Network Innovations and Medical Management Success
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This presentation talks about provider contracting and introduces a new program in our medical management department.
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Network Innovations and Medical Management Success
- 1. Network Innovations and Medical Management Success Mary D Strasser & Mary Hughes
- 2. Our Network How do we build our Network? • Find the right provider partners • Commit to evidence-based decisions and results • Reduce variation
- 3. Northwest Success • 4 health plans left the NW ETF market • Through innovative Network strategies, we changed the story • The result – MLR reduction of 18.3%
- 4. Better care, more value • Keep members well • When care is needed, it is appropriate • Decrease variation in resource use • Shared decision making with members • Anticipate future care needs
- 5. Why Preauthorization? • Safety of our members • Only appropriate care provided • Right setting • Right price
- 6. Example: Sleep Studies What yields better results for the member? Sleep Studies done in the home or in a sleep clinic?
- 7. Shared Decision Making Low Back Pain Program • Helps members to make an informed decision about their care • Percent of low back pain sufferers that require surgery: 1%
- 8. Soap Gauze Knee Implant Hospital Day Physical Therapy Orthopedic Surgeon = Knee Bundle (One price for all services necessary) Warrantee against complications for 90 days Today, we too often pay for one item at a time – example: knee replacement
- 9. Bundling Innovation Orthopedic & Sports Institute of the Fox Valley • 40 procedures • Bundled price includes all services related to the procedure • A 90 Day warranty is included
- 10. Bundles – A Quality Difference • Infection Rate 0.3% • Re-admission Rate: 0.8% (National Average: 4%) • Average cost of a complication: $100,000
- 11. Bundles – The Numbers Procedure Potential Savings Total Hip Replacement $22,029 Total Knee Replacement $35,417 Rotator Cuff Repair $8,406 $250 Visa debit card will be given to members to drive them toward bundled services.
- 12. Neighborhood Family Clinic • Partnered with as a low-cost, high quality option for Trust members • Trust members can access at no cost • Shared mission of reclaiming healthcare
- 13. • Member-centric approach • Anticipate future care needs • Transition of Care • Personal Touch
- 14. Our Nurses
Editor's Notes
- Brief intro to say hello I’m Mary D. Strasser Director of Provider Network Management and I’m Mary Hughes Director of Member Health Services. We are excited to have time with you today to tell you more about what it means to Reclaim Healthcare and share some examples of what’s this it looks like as we work with our providers and members.
- The NW example shows one of the ways we are working with providers across the state to Reclaiming Healthcare. To Mary, Dr. Bartholow and me Reclaiming Healthcare means – we will bring our members a newtwork of providers who share the commitment of improving health and delivering high quality care for a reasonable price. This the same goal of IHI (Institute for Healthcare Improvement) with The Triple Aim Improving the patient experience of care (including quality and satisfaction); Improving the health of populations; and Reducing the per capita cost of health care. With a statewide health plan we need to have a variety of approaches to find our partners. 1. Specialty society engagement - We are working with physician leaders within specialty societies so they as a peer group can drive discussions on how to improve outcomes and reduce variation. We have developed new analytical tools to assist them with this work. Rheumatology, GI, Oncology, psychiatry. 2. Using data to show variation in resource use – Variation isn’t just about managing cost. Increased LOS and higher cost episodes of care equals more care – time in a hospital, CT scans, medications, etc. Dr. Bartholow and Tony Herman will show you some examples of what we’ve developed. 3. Risk sharing and innovative reimbursement structures 4. Care management collaboration Unfortunately – not all providers are ready to engage in these conversations and we have needed to remove them from our network.
- Trust entered the market in 2012 and in our first two years things weren’t looking good for us either. Try something different – created two separate distinct networks for members to select – Mayo and Chippewa Valley This strategy brought us a partnership opportunity with a provider system that hadn’t existed. Provider partners who are interested in ReClaiming Healthcare. Not all providers are partners and an exercise like this helps define relationships. The result was tremendous MLR improvement for 2014 and we expect continued improvement in 2015 The strategy was tested with ETF membership and we are now offering this proven strategy to current and future customers.
- Sharing risk in the quality and resource use for care. A POB or fee schedule reimbursment method pays providers for one item at a time which has us focusing on the cost of each little and big piece rather than the episode. In bundled payment arrangements the providers involved in the care are paid one fee and they have the responsibility to manage the care and the care comes with warranties. Providers accept financial responsibility for complications that may occur. Providers with a focus on Reclaiming healthcare are the type that will stand behind their work and focus on reducing waste. I’m excited to tell you about one such partner with The Trust.
- Walk through the slide telling Inpatient and outpatient services – tka, rotator cuff, carpal tunnel, spine Let’s look at their quality story and you’ll see why they are confident in giving warranties.
- National average infection rate – 1.5
- Review the savings info and tell about the incentive program that will begin being promoted on April 1st. OSI is a partner in Reclaiming Healthcare. They are committed to improving health and providing high quality care at affordable prices.
- Another partner we’ve found is making an impact in a different way. NFC in LaCrosse was established by Dr. Ted Thompson after he retired from Gundersen Clinic.. He was frustrated with the cost of healthcare in his community. Patients were getting bills for $300 applied to deductibles for strep throat. He knew his services didn’t cost that much. Today at NFC he charges $39 for an office visit and $20 for a rapid strep test. $59 vs $300 for the same service. Dr. Thompson educates his patients on second market decisions when they need care he cannot provide in his clinic so together they make cost effective decisions to obtain high quality care. Any WEA Trust members can access NFC at no cost. No deductibles or copayments. His clinic is such a success that he’s opened additional locations and add more physicians. His team is now seeing around 60 patients a day.