Finding New Opportunities With Health Plans: How To Market ... · 1. Having preferential referrals...

1© 2017. All Rights Reserved.

www.openminds.com163 York Street, Gettysburg, Pennsylvania 17325Phone: 717-334-1329 - Email: [email protected]

The 2017 OPEN MINDS Strategy & Innovation Institute Tuesday, June 6, 2017 | 2:30pm – 3:45pm

Steve Ramsland, Ed.D., Senior Associate, OPEN MINDS

Finding New Opportunities With Health Plans: How To Market To Managed Care


I. Marketing To Managed Care Plans

II. Matthew O. Hurford, M.D., Chief Medical Officer, Community Care Behavioral Health Organization

III. Alyssa L. Rose, JD/MSW, Director, Network Strategy, Beacon Health Options

IV. Questions & Discussion

Agenda


Trends In Health Plan Contracting

Trend 1: More transparency in

fees

Trend 2: More Transparency In

Performance Measures

Trend 3: More Value-Based Purchasing

Marketing To Managed Care Plans


Building Successful Partnerships With Managed Care – Improving Your Positioning

The fee-for-service payer network contract

Being ‘preferred’ within a payer network

Gaining ‘exclusivity’ within a payer system


The Fee-For-Service Payer Network Contract

Most fundamental of all business relationships for provider organizations in health and human services

Often need to begin with privileging professionals individually, rather than being privileged at the organization level

Difficult market position but often necessary

No assurance of volume and no likelihood of referrals

Often ‘commodity’ positioning


The Goal: Preferred & Exclusive

Being ‘Preferred’ Within A Payer Network

1. Having preferential referrals due to some market differentiation

2. Need a demonstrable value proposition – almost always involving P4P or value-based payment

Gaining ‘Exclusivity’ Within A Payer System

1. Having a financial relationship (most often with significant financial risk) that gives you exclusivity by geography and/or consumer type

2. Your organization is the ‘narrow network’


Steps To Building Successful Partnerships With Managed Care Organizations

1. Market mapping

2. Solution-focused sales and payer

strategy development

3. Developing a service with the

payer value proposition in mind


XXXXXXXXXX Payer Market MapPayer ProfilesLast updated: April 1, 2013

Government Insurers Total Enrollment (CA) Enrollment, San Diego Enrollment, Imperial Enrollment, OrangeEnrollment, San

Bernardino Enrollment, Riverside Headquarters Street Address CityMedicare 5,000,198 178,583 2,466 189,292 123,223 152,359MediCal 7,339,984 453,494 55,519 469,970 484,988 410,9321501 Capitol Ave., MS 4400 SacramentoTri-Care/Military (UnitedHealthcare beginning April 1,2013) 290,219 1,823 20,586 49,946 43,653425 Market St., 27th Fl. San Francisco

Blue Shading indicates plan with enrollment ≥ 1000 - threshold to complete demographic research for this planNote: Medicare Advantage Enrollment data does not include numbers <10 in each county according to Health Plan

Some Medicare Advantage plans are under same plan name/entity but have a different contract number with CMS, therefore under separate columns (Plan ID included in the last column)

Medicare Advantage Total Enrollment (CA) Enrollment, San Diego Enrollment, Imperial Enrollment, OrangeEnrollment, San

Bernadino Enrollment, Riverside Headquarters Street Address City

Aetna Health Of California, Inc. 25,452 1,844 2,410 5,837 6,813P.O. Box 10169 Van NuysAnthem Blue Cross Life And Health Ins Company 37,375 4,668 294 7,457 116 2,08050 Beale Street San Francisco

Blue Cross Of California 12,251 1,746 16 945 1,420 2,46350 Beale Street San Francisco

California Physicians' Service 66,727 569 118 18,124 4,422 2,52250 Beale Street San Francisco

Care1st Health Plan 30,369 7,288 1,075 445 219601 Potrero Grande Drive Montery ParkCaremore Health Plan 51,262 27 8,321 3,835 12900 Park Plaza Drive, Suite 150 Cerritos

Central Health Plan Of California, Inc. 12,211 748 1,320 311540 Bridgegate Drive Diamond BarCitizens Choice Healthplan 14,388 1,113 1,543 3,27117315 Studebaker Road, Suite 200 CerritosCommunity Health Group 1,221 1,221 740 Bay Blvd Chula vistaEasy Choice Health Pla Inc. 53,767 1,643 593 7,569 3,220 7,634180 East Ocean Boulevard, Suite 700 Long Beach

Health Net Of California 138,335 12,390 31 12,320 10,884 14,73021281 Burbank Boulevard, B3 Woodland Hills

Humana Health Plan Of California, Inc. 20,961 2,329 1,439 1,449 3,4915421 Avenida Encinas, Suite N Carlsbad

IEHP Health Access 9,452 5,034 4,397303 East Vanderbilt Way, Suite 400 San Bernardino

Inter Valley Health Plan, Inc. 20,191 17 6,859 8,230300 South Park Avenue, Suite 300 PomonaKaiser Foundation HP, Inc. 881,902 70,539 102 47,975 41,118 40,828300 Lakeside Drive, 13th Floor Oakland

Molina Healthcare Of California 7,469 1,344 16 1,357 706200 Oceangate, Suite 100 Long Beach

Orange County Health Authority 14,646 14,624 505 City Parkway West Orange

Sample Data

1. Payer Market Mapping – Payers, Consumers, Competitors


2. Solution-Focused Sales & Payer Strategy Development

Solution-focused sales is focused on understanding the needs of the customer – and developing a solution (rather than ‘selling’ the services currently offered)

Meeting with payers to identify problems and concerns

Developing ‘services’ that address those payer problems


3. Developing A Service With The Payer Value Proposition In Mind

Concept development – Service description

– Cost/benefit or ROI analysis

Proposal development

Contracting

Implementation

Expansion

1. Concept

2. Build

3. Test

4. Feedback

5. Revisions Concept

Development Cycle


Partnering With MCOs: Get It Right

Deliver Rapid Access

Demonstrate Outcomes• Clinical

Effectiveness• Process Efficiency• Reduced Inpatient

Utilization• HEDIS & Other

National Measures

Follow Through On Contractual And Clinical Expectations

Demonstrate Operational Excellence Via National Accreditation, Licensing & MCO Site Visits

Provider organizations must


Partnering With MCOs: Innovate

Be creative - conduct pilots and share what you learn Integrate with medical and behavioral partners Evidence-based practices Peer and/or family support models Centers of excellence Telepsychiatry Web-based member engagement and social networking options EMR and data management Submit claims electronically and promptly


The Golden Rule Of Managed Care Contracting

Treat the MCO like a

partner – not an adversary

• Communicate • Develop relationships with clinical and network

staff• Participate in periodic meetings with MCO clinical

staff• Learn about their needs and plans, and how you

can help them• Keep them informed about you• Track your outcomes, share your data, talk about

your accomplishments


Use A Solution-Focused Payer Strategy

Focus on understanding the needs of the customer

– and developing a solution (rather than ‘selling’ the services currently offered)

Meet with payers to identify problems and

concerns

Develop ‘services’ that address those payer

problems

Community Care Behavioral Health OrganizationMatthew O. Hurford, M.D., Chief Medical Officer, Community Care Behavioral Health Organization

Partnering with Clarity, Alignment and Flexibility

Matthew O. Hurford, M.D.June 6, 2017

© 2017 Community Care Behavioral Health Organization

Agenda

• Conclusion

• Introduction

• Landscape

• Keys to Successful Partnership: Examples from Community Care

18© 2017 Community Care Behavioral Health Organization

Conclusion


Keys to Successful Partnership

1. Clarity: what are you trying to do and how will you know that you’ve done it?

2. Alignment: is it consistent with your organization’s mission, culture and strengths?

3. Flexibility: is your organization willing and able to change administrative, clinical and fiscal operations?


Introduction


Community Care


• Behavioral health managed care company founded in 1996; part of UPMC and headquartered in Pittsburgh, PA

• Federally tax exempt non-profit 501(c)(3)

• Major focus is publicly-funded behavioral health care services; currently doing business in PA and NY

• Licensed as a Risk-Assuming PPO in PA

• Serving over 1.6 million individuals in 39 counties through a statewide network of over 1,800 providers

Community Care’s PA Presence


Landscape

• Value-based payment reform

• The rise of outcomes

• Integration

• Population health

• Proliferate, partner or perish


Clarity


Partnering with clarity

• Given landscape, organizations must be clear about their goals

• Elevator pitch

• It’s the destination not the journey


Partnering with clarity: ACT P4P


• Goal: incent providers of ACT services to reduce inpatient mental health (IPMH) utilization of ACT service recipients

• Collaboration between:– Two ACT providers in Allegheny County– Allegheny County, Office of Behavioral Health– Allegheny HealthChoices Inc. (AHCI)– Consumer Advisory Committee– Community Care

ACT P4P: Reduction in inpatient mental health


Provider 2012 2014 2015

Provider A (n=224) 16.8 8.7 6.9

Provider B (n=126) 15.1 10.5 6.6

Combined 16.2 9.3 6.8

Average annual inpatient mental health days

ACT P4P: cost savings


Provider 2012 2014 2015ACT $ per member, Provider A

$24,260 $19,321 $18,182

IPMH $ per member, Provider A

$9,911 $3,573 $2,364

ACT $ per member, Provider B

$15,835 $16,215 $18,477

IPMH $ per member, Provider B

$12,413 $8,979 $3,486

Average annual cost of ACT and IPMH

Alignment


Partnering with alignment

• Clarity about the “right” things

• Organizational mission

• Culture

• Play to your strengths: historical and potential


Partnering with alignment: Recovery Oriented System of Care (ROSC-II)

• Introduced a range of innovations to restructure the system from an acute, vertical system to a horizontal continuum based on specific drug use behaviors

– The long-term goal is to engage more people in treatment through health care as well as integrate medication-assisted treatment within existing services

– Individuals with an opioid use disorder, which account for two-thirds of all treatment admissions in PA, will have rapid access to high-quality MAT


Engage More People in the Front Door


• 24 agencies involved in improving show rates through increased outreach

• Significant improvements in show ratesEngage & retain

clients

• Trained peers to engage patients in ED & hospital settings who may have an SUD

• 120 patients have been engaged in medical settings

Community Outreach &

Recovery Services (CORS)

• All OP programs in NE contract have opportunity to receive P4P funds by improving show rates and retention –initiated in summer 2016

Pay for Performance (P4P) to increase engagement & retention in NE

• Multiple teams of nurses, social workers & patient navigators are engaging high utilizers of hospitals & EDs with complex medical problems

Community Team –community-based teams working with

high users of hospitals

ROSC-II Improve Show Rates


780

242155

328

0

100

200

300

400

500

600

700

800

900

received a contact did not receive a contact

Showed for 1st day of treatmentNo-showed for 1st day of treatment

Avg. # Days – Assessment to 1st Appt.


13.11

10.00 9.32 9.648.40

7.52 7.22 7.127.87

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

ROSC II agencyaverage

Flexibility


Partnering with Flexibility

• Implementations seldom go according to plan

• Learning organization

• Identify and address barriers to change


Partnering with Flexibility: Behavioral Health Homes

• PCORI: Optimizing Behavioral Health Homes by Focusing on Outcomes that Matter Most to Adults with SMI

• Main partners include:– BHARP, NC and Chester Counties– Providers– UPMC Center for High-Value Health Care– Community Care – University of Pittsburgh– Stakeholder Advisory Board

• Principal investigators:– James Schuster, MD, MBA, Community Care– Charles (Chip) Reynolds III, MD, University of Pittsburgh– Tracy Carney, CPRP, CSP, Community Care


Recap: Study & Interventions

Comparative effectiveness study of two behavioral health home model approaches to improve the health status of individuals with serious mental illness, increase patient activation in care, and improve engagement with primary/specialty physical health care


Provider-Supported CareWellness nurses focused

on PH & wellness(5 providers)

Self-Directed CareSelf-management toolkits & resources

(6 providers)

Enhancing patient & BH provider capacity to

address PH & wellness

Findings Executive Summary

• Learning Collaborative/Implementation Findings:– Performance on all process/outcome goals improved over time– Provider-supported arm reported higher degree of achievement on all

process goals after one year of implementation• Qualitative Interview Findings:

– Little difference in findings between intervention arms– Overall positive experiences participating in (service users) or

implementing (providers) interventions • Quantitative Findings:

– Intervention type (Provider-Supported vs. Self-Directed) has a differential impact on some patient-centered outcomes (treatment X time interaction effect)

– Both interventions positively impact several of our outcomes over time (change over time)

• Financial Findings:– Indicative of long-term cost reductions in Provider-Supported

(Wellness Nurse) sites, with some evidence of long-term decreases in Self-Directed (Self-management Navigator) sites.

– PH costs shift towards more ambulatory and lower inpatient.


Trial Data Only: Results


- 0.020 0.040 0.060 0.080 0.100 0.120 0.140 0.160

Year 1 Year 2

PH penetration change vs. Year 0

Navigator Nurse

$(150)

$(100)

$(50)

$-

$50

Year 1 Year 2

BH PMPM change vs. Year 0

Navigator Nurse

LC to Support Implementation


Structured approach for

change

Adopt best practices in

multiple settings

Uses adult learning

principles & techniques

Time-limited learning process

Shared learning and

collaboration

•Learning Sessions

Training Manuals

•Action Periods

Apply Skills Test Changes •Collaborative

Meetings

Ongoing TA & Support

•Measure Outcomes

Share Progress

Qualitative Interview Data: Providers

• Agency response:– High degree of agency support for wellness coaching– Establishment of culture of wellness– Continued use of model post study implementation period– Staff turnover problematic for maintaining wellness

coaching continuity– Worry about service user “relapse” when discharged from

CMHC

• Individual provider response:– Providers simplified/casualized wellness coaching to

increase service user engagement– Nurses often mentioned as most beneficial component of

the model – Providers often established their own wellness goal(s)


Behavioral Health Home Expansion

• Additional populations served: adolescents, opioid treatment programs• Population Health LC for mature providers focused on hypertension & smoking

cessation: 19 BHHs participating in first cohort, second cohort beginning this spring


Erie

Allegheny

Clarion

Forest

Warren McKean Potter

CameronElk

Jefferson

Clearfield

Blair

Centre

Clinton

Adams

Snyder

Union

Lycoming

Tioga Bradford

Columbia

Montour

YorkChester

Berks

Schuylkill

Luzerne

Wyoming

Susquehanna

Lackawanna

Wayne

Pike

Monroe

Carbon

Juniata

Sullivan

Mifflin

Huntingdon

Northumberland

Conclusion….wait, we covered that


Beacon Health Options

Alyssa L. Rose, JD/MSW, Director, Network Strategy, Beacon Health Options

The Value of Access: Partnering with Commercial Payors

Alyssa Rose, JD, MSW, Director of Network Strategy, Beacon Health Options

47

Beacon is transitioning to a collaborative approach to strategic provider management

48

A collaborative partnership model is the target destination

49

Beacon Offers:• Clinical best practices• Longitudinal clinical/

care management• Developed “system of

care” services• Shared data analytics• Provider benchmarking• Value-based purchasing

Providers Offer:• Efficacious

clinical care• Robust transition/

discharge planning• Primary care

linkages

Providers Receive:• Reimbursement based

on quality/outcomes• More volume• Less administrative

burden• More clinical self-

management

Beacon Receives:• High-performing

network• Superior member

outcomes• Fewer resources

dedicated to clinical reviews

Value-based payments

50

51

Overtreatment Under-treatment

INCENTIVE-BASED TREATMENT RISK

CO

MPL

EXIT

Y

VALUE-BASED PURCHASING OPTIONS

Proprietary and Confidential

Value-based purchasing comes in many different forms besides capitation

Behavioral Health Capitation• Risk for providers• Full behavioral health payment• Defined coverage set

Fee-for-service• One service• One payment

Case Rate• Group of services• Combined payment• Monthly/weekly payment

Episode Bundle• Group of services• Combined payment• Quality goals• Defined time period

Total Health Outcomes• Shared risk on total

member experience

Pay for Performance (P4P)• “Upside only”• Key process measures

Development of Preferred Networks

52

We know that access is a critical issue in behavioral health

53

WAIT TIMES HAVE A HUGE IMPACT ON NO-SHOW AND E.R. ADMISSION RATES

~25% no-show rate if patient has to wait a single day

Sources: 2014 Beacon site visits, Massachusetts Gallucci et al, 2005. Impact of the Wait for an Appointment on the Rate of Kept Appointments at a Mental Health Center.

0

If patients do not receive timely BH care, they:

• Have a higher likelihood of using Emergency Rooms

• Lower treatment retention rate• Higher hospitalization and re-

hospitalization rate

Every subsequent wait day increases no-show rate by ~1%

THERE ARE ACCESS ISSUES TO BEHAVIORAL HEALTH PROVIDERS

• 1 in 5 adults with mental health needs report that they are not receiving the services they need

• Nationally, only 41% of adults with mental illness received any care in the past year

• Only four states were able to provide care to >50% of their mentally ill populations

• 59% of primary care physicians report being unable to obtain outpatient mental health services for patients due to local provider shortages/wait lists

Traditionally, access has been defined by geographic proximity and provider size

54

We envision a future whereaccess means something more

Proximity SizeA member has a provider within a certain

geographic distance from their homeA provider is large enough to meet member demand

for its services (clinician-to-member ratios)

We hope to redefine access by its key outcome: the ability to secure an actual appointment

55

Care Flexibility

Appointment Completions

Provider Quality

Members are not just referred, but secure actual appointments. Same-day and next-day appointments are available, and members have the appropriate transportation and resources to completethose appointments

Providers are not measured by their scale, but by the value they create. Members play a critical role in determining and reporting on provider quality

Members have the flexibility to choose the modality of their appointment (in person or online), and providers have the technology tools at their disposal to accommodate that choice

Redefine access as:

To support this vision, we will leverage innovative tools and strategies

56

Care Flexibility

Appointment Completions

Provider Quality

• Interconnected scheduling platforms• Open access provider scheduling &

same-day next/day availability• Telehealth• Value-based payments (e.g., P4P

incentives for decreasing wait times)

• Online CBT and counseling• SMS & mobile messaging• Telehealth

• Preferred provider network, tiered by quality

• Value-based payments (based on outcomes)

• Member-reported outcomes

Giving out phone numbers and addresses is not enough – we aim to create a system where same-

day and next-day appointments are achievable and completed

In today’s world, access is about more than face-to-face time. Technology solutions enable

members to choose from a wider set of providers, appointments, and

treatment modalities

Access to care should always imply access to quality care. We envision a world where members have a critical role in determining

provider quality, not just claims and clinical data

Goa

lB

eaco

n fo

cus

Mobile platforms

(self-tracking and support)

iPad member survey

Solu

tions

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCN3g8Z7jisgCFQQ3PgodjjcJ8Q&url=http://iesohealth.com/accessing-ieso/patients/&psig=AFQjCNEgMAdSrk9RinOLghkPlyGdStZB7A&ust=1443015882726059

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCN3g8Z7jisgCFQQ3PgodjjcJ8Q&url=http://iesohealth.com/accessing-ieso/patients/&psig=AFQjCNEgMAdSrk9RinOLghkPlyGdStZB7A&ust=1443015882726059

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCNfrmOPjisgCFQJWPgodtWIA0Q&url=http://www.cambridgenetwork.co.uk/news/ieso-digital-health-revolutionising-access-mental-health-therapy/&psig=AFQjCNEgMAdSrk9RinOLghkPlyGdStZB7A&ust=1443015882726059

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCNfrmOPjisgCFQJWPgodtWIA0Q&url=http://www.cambridgenetwork.co.uk/news/ieso-digital-health-revolutionising-access-mental-health-therapy/&psig=AFQjCNEgMAdSrk9RinOLghkPlyGdStZB7A&ust=1443015882726059

There are steps we can take today in an attempt to enhance access while innovation grows

57

WE PROPOSE USING VALUE-BASED PAYMENTS TO INCREASE ACCESS

START WITH 1 MSA, BUILD OUT AS WE DEMONSTRATE SUCCESS

• Block-purchase time: pre-purchase time from psychiatrists or group practices to ensure they always make time for members

• Enhanced rate for same-day/next-day access: negotiate an enhanced rate for providers in exchange for guaranteed appointment within 24 hours

• Develop urgent access telehealth provider: negotiate with a willing telehealth partner to guarantee access

• Choose specific MSA • Identify providers, likely those with low

current utilization, high desired utilization, and in high-member-density locations

• Approach providers to request differential service levels with different payment mechanisms, either direct outreach or via RFP process

• Focus on outpatient psychiatry to start, but be open to other access points

• Track progress in year 1 and roll-out to other MSAs as success is demonstrated (proof of concept and cost containment)

Provider partnership program

58

59

Provider Profiler Enhances Collaboration and Supports Practice Transformation

We share 20+ metrics with providers, including both standard and novel measures

We craft a narrative to draw attention to what we believe is important

Benchmark against like providers in the state

We are not rigid in our application of the data – context matters

We work to set goals from each meeting that we collectively agree on

We partner to deliver the training and administrative support providers need to improve

Thank you!

60

Questions?

www.openminds.com 163 York Street, Gettysburg, Pennsylvania 17325 717-334-1329 [email protected]

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