managed care organizations and provider networks challenges and opportunities november 7, 2003...
TRANSCRIPT
Managed Care Organizations and Provider Networks
Challenges and Opportunities
November 7, 2003Presented by: Neal Cash, CEO
Features of the Arizona System
Statewide behavioral health carve out Integrated substance abuse and mental
health services (Adults & Children) Combined Medicaid and non-Medicaid
funding streams Private Regional Behavioral Health
Authorities Open competitive bidding for authorities First public sector full-risk behavioral
health care system in United States
BEHAVIORAL HEALTH PROGRAMS FUNDING
ADHS/DBHS Receives Funds for Behavioral Health Services
ARIZONA LEGISLATURE APPROPRIATION/MATCH
STATE HOSPITAL SUBVENTION
TOBACCO TAX TITLE XXI TITLE XIX
ARIZONA LEGISLATURE APPROPRIATION/MATCH
STATE HOSPITAL SUBVENTION
TOBACCO TAX TITLE XXI TITLE XIX
ARIZONA DEPARTMENT OF HEALTH SERVICES
(ADHS)
DIVISION OF BEHAVIORAL HEALTH
SERVICES (DBHS)
REGIONAL BEHAVIORAL HEALTH AUTHORITIES
(RBHA)
SUBSTANCE ABUSE & MENTAL
HEALTH SERVICES ADMINISTRATION
(SAMHSA)
BLOCK GRANTS
SUBSTANCE ABUSE & MENTAL
HEALTH SERVICES ADMINISTRATION
(SAMHSA)
BLOCK GRANTS
FEDERAL HEALTH CARE FINANCE
ADMINISTRATION (HCFA)
MEDICAID/TITLE 19
CENTER FOR MEDICARE/MEDICAID
SERVICES
MEDICAID/TITLE XIX
ARIZONA HEALTH CARE COST
CONTAINMENT SYSTEM
(AHCCCS)
ARIZONA HEALTH CARE COST
CONTAINMENT SYSTEM
(AHCCCS)
The state is divided into six geographic regions. Each region is assigned to a RBHA.
NARBHA
EXCEL
VALUE OPTIONS
PGBHA
(GSA 5)
Pima
(GSA3)
Graham
Greenlee
Cochise
Santa CruzCPSA
FEATURES OF CPSA MODEL
Community governance and oversight Shared Risk with Providers Comprehensive Service Networks that
are able to provide integrated services Consumer involvement Community reinvestment Coordination with collateral systems
Evolving Systems of Care for Persons with Behavioral Health
Disorders1. State Systems Budget Deficits Reorganization of State Agencies, Departments and
Divisions Greater Cross Agency Collaboration
Managing Entities Regional Models County Models Private Managed Care Organizations Administrative Service Organizations
Community Based Providers Affiliation of Providers Networks Integrated Systems of Care Greater Community Collaboration
2. Evidenced Based Practice
Science to Service Co-occurring Treatment Assertive Community Treatment
Teams Wraparound Models Pharmacotherapy
Evolving Systems of Care for Persons with Behavioral Health
Disorders (con’t)
3. Information Technology
a. IT Networking Design, Configure and Maintain
Servers, Computers, Printers, etc. Data Transmission and Security Data Storage
Evolving Systems of Care for Persons with Behavioral Health
Disorders (con’t)
b. Telecommunications Telephones, Voice mail Video Teleconferencing Pager and Cell Phone Systems
Evolving Systems of Care for Persons with Behavioral Health
Disorders (con’t)
c. Systems Operations Coordination and Configurations
with Member Services Enrollment, Intake, Assessments Data/Demographic Claims
Evolving Systems of Care for Persons with Behavioral Health
Disorders (con’t)
d. IS Development Automate Work Processes Improve Availability and
Integration of Data Web Sites
Evolving Systems of Care for Persons with Behavioral Health
Disorders (con’t)
4. Consumerism and Recovery (Voice & Choice)
System Partners Advisory Councils Boards Employees
Evolving Systems of Care for Persons with Behavioral Health
Disorders (con’t)
Managed Care OrganizationAuthority Core Functions
Provider Network Management Strategic Planning Customer Services Quality Management Utilization Management Financial Management Information Management
CPSA Core Functions:Administrative Oversight
Network and ClinicalManagement
InformationManagement
Business Operations
Southeast Region ProviderManagement
Children's’ BHC SystemManagement
Persons with SMI BHC SystemManagement
GMH/SA and Crisis BHC SystemManagement
UM, UR, Member Benefits, DataAnalyses and Reporting
Claims Encountering
Contracts Function
Financial Compliance
Financial Analyses andReporting
Information SystemsDevelopment
IT Management
Data Processing
Telecommunications
Ad-Hoc Data ReportingFinancial Auditing
Member Services
In-House LegalCounsel
Ethics andPrivacy
Grievances &Appeals
ContractsDevelopment
Performance Improvement andQuality Management
Facilities Management
Prevention, Health Promotion andTraining
Human Resources
Employee Hiring
Employee Benefits
Employee Orientation
INTERNAL DEVELOPMENT Upgrade management information system Integrate I.T. and financial management system Establish an agency-wide Performance Improvement
Activity (Accreditation Privileging and Credentialing) Competency Based Employment Compensation Analysis Develop targeted staff development program Retrain your board; repopulate Consumers/Other Stakeholders Environment of Care Issues Establish Development Capability (Grants, Contracts,
Fundraising) Explore Collaborative Partnerships
KEY AREAS FOR CONSENSUS1. Competition
Restricted Limited Open
2. Centralized vs. Decentralized Devolution to local entitles Types of collaboration and community partnerships
3. Level of Integration Mental health; substance abuse and DD systems Co-occurring/co-morbidity Health care systems
4. Regionalism/Geomapping Numbers of regions Size
5. Service Delivery Models Staff Community Mixed
OPERATING ASSUMPTIONS
We are strong enough to assume substantial risk.
We have the management infrastructure and skill at all levels to succeed in a risk-based environment.
We have the overall clinical skill and credentials to produce quality outcomes within a competitive price structure.
Our service capacity is greater than current level of business. What we don’t have we can build, buy, create alliances.
SOME BASIC QUESTIONS1. Do the various stakeholders support this action?
Consumers Board Legislators Community at large
2. Can you operate at-risk?
Are your capital reserves adequate? Can you manage the State’s rate(s)? How good is the available date?
3. Do you have an adequate infrastructure?
MIS Utilization management On-line eligibility evaluation Financial management
4. Would you consider a private sector partner?
5. What are the anti-trust implications?
TRANSITION TO PROVIDER NETWORKS
Culture Change
Changing attitudes Level of sophistication Professionalism Competition Values challenged
Tradition & PassionVs.
Business Climate & Practices
TRANSITION TO PROVIDER NETWORKS(continued)
Information System
Integration of clinical, fiscal and management data
Customer based Outcome driven System wide Value added product
Up front and ongoing cost associated with training and
capital expenses
TRANSITION TO PROVIDER NETWORKS(continued)
Strategic Positioning
Education of executive director, board and staff
Short and long term plan Inclusion of board and staff at all levels Marketing and public relations Capacity building
Affiliation Merger
AFFILIATION STRATEGY MODEL
Deficits
Alternatives
TheDeal
Strategic
Direction
Establish Organizational
Goals
Diagnose Your
Shortcomings
Determine the Options
Negotiate and Execute
Attain strong negotiating position in managed care
Incomplete service offerings
Merge Target entity for acquisition / affiliation
Spread costs over larger client base
Small size prevents economics of scale
Joint venture Enter joint planning exercises with target
Rationalize excess capacity
Ineffective management
Acquire Do due diligence and execute
Reduce Costs of Service Delivery
Enhance Access to Managed
Care Contracts
PRIMARY OBJECTIVES OF INTEGRATION/AFFILIATION
Increase Access to
Care
Improve Quality of
Care
Retain Mission
ANTITRUST CONSIDERATIONS
1. Are the network providers otherwise free to compete on their own or through other arrangements?
2. What are the restrictions or limitations on joining or remaining with the network?
3. How will the network price its services to third party payers or other customers? For example, will it utilize a non-competitor (i.e., non-provider) to negotiate between the buyer and each participating provider?
4. Will the network attempt to attract contracts that are on a capitated basis or which make use of risk withholds?
5. Will each member of the network be free to participate or not participate as to each contract?
6. Will the network be prepared from the beginning to offer such pro-competitive and integrated services as quality assurances, utilization review, administrative services, etc?
7. How will cost and price data be kept as confidential or generic as possible?
DEAL KILLERS
Lack of support from stakeholders/politics
Absence of mutual trust
Lack of common vision/business purpose
Governance/control issues
Financial barriers/liabilities/arrangements
SOUTHERN ARIZONA CHILDREN’S CONSORTIUM
(L.L.C.)CPSA$
CODAC Behavioral
Health Services (Fiscal Agent)
Arizona Children’s Association
SACC2 Member Board
6 DirectorsAnd
2 CEO’s
SubcapitatedLas Families
SubcapitatedCODAC BHS
SubcapitatedAz. Children’s Assn.
SubcapitatedCDC
Capitalization
Discounted fee for service and block purchase (Hospitals, RTC and Group Homes)
Discounted fee for service – small group and individual practices, specialty providers
- Intensive case management systems- Medical/Psych. Services- Management of “high end” children
Capitalization
LESSONS LEARNED1. That aggressive management is not only the high end
but also the middle end is extraordinarily important.
2. That a loose affiliation or a loose partnership will not work in a full at-risk situation.
3. That good MIS systems and very good management infrastructure is vital to the operation and needs to be funded right off the top.
4. That aggressive contracting either on a sub-capitated basis or with discounted fees for service or block purchases is necessary to manage scarce resources.
5. That entrepreneurial efforts and creativity are as important as anything is in making managed care work.
LESSONS LEARNED (CONTINUED)
6. That there needs to be incentives to change an agency’s culture, as you are as good as the philosophy and approaches of the line staff delivering the services.
7. That agency cultures have myths and unconscious themes that can be detrimental to managed care and may not be easily recognized
8. Continuous quality improvement is extraordinarily important to further cost savings and appropriate utilization of resources.
9. Treatment protocols need to be continually improved upon
10. You need to take the long view in creating managed care programs, companies, processes and systems. While you must think of transition, start up, and the first year, your vision ought to be 3-5 years out.
HIGH PERFORMANCE BEHAVIORAL HEALTH SYSTEMS
Indicators of Obsolete Delivery Systems
Indicators of Improving Delivery Systems
Indicators of High Performance Delivery Systems
Access No intake and triage system, no treatment plans
Sophisticated intake and triage system with individualized treatment planning
Anticipation and management of illness averts the need for crisis intervention, intake, and triage
Care Practice pattern variation Validated practice standards, guidelines, and protocols
Team ownership and continuous improvement of clinical processes
Services Fragmented, uncoordinated illness treatment services
Coordinated, vertically and horizontally integrated illness treatment systems
Organized behavioral health promotion and management systems that are backwards integrated into the workplace and the community
Systems No continuum of care Expenditure-effective continuum of care
Cost-effective continuum of health
Operations Lack of process measurement, monitoring, and outcome assessment
Process measurement, monitoring, and outcome assessment in place
Continuous, data driven process improvement
Technology Technology profit centers Appropriate technology Critical technology
Cost Cannot measure behavioral costs for expenditures
Can measure and manage behavioral expenditures but not costs
Can measure and manage both behavioral health expenditures and costs
Knowledge Minimal learning and knowledge deployment
Rapid learning and knowledge deployment
Knowledge creation
PAYOR DRIVEN
PAYOR PROVIDER ORGANIZATION
INDIVIDUAL CLINICIAN
More sophisticated purchaser of care
Demand value
Require defined and quantified products/services
Pressed to define and quantify products/services
Cost conscious; effective; efficient practices; accreditation
Defined benefit package; services within timelines; measured outcomes
Performance based employment relationship
Credential specific and different levels of employment
Clinical care defined by other than clinician
CUSTOMER-SENSITIVE
CUSTOMER PROVIDER ORGANIZATION
INDIVIDUAL CLINICIAN
Empowered by advocates; choice in marketplace
Competitive environmentRegulatory environment
Negotiate benefits with consumer/contract of service
Professional liability intensified
Service is a partnership;Client satisfaction;Outcome;
Clinical paperwork increased
OUTCOME-ORIENTED
PAYOR PROVIDER ORGANIZATION
INDIVIDUAL CLINICIAN
Feedback loop expected; Progress; implications for primary care, job, etc.
Highly dependent on payor type
History of outcome measurement;
Differential reporting
C.Q.I. environment essential
Practice within competence
Highlights CO needs
Heightens collaboration/ consultation
Manage Care
Manage Benefit
Manage Health
Goals of Future Behavioral Health
Systems To improve the behavioral
health status and quality of life of defined populations
To enable beneficiaries to stay healthy, improve wellness, and help reduce the medical utilization and costs of defined populations and communities
To improve functioning and productivity of the American people and work force
To continuously improve the accessibility, affordability, and effectiveness of behavioral health services
Provider Network Management
Planning and Identification of Network Components
1. Parameters of the continuum of care2. Comprehensive community planning process3. Type, number and qualifications of providers
Procurement and Selection of Provider Networks
1. Open and competitive process2. Selection criteria3. Evaluation4. Approval process
Provider Network Management(continued)
Credentialing Documentation of licensure Accreditation Professional credentialing
Management of Provider Network Communication processes (administrative and clinical) Community input Assessment of continuum of care Training and technical assistance
Strategic Planning
Annual review of services Gap analysis Review of utilization data Geo access information Needs assessment information Outcome studies Member satisfaction
Customer ServicesCustomer Relations1. Members2. Providers3. Funders4. Advocacy groups5. State and local agencies
Member Handbook1. Benefits and services2. Member advocacy3. Rights and responsibilities4. Grievance and appeal process
Customer Services(continued)
Coordination with other Systems of Care
1. Health care2. Education3. Juvenile justice4. Child welfare5. Corrections
Member Satisfaction
Community Focus Groups
Quality ManagementIncludes quality assurance, continuous quality improvement,
and performance improvement.
Leadership and Staff Commitment1. Accreditation2. Board and Executive Management
Organization Quality Management GoalsExamples:1. Enhance the accessibility, adequacy and quality of administered
mental health services2. Improve coordination between medical and mental health care
within the geographic service areas3. Promote the effective and economical use of resources within the
system
ADHS/DBHS RequirementExamples:1. Case file reviews2. Provider profiling3. Member surveys4. Medical records review
Quality Management(continued)
Includes quality assurance, continuous quality improvement, and performance improvement.
Performance Measures1. High risk areas (vulnerable populations, fragile2. populations, unstable populations)3. High volume areas (based on demographics and4. diagnosis or high volume treatment modalities)5. Problem prone areas (breakdown in processes, problematic6. trends or patterns)
Performance Improvement Measures1. FOCUS - PDCA performance improvement model
Utilization ManagementPrior Authorization1. Covered services requiring prior authorization2. Medical necessity3. Least restrictive level of care
Concurrent Review1. Continued medical necessity2. Appropriateness of level of care3. Continued stay reviews
Second Level of Review1. Adequacy and clinical soundness of a member, assessment and2. treatment plan3. Used primarily in the determination of SMI or SED status
Retrospective Reviews1. Emergency admissions2. Consistency with level of care criteria and length of stay criteria
Non emergency inpatientNon emergency transportationNon formulary and brand name medications with generic equivalencyPartial careLevel I RTC
Financial ManagementRegulatory Compliance1. Legal requirements2. Contract compliance3. Grants management
Accounting applications and controls1. Mitigate loss2. Safeguard corporate assets3. Monthly, quarterly and annual financial statements4. Annual budget and forecasts
Integration of Financial and Clinical Data1. Rate setting2. Cost analysis3. Clinical analysis
Information ManagementMember Management1. Enrollment2. Eligibility status3. Demographics4. Benefit plans
Utilization Management1. Prior authorization2. Utilization analysis
Claims/Encounter Management1. Pharmacy claims2. Encounter claims processing and reconciliation
Provider Network Management1. Contracted services2. Demographic data3. Eligibility
Synopsis of Covered Services Behavior Management Crisis
Services Crisis Stabilization DUI Education & Screening Laboratory Partial Care (Basic & Intensive) Pre-petition Screening Court Ordered Evaluation &
Treatment Medications Prevention Services Psychosocial Rehabilitation Psychiatric Services Psychiatric Nursing Services Psychological Services Respite Substance Abuse
Assessment/ Evaluation & Screening
Case Management Consumer-run Club House Detoxification Family Therapy & Counseling Individual Therapy & Counseling Inpatient (Acute) Hospital
Services Residential Treatment Center
(RTC) Psychiatric Health Facility (PHF) Therapeutic Group Home (TGH) In-Home & Community Services Radiology & Medical Imaging Supported Housing Services Therapeutic Foster Care Transportation Vocation Services