasing Drug Expenses– Ever increasing drug and treatment expenses are putting pressure on patient access and

the healthcare system. $100k drugs are being released consistently

Utilization Expenses– Unnecessary ER visits and admits that could be managed more effectively in other

settings, patient triaging or by opening later/weekend hours– Continued Duplication of services along with substantial site of service differentials for

commoditized services

Impact of Provider Consolidation–Hospital consolidation has increased the total cost of care once employment occurs as referral patterns change–Smaller physicians groups find it very difficult to compete in a value based world

6

DRAFT 3/14/2016

4


Drugs, Drugs and More Drugs………

Demand Drivers

Drug Pipeline

Oncology costs are expected to dramatically increase as much of the current drugs treatments are replaced

7


Cost Differences – Community Oncology vs. Hospital Based

Study found “significantly higher per-episode cost for chemotherapy drugs, radiation oncology, imaging (CT, MRI and PET scans) and laboratory services”

in outpatient hospitals

8

Cancer Type Location

PhysicianOfficeVisit

(POV)

HospitalOut-Patient

(HOP)

HOP/POV Episode Cost –

% Higher in HOP

Metastatic

Non-Small Cell Lung $ 82,849 $ 122,909 48.4%

Colo-Rectal $ 122,300 $ 186,541 52.5%

Breast $ 115,308 $ 158,727 37.7%

Adjuvant

Non-Small Cell Lung $ 44,769 $ 60,994 36.2%

Colo-Rectal $ 79,058 $ 101,060 27.8%

Breast $ 57,809 $ 86,857 50.2%

Source: Comparing Episode of Cancer Care Costs in Different Settings: An Actuarial Analysis of Patients Receiving Chemotherapy, Milliman, August 2013

DRAFT 3/14/2016

5


Our Approach

9


Strategy for these programs

Standardization of Quality Metrics• There are various sources for quality metrics: CMS, QOPI, NQF, IOM• Ensure alignment with our EMR vendor from a reporting standpoint –automation key

Non-standardization as it relates to the Dollars• Flexibility needed here and goal is to learn how each works• We are currently in bundles, episodes, oncology medical homes and shared savings

arrangements although very little downside risk currently• The goal is to prepare now for added risk prior to market calling for it• Need for up front investment in technology

We will need to get data and also to give data• Plans also have different capabilities as it comes to providing info• We have the capability to provide specific data points back through our partnership with

COTA – we can provide info at a specific subtype of cancer• This will enable us to measure treatment variation

Need to be at the forefront of narrow and tiered networks and clinical integration– Medicaid and medicare present growth opportunities

10

DRAFT 3/14/2016

6


Why is participating in these important???

The market is moving in this direction with or without us. Medicare and the plans have made announcements to pay 50-80% of care based on value (OCM)

The data we can get is invaluable – shows us life outside of our walls, gaps and also best treatments by type of condition and also variation by physician

Patients deserve coordinated care, especially when they have other co-morbidities

Enables us to keep our patients in our communities. We have new market entrants who want our patients. We need to integrate with other independents and these programs provide the foundation for this

Narrow networks are becoming more important – providers have to continually show value to be included.

11


Clinical Integration

12

DRAFT 3/14/2016

7


Clinical Integration is Key to any Partnership

RCCA has created an oncology clinical integration plan to work in conjunction with Hospitals, ACO’s and independent physician groups

• Each group and ACO are at different stages in their value based journey

• We like to plug our standardized program into what they have created

• We are fantastic at treating cancer, not as great at treating diabetes or asthma – how do we return patients?

• Referral management and patient navigation within the clinically integrated network is key

• Clinical integration doesn’t always have to require technological integration, could be shared treatment plans and care coordination

• Shared data among entities enables better decisions, less duplication and better patient experience

13


RCCA’s Oncology Care Clinical Integration Model

Disease Mgt Plan

Active Care

Follow-Up Care

Primary Care

Transition Execution

Oncology Treatment

Comorbidity Mgt

PAC Mgt

Patient Performance

Clinical Performance

Oncologic Care

Primary Care

Monitor

Clinical Integration ModelFocus is on a comprehensive disease management plan

Coordinate execution with existing overall care.– Oncology Specific Care. Manages oncology treatment to

deliver maximum dose intensity, progression free survival and overall survival.

– Non-Oncology Care. Ensures continuing delivery of primary care to manage comorbidities and reduce adverse conditions that might adversely impact oncology treatment.

Analyze clinical outcomes after active oncology treatment– Continue Active Care– Commence Follow-Up Care– Return to Routine Primary Care

14

DRAFT 3/14/2016

8


Data is IN!

15


Data is a Valuable Currency

Membership attribution isn’t easyWhich patients are included in our programsHow will they be identified?How are costs different?When does a cancer episode start and end?What other conditions do patients have?

Data from our plan partners is critical (did I say timely) Some plans are further ahead than others in their capabilitiesWe have been advocating for PCMH level dataOnce you get the data, it can’t sit on an SFTP site – we have to do something with itHow will we identify people who need action/intervention based on that data

Need for analytics to identify variation in careThe key is at the physician level – whether its regimens, imaging utilization, in network referrals,

hospital spend, labs Its not only your own utilization, but also the cost and utilization of who you refer to.

16

DRAFT 3/14/2016

9


Its all Connected

To ensure patients get better high quality care where costs in the system are lowered, you need:

Data – not only as to what happens around you, but also how each person performs

Contracting has to align with end goals to ensure this change is financed

Clinical Integration will ensure patients continue to come even with continued consolidation and also that they stay with us and receive holistic, coordinated care

Standardized Quality metric reporting will ensure we hit not only our patient goals but financial incentives

Technology is critical! Easier to change things when its user-friendly and easy

This is a journey, but it requires a culture to successfully enable it

17

Thanks For Your Time!

Any Questions?

Contact Info:Michael Ruiz de Somocurcio

Vice President, Payer and Provider CollaborationRegional Cancer Care Associates

[email protected]

Thanks For Your Time!

Any Questions?

Contact Info:Michael Ruiz de Somocurcio

Vice President, Payer and Provider CollaborationRegional Cancer Care Associates

[email protected]

Track C

High‐Risk Population Management: The New Frontier of Care Delivery

Andrew Walsh, Chief Marketing Officer

POPHEALTHCARE

Pam Coleman, Former Deputy Director for Medicaid / CHIP

TEXAS HEALTH & HUMAN SERVICES COMMISSION

Andrew Walsh, Chief Marketing Officer, PopHealthCare Andrew Walsh is the Chief Marketing Officer at PopHealthCare with over 20 years of sales, operating and leadership expertise that spans across the healthcare and outsourcing industries. Andrew was the founder and CEO of Educerus Health, which was acquired by PopHealthCare in 2014, where he developed a clinical assessment platform for identifying patients at risk for a variety of undiagnosed chronic conditions. Through this work, Educerus helped clients bridge significant revenue and quality gaps through earlier detection of disease burden among their members. Before launching Educerus, Andrew held leadership positions within the healthcare industry, including DaVita Healthcare Partners, UnitedHealth Group and its subsidiaries, including Optum, where he was responsible for Medicare risk adjustment product strategy, and SecureHorizons, where he was responsible for all sales operations within their Medicare Advantage business, including full staff and $65MM budget responsibility for a distribution network of over 30,000 licensed agents.

Pam Coleman – Former Deputy Director for Medicaid / CHIP, Texas Health & Human Services Commission Pam is a health and human services executive with extensive experience creating solutions for funding, managing, and improving Medicare and Medicaid services for the disabled. Pam is a pioneer in LTSS nationally and in Texas. In Texas she was a leader in the design and implementation of the STAR+PLUS program – the first mandatory managed long term services and supports model and the first 1915(b)(c) waiver combination in the country. STAR+PLUS became the model used by other states for their MLTSS programs. Over the years Pam has consulted with a number of other states including California, Florida, Rhode Island, New Mexico and Pennsylvania on the design of their integrated managed care programs. Prior to her work in managed care, Pam was lead on the development and implementation of a new case mix based reimbursement system for Texas nursing homes.

3/15/2016

1

Proprietary and confidential, PopHealthCare LLC 2014 1

High-Risk Population Management: The New Frontier of Care Delivery

Introductions

Pam Coleman

• Former Deputy Medicaid Director for the Texas Health & Human Services Commission

– Responsible for state’s Medicaid & CHIP programs serving > 3.5M beneficiaries

– Led the development of the STAR+PLUS managed care model that provides integrated acute, behavioral and long term services & supports for seniors and persons with disabilities

• Well known expert in Medicaid integrated managedcare, with experience:

– Implementing programs for complex populations with the need for home & community-based services

– Healthcare delivery system redesign & transformation

– Innovative accountable care approaches to service delivery & payment reform

Andrew Walsh

• Current Chief Marketing Officer, PopHealthCare

• Founder & CEO of Educerus Health (acquired by PopHealthCare in 2014)

• Various leadership roles with Davita Healthcare Partners, Optum and Secure Horizons

© 2015 PopHealthCare LLC All rights reserved. Not for distribution. 2

3/15/2016

2

Abstract

Even with system-level changes underway

as a result of the shift towards value-based

purchasing, opportunity still exists (and

will continue to exist) to improve the costs

and outcomes associated with high-risk

populations. Proprietary and confidential, PopHealthCare LLC 2014 3

System challenges at a glance


16.9

11.6 11.3 10.910

9.3 9.3 9.1

7.36.2

5.4

0

2

4

6

8

10

12

14

16

18Despite higher costs, health care outcomes in the U.S. are not significantly better.

Despite higher costs, health care outcomes in the U.S. are not significantly better.

Hea

lth $

as

a %

of G

DP

Source: OECD Health Statistics 2014. http://www.oecd.org/unitedstates/Briefing-Note-UNITED-STATES-2014.pdf

3/15/2016

3

Higher spending doesn’t correlate to better outcomes…


USA Ranking

Overall Ranking (2013) Last

Patient-Centered Care Middle Quartile

Access Bottom Quartile

Efficiently Last

Equity Last

Healthy Lives Last

Health Expenditures/Capita, 2011** $8,508

Source: Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund, June 2014. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

Factors complicating progress


Industry silos:

• Delivery system – plans / providers / specialists

• Health plans – Legacy functional structures don’t always interrelate well

The Slow Turn Towards Value:

• Delivery system still rooted in fee-for-service

• Inherent challenges even with the most promising models – ACOs & PCMH

• “Heads in Beds” vs. Pay for Value

3/15/2016

4

Demographics complicating progress


43.15

72.77

0

10

20

30

40

50

60

70

80

2012 2030

Millions

The aging of America – The >65 age group is expanding

significantly

Source: US Census. An Aging Nation: The Older Population in the United States, May 2014. https://www.census.gov/prod/2014pubs/p25-1140.pdf

All Members All Spending

And Medicare spending is already highly concentrated – expect continued

cost pressure

Source: MedPac. A Data Book: Health Care Spending and the Medicare Program, June 2014. http://www.medpac.gov/documents/publications/jun14databookentirereport.pdf

A closer look at the 5% (aka “Super-Utilizers”)

Other Super-Utilizer characteristics

– 2 or more ADL dependencies

– Experienced at least one hospitalization in the last year followed by a rehab stay

– Meet the medical necessity criteria for nursing facility care

– Many are dually eligible for Medicaid and Medicare


$87,236$77,833

Serious Mental Health Diagnoses

(41%)

Multiple Chronic Diseases (42%)

The Two Largest Clinical Categories

Source: MedPac June 2015 Data Book – Section 4 Dual Eligible Beneficiaries

3/15/2016

5

Dynamics are even more complicated when Duals factor into the population mix


10MM Dual Eligible beneficiaries (approx 25% of Medicare population)

Average PMPY cost for a Dual member = $30K

$30K

$10K

25%

Duals often don’t have a usual source of care Significant state interest in shifting location of care from nursing homes and into the community

PLACEHOLDER - Third bullet of abstract

• Restructuring contracts

– It’s not all or nothing

• When they have moved to value based model, focus on high risk members

• Not good enough to just move members under a new contracts

• New arrangement will still have members that are high risk

• HP should not assume the provider group has the means and tools to support the high risk

• Does not solve the problem


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6

Moving members to a new contract does not change risk profile of the population


Health Plan

MED RISK

LOW RISK

HIGH RISK

Moving members to a new contract does not change risk profile of the population


Health Plan Provider (ACO / PCMH)

MED RISK

LOW RISK

HIGH RISK

Value-Based Contract

3/15/2016

7

Value-based arrangements do not change the underlying reality: high risk members have very unique needs that warrant a different approach


High Risk Patients still need access to the right tools and care

Can’t assume the provider group has the means and tools to support the high risk

© 2015 PopHealthCare LLC All rights reserved. Not for distribution. 14

HIGH RISK

3/15/2016

8

Instead, consider alternate strategies for high-risk members

15

MED RISK

LOW RISK

HIGH RISK

Value-Based Contract

Health Plan Provider (ACO / PCMH)


16

3/15/2016

9


17

MED RISKLOW RISK HIGH RISK


18

MED RISKLOW RISK HIGH RISK

3/15/2016

10

Strategies to consider for high risk populations

• Reaching persons that have difficulty accessing care – by bringing the care to them where they live

• New person centered approaches to serve persons in the community and keep them out of institutions including hospitals and nursing facilities

• Acute care transitions that ensure appropriate supports are in place in the home following hospitalization including provider or nursing visits.

• Transition of persons from nursing facilities to home before they become long-term stays

• For long term nursing facility residents offer transition assistance and housing options to return to the community.

What does a focused high risk program look like?


It is a high‐risk population care program that delivers face‐to‐face, in‐home treatment and care support

It is a high‐risk population care program that delivers face‐to‐face, in‐home treatment and care support

It is unique in bringing together the best practices from care management, provider house calls, and risk‐adjusted revenue programs

It is unique in bringing together the best practices from care management, provider house calls, and risk‐adjusted revenue programs

It delivers care, including:• 24/7 care team access• Accountability for member

engagement• Rx management • Care coordination across

patient’s entire care team

It delivers care, including:• 24/7 care team access• Accountability for member

engagement• Rx management • Care coordination across

patient’s entire care team

It is NOT simply an evolved in‐home assessment model!

It is NOT simply an evolved in‐home assessment model!

3/15/2016

11

Top Components of Chronic Care Management Programs


11.3%

50.9%

56.6%

56.6%

66.0%

67.9%

69.8%

81.1%

81.1%

81.1%

83.0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Other

Palliative Care

Community Links

Medication Assessment

MD Referrals

Written Plan of Care

Caregiver Education

Case Transition Management

Self Management

Prevention

Post-Discharge Follow-up

Source: 2015 Healthcare Benchmarks: Chronic Care Management, March 2015. http://www.hin.com/chartoftheweek/top_components_of_chronic_care_management_programs_printable.html#.VgRsw01OUy9

Must all be part of effective High Risk ProgramMust all be part of effective High Risk Program

Effective approach to managing High-Risk Populations


3/15/2016

12

Analytics: Program-level scoping & member-level targeting


Program-level scoping:

• Critical baseline analysis for pre/post methodology

• Joint understanding of what & where the impact lies

• “What levers can we pull?”

Member-level targeting

• Target the right members –not just the most expensive, but also the most impactable

• Prioritize based on anticipated acuity levels

Engage – Member Outreach Enrollment & Scheduling


Engage: Member Outreach, Enrollment & Scheduling

Outreach takes two forms: 1. Proactive outreach conducted

by PopHealthCare on behalf of the plan

2. Referral-based enrollment from various provider and health care resources

Eligibility is based on mutually agreed upon criteria

Referral Based

Enrollment

Proactive Outreach

3/15/2016

13

Assess & Plan Care – Medical and Behavioral Evaluations


Assess & Plan: Medical & Behavioral Evaluations

• Our goal during this stage: get to know the member on an individualized basis and understand what is driving the utilization and care patterns

• We work with the member to develop a person-centered care plan that is based on medical, behavioral and social elements and is customized to work for them and desired outcomes

• In doing so, we close HCC and quality gaps.

Provide Care - Complex Medical and Behavioral Interventions


Care: In-Home Complex Medical & Behavioral Interventions• Our in-home care delivery

focuses on executing and adjusting, where necessary, the patient-centric care plan

• The customized care plan is based on medical, behavioral and social elements

• Provider-led care team• Care team is available 24/7/365

3/15/2016

14

Outcomes Evaluation and Program Reporting


Report: Outcomes Evaluation & Program Reporting

Our reporting aspires for program transparency • Operational Reporting: visibility

into success of patient engagement

• Clinical and Financial Reporting: demonstrates the direct impact we’re having on the ROI goals we set for the program

High-Risk Member Care Program: Case Study

• Participant Highlights:

– 16,298 member months in 2015

– Intensive level membership: 39% of total MMOS

– 48% assisted living center (ALC) and 52% community-based members

• Clinical Process Measures

– Exceeded performance benchmarks on all contractual measures, including:

• HbA1c Testing

• HbA1c Control (<9.0)

• LDL Screening

• Flu Shot administration

• Readmission Rate target

• In-Home Assessments Revenue Impact

– $1,489,881 in estimated value (net of community provider HCC capture and death and disenrollment estimates)

– ROI of 2.84


3/15/2016

15

High-Risk Member Care Program: Case Study


-30.0%

-32.3%

-35.6%

-30.1%

Performance vs. Baseline

MLR: Sum of claims/(RAF*760)Baseline: Prior 12 months from CareSight Eligible (Feb 2014 – Sept 2015)Program: Cost and utilization while a program participant (Jan 2015 – Sept 2015

Admits/K SNF Admits/K MLRPMPM

Summary

• Healthcare system has some systematic and demographic factors that complicate a quick turn towards progress

• Plans should consider different, parallel &/or carve-out strategies

– Shifting risk is not enough

– Delivery system not optimized to care for the high-risk member

• Person-centered is key

• A comprehensive longitudinal care program that focuses on high-risk members has been proven to show results in care, quality and revenue


3/15/2016

16

Questions?

Track C

Early Insights into Medicaid Expansion: What We’ve Learned To‐Date

Moderator:

Kim Browning, CHRS, PMP, CHC, Executive Vice President

COGNISIGHT

Co‐Presenters:

Eric C. Hunter, Chief Operating Officer

BMC HEALTHNET PLAN/WELL SENSE HEALTH PLAN

Dhyan D. Lal, Vice President, Network Strategy and Contracting ‐ Payer Strategy Group | Pacific

Northwest Region

CATHOLIC HEALTH INITIATIVES

K. Browning Bio for Risk Adjustment Forum (due 4/14) 04/02/15

Name: Kim Browning

Title: Executive Vice President

Company: Cognisight, LLC

Email: [email protected]

Phone: 585.662.4215

Headshot:

Bio: As Executive Vice President at Cognisight, Kim is responsible for corporate operations, compliance, and product development. She has more than 20 year’s experience in health care business and technology, including software development, sales and marketing, strategic planning, and management.

Kim’s particular expertise lies in health care operations and P&L accountability of Medicare and Medicaid lines of businesses. She has held leadership positions with health care plans and developed proprietary software solutions in the risk adjustment arena. Under Kim’s leadership, Excellus BCBS was ranked #1 in New York State and tied for #2 in the nation by US News & World Report in 2009 for Medicaid contractors.

Kim is a graduate of SUNY Buffalo where she received her BS in both Business Studies and Business Administration. She also holds several post graduate certifications, including: Certified Project Management Professional, Certified Healthcare Consultant and most recently, Certified Healthcare Reform Specialist.

### 147 words

Eric C. Hunter serves as the Chief Operating Officer for the Boston Medical Center HealthNet Plan based in Boston, Massachusetts. In this role, Mr. Hunter is responsible for the leadership and strategic direction of multiple operating units at BMCHP and he is the Executive sponsor of the Well Sense Health Plan Medicaid line of business in New Hampshire. Prior to joining BMCHP, Mr. Hunter held Executive roles with ValueOptions, Centene, Schaller Anderson Inc., the State of Oklahoma Health Care Authority and the Oklahoma Office of the Governor.

Dhyan D. Lal Regional Vice President of Payer Strategy & Operations Pacific Northwest Region

Dhyan Lal serves CHI Franciscan Health as the Regional Vice President of Payer Strategy & Operations for the Pacific Northwest region. Mr. Lal is a seasoned healthcare professional with an extensive and diverse background. His career highlights include senior management positions at Tenet Healthcare, Vice President of Operations for a multi-specialty medical group in Southern California, and most recently he was the Director of Payer Contracting for Providence Health & Services, Washington/Montana Regions and Swedish Health System.

He was a member of the Insurance Reform Advisory Group as part of the Joint Select Committee on Health Reform for the State of Washington. Dhyan Lal served as a member of the Washington State Health Exchange Advisory Committee from 2012 – 2015.

Mr. Lal received his Bachelor of Science degree in Health Administration from California State University, Northridge and holds a Master’s degree in Business Administration from Saint Mary’s College of California.

2/16/2016

1

Early Insights Into Medicaid Expansion: What We’ve Learned To‐Date | 03.22.16

Part I: Part II: Moderator:Eric C. Hunter Dhyan D. Lal Kim M. BrowningChief Operating Officer VP of Network Strategy & Contracting Executive Vice President

Early Insights Into Medicaid Expansion | Part I:What We’ve Learned To‐Date

2/16/2016

2

3

Boston Medical Center HealthNet Plan Mission

To serve Boston Medical Center and to assist BMC’s mission in providing and enhancing access to effective, efficient

medical care among low income, underserved, disabled, elderly and other

vulnerable populations

4

Massachusetts Expansion

• Massachusetts was ahead of the curve with Medicaid expansion

• Created new aid categories within the MassHealth Medicaid system for expansion members

• Medicaid care delivery system is fragmented with MassHealth/CarePlus, Fee‐For‐Service, and PCC system

• Made the decision to incorporate new Affordable Care Act expansion and exchange requirements into existing eligibility system

2/16/2016

3

5

New Hampshire Expansion

• 49k members

• New Hampshire was a late adopter of Medicaid Managed Care and Expansion

• New Hampshire is moving with due diligence to bring all populations into Managed Care

• Political Realities led to creation of a “Bridge” program for expansion

• Legislature is currently debating the future of expansion

6

Common Financing Issues

• There have been challenges for actuaries to accurately predict the costs related to serving this population

• States are preoccupied with the future obligations for their budgets when the Federal share decreases

• Budget impacts of the “woodwork” or “welcome mat” effect

2/16/2016

4

7

Common Administrative Issues

• States, Health Plans, and Providers must deal with members moving between products

– Worse than expected

• Health Plan networks were not necessarily aligned with the needs of the new population

• Utilization uncertainty makes alternative payment methods more challenging

Early Insights Into Medicaid Expansion | Part II:What We’ve Learned To‐Date

2/16/2016

5

9

Current Medicaid Environment Coverage expansion through ACA resulted in significant increased enrollment in Medicaid

• Approximately 1.7 million covered lives

• 534K new enrollees via expansion (as of 3/1/2015)

Market dynamics and challenges

• Enrollment moving to Managed Plans

• Shifting payer mix

• Primary care capacity (lack of…)

• Payers payment policies reducing reimbursement

PayerFranciscan HealthMarket Share

Molina 33%

United 20%

CHPW(CommunityHealthplan of WA)

20%

Centene(Coordinated Care)

15%

Amerigroup(Anthem)

12%

Medicaid Overview in Washington

10

Strategy To better manage the population within existing funding levels Move to value based contracts with shared savings payment methodologies Create innovative approaches to handle the unique needs of a Medicaid population Develop primary care strategies to increase physician and clinic capacity Collaborate with payers on new models of care

PayerFranciscan HealthMarket Share

Molina 33%

United 20%

CHPW(CommunityHealthplan of WA)

20%

Centene(Coordinated Care)

15%

Amerigroup(Anthem)

12%

Medicaid Overview in Washington, cont.

2/16/2016

6

11

There were significantly more newly eligible and previously eligible but enrolled (welcome mat) patients than anticipated by WA• Highest estimate prior to ACA was approximately 380K• Actual is closer to 550K (numbers likely to rise by Q1 2016)

Surprisingly, the concerns about pent‐up demand for healthcare and adverse selection did not come to fruition• In most instances across the Managed Medicaid Organizations, overall PMPMs were less than current cost experience

Lessons Learned from Expansion

12

The Good Reduced bad debt and charity care due to more people having coverage. Patients having access to care and connecting with a provider and health system.• Greater coordination of care across the continuum

Better outreach and education to patients (ED diversion)

The Bad Eroding payer mix Causing capacity and access issues in primary care and hospitals Patient churn and lack of understanding how to navigate healthcare

Impact to Providers: The Good & Bad

2/16/2016

7

13

Medicaid Risk:The Value Proposition for Taking Medicaid Risk

1. Appropriate reduction of utilization through effective care management• ED use reduction

• Readmissions

• Access to prenatal care

• Reduced operating expenses since most Medicaid is negative margin business

2. Create capacity for patients who need access to care

3. Share in the arbitrage (or take full risk) due to lower total cost of care accomplished through appropriate reduction in utilization and more effective care management across the continuum

14

Thank You!

Track C

Engaging Your Dual Eligible Population: Member Segmentation and

Outreach Strategies That Drive Results

Mary R. Mailloux MD, MMM, FACEP, Medical Director Medicare Special Needs Plans (SNP)

COVENTRY HEALTH CARE OF FLORIDA, AN AETNA COMPANY

Katrina Cope, Vice President Operations

HEALTH CHOICE ARIZONA

HEALTH CHOICE GENERATIONS

David Goodspeed, Director Member Engagement

MATRIX MEDICAL NETWORK

Mary R. Mailloux MD, MMM, FACEP

Dr. Mary Mailloux is a Medical Director at Coventry Health Care of Florida since August of 2008.

During this time, she helped develop and grow the plan’s Medicare Dual‐Eligible Special Needs

Plan program and continues to provide its clinical oversight. Dr. Mailloux is a residency‐trained,

board‐certified Emergency Medicine Physician with a strong background in pre‐hospital/EMS

medical direction and education.

Dr. Mailloux was raised and attended college in south Florida and earned her medical degree

from The Johns Hopkins University School of Medicine. After completing residency, she worked

clinically in the south Florida area for over fifteen years, serving as an Emergency Department

director for six of those years. Additionally she served as an EMS Medical Director for six cities

in Florida for 16 years. Dr. Mailloux was also a Clinical Assistant Professor at Nova Southeastern

School of Medicine for seven years. While earning her Masters’ of Medical Management

(MMM) from Carnegie‐Mellon, she transitioned from clinical medicine to the health insurance

industry. Dr. Mailloux is a fellow of the American College of Emergency Medicine. She is

married and has a son who is a mechanical engineer and a daughter in college.

Katrina Cope

Ms. Cope currently serves as the Vice President of Operations for Health Choice’s Arizona Medicare and Medicaid health plans. In this role, Ms. Cope is the product owner responsible for operational and financial performance of the health plans. Ms. Cope's responsibilities include increasing Medicare enrollment, improving quality measures, and leading initiatives that continue to move the organizations forward.

Prior to her tenure at Health Choice, Ms. Cope served as the Medicare‐Medicaid contact for the Arizona Health Care Cost Containment System (AHCCCS: Arizona’s Medicaid organization). In this role, she led initiatives to improve the quality of care provided to Medicare‐Medicaid enrollees, including the development of the AHCCCS Financial Alignment Demonstration proposal.

David Goodspeed Director, Member Engagement Matrix Medical Network

Mr. Goodspeed is responsible for all member outreach for Matrix Medical Network; working

closely with Corporate Marketing and Business Development – as well as with client health

plans - on the design, implementation and execution of strategies to improve member

experience, response and increase overall yield. His team includes client-focused marketing

specialists, and analysts who oversee the quality, accuracy and timeliness of all Matrix member

engagement outreach.

Prior to joining Matrix in 2012, Mr. Goodspeed held a variety of communications roles with

Healthways and its nationally recognized senior health offering, The SilverSneakers® Fitness

Program. Those roles included corporate communications and marketing, public relations,

education and internal communications. Mr. Goodspeed also designed educational

programming for the National Council for Prescription Drug Programs (NCPDP), a Scottsdale-

based national standards development organization for electronic healthcare transactions used

in prescribing, dispensing and paying for medications and pharmacy services. Mr. Goodspeed

has 20 years’ experience in healthcare communication, marketing, and education.

Prior to moving to his current residenceArizona, Mr. Goodspeed was a writer and editor for

several New York City-based magazines. He earned a Bachelor of Arts in English Literature

from Adelphi University in Garden City, NY.

2/29/2016

1

ENGAGING YOUR DUAL ELIGIBLE POPULATION

MEMBER S EGMEN TAT I ON AND OUTR EACH S T R AT EG I E S T HAT DR I V E R E SU LT S

Presented by:

Katrina CopeHealth Choice ArizonaHealth Choice Generations

David M. GoodspeedMatrix Medical Network

Mary R. Mailloux MD, MMM, FACEPCoventry Health Care of Florida, an Aetna Company

Overview

Effective engagement requires a deep

understanding of a member’s motivation

and behavior

Touch points at appropriate stages in a member’s journey are critical for continued

engagement

The distinct, diverse nature of dual

eligible members make this population uniquely challenging

Empower members with information and resources necessary to improve care and

outcomes

2

2/29/2016

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Profile of Dual Eligible Members

Dual eligible members have unique challenges that hinder engagement

Diversity

• Eligibility differences: old and low income; young, low income and disabled

• Multiple complex medical & behavioral health conditions

• Often significant disability

• Substantial social disadvantages

• Culturally and ethnically diverse

Issues impacting the ability to build trust and engagement

• Educational/language

• Cultural biases/stereotyping/ethnocentrism

• Fragmented/ad‐hoc care system

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*opinions set forth in this presentation are Dr. Mary Mailloux’s and are not a reflection of Aetna

Member Engagement

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Member engagement is a continual process that uses multiple channels to deliver targeted communications to achieve desired outcomes

Helps members understand the value of the service

provided by the health plan

Answers the “what’s in it for me” (WIIFM) question

Delivers personalized communication based on

understanding of member behavior and motivations

Reinforces the health plan’s brand promise to members

and improves loyalty

Increases likelihood of continued engagement, yielding

better outcomes

Awareness

Interest

Consideration

Intent

Activate

Loyalty

Continuity

Outcomes

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Engaging Dual Eligibles

Importance of understanding the dual eligible population and the ways they communicate

Step 1: know your population

• Understand population demographics

• Track what is successful and what is less effective

Step 2: cater to needs of the population

• Work closely with caregivers

• Training employees on dual eligible members’ unique demographics and

needs

• Arming employees with resources to available social supports

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Test

Optimize

Research

Research Member experience surveys drive understanding of opportunities

and points of resistance throughout member’s life cycle Demographic, behavioral and situational factors evaluated End‐to‐end member experience program

Test Concurrent A/B testing enables statistically relevant conclusions on

campaign efficacy Testing physician endorsements, incentives, segmentation specific

messaging, etc. Testing is applied across all delivery channels (e.g., mail, email, text,

contact center, face‐to‐face)

Optimize Predictive modeling used to attribute test results across broader

population (member segmentation) Communication preferences managed at the member level Life cycle approach evaluates pre‐ and post‐assessment interactions

Step 1

Step 2

Step 3

Improving the member’s experience and outcomes

Member Engagement Life Cycle

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Appropriate messaging to support each step in member’s journey

• Ensure the optimal delivery medium (e.g., mail, email, text, phone, in‐person)

• Align goals of communication with situational need (e.g., awareness, education, follow‐up)

Using psychographic segmentation to personalize messaging based on

personas

• Health literacy, health status, emotional state

Tools and technology to have better member discussions (contact center)

• Conversation guides continually tested for improvements in content, flow, duration and outcomes

• Ability to customize discussions based on member’s stage in life cycle, demographics, unique program

characteristics, incentives, etc.

• Contact center analytics and data integrated into end‐to‐end member experience program

Situation‐specific outreach guides the way

It’s All About the (Member’s) Journey

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Health Choice Arizona Experience

Provider engagement

• Ongoing education

• Most trusted connection

Community outreach

• Member events at centralized locations

• Community BINGO events

“Buddy Program”

• Interpersonal communication strategies (calendars, newsletters, etc.)

• Letters, carry cards

• Success stories

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Care Management

Care Management

• “Care” not “case” management

• Care manager and member are a team

• Non‐authoritarian and culturally competent

Identify what is most important to the member

• Understand and address social determinants of health

• Use people that can relate to the members

• Help member maintain benefits

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In Summary...

Understanding the challenges of your Dual Eligible

population is just the starting point for effective member

engagement

Personalized, relatable messaging must align with the

member’s journey and build their trust

Engage caregivers and providers in the care management

process with the member

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Contact Information

Mary R. Mailloux MD,

MMM, FACEPMedical Director, Medicare

Special Needs Plans (SNP)

Coventry Health Care of Florida,

an Aetna Company

954.858.3174

[email protected]

Katrina CopeVice President, Operations

Health Choice Arizona

Health Choice Generations

480.760.4661

[email protected]

David M. GoodspeedDirector, Member Engagement

Matrix Medical Network

480.862.1970

[email protected]

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