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Medicare risk revenue management 11 jun12 washington dc
1. Leveraging the Entire Care Team to Improve
Care Management and Data Capture
Wayne Pan, MD, MBA
Chief Medical Officer
Pacific Partners Management Services, Inc.
Medicare Risk Revenue Management - Best Practice Operation Strategies • Washington, DC • June 11, 2012
40. THE
Apr 21,2012 Price 75 FB C REDITS
VIEW FROM THE VALLEY
EUROPE ENGLAND RUSSIA
ATLANTIC OCEAN
NEW YORK CITY FLORIDA M
DA EX
NA IC
C
A
CLEVELAND APPALACHIA O
ILLINOIS
the Mississippi River
INFINITE LOOP
SAND HILL ROAD
41. 5 PCP
80 Specialists
173 PCP
343 Specialists
57 PCP
104 Specialists
11 PCP
30 Specialists
SCCIPA
founded in 1986
physician-owned, physician-governed
800+ physicians - 240+ PCPs, 550+ specialists
all 9 hospitals - including a tertiary care center
9 health plans (Commercial and Medicare Advantage)
Anthem Commercial ACO pilot (2011)
42. urban/
suburban
rural
SCCIPA
founded in 1986
physician-owned, physician-governed
800+ physicians - 240+ PCPs, 550+ specialists
all 9 hospitals - including a tertiary care center
9 health plans (Commercial and Medicare Advantage)
Anthem Commercial ACO pilot (2011)
85. peopleprocesses
hospitalists
available 24/7
evaluation of patients for possible redirection to SNF
aggressive use of observation status
annual coding/documentation training for risk adjustment
notification of PCP of admission/discharge
discharge summary faxed to PCP
86. peopleprocesses
hospitalists
available 24/7
evaluation of patients for possible redirection to SNF
aggressive use of observation status
annual coding/documentation training for risk adjustment
notification of PCP of admission/discharge
discharge summary faxed to PCP
88. peopleprocesses
onsite case managers
daily review of patients based on Milliman guidelines
actively involved with discharge planning
all discharge needs authorized/arranged prior to
discharge
post-discharge follow-up on all patients with
DME/HHC needs
89. peopleprocesses
complex case managers
warm hand-off between onsite and ccm
use of clinical and non-clinical staff to assist
patient and family caregivers with care coordination
insure follow-up with PCP/specialist within 2 weeks
90. peopleprocesses
utilization review staff
all authorizations/referrals reviewed using Milliman guidelines
working closely with PCPs/specialists/ccm to facilitate care
coordination
compliance with regulatory guidelines
generate member/provider letters regarding medical necessity
decisions
physician performance and quality reporting
identification of potential quality issues
continuous process improvement
95. peopleprocessesplatform
common web-based communication platform
facilitates administrative functions
rules-based management of processes
intuitive user-interface
embed quality reminders into office/provider workflow
provider feedback
96. peopleprocessesplatform
common web-based communication platform
facilitates administrative functions
rules-based management of processes
intuitive user-interface
embed quality reminders into office/provider workflow
provider feedback
provide actionable clinical data at point of care
allow patients to access their own data
97. peopleprocessesplatform
common web-based communication platform
facilitates administrative functions
rules-based management of processes
intuitive user-interface
embed quality reminders into office/provider workflow
provider feedback
provide actionable clinical data at point of care
allow patients to access their own data
allow patients to provide feedback/enter their own data
115. patient
analog to digital
front desk staff
converter
116. AMERICAN HEALTH PLAN
112
MARY SMITH 1/1/2011
1234567890
$5.00
$10.00
$25.00
analog to digital
analog to digital eligibility check
converter
converter
117. Quality
Access Express
TM
Management
Click here to register
for a password or
request more information
Powered by Access ExpressQ-v5.0.#.0.1 Build 2011.04.04.00
118. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
119. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
AMERICAN HEALTH PLAN
120. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
SMITH, MARY
8/15/1945
POP-UP
1234567890
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD
121. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
SMITH, MARY
8/15/1945
1234567890
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD
CLICK HERE
124. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
ENABLING
SMITH, MARY
8/15/1945
1234567890
FRONT OFFICE
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
STAFF
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD
125. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
SMITH, MARY
8/15/1945
SIMPLE
1234567890
CARE PLAN
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD
126. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
SMITH, MARY
8/15/1945
1234567890
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD
127. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
128. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
129. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
130. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
131. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
135. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
TH
PA
AMERICAN HEALTH PLAN
E
TH
IN
136. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
ER
SMITH, MARY
8/15/1945
G
1234567890
IG
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
TR
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD
T
O
H
137. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
N
O
TI
VA
TI
O
M
161. “put hot
triggers in
the path of
motivated
people”
BJ Fogg, PhD
Director, Persuasive Technology Lab
Stanford University
162.
163.
164.
165. Santa Clara County IPA (SCCIPA)
Medication Reconciliation Pilot Project
How to find the medication list for patients using AccessExpress
1. Go to the PPMSI AccessExpress provider portal
(http://ppmsi.com/accessexpress.html):
2. Select Santa Clara County IPA:
3. Enter USER NAME and PASSWORD, click on “SUBMIT”:
166.
167. Your SCCIPA doctor wants to help you with
your medications, after you leave the hospital.
Michael Lam, RPh
pharmacist
Samaritan Medical
Center Pharmacy
2505 Samaritan Drive
San Jose, CA
(408) 356-7111
Please visit the Samaritan Medical Center Pharmacy to pick up
your new prescriptions and have a pharmacist review your
medications with you.
SCCIPA
A Pacific Partners Medical Group
173. 80
Milliman - Loosely-Managed
70
Milliman - Moderately-Managed
60
Milliman - Well-Managed
50
SCCIPA
40
11
10
1
1
0
1
0
0
R1
N1
L1
L1
R1
N1
CT
CT
JU
JU
AP
JA
AP
JA
O
O
> commercial admits/1000
174. 275
Milliman - Loosely-Managed
250
225
Milliman - Moderately-Managed
200
SCCIPA
175
Milliman - Well-Managed
150
11
10
1
1
0
1
0
0
R1
N1
L1
L1
R1
N1
CT
CT
JU
JU
AP
JA
AP
JA
O
O
> commercial bed days/1000
175. 4.5
4.0
Milliman - Loosely-Managed
3.5
Milliman - Moderately-Managed
SCCIPA
3.0
Milliman - Well-Managed
2.5
11
10
1
1
0
1
0
0
R1
N1
L1
L1
R1
N1
CT
CT
JU
JU
AP
JA
AP
JA
O
O
> commercial average length of stay
176. 400
Milliman - Loosely-Managed
350
Milliman - Moderately-Managed
300
Milliman - Well-Managed SCCIPA
250
200
11
10
1
1
0
1
0
0
R1
N1
L1
L1
R1
N1
CT
CT
JU
JU
AP
JA
AP
JA
O
O
> medicare admits/1000
177. 2,200
2,000 Milliman - Loosely-Managed
1,800
1,600
Milliman - Moderately-Managed
1,400
SCCIPA
1,200
Milliman - Well-Managed
1,000
11
10
1
1
0
1
0
0
R1
N1
L1
L1
R1
N1
CT
CT
JU
JU
AP
JA
AP
JA
O
O
> medicare bed days/1000
178. 6.0
5.5
Milliman - Loosely-Managed
5.0
Milliman - Moderately-Managed
4.5 SCCIPA
Milliman - Well-Managed
4.0
11
10
1
1
0
1
0
0
R1
N1
L1
L1
R1
N1
CT
CT
JU
JU
AP
JA
AP
JA
O
O
> medicare average length of stay