Partnering with Managed Care Organizations: A Case Study for Success
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1 Partnering with Managed Care Organizations: A Case Study for Success Tracy Altman, M.H.Ed. Manager, Provider Services & Contracting Molina Healthcare
2 Most Trusted on ACA: Doctors and Nurses, Federal and State Agencies, Pharmacists Trusted source Heard from Your doctor or nurse Federal agencies State agencies 0% 20% 40% 60% 80% 100% Your local pharmacist An employer Your local church or place of worship Non-profit or community Friends and family A health insurance company The news media* Social networking sites SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted August 13-19, 2013)
3 Disrupting the status quo We believe that striving toward a culture of health will help us realize our mission to improve health and healthcare for all Americans. Still, we know that building this vision of a culture of health will take time. It will take fortitude. It will take collaboration. Risa Lavizzo-Mourey, MD,MBA President & CEO of RWJF
4
5 NCQA Accreditation NCQA Accreditation Click to edit Master title style
6 Molina National Footprint 2.1 Million Members
7 One Molina Concept Initiatives from corporate Requests from state plans Broad experience Enhanced flexibility
8 How Do You Get Insurance These Days? Employer High levels of subsidy, paid by the employer Government High levels of subsidy, paid by the government Medicaid, CHIP, Medicare, Tricare, VA, Mail Handlers Individual No subsidy, high cost Marketplace Tiered levels of subsidy depending on income, paid by the government
9 Make It Simple Molina Can Help Community Government Members Hospitals Practitioners Caregivers Housing/shelter Behavioral health Social Needs
10 Network Focus is changing from Bigger to Most effective Smaller Ancillary network Better managed overall network Produce High-quality results with managed costs
11 Network Changes Better care management Community Connectors Better cost control Focus on Provider Partner in the care of our members
12 Climate of Collaboration Community Nursing Services and Molina Healthcare identify mutual goals: To achieve meaningful, high quality health outcomes for patients served by both organizations To build a sustainable partnership which improves quality and manages healthcare costs
13 Why CNS? Home Health, Hospice, Infusion and now DME Geographical coverage History of successfully managing our members Proven effective in helping to manage costs Up front communication Follow through in the care of our members
14 Barriers to Effective Collaboration Ineffective working relationships and disruption in delivery of clinical services secondary to communication problems Delays in authorization response time Numerous denials for authorization Inconsistent processes for both HH agency and payer
15 Collaborative Action JOCs to identify strengths and areas for improvement Identify Objectives Focus on meeting objectives Touch points
16 How do we get along?
17 Strengthening the Relationship Continuous and consistent communication Talk about issues when they arise Utilization data Care coordination Case management
18 Value Based Reimbursement Review base data on patients affiliated with provider Identify areas that can be better managed Split savings with providers
19 Value Based Reimbursement CMS and the Value Based Reimbursement Modifier (VM) Implementation: ure=youtu.be Implementation of State Medicaid ACO plans
20 Midwest Region Who are the plans? What are the networks? Where do we go for answers? How do we get paid? Why do they do what they do??
21 Regional Specific Issues Competition Network Compensation Governmentfunded vs. commercial plans Patient population Geographic issues
22 Barriers to Effective Collaboration What other Barriers have you seen? Claims processing Plan policies and procedure differences
23 Problems Who to call? What is the issue? What would you like to see as a resolution? Timeframe
24 Questions
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