Management Services Organizations: Efficiency in Payer Engagement Ohio Association of Community Health Centers July 2014 Contact Us Andrew Principe andy@starlingadvisors.com Amanda Stangis, MPH amanda@starlingadvisors.com PO Box 410221, Cambridge, MA 02141 P. 617.863.7807 1 Today s Discussion What is an MSO? Why build an MSO? MSO examples How do MSOs and IPAs differ? Can they work together? Will we need an MSO? Our next steps 2 1
About Starling Advisors We work nationally with Health Centers, Networks, and PCAs to answer the question: What changes, if any, do we need to make to insure a role in providing high quality, comprehensive primary care under Health Reform? 3 Background In May, we met with the Health Center leaders to discuss different options for organizing under Health Reform So far, we have convened one webinar on the function of IPAs and ACOs Now, we will discuss MSOs and the value they bring to health center networks 4 2
Exploring Network Development We will be delivering 3 live webinars and recording these to help share information with Health Center Staff and Boards. Network Context Discovery 2 3 Weeks Education 4 5 Weeks Data Gathering 4 5 Weeks Strategy Development 4 Weeks Overlap 5 WHAT IS AN MSO? 6 3
Each type of network has a specific purpose IPA ACO MSO We need to be free to negotiate with any and all payers in our region. I need to enter a very specific program with specific requirements. I need to support better organization and performance to participate. 7 Network Models for Engagement Managed Services Organizations A different kind of network, a managed service organization (MSO), is focused on providing services to its provider and insurance plan members. MSOs provides services that add value to both the providers and plans, such as: Revenue cycle management Quality improvement Care coordination Human resources and recruitment Group purchasing and supplies Although not generally used to pool patient risk, MSOs do create similar network effect by consolidating back office processes. 8 4
Working Definition of an MSO An entity that, under contract, provides services such as a facility, equipment, staffing, vendor contract negotiation, administration, and marketing. Services may be provided to independent practices through a fee based arrangement paid by the practice or an insurer. A shared infrastructure for co management of functions to create economies of scale. 9 How we believe you should think about MSOs An MSO is a way for health centers to: Establish an initial, transitional networking structure to More closely engage with payers and the health system ecosystem Without giving up autonomy or control of operations In a way that allows you to generate efficiencies And ideally employ best practices to raise the overall performance of the provider organizations (FQHCs) served. 10 5
Which types of services can an MSO provide? Clinical Support Financial Services Operational Services Human Resources Quality Improvement Care Coordination Medical necessity services (e.g. pre authorizations) Revenue Cycle Management Coding and Compliance Credentialing of providers for billing purposes Contract management Group purchasing and supplies Market Analysis HR and Payroll Recruitment and retention Continuing Education & ongoing provider communication 11 You may already work with MSOs These represent very similar structures to MSOs: Health Center Control Networks Group purchasing entities Other Health Center Networks Any outsourced services providers you may work with 12 6
WHY BUILD AN MSO? 13 Why Build an MSO There are many reasons to consider an MSO: Scale and leverage help improve our financial efficiency Need to compete financially with organizations that have much greater purchasing power Certain insurance relationships require a third party entity such as an MSO Various factors require a contract to be held by a group representing clinicians MSO more nimble or efficient in managing key operations Credentialing or pre authorization better handled by an association with historical relationship with the providers When there is a need to diversify revenue Can be a for profit but distribute gains to notfor profits Also a better vehicle for a not for profit for generating outside investment 14 7
Why MSO? Example services an MSO might provide High value to insurer High value to both High value to CHC Provider communication Implementing insurer payment changes Continuing medical education Quality improvement Revenue cycle management Coding and compliance Credentialing providers HR and Payroll Information Technology Recruitment and retention Frankly, the limits of the types of services an MSO provide are bound only by your creativity and entrepreneurial thinking. There is no one formula. Therefore, it is truly an exercise in outside the box business planning. 15 Why MSO? Management Services Fees Insurers may be willing to support an MSO Unlike an IPA, the fees an MSO is paid are for non healthcare related (administrative) services Because they are paid to a provider owned organization, MSO fees may qualify as Medical Loss 16 8
What s the deal with Medical Loss? Insurance companies must spend no less than 85% of their total budgets on actual healthcare expenditures for their beneficiaries, known as Medical Loss. Fees paid to healthcare providers to perform services for beneficiaries can, in most cases, qualify as Medical Loss Therefore it can be advantageous to form a relationship with an MSO type entity. 17 MSOs and Medical Loss: Loophole or value-add? If the Medical Loss rules are to prevent administrative cost overruns, is it good that we can use Medical Loss dollars to move administrative type functions into an MSO? As a philosophy, we recommend that MSOs continually evaluate and measure the value they are adding to the care continuum. We will discuss this further when we talk about how MSOs and IPAs compare. 18 9
Other reasons to consider an MSO Grant funding may help support infrastructure development Establishing and MSO allows any health center willing to pay for services to participate, thus eliminating the need for participation standards Existing organizations (i.e. the PCA or HCCN) may have infrastructure that can help support the offering of MSO services Health centers want to create an infrastructure that can ramp up to an IPA or ACO if new payer relationships begin to take priority 19 MSO EXAMPLES 20 10
An MSO to handle Revenue Cycle Management Challenge Goals Process Results Health Centers in a region underperform commercial billing benchmarks and face increasing exposure to commercial contracts Outsource all insurance billing and collection Improve cash collection by 10% Decrease days in A/R by 15 MSO created to perform Revenue Cycle Assessments and purchase outsourced billing on behalf of all health centers Benchmarks established for Health Centers Moved underperforming health centers to outsourced model All health centers now preform above goal Cost to manage RCM processes reduced by 20% 21 An MSO to Recruit and Credential Providers Challenge Goals Process Results New insurers require providers before claims will be paid Create revenue stream whereby insurers pay MSO for recruiting and credentialing providers MSO created to perform credentialing MSO identifies and outreaches to qualified providers MSO is paid when a provide is set up completely and able to bill the insurer MSO paid fair market value for recruitment and credentialing process Providers credentialed within 1 week 22 11
An MSO to Managed Insurance Contracts Challenge Goals Process Results Insurer offers Health Centers incentives based on quality measures, but has no measurement capacity Measure performance against contracts Ensure timely payments of incentives Help health centers maximize payments under incentive program MSO created to collect data and measure outcomes MSO submits reports to insurers to authorize payment to Health Centers MSO reports to Health Center where financial opportunities were missed and help them re plan for future periods Cost to run process paid by insurer Health Centers gain analytics capacity Health Centers get access to improvement information to maximize financial performance 23 Case Study: Complex Models No single strategy will work for all states Large, complex states will support unique configurations In this model, contracting capacity and other services live in the MSO The clinical or financial integration occurs regionally There is still sufficient economy of scale in having the MSO present FFS Managed Care ACO FQHC Led ACO Statewide Health Center MSO Regional FQHC IPA Health System ACO FQHC 24 12
When should you consider forming an MSO? Insurers seek a partner to handle provider side functions You have new business requirements and limited resources. You want to begin the process of network formation. Some insurers will seek partners within the provider community to perform functions that the providers themselves are better equipped to handle. Alternatively, providers might earn incentives by doing certain administrative functions well on behalf of the insurer. A MSO operates as a sophisticated group purchasing organization for services that cannot be typically purchased on the open market. For example, if all Health Centers want to hire a CMIO but do not have the resources to do so, they might share one through an MSO. An MSO can be a lower risk proposition than an IPA or MSO, because it does not impact reimbursement for medical services. Still, it formalizes a network that can be pivoted into other structures (IPAs or ACOs) at a later point. 25 Which MSO is right for you? In some cases, its not necessary to have an MSO at all The functions an MSO will perform will be based on things that: Can reduce the cost or improve the quality of services the Health Centers receive The insurers in their market are willing to outsource to the providers The providers need to develop anyway Due to various Federal and State regulations are better positioned to occur by the providers than by the insurers 26 13
MSO VS. IPA 27 MSO vs IPA IPA Function Primarily concerned with securing better compensation for medical services. MSO Primarily concerned with generating sustainable revenue by creating shared services programs for nonmedical services. Risk Highly susceptible to anti trust action and must have clear approaches to managing this risk. Value Creation Members agree to and achieve a set of shared standards and hold each other accountable. May still face anti trust issues for nonmedical services* Reduced risk of antitrust action given MSOs do not attempt to negotiate insurance contracts for medical services** Can help raise the level of performance of its members to meet standards, but generally does not hold members accountable. * Since MSOs contract with suppliers and vendors, they should be consult legal counsel regarding separate anti trust issues that could be triggered. ** MSOs that attempt to negotiate for medical services face same antitrust risks as IPAs 28 14
Do I need both? If your goal is to work together to improve your contracts with health insurers, you should consider developing an IPA. Since an IPA can perform many MSO functions, if you have an IPA it is likely you do not need to create an MSO as well. 29 When to consider both You want to use separate corporate vehicles to protect assets against risk You serve different members You have different governance requirements that cannot be easily dealt with within a single entity There are different funders: e.g. grant funded non profit MSO (HCCN) and forprofit self funded IPA 30 15
MSOs can also support ACOs An MSO can support a Health Center led ACO, or an individual Health Center within an ACO in much the same way as it supports an IPA. 31 A potential model for Ohio Statewide MSO Region 1 ACO Region 2 IPA Region 3 IPA In this potential model, smaller IPAs or an ACO are created to contract with regional payers, each with its own regional governance, supporting Health Centers in that region. These IPAs and ACO leverage services from a statewide MSO, who supports all health centers and perform the majority of the services the IPA/ACO needs. This model offers the best blend of cost efficiency, legal protection, and ability to address regional priorities. 32 16
WILL WE NEED AN MSO? 33 Will we need an MSO? Unfortunately, as with most issues of dealing with Health Reform, the answer is maybe: Insurers have been known to require an MSO If you decide to build an ACO, participating providers could benefit from MSO infrastructure An MSO may make sense if administrative costs and associated outcomes are not at benchmark levels of performance An MSO might be the right vehicle the best align the mission of Health Centers with that of the Insurers If you do not have an IPA, an MSO might be more important 34 17
Factors that will favor an MSO New plans enter the market that are looking to outsource (rather than build) key plan functions: Network development and credentialing are very common Existing plans need to add capacity You decide not to create a contracting vehicle (IPA) Outside funding available to support MSO formation If Health Centers are financially fragile, underperform benchmarks in key areas, or risk closure, consolidation, or acquisition 35 Factors that will make an MSO less important or valuable No financial, legal, or regulatory reason for creating a new entity You have an IPA that can perform any necessary services Insurers have limited need to outsource services Health Centers have all of the components they need to address the needs of their insurance partners 36 18
Typical Process for Determining the Need for an MSO Typically, an MSO is formed as the result of one or more key events: A group of providers are presented with an opportunity that can only be capitalized on through the formation of a new entity These providers determine that they can most efficiently respond to changes in their market by working together Funding is made available to perform certain services across multiple providers could include grant funding, insurer funding, or self funding 37 Q & A 38 19
Moving Ahead NEXT STEPS 39 Recommendation and Strategy Development Sign up for interviews and complete interviews Starling will analyze survey data to identify priorities, assets, and opportunities Strategy recommendations will be presented for consideration in September OACHC membership will identify next steps 40 20