entering the south carolina market in january 2014 a “consumer operated and oriented health...

ENTERING THE SOUTH CAROLINA MARKET IN JANUARY 2014

A “CONSUMER OPERATED AND ORIENTED HEALTH PLAN”

OR“CO-OP”

1

What this presentation will address2

What is a “CO-OP”?How did it develop in South

Carolina?Who owns and manages it? What is its Mission?How will it relate to Providers What differentiates it?

Consumer Operated and Oriented Plan

3

A “CO-OP” is:

the private sector alternative to “public option” in the ACA

Not for profit

Funded by Federal loans paid back over 30 years

Governed by its Beneficiaries, including network

physicians and hospitals

Mandated to develop low cost options for individuals, small

groups, and to encourage the uninsured into the market

4

Consumers’ Choice Development

Senior Management5

Jerry Burgess, Chief Executive Officer

David Young, Chief Financial Officer

Judy Slagle, Chief Operating Officer

Jerry Reeves, MD, Chief Medical Officer

Francis G. Middleton, M.D., VP Network Development

Kimberly Coad-Ascue, Director Network Development

Robin Tester, Consultant for Network Development

Mission6

Provide affordable benefits for individuals

and small groups through the public

exchange

Reduce the ranks of the uninsured

Engage consumers in their health

Provide a platform for providers’

innovations

The Role of Providers7

1. In Governance - Three board seats will be

held by network providers

2. As Advisors - Network Providers, through a

Medical Advisory Committee, will report

directly to the Chief Executive Officer

3. As Network providers

Promote Medical Homes8

Support and reward “medical homes” processes

Enhanced access

Population management via robust analytics

Care plans supported by health care coaches

Engaging community support

Tracking and coordinating care

Continuous improvement in measures and

outcomes

Promote Medical Homes9

Referral Authority – PCP (not plan)

PCP/Patient contract and care plan

supported by Nurse Coach

Plan supports PCP to achieve three aims:

1. Cost Management

2. Quality Measures

3. Patient Satisfaction

Summary of Contracting Principles

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Finding partners who share our vision

Gain sharing for quality improvement and

efficiency

Promotion of clinical coordination:

- medical home and nurse coach

- medical home, specialists and others

- “accountable care organizations”

Patients have Responsibilities, too

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We will develop incentives designed to

promote:

patient compliance with care plans

Engagement with nurse coach

improvements in health status

Consumers’ Choice Differentiators

12

Gains go back to the community of

providers and members

Focus on reducing ranks of the

uninsured

Providers participate in governance

Strong support from the provider and

business communities

A Fresh StartA Fresh StartHelp us to get it rightHelp us to get it right

To discuss Network participation, contact:

Kimberly Coad-Ascue, Director, Network Development

843.732.0393kascue@consumerschoicesc.org

Robin Tester, Consultant for Development803-466-4896

Rob.tester.10@gmail.comFrancis G. Middleton, M.D., VP Network

Development843.608.9540

fmiddleton@consumerschoicesc.org