JHHC Medical Policy Process Presentation to the Center for Health Services and Outcomes Research

January 3, 2017

Presented by: 06-Jan-17 Mark R. Fracasso, MD, MBA

Interim Chief Medical Director

Why Discuss Policy and what does it have

to do with Medical Coverage?

The purpose of a medical policy is to provide guidelines for determining coverage criteria for specific medical and behavioral health technologies, including procedures, equipment, and services.*

*http://blue.regence.com/trgmedpol/intro/

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Agenda

• Policies & Reimbursement

• Policy Organizational Chart

• SEEPAC Membership

• Decision Approval Process

• New Approval Process

06-Jan-17 06-Jan-17

Johns Hopkins HealthCare LLC

Why are Medical Policies important to Reimbursement?

• Medical Policies touch every aspect of the organization

• They strongly influence member and provider satisfaction

• They may create a competitive advantage for the organization

• They are required by NCQA, Delmarva, CMS and other regulators

• They have significant financial impact on the organization

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Agenda

• Policies & Reimbursement

• Policy Organizational Chart

• SEEPAC Membership

• Decision Approval Process

• New Approval Process

Scientific Evidence

Evaluation and

Policy Advisory

Committee (CMS)

Corporate

Policies

(COR)

JHHC Clinical Polices

Johns Hopkins HealthCare LLC Policy Organizational Chart

Pharmacy &

Therapeutics

(Pharm/Meds)

Quality

Policies

(MSQI)

Utilization &

Management

(UM)

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Scientific Evidence Evaluation Policy Advisory Committee

Medical Policy - Core Goals

• Regulations, Benefits and Contractual Requirements

• Based upon Evidence Based Medicine

• Industry Wide Standards

• Expert Evaluations (e.g. Genetic Tests) – Analytical Validity – accuracy for a genetic variant (+) or (-)

– Clinical Validity – variant associated with a phenotype or outcome

– Clinical Utility – tests effect on member outcome

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Scientific Evidence Evaluation Policy Advisory Committee

Medical Policy – Scope of Practice

• Quarterly SEEPAC Meetings – Technical Assessments

– Biannually Review Current Policies – content/coding

– New Policy Development – research/collaboration/content/coding

– Medical Directors Pre – SEEPAC Meeting

– Medical Policy PR Communication & Staff Training

• Clinical Practice Guidelines

• Preventive Health Guidelines

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Agenda

• Policies & Reimbursement

• Policy Organizational Chart

• SEEPAC Membership

• Decision Approval Process

• New Approval Process

Johns Hopkins HealthCare LLC Voting Members

Last Name First Department

Doyle Damien Medicare - Medical Director

Fracasso Mark Chairperson - Medical Director

Pettway Kathy Priority Partners - Program Management

Ross-Gavin Michelle EHP - Client Relations

Safeer Richard EHP – Medical Director

Teves Melissa USFHP - Program Office

Bonilla Geovani Utilization Management - Director

Johns Hopkins Medicine Voting Members

Last Name First Department

Bellantoni Michele JHBMC, Geriatric Consultation and Preventative Health

Bolanos - Meade Javier SOM Oncology Hematologic Malignancies

Clark Michael SOM Psy General Hospital Psychiatry

Ford Daniel Medicine, Internal Medicine

Hamosh Ada JHH Genetics

Lam Clarence JHSPH - Health Policy & Management/GPHR Director

Neale Donna Howard County, Maternal Fetal Medicine

Pahwa Amit JHH Hospitalists

Plotnick Leslie SOM Ped Endocrine

Redett Richard JHH Plastic Surgery

Richard Elisabeth JHH Dermatology

Wu Albert Medicine, Internal Medicine

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Agenda

• Policies & Reimbursement

• Policy Organizational Chart

• SEEPAC Membership

• Decision Approval Process

• New Approval Process

Regulations Federal, State, DHMH, CMS, DOD Requirements

Benefits Coverage agreed upon across entire payer LOB

Contracts Individual coverage agreed by a client within a LOB

Authorizations without or with Medical Review

Software/non-clinical review and/or clinical nursing/medical director review

Decision Approval Process

Then and only then …

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Agenda

• Policies & Reimbursement

• Policy Organizational Chart

• SEEPAC Membership

• Decision Approval Process

• New Approval Process

Johns Hopkins – The Academic Solution

• Pre-meetings are critical for success • Trust is developed over time • Set reasonable committee expectations • Hold committee members accountable • Require Teams work collaboratively • Co-Develop policies with both teams • Patience is a virtue

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Polepole …. Slowly