a managed care organization for the entire family ppc to advicare: making the transition presented...
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A Managed Care Organization for the Entire Family
PPC to Advicare: Making the Transition
Presented to: Office of Rural HealthJuly 23, 2013
Medicaid Update
Company Structure
Cesar D. Martinez, MBA, MPAExecutive Director, Advicare
CEO, PPC Health Plan Management
Gerald Harmon, MDMedical Director
Mikki Barrett, BSN, RN
Director, Care Management Bea Prashad,
RN, BSN, MBA, CNORTeam Leader,
Care Management
1.Donna Steele, LPN,
2.Rhonda Dowie, RN
Case/Disease Management
Deryl Macaulay, RN
Utilization Management
LaTasha Bomer, LMSW
Social Work
OpenQuality
Management
Kisha PriceDirector, Claims and
Provider Data Management1.Sherrie Marrapode
2.Dilsa Bailey3.Raquel Soto
Provider Credentialing
1.Nikki Moore2.Shanitha Robinson
3.Yvonne BishopClaims Service
Center
Dell JeterDirector, Network
ManagementMary Wasden,
MBAManager/Team
Leader,Provider Relations
1.Kelli Williamson2.Joan Reeves
3.Jeanne Watson4.Pam Boyd5.Jodi Key
6.Wendy McCrea7.Neshelle Miller
8.Pat RubioProvider Relations
Representatives
Kisha PriceDirector, Customer Service
Flavia FigueroaTeam Leader,
Customer Service
1.Karen Cantrell2.Yesenia Perez
3.Ruto Soto4.Charlene CarterCustomer Service Representatives
OpenAppeals & Grievance
Coordinator
Tandi Card, JD Director, Complianceand Human Resources
Joe Lowry, CPAVP, Finance, Administration
Board of Directors
Patrick CasterPresident
Organizational Chart
May/June, 2013Ken Meinke
CFO
Kathryn Gailey, JD, MPHCompliance Officer
Toni HunterManager, Training
and Human Resources
OpenAssociate Medical Director
Clara FigueroaAdministrative. Assistant
Harold MooreCIO, Information Services
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Medicaid Update
DHHS / Medicaid Update
Medicaid Update
Data Source: SCDHHS, July 2012 3
4
Medicaid Update
170,000 205,000Eligible Under Current
Medicaid Rules
Will Enroll In Medicaid Managed Care Per Individual Mandate
Data Source: SCDHHS and Milliam, July 2012
236,000ACA Expansion
Potential New Membership
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Medicaid Update
Data Source: SCDHHS, October 2012
SCDHHS meets promise to insure more poor children through ‘Express Lane’ eligibilityPosted Thu, 10/04/2012 - 10:22 COLUMBIA, S.C.— Approximately 65,000 children who are currently eligible for South Carolina’s Medicaid program but are not signed up will be enrolled and immediately able to receive services through a coordinated care health plan, the South Carolina Department of Health Human Services (SCDHHS) announced Thursday.
Company Update
Company Overview and Update
Company Update - Goals
1) Accessible, comprehensive, family centered, coordinated care.
2) Provide a medical home with a primary care provider -
manage the patient’s health care,
perform primary and preventive care services,
arrange for any additional needed care, and,
focus on the physician-patient relationship.
3) Patient access to a “live voice” 24 hours a day, 7 days a week to ensure appropriate
care.
4) Patient education regarding preventive and primary health care, utilization of the
medical home and appropriate use of the emergency room.
Connecting Patients to their Medical Home
7
8Mar-
11
Apr-11
May-11
Jun-11Jul-1
1
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12Jul-1
2
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
-
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
319 1,098
2,341 3,268
4,250
5,384 6,294
8,651 9,519
10,709
11,735 12,293 12,548
13,299 13,562 13,600
14,435 14,474
14,476 14,883 15,006
15,595 16,149
16,542
Start-Up
EQRO Audit92%
Approved in 46th County
CMS Approves Model of Care/Ops Manual for 3 Years
Readiness Review 87%
SRHS Acquisition of PPC
No Complaints to Medicaid – Mar ‘11 to Current
Company Update -Membership and Outreach
20,225Members Statewide
July Effectives
SCDOI: Approves HMO License
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Service Area - Driven by Provider Network
20,225Members Statewide
Jul 1 Effectives
Contracted674 291 574
1,539
Speciality Contracted Speciality ContractedAllergy and Immunology 60 Optometry 61 Anesthesiology 106 Orthopedic 5 Audiology 2 Orthopedic Surgery 83 Cardiology 129 Orthotics/Prosthetics 43 Chiropractor 19 Otorhinolaryngology 9 Dermatology 12 Pediatrics, Cardiology 3 Durable Medical Equipment 103 Pharmacies* 1,306 Emergency Medical 83 Physiatry, Rehab Medicine 8 Endocrinology and Metab 10 Plastic Surgery 11 ENT/Oto-laryngology 26 Podiatry 24 Gastroenterology 60 Private Occupational Therapy 25 General Surgery 48 Private Physical Therapy 79 Gynecology, OB/GYN 173 Private Speech Therapy 43 Hematology/Oncology 60 Psychiatry 132 Home Health 17 Psychologist 2 Infectious Diseases 15 Pulmonology 68 Infusion Therapy** 17 Radiology, Diagnostic 99 Laboratory Services 15 RHC's/FQHC's 64 Licensed Independent Social Workers 6 Rheumatology 16 Licensed Marriage & Family Therapist 3 Surgery--Cardiovascular 5 Licensed Professional Counselor 16 Surgery--General 51 Neonatology - Surgery--Neurological 3 Nephrology 104 Surgery--Pediatric - Neurology 29 Surgery--Plastic 9 Neurosurgery - Surgery--Thoracic 5 Oncology - Medical, Surgical 22 Urology 22 Oncology - Rad/Rad Oncology 24 Vascular Surgery 1 Ophthalmology 88
3,424
4,963 Specialist Total
TOTAL PROVIDERS
Primary Care Family/General Practice Internal Medicine Pediatrics PCP Total
Hospital ContractingAs of 07/09/2013
Phase 3
Phase 2
Phase 1Tenet
Tenet
HCA
4
Phase 4
Innovation in Care Coordination: System Features and Sample Screen Shots of Web Based System Available
to Providers and PPC Staff
Innovation in Care Coordination
Innovation in Care Coordination
1) Care Coordination and Case Management.
2) Disease Management
3) Pharmacy Management
4) Service Referral Management
5) Tracking of services provided to members
6) Oversight and Clinical Risk Identification
7) Outcomes measurement and data feedback
8) Member Enrollment, Education and Outreach
9) Provider Contracting, Education and training on evidence-based medicine
10) Performance tracking & reporting (financial, medical, quality & enrollment)
11) Distribution of care coordination fee to participating physicians
12) Shared Savings for Participating Providers – No Downside Risk
Care Management
CustomerService
QualityManagement
MedicalEconomics
Use of Evidence-based Clinical Practice Guidelines and Protocols:
National Guidelines Clearinghouse™ (NGC) www.guideline.gov.
System integrates Interqual Medical Guidelines
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CLOUD SYSTEM
1. NCQA HEDIS & P4P Certified
Innovation in Care Coordination – 2012 PIPs
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PIPsNCQA QI Format
PIP Goal Results
1. Maternity Initiative (SBIRT) Improve Quality & 1. Decreased Costs inLower Mater./NICU Cost ‘12 by $3.50pmpm
2. Prenatal & Postpartum Care HEDIS ~ 90% percentile; State is < 25%
2. Child Immunizations 75th Percentile of HEDIS Over 4K Outreach - Led (EPSDT/Well-Child) ~ 40% Improvement Over
Baseline (CY 2011)
3. Pediatric Asthma Decrease Asthma Admits Admits / 1,000 dropped to2.8 from 9.3 in ‘12 over ‘11
4. Member Recertification At or Better than Disenrollment Rate 5% Disenrollment dropped to 8% from 11%
Innovation in Care Coordination – Risk Profile
No-Level Level 1 Level 2 Level 3All Others DM Candiates CM Candidates Complex CM Candidates Total
Sex Low Risk Risk Score 2.0 thru 4.99 Risk Score 5.0 thru 9.99 Risk Score 10 or Greater MembershipFemale 5,730 657 81 122 6,590 Male 4,817 227 39 63 5,146
TOTAL 10,547 884 120 185 11,736
Percent 90% 8% 1% 2% 100%
Membership Profile - As of 1Q2012
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Membership Profile - As of 1Q2013
Risk Level Improvement
Membership by Sex and Risk LevelMembership as of March 2013
No-Level Level 1 Level 2 Level 3 Total All Others DM Candidates CM Candidates Complex CM Candidates Membership
Sex Low Risk Risk Score 2.0 thru 4.99 Risk Score 5.0 thru 9.99 Risk Score 10 or GreaterFemale 7,807 1,268 211 29 9,315
Male 6,561 562 162 35 7,320
Total 14,368 1,830 373 64 16,635
Percent 86.37% 11.00% 2.24% 0.38% 100.00%
Innovation in Care CoordinationProvider Monthly Panel for Patients to PCPs with Risk Score
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Month of Enrollment Mar, 2011
Group Name: Family Medicine Center
Group Number: GP1234
3
2.50$ Total Case Management Fee: 7.50$
Member Name - Last, FirstPlan Begin
DatePhone
NumberSex Age Risk
DOE J OE 3/1/2011 8031234567 M 44 1.02
DOE J OE J R 3/1/2011 8032224567 M 3 0.75
DOE J ANE 3/1/2011 8031234444 F 26 2.51
Medicaid ID#
1234567891
1234568667
1234569444
123 First Street, Irmo, SC 29063
321 Main Street, Irmo, SC 29063
777 Second Ave, Irmo, SC 29063
PCP Panel Group Report
Total Members:
Per Member Case Management Fee:
Member Address
Risk Score: A measure of the members' severity / illness burden based on claims history. The mean Risk score across the population is 1.0. The . higher the score above the mean the higher the severity / illness burden of the member.
PPC shares with its PCPs a monthly panel report with the patient risk score for each member assigned to the PCP. This allows the PCP and PPC to target the most severely ill members and those that are predicted to have high risk burdens.
Innovation in Care Coordination
“Point and Click”Identify All Quality
Measures and Members Non-Compliant with
HEDIS
“Point and Click”Identify All ER Utilizers and Patients with High
Service Utilization
Innovative Technology : Identify HEDIS / Care Gaps and High Utilizers
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“Point and Click”Care Plans with Problems,
Goals, Interventions
Innovative Technology : 360 Degree View of Info on Enrollees
Innovation in Care Coordination
“Point and Click” Enrollee Info at Finger-Tips for Providers and PPC StaffFull Glance of Enrollee, Clinical Profile, Medical Records, Conditions, Self Reported Info, Vitals, Notes, Quality History, Quality Management, Quality
Measures, Care Management, Assessments, ER Visits, Hospital Admission
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Innovation in Care Coordination
“Point and Click”List Chronic Conditions
On Patients
“Point and Click”Predicts Cost for Next
12 Months
“Point and Click”Predicts Probability of
Hospital Admission
“Point and Click”Total Current Costs
Of Patients
“Point and Click”
Tells You If Condition
Is Being Treated
Innovative Technology : Clinical Profile and Predictive Model on Members
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Innovation In CareBy end of 2012 launch PPC/MedHOK system via provider portal to select IPAs/groups to enhance care coordination.
Every Member in the programs gets a full Comprehensive Patient Clinical Profile Report.
This Comprehensive Patient Clinical Profile Report will / can be shared with other providers and will help the patients’ PCP provide the capability to target individual members for inclusion in care management programs.
Because our system uses predictive modeling, our reporting content leverages the predictive modeling methodology and care opportunities to support high risk member identification, provider effectiveness reporting, and patient risk profiles.
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Advicare Risk Adjusts All Members and Performs Predictive Modeling
SCDHHS Quality Initiatives
• Patient Centered Medical Homes (PCMH)– NCQA Application Phase ($0.50)– NCQA Level I ($1.00)– NCQA Level II ($1.50)– NCQA Level III ($2.00)
• Centering Program• Nurse Family Partnership• Screening Brief Intervention & Referral to
Treatment (SBIRT)
Wrap Around Payments• Advicare has been
working with SCDHHS and SCDHHS is committed to making wrap payments in a timely manner.
• Advicare is committed to ensuring that all encounter data is submitted to the state in a timely manner. We are also committed to working with the clinics to ensure our patients get the best quality of care.
Website : www.AdvicareHealth.com
A Medical Home Network for the Entire Family
•Home Page •Goals of the MHN •Career •Contact UsHome PageWelcome to Palmetto Physician Connections.
We are launching a NEW South Carolina Medical Home Network headquartered in Irmo (Columbia), South Carolina .
A Medical Home Network (MHN) is a group of physicians, who have agreed to serve as Primary Care Case Management providers, and other health care providers who will partner with Palmetto Physician Connections to accept the responsibility for providing medical homes for members and for managing members’ care.
Our sole purpose is to provide quality healthcare within a coordinated care framework, in a cost effective patient centered medical home manner available for the entire family.
Providers who would like to join us or if you need more information, please go to the Contact Us link above or write to us at -
Palmetto Physician Connections 7321 St. Andrews Road, Suite E Irmo, South Carolina 29063
Please come back soon to learn more about the company and for new updates to the website.
Content copyright 2010. Palmetto Physician Connections. All rights reserved.
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1. On-Line PCP Directory2. Provider Manual3. Clinical Guidelines4. Clinical Action Plans5. Drug Look-Up6. Pharmacy Look-Up7. Download Forms8. Member Benefit
Information9. Member Enrollment10. Receive News &
Updates