Building a consumer driven healthcare system of care
ā¢
0 likesā¢23 views
Building a population-driven system of healthcare should start with the consumers you serve. We provide a framework to design system features based on patient/member needs to drive the best performance for your organization.
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Building a consumer driven healthcare system of care
Similar to Building a consumer driven healthcare system of care (20)
Recently uploaded
Recently uploaded (20)
Building a consumer driven healthcare system of care
- 1. Building a Consumer-Driven System of Care (SoC) Ā§ Health product design is often backwards ā with service availability and mix driving what is available to consumers and how much it costs Ā§ Even products that purport to be consumer-directed often fail to start with deep understanding of consumer/purchaser needs and preferences (care, costs, purchase and engagement preferences) Ā§ These products also often focus only on pricing features, minor differences in service mix, and cost differentials around provider access (in/out of network, preferred providers) Ā§ The result is a system in which the consumer/purchaser often must buy whatever is available, at the price demanded --- and consumer need --- particularly as it relates to total costs, ease of use, key product features, and preferred outcomes --- may not be known and may go unmet Ā§ This leaves strategic opportunities for organizations that are bold enough to use consumer-driven design principles (including Blue Ocean Strategy and Frugal Innovation) to create and deliver a System of Care (SoC) with products and product features that address those unmet needs, including targeted affordability --- while driving unnecessary costs out of product and system design 1
- 2. Population/Contract-Specific SoC Features Defined for Targeted Populations, Key Preferences, Strategic Goals and Positioning Coverages and Services Design Delivery System Design Care Management Design Consumer Engagement Design Quality and Outcomes Monitoring SoC Governance and Management Consistent Modular Elements Consumer-Driven Comprehensive SoC Design 2
- 3. Consumer Segmentation and Stratification Drives Product and SoC Design ā¢ Infants (0-3) ā¢ Children (4-12) ā¢ Teens/Pre-Adult (13-18) ā¢ Adult (19-64) ā¢ Senior (65-84) ā¢ Aged (85+) ā¢ Healthy ā¢ Stable Chronic1 ā¢ Unstable Chronic2 ā¢ Unstable Multi-Morbid ā¢ Advanced Illness ā¢ Palliative Care/EOL ā¢ Mental, Emotional and Behavior Disorder ā¢ SED ā¢ SMI ā¢ SUD ā¢ Food Insecurity ā¢ Housing Insecurity ā¢ Financial Insecurity ā¢ Abuse ā¢ Justice Involved Demographics Medical Behavioral Social Determinant 1 = Includes non-complex pregnancy 2 = Includes high-risk pregnancyBy Gender Common stratification approach, that incorporates bio-psycho-social population assessment, and supports population/product specific SoC design. Product/Contract Requirements and Targeted Outcomes by Key Cohort SoC Elements and Design Features Based on Lean/Agile Principles Product/Contract Requirements Cost, Reimbursement & Target MarginTarget Clinical and Quality OutcomesProjected Unmanaged Care Costs Benefit/Service Design & Medical Policy Delivery System & Contracting Care Management Model Member Engagement Model Quality and Outcomes Monitoring Delivery and Outcomes Management 3
- 4. Modular Elements of Product/SoC Design (Simplified for Presentation Purposes) Ā§ Benefit Design/Services Mix Ā§ Formulary, PDL and Pharmacy Programs Ā§ Medical Policy, Clinical Guidelines and Medical Necessity Ā§ Targeted Outcomes Ā§ Provider Network & Delivery System Design Ā§ Provider Relations and Supports Ā§ Contracting and Credentialing Ā§ Reimbursement and Incentives Ā§ Utilization Management Ā§ Population Health, Wellness Ā§ Case and Disease Management Ā§ Care Coordination/Transitions Ā§ Advanced Illness and EOL Management Ā§ Methods for Direct Member Support Ā§ Member Incentives, Self-Management and Education Ā§ Social Engagement and Support Ā§ Member Portal and Digital Engagement Ā§ Behavioral Change Design Ā§ Quality and Outcomes Management Ā§ Quality Monitoring Ā§ Quality Reporting and Certification Ā§ Quality, Health Services, P&T, etc. Committees Ā§ Compliance Ā§ Staff Hiring, Training and Development Coverage/Services Design Delivery System Design Care Management Design Consumer Engagement Design Quality and Outcomes Design System of Care (SoC) Governance, Management Simplified Design Elements 4
- 5. Benefit/Services Design Medical Policy Formulary & PDL Rx Guidelines P & T Management Appeals and Grievances Targeted Outcomes Functional Activities Function Specific Ā§ Medical Necessity Ā§ Consistency Ā§ Adaptability Business Specific Ā§ Competitive Advantage Ā§ Key Product Features Market Specific Ā§ Underlying Population Ā§ Delivery System Characteristics Ā§ Targeted Outcomes Ā§ Contract Requirements Design Drivers Medical Necessity, Clinical Guidelines Claims Payment Policy Pharmacy Programs Medical Coverage/Services Design 5
- 6. Contracting and Credentialing Reimbursement Design Network Design Provider Capability Assessment Access and Outcomes Standards Member Demand Modeling Provider Relations, Support, Outreach Functional Activities Function Specific Ā§ Member Needs Ā§ Capability Ā§ Provider Willingness Business Specific Ā§ Competitive Advantage Ā§ Key Product Features Market Specific Ā§ Underlying Population Ā§ Delivery System Characteristics Ā§ Targeted Outcomes Ā§ Contract Requirements Design Drivers PCP/Medical/Health Home Design TeleHealth Provider Training Delivery System Design 6
- 7. Function Specific Ā§ Member Needs Ā§ Provider Capabilities Ā§ Delegation Business Specific Ā§ Competitive Advantage Ā§ Key Product Features Market Specific Ā§ Underlying Population Ā§ Delivery System Characteristics Ā§ Targeted Outcomes Ā§ Contract Requirements Design Drivers Condition/Disease Management Wellness, Prevention Education and Self-Management Utilization Management & PA Segmentation and Stratification Member Screening Risk Assessment Complex Case Management Functional Activities Care Coordination/Transition Management Advanced Illness Management Catastrophic Management/Palliative Care Care Management Design 7
- 8. Function Specific Ā§ Member Characteristics Ā§ Intervention Effectiveness Ā§ Targeted Outcomes Business Specific Ā§ Competitive Advantage Ā§ Key Product Features Market Specific Ā§ Underlying Population Ā§ Delivery System Characteristics Ā§ Targeted Outcomes Ā§ Contract Requirements Design Drivers Member Incentives Self-Management Design Education Curriculum Development Behavioral Design Social Determinants Analysis Psychographic Clustering Direct Member Support Functional Activities Community Assessment Member Portal/Apps Consumer Engagement Design 8
- 9. Function Specific Ā§ Certification Ā§ Outcomes Ā§ Delegation Business Specific Ā§ Competitive Advantage Ā§ Key Product Features Market Specific Ā§ Underlying Population Ā§ Delivery System Characteristics Ā§ Targeted Outcomes Ā§ Contract Requirements Design Drivers Provider Gap Closure Provider Reporting Internal Outcomes Reporting Key Performance Indicators HEDIS/Quality/Contract Reporting Accreditation Quality Program, Plan, Evaluation Functional Activities Quality Monitoring Health Plan/System Programs Internal Outcomes Standards Quality and Outcomes Design 9
- 10. Function Specific Ā§ Program Scope Ā§ Certification Ā§ Delegation Business Specific Ā§ Competitive Advantage Ā§ Key Product Features Market Specific Ā§ Underlying Population Ā§ Delivery System Characteristics Ā§ Targeted Outcomes Ā§ Contract Requirements Design Drivers Credentialing Committee UM/Health Services Committee Pharmacy & Therapeutics Committee National Medical Policy Committee Facility/Program Quality Committee Enterprise Quality Committee Compliance Committee Functional Activities Population Health Committee Vendor Oversight/Delegation Committee Staffing, Hiring, and Development System of Care (SoC) Management 10
- 11. Examples of SoC Application ā Opioid Use Disorder Ages 19-64 Commercial (Illustrative, Not Comprehensive) Product/Contract Requirements Reimbursement & Target Margin Target Clinical and Quality Outcomes Projected Unmanaged Care Costs Product Features and Requirements ā¢ Screening ā¢ Diagnosis ā¢ Treatment ā¢ Rx ā¢ $ PMPM ā¢ P4P Incentives ā¢ Shared Savings Pool ā¢ 5% Target Margin ā¢ HEDIS OUD Screening & Treatment ā¢ Screening & Referral for PH Comorbidities ā¢ Rx Poly-pharmacy and FWA ā¢ Preventable events ā¢ 90% Claims Costs ā¢ 5% Quality Improvement Expense Pregnant Women SMI Medical Co-morbidity Justice Involvement and/or Abuse Key System of Care Elements Benefit/Services Design Delivery System Design Care Management Design Member Engagement Design Quality & Outcomes Design System of Care Management ā¢ MAT ā¢ SBIRT ā¢ dCBT ā¢ Day Treatment ā¢ IP Treatment ā¢ BH, IHH, IBHP, Rx, IP, OP, Community Organizations ā¢ Collaborative Care ā¢ Bundled Payment, Per Diem, P4P ā¢ Automated care reminders ā¢ dCBT ā¢ Hi-Risk Integrated CC/CM ā¢ Pharmacy Lock-In ā¢ Jail In-Reach ā¢ Automated Messaging ā¢ Social Engagement ā¢ Peer Counseling ā¢ Member Incentives ā¢ Targeted Education ā¢ Targeted Provider Incentives ā¢ MRx and Integrated Care Outreach and Training ā¢ ADT and EMR Interfaces ā¢ Collaborative Program, Policy, Incentives, and Reporting Design ā¢ Integrated P and T 11
- 12. Examples of SoC Application ā Medicaid TANF Ages 4-12 (Illustrative, Not Comprehensive) Product/Contract Requirements Reimbursement & Target Margin Target Clinical and Quality Outcomes Projected Unmanaged Care Costs Product Features and Requirements ā¢ EPSDT ā¢ Well-Child Care ā¢ Routine and Acute Care ā¢ Developmental Coordination ā¢ Rx ā¢ $ PMPM ā¢ Outcomes Based Incentive WH ā¢ 10% Target Margin ā¢ EPSDT ā¢ HEDIS Child ā¢ Late developmental screenings ā¢ BH Rx use without screening or diagnosis ā¢ ACES ā¢ 85% Claims Costs ā¢ 5% Quality Improvement Expense Developmental Diagnosis SED Asthma, Diabetes, Cancer ACES, Food/Housing Insecurity Key System of Care Elements Benefit/Services Design Delivery System Design Care Management Design Member Engagement Design Quality & Outcomes Design System of Care Management ā¢ Routine Wellness ā¢ Primary/Acute ā¢ Pediatric Specialty ā¢ Developmental Pediatrics ā¢ PCP, Urgent Care, Telemedicine ā¢ PCP Capitation and FFS with P4P ā¢ Hospital Routine, Urgent Care Savings ā¢ Automated Quality, Education Reminders ā¢ Parenting, Asthma, Diabetes Apps ā¢ Developmental CC/CM ā¢ Post-ED Follow Up ā¢ Automated Messaging ā¢ Parenting, Housing and Nutrition Programs ā¢ Member Screening, Immunization Incentives ā¢ Targeted Provider EPSDT Incentives ā¢ EMR, Immunization Registry Interfaces ā¢ Parent messaging and reminders ā¢ Collaborative Program, Policy, Incentives for DD, SED 12
- 13. Examples of SoC Application ā Commercial BH Specialty Ages 13-18 (Illustrative, Not Comprehensive) Product/Contract Requirements Reimbursement & Target Margin Target Clinical and Quality Outcomes Projected Unmanaged Care Costs Product Features and Requirements ā¢ Screening ā¢ Diagnosis ā¢ Treatment ā¢ Rx ā¢ $ PMPM ā¢ P4P Incentives ā¢ Shared Savings Pool ā¢ 15% Target Margin ā¢ HEDIS BH, SUD Screening & Treatment ā¢ Late Screening for Developmental Diagnoses ā¢ Rx Poly-pharmacy, Non-FDA and FWA ā¢ Preventable events ā¢ 85% Claims Costs ā¢ 5% Quality Improvement Expense Key System of Care Elements Benefit/Services Design Delivery System Design Care Management Design Member Engagement Design Quality & Outcomes Design System of Care Management ā¢ SBIRT ā¢ dCBT ā¢ Day Treatment ā¢ IP Treatment ā¢ BH, IHH, Rx, IP, OP, Developmental Pediatrics, Community Organizations ā¢ Collaborative Care ā¢ Per Diem, FFS, P4P ā¢ dCBT ā¢ Hi-Risk Integrated CC/CM ā¢ First Episode Psychosis ā¢ Member and Parent Education ā¢ Social Engagement ā¢ Post-Crisis Outreach ā¢ Targeted Education ā¢ Provider Screening Incentives ā¢ MRx Outreach and Training ā¢ ADT and EMR Interfaces ā¢ Collaborative Hi-Risk Program, Policy, Incentives, and Reporting Design ā¢ Integrated P and T SMI Medical Co-Morbidity Justice Involvement, ACESSEDDDCo-Occurring SUD 13
- 14. Let us know if we can help you design your system of care Contact us at: dpmoller@dmollerassociates.com www.dmollerassociates.com 1