Changing Nature of Managed Care
Organization-Provider
Relationships
WAMSS Conference
April 28, 2017
Andrew Nelson, Vice President, Provider Network Management
Molina Healthcare of Washington
Company History
Founded in 1980 by
Dr. C. David Molina
with a single clinic
Provide quality
healthcare to those
most in need and least
able to afford it
Serves more than
4.2M Medicaid,
Medicare, Duals and
Marketplace members
Serves more than
775,000 members in
Washington State
16 states and two
territories
2
Molina Medical
Group Clinics in
states
Hospital Providers
101
PCPs 5,470
Specialists 12,780
HCA’s “Value-Based Purchasing” goals
2021
90%
In 2021, at least 90% of state-financed health
care payments and 50% of commercial health
care payments are linked to quality and value
through Alternative Payment Mechanisms
(APM) (Categories 2c-4b)
state-financed
50%
commercial
Washington’s annual health care cost growth
will be below the national health expenditure
trend.
Tools to accelerate VBP and health care transformation:
•
•
•
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2014 Legislation directing HCA to implement VBP strategies
State Innovation Model (SIM) Round 2 grant, 2015-2019
DSRIP Medicaid Transformation Demonstration Project, 2017-2021
What is “Value”?
What is “Paying for Value?”
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•
•
•
Patient experience
HEDIS
Avoidable emergency
room visits or
readmissions
•
•
Medical cost ratio
Per member per month
Provider relationships focus on value
•
Emerging focus on specific populations
– Share, not shed, risk with providers who manage populations with complex needs, AH Blind
Disabled and Medicare (DSNP)
•
Evolution from volume to value-based relationships
– Focus on long-term relationships, not just ‘contracts’
– Path-to-Value
– Gain-sharing and risk-sharing on population –based outcomes performance. We have
capitation arrangements with some integrated delivery systems
– Not all providers are ready
– Meet providers where they are at and start there
•
Increasing transparency into Provider Performance
– Quality outcomes, cost, member satisfaction
– Member self-direction & choice of provider and health plan
•
Aggregation of groups combine forces to create scale
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Molina’s Value-Based Care “Path to Value” Approach
Shared Savings and
Quality
• Savings shared relative to a
medical pmpm or medical
cost ratio target
• Savings tied to achievement
of 4-6 HEDIS targets
Shared Risk and Quality
Global Risk and Quality
• Greater shared savings
potential in exchange for
shared downside risk
• Savings tied to achievement
of 4-6 HEDIS targets
• Provider takes global risk as
percent of premium
• A portion of premium is tied
to achievement of 4-6 HEDIS
targets
• Delegated functions such as
UM, CM and claims
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Challenges and opportunities
in achieving a successful
Value-Based Care relationship
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An Aligned Culture of Quality
Know and
Engage the
Patient
Managed Care
Organization
•Share lists of nonengaged members
•Shared outreach
Provider
•Patient outreach and
engagement
•Provide appointment
access
Sharing
Information &
Resources
Promote Best
Practice
Leverage
Technology
Managed Care
Organization
•Timely access to
actionable data
•Missing HEDIS services
•HEDIS reporting
•Align to provider
workflow
•Case Management
Managed Care
Organization
•Align Prior
authorizations and
Utilization
Management functions
to reduce barriers and
promote consistent
quality of care
Provider
•Share EMR Access
•Member Satisfaction
•Case Management
Provider
•Clinical pathways
Managed Care
Organization
• Molina Virtual Care
• 24 /7 access
• Shared
documentation
• CM referrals
• My Molina – PHR
• Care Team Integration
• PreManage (EDIE)
Provider
• PreManage (EDIE)
• ClinicalData Repository
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VBC HEDIS Provider Performance Reporting
Acme Medical Group CY 2017 H18
Current
p75
p50
p25
Target
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
Adult BMI Assessment Comp Diabetes Care; Comp Diabetes Care; Comp Diabetes Care;
Childhood
Eye Exam
HBA1C Testing
Monitoring for
Immunizations; combo
Nephropathy
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VBC HEDIS Provider Performance Reporting
Pcp_PayTo
HedisYear
Acme Medical
Group
H18
MeasureID
ABA
CDC
CIS
Description
Category
Adult BMI Assessment
Comp Diabetes Care; Eye Exam
Comp Diabetes Care; HBA1C Testing
Comp Diabetes Care; Monitoring for
Nephropathy
Childhood Immunizations; combo 10
Grand Total
Pcp_PayTo
Acme Medical
Group
Grand Total
P25
P50
P75
Current
HEDIS Target Performance
Hybrid
Hybrid
Hybrid
75.47%
47.06%
83.19%
83.45% 89.62%
54.74% 63.23%
86.20% 89.55%
77.98%
63.23%
89.55%
21.77%
31.86%
30.21%
Hybrid
Hybrid
77.95%
28.70%
81.75% 84.88%
35.88% 42.13%
84.88%
42.13%
69.13%
34.53%
27.43%
Missing MbrsTo MbrsTo MbrsTo
Member Target_ Target_ Target_ MbrsTo
Numer. Denom. Pool
P25
P50
P75
Target
1,305
194
184
5,995
609
609
4,690
415
425
3,220
93
323
3,698
140
341
4,068
192
362
3,370
192
362
421
202
2,306
609
585
8,407
188
383
6,101
54
0
77
8
96
45
96
45
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EMR Chart Retrieval Analysis: HEDIS 2016
• The rainbow colored column represents “compliance rate” by methodology
• “Full” remote access benefits both providers and MCOs
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VBC Medical Cost Provider Performance Reporting
Key Data Categories
• Member Months
• Premium
• Capitation Amounts
• Care Coordination Costs
• Inpatient Hospital
• Outpatient Hospital
• Professional Services
• Rx
• Incurred But Not Reported Claims
• Medical Cost Ratio
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Future of Strong MCO-Provider Relationships
• Open communication on common goals Quadruple Aim
• Quality focused approach
• Establishing trust and
credibility
• Focus on the relationship
not just the contract
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Contact information
Andrew Nelson
Molina Healthcare of Washington
[email protected]
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Questions?