Annual KPCA Meeting October 2014

Transcription

1 Annual KPCA Meeting October 2014

2 Background Precision Healthcare Delivery, LLC (PHD) Louisville, Kentucky based company 12 years of operations as independent company (team has over 100 years of medical management experience) Full service Medical Management Company focused on Independent Physician Associations (IPA) management Managed Care Contracting and Credentialing Over 15 managed care contracts with the likes of Humana, Anthem, Coventry, Wellcare for our IPA Membership Clinical management team with Medical Directors, RN s and Pharmacist. Health data analytics. Initiating and Managing a Physician Led Accountable Care Organization Precision s Mission is to help support the independent practice of medicine. 2

3 3 10/14/2014 Association of Primary Care Physicians Louisville IPA including surrounding counties in Southern Indiana Represents 550 credentialed providers 180 PCPs 270 Specialists 100 Physician Extenders IPA Mission To provide unique, innovative and value added healthcare system management services to a community of patients, physician networks, hospitals, employers, insurers and other healthcare organizations.

4 The Physicians Network Located in Central Kentucky, Lexington and surrounding counties Represents 615 credentialed providers 180 PCPs 320 Specialists 115 Physician Extenders Mission 4 10/14/2014 Affect favorably the health and economic well-being of the community. Plan for and promote the delivery of high quality, costeffective health care and provide a congenial professional atmosphere for our members.

5 5 10/14/2014 IPAs Vision To be recognized leaders and physicians of choice for healthcare services in the communities in which we practice, distinguished by: Established superior quality standards and review Enhanced patient education Enhanced referral system to allow physicians knowledge of efficient specialist physicians and facilities Innovation and continuous improvement in Physician practices

6 Vision led to formation of Physician-based ACO Changing dynamics and role of private practice of medicine Independent Physicians face declining reimbursements Increases in cost to practice Competitive challenges from integrated systems ACO Provides advantages to stay independent Additional resources to coordinate care with patients Possible increased revenue ACO provides competitive to IPA Organizations 6

7 Quality Independent Physicians ACO Only 56 PCP are in the ACO from our 300 PCP s Strict requirements dictated by CMS and Precision Meet the quality measures reporting requirements Communicate with patients on participation in ACO Provide ACO with daily hospital admission/discharges Work with ACO Care Team on high risk patients Committee participation Connect and use of Health Information Exchange (HIE) 7

8 ACO Organization Quality Independent Physicians, LLC created in fall of 2011 to be the legal structure for the ACO application Majority owned by 2 IPA s and PHD has minority stake. 15,000 Beneficiaries attributed to the 56 Doctors Board of Directors composed of 75% of ACO physicians 12 PCP in ACO 1 hospital system representative 1 skilled nursing facility representative 1 Medicare beneficiary required by CMS Five Physician Led Committees every Participating doctor has to sit on at least 1 committee. 8

9 Met with KPCA Executive Team in February 2014 Discussed ACO readiness Changes in Medicaid and impact on Clinics Discussed the desire to become a high performing network In the spring, we received and responded to the RFP for services

10 The Kentucky Primary Care Association Mission Statement The Association is charged with determining and promoting the mutual interests of its members, throughout the Commonwealth, with a mission of promoting access to comprehensive, community-oriented primary health care services for the underserved. This mission is carried out through the training and education of health care providers, technical assistance, community development, and advocacy.

11 Services Provided by Precision Credentialing and Provider roster/database management Physician relations representatives in the field and in office dedicated to KPCA members, visiting offices and working with MCOs. Medical Loss Ratio Analysis and Reporting

12 Greg Ciliberti, MD CEO Tom Samuels, CPA CFO/CIO/ Compliance Officer Barbara Newton, COO -PHD Executive Director Data / Finance/ Compliance Sharon Spurrier Terri Bates Director of Network Development Susan Thompson sthompson@phdelivery.com Quality Measurement and Performance Paula Straub RPh pstraub@phdelivery.com Provider Relations Mary Elam melam@phdelivery.com Joni Kissel jkissel@phdelivery.com Credentialing Umaara Hadley uhadley@phdelivery.com Sarah Hoeppner shoeppner@phdelivery.com Stacey Creek screek@phdelivery.com

13 GOALS and OBJECTIVES for 2014 Accurate data on all KPCA providers and facilities Delegated entity status for KPCA with contracted partners Development of claims database for reporting and analyses Establish payor relationships for loading and issue resolution

14 What has been accomplished so far? Database of KPCA providers accomplished in 2 phases Phase 1 Organization and location Phase 2-Physician and Physician location

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18 What has been accomplished so far? Delegation credentials process Credentials Committee Approved KPCA credentialing P&Ps Over 150 credentialing files approved Established Relationships Regular communication with contracted partners to address loading and other issues Daily communications Bi-weekly calls with most partners

19 GOALS and OBJECTIVES for 2015 Migrate to more strategic relationships with contracted partners Assist KPCA in developing a High Performance Network Assist KPCA in developing standard reports for enhanced performance for facilities with regard to: MLR (Medical Loss Ratio) Utilization Care Gaps

20 KPCA Contracts CoventryCares Medicaid FQHC / RHC Primary Care: 100% Medicaid fee schedule LPCC Primary Care: 105% Medicaid fee schedule Dental: 100% Medicaid fee schedule Behavioral Health: 100% Medicaid fee schedule Delegated Credentialing: Yes Incentive: Gain share at or below 80%-85% MLR Split: 50% MLR & 50% Quality Humana CareSource Medicaid Primary Care: 100% Medicaid fee schedule Dental: 100% Medicaid fee schedule Behavioral Health: 100% of Medicaid fee schedule Delegated Credentialing: in process Incentive: Pharma Generic Rx Opportunity to earn % of processed claims Passport Medicaid Primary Care: 100% of PPS rate or Medicaid fee schedule After-hours Primary Care: 100% of PPS or fee schedule for non-assigned patients Dental: 100% of PPS rate or Medicaid fee schedule Behavioral Health: 100% of PPS rate or Medicaid fee schedule Delegated Credentialing: No Incentives: Patient Centered Medical Home PMPM: $4.00 per par provider / $8 per nationally recognized medical home P4P being developed

21 KPCA Contracts WellCare Medicaid Primary Care: 100% Medicaid fee schedule Specialty: 102% Medicaid fee schedule Dental: 100% Medicaid fee schedule Behavioral Health: 100% Medicaid fee schedule Delegated Credentialing: Yes Incentives: Gain share at or below 86% MLR P4Q based on HEDIS measures Medicare Advantage Dental: 100% Medicaid fee schedule Delegated Credentialing: Yes Incentives: Percentage of aggregate surplus P4Q based on HEDIS measures Anthem Enhanced Personal Health Care (EPHC) Commercial incentive program (practices still hold a direct contract with Anthem) Minimum patient panel of 100 $2 PMPM for care coordination Opportunity to earn 35% of shared savings pool based on utilization and quality measures

22 KPCA Contracts Kentucky Health Co-op Commercial QHP Primary Care 107% Medicare fee schedule Delegated Credentialing: in process No Incentives CareSource Commercial QHP Commercial QHP Primary Care 107% Medicare fee schedule Delegated Credentialing: in process No Incentives

23 KPCA Credentialing Credentialing is a crucial step in the revenue flow of a provider and facility. Please notify Precision Healthcare Delivery (Precision) of all ADDS, CHANGES AND TERMS related to your providers and facilities as timely as possible.

24 What is needed for credentialing? Notify Precision of your information related to adds, changes and terms. Update CAQH. If you need assistance in establishing a CAQH record; please notify Precision. Precision will provide you with a credentialing packet which will describe all the documents, applications and information required for credentialing.

25 What is required for a complete credentialing file? An updated CAQH application An updated signed attestation Current medical license Current DEA Current Professional Liability Cover Page Complete work history (included in CAQH) with no unexplained gaps of employment or practice

26 KPCA Contracts Report Basis for robust contract performance reporting is claims data. CoventryCares No data available at this time Humana CareSource No data available at this time. Passport Data access is in process Anthem Enhanced Personal Health Care (EPHC) Data access is in process WellCare On line access is available. Planned Reporting is to have: Medical Loss Ratio (MLR) reporting, at IPA, Region and practice level Utilization trends for each contract Practice level report and claims based care gap reporting for each practice.

27 Dashboard Reporting Technology provider is Care Evolution Based in Michigan Provides state wide Health Information Exchange (HIE) services to several states Provides reporting and care management tools for large health plans and ACO s Precision implemented 2 products 4 years ago Currently have health plan and Medicare data Live data feeds from hospital system, national lab companies and practices on Athena. Envision KPCA using this tool.

28 Galileo Current Version: Redesign to launch later in November Easy hyperlink Navigation

29 Drill Down Capabilities

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32 Disease and Care Management sections helps with Care Gaps These 4 functions provide best information.

33 Ability to filter data Summary Information and Detail Information Provided xxx

34 Galileo Is claims data driven and we need MCO s to provide enough claims data to have a valuable tool. Providers will have access to their practice data.

35 Current Available Data Wellcare has provided the best source of reporting today. Providers could possibly gain access to data warehouse. Discussions are on going with all MCO s to gain claims data.

36 Wellcare WellCare Summary Reporting - Medicaid Medicaid Based on June 2014 Data Member months Revenue PMPM ER PMPM Out- In- Patient PMPM Patient PMPM Physician PMPM PCP PMPM Pharmacy PMPM Other PMPM Surplus/( Deficit) MLR Peer Group for KY 4,098,733 $ % KPCA 692,053 $ % APCP 44,243 $ % TPN 97,253 $ %

37 Distribution of s Other 11% Rx 19% Physician 21% Wellcare KY PCP 5% In-Patient 31% Out- Patient 13% Other 11% Rx 21% Physician 21% Rx 13% Other 14% TPN APCP PCP 7% In-Patient 27% Out-Patient 13% In-Patient 36% Physician 19% PCP 7% Out-Patient 11%

38 Distribution of s- IPA Comparison Rx 22% Other 9% KPCA In-patient 30% Rx 13% Other 14% APCP In-Patient 36% Physician 21% PCP 6% Out Patient 12% Physician 19% PCP 7% Out-Patient 11% Other 11% Rx 21% TPN In-Patient 27% Physician 21% PCP 7% Out-Patient 13%

39 Distribution of s Rx 22% Physician 21% Other 9% KPCA PCP 6% In-patient 30% Out Patient 12% Other 11% Rx 19% Wellcare KY In-Patient 31% Physician 21% PCP 5% Out-Patient 13%

40 WellCare Medicaid Wellcare Summary Reporting - Medicaid Based on June 2014 Data Member months Admits/1,000 Days/1000 ALOS Peer Group for KY 4,098, KPCA 692, APCP 44, TPN 97,

41 KPCA Wellcare Trending Funding Institutional cost Professional cost Rx Cost Other Total Surplus/(Deficit (24.53) (3.50) (31.34) (39.52) Jan-14 Feb-14 Mar-14 Apr-14 (50.00)

42 Other Reports Forthcoming Trending of Hospital and ER Utilization. Re-admission Rates. Utilization statistics by disease states, e.g. COPD, CHF. Performance by regions and practices.

43 Utilization per 1000 beneficiary 43 Hospitalizations Utilization per 1,000 Person Years 1, QIP ED Visits Cohort ED Visits % of ED Visits that lead to IP is equal for QIP and Cohort Q Q Q Q Q Q QIP Cohort ACO QIP ER Visits Cohort ER Visits Linear (QIP) Linear (Cohort ACO) Quality Independent Physicians Confidential All numbers and calculations are based on CMS' Quarterly reports as provided to ACO. Savings are estimates and subject to change.

44 44 Percent of Patients with ER Visits

45 Annual s per beneficiary Day All Cause Readmissions per 1,000 Discharges Q Q Q Q Q Q QIP Cohort ACO Linear (QIP) Linear (Cohort ACO) Quality Independent Physicians Confidential All numbers and calculations are based on CMS' Quarterly reports as provided to ACO. Savings are estimates and subject to change.

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47 47 Admissions per 1000 across 12 month periods

48 Other Reports State Wide July 2013 to Jun 2014 Member Months Funding PMPM Paid Claims PMPM Surplus w/o IBNR % Claims Paid % Claims Denied % Claims Suspended % Claims in Process Wellcare 3,946,551 $ $ $ % 18% 1% 6% Coventry 3,415,289 $ $ $ % 19% 3% 0% Passport 1,847,846 $ $ $ % 24% 11% 0% Humana 436,496 $ $ $ % 21% 10% 0%

49 Questions/Concerns What is the most useful reporting you currently receive? What other information is key to your clinic? Other questions or suggestions?