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An Introduction Illinois Health Practice Alliance
CBHA 46th Annual Winter ConferenceDecember 10, 2018
Hyatt Regency Woodfield
IHPA Legal Structure
2
Providers
ProviderCo LLC
Centene
Illinois Health Practice Alliance
50%50%
Illinois Health Practice Alliance Goals
• Align providers and allow opportunity to invest in shared infrastructure
• Leverage scale and efficiencies – more safely able to take on risk
• Work together to transform practices and provide supports necessary to be successful
• Develop formal structure to drive quality and efficiency• Develop strategies to become a vehicle for Integrated Health
Homes (IHH)• Over time, include FQHCs and primary care providers in
implementation of IHH
3
IHPA is a state-wide Behavioral Health IPAleveraging expertise of providers and Centene Corporation
IHPA Governance
4
IHPA Board
ProviderCo CBHA Centene
• 50% vote• 4 members
• 50% vote• 9 members
• Non-voting• Ex-officio
Committees Management team
• Executive• Clinical Operations• Finance• Ad hoc
• CEO Started July ‘18• Senior Director of Finance Started
December ‘18• CCO – Offer Pending• Analyst, Admin – Offer Pending
5
IHPA Value Proposition
MCO Contracting• Complex: multiple contracts require
need to manage provider engagement, credentialing and other administrative activities with each organization
• Efficient: Single contract with minimal administrative overhead: IHPA supports MCOs in provider enrollment
Payment Models• Outdated: FFS based only;
unpredictable cash flow; onerous reconciliation
• Value-Based: FFS + incentives; MCOs and providers benefit from enhanced quality and aligned incentives
Compliance• Transactional: MCO monitors and
responds to multiple providers and organization with varying clinical sophistication and infrastructure
• Self-directed: IHPA is sole interface with MCOs creating consistent rules with all IHPA BH organizations
Technology/Data• Siloed: Systems not integrated with
MCO or other providers; data limited to individual provider services
• Accessible: Claims and performance data; care management platform; real time updates; predictive risk stratification modeling; BH/physical health visibility enabled
Care Management• MCO Centralized: Often reliant
on telephonic outreach to members; limited coordination with providers; screening, assessment, and care plan duplication between plan and providers
• Provider Engaged: Embedded care managers; shared assessment and care plan capability; leverage expertise of plan and providers
Current IHPA
Catalyst to enable Integrated Health Homes and enable Value Based Care
IHPA Network Overview • Statewide network provides services both in
the community and in clinics
• 74 Community Behavioral Health Provider Organizations in network with 40% being owners
• Network Includes Required Professionals Under Integrated Health Home Guidelines
• Primary Care, BHS Specialists, SUD Specialists, Social Services, Nurse Care Manager, Clinical Coordinator
• Management Services Organization (MSO) Capable of Processing Claims and Providing Required Case Management Infrastructure and Supports
• Implementing Integrated Information Systems to Support Effective Care Coordination
6
IHPA Network Capabilities• Outpatient counseling and therapy• Group and Family Therapy• Comprehensive Substance Abuse Treatment and Rehabilitation • Crisis Intervention Services• Comprehensive Community Treatment• Assertive Community Treatment• Residential Services for Behavioral Health and Substance Abuse • Member find and engagement services• Case Management Services• Support for Social Determinants of Need• Primary Health Care Services
7
IHPA Financial Structure
8
MCO BIlliniCareContract
PMPM plus quality and total cost of care incentives
IHPA
ProviderCo members
(2 options)
90-95% FFS plus enhanced
performance incentives
PMPM plus highest performance
incentives
Contracted Providers
(3 options)
100% FFS plus performance
incentives
90-95% FFS plus enhanced
performance incentives
PMPM plus highest performance
incentives
MCO C
Outpatient BH
MSO Contract
CBHA Contract
CBHA (Community Behavioral Healthcare Association of IL) supports:+ Provider recruitment+ Provider technical
assistance+ Practice management
support
MSO (Management Services Organization) supports:+ Access to data+ Population health analytics+ Provider level and IHPA
performance measures+ Provider education+ Claims processing+ Provider call center
IHPA Operating Structure
9
Illinois Health Practice Alliance
Contracted Providers
(BH Network)
MCO DContract
MCO CContract
MCO BContract
IlliniCare Contract
CBHA
Centralized MSO
Local MSO Staff
IHPAStaff
Confidential and Proprietary
IHPA ImplementationTimeline
Mar‘18
Apr‘18
May‘18
Jun‘18
Jul‘18
Aug‘18
Sept‘18
Oct‘18
Nov‘18
Dec‘18
Jan‘19
Feb‘19
Mar‘19
ProviderCo Joins IHPA, LLC
IHPA Leadership CEOHired
CFO/Analyst Hired
CCO Hired
Outreach and Engagement
ContractSigned
Find and Engage Pilot
Value Based Payment (VBP)
AssessmentComplete
AssessmentsMSO Agreement
Executed
IHPA Contract with MCOs
InNegotiations
VBP Amendments and Metrics
Integrated Health HomesBi-directional
PortalPopulation
HealthPlatform
10
IHPA Is Uniquely Positioned for IHH SuccessIHPA’s mission and model is designed to improve the care and linkages between behavioral health and physical health…which fits the IHH Model
IHPA’s providers have long-standing collaborative relationships with local PCPs, FQHCs and other IHH stakeholders
IHPA is supported by an experienced, Illinois-based MSO that complements the network’s capabilities to deliver results for Managed Care Organizations
IHPA leverages a state-of-the-art population health and care management platform that drives accountability and performance insights
Managed Care Organization contracts with an IHH network aligned with its goals and objectives from Day 1
Managed Care Organization reduces its own administrative contract burden while maintaining a comprehensive, state-wide network for IHH
Managed Care Organization can be confident that services are delivered as contracted with a focus on improved outcomes and TCOC
Managed Care Organization benefits from high-quality data analytics and reporting that connects claim and EMR data for the IHH attributed member population
Benefits to the MCOsThe IHPA Difference
11
IHPA IHHFinancial Structure
Managed Care Organizations (MCOs)
Provider A (Sub-Contractor)
Provider B (Sub-Contractor)
State of Illinois
Provider C(Collaborating BH Provider)
Collaborating BH provider
Collaborating PCP provider
Collaborating BH provider
Collaborating PCP provider
Collaborating PCP provider
IHPA(IHH)
12
IHPA Contract/IHH Quality Metrics
Service Agreements• HRA Completion• Annual PCP Visit• 7 Day F/U After Inpt MH• 30 Day F/U After Inpt MH• MH ED Visit F/U • Initiation of AOD Treatment• Engagement of AOD Treatment• AOD ED Visit F/U• Total Cost of Care: Attribution Only
ED Visits per 1000IP Admissions per 1000Readmission Rate
Integrated Health Homes • Initiation/Engagement of AOD
Treatment• Screening/Care Plan for Depression• Chronic Condition for Admits• Adult BMI Assessment• Inpatient Discharge F/U• ED Visits per 1000• Immunization Combo 3• Breast Cancer Screening• Diabetes Management• Antidepressant Medication
Management
13
Why IHPA? IHH Statewide Coverage • Adams
• Bond
• Carroll
• Clinton
• Cook
• DuPage
• Fayette
• Gallatin
• Hamilton
• Henderson
• Henry
• Jackson
• Kane
• Kendall
• Knox
• Lake
• Lee
• Macon
• Madison
• Marion
• Monroe
• Morgan
• Ogle
• Peoria
14
• Randolph
• Saline
• Sangamon
• St. Clair
• Warren
• Washington
• Wayne
• White
• Whiteside
• Will
• Winnebago
Find and Engage Pilot Results• Pilot Objective:
• Find and Engage High Risk/High Cost Members in Outpatient Behavioral Health Services
• Pilot Results:• Total Pilot Population: 3,275 Cook County Members• Total Annual Cost Over $60M• Completed Over 18,000 Outreach Activities• Found 59% of the Eligible Members• Members Found = 17% Higher Risk Score and 32% Higher Cost
Than Members Not Found• 18% of Eligible Members Engaged in Services• Completed Over 200 Linkages/Referrals to Housing, Food, Other
Social or Health Needs, Primary Care, or Plan Utilization Management Team
15
Management Services OrganizationApproach and Services
© 2018 Envolve. 16
MSO Overview
• Envolve brings together the capabilities of Centene and other partners to serve IHPA
• Leverages scale and maturity of Centene to deliver value to clients• Currently contracted to serve ~500K Medicaid lives nationally in
various markets• IHPA has engaged Envolve as its MSO partner to perform a range of
services on behalf of the IPA.– Full suite of managed services to enable IHPA to contract with
MCOs in delegated and other arrangements.• IHPA and Envolve MSO will initially focus on IlliniCare contract in 2018
with goal to expand to other payers in future months/years.• Target go-live is 2/1/19• MSO Location: Chicago, IL
17Confidential & Proprietary © 2017 Envolve, Inc.
High Level MSO Scope of Services
18Confidential & Proprietary © 2017 Envolve, Inc.
Provider Relations,
Contracting and Education
Data Analytics & Reporting
Eligibility & Enrollment
Provider Performance Management
Finance & AccountingIT Infrastructure
Claims
Provider Data Management
IHPA Human Resources
IHPA Facilities
IHPA Compliance
Compliance
IHPA IT Support
Admin Service
MSO Scope
Population Health Technology
Coming Soon
Integrated Health Homes
Enrollment and EligibilityAttribution and Assignment
• Initial attribution logic was based on attributing existing “known” IHPA clients
• MSO receives file from MCO monthly based on pre-defined IHPA/MCO methodology
• MSO processes Provider Assignment based on rules established by IHPA’s Clinical Operations Committee
• Envolve systems cascade this information to enable accurate claims processes
19Confidential & Proprietary © 2018 Envolve, Inc.
Claims RoutingStructured to minimize erroneous payments while maximizing flexibility for IHPA Claims setup will minimize the changes needed by IHPA providers at go-live
20Confidential & Proprietary © 2018 Envolve, Inc.
IHPA Provider
Not IHPA Provider
IHPA Pays
Claim
Illinicare Pays
Claim
Member Attributed to IHPA
Member Not Attributed
Outpatient Community-based BH Service
Not Community-based BH Service
Member Attributed to IHPA
Community-based BH Service
Not Community-based BH Service
Community-based BH Service
IHPA Provider Member Not Attributed Not Community-based BH Service
Community-based BH Service
IHPA Provider Member Attributed Not Community-based BH Service
Provider (and Member) Services • MSO will assume responsibility for Provider calls and related functions• IHPA is unique for Centene since the MSO will have accountability for a portion
of some processes while Illinicare maintains responsibility for other portions– Objective: Enhance provider experience while maintaining an efficient and
effective operation• Collaboration with Illinicare to establish process flows and warm hand-offs has
been very productive• The MSO will coordinate the following areas on behalf of IHPA Providers:
– Claim inquiries/disputes and member eligibility calls – Appeals and Grievances– Prior Authorizations– Provider Relations
21Confidential & Proprietary © 2018 Envolve, Inc.
22Confidential & Proprietary © 2018 Envolve, Inc.
Find a Provider IHPA Public Website
Provider Portal
Provider Manual and Data Management
Provider Manual• MSO is setting up companion
provider manual for IHPA• Collaborating with Illinicare
team on any changes to Illinicare’s manual
• Will reflect significant process changes and instructions on IHPA claim submissions, A&G processes etc
PDM• MSO will handle all provider
network updates beginning 2/1/19
• Providers will be able to make changes with Call Center or through the Portal
23Confidential & Proprietary © 2018 Envolve, Inc.
Provider Performance Support• MSO will create a new function to collaborate with healthcare providers to help
them achieve high performance with regard to their value-based contracts.– Own relationship with assigned provider group(s).– Assist in identification, development, and establishment of key performance metrics
to measure performance of providers related to their value based contracts– Collaborate with provider staff to develop and implement operational/clinical
process improvements to help providers achieve higher performance– Discuss KPI reports periodically with providers to identify improvement
opportunities and support providers with the development of actionable plans– Promote collaboration across provider groups to enable sharing of best practices
and performance improvement opportunities– Develop and provide training and support to provider staff to assist them in
understanding performance metrics and implement operational/clinical improvements
• Education/Experience:– Blend of experience on the team– clinical, primary care, behavioral health, quality,
process/performance management
Confidential & Proprietary © 2018 Envolve, Inc. 24
Data Analytics and Reporting• Objective: to enable visibility and
analysis of IHPA’s member population and support reporting requirements
• Reports at Provider and IHPA levels:
– Top 100 Members by Cost– ER and Inpatient Conversion– Medication Fill Rates and Labs– First Episode Psychosis – Pay for Performance/HEDIS
• Operational Reports at the IHPA Level:
– Cost of Care– Membership– Call Center Metrics– Claims– Encounters
25Confidential & Proprietary © 2018 Envolve, Inc.
Report Type: WeeklyThis Period: 1/6/19 - 1/12/19Last Period: 1/1/19 - 1/5/19Last Modified: August 22, 2018
MonthlyMembership Target 1/1/19 - 1/5/19 1/6/19 - 1/12/19 Jan Feb Mar Apr May Jun Jul YTD
Attributed Membership 30,000Member Assignment TBDMember Assignment TAT (after attribution) < = 3 Calendar days
Provider Services Target 1/1/19 - 1/5/19 1/6/19 - 1/12/19 Jan Feb Mar Apr May Jun Jul YTDCalls Offered ###Daily Average Volume ###Service Level ≥ 80.00%ASA ≤ 30 SecAbandonment Rate ≤ 5%Quality Audit ≥ 80.00%
Web/MobileProvider Portal RegistrationsMobile App Downloads
Claims Target 1/1/19 - 1/5/19 1/6/19 - 1/12/19 Jan Feb Mar Apr May Jun Jul YTDReceiptsPend Volume % ≤ 15%
Pended Inventory at Last Day of PeriodAA Rate ≥ 85.00%Reject Rate (% rejects of receipts) ~ 5.00%EDI Rate ~ 96.00%Payspan Registration Rate ≥ 80.00%Avg Age of Pending Claims < 15 DaysPay TAT (Avg days from receipt to paid) ≥ 95%Denial Rate ≤ 10%Interest $ PaidInterest % of Paid Amount ≤ 0.03%Payment Accuracy 97.00%Financial Accuracy 97.00%Claims Paid ($)
Encounters Target 1/1/19 - 1/5/19 1/6/19 - 1/12/19 Jan Feb Mar Apr May Jun Jul YTD% Accepted ≥ 95.0%% Pending% Rejected# of Not Yet Submitted
Provider Data Management Target 1/1/19 - 1/5/19 1/6/19 - 1/12/19 Jan Feb Mar Apr May Jun Jul YTDProvider Batch File TAT ≤ 30 daysPDM Update TAT ≥ 95%PDM Update Pending InventoryPDM Update Pends Avg Age ≤ 15 days
Illinois Health Practice AllianceMSO Operations - Executive Dashboard
Monthly
≤ 5.00%
End of QuarterEnd of Quarter
For Illustration Only
Sample Report – Medication Fill Frequency
26© 2016 Envolve.
Amisys # Age RangeMost Recent Fill
Date
99999999999 49-64 2018/10/01
99999999999 34-48 2018/10/25
99999999999 34-48 2018/10/15
99999999999 49-64 2018/10/06
99999999999 19-33 2018/03/22
99999999999 19-33 2018/03/20
99999999999 19-33 2018/01/19
99999999999 19-33 2018/03/12
99999999999 19-33 2018/01/19
Member Fill Frequency & Assigned
Provider TINAssigned Provider
Name Medicaid # Member Name
Fill Frequency & Metabolic Lab Report Tracking fill frequency for the following drug theraphy classes:
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSANTIANXIETY AGENTS
ANTIDEPRESSANTSANTIPSYCHOTICS/ANTIMANIC AGENTS
HYPNOTICSPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS -
MISC.
Nov 2017 - Oct 2018
999999999 - IHPA PROVIDER
57100010000315 Alprazolam Tab 1 MG999999999 IHPA PROVIDER 999999999 Rivers EVELYN 1977/11/05
Date of Birth GPI Number Generic Drug Name
999999999 IHPA PROVIDER 999999999 Rubble BETTY 1956/09/11 58180090107020 Venlafaxine HCl Cap ER 24HR 37.5 MG (Base Equivalent)
57100040000315 Diazepam Tab 10 MG
999999999 IHPA PROVIDER 999999999 Gravel, GABRIEL 1991/03/25 57100040000310 Diazepam Tab 5 MG
999999999 IHPA PROVIDER 999999999 Morehouse, ROGER 1963/10/01
999999999 IHPA PROVIDER 999999999 Nader, NADINE 1983/08/01 57100010000315 Alprazolam Tab 1 MG
58120080100310 Trazodone HCl Tab 100 MG
999999999 IHPA PROVIDER 999999999 Gravel, GABRIEL 1991/03/25 59153070100330 Quetiapine Fumarate Tab 200 MG
999999999 IHPA PROVIDER 999999999 Gravel, GABRIEL 1991/03/25
57100040000315 Diazepam Tab 10 MG
999999999 IHPA PROVIDER 999999999 Gravel, GABRIEL 1991/03/25 57200005100330 Buspirone HCl Tab 15 MG
999999999 IHPA PROVIDER 999999999 Gravel, GABRIEL 1991/03/25
Sample Report – Top 100 Members by Cost
© 2016 Envolve. 27
Population Health Technology
28Confidential & Proprietary © 2018 Envolve, Inc.
Advanced Systems IntegrationEnsures access, translation, normalization and aggregation
of data, regardless of system, care setting, source, or format
Rapid Implementation Typical go-live timelines of 6 to 8 weeks with a shortened contract time given existing agreement with Envolve.
Advanced AnalyticsConnect claims, clinical, and quality data and deliver
real-time, point-of-care insights. Clinicians are empowered to make patient-centric decisions quickly and confidently.
Adaptable Care ManagementAllows IHPA to initiate, track, and/or automate member outreach, patient assessments, care plans, intervention
scheduling, and document uploading and storage.
Revenue Cycle FunctionalityAllows IHPA to expand its own care management function
should it decide to hire its own care management team requiring it to submit claims to MCOs.
Envolve will leverage the Health EC platform for IHPA
Organization Key Performance Indicator (KPI)
Quality Measurement Monitoring
Inpatient Utilization Reports
Population Risk StratificationJohns Hopkins ACG Risk Model
Questions?
(I know you have them)
Michael Fierro-RandazzoSenior Director, OperationsO: 312-619-3038 mfierrorandazzo@envolvehealth.comlinkedin.com/in/mfierrorandazzo
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