Webinar: Managing the Network: You ve Built It; Now How do You Keep Patients in It. Oct 2, 2014

Transcription

1 Webinar: Managing the Network: You ve Built It; Now How do You Keep Patients in It Oct 2, 2014

2 Objective from Today s Discussion: Identify Approaches to Keeping Patients in Your Network Identify ways to keep patients in network Know the characteristics of strong networks Understand what has changed and the evolution of the network About the Speaker Provides oversight and leadership to Valence Health s consulting solutions for provider organizations as they transition to value-based care. Bill Wachs, CPA, CVA Managing Director, Consulting Services Key areas of expertise include risk-based contracting strategies, clinical integration program development, transition planning and population health management structural design and implementation. Over 25 years of experience in the healthcare industry from payor, provider and consultative perspectives. 2

3 How Do You Keep Patients in Your Network? A new, critical management question with several answers: Make sure your network knows it is a network Make the network bigger bigger is better, right?* Increase the value of the network Patient collaterals and education Collaborations with non-traditional providers *Actually, it is a start; in time, smaller will become better 3

4 Driven to Decrease Costs, Physicians and Hospitals Come Together to Manage the Continuum of Care In response to commercial and government payors efforts to reduce costs, a number of alternative business model solutions have emerged for hospital systems and physicians Declining Medicare reimbursement State Medicaid cutbacks Accountable Care Organizations + Payment Bundling Capitation 2.0 Photo Source: iclipart.com Facility-based Reimbursement changes HITECH / Meaningful Use Medicare Shared Savings Program 4

5 Changing the Thinking from Volume to Value Patient Revenues as a revenue source will be replaced by dollars tied to risk: premiums, capitation, allocations of care dollars Patient Volume (Members) New Patients from Enhanced Value 000s Existing Volume coming INTO the ACO ACO: Year Revenue sources are taking on a new form and context Success will be impacted by greater consumerism in health care services Look for new metrics to help manage and optimize Plan Design; Care Management Improved Retention 100% Cost of Care (Member PMPM) 5

6 Driving Results Will Require an Increasing Level of Integration Networks have been around for a long time Cost/Effort/Risk High Integrated Full-risk Provider Employment Risk Contracting Employment Clinical Integration ACO MSO PHO Joint Venture Value Low Admitting Med Staff Co- Management Low Degree of Provider Integration High 6

7 Why is This So Different Than Yesterday? Manage patients Serve patients when they come for care Referrals: Who you know, trust Where the patient lives Eat what you kill Hospital and physician focus Manage a population Care coordination Full continuum of care becomes a manageable reality Performance measurement Big data and data governance Patient focus; wellness Network development and design Accountabilities: Quality Cost Access Patients and Families VALUE 7

8 Valence Perspective Hospital-Physician Alignment Is A Now Imperative That Must Be Approached Thoughtfully Factors Driving Physician-Hospital Alignment Administrative burdens IT capability build Unpredictable compensation Leadership opportunities Reimbursement decline Population health Value-based payment Onset of healthcare consumerism Contracting capabilities Quality of care improvements Narrow networks Ambulatory competition Cost control Leakage 1 Tighter physician alignment gives both physicians and hospitals more opportunities for surviving in the new value-based world to come 2 Each market will have its own unique set of value propositions that will inform the right approach 3 Organizations that are thoughtful and deliberate in their approach to physician alignment, and who offer multiple options for alignment, will be the winners 8

9 Taking New Accountabilities Requires Different Expertise; Can Be Shared or Acquired Expertise Data Management Financial Management Detailed Description Ensure payers are providing complete and accurate data on a frequent basis, eg Claims, Pharmacy, Provider, Member, Premium Supplement with Clinical Data: EHR, Lab results, Immunization Databases Validate the data and tie it to the monthly reconciliations Administer incentive programs Distribute funds if needed IBNR Produce financial statements Reinsurance Pro forma projections Monthly Reconciliations Analytics Clinical Provider / Network Management Financial / actuarial Operational Care Coordination Manage the population that will benefit most for the efforts High risk / high cost patients Gaps in Care Most likely to be admitted, readmitted or to an ED Chronic conditions 9

10 Make sure your network knows it is a network

11 Physicians Control 87% of Personal Health Spending in the U.S. U.S. Personal Health Spending 13% Physicians' own incomes 66% 21% Hospital, Rx, long-term care, and other items controlled by MDs Dental, professional, and other products not controlled by MDs 87% Controlled by Physicians IMPLICATION Physician decisions are key to bending the cost curve Knowledge of the environment (where is waste located, what care works and for whom) Increasing reliance on clinical guidelines and evidence-based practices Opportunity to build trust between physicians and administration Careful, effective and human approach to addressing healthcare costs Approach likely to gain traction among physicians Source: A Sager and D Socolar, Health Costs Absorb One-Quarter of Economic Growth, , Boston Univ. School of Public Health, 9 Feb

12 The Content of the Conversations Should Evolve in Both Breadth and Depth 30 Minutes 10 Minutes Value added services included in the CIN 30 Seconds What is a CIN Why the CIN is being developed Who was involved with the design of the CIN Contact for further information 5 Minutes CIN is physician led Focused on quality and value Private representation Maintain pediatric delivery integrity Mitigate changing market dynamics Other CIN participating practices How the CIN supports the private practice model Willingness and ability to share data CIN s resource and IT support Benefits of joining the CIN Dues structure Potential incentive structure Contracting approach/strategy Evolution to new payor, hospital and physician relationships Overall practice (including staff) expectations Governance model 12

13 Network Development and Communications Work in Parallel to Develop a Recruitment Strategy The CIN must decide who should carry the message, when they should carry the message and how they will carry the message Network Development Create prioritization criteria Prioritize practices Finalize Strategy Communications Mission/Vision Value Propositions Burning Platform FAQs Website Branding Stakeholders Practice Lead Admin Lead Employer Admin Rank and File Text Text CIN Champions Physicians Text -CIN SC -CIN Board -CIN Workgroups -PLC Text -CPAC -TCHN Board Physician Liaisons Med Dtr & Exec Dtr Channels One-on-one Forums (when appropriate) Webinars Med Bytes Test and Revise Value Propositions Approach Assumptions Approach Market 13

14 Make the network bigger bigger is better, right?*

15 The Basic Components of the Network Apply to Multiple Reimbursement Structures P4P P4P PCMH PCMH CLINICAL CLINICAL INTEGRATION INTEGRATION SHARED SHARED SAVINGS SAVINGS BUNDLED BUNDLED PAYMENTS PAYMENTS SHARED SHARED RISK RISK CAPITATION CAPITATION FULL RISK FULL RISK PROVIDER- Provider- SPONSORED SPONSORED PLANS PLANS Payor A Payor B Negotiated, risk-adjusted PMPM payment for defined populations Payor n Alternative payment models including incentives, shared savings, capitation, etc. Fee for Service Payments Credentialing Care Management Utilization Management Disease Mgmt Quality Measures Data Analytics Quality Incentive Payments Member A Member B Member C Member D Non- Network Providers Network Members or Participants 15

16 Providers Can Start Small When Managing Risk and Evolve into More Advanced Models over Time Pilot a Geography Evolve into Final Model Full Risk without Corridors Full Risk without Corridors Full Risk with Corridors Shared Risk without Corridors Shared Risk with Corridors Start with final risk model, but in limited geography Still could allow for pilot by business line Requires ability to be flexible by geography, both operationally as well as payor participation Greater risk / reward financially for initial geography puts more pressure on that one organization to perform Start with least viable risk-reward model and climb the ladder over time Could still allow for other pilot factors such as geographies or business line Gives up some financial upside, but puts less pressure on organization to transform Some increased risk of never getting to the end goal 16

17 There are Several Examples of PCPs Receiving Additional Compensation for Enhancing the Quality of Patient Care Example Health Plan pays PCPs a $1 PMPM management fee and provides extra compensation for after hours care PCP Requirements Act as a gatekeeper to manage utilization of PT/OT/ST services for their patients Participate in health plan sponsored activities that address medical necessity and PT/OT/ST utilization Keep practices open to treat patients after hours State Medicaid program pays PCPs between $2 and $4 PMPM for participating in the Primary Care Case Management program Ensure enrollees get checkups, immunizations and other preventive healthcare Ensure enrollees receive the most appropriate level of care Improve the quality of care that an enrollee receives Coordinate all of the enrollee s care Proposed Approach to Enhanced PCP Compensation The PCPs participating in the CIN will receive a rate enhancement as compensation for additional care management activities and increased quality of care amount can vary depending on level of engagement needed PCPs measured on quality metrics and physician engagement metrics Execution of care collaboration initiatives Implementation of medical home capabilities in the PCP practices Data capture and reporting 17

18 Increase the Value of the Network

19 The Goal for a Network is Aligned Goals DESIRED STATE Engaged, collaborative, aligned to common goals NETWORK DEVELOPMENT CURRENT STATE Disparate physician groups with varied perspectives 19

20 To Remain Viable Long-term, a CIN Must Be Designed to Deliver Value to All Involved Stakeholders Member Physicians CIN Success will require: Consistent and ongoing leadership commitment through the full implementation of the clinically integrated network Collaboration and coordination across the health system Physician engagement and contribution Speed to market Hospitals Community 20

21 A Clear Value Proposition is Key to Clinical Integration Network Development Different value propositions may exist depending on the groupings of participating physicians: Employed PCPs Employed Specialists Independent PCPs Independent Specialists What are desirable elements that would entice a physician to participate? Infrastructural support to track and measure performance Incentive payments for achieving certain performance levels Group contracting serves as a risk mitigation strategy 21

22 The Relationship Between the Physicians and the Hospital Will Ultimately Lead to the Success of the CIN Relationship Factors 1 Previous History 2 Current Relationship 3 Community Primary Care 4 Community Specialists Hospital initiatives that went poorly Former leadership Misalignment of values Political concerns Ongoing initiatives Current leadership Communication Level of collaboration Future potential Inpatient vs. outpatient needs Technology support ED, admit and discharge processes Medical staff requirements Inpatient vs. outpatient needs Medical staff requirements Operating Room access In order to mitigate potential barriers, the CIN must incorporate fundamental elements: Value Propositions Transparency Voice in the Design Collaborative CIN Design Value Added Services 22

23 Mechanism Objective Use the Network Design Model to Meet Your Objectives Providers in Silos Loosely- Affiliated Model Tight Physician Integration Clinical Integration ACO (-like) Model Secure referral streams Foster cooperative medical staff relationships Develop depth of physician capabilities and leadership Secure market share Directed physician behavior Establishing common compensation and incentive pools Shared continuous efforts to decrease costs and increase quality while receiving financial benefit for improvements made Information sharing between hospitals and practices Acceptance of full risk between independents and institutions to manage population health Customer service Recruitment support MSO services Traditional managed care contracting support Economic joint ventures Direct, subsidiary, or foundational employment Specialty/ subspecialty PSAs or joint contracting Integrated clinical systems across ambulatory and acute settings Effective IT systems to measure cost and quality improvements across ambulatory and acute settings Joint managed care contracting for value/quality Utilization management/ review disease management Closed or restricted physician network Membership/risk management competency Actuary competency Partnership development with upstream and downstream providers for services not in the ACO 23

24 Network Development Workgroup Process Some objectives will be in parallel, while others will be sequential Objective: Design the Network Value Propositions Value Added Services Network Recruitment Description: Market Assessment High Level Strategy Detailed Physician Strategy Physician Participation Agreement Criteria Provider Value Propositions Hospital Value Propositions Employer Value Propositions Value Added Services Survey Current Offerings New Offerings MSO Business Plan Provider Relations Policies and Procedures Business Processes Transition Plan Advisory Council Approach the Market Key Points: Clearly defined value propositions for providers, the hospital and employers serve as a repository for conversation topics and communication materials MSO Offerings are an added benefit to providers with cost pressures and/or lack of available resources Pediatric CINs will often need to consider partnership strategies with adult systems for commercial payors The Participation Agreement will need to be developed in collaboration with the Finance and Contracting Workgroup 24

25 Physician Value Propositions are Critical to Initiate Network Management Primary Care Specialists Increased access to continuum of care data Performance and benchmarking data Promotion of a quality brand All Physicians Private Viability for remaining independent Higher reimbursement opportunities Enhanced clinical quality processes Improved communication with specialists More voice in System governance Support for Medical Home Improved access to information technology Increased patient volume Improved relations with System & PCPs Improved alignment of services across system facilities Improved access to information technology Employed Improved communication with Specialists Improved coordination of care and services for patients Increased patient volume Improved partnership model with Private PCPs Improved alignment of services across system facilities 25

26 Alignment with Key Physicians Requires Balance Between Value Drivers Qualities the CIN Needs (Recruitment Criteria) High-quality groups; strong values Good cultural fit; appetite for innovation Experience in value-based models Will and ability to share data Eagerness to engage in leadership (especially PCPs) Provide care across the continuum Benefits the CIN Offers (Value Proposition) Access to continuum of care data Performance & benchmarking data Promotion of a quality brand Preserve reimbursement opportunities More voice in market Improved PCP-Specialist communication Improved coordination of care and services for patients Optimize current IT capabilities Maintain or enhance patient volume * CIN = Clinically Integrated Network 26

27 Patient Collaterals and Education

28 Consumerism is Grabbing the Attention of Patients and Populations The current system is being asked to shift focus to the patient. Economic drivers, among others, challenge this goal. Collaboration among delivery model constituents is one of the selected answers to this problem Healthcare consumer tipping point: 50% of costs PAID by the patient/family 28

29 Reimbursement Decisions Impact Service Line & Market Relevance Contracting decisions significantly impact volumes Non-traditional reimbursement modalities Contracting for Value Transparent Elastic Commodity services Risk contracts Bundles Progressive plans, MCOs, purchasers Distinguished quality Demonstrated patient and market acceptance Disengage from threat-induced contracting decisions; preserve and defend peerless services 29

30 As Healthcare Changes the Way It Reaches Patients, Health Systems Can Learn from Others Best Practices Empower Network-wide Brand Champions Take a horizontal approach to branding by involving employees at various levels in the name and brand selection process. Invest in training brand champions throughout the network to educate and engage other employees around the brand promise. Proactively Manage Your Brand from the Inside Out Just as the CIN must align disparate physician groups, its brand must unite multiple provider entities. A unifying brand prevents confusion and distrust by operating internally as well as externally. Tell a Story Convey the CIN s vision and story in an inspiring way to connect with the communities you serve. Let your brand reflect the compassionate nature of healthcare. Treat Your Brand as an Asset More than just a logo, a strong brand drives differentiation, patient preference, and network loyalty. Be Consumer Centric Use common language and images of actual people to which the consumer can relate. A consumer centric brand strategy establishes credibility and trust. 30

31 News Media is Having an Impact on Consumer Perceptions 31

32 And the Realities are Beginning to Sink In. Life Expectancy 38th 15th 16th 20th 20th 9th 8th Source: Fischbeck, Paul. US-Europe Comparisons of Health Risk for Specific Gender-Age Groups. Carnegie Mellon University; September,

33 Collaborations with non-traditional providers

34 Delivery Implications of this Fundamental Shift These trends are combining to create a fundamental shift in how we deliver and pay for healthcare services. Element of Change TODAY FUTURE Health Care Focus Sick Care Wellness and Prevention Care Management Manage utilization and cost within a care setting Manage on-going health (& Optimize Care Episodes) Delivery Models Fragmented / Silos Care Continuum & Coordination (Right Care, Right Place, Right Time) Care Setting In office / hospital In-Home, virtual (e-visits, home monitoring, etc ) Quality Measures Process-focused, Individual Outcomes-focused, Population based Reimbursement Fee-for-service Value-Based (Outcomes, Utilization, Total Cost) Financial Incentives Do more, make more Perform better, make more Financial Performance Margin per service, procedure, etc. (bed, doc, etc.) Margin per life 34

35 Thank You To learn more about Valence Health s capabilities, contact : Bill Wachs at or wwachs@valencehealth.com vquest Medical Cost & Utilization Risk Adjustment Vision Clinical Integration Quality Measures Population Health for Multi-TIN Settings Registries Population Health Management Solutions Health Plan Services Claims Processing Premium Billing Provider Portal Member Portal Care Manager Case Management Care Coordination Patient Outreach 35