Demo: Instructor’s Presentation - HealthExecStore · including electronic health records, performance incentives, accountability and evidence based medicine are all typical objectives

©2015, MCOL. All Rights Reserved.

Version 14.0

Demo: Instructor’s Presentation

1

This demo provides selected slides from the 200+ slides in the Instructor’s Presentation, along with additional demo narrative

copyright 2015, MCOL. All rights reserved. 2

Topics Learning Objectives

Intro to Managed Care

TimeLine

Managed Care Fact Sheets

DataMaps

Advanced Topics

Using The Training Manual


Learning Objectives The overall learning objectives for the Managed Care Training Manual is to elevate any user’s understanding of managed care concepts, relationships, terms, issues and trends.

Through use of separate modules, the Training Manual is designed to provide applicable component resources for audiences that might by at various points in the spectrum in their existing managed care knowledge.


Learning Objectives Learning objectives for each module are as follows:

The Training Manual Introductory Video is designed to provide users a very brief overview of the Training Manual features and contents.

The Intro to Managed Care Training Manual is designed for those relatively less familiar with managed care concepts and terms, and provides major concepts, relationships, terms and issues in summary format and progressive order.



TimeLines provide users a sense of the timeframes involved in the development of managed care, marked by key events and statistical milestones

DataMaps provide users a sense of the geographical and regional trends in applicable data for selected topics

The Managed Care Fact Sheets provides users a snapshot of key managed care statistics that currently shape the managed care industry.



The Advanced Topics Seminar is designed to provide more detailed knowledge addressing a wide variety of relevant specific managed care operational topics and issues to users that have at least a basic understanding of managed care concepts


“ What Americans want is really quite simple: all the health care they or their doctors can imagine, virtually free, without added taxes for health care and without higher out-of-pocket costs for their 'employer-provided' health insurance. That's all. Uwe E. Reinhardt, professor of political economy at the Woodrow Wilson School of Public and International Affairs at Princeton University

Quote

“”

A number of selected quotes are provided in transition areas of the presentation, to assist with making the presentation more interesting.

Menu

1. Overview 8. Structure 2. Financing 9. Specialty Org.

3. Purchasers 10. Marketing

4. Organizations 11. Legal & Regulatory

5. Delivery Systems 12. Data 6. Benefits 13. Trends

7. Care Management 14. Consumerism Quiz Summary



The Instructor’s Kit selects the key slides from each chapter in the Module that the Instructor should emphasize.

In some cases the Kit provides a new slide that summarizes points from multiple slides in the Module…..


The following provide a few representative slides of the fifty Instructor’s slides included with this module …..


1. Overview Follow the Money


2. Health Care Financing

Salaries Provider is paid a fixed amount, regardless of the # of members or the services delivered.

Capitation Provider is paid a fixed amount per member enrolled, regardless of the # of services delivered to that member.

Bundled Payment Provider is paid a fixed amount for defined group of services, regardless of the volume of services delivered.

Fee for Service Provider is paid for each service provided, just like in traditional care. The difference is rates are contractually set.

Value Based Payments

Payment differentials designed to reward excellence in health care delivery through enhanced reimbursement.

How Managed Care Pays Providers


2. Health Care Financing Accountable Care Organizations (ACOs)

An Accountable Care Organization (ACO) is a local health care organization, designated by an applicable purchaser (such as Medicare) to be accountable for all applicable expenditures and care of a defined population of beneficiaries. ACOs include some combination of primary care physicians, specialist physicians, hospitals and other professional providers that deliver and administer care in a coordinated model that promotes provide evidence-based medicine; emphasizes performance measurement; and adopts payment structures that incorporate shared savings with applicable stakeholders.


5. Provider Delivery Systems

Medical Homes

Patient-Centered Medical Homes involve a partnership between patients and their primary care physician, who leads a team of health care professionals in their practice, and coordinates patient care across all elements of the health care system.

Increased quality, patent safety, use of technology including electronic health records, performance incentives, accountability and evidence based medicine are all typical objectives for Medical Home initiatives.


Readmissions Management

Reduction of avoidable hospital readmissions has emerged as an area of significant focus by CMS for the Medicare programs, as well as other programs and purchasers.

Readmissions Management strategies can involve retrospective review of readmissions that occur within 7 days and 30 days of discharge, for purposes of identifying trends and profiles that merit potential corrective actions that could reduce future readmissions.

Readmissions Management also involves developing strategies to improve readmission performance through identifying and managing patients at greater risk for readmissions, collaborations between hospitals and other post-discharge providers, and patient communication.

7. Care Management


8. Organizational Structures Health Plans

Medical Management Marketing Provider Relations Medical Management

Eligibility Finance Claims Member Services

Information Systems

Health Plan Administrator

Note: Health Plans sometimes will contract with third party BPO (Business Process Outsourcing) organizations to perform various components of applicable functions listed above.


Fraud, Waste and Abuse

Medicare and other regulatory agencies and purchasers are enhancing efforts to identify and take corrective action against providers, patients or third parties involved with Fraud, Waste and Abuse of billed health care services.

Health Care Fraud involves intentional deceit, false information presented as truth, and stealing. Health care waste typically refers to poor administrative performance by purchasers involving payment errors or weak policies, but may also refer to provider system waste. Health care abuse typically refers to provider practices that are inconsistent with sound fiscal, business, or medical practices that result in unnecessary costs.

11. Leg. & Reg. Environment


12. Managed Care Data Key Indicators

Indicator Calculation Purpose

Revenue PMPM ($XXX.XX) Revenue/ Member Months Measures revenue

performance

Medical Loss Ratio (%) Medical Expenses/Rev. Measures medical expense performance

Adm Expense Ratio (%) Administrative Expenses/Rev.

Measures administrative cost performance

Days per 1,000 (XXX) (Annual Inpatient days/Annualized members)*1,000

Measures inpatient utilization performance (per 1,000 members)


14. Consumerism Sample Consumer Driven Plan Design

First Dollar Coverage Preventive Care Benefit

Deductible (HSA High Deductibles Health Plans must have at least $1,200 / $2,400 deductibles for 2012)

High Deductible Health Plan Coverage (PPO or HMO) with percentage

coinsurance or copays after deductible is met

Employer Funded HSA or HRA

Gap (that employee must pay out of pocket before deductible is met)

or Employee FSA funded


1917 Western Clinic in Tacoma provides prepaid services for lumber industry 1929 Baylor Hospital, Texas creates' prepaid hospital plan with Blue Cross logo 1929 Ross-Loss prepaid clinic serves L.A. Dept of Water and Power employees 1929 Rural Farmers' Cooperative Health Plan started in Elk City, OK 1933 Dr Garfield establishes Hospital/clinic prepaid plan for L.A. Aqueduct 1937 Group Health Association in Washington, DC serves Bank employees1938 Henry Kaiser recruits Dr. Garfield to establish prepaid hospital/clinic in WA1939 Blue Shield program adopted for participating prepaid physician plans 1942 Henry Kaiser asks Dr. Garfield to expand to Kaiser shipyards & steel mill 1945 Group Health Cooperative of Puget Sound established in Seattle, WA 1945 Permanente Health Plans opens to the public in California1947 AMA convicted of antitrust violations in Group Health Plan case1947 Health Insurance Plan (HIP) of Greater NY established 1949 81 Blue Cross hospital and 44 Blue Shield medical plans cover 24 million 1952 Permanente Health Plans changes name to Kaiser; membership at 250,000

Three pages of Timelines are provided…


Contents National HMO Enrollment Graph

Current National Managed Care Enrollment

National Managed Care Penetration

Key Performance Measures

Medical Cost Components

Premium Rate Increase Trends Graph

2015 Premium Rate Increase Estimates

Major National Health Plans

The Kit provides selected Fact Sheet slides, which display a current snapshot of the industry. Following is a represent-ative Fact Sheet slide …..


Major National Health Plans Enrollment*

United Health Group* 45.0 million

Anthem 37.5 million

Aetna 23.5 million

Health Care Service Corporation* 14.7 million

Cigna HealthCare 14.5 million

Humana 13.8 million

Kaiser Permanente 9.6 million

Centene 4.1 million

Health Net 3.2 million * Data as of 3/31/2015 for these plans – Data is as of 12/31/14 for all others

copyright 2015, MCOL. All rights reserved. 23 23

The Instructors Kit displays selected key Datamap slides of the 34 provided in the Training Manual. A representative Datamap follows….


Medicare Prescription Drug Program State Penetration


The Advanced Topics Seminar involves detailed narrative papers on 73 different selected topics. The Instructor’s Kit provides a summary slide (or sometimes two or three ) for each topic. The menu, as well as representative slides from the summary slides available in this portion of the Kit follow …..


Premiums: HMO Premium Rate Calculations Setting Group Renewal Premium Rates The Impact Of Employer Contribution Policy On Premium Rate Setting Group-Specific Experience: Financial And Utilization Performance Plan Targeted Premium Rate Increases Versus Actual Premium PMPM Benefits: Issues In Member Payment Responsibilities Calculating The Financial Impact Of New Benefits Or Benefit Changes Measuring the Total Cost Impact of Cost Sharing Changes Deductible Management Value Based Insurance Design: A Primer Selected Medicare Advantage Terminology Terminology of Selected Components of Health Care Change


Financial: 2015 CMS Readmissions Penalties Transitioning Physicians to a Performance-Based Compensation Model ACO Lessons Learned: Revisiting the Timing of Downside Risk Tips to Survive the Transition from Volume to Value Pay-for-Success Financing: A New Vehicle for Improving Population Health? Health Plan Financial Performance Indicators Identifying Managed Care Accounting Soft Spots Analyzing And Budgeting Managed Care Administrative Expenses Coordination Of Benefits (COB) and Third Party Liability (TPL) Recoveries Understanding Health Plan Broker Compensation Medical Loss Ratio Requirements Estimations: Tips for Mining Big Data to Tackle Privacy Concerns in Predictive Modeling Practical Predictive Analytics for Healthcare 101 Predictive Analytics Comes to Healthcare Estimating PMPMs Estimating Medicare Risk vs. Commercial HMO Indicators Estimating Member Market Share After A Contract Terminates Using Capitation Principles When You’re Not Capitated Predictive Modeling: A Primer Predictive Modeling Made Simple


Metrics: Big Data, Big Ethics: Ensuring Appropriate Use of Large Data Sets PPO Market Metrics Web Metrics for Health Care Organizations Health Plan Ratings and Report Cards Revenue Cycle KPIs Provider Comparisons: A Primer Administrative Operational Metrics for Health Plans Medical Management: Better Care for the Over Serviced: Lessons from an Ambulatory ICU Reducing Readmissions Through An Effective Nursing Program How to Use the CMS Readmissions Hospital Specific Report The Importance of Medication Management During Care Transitions Incorporating Customer Relationship Strategies into Population Health Mgmt. Architect for Health -- the Clinical Health Coach mHealth: Essential for Drug Adherence Reducing Readmissions Through the Use of Technology Getting The Patient’s Perspective To Reduce Hospital Readmissions Leveraging Big Data: Identify & Communicate Risk Drivers for Readmissions Neonatal Medical Home: A Novel Post-Discharge Care Model


Medical Management continued: Calculating Inpatient Days Per 1,000 Pharmaceutical Management Concepts Monitoring And Reporting Out-Of-Local Network Utilization Contact Measurement Obesity: Understanding Body Mass Index (BMI) Wellness Incentive Programs Pay for Performance Incentives Health Plans and Pandemic Flu Comparative Effectiveness Primer The Behavioral Risk Factor Surveillance System


Provider Issues: The Pioneer ACO: A Strategy for Population Health Management Hospital-Physician Partnership Holds Key to Value over Volume Is Your ACO Prepared for HIPAA? Measuring Managed Care Participating Provider Changes Traditional Capitation Concepts Medical Identity Theft


Membership Issues: Member Disenrollment Bulk HMO Member Transfers Measuring Service Contact Performance Consumerism Issues: Calculating Consumer Out Of Pocket Costs Budgeting and Projections for High Deductible Plans and Higher Cost Sharing Reporting Consumer Driven Enrollment Customized Health Plans Price Transparency


Advanced Topics Seminar: Premiums

HMO Premium Rate Calculations continued

Five alternative premium tier categories are most often used. Only one category is selected and used for each employer group. One Tier (Composite) rates: same premium applies regardless

if subscriber is single or has any number of dependents Two Tier rates: (1) Single and (2) Family. Family would include

any combination of subscriber plus dependents Three Tier rates: (1) Single, (2) Couple and (3) Family. Family

is subscriber plus all other combination of dependents. Four Tier rates: (1) Single, (2) Couple (3) Family and (4)

Subscriber plus child(ren). Five Tier rates: (1) Single, (2) Couple (3) Family (4)

Subscriber plus children (5) Subscriber plus child.


Advanced Topics Seminar: Financial

Medical Loss Ratio Requirements

Medical Loss Ratio Regulations have been issued by Department of Health and Human Services (HHS), based upon uniform definitions and standard methodologies for medical loss ratio submitted by the NAIC (National Association of Insurance Commissioners) that were called for under the Affordable Care Act.

Effective with 2011, health plans must publicly disclose their medical loss ratio information in a standardized manner, and are required to spend at least a specified percent of their premium dollars on medical care and quality improvement activities.

33 copyright 2015, MCOL. All rights reserved.


Advanced Topics Seminar: Estimations

Predictive Modeling – A Primer

Predictive Modeling in health care is a process involving risk/behavior assessment and adjustment applied to a given population based upon available data for purposes of stratifying that population according to their future probabilities of incurring a given outcome or behavior.

The purpose of Predictive Modeling is to risk stratify a population to identify individual opportunities for intervention or action before the projected outcome as occurred.

Predictive Modeling requires an existing data repository, in which data is mined, and selection of a specific modeling tool to apply to the historical timeframe to predict outcomes for an alternative timeframe.


Advanced Topics Seminar: Metrics

Administrative Operational Metrics for Plans

How primary demand, productivity, unit costs, staffing ratios and costs per employee are calculated and inter-relate for desired administrative operational metrics:

Transactions per Member

x

Members per FTE

=

Transactions per FTE per

Year

x

Cost per Trans-action

=

Cost per

FTE

x

FTEs per 10,000

Members

=

Cost PMPM

1.1 x 9,000 = 9,900 x $7.50 = $74,250 x 1.11 = $0.69

Primary Demand Staffing

Ratio Productivity Unit Cost Per FTE Cost

Staffing Ratio Cost

PMPM



Comparative Effectiveness Primer Advanced Topics Seminar: Medical Management

A type of health care research that compares the results of one approach for managing a disease to the results of other approaches

Comparative effectiveness usually compares two or more types of treatment, such as different drugs, for the same disease. Comparative effectiveness also can compare types of surgery or other kinds of medical procedures and tests. The results often are summarized in a systematic review.



Advanced Topics Seminar: Membership

Measuring Service Contact Performance

NCQA HEDIS call center performance measurements are:

Call Abandonment: which determines the rate of calls to the health plan call center (during operating hours) that were abandoned (i.e., the caller decided to hang up) before being answered by a live voice.

Call Answer Timeliness: which also addresses the performance of plan call centers, calculating the percentages of calls answered by a live voice within 30 seconds.

General Methods of service contacts include:

Phone contact to designated service call centers; Other phone contacts; Regular mail contacts; Walk-in contacts; Contacts through third parties; Internet based contacts


Using The Training Manual Tips in using the Training Manual:

Opening the Manual: You will need a current or recent version of adobe acrobat reader to view the Manual.

Printing: You can print any portion of the Manual from your Adobe Acrobat reader, but be careful to change the print range from “All Pages” to “Pages from _ to _” and indicate the pages you want printed. You won’t want to print the entire Manual, as the back portion contains the interactive quiz pages that are repetitive, plus your printer probably can’t handle printing too many pages at one time.


Using The Training Manual Tips in using the Training Manual:

Navigating through the Manual: The Manual is one large document. Links are provided on virtually every page that can return you to a main menu. Page number are provided at the bottom of each page. Familiarize yourself with adobe acrobat navigation buttons, and you’ll have an easier time moving through the manual.

The Advanced Topics Seminar: The Seminar papers often assume the reader has a basic understanding of some referenced terms. There is a wide scope of subjects addressed, and not every topic might be relevant to you, depending on your situation.


In addition to the slide Instructor’s Presentation, available in Powerpoint and Adobe Acrobat formats, the Instructor’s Kit also provides a separate Study Guide, an additional copy of the Intro to Managed Care Quiz with answer key, and a 50 Question Supplemental Quiz

Documents

Demo: Instructor’s Presentation - HealthExecStore · including electronic health records, performance incentives, accountability and evidence based medicine are all typical objectives