From Volume to Value: Building the Bridge While You Cross It Bob Finuf, Vice President, Payor Relations & PCN Executive Director January 21, 2015
Agenda • In The Beginning… • Transforming the Health Delivery System • Increasing the Value of Primary Care • Building the Community-Based Network • Complex Care • The Changing Payor Landscape • Pathway to Commercial Value-Based Payment • Lessons Learned 2
Children’s Mercy – Kansas City Scope of Service • Only Pediatric Trauma Center between St. Louis and Denver
• • • • •
5 Locations in the KC Metro Area 355 Inpatient Beds 15,000+ Inpatient Admissions/year 370,000+ Outpatient Visits/year 150,000+ ED/Urgent Care Visits/year 3
Children’s Mercy – Kansas City Scope of Service cont…
• 40+ Pediatric Specialties • 20+ Outreach Clinics • 51% Medicaid as a percentage of annual patient revenue • 450+ Employed Physicians • 7,000+ Employees • ACO entity with 88,000 at-risk capitated Medicaid enrollees and 15,000 shared savings Medicaid enrollees 4
Primary Service Area Extends Over a Broad Regional Geography MISSOURI Put Put Putnam nam nam nam Put Put Put nam nam
Wort Wort Worthhh
Nodaw Nodaw Nodaway ay ay ay Nodaw Nodaw Nodaw ay ay
At At Atchison chison chison chison At At At chison chison
Gent Gent Gentry ry ry ry Gent Gent Gent ry ry
Washingt Washingt Washington on
Marshall Marshall Marshall
Brow Brow Brown nn nn n Brow Brow Brow
Nemaha Nemaha Nemaha
Doniphan Doniphan Doniphan
St St St...... Joseph Joseph Joseph Joseph St St St Joseph Joseph Buchanan Buchanan Buchanan Buchanan Buchanan Buchanan
Graham Graham Graham Graham Graham Graham
Rooks Rooks Rooks Rooks Rooks Rooks
Osborne Osborne Osborne Osborne Osborne Osborne
Plat Plat Platttteee
Jackson Jackson JJackson Jackson Jackson ackson
Mit Mitchell chell chell
Clay Clay Clay Clay Clay Clay
Riley Riley Riley Riley Riley Riley
Pot Pot Potttttaw aw aw awat at atomie omie omie omie Pot Pot Pot aw aw at omie omie
Ot Ot Otttttaw aw aw a aa aa a Ot Ot Ot aw
Trego Trego Trego Trego Trego Trego
4+ hrs
Rush Rush Rush Rush Rush Rush
Dickinson Dickinson Dickinson Dickinson Dickinson Dickinson
Ellsw Ellsw Ellswort ort orthhh
Ness Ness Ness
Geary Geary Geary Geary Geary Geary ion Junct Junct Junct ion ion ion Junct Junct Junct ion ion
Russell Russell Russell Russell Russell Russell
Hays Hays Hays Hays Hays Hays
Great Great Bend Bend Bend
Salina Salina Salina Saline Saline Saline Saline
Rice Rice Rice
Wabaunsee Wabaunsee Wabaunsee Wabaunsee Wabaunsee Wabaunsee
Cit Cit Cityy Cit y
50 min
Shaw Shaw Shawnee nee nee nee Shaw Shaw Shaw nee nee
Law Law Law rence rence rence rence Law Law Law rence rence Douglas Douglas Douglas Douglas Douglas Douglas
Ly Ly Ly on on Ly Ly Lyon on on on Marion Marion Marion Marion Marion Marion
M M M cPherson cPherson cPherson cPherson M M M cPherson cPherson
Chase Chase
Prat Prat Prattttttt Prat Prat Prat Kiow Kiow Kiowa aa aa a Kiow Kiow Kiow
Kingman Kingman Kingman Kingman
Franklin Franklin Franklin Franklin Franklin Franklin
Comanche Comanche Comanche
Barber Barber Barber Barber Barber Barber
Harper Harper Harper
Lincoln Lincoln Lincoln Lincoln Lincoln Lincoln
Laf Laf Lafay ay ayet et et ettttte ee ee e Laf Laf Laf ay et et
Columbia Columbia Columbia Pet Pet Petttttttis is is is Pet Pet Pet is is
Mont Mont Mont gomery gomery Mont Mont Montgomery gomery gomery gomery Callaw Callaw Callaway ay ay ay Callaw Callaw Callaw ay ay
Warren Warren Warren Warren Warren Warren St St...... Charles Charles Charles Charles St St Charles
Miami Miami Miami Miami Miami Miami
Monit Moniteau eau eau eau Monit Monit eau eau Henry Henry
Anderson Anderson Anderson
Linn Linn Linn
Woodson Woodson Woodson Woodson Woodson Woodson
Allen Allen Allen Allen Allen Allen
Neosho Neosho Neosho Neosho Neosho Neosho
Parsons Parsons Parsons
Parsons Parsons Parsons Labet Labet Labettttee
Cow Cow Cowley ley ley ley Cow Cow Cow ley ley Mont Mont Montgomery gomery gomery gomery Mont Mont Mont gomery gomery
Craw Craw Crawfffffford ord ord ord Craw Craw Craw ord ord
Hickory Hickory Hickory Hickory Hickory Hickory
Bourbon Bourbon Bourbon Bourbon Bourbon Bourbon
Cedar Cedar Cedar
Polk Polk Polk
Dallas Dallas Dallas Dallas Dallas Dallas
Primary Service Area (18 co unt ies) Seco ndary Service Area (50 co unt ies)
Pulaski Pulaski Pulaski Dent Dent Dent Dent Dent Dent
Bart Bart Barton on on Bart Bart Bart on Dade Dade Dade
Pit Pit Pittttt sburg sburg sburg sburg Pit Pit Pit sburg sburg
Cherokee Cherokee Cherokee Cherokee Cherokee Cherokee
Greene Greene Greene Greene Greene Greene Caryt Caryt Carytow ow ow own n n n Caryt Caryt Caryt ow ow n n JJJasper Jasper asper Jasper Jasper asper Joplin Joplin
120 mile radius
Webst Webst Webster er
Law Law Lawrence rence rence
3 hrs ield Springf Springf Springf ield ield
Rey Reynolds nolds nolds nolds Rey Rey nolds nolds Wright Wright Wright Wright Wright Wright Texas Texas Texas Texas Texas Texas Shannon Shannon Shannon Shannon
2.5 hrs
Barry Barry Barry Barry Barry Barry McDonald McDonald McDonald McDonald McDonald McDonald
Children's Mercy Specialt y Out reach Lo cat io n
Lebanon Lebanon Lebanon Lebanon Lebanon Lebanon Laclede Laclede Laclede
Craw Craw Craw ord ord Craw Craw Crawfffffford ord ord ord
Cart Cart Carter er
Douglas Douglas Douglas Douglas Douglas Douglas
St St Stone one one one St St St one one Taney Taney Taney Taney Taney Taney
Oz Oz Oz ark ark Oz Oz Ozark ark ark ark
Oregon Oregon Oregon Oregon How How Howell ell ell ell How How How ell ell
Out reach Areas (43 co unt ies) 2 0 m iles
x hrs
Washingt Washingt Washington on on
Phelps Phelps Phelps Nevada Nevada Nevada Nevada Nevada Nevada
Wilson Wilson Wilson Wilson Wilson Wilson
Maries Maries Maries
Osage Beach Osage Osage Beach Beach Osage Beach Camden Camden Camden
St St...... Clair Clair Clair Clair St St Clair Clair
Christ ian Christ Christian ian Christ ian
Children's Mercy Ho spit al o r Majo r Ambulat o ry Lo cat io n
Gasconade Gasconade Gasconade Gasconade Gasconade Gasconade
Bent Bent Benton on on
Bat Bat Bates es es Bat Bat Bat es
But But Butler ler ler ler But But But ler ler
Chaut Chaut Chautauqua auqua auqua auqua Chaut Chaut Chaut auqua auqua
Osage Osage Osage Osage Osage Osage
Franklin Franklin Franklin Franklin Franklin Franklin
Sedgw Sedgw Sedgwick ick ick ick Sedgw Sedgw Sedgw ick ick
Sumner Sumner Sumner Sumner Sumner Sumner
St. Louis 4 hrs From CMH
Miller Miller Miller Lake Lake Lake Ozark Ozark
Vernon Vernon Vernon Vernon Vernon Vernon
Wichit Wichit Wichitaa Wichit aa
Cole Cole Cole Cole Cole Cole
Morgan Morgan Morgan Morgan Morgan Morgan
New New Newtttttton on on on New New New on on
2 hrs
Cooper Cooper Cooper Cooper Cooper Cooper
Cass Cass Cass Cass
Clint Clint Clinton on on on Clint Clint Clint on on
Elk Elk Elk Elk Elk Elk
Clark Clark Clark Clark Clark Clark
Boone Boone Boone
M M arshall arshall arshall M M arshall
Emporia Emporia Emporia Emporia Emporia Emporia
Greenw Greenw Greenw ood ood Greenw Greenw Greenwood ood ood ood
3 hrs
Ford Ford Ford Ford Ford Ford
How How Howard ard ard ard How How How ard ard
JJJackson ackson ackson
JJJohnson ohnson ohnson
Reno Reno Reno Reno Reno Reno
Edw Edw Edwards ards ards
Pike Pike Pike Pike Pike Pike Audrain Audrain Audrain Audrain Audrain Audrain
Saline Saline Saline Saline Saline Saline
Harv ey Harv Harvey ey Harv ey
Hut Hut Hutchinson chinson chinson chinson Hut Hut Hut chinson chinson
Ralls Ralls Ralls Ralls Ralls Ralls
Monroe Monroe Monroe Monroe Monroe Monroe
Sedalia Sedalia Sedalia
Paw Paw Pawnee nee nee Paw Paw Paw nee St St Staf af af affffford ord ord ord St St St af af ord ord
Marion Marion Marion Marion Marion Marion
Shelby Shelby Shelby
Randolph Randolph Randolph
Charit Charit Charit on Charit Charit Chariton on on
Carroll Carroll Carroll Carroll
Clay Clay Clay Clay Clay Clay
Johnson Johnson JJohnson Johnson Johnson ohnson
Osage Osage Osage
Cof Cof Cofffffffey ey ey Cof Cof Cof ey Hodgeman Hodgeman Hodgeman
Clint Clint Clinton on on
Wy Wy Wyandot andot andottteee
T T Topeka opeka opeka
Morris Morris Morris
McPherson McPherson McPherson
Bart Bart Barton on on on Bart Bart Bart on on
1 hr
M M M anhat an an M M M anhat anhat anhattttt an an an an
Lincoln Lincoln Lincoln Lincoln Lincoln Lincoln
Caldw Caldw Caldwell ell ell ell Caldw Caldw Caldw ell ell
Macon Macon Macon Macon Macon Macon
Liv Liv Livingst ingst ingst ingston on on on Liv Liv Liv ingst ingst on on
Ray Ray Ray
Leav Leav Leavenw enw enw enwort ort ort orth hh hh h Leav Leav Leav enw enw ort ort Jef ef ef fffferson erson erson erson JJJJJef ef ef erson erson
Ellis Ellis Ellis Ellis Ellis Ellis
Linn Linn Linn Linn Linn Linn
Chillicot Chillicot Chillicothe he he Chillicot Chillicot Chillicot he
1 hr
At At Atchison chison chison chison At At At chison chison
Cloud Cloud Cloud
Lew Lew Lewis is is is Lew Lew Lew is is
Dav Dav Daviess iess iess DeKalb DeKalb DeKalb DeKalb DeKalb DeKalb
Republic Republic Republic Republic Republic Republic
JJJew ew ewell ell ell
Knox Knox Knox Knox
Adair Adair Adair
T T Trent rent rent renton on on on T T T rent rent on on
Andrew Andrew Andrew Andrew Andrew Andrew
KANSAS Smit Smit Smithhh
Clark Clark Clark Clark Clark Clark
Sulliv Sulliv Sullivan an an an Sulliv Sulliv Sulliv an an
Grundy Grundy
Holt Holt Holt Holt Holt Holt
Phillips Phillips Phillips
Scot Scot Scotland land land land Scot Scot Scot land land
Harrison Harrison Harrison
M M M aryville aryville aryville aryville M M M aryville aryville
Nort Nort Norton on
Schuy Schuy Schuyler ler ler ler Schuy Schuy Schuy ler ler
Mercer Mercer Mercer Mercer
Drive time to CMH Main
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History with Medicaid Managed Care • Formed a Medicaid managed care organization (MCO) in 1996 (Family Health Partners) • By 2011 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 its Medicaid MCO to Coventry Health Care January 1, 2012 6
History with Medicaid Managed Care • As part of the FHP transaction Children’s Mercy retained key infrastructure components from FHP. Clinical Services
Information Technology
Administration
• Simultaneous with the sale of its MCO 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.
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• CMPCN entered into a global capitation agreement with Coventry Health Care and their Medicaid MCO subsidiaries in Missouri and Kansas in the KC Metro area. • Currently contract under global capitation with 2 Medicaid MCOs in Missouri for 88,000 kids and 2 MCOs for shared savings in Kansas for 15,000 kids. 8
How Do We Get From HERE
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THERE?
to
9
Where we started
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Objectives • Move the health care delivery system from volume to value • Build a network of community PCPs • Implement new provider payment models for Medicaid • Explore new payment models for commercial payers 11
Vision 2022
Demonstrate Quality Outcomes Goals 2017
Public Policy Leadership
Innovation
Be a national and international leader recognized for advancing pediatric health and delivering optimal health outcomes through innovation and a highhigh-value, integrated system of care
A. Demonstrate quality, safety, and clinical effectiveness
Improve Performance
Strengthen Market Position
Deliver Value
B. Improve processes, increase capacity for innovation and service excellence, and strengthen financial position
C. Maintain CMH’s market position in the Metro area and grow it throughout the region
D. Develop an integrated pediatric health care system that demonstrates value, expertise, and efficiency
Elevate Academic Profile E. Enhance the research capabilities and accomplishments of CMH and strengthen the quality of the educational experiences
Values Accountability Clinical Excellence Continuous Improvement Empowerment Transparency Respect Teamwork Mission Improve the health and wellwell-being of children by providing comprehensive familyfamily-centered health care, committing to the highest level of clinical and psychosocial care, and exhibiting research, educational and service excellence
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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.
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CMPCN: What We Do 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. • 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. 14 14
Transformation from Volume to Value • The Big 3- PCMH, Medical Neighborhood and Complex Care – PCMH Transition in a large academic safety net and community practices – Collaborative Care Agreements with the Medical Neighborhood – Coordinated Complex Care Program for the most vulnerable and costly patients
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The Missed Value of Primary Care
Specialists 16
Percent of CMPCN ED and Urgent Care Patient Visits (6 mos) by Day of Week and Time of Day
8am – 5pm
% visits
6pm – 12am
1 am – 7am
% by day of week
12%
18%
16%
16%
14%
12%
12% 17
CMPCN ED and Urgent Care Visits by Acuity (6 mos)
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Practice Transformation
Patient Centered Medical Home Transformation Team Patient Outreach Relaxed Medical Management
Quality Improvement Resources
Clinical Practice Guidelines
Web Hosting
HIE
Standard Disease Management Programs MOC Help
Health System Concierge Back Office Support 19
PCMH Transformation Team • Physician, Social Worker, QI Specialist, Case Manager, Provider Relations, Patient Outreach Support • Work with each practice to guide them on the journey • NCQA Recognition Desired (and rewarded) but not Required 20
Support of the Medical Home • Data for Population Management at the Practice Level – Practice Report Card on Web Portal – ED use, high cost patients, disease registries • Disease Management- Medical Home Style • Web Services to Support the Medical Home 21
Data Driven
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Using Data to Provide Care
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Transformation Timeline Population Health/Standardized Care
Patient Engagement
Patient Registries Empanelment Evidence-Based Guidelines Open Access/Same Day Appointments
Medical Home Brochure Patient Satisfaction Survey Self-Management Tools
Foundation Getting to Know You Key Contact Identified Quality Improvement Plan
within 6 months
over the next 9-12 months
Team-Based Planned Care Pre-Visit Planning Written Care Plans Clinical Summary
Coordinated Care Referral Tracking
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Community PCP Network Payment Model
FFS 90% Admin Cap 10%
$ $
FFS 70%
$
Engagement Cap 15%
$
Performance Cap 15%
$
FFS 70% Outcome Cap 30%
$ $
Clinical Integration 2011
2012
July 2014 25
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Complex Care • 6% of kids generate 40% of cost • Formation of formal complex care coordination program (“Beacon”) • State-based Collaborative of Children’s Hospitals for Complex Care • National collaborative with 9 children’s hospitals regarding care coordination for children with medical complexity – Awarded CMMI Grant in 2014
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The Changing Payor Landscape • MO – State did not expand Medicaid • KS – State did not expand Medicaid – Moved all Medicaid/CHIP population into capitated managed care 1/1/13 – Medicaid MCOs lost an estimated $197 M (9%) in first 12 months – Budget issues significant 28
Marketplace/Exchange • Unknowns regarding whether the marketplace/exchange will erode commercial coverage and harm the payer mix • Only 5-6% of enrollment is under age 18 • 80+% income subsidized • Narrow network limitations • Price point purchasers not making fully informed decisions regarding real cost • Decreased collection rates, increased bad debt, and disgruntled enrollees 29
Pathway to Commercial/Employer Population Health Models • • • •
Antitrust Issues and True Clinical Integration The Pediatric Role in the Big (spend) Picture Switzerland The Value of Managing Delegated Functions – Credentialing – Medical Management • Utilization Review • Care Management • Disease Management 30
Medicaid Delegated Administrative Services Shared Services CMPCN/Health Plans
CMPCN
• Care Management (high use / high cost) • Data Analytics “Shared Services” are performed separately by CMPCN and Health Plans but • Disease Management (Asthma, Diabetes) not necessarily with the same allocation of • HEDIS Data Collection Support resources by each. • Inpatient Transition • Medical Home Support • Credentialing • Payment Level and Model Determination • Financial Reporting • Prescription Drug Management (if • Government Relations applicable) • HIT Platform • Prior Authorization • Patient Outreach and Prevention • Provider Performance Reporting and Analysis • Provider Relations and Contracting • Utilization Management • Website Design and Maintenance • 24-Hour Nurse Advice Line
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Pathway to Commercial/Employer Population Health Models • Narrow Network Products in Exchange • Narrow Network Products Off Exchange • Adult Hospitals/Systems Forming Networks with Pediatrics as the Common Denominator 32
Where we are
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Lessons Learned • Critical to identify and engage physician champions who “believe” • Be very prescriptive with data requirements from payers • Move as far along the continuum of clinical integration as possible • Sell value internally and externally, and keep selling! 34
Lessons Learned • Success metrics are difficult; define them carefully • Align payment strategy within the health system • Market changes necessitate flexibility in strategy • Make your plan, then plan to change it • Payment and care delivery must be changed together 35
Contact:
Bob Finuf
[email protected]
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