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Medicare risk revenue management 11 jun12 washington dc
Medicare risk revenue management 11 jun12 washington dc
Medicare risk revenue management 11 jun12 washington dc
Medicare risk revenue management 11 jun12 washington dc
Medicare risk revenue management 11 jun12 washington dc
Medicare risk revenue management 11 jun12 washington dc
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Medicare risk revenue management 11 jun12 washington dc
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Medicare risk revenue management 11 jun12 washington dc

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Presentation given at the Medicare Risk Revenue Management - Best Practice Operation Strategies meeting in Washington, DC - June 11-12, 2012

Presentation given at the Medicare Risk Revenue Management - Best Practice Operation Strategies meeting in Washington, DC - June 11-12, 2012

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  • 1. Leveraging the Entire Care Team to ImproveCare Management and Data Capture Wayne Pan, MD, MBA Chief Medical Officer Pacific Partners Management Services, Inc. Medicare Risk Revenue Management - Best Practice Operation Strategies • Washington, DC • June 11, 2012
  • 2. 3takeaways
  • 3. 1drawtheBIGpicture
  • 4. 2showmetheDATA
  • 5. gowiththeFLOW3
  • 6. 1
  • 7. vision
  • 8. process
  • 9. process
  • 10. same page
  • 11. teammates
  • 12. goals goals
  • 13. metrics
  • 14. outcomes
  • 15. rewards
  • 16. 2
  • 17. it’smorethanjustdata
  • 18. it’salsoaboutwhomyour DATAservingdata to
  • 19. savvyconsumers
  • 20. not current error prone MPASTEEno comparator
  • 21. unadulterated
  • 22. michaelvandurenmdmbasutterhealth
  • 23. variationreduction
  • 24. 3
  • 25. intheflowoflife
  • 26. zen: one with the universe
  • 27. the new way of doing things... ...feels just like the old way
  • 28. user-centereddesign
  • 29. theSCCIPAstory
  • 30. ? who whatwherewhen why how
  • 31. Who is ?
  • 32. Individual Practice Association Medical Group of Santa Clara County
  • 33. Individual Practice Association Medical Group of Santa Clara County
  • 34. SCCIPA
  • 35. largest IPA in Santa Clara County
  • 36. Santa Clara Countysize 1,304.01 sqmiles pop 1,781,642 (2010)medianincome $74,335
  • 37. THEApr 21,2012 Price 75 FB C REDITSVIEW FROM THE VALLEY EUROPE ENGLAND RUSSIA ATLANTIC OCEAN NEW YORK CITY FLORIDA M DA EX NA ICCA CLEVELAND APPALACHIA O ILLINOIS the Mississippi River INFINITE LOOP SAND HILL ROAD
  • 38. 5 PCP 80 Specialists 173 PCP 343 Specialists 57 PCP 104 Specialists 11 PCP 30 SpecialistsSCCIPA founded in 1986 physician-owned, physician-governed 800+ physicians - 240+ PCPs, 550+ specialists all 9 hospitals - including a tertiary care center 9 health plans (Commercial and Medicare Advantage) Anthem Commercial ACO pilot (2011)
  • 39. urban/ suburban ruralSCCIPA founded in 1986 physician-owned, physician-governed 800+ physicians - 240+ PCPs, 550+ specialists all 9 hospitals - including a tertiary care center 9 health plans (Commercial and Medicare Advantage) Anthem Commercial ACO pilot (2011)
  • 40. 25,000commercialACO
  • 41. 40,000commercialHMO
  • 42. 5,000MedicareHMO
  • 43. nooriginal Medicare, Medi-Cal, CHIP, uninsured
  • 44. = managementservicesorganization medicalmanagement casemanagement networkmanagement providercontracting qualityimprovement credentialing memberservices claims&encounterprocessing clinicaldataanalytics&reporting marketingoutreach grievance&appeals compliance&auditing ITservices finance&riskmanagement
  • 45. partialrisk
  • 46. managingDOFR
  • 47. DivisionOfF inancialResponsibility
  • 48. outpatientservices
  • 49. inpatientservices
  • 50. capitatepcps
  • 51. specialistspaidffs
  • 52. performancebonus
  • 53. IHAP4P&HCC
  • 54. IPAcitizenship
  • 55. roughroad
  • 56. roughroad 4x4 healthcare
  • 57. 4processes x4dimensionaldata
  • 58. 4processes
  • 59. communication
  • 60. collaboration
  • 61. Case ManagersPatients PCPs Specialists coordination
  • 62. anticipation
  • 63. 4dimensionaldata
  • 64. financial
  • 65. administrative
  • 66. clinical
  • 67. retrospective retrospective
  • 68. reactivecare
  • 69. $$$$$$
  • 70. + behavioral
  • 71. predictive
  • 72. proactivecare
  • 73. provideactionabledata
  • 74. @pointofcare
  • 75. @home
  • 76. thecareteam
  • 77. thecarecontinuum
  • 78. peopleprocessesplatform
  • 79. peopleprocessesplatform
  • 80. peopleprocesseshospitalistsavailable 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
  • 81. peopleprocesseshospitalistsavailable 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
  • 82. peopleprocessesSNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP
  • 83. peopleprocessesonsite 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
  • 84. peopleprocessescomplex 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
  • 85. peopleprocessesutilization 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
  • 86. people:physicians/staffprimary care physiciansspecialistsancillary providerscommunity pharmacists
  • 87. people:physicians/staffprimary care physiciansspecialistsancillary providerscommunity pharmacistsfront office staff
  • 88. people:plan staffcase managersdisease managersmember outreachbenefit design
  • 89. peopleprocessesplatform communicate collaborate coordinate anticipate
  • 90. peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedback
  • 91. 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
  • 92. 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
  • 93. designphilosophy
  • 94. “put hottriggers inthe path ofmotivatedpeople”BJ Fogg, PhDDirector, Persuasive Technology LabStanford University
  • 95. Are incentives aligned properly?How can I increase their motivation?
  • 96. Have I made it easy for people to act?How can I make it even simpler?
  • 97. Are people being triggered at the mostappropriate time and in their workflow (path)?
  • 98. putting it all together: how does it work?
  • 99. QualityAccess Express Management TM
  • 100. patient
  • 101. patient front desk staff
  • 102. patient analog to digital front desk staff converter
  • 103. AMERICAN HEALTH PLAN 112 MARY SMITH 1/1/2011 1234567890 $5.00 $10.00 $25.00analog to digital analog to digital eligibility check converter converter
  • 104. QualityAccess Express TM Management Click here to register for a password or request more informationPowered by Access ExpressQ-v5.0.#.0.1 Build 2011.04.04.00
  • 105. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 106. ACCESSEXPRESS Q New Eligibility Response New Message (3) AMERICAN HEALTH PLAN
  • 107. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 POP-UP 1234567890 MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
  • 108. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 1234567890 MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD CLICK HERE
  • 109. AMERICAN HEALTH PLAN
  • 110. AMERICAN HEALTH PLAN
  • 111. ACCESSEXPRESS Q New Eligibility Response New Message (3) ENABLING SMITH, MARY 8/15/1945 1234567890 FRONT OFFICE MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, STAFF GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
  • 112. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 SIMPLE 1234567890 CARE PLAN MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
  • 113. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 1234567890 MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
  • 114. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 115. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 116. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 117. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 118. ACCESSEXPRESS Q New Eligibility Response New Message (3)
  • 119. Description ofmeasure
  • 120. Capability forphysician officeentry
  • 121. ACCESSEXPRESS Q New Eligibility Response New Message (3) TH PA AMERICAN HEALTH PLAN E TH IN
  • 122. ACCESSEXPRESS Q New Eligibility Response New Message (3) ER SMITH, MARY 8/15/1945 G 1234567890 IG MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, TR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD T O H
  • 123. ACCESSEXPRESS Q New Eligibility Response New Message (3) N O TI VA TI O M
  • 124. Capability forphysician officeentry Y IT IL AB
  • 125. medicationreconciliation
  • 126. patient perspective
  • 127. on average,there is a pharmacy within 2.5 miles of every US resident Source: National Association of Chain Drug Stores
  • 128. Source: Gallop, November 28, 2011-December 1, 2011
  • 129. get out of the rut?
  • 130. from: Jeanne Liedtka and Tim Ogilvie, Designing for Growth (2011)
  • 131. IPAhosspital onsitedischarge case planner manager hospitalist patient discharge planning thepatientjourney
  • 132. hospitalist Rx patientdischarge medicationplanning reconciliation thepatientjourney
  • 133. hospitalist discharge instructions patient outpatientdischarge medication physicianplanning reconciliation follow-up thepatientjourney
  • 134. Rx discharge instructions family patient outpatientdischarge medication physician dischargeplanning reconciliation follow-up thepatientjourney
  • 135. failsafe
  • 136. hosspitaldischarge IPA onsite hospitalist hospitalist Rx discharge instructions case planner manager hospitalist Rx discharge instructions family patient patient patient patient outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
  • 137. hosspitaldischarge IPA onsite hospitalist hospitalist Rx discharge instructions case planner manager hospitalist Rx discharge instructions family patient patient patient patient outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
  • 138. from: Jeanne Liedtka and Tim Ogilvie, Designing for Growth (2011)
  • 139. brainstorm
  • 140. hosspitaldischarge IPA onsite hospitalist hospitalist Rx discharge instructions case planner manager hospitalist Rx discharge instructions family patient patient patient patient outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
  • 141. hosspitaldischarge IPA onsite pharmacist hospitalist Rx discharge instructions case planner manager hospitalist Rx discharge instructions family patient patient patient patient outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
  • 142. “put hottriggers inthe path ofmotivatedpeople”BJ Fogg, PhDDirector, Persuasive Technology LabStanford University
  • 143. Santa Clara County IPA (SCCIPA)Medication Reconciliation Pilot Project How to find the medication list for patients using AccessExpress1. 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”:
  • 144. Your SCCIPA doctor wants to help you withyour medications, after you leave the hospital. Michael Lam, RPh pharmacist Samaritan Medical Center Pharmacy 2505 Samaritan Drive San Jose, CA (408) 356-7111Please visit the Samaritan Medical Center Pharmacy to pick upyour new prescriptions and have a pharmacist review yourmedications with you. SCCIPA A Pacific Partners Medical Group
  • 145. from: Jeanne Liedtka and Tim Ogilvie, Designing for Growth (2011)
  • 146. what happened?
  • 147. failfast
  • 148. ourresults
  • 149. 80 Milliman - Loosely-Managed70 Milliman - Moderately-Managed60 Milliman - Well-Managed50 SCCIPA40 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> commercial admits/1000
  • 150. 275 Milliman - Loosely-Managed250225 Milliman - Moderately-Managed200 SCCIPA175 Milliman - Well-Managed150 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> commercial bed days/1000
  • 151. 4.5 4.0 Milliman - Loosely-Managed 3.5 Milliman - Moderately-Managed SCCIPA 3.0 Milliman - Well-Managed 2.5 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> commercial average length of stay
  • 152. 400 Milliman - Loosely-Managed350 Milliman - Moderately-Managed300 Milliman - Well-Managed SCCIPA250200 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> medicare admits/1000
  • 153. 2,2002,000 Milliman - Loosely-Managed1,8001,600 Milliman - Moderately-Managed1,400 SCCIPA1,200 Milliman - Well-Managed1,000 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> medicare bed days/1000
  • 154. 6.0 5.5 Milliman - Loosely-Managed 5.0 Milliman - Moderately-Managed 4.5 SCCIPA Milliman - Well-Managed 4.0 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> medicare average length of stay
  • 155. managingACOpatientsinafee4serviceworld
  • 156. challenge#1managingproviderbehavior
  • 157. challenge#2managingpatientbehavior
  • 158. challenge#3alignincentives
  • 159. HMOworld
  • 160. patientsassignedPCP
  • 161. PCPmanagesreferrals
  • 162. patientsstayinnetwork
  • 163. ACOworld
  • 164. patientsnotassigned
  • 165. physiciansendspatient
  • 166. notrestrictedtonetwork
  • 167. whataboutquality?
  • 168. whoisaccountable?
  • 169. carecoordination?
  • 170. oursolution
  • 171. make the newway...
  • 172. feel just like the oldway
  • 173. 1trackingauths> using the same auth system, have providers enter in tracking auths for aco patients
  • 174. keepspatientinnetwork
  • 175. 2providerselectiontool> when selecting “referred to” providers, these providers are listed in descending order of quality, efficiency, satisfaction
  • 176. promotesquality
  • 177. promotesefficiency
  • 178. promotessatisfaction
  • 179. 3rewardaccountability> referring physicians can be tracked to incentivize use of provider network
  • 180. 4checkinbutton> allows for real-time patient tracking, provides opportunity for care coodination efforts
  • 181. automatedtracking
  • 182. alertingcasemanager
  • 183. nocheck-inby_________
  • 184. requestimmediatehelp
  • 185. 5qualityreminders> @every encounter with the healthcare delivery system, quality is reinforced
  • 186. entireteamisaccountable
  • 187. virtualpcmhmodel
  • 188. air trafffic controlfor patients
  • 189. ibelieve...
  • 190. asknot...
  • 191. culturalrevolution
  • 192. thinkdifferent
  • 193. 3takeaways
  • 194. 1drawtheBIGpicture
  • 195. 2showmetheDATA
  • 196. gowiththeFLOW3
  • 197. HAVE FUN
  • 198. welcome tohealthcare2.0
  • 199. Thank you! wpan@ppmsi.com slideshare.net/bonedoc97WWW.SNOOPY.COM

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