Priceless Partners: Common Patients, Common Goals

Transcription

1 Priceless Partners: Common Patients, Common Goals Erin Hodson, RN, BSN, ACM Senior Director Case Management Inova Fairfax Hospital Pamela Andrews, RN, MSW, MBA, CCM, ACM Director Medical Management INTotal Health/ Inova Health Plan

2 Objectives I. Organization Overview a) Inova Health System b) Inova Fairfax Hospital c) INTotal Health II. Journey to Redefine Relationships III. Managing our Population IV. Resources/ Tools to partner V. Sharing common patients and common goals VI. Results

3 Inova Health System - 4 Acute Care Community Hospitals Inova Alexandria Hospital 360 Inova Mount Vernon Hospital 267 beds Acute Rehab Psych Inova Fair Oaks Hospital 187 beds Inova Loudoun Hospital 187 beds Psych 1 Tertiary Acute Care facility Inova Fairfax Hospital 900 beds Physician Practices 55 Primary Care 385 Specialist 3 Health Plans Managed Medicaid: INTotal Health Commercial Payer : Innovation Health Signature Partners Exclusive Provider Network Transition Clinics Transitional Care Management Loudoun Rehab and Nursing

4 Inova Health System-Vision 2015 Vision 2015 is our strategy to lead the transformation of the health care industry, rather than simply react to it. Our new vision: To optimize the health and wellbeing of each individual we serve.

5 Inova Health System Location

6 Inova Fairfax Hospital recognized as the Best Hospital in the Mid-Atlantic Region

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8 About Inova Fairfax Hospital 900 bed Level 1 Trauma facility located in Northern Virginia 5 adult Critical Care Units 5 Telemetry Units 10 Medicine/Surgical Units 23 bed adult observation unit & 36 adult short stay unit Central Access Bed Planning Center Service Lines Pediatrics Transplant Trauma Neurosurgery Orthopedics Oncology One of the largest NICUs in the country OB Gynecology Psychiatry

9 Case Management Department Case Management Department composed of: 21 Utilization Review RN Case Managers 5 Utilization Review Case Management Assistants (CMA) 4 Managers & 1 Senior Director CMA Manager, UR Manager, CCM Manager & DC Planner Manager 17 Clinical Case Managers (CCM) 38 Hospital Discharge Planners 7 day a week UR CMs hour/day coverage 24/7 ED DC Planners Readmissions Prevention Level 1 Trauma Center 7 day a week DC Planners Coverage until 8 pm 7 day a week CCMs CCM Weekend lead for LOS Management

10 Medicaid Managed Plan

11 INTotal Health Coverage Map

12 About INTotal Health Managed Medicaid Plan in the State of Virginia Purchased by Inova Health System December 2012, branded INTotal Health July 2013 Serves 57,000 members 80% of membership resides in Northern VA Service area extends to the Far Southwest near Tennessee line. Over 15,000 Providers Major Health System Partners Inova UVA Carilion Health System ISHN Health System Children s National Medical Center

13 INTotal Medical Management Teams include Utilization Management RNs Case Management RNs/ MSW Disease Management Health Coaches Pharmacy CMO Medical Directors VP Clinical Services Quality Director

14 Redefining our Relationship Powers in our own right Power #1 Health Care Providers Mission Meet the needs of the community, serve the population without bias Expectation- Receive just and adequate compensation for services rendered Achieve quality outcomes Power #2 Payer Plan Mission- Meet the needs of our population, provide access within the defined network Expectation- Pay for services that meet medical necessity at the appropriate level of care Achieve quality outcomes

15 Benefits of being Family Shared vision population management Operations knowledge Financial Strength Cross organization resources Sharing team talent Shared Providers Shared philosophy and tools to demonstrate medical necessity Inova Health System Acute Care transitioned to MCG January 2012 INTotal Health transitioned to MCG January 2014

16 Challenges of Family Business Sibling Rivalry Inpatient Acute Care is the Primary Business Acute care delivery for over 30 years Great success with brand recognition Nationally recognized quality outcomes Managed Medicaid Unproven entity within the System Newly acquired entity to support population health goals High acquisition and start up cost Historical profitability (under prior management) Impact of Healthcare Reform Preparation for Medicaid Exchanges

17 One Inova Our System mission and goals required a response from all entities to align to successfully manage our populations, the expected response: Collaboration in identifying processes in support of system goals: 1. Efficient management of resources 1. Acute facilities - LOS 2. INTotal Health Decreased percentage of Medical Loss Ratio ( medical spend) 2. Successful Care transitions 1. Acute facilities-improved access for continuum of care 2. INTotal-Improved access for continuum of care/ timely authorization 3. Decrease denials management 1. Acute facilities reduce percentage of denials 2. INTotal Health reduce administrative cost

18 Working Together process review Inova Fairfax Switch from Interqual to Milliman Care Guidelines (MCG) in November 2012 EpicCare EMR implemented in November 2012 Case Management model split in October 2013 ED/OBS Unit UR Case Manager implemented in August 2014 All Observation and Inpatient Non-OB patients reviewed within 24 hours of admission 7 days a week Work closely with onsite Physician Advisors Clear accountability in Epic EMR documentation UR CMs all cross trained Daily assignments are geographical by unit but all team members can work NICU, Psych, Transplant, Adult Medicine, Pediatrics or OB All UR Case Managers have the option to Telework Extended work day starting at 6 am High Retention Rate Able to recruit nationally

19 Working Together, process review INTotal Assessment of Medical Management Processes UR/CM/DM July 2013 Switch from Interqual to Milliman Care Guidelines (MCG) in January 2014 EpicCare EMR- Shared reporting Daily Emergency Room Utilization Normal Newborn Reporting Bi-weekly denials management meetings INTotal/ Inova Acute Facilities Quarterly Collaborative System Case Management Meetings Implementation of Health Coaches Work closely with Medical Directors Clear accountability in response to request for authorization of services UR cross training All UR Case Managers have the option to Telework High Retention Rate

20 What we learned from working closely with INTotal Goals were more aligned than we realized LOS Readmissions Denials Understood the contract Learned how we were paid on Observation and Short vs. Long Stay patients Case Rates Percent of Charges (NICU patients) Understood the quality indicators for a Medicaid product Understood the regulations of Medicaid products Cannot make a margin greater than 1% Example: Requirement to pay regardless of when clinical review is sent or when notification is provided for newborns

21 The Payer Workflow from the Provider s Perspective More focused on quality than expected Communication between the payer and provider needs improvement Life would be easier on both ends if we allowed dual access to our Medical Record systems More focused on paying us timely and accurately than expected Claims are paid via a 3 rd party provider Incentivized to keep patients in Observation Payers do not like it when the status is wrong Creates unnecessary work they will penalize you for Denials Remittance Codes differ based on the payer When Admission and Discharge Dates on the claim to do not match, an automatic denial is sure to occur! Revenue highly based on members health Higher Risk, more chance of a loss for high cost medications and hospitalizations for chronically ill members

22 Changes we made to improve communication with our payers Created Case Management Assistant Payer Liaisons Require all communication to route through a CMA instead of a UR CM UR CMs have unit based assignments CMAs have payer based assignments Require written communication for clinical requested and days approved from our payers Do not encourage our payers to leaving voic s for clinical requests Provided Discharge Reports for each of our payers daily Created a Pre-Admission UR Team to get the status right from the beginning Held the claim from billing until our payer confirmed their system was updated with the: Discharge Date Admission Date Days Approved Approval Number

23 Common patients, common goals Process that defines the Health care Provider management and measurement with the following identified goals: Ensure efficiency in resource utilization (right service at the right level of care for the right amount of time) Ensure management that supports quality outcomes (MCG) Identify transitional care support needs for ongoing community management to reduce the probability of readmission Meet State and Regulatory obligations to maintain good standing with The Joint Commission and other accrediting bodies. Reducing revenue risk

24 Common patients, common goals Process that defines the Health Plan s management and measurement with the following identified goals: Ensure efficiency in resource utilization (right service at the right level of care for the right amount of time) Ensure management that supports quality outcomes (MCG) Identify transitional care support needs for ongoing community management (CM/DM services) reducing the probability of duplicate services and/or readmission Meet State Contract and Regulatory obligations to maintain NCQA Accreditation. Build great partnerships with the provider community

25 Inova Fairfax Hospital What we expected MCG transition 2012 Efficient resource management Reduction in LOS Reduction in denials Increase in payer partnerships Increase in team engagement

26 Inova Fairfax: The Results Overall Reduction in LOS 2013 Inpatient = Inpatient = % Reduction Top quartile 1.00 days Source: Premier Reporting Steve Summers Business Analyst Inova Health System Denials Management 2013 Denials write off 1.64% 2014 Denials write off 0.86% 6% Reduction Source: Premier Reporting Steve Summers Business Analyst Inova Health System

27 INTotal DRG Management Concurrent reviews Providers were not a fan! Utilization of variances Proactive visibility to potential transition barriers Provider/ Plan engagement of quality care elements Proactive referral to community case management Providers were big fans! Support for the hospital transition team with discharge planning Care planning and Coordination for members identified as frequent consumers Provider/ Plan engagement of quality care elements

28 INTotal: What we expected Our Journey began July 2013 Transition to MCG January 2014 We expected to see the same trends achieved within our inpatient population: Reduction in LOS Reduction in cost due to resource and level of care management (OP/IP) Improved quality outcomes Members being serviced at the most appropriate level of Care

29 INTotal: The Results Reduction in inpatient medical spend trend 2013 Inpatient medical spend = 39.1M 2014 Inpatient medical spend = 36.4M Source Glenn Lohrmann CFO Inova Health System/ Population Health Increase in outpatient spend trend 2013 Outpatient medical spend = 74.4M 2014 Outpatient medical spend = 74.7M Source Glenn Lohrmann CFO Inova Health System/ Population Health Increase in provider satisfaction % % Source Mary Fountain INTotal Health / Inova Health Plan

30 Super Powers Through collaboration we have experienced the power of partnership: Successful population management requires process integration equaling a shared mission and individual success. Our greatest lesson; we are more powerful together!

31 Questions Questions

32 Erin Hodson; Pamela Andrews: PA