1. law, govt and politics
2. legal issues
3. civil law
4. copyright

How To Create Successful Partnerships with
Managed Care Organizations
Deb Adler
SVP of Behavioral Network Services
Optum
Greater Need for Clarity of Provider Competences Especially for
Complex/High Cost Conditions
Complex and high cost populations need specialized trained provider types and systems to be
maximally effectively. Research has shown in many areas that highly trained clinicians had a
better outcome than care through a generalized usual care provider.
Current generalized training and licensure does not clarify experience nor competence for these
populations
The system will need to have processes to measure and identify competencies
Dual Eligible
Eating Disorders
Autism
(Disabled)
Chronic
Relapsing
Mental Illness
Military
Population
Developmentally
delayed
Child/Adolescent
Mental Illness
Behavioral
Learning
Co-morbidities
Disabilities
*Copy and paste this text box to enter notations/source information. 7pt type. Aligned to bottom. No need to move or resize this box.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Behavioral Health System – Multi- Stakeholder Complexity
For behavioral health services, there a many different types of providers for
the variety of services needed to prevent, diagnoses and treat behavioral
health conditions. How do they fit and how do they connect to be a efficient
and effective care system.
Marriage and
Family
Counselors
Nurses
Peer Services
Social
workers
Primary Care
Physicians
Psychologist
Community
Services
Psychiatrist
Addiction
counselors
Consumers, Families and the Community
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Behavioral Health Functional System Structure
• Functional systems are necessary components of care delivery. How
they are organized, structure and provided may differ in the future.
Preventive Health /Wellness
System
•
Acute Crisis Service
System
Integrates with Community
Systems
• Handles Acute Crisis
•
Recruitment and Screening
•
At risk population management
•
Prevention Training
•
Well –being/Resiliency
Chronic Care
System
Medical with Comorbidities System
• Tracking and monitoring
• Consultation
• Coordination capabilities
• Training/coaching
• Stabilization
• Engagement capabilities
• 24/7 system
• Behavior change
capabilities
• Manage thru
others
• Medical familiarity
• Flexible and mobile
access
*Copy and paste this text box to enter notations/source information. 7pt type. Aligned to bottom. No need to move or resize this box.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
The Integration Continuum
Source: Adapted from Blount 2003
Coordinated Care Model
Routine screening for
behavioral health
problems conducted in
primary care setting
Co-located Only Model
Medical services and
behavioral health
services located in the
same facility
Fully Integrated Model
• Medical services and
behavioral health services
located either in the same
facility or in separate
locations
Health Plan
Plan with
with Established
Health
or Developing
ACO
• Referral
process for
•Patient
Referral relationship
medical cases to be seen
Centered
• One treatment plan
between primary care and
by behavioral specialists
with behavioral and medical
Medicalhealth
Home
(s)
behavioral
settings
elements
States Pursuing Health Home
State Plan Amendments
• Enhanced informal
• Routine exchange of
information between
both
treatment
settingsProviders
to
Direct
to ACO
bridge cultural differences
communication between the
primary care provider and the
behavioral health provider due to
proximity
Primary care provider
to deliver behavioral health
interventions using brief
algorithms
• Consultation between the
behavioral health and medical
providers to increase the skills of
both groups
•Providers
Connections made
between the patient and
resources in the community
• Typically, a team working
together to deliver care,
using a prearranged protocol
• Use of a health record or
patient registry to track
the care of patients who are
screened into behavioral
health services and a common
platform to track and monitor
patients that the entire team
can use.
Proprietary and Confidential. Do not distribute.
Network Referrals Geared by Provider Performance
We are exploring three distinct approaches to differentiate providers and
steering members toward the most appropriate high-performing providers
Provider Tiering
Specialty Networks
Centers for Excellence
Encourage use of in-network
preferred providers, facilities
or places of service
High-performing networkspecific population or
specific modality
Superior performing
providers that apply
evidence-based practices,
targeted at high-cost,
high-risk populations
• No changes to network;
preserves choice
• Requires high level of
consumer engagement and
understanding of benefit plan
• Provides consumers with
information and/or
transparency tools (cost and
quality) which enable more
informed decisions
Cost and quality ratings available
online at LiveandWorkWell
• Requires specific criteria
(e.g., certified suboxone
providers)
• Network typically created
from a subset of our broader
Choice Network
• Based on expert panel,
literature review and
research regarding best
practices
• Requires specific criteria for
participation and ongoing
system sustainability
Disability, EAP, Peer Support,
Outpatient Substance Use, Autism
Eating Disorders
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
New Network Configurations
•
Organizations
are starting to
recruit
and/or build
service
capabilities to
supply a need to
system
administrators,
and other
payers.
•
•
•
•
Autism Intensive
Behavioral therapy
services
SUD after and
Eating Disorder
residential care
Umbrella Organization
IT/EMR
Contracting
Billing
Reaching Outside
Of Service Area
Crossing State
Lines
Global
Expansion
South
America
Europe
Service
Area
Provider
Provider
Provider
EAP
Peer Based
Services
India
China
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Achieving the Triple Aim
Improved Population Health, Patient Centered and Affordable
Fundamental levers within the Triple Aim that are changing in the health care
delivery systems.
Triple Aim
Payment
Reform
Practice
Performance
Measurement
Transparency
• Movement from
volume based
payments to
performance-based
contracting.
• Linking performance
with payment
• Bundling rates across
discipline and levels
of care
• Require ability to
frequently status
performance and
conduct causal
analysis
• Shifting more financial
accountability to
providers
• Linking performance
with ability to in a
system
• ‘Learning
Organization”
Accountability
• Process, clinical
effectiveness and
cost transparency
• Balancing clinical
and financial
decisions
• Info for Consumers
• Info available to
Competitors
• Access to relevant
data to support
management.
• Benefit linked to
high performing
networks
• Population
management
approach
• Shared
accountability
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Challenges for Providers in Managing Population Health
Ability to Mitigate
Readmission Risk
Ability to Impact the Future
Medical Costs of a Population
• Over half of readmits did not see a
psychiatrist post-discharge¹
• Over half of inpatient claimants had
minimal to no engagement with the
behavioral health delivery system in
the prior year1
• Failure to follow-up with prescriber or
therapy is the most common cause
of readmits¹
Managing Psych Crisis
Over 40% of mental health cases
in the ER are admitted vs2
less than <5% of medical
Early Identification/Prevention
3x higher incidence of
Mental disorder in offspring's
of depressed parents5
Ability to Control
Resource Utilization
• A quarter of patients given
more information about treatment
options choose a less intensive
option, or services³
Treatment Adherence
17 -22% drop out
of psychotherapy
prematurely3.
3.75 times the risk of
psychotic relapse with
med Non-compliance4
1. Commercial insured population analysis, 2010. 2. Owens, P. HCUP MH and SA Related ED Visits Adults. AHRQ 2007 3. Olfson ‘Dropout from Outpatient MH Care. Psych Services July 2009
4. Fenton, WS. Med non adherence in Schizophrenia. Schizo Bull 1997;5. Weissman et el 2006
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
“Learning Systems”
• Recent IOM study, “Best Care at a Lower
Cost”: The Path to Continuously Learning
Health Care in America
• Large randomized clinical trial are not
practical and too costly to implement
• Digital records present a tremendous
opportunity to generate information and
facilitate practice based learning
• Large clinical and administrative data
bases, clinical registries, personal
electronic records, ( smart phones, mobile
devices)
• Provider- patient interface becomes the
critical source of data for care decisions,
research and ensuring the quality of the
data
• Promotes the use of practice based data
• Registry data availability in real time
• From data to information to facilitate
practice decision and increase knowledge
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Managed Care Organizations – System Administrator Role
– Facilitating systems of care
• Looking for comprehensive providers for high risk populations
• Cross level of care accountability
• incorporating community services into delivery system, (peer services)
– Sharing accountability, risk and leveraging incentives
– Facilitator of creative contracting and progressive
move to shift to sharing financial saving/risk
• Pay for Performance
• Shared Savings Models
• Partial capitation
• Facilitate business acumen
– Broker access to technology
– Incentivize needed practice changes to
address gaps in care and organized
systems
– Broker of standardization of data
– Facilitator of transparency of
performance
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Essential Provider Capabilities
for the Health Care Industry Storm
1
Structure and Process to Manage Higher Levels
of Accountability (performance/financial)
2
Different Type of Provider Practice - System
Practice
3
Integration of Information Technology
4
Measurement and management clinical
performance (efficiency and effectiveness)
5
Population and Individual Health Management
6
Clinical and Financial Risk Management
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Are You Ready For The Change?
1
If accountable for a population, do you have the necessary
visibility to the critical clinical and cost risk factors?
2
Are your clinical staff appropriately trained and/or experienced for
the incoming population?
3
Do you have the appropriate technology working to enhance your
work flow and clinical operations?
4
Do you know your clinical effectiveness and efficiency stats?
5
Do you know the outcomes stats for the population you have
touched?
6
Are you sufficiently capitalized to take risk or withstand shifts in
revenue changes?
7
Do you have the clinical operations in place to fit into or implement
one of the needed systems of care?
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
The Storm of the Changing Industry
Are You Ready For the Change?
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Behavioral Health Providers –
Characteristics of provider practice – Old and New
• Single facility
• Unconnected to other behavioral
health providers
• Linked Levels of Care - formal or
virtual Integrated into a care system
• Unconnected to PCP providers
• Connected to a multidisciplinary
behavioral health and medical team
• Limited use of technology and data
• Population management approach
• Clinical judgment
• Uses computers for tracking treated
patients - EMR/tracking systems
• Limited experience in financial risk
• Singular patient focus
• Single episode dependent
• “Illness” approach
• Quantitative demonstration of
clinical effectiveness and efficiency
• Incorporate more efficient treatment
techniques- recovery/resiliency
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Outline
• What are Managed Care Companies Doing to
– Support Providers
– Support Members
• How providers can
– Differentiate their services
– Prepare for the Changes in Healthcare
– Negotiate better contracts
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Areas of Focus
Engagement
• To become the most respected managed care organization
• To treat our providers as important customers and valued resources
• To listen and respond to provider’s needs and expectations
Transparency
• To provide feedback to providers to promote improved performance
• To facilitate informed decisions through cost and quality transparency
• To provide real-time access to the right providers at the right cost
Affordability
• To use tools that support a shift towards outcome-based payment models and delivery
systems
• To use network tiering to support access to preferred providers or places of service
• To use network tools to make the healthcare system more engaging, effective and
affordable in the local community
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
The Voice of the Provider
Listen, Learn, Respond
What We Have Learned
• Providers expressed a keen interest
in using web portals more frequently
and requested enhancing online
transaction options to save time and
avoid phone calls
• Providers want communication
materials that are brief, meaningful,
and timely
• Providers don’t feel empowered and
respected by managed care
companies; they want to feel valued for
their clinical expertise
• Providers want global solutions (e.g.,
CAQH), including consistent and
streamlined processes both within and
across managed care companies
How We Have Responded
• Targeted Portal Enhancements
•
On-line Claims adjustments
• Layered Communication Strategy
•
ONE Toll-free provider
participation line, emphasizing
first call resolution
•
Proactive messaging and
monitoring of provider requests
•
Secure Message Center
• Providers Are Customers Too!
• Clinical Initiatives focused on
consistent, web-enabled and
streamlined tools
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Incentivizing Performance on What Matters
• We empower providers in tangible ways
Center for Clinical
Excellence
CEUs
Offering one year of free
access to 400 online
behavioral health CEUs as
rewards for increased
provider adoption of
wellness assessments
This online provider
community facilitates the
sharing of best practices
and innovative ideas to
improve behavioral health
practices
Discounts for Electronic
Health Record products
Loans
Three-tiered offering at
different price points
Low-interest loans to
support provider adoptions
of Electronic Health
Records
04/20/2012
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Leveraging technology to promote engagement
• Partner with a trusted provider for a
pilot study of a new program
PROGRAM GOALS:
• Increase the completion of
Wellness Assessments
– To begin April 2013 and will last
three months
• Assist the clinic with
appointment reminders
– A high volume group in South
Carolina was selected
• Decrease missed appointments
and provider downtime
• Provide a tool to aid providers with
appointment reminders
– Text reminders automatically sent
to clients for each session
– Not limited to just Optum members
– Decrease missed appointments
Your wellness
appointment is
tomorrow at 9:30 am.
Don't forget to complete
your wellness
assessment at your
appointment.
• Enhance patient experience by
encouraging the completion of
Wellness Assessments
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Peer Support Tools for Enhancing Wellness
Optum Whole Health Tracker Smartphone Application
• Free to consumers
• Private and confidential (access code
protected)
– Employees can share goals and progress pages
via e-mail with treating clinicians and peer
coaches
• Built in collaboration with national expert Larry
Fricks, VP of the SAMHSA/HRSA Center for
Integrated Health Solutions
• Also available as a “paper-and-pencil tool”
The exponential growth of mobile communications*
•
The UN’s International Telecommunication Union
estimates that 78% of the world’s population will have a
mobile phone subscription by the end of 2010 (5.3 billion
mobile subscriptions)
•
The International Data Corporation reports that global
smartphone sales jumped by 90 percent year-over-year.
Employees set goals that are
important to them in ten health
lifestyle domains:
1.
2.
3.
4.
5.
6.
7.
Healthy Eating
Physical Activity
Restful Sleep
Stress Management
Service to Others
Support Network
Maintaining a
Positive
Outlook
8. Countering
Negative
Self-talk
9. Spiritual
Beliefs and
Practices
10. Purpose
*Source: J. Walter Thompson, “10 Trends for 2011,” December 2010.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Compensation Continuum
In selected provider arrangements based on provider readiness, we are
supporting financial risk, accountability, and utilization management practices.
Compensation Continuum
Small % of financial risk
Fee-forservice
No Accountability
Performance
- based
Contracting
Moderate % of financial risk
Bundled
and
Episodic
Payments
Shared
Savings
Moderate Accountability
Large % of financial risk
Shared
Risk
Capitation
Capitation +
Performancebased
Contracting
Full Accountability
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Performance-Based Contracting – At A Glance
Incentivizing provider performance leads to better outcomes for employees.
Facility
Participation
Requirements
Metrics
Performance
Incentives
• Adheres to our utilization management process, Level of Care Guidelines and Coverage
Determination Guidelines, including attending MD visits, pre-authorization requirements,
and discharge planning
• Qualifies as an OptumHealth High-Volume provider
• Participates in periodic meetings with OptumHealth clinical operations staff to review data
• Submits claims electronically
• Reduction in Average Length of Stay
• Reduction in 30 day Readmission rate to any inpatient LOC
• Improved results on ambulatory follow-up rates (7 days post inpatient discharge)
• Facility will earn escalator based sharing of savings if performance is within targeted range
• Facility will earn additional escalator through greater sharing of savings if performance
exceeds range (up to a cap)
• Can earn return if only one measure is met as long as there are savings in total days
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Leading the way
Pay for Performance
Formal agreements
Member Transparency
Agreements in process
• Reward providers for increased collaboration,
outcome-based results, and improved
cost-efficiencies.
• Preferred clinicians “star-rated” for quality
can earn a second star rating for meeting
cost-efficiency standards
• Nearly 10% of our total spending on
network-based health care services is tied to
performance-based incentive contracts
• Seeking formal accreditation for our provider
performance programs through NCQA
Physician Quality Accreditation program
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Concierge Service for Platinum Facilities
The Best for the Best
• Two stars on LAWW
• Public acknowledgement of Platinum status via formal notification to all
network providers in the same geographical area
• Certificate of Achievement for public display
• Assigned Practice Mgmt Specialist
• Dedicated claim resolution resource
• Direct phone line to Medical Director
• Dedicated Network contact
• Facility/Provider newsletter recognition
• Smart phone application for members
to locate facilities with stars
• Partner Pilot opportunities
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
25
Transparency
“I feel very comfortable
using this online tool to
estimate the costs for
behavioral health care
because it helps me find
the best providers for the
best price in the comfort
of my own home.”
— Member Testimonial
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Member Transparency To Provider Cost and Quality
•Members can compare clinicians
by cost (actual out-of-pocket
expenses) as well as clinical
performance ratings on quality and
efficiency.
Preferred clinicians “star-rated” for
quality can earn a second star rating
for meeting cost-efficiency standards
"This looks a lot like picking a
flight…it is already feeling familiar.“
“Ratings matter.”
— Consumer Testing Responses
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.