Nevada Health CO-OP Provider Network March 25, 2015

Transcription

1 Nevada Health CO-OP Provider Network for the Assembly Committee on Health and Human Services March 25, 2015 Assembly Committee: Health and Human Services Exhibit: L Page 1 of 7 Date: 03/25/2015 Submitted by: Nicole Flora

2 The CO-OP Philosophy Nevada Health CO-OP s (NHC) philosophy includes the belief that members do better when they can access appropriate care in a timely manner. We are committed to ensure quality of services and access that translates into good outcomes. We believe both our members and our communities are served well when we prevent disease and proactively manage illness. In order to achieve these goals, members must have quality, cost effective providers balanced by personal choice. For us, network access means consumers can get the care they need at a cost they can afford without unreasonable barriers. NHC is committed to offering products that balance choice with quality and cost effective care. While we are aware that narrow networks may be advantageous toward provider collaboration and improving evidence based practice measures, we also recognize the need for consumer and provider choice in order to optimize engagement in health care and outcomes. The ability to contract with selected providers supports quality improvement, member outcomes, provider engagement and affordability. We are committed to offering plans that meet our consumers needs and improve health care in our communities. Our Provider Partners The Nevada Health CO-OP is dedicated to providing health coverage that enables access to high quality health care across the state. In order to deliver on this promise, we have contracted to build network structures that offer a range of provider choice for consumers. In total, our networks include 2,343 Primary Care Physicians (PCPs) and 8,467 Specialists. Our network and provider partners include: First Health (previously Coventry) - In the Northern and rural regions of NV, outside of Clark and Nye counties, we have contracted with the First Health network to provide care for our members. The First Health network consists of 1077 PCPs and 1584 Specialists. Culinary Health Fund - We have partnered with the Culinary Health Fund to provide members access to their broad provider network. We currently access 753 PCPs and 1,275 Specialists through the Fund. WellHealth Accountable Care Network - The WellHealth Accountable Care Network currently includes 176 PCPs and 349 Specialists who serve the Southern Nevada market. Turntable Medical Group and the Nevada Health Centers - Based on Medical Home models, this group is small by design and includes 17 Family or Internal Medicine providers located in 5 clinics. L-2 2

3 Telehealth Services - The CO-OP offers telephonic and video based visits for acute outpatient needs, behavioral health services, management of chronic conditions, educational programs and group visits. We are working to expand telehealth services for chronic disease, specialty services and complex care management. Direct NHC Provider Contracts - NHC has secured direct provider contracts for any specialties where gaps or needs were identified. The CO-OP Plans Northern Simple & Frontier Simple Products In the Northern and rural regions of NV, outside of Clark and Nye counties, we offer products that include a broad provider network. We contract with First Health (previously Coventry) to provide members access to their physician panel. In addition, we offer telehealth services, including telehealth visits with behavioral health providers. We do not require referrals for services in order to allow members the greatest choice and to reduce barriers to care. In the South, including Clark and Nye Counties, we offer our members several options for provider networks when they select plans. Simple Products Our Southern Simple products include the broad network provided through the Culinary Health Fund and an additional set of direct-contract providers. This product line allows open access without referral to PCP and Specialist services to facilitate member choice. STAR Products Our STAR products offer provider access for members in a 2 tier system. The first and lowest cost tier is made up of a selective provider network contracted through the WellHealth Accountable Care Network. Members continue to have access to our broad Simple Network of 2,663 Nevada providers as a Tier 2 benefit. Members also have access to telehealth services for acute care and behavioral health issues. VIP Products Our VIP product line is also a 2 tier product with a very narrow tier 1 PCP network. We specifically partner with Turntable Medical Group and the Nevada Health Centers for our tier 1 access in order to offer a high service level based on Patient Centered Medical Home concepts. Services are free to members when provided by these groups. If desired, members also have access to our Simple network PCPs at a moderate cost. Members have provider access through telehealth for acute care issues, as well as video based visits for ongoing management of chronic conditions, educational programs and group visits through Turntable. Connected Products Our Connected products are a true selective network offering. Members have access to a limited selection of providers affiliated with the WellHealth Accountable Care Network. In exchange for the limited selection, members have available greater coordination of care and high-touch service including on-line appointments, dedicated health advisors and care coordinators. The providers are committed to work to coordinate care and communications to improve quality and outcomes for members. Acute care telehealth services are currently available to members. NHC & WellHealth Quality Care are working to expand telehealth-based services for chronic disease, specialty services and complex care management. L-3 3

4 CO-OP Quality We formally assess our networks quarterly, comparing contracted providers to active membership on a geographic basis. We use State guidelines and NCQA standards to determine minimal geographic thresholds. We also evaluate access based on time to available appointment for both established and new patients. (See attached sample maps.) As part of continuous quality improvement initiatives, our Provider Network team regularly assesses member, provider and broker communications, as well as internal medical management observations, to improve availability of services. In the event that a consumer does not feel they have adequate access to the care they need, we offer a formal appeal process governed by NCQA and State appeal standards. Appeals that are denied are coordinated with GOVCHA for second level consideration as needed. While these formal channels are always available to consumers, NHC is dedicated to proactive customer service. We strive to manage access and other member needs through our Health Advocacy services. Members are encouraged to call and our dedicated Health Advocates will work on their behalf with the Provider Network, Medical Management or other teams, as needed, to ensure services that satisfy our customers. In our first year of coverage, we have resolved the vast majority of concerns through this membercentric, collaborative approach. We recognize the burden of excessive travel time, wait times, and continuity of care as common healthcare issues and have made network exceptions where appropriate. Network Challenges Providing easy and high quality access to meet all of our members needs is a complex and ongoing challenge. With the geographic and population diversity we encounter, network solutions must be flexible to meet customer needs. Especially challenging have been areas where providers are limited. We found that members in border areas of Mesquite and Laughlin had limited provider choices within Nevada. We have expanded services into Utah and Bullhead City based on member calls. We also have worked with members in Nye County to expand services. In 2015, members in northern Nye County could no longer purchase products offered only in northern regions and had to select Clark County based plans. We worked to expand services to Nye County members beyond the primary Simple Network by adding First Health contracted providers. We have added direct NHC/provider contracts and are working toward hospital contracting so that members can get care in their local communities. We have found challenges in some communities obtaining cost effective care options. Due to the scarcity of providers, we have observed charges that significantly outpace same services elsewhere. If the cost to contract providers is too high, whether due to limited competition, limited availability or market rates, then premiums in our state will climb. Cost effective network contracts are crucial to maintaining affordable premiums for consumers into the future. L-4 4

5 Network Analysis - Clark and Nye Counties Southern Simple Providers.75" = miles 2015 Quest Analytics, LLC. 753 PCPs and 1,275 Specialists at multiple locations. Additional providers are available in Utah and Mohave County, Arizona. L-5 5

6 Network Analysis - Clark and Nye Counties Star Providers.75" = miles 2015 Quest Analytics, LLC. 176 PCPs and 349 Specialists at multiple locations as Tier 1 providers in Nevada. Additional providers are available as Tier 2. Tier 2 has 753 PCPs and 1,275 Specialists at multiple locations. L-6 6

7 Network Analysis - All Counties Northern and Frontier Providers.75" = miles 2015 Quest Analytics, LLC. 1,077 PCPs and 1,584 Specialists at multiple locations in Nevada. Additional providers are available in Utah and Mohave County, Arizona. L-7 7