Posts Tagged ‘payors’

Healthcare Payor Strategies for Co-Located Case Management

January 29th, 2015 by Cheryl Miller

How to best strategize the co-location of case managers at points of care? The key is to understand the population you’re serving, be very targeted, and direct your services appropriately, says Dorothy Moller, managing director in the government healthcare solutions business unit of Navigant Healthcare.

Question: New market data on embedded case management found that two-thirds of respondents have co-located case managers at points of care, including primary care practices, hospital ERs and patients’ homes. What are some payor strategies for matching case managers with providers, and how do health plans benefit from co-location?

Response: (Dorothy Moller) I must acknowledge the safety net payors, who have been co-locating case managers for a number of years — in particular in hospital ERs. Very often the case managers you co-locate are not healthcare case managers, but behavioral health or social services case managers.

In terms of strategies for co-location, it depends on the population you’re serving and what you’re trying to accomplish with that population. There are a number of places where you can co-locate case managers — not so much case managers as case or care coordination services. Very often in large multi-specialty or primary care practice settings such as federally qualified health centers (FQHCs), community clinics, or multi-specialty clinics, case managers are sometimes nurses, sometimes social workers, sometimes physician assistants performing various functions. They may link members with specific services that are non-health related or coordinate care.

The key is to understand the population you’re serving and to make sure you include case management and care coordination services appropriate for that population. If you have a very acute population with high risks or readmission or other health complications, clearly you’re going to have a different kind of co-located service and you’re going to place them in a different location than you would otherwise. If you’re trying to encourage more effective access of services, use of preventive services, use of nurse call lines, and so on, you might place those services in a primary care practice. Those are going to be very different.

Embedded case managers could even be community health workers. In fact, I’ve worked with payors in the Southwest using community health workers in that role. They are sometimes co-located within the practice but then go into the community and deliver education services there as well, sometimes in collaboration with medical and education specialists.

It depends on the population you’re serving, the types of services you want to encourage or direct members to, and the most efficient staffing model for those services. Ultimately, you must remember you’re trying to develop a better staffing pyramid within the practice so that physicians do the most complex work — where a physician’s skills and capabilities are most needed. Nurses and other staff deliver care and services appropriate for their skills, education and capabilities. Be very targeted, understand your population, and direct the services appropriately.

healthcare trends
Dorothy Moller, MBA, is a managing director in the Government Healthcare Solutions business unit of Navigant Healthcare. She has nearly 30 years of experience specializing on a wide range of strategic issues from business intelligence and competitive analysis, to market, business and product strategy and design, business and product innovation, and business and operations turnaround and repositioning.

Source: Healthcare Trends & Forecasts in 2015: Performance Expectations for the Healthcare Industry

3 2014 Trends for Health Plans

January 21st, 2014 by Jessica Fornarotto

Influencing primary care, aggregating and mining data, and embracing bundled or episode-based payments are three trends that will influence health plans in 2014, predicts Catherine Sreckovich, managing director in the healthcare practice at Navigant Consulting.

HIN interviewed Sreckovich on these trends prior to her presentation during HIN’s tenth annual webinar on Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.

HIN: Where will data analytics take health plans in the coming year, and how will this shape population health management offerings?

(Catherine Sreckovich): We’re certainly hearing a lot about big data, and it will be an integral approach to merging this practice’s or population’s health, the ability to aggregate and mine data is going to be an essential capability for health plans for their predictive models. And the outputs of these models are going to enable the health plans to identify and stratify their members or population health. Member and patient demographics can also inform consumer engagement strategies to support population health. And the analytics are going to inform the effectiveness of different care management interventions and consumer engagement strategies.

HIN: Health plan case managers embedded alongside providers has become almost a de facto model. How will payors influence primary care delivery in the year to come?

(Catherine Sreckovich): There is a number of approaches evolving right now and that will continue to evolve as payors attempt to influence primary care delivery. One is the use of patient-centered medical homes (PCMHs) and other integrated models to expand the payor’s role as the primary care case manager.

In addition to paying primary care providers to hire case managers and care coordinators, payors are pushing for shared savings arrangements with these primary care providers, such as within an accountable care organization (ACO), and to push them to manage the care for those with chronic conditions.

We’re also seeing payors paying for primary care physicians to become certified PCMHs and to implement electronic health records (EHRs), either by paying directly for the certification of the technology or by adding bonus payments to their FFS rates.

Payors are also paying for incentives for primary care physicians to offer wellness programs such as smoking cessation or weight loss programs and are trying very hard to influence where and to whom primary care physicians refer their patients by giving them information about the cost and quality of other provider types, such as specialists and hospitals.

And we will continue to see that payors will target the larger primary care physician practices with whom they have a critical mass of members to achieve enough savings to offset the added costs of incentives, bonuses and shared savings arrangements. As a result, we expect that some of the smaller primary care practices will likely not receive the same level of support and push from payors.

In another example, we see payors increasingly partnering with non-traditional providers, such as retail-based clinics and community health centers to offer easily accessible primary care at lower costs. And this will certainly be an opportunity to address some of the physician supply shortages that we anticipate seeing in the next year or so as more and more people have access to healthcare insurance and coverage.

Finally, another approach payors are using is to offer members access to virtual doctor visits via webcam, for example, and other telemedicine approaches that are giving individuals access to these primary care providers to increase access to convenient and low cost primary care for their patients.

HIN: CMS and top-performing Pioneer ACOs are heavily invested in bundled or episode-based payments. Will more private payors embrace this reimbursement method as well?

(Catherine Sreckovich): Definitely. The bundled or episodic-based payment approaches are here to stay. We’re starting to see this take off in a number of states. For example, there are state innovation grants that CMS has provided to states like Arkansas, Ohio, Delaware and others looking for opportunities to implement multi-payor bundled payment initiatives. Although these are not necessarily the traditional ACO model, they built off of that ACO model.

We also see that the large health plans in various states are starting to build and develop ACOs. Key to these are the shared savings arrangements that they’re implementing with these payment approaches. So whether they’re bundled or episodic-based payments or whether they look more like a traditional ACO, if there is such a thing, we’re starting to see takeoffs on those kinds of models as payors and health plans become more creative in the development of their alternatives.

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry

Infographic: Leaks in the Healthcare Claim Process

November 26th, 2013 by Jackie Lyons

In healthcare’s post-reform volume-to-value world, payor reimbursement strategies are tipping in favor of providers who can deliver clinical and financial goods.

However, most practice are leaving up to 30 percent of potential revenue on the table due to insufficient internal resources, processes and technology, according to a new infographic from CareCloud. This infographic shows exactly where physicians are losing money, specifically during the pre- and post-visits, and the visit itself.

Leaks in the Claim Process

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

You may also be interested in this related resource: Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for Performance.

Medication Adherence Gets Boost from CMS Innovation Advisors

August 1st, 2012 by Jessica Fornarotto

“Payors are interested in finding ways that they can improve medication adherence for their members using community pharmacy resources,” says Dr. Janice Pringle, director of the program evaluation research unit at the University of Pittsburgh School of Pharmacy. This is just one of many lessons Dr. Pringle learned after being selected for the Centers for Medicare and Medicaid Services Innovation Advisors Program.

During an interview with HIN’s executive vice president and chief operating officer, Melanie Matthews, Dr. Pringle discussed why she applied for the Innovation Advisors Program, the medication adherence intervention she developed with Highmark and Rite Aid, other initiatives supporting medication adherence, and much more.

HIN: What prompted you to apply for the Innovation Advisors Program?

(Dr. Janice Pringle): I have always been interested in innovations and I teach a course on healthcare innovations at the University of Pittsburgh. I also have been involved in a program where we took some strategies that are used in behavioral health and applied them in community pharmacy services, and we looked to see if that had an impact. I considered that an interesting innovation. And I have to emphasize that I did this with my collaborators: Highmark, which is a commercial payor and is now Gateway, a Medicaid payor; and Rite Aid Corporation and CECity have all been part of this particular program. We’re funded through the Pharmacy Quality Alliance (PQA).

HIN: What have you learned thus far?

(Dr. Janice Pringle): We’ve learned a lot. First of all, we’ve learned that pharmacists want to have a greater impact on their patients, so when you’re giving them the opportunity to do so, they rise to the occasion. We’ve also found that community pharmacy organizations such as Rite Aid are interested in supporting this. We also know that the payors are interested in finding ways that they can improve medication adherence for their members using community pharmacy resources. We know that CECity, which provides some platforms to help us scale things, is a very important and necessary partner.

Finally, the PQA is important because they provide us with the national contacts. We’ve learned that the implementation barriers can be attenuated; we can get over them. Where there’s a will there’s a way. Even though pharmacists are very busy in community pharmacy settings, they can learn to have meaningful discussions with patients about their adherence and learn to fit it into their work. We’ve also learned that once they see this, they can continue to do it even more.

Our preliminary results have demonstrated to us, when we compare the medication adherence rate for the medication classes we’ve studied, that the pharmacy is better involved. 118 pharmacies improved medication adherence for the patients who received services there, compared to the pharmacies that we used as controls that were not using this intervention. What’s really key is that this effect seems to improve or increase over time, which shows us that the pharmacist gets better and better at it as they go forward. We’ve studied these data over a 12-month, or in some cases, a 13-month period. That’s everything that we’ve learned and we’re excited to see if we can continue to push this forward, and maybe change the conversation about the importance of community pharmacy in the healthcare arena and landscape.

HIN: What role do you believe medication adherence will play in the recommendations developed by the Innovation Advisor program?

(Dr. Janice Pringle): Medication adherence is definitely an important issue for many of my advisors. They’re programmed by looking at adherence, and it came up multiple times whether we were looking at transitions of care, palliative care issues, whether it was looking at issues of integrating and doing models using primary care, and so forth. Medication adherence has definitely come up. I would imagine, especially given we know that Dr. Will Shrank is a member of Brigham & Women’s Hospital Department of Medicine, Division of Pharmacoepidemiology & Pharmacoeconomics and his expertise is in medication adherence, it’s an important issue for them, and also for CMS in general and the innovation center.

HIN: Of the innovators selected to participate, what other types of initiatives support medication adherence? How do these programs complement or differ from yours?

(Dr. Janice Pringle): There was much interest in the issue of medication adherence, specifically some of what we were doing in our program and how they could apply it to their models. For most of the models that I heard about, the vast majority seem to have an interest in how they can improve medication adherence because they understood that this was an issue for them in improving health — or their “three-part aim” as they call it, which is improving health, improving care and reducing cost.

HIN: Can you briefly describe the intervention you’ve developed with Highmark and Rite Aid to improve medication adherence rates?

(Dr. Janice Pringle): The intervention involves screening, brief intervention (SBI) of patients for medication adherence issues. This way, you can place them in a risk profile. You use any screen that has validity in that purpose. You can sort your patients based on prior data and information. You can also do a universal screen where you ask them questions when they come in, but you want to bring up those patients that seem to be at greater risk than others. You can then apply a brief intervention, which is a two to five minute conversation that is based on motivational interviewing principles that address the issues of how we can help you improve your medication adherence. This is called a facilitative manner — you’re trying to have the patient and the pharmacist work together to address that issue.

HIN: When you spoke with us in May 2011, you were evaluating the preliminary results for the community pharmacist’s intervention. Can you share what results the program has achieved to date?

(Dr. Janice Pringle): With the pharmacies that were involved in the intervention, we looked at the patients that came to those pharmacies and looked at their formulary claims data. We found that their adherence significantly improved and continued to improve over time, so there was an acceleration of an effect over time. For the 13 months or so that we examined the data, compared to the control pharmacies that were fairly similar in many different ways, we examined the similarities to the intervention pharmacies on the same medication classes and the same adherence measures.

HIN: What did you learn in year one of the intervention and how have you modified the intervention based on these findings?

(Dr. Janice Pringle): One of the things that we’ve learned is that you have to keep in touch with the pharmacists consistently to make them aware, if they’re applying this innovation, that this is an innovation that has importance. Pharmacists have many competing requirements; immunizations, different tasks that come through in a community pharmacy chain. We keep in regular monthly contact with the pharmacists to determine what issues or concerns they may have or limitations. We want to get the issues addressed as quickly as possible. We also keep track of where they stand in the innovation process. That’s one thing that I think is important.

The second is, Rite Aid has reported this whole program and that’s key. Rite Aid put some very talented people in charge, such as Jesse McCullough, who is the clinical services manager for Rite Aid, and Rick Mohall, the director of clinical services at Rite Aid. They cleared the way for this to become an initiative for the pharmacies where we’re implementing so that it would continue to be priority. And they changed how they are evaluating the pharmacists.

There are raises also related to the pharmacy, but not just the pharmacist’s performance. The pharmacies are being evaluated as a unit. We found that one pharmacist could be on board, another may be less on board, and they could cancel each other out as they move forward. If you’re now evaluating the pharmacy as opposed to the pharmacists, that changes the conversation.

HIN: Do you have plans to expand the program to include other pharmacy chains?

(Dr. Janice Pringle): Yes. PQA and CECity have been working on the second phase of this, which is called Equipp. They are targeting the entire state of Pennsylvania, looking at some other pharmacy chains and other payors. They also have been talking to some other states. Dr. David Nau, PQA’s senior director of research and performance measurement, has been involved with CE City and is moving this forward to the other states, especially Pennsylvania.

HIN: Are the pharmacists receiving any higher payment for their services?

(Dr. Janice Pringle): Rite Aid has many programs that they’re using to provide incentives to their pharmacists, or to make up the way in which they’re reimbursed. Some of them relate to this study and some do not. What I’m about to say is one aspect of the many ways in which the pharmacists’ salaries were determined. I’m not privy to all of them.

I do know that Rite Aid has, as of January of this year, decided to look at ways that the entire pharmacy is performing, and adherence is one way to be able to look at that. There are other things that they’re looking at as well, but this was partially in response to our study and in response to other things, too, that indicated that it’s good to have the pharmacy be one unit in terms of how the pharmacy takes on innovation, or approaches ways in which we can be considered productive.

We will also be looking at, with Highmark, ways in which we can provide additional pay for performance, or value-based purchasing strategies for the pharmacist. We’ll be testing and developing some models for our colleagues. I wouldn’t expect those to be moved into the field until some time in 2013.

HIN: The community pharmacists can have a measurable impact on medication adherence, according to the results of your program. After the pharmacists, where should organizations concentrate their efforts to boost medication adherence? What should be done within the primary care practice?

(Dr. Janice Pringle): For our next step, we should bring physicians and pharmacists together. The same strategies we’ve used with the pharmacists can be used in the physician’s business. What could be interesting is having the physicians and pharmacists together with an understanding of common quality metrics, such as what CECity provides and what PQA has suggested regarding the measurement. This way, you can keep track of what’s going on with the patients between the physician’s practice and the pharmacy practice.

I think it would change the whole conversation of how we’re receiving medications in our community — if pharmacists are working in collaboration with physicians and physicians are learning the same skills. We could greatly enhance medication adherence and we could change the health of our communities. Again, it’s a matter of will to do that.