Transcript Slide 1

Managed Care Organizations
and
Provider Networks
Challenges and Opportunities
November 7, 2003
Presented 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
ARIZONA LEGISLATURE
APPROPRIATION/MATCH
APPROPRIATION/MATCH
FEDERAL HEALTH
CENTER
FOR
CARE FINANCE
MEDICARE/MEDICAID
ADMINISTRATION
SERVICES
(HCFA)
MEDICAID/TITLE 19
MEDICAID/TITLE XIX
ARIZONA HEALTH
ARIZONA HEALTH
CARE COST
CARE COST
CONTAINMENT
CONTAINMENT
SYSTEM
SYSTEM
(AHCCCS)
(AHCCCS)
STATE HOSPITAL
STATE HOSPITAL
SUBVENTION
SUBVENTION
TOBACCO TAX
TOBACCO TAX
TITLE XXI
TITLE XXI
TITLE XIX
TITLE XIX
ARIZONA DEPARTMENT
OF HEALTH SERVICES
(ADHS)
SUBSTANCEABUSE
ABUSE
SUBSTANCE
& MENTAL
& MENTAL
HEALTH SERVICES
HEALTH SERVICES
ADMINISTRATION
ADMINISTRATION
(SAMHSA)
(SAMHSA)
BLOCKGRANTS
GRANTS
BLOCK
DIVISION OF
BEHAVIORAL HEALTH
SERVICES (DBHS)
REGIONAL BEHAVIORAL
HEALTH AUTHORITIES
(RBHA)
The state is divided into six geographic regions. Each region is
assigned to a RBHA.
NARBHA
EXCEL
VALUE
OPTIONS
PGBHA
(GSA3)
Graham
(GSA 5)
Pima
CPSA
Greenlee
Cochise
Santa Cruz
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 Disorders
1.
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
Evolving Systems of Care for Persons with
Behavioral Health Disorders (con’t)
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
Managed Care Organization
Authority Core Functions
Provider Network Management
Strategic Planning
Customer Services
Quality Management
Utilization Management
Financial Management
Information Management
CPSA Core Functions:
Administrative Oversight
Network and Clinical
Management
Business Operations
Southeast Region Provider
Management
Children's’ BHC System
Management
Claims Encountering
Persons with SMI BHC System
Management
Financial Compliance
GMH/SA and Crisis BHC System
Management
UM, UR, Member Benefits, Data
Analyses and Reporting
Member Services
Performance Improvement and
Quality Management
Prevention, Health Promotion and
Training
Contracts Function
Financial Analyses and
Reporting
Financial Auditing
Information
Management
In-House Legal
Counsel
Information Systems
Development
Ethics and
Privacy
IT Management
Grievances &
Appeals
Data Processing
Contracts
Development
Telecommunications
Ad-Hoc Data Reporting
Human Resources
Facilities Management
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 CONSENSUS
1.
Competition



2.
Centralized vs. Decentralized


3.


Mental health; substance abuse and DD systems
Co-occurring/co-morbidity
Health care systems
Regionalism/Geomapping


5.
Devolution to local entitles
Types of collaboration and community partnerships
Level of Integration

4.
Restricted
Limited
Open
Numbers of regions
Size
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 QUESTIONS
1.
Do the various stakeholders support this action?




2.
Can you operate at-risk?



3.
Consumers
Board
Legislators
Community at large
Are your capital reserves adequate?
Can you manage the State’s rate(s)?
How good is the available date?
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 & Passion
Vs.
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
Strategic
Direction
Establish
Organizational Goals
Alternatives
Deficits
Diagnose Your
Shortcomings
Determine the
Options
The
Deal
Negotiate and
Execute
Attain strong
negotiating position
in managed care
Incomplete service Merge
offerings
Target entity for
acquisition /
affiliation
Spread costs over
larger client base
Small size prevents Joint venture
economics of scale
Enter joint planning
exercises with
target
Rationalize excess
capacity
Ineffective
management
Do due diligence
and execute
Acquire
Improve
Quality of
Care
Retain
Mission
PRIMARY OBJECTIVES OF
INTEGRATION/AFFILIATION
Enhance
Access to
Managed
Care
Contracts
Reduce
Costs of
Service
Delivery
Increase
Access to
Care
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
Capitalization
Capitalization
- Intensive case
management systems
- Medical/Psych. Services
- Management of “high
end” children
Subcapitated
Las Families
SACC
2 Member Board
6 Directors
And
2 CEO’s
Subcapitated
CODAC BHS
Discounted fee for service
and block purchase
(Hospitals, RTC and Group
Homes)
Subcapitated
Az. Children’s Assn.
Subcapitated
CDC
Discounted fee for service –
small group and individual
practices, specialty
providers
LESSONS LEARNED
1.
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
Access
Indicators of Improving Delivery Systems
Indicators of High Performance Delivery
Systems
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
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
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
Minimal learning and knowledge
deployment
Rapid learning and knowledge deployment
Knowledge creation
Care
Cost
Knowledge
PAYOR DRIVEN
PAYOR
PROVIDER ORGANIZATION
INDIVIDUAL CLINICIAN
More sophisticated purchaser of care
Pressed to define and quantify
products/services
Performance based employment
relationship
Demand value
Cost conscious; effective; efficient
practices; accreditation
Credential specific and different levels of
employment
Require defined and quantified
products/services
Defined benefit package; services within
timelines; measured outcomes
Clinical care defined by other than
clinician
CUSTOMER-SENSITIVE
CUSTOMER
Empowered by advocates; choice in
marketplace
PROVIDER ORGANIZATION
Competitive environment
Regulatory environment
Negotiate benefits with
consumer/contract of service
Professional liability intensified
INDIVIDUAL CLINICIAN
Service is a partnership;
Client satisfaction;
Outcome;
Clinical paperwork increased
OUTCOME-ORIENTED
PAYOR
Feedback loop expected; Progress;
implications for primary care, job, etc.
PROVIDER ORGANIZATION
INDIVIDUAL CLINICIAN
History of outcome measurement;
Practice within competence
Differential reporting
Highlights CO needs
C.Q.I. environment essential
Heightens collaboration/ consultation
Highly dependent on payor type
Manage Benefit
Goals of Future Behavioral
Health Systems
 To improve the behavioral health
status and quality of life of defined
populations
Manage Care
 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
Manage Health
 To continuously improve the
accessibility, affordability, and
effectiveness of behavioral health
services
Provider Network Management
Planning and Identification of Network Components
1.
2.
3.
Parameters of the continuum of care
Comprehensive community planning process
Type, number and qualifications of providers
Procurement and Selection of Provider Networks
1.
2.
3.
4.
Open and competitive process
Selection criteria
Evaluation
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 Services
Customer Relations
1.
2.
3.
4.
5.
Members
Providers
Funders
Advocacy groups
State and local agencies
Member Handbook
1.
2.
3.
4.
Benefits and services
Member advocacy
Rights and responsibilities
Grievance and appeal process
Customer Services
(continued)
Coordination with other Systems of Care
1.
2.
3.
4.
5.
Health care
Education
Juvenile justice
Child welfare
Corrections
Member Satisfaction
Community Focus Groups
Quality Management
Includes quality assurance, continuous quality improvement, and
performance improvement.
Leadership and Staff Commitment
1. Accreditation
2. Board and Executive Management
Organization Quality Management Goals
Examples:
1. Enhance the accessibility, adequacy and quality of administered mental health
services
2. Improve coordination between medical and mental health care within the
geographic service areas
3. Promote the effective and economical use of resources within the system
ADHS/DBHS Requirement
Examples:
1. Case file reviews
2. Provider profiling
3. Member surveys
4. Medical records review
Quality Management
(continued)
Includes quality assurance, continuous quality improvement, and
performance improvement.
Performance Measures
1.
2.
3.
4.
5.
6.
High risk areas (vulnerable populations, fragile
populations, unstable populations)
High volume areas (based on demographics and
diagnosis or high volume treatment modalities)
Problem prone areas (breakdown in processes, problematic
trends or patterns)
Performance Improvement Measures
1. FOCUS - PDCA performance improvement model
Utilization Management
Prior Authorization
1. Covered services requiring prior authorization
2. Medical necessity
3. Least restrictive level of care
Concurrent Review
Non emergency inpatient
Non emergency transportation
Non formulary and brand name medications with
generic equivalency
Partial care
Level I RTC
1. Continued medical necessity
2. Appropriateness of level of care
3. Continued stay reviews
Second Level of Review
1. Adequacy and clinical soundness of a member, assessment and
2. treatment plan
3. Used primarily in the determination of SMI or SED status
Retrospective Reviews
1. Emergency admissions
2. Consistency with level of care criteria and length of stay criteria
Financial Management
Regulatory Compliance
1. Legal requirements
2. Contract compliance
3. Grants management
Accounting applications and controls
1.
2.
3.
4.
Mitigate loss
Safeguard corporate assets
Monthly, quarterly and annual financial statements
Annual budget and forecasts
Integration of Financial and Clinical Data
1. Rate setting
2. Cost analysis
3. Clinical analysis
Information Management
Member Management
1.
2.
3.
4.
Enrollment
Eligibility status
Demographics
Benefit plans
Utilization Management
1. Prior authorization
2. Utilization analysis
Claims/Encounter Management
1. Pharmacy claims
2. Encounter claims processing and reconciliation
Provider Network Management
1. Contracted services
2. Demographic data
3. 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