Children’s Mercy Pediatric Care Network (PCN) an Integrated Pediatric Network (IPN) Bob Finuf, Vice President & PCN Executive Director Agenda • Children’s Mercy’s Scope of Services • Children’s Mercy’s History with Medicaid Managed Care • Why Develop Children’s Mercy Pediatric Care Network? • Overview of Children’s Mercy Pediatric Care Network • Provider Value Proposition 2 Children’s Mercy Hospitals & Clinics Size and Scope • 21: • 44: • • • • • • • • Pediatric oncologists on staff States from which patients visited Children’s Mercy in 2011 319: Inpatient beds (391 beginning in September with the opening of Hall Tower) 400+: Employed Pediatric specialists and subspecialists 2,000+: Cancer patients seen annually 4,500+: Transports each year (top 3 busiest teams in the country) 6,000+: Employees 14,875+: Admissions annually 17,750+: Surgical procedures performed each year 400,000+ Patient visits annually 3 Community Provider • 1: • • • • • • Only Pediatric Trauma Center between St. Louis and Denver 5: Locations in the KC Metro Area 51%: Medicaid as a percentage of annual patient revenue 75+: Medical residents employed by Children’s Mercy each year 400+: Medical students who annually rotate through Children’s Mercy 1897: Year founded as a single‐bed hospital for children $120+M: Total community benefit provided each year 4 Industry Leader • 1st: Human Genome Center within a Children’s Hospital • 1st: Hospital in Kansas or Missouri (and just the third Children’s Hospital nationwide) to achieve Magnet Designation for excellence in nursing • 1: Largest Pediatric Clinical Pharmacology program in North America • 10 out of 10: Pediatric specialties at Children’s Mercy ranked by US News & World Report 5 CMH’s Service Area Extends Over a Broad Regional Geography MISSOURI Putnam Putnam Putnam Worth Worth Worth Nodaway ay Nodaw Nodaw ay Atchison Atchison Atchison Harrison Harrison Harrison aryville M aryville M aryville aryville M aryville Gentry Gentry Gentry Andrew Andrew Andrew KANSAS Phillips Phillips Phillips on on ton on on Smith Smith Smith Republic Republic Jewell ell Jew ell Jew Jew ell Brown n Brow n Brow Brow n Nemaha Nemaha Nemaha Marshall Marshall Washington Washington Washington Daviess Dav Dav iess Buchanan Buchanan Buchanan Atchison Atchison Cloud Cloud Cloud Rooks Rooks ham ham ham Osborne Osborne Osborne Platte Platte Platte Jackson Jackson Jackson Mitchell Mitchell Mitchell Clay Clay Clay Riley Riley Pottaw Pottawatomie atomie atomie Pottaw Leav Leavenw enworth orth orth Leav enw orth Leav enw orth Leav Leav orth Ottaw Ottawaa Ottaw ego ego ego  4+ hrs Russell Russell Russell Ellsw Ellsworth orth orth Ellsw orth Ellsw orth Ellsw Ellsw orth Rush Rush Rush ss ss alina SSSalina alina Saline Saline Saline Saline Saline Saline City City Cit y Rice Rice Rice Wabaunsee Wabaunsee Wabaunsee 50 min Shaw Shawnee nee rence Law Law rence Lyon Ly Ly on Marion Marion Marion Chase Chase Stafford Stafford Stafford rd rd rd Hutchinson Hut chinson Kiowaa Kiow Greenwood ood Greenw Greenw 3 hrs Pratt Pratt Pratt Kingman Kingman  Wichita Wichita Wichit a Woodson Woodson Woodson Allen Allen Allen Comanche Comanche Barber Barber Harper Harper Harper Howard ard How How ard Linc Linc Linc Columbia Columbia Columbia Pettis Pettis Pettis Wilson Wilson Wilson Neosho Neosho Neosho Sumner Sumner  Parsons Parsons Parsons Parsons Parsons Parsons Labette Labette Labette Cowley ley Cow Cow Chautauqua Chautauqua Chautauqua Montgomery Montgomery Montgomery Henry Henry Henry  Benton Benton Benton Miller Miller Miller Lake Ozark Lake Ozark Ozark Lake Osage Osage Beach Beach Osage Camden Camden Camden Polk Polk Polk  Children's Mercy Specialty Outreach Location Outreach Areas (43 counties) Osage Osage Osage Dallas Dallas Dallas Lebanon Lebanon Lebanon Pulaski Pulaski Pulaski Dent Dent Dent Dade Dade Dade  Greene Greene Greene Caryt Carytow ow n n n Carytow n Carytow n Carytow Caryt ow n Jasper Jasper Jasper Jasper Jasper Joplin Joplin Webster Webster Law Lawrence rence Law rence Law rence Law Law 3 hrs ield pringfield ield SSpringf pringf pringf ield pringf ield S 120 mile radius no Rey Rey no Texas Texas Texas Shannon Shannon 2.5 hrs Barry Barry Barry McDonald McDonald Wright Wright Wright Ca Ca Ca Douglas Douglas Douglas Stone Stone Stone Taney Taney Taney Oz ark Ozark ark Oz Oregon Oregon Oregon Howell ell How How 20 miles x hrs Wa Wa Wa Wa Phelps Phelps Phelps Barton Barton Barton Pit Pitttsburg sburg Pittsburg Cherokee Cherokee Cherokee Franklin Franklin Franklin Maries Maries Maries Laclede Laclede Laclede Craw Crawford ford ford Craw ford Craw ford Craw Craw ford Gasconade Gasconade Gasconade St. Louis 4 hrs  From CMH Craw Crawford ford ford Craw ford Craw ford Craw Craw ford Hickory Hickory Hickory Christian Christian Christian Secondary Service Area (50 counties) Cole Cole Cole Morgan Morgan Morgan St. St. Clair Clair Clair St. Cedar Cedar Cedar Warren Warren Warren St St St Newton ton New New ton Primary Service Area (18 counties) Children's Mercy Hospital or Major Ambulatory Location Callaw Callaway Callaw ay Moniteau Moniteau Moniteau Vernon Vernon Vernon Montgomery Montgomery Montgomery Sedalia edalia SS edalia edalia S Cass Cass Nevada Nevada Nevada Sedgw Sedgwick ick 2 hrs Cooper Cooper Cooper Bates Bates Bourbon Bourbon Boone Boone Boone Marshall M arshall Lafayette ette Lafay ette Butler Butler Butler Elk Elk Elk Clark Clark Clark Clark Clark Clark Linn Linn Linn Pike Pike Pike Harv Harvey ey Harv Reno Reno Edw Edwards ards ards Edw ards Edw ards Edw Edw ards Anderson Anderson Anderson Ralls Ralls Monroe Monroe Monroe Audrain Audrain Audrain Jackson Jackson Jackson Clinton Clinton Clint on Coffey Coffey Marion Marion Marion Shelby Shelby Randolph Randolph Randolph Randolph Randolph Randolph Chariton Chariton Saline Saline Emporia mporia EEmporia Pawnee nee Paw Paw eman man eman Miami Miami Miami Macon Macon Macon Ray Ray Ray Johnson Johnson Johnson Franklin Franklin Franklin Linn Linn Linn Carroll Carroll Johnson Johnson Johnson Osage Osage Osage Morris Morris Morris M cPherson cPherson M Wyandotte andotte andotte Wy andotte Wy andotte Wy andotte opeka T Topeka opeka Douglas Douglas Douglas McPherson McPherson McPherson Barton Barton Barton Great Great Bend Bend Great Bend Bend Great Bend Great Great Dickinson Dickinson Dickinson  Hays Hays Hays 1 hr anhattan M M anhat anhatt tan an Geary Geary Geary ion Junct ion Junction Junction Junct Junction Lincoln Lincoln Lincoln Ellis Ellis Ellis Lew Lewis is Lew is Lew Lew Lew is Livingston ingston Liv Liv ingston Clay Clay Clay     Jefferson Jefferson Jefferson Caldwell ell Caldw Caldw Clinton Clinton Clinton Knox Knox Adair Adair Adair Chillicothe Chillicot Chillicot he he 1 hr  Joseph t.. Joseph Joseph SStt. Clark Clark Clark T Trenton renton DeKalb DeKalb DeKalb Doniphan Doniphan Doniphan Scotland Scotland an Sulliv Sulliv an Grundy Grundy Holt Holt Holt Schuyler Schuy Schuy ler Mercer Mercer Drive time to CMH Main 6 Children’s Mercy Hospitals & Clinics – Kansas City History with Medicaid Managed Care • Children’s Mercy & Truman Medical Center formed Family Health Partners (FHP), a Medicaid managed care organization (MCO) in 1996 • Children’s Mercy acquired Truman’s interest in FHP in 2002 • By 2011 FHP was serving 210,000 Medicaid recipients (Adults and Children) in Missouri and Kansas • In anticipation of health care reform and the changing landscape in Medicaid managed care, Children’s Mercy sold FHP to Coventry Health Care January 1, 2012 7 Children’s Mercy Hospitals & Clinics – Kansas City History with Medicaid Managed Care cont…. • As part of the FHP transaction Children’s Mercy retained key infrastructure components from FHP. • Simultaneous with the sale of FHP on January 1, 2012 Children’s Mercy formed Children’s Mercy Pediatric Care Network (CMPCN), a new Pediatric “ACO‐like” organization to function as an Integrated Pediatric Network. • CMPCN entered into a global capitation agreement with Coventry Health Care and their Medicaid MCO subsidiaries in Missouri and Kansas January 1, 2012 for 112,000 Medicaid eligible children in the KC Metro area. 8 Why Sell the Medicaid MCO and Develop CMPCN? • The current payment model is unsustainable (fee‐for‐service is in Hospice) • Care is fragmented • Poor cost/outcome ratio vs. the world 9 Why Sell the Medicaid MCO and Develop CMPCN cont… • Pediatric practices are under resourced and overburdened with administration • A model for real and sustainable community‐ based population health is needed • The care delivery and payment models need to be aligned and CMPCN provides a vehicle to accomplish that while focusing on Pediatrics 10 Health Care Spending as a Percentage of GDP, 1980–2009 18 US NETH 16 FR 14 GER DEN Percent 12 CAN SWIZ 10 NZ 8 SWE UK 6 NOR AUS 4 JPN 2 0 1980 1984 1988 1992 GDP refers to gross domestic product. Source: OECD Health Data 2011 (June 2011). 1996 11 2000 2004 2008 Current State Build ‘n Fill 12 Right Time Future ‐ Incentives Aligned to do the Right Thing Preventative Care Chronic Disease Management Right Care Coordinated Evidence Based Appropriate Intensity Right Setting Patient Centered Medical Home Convenient and Timely (home, school, technology enabled) Acute & Specialty Care when Needed 13 How Do We Get From Here to There? 14 15 Assumptions • Better care does not have to result in higher cost in the aggregate, but it may (and should) result in higher costs within components of care. • Providers will face steadily increasing pressure to be accountable for the cost of care (take cost out) while maintaining and increasing the quality of care. • The care delivery model and the payment model must be fundamentally redesigned simultaneously to achieve meaningful improvement in quality and cost. • The government will not provide the solution, but the government may very well provide the motivation to find the solution. 16 Assumptions cont… • The only person that likes change is a wet baby. Change is hard, and it requires hard work, innovation, and diligence to produce meaningful change. • You must believe, and go “all in”. • Disruptive innovation often produces real or perceived winners and losers. All stakeholders will need to reexamine their role in the health care ecosystem. • An innovation’s initial form is rarely its final form. 17 Children’s Mercy Pediatric Care Network’s Mission To improve the health and well‐being of children through an integrated pediatric network in the greater Kansas City area that is value‐based, community‐focused, patient‐centric, and accountable for the quality and cost of care. 18 Current Patient Inclusion: • • • • KS‐ 21 yo and under MO‐ 20 yo and under Enrolled with participating Medicaid MCO Patient’s PCP is located in one of the included counties • Patient Selected PCP • Auto‐assigned PCP Future Patient Inclusion: 20 yo and under Live in PCN Service Area Attributed to a sponsoring organization (employer, private or public payer) • • • 19 How Does It Work? CMPCN: • Is accountable for the quality and cost of care for a defined pediatric population through a global prospective payment model. • Provides resources to the community‐based providers for the patient‐centered medical home. • Reduces the barriers of traditional medical management and utilization review • Exports Children’s Mercy resources and expertise into the community • Compensates providers based on level of engagement and outcomes 20 What We Do We improve health care delivery by offering: • Simplified administration and reduced fragmentation, including standardized claim submission requirements, payment policies, and credentialing processes. • Better population‐based clinical tools and medical home support tools such as Health Information Technology and aggregated data for the pediatric population in the Kansas City area. • Payment system reform: “value based” payment, opportunities for at‐risk contracting, sharing savings, and other creative payment models. • Delegated health plan administration, including medical management, provider credentialing, and disease management programs. 21 Data Driven 22 Using Data to Provide Care 23 Children’s Mercy Pediatric Care Network (CMPCN) Medicaid Managed Care Administrative Services Shared Services CMPCN/Health Plans CMPCN Health Plans “Shared Services” are performed separately by CMPCN and Health Plans but not necessarily with the same allocation of resources by each. •Appeals (first level for network providers) •Care Management (high use / high cost) •Data Analytics •Disease Management (Asthma, Diabetes) •HEDIS Data Collection Support •Inpatient Transition •Medical Home Support •Payer Contracting/Relations •Payment Model Determination •Prescription Drug Management (if applicable) •Prior Authorization •Performance Reporting and Analysis •Utilization Management •24‐Hour Nurse Advice Line •Appeals (except first level for network providers) •Benefits Administration •Claims Administration •Community & Member Outreach •Compliance •Customer Service •HEDIS Data Collection & Reporting •Enrollment •Marketing •Non‐Medical Services (transportation, dental) •Pharmacy Benefits Management Services •Pharmacy Network •Quality Improvement •State Contracts •Underwriting •Credentialing •Financial Reporting •Government Relations •HIT Platform •Patient Outreach and Prevention •Provider Relations and Contracting •Website Design and Maintenance 24 Children’s Mercy Pediatric Care Network (CMPCN) Provider Flow of Funds/Data 25 Provider Value Proposition PCN Services Current • • • • Intermediary with MCOs for streamlined communication Standardized Payment Model • FFS (70%) • Medical Home Admin Cap (15%) • Incentive Based Cap (15%) Standardized Medical Management Non‐Redundant Credentialing Process 26 Provider Value Proposition cont… PCN Services cont.. Current cont.. • • Liaison for all things CMH  Office Based CPGs  CMH Concierge  MOC  Quality Improvement Medical Home Resourcing  Data Exchange  Patient outreach and intervention 27 Provider Value Proposition cont… • PCN Services cont… Future • Shared Risk/Savings Payments • Relaxed Medical Management • Office Quality Resources • Use of CMH Resources like HR • Business Office Support • HIT Services  Web hosting, content and tools  Health Information Exchange 28 Provider Value Proposition cont… Provider Engagement Obligations • Appropriate use of Acute and Specialty Settings • Address Gaps in Care • Address Access to Care • Medical Home Collaboration • Disease and Case Management Collaboration • Provide Data to PCN 29 Disruptive innovation often produces real or perceived winners and losers. All stakeholders will need to reexamine their role in the health care ecosystem. 30