Medicare risk revenue management 11 jun12 washington dc

Leveraging the Entire Care Team to Improve Care Management and Data Capture

Wayne Pan, MD, MBAChief Medical OfficerPacific Partners Management Services, Inc.Medicare Risk Revenue Management - Best Practice Operation Strategies • Washington, DC • June 11, 2012

takeaways3

drawtheBIGpicture

1

showmetheDATA

2

3

gowiththeFLOW

1

vision

process

process

same page

teammates

goalsgoals

metrics

outcomes

rewards

2

it’smorethanjust data

it’salsoaboutwhomyourserving data to

DAT

A

savvy consumers

not currenterror proneMPASTEE

no comparator

unadulterated

michaelvandurenmdmba

sutterhealth

variationreduction

3

intheflowoflife

zen: one with the universe

the new way of doing things...

...feels just like the old way

user-centereddesign

storySCCIPA

the

?whowhat

wherewhen

whyhow

Who is?

Individual Practice Association Medical Group of

Santa Clara County

Individual Practice Association Medical Group of

Santa Clara County

SCCIPA

largest IPA in Santa Clara County

Santa Clara Countysize 1,304.01 sqmilespop 1,781,642 (2010)

medianincome $74,335

SAND HILL ROAD

the Mississippi River

INFINITE LOOP

VIEW FROM THE VALLEYTHE

ATLANTIC OCEAN

ENGLANDEUROPE

MEXICOCAN

ADA

RUSSIA

ILLINOIS

FB CREDITSPrice 75Apr 21,2012

APPALACHIACLEVELAND

NEW YORK CITY FLORIDA

5 PCP80 Specialists

57 PCP104 Specialists



SCCIPAfounded in 1986physician-owned, physician-governed800+ physicians - 240+ PCPs, 550+ specialistsall 9 hospitals - including a tertiary care center9 health plans (Commercial and Medicare Advantage)Anthem Commercial ACO pilot (2011)

SCCIPAfounded in 1986physician-owned, physician-governed800+ physicians - 240+ PCPs, 550+ specialistsall 9 hospitals - including a tertiary care center9 health plans (Commercial and Medicare Advantage)Anthem Commercial ACO pilot (2011)

urban/suburban

rural

25,000 commercialACO

40,000 commercialHMO

5,000 MedicareHMO

nooriginal Medicare,

Medi-Cal,CHIP, uninsured

= managementservicesorganization

casemanagementmedicalmanagementnetworkmanagement

qualityimprovement

grievance&appeals

clinicaldataanalytics&reporting

compliance&auditing

claims&encounterprocessing

providercontracting

credentialingmemberservices

marketingoutreach

ITservicesfinance&riskmanagement

partialrisk

managingD ROF

Divisionfinancial esponsibilityR

OF

outpatientservices

inpatientservices

capitatepcps

specialistspaidffs

performancebonus

IHAP4P&HCC

IPAcitizenship

roughroad

roughroad4x4 healthcare

4processes

4dimensionaldata

x

4processes

communication

collaboration

coordination

PCPs

Specialists

Patients

CaseManagers

anticipation

4dimensionaldata

financial

administrative

clinical

retrospectiveretrospective

reactivecare

$$$$$$

behavioral+

predictive

proactivecare

provideactionabledata

@pointofcare

@home

thecareteam

thecarecontinuum

peopleprocessesplatform


hospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observation statusannual coding/documentation training for risk adjustmentnotification of PCP of admission/dischargedischarge summary faxed to PCP

peopleprocesses

hospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observation statusannual coding/documentation training for risk adjustmentnotification of PCP of admission/dischargedischarge summary faxed to PCP

peopleprocesses

SNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP

peopleprocesses

onsite case managersdaily review of patients based on Milliman guidelinesactively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs

peopleprocesses

complex case managerswarm hand-off between onsite and ccmuse of clinical and non-clinical staff to assist patient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks

peopleprocesses

utilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordinationcompliance with regulatory guidelinesgenerate member/provider letters regarding medical necessity decisionsphysician performance and quality reportingidentification of potential quality issuescontinuous process improvement

peopleprocesses

primary care physiciansspecialistsancillary providerscommunity pharmacists

people:physicians/staff

primary care physiciansspecialistsancillary providerscommunity pharmacistsfront office staff

people:physicians/staff

case managersdisease managersmember outreachbenefit design

people:plan staff

communicatecollaboratecoordinateanticipate


peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedback

peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own data

peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own dataallow patients to provide feedback/enter their own data

designphilosophy

“put hot triggers in the path of motivated people”BJ Fogg, PhDDirector, Persuasive Technology LabStanford University

Are incentives aligned properly?How can I increase their motivation?

Have I made it easy for people to act?How can I make it even simpler?

Are people being triggered at the most appropriate time and in their workflow (path)?

putting it all together: how does it work?

QualityManagementAccess ExpressTM

patient

patient

front desk staff

patient

front desk staffanalog to digitalconverter

analog to digitalconverter

eligibility check

MARY SMITH1234567890

1121/1/2011

$5.00$10.00$25.00

analog to digitalconverter

AMERICAN HEALTH PLAN

Click here to registerfor a password or

request more information

Powered by Access ExpressQ-v5.0.#.0.1 Build 2011.04.04.00

QualityManagementAccess ExpressTM

ACCESSEXPRESSQ New Message (3)New Eligibility Response



BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890

MAMMOGRAPHY, CRC, CARDIO CARE,DIABETES CARE, HYPERTENSION,

GLAUCOMA, MED MONITOR, FLU VAC,PNEUMO VAC, DEXA, OSTEOPOROSIS,

RHEUM, COPD

POP-UP

BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890



RHEUM, COPD CLICK HERE



BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890



RHEUM, COPD

ENABLINGFRONT OFFICE

STAFF

BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890



RHEUM, COPD

SIMPLECARE PLAN

BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890



RHEUM, COPD






Description ofmeasure

Capability forphysician officeentry


IN THE PATH


BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890



RHEUM, COPD

HOT TRIGGER


MOTIVATIO

N

Capability forphysician officeentry

ABILITY

medicationreconciliation

patient perspective

on average,there is a pharmacy

within 2.5 milesof every US resident

Source: National Association of Chain Drug Stores

Source: Gallop, November 28, 2011-December 1, 2011

get out of the rut?

from: Jeanne Liedtka and Tim Ogilvie, Designing for Growth (2011)

thepatientjourney

dischargeplanning

hosspitaldischargeplanner

IPA onsitecase

manager

hospitalist

patient

thepatientjourney

Rx


patient

hospitalist

dischargeplanning

thepatientjourney

dischargeplanning

dischargeinstructions


outpatientphysicianfollow-up

patient

hospitalist

thepatientjourney

dischargeplanning



discharge

patient

family

dischargeinstructionsRx

failsafe

thepatientjourney

dischargeplanning


IPA onsitecase

manager

hospitalist

patient




discharge

patient patient patient

hospitalist hospitalist

family


thepatientjourney

dischargeplanning


IPA onsitecase

manager

hospitalist

patient




discharge



family



brainstorm

thepatientjourney

dischargeplanning


IPA onsitecase

manager

hospitalist

patient




discharge



family


thepatientjourney

dischargeplanning


IPA onsitecase

manager

hospitalist

patient




discharge


pharmacist hospitalist

family


“put hot triggers in the path of motivated people”BJ Fogg, PhDDirector, Persuasive Technology LabStanford University

Santa Clara County IPA (SCCIPA)Medication Reconciliation Pilot Project

How to find the medication list for patients using AccessExpress

1. Go to the PPMSI AccessExpress provider portal (http://ppmsi.com/accessexpress.html):

2. Select Santa Clara County IPA:

3. Enter USER NAME and PASSWORD, click on “SUBMIT”:

Your SCCIPA doctor wants to help you with your medications, after you leave the hospital.

Please visit the Samaritan Medical Center Pharmacy to pick up your new prescriptions and have a pharmacist review your medications with you.

Michael Lam, RPhpharmacist

Samaritan Medical Center Pharmacy2505 Samaritan DriveSan Jose, CA(408) 356-7111

SCCIPAA Pacific Partners Medical Group


what happened?

failfast

ourresults

> commercial admits/1000

40

50

60

70

80

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

40

50

60

70

80

OCT11

Milliman - Well-Managed

Milliman - Moderately-Managed

Milliman - Loosely-Managed

SCCIPA

> commercial bed days/1000

150

175

200

225

250

275

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11




SCCIPA

> commercial average length of stay

2.5

3.0

3.5

4.0

4.5

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11




SCCIPA

> medicare admits/1000

200

250

300

350

400

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11




SCCIPA

> medicare bed days/1000

1,000

1,200

1,400

1,600

1,800

2,000

2,200

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11




SCCIPA

> medicare average length of stay

4.0

4.5

5.0

5.5

6.0

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11




SCCIPA

managingACOpatientsinafee4serviceworld

challenge#1 managingproviderbehavior

challenge#2 managingpatientbehavior

challenge#3 alignincentives

HMOworld

patientsassignedPCP

PCPmanagesreferrals

patientsstayinnetwork

ACOworld

patientsnotassigned

physiciansendspatient

notrestrictedtonetwork

whataboutquality?

whoisaccountable?

carecoordination?

oursolution

make the newway...

feel just like the oldway

trackingauths

> using the same auth system, have providers enter in tracking auths for aco patients

1

keepspatientinnetwork

providerselectiontool

> when selecting “referred to” providers, these providers are listed in descending order of quality, efficiency, satisfaction

2

promotesquality

promotesefficiency

promotessatisfaction

rewardaccountability

> referring physicians can be tracked to incentivize use of provider network

3

checkinbutton

> allows for real-time patient tracking, provides opportunity for care coodination efforts

4

automatedtracking

alertingcasemanager

nocheck-inby_________

requestimmediatehelp

qualityreminders

> @every encounter with the healthcare delivery system, quality is reinforced

5

entireteamisaccountable

virtualpcmhmodel

airtrafffic control

for patients

ibelieve...

asknot...

cultural revolution

thinkdifferent

takeaways3

drawtheBIGpicture

1

showmetheDATA

2

3

gowiththeFLOW

HAVE FUN

welcome tohealthcare2.0

[email protected]/bonedoc97

Thank you!

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Medicare risk revenue management 11 jun12 washington dc