Presentation on theme: "Provider-Sponsored Networks"— Presentation transcript:
1 Provider-Sponsored Networks “Building Partnerships”Presented by…Linda McKinnon, Chief Executive Officer, Central Florida Behavioral Health NetworkBob Holm, Regional Substance Abuse Director, Suncoast Region DCFRichard Brown, Chief Operating Officer, The Agency for Community Treatment ServicesNancy Hamilton, Chief Executive Officer, Operation PAR
2 CFBHN MissionCentral Florida Behavioral Health Network is a not-for-profit organization of community providers incorporated to ensure and enhance an array of behavioral health and other human services needs for the citizens of our communities.
3 CFBHN History Linda McKinnon Chief Executive Officer Central Florida Behavioral Health Network
4 CFBHN History “Not an overnight sensation!” 1995No collaboration among providers or between disciplines1996Collaboration among mental health providers in Hillsborough and Manatee counties related to pre-paid Medicaid pilot1997Collaboration between ADM and substance abuse providers in Hillsborough and Manatee counties to create CFBHNNo collaboration between mental health and substance abuse providersDCF contracts with CFBHN to manage funds targeted at SSD and SSI dis-enrolled and intervention services
5 CFBHN History1998Hillsborough County mental health providers join collaboration as vendorsDCF contracts with CFBHN for TANF-funded services and children’s substance abuse servicesCFBHN assumes additional administrative responsibilities for outcomes and quality oversight for contracted services1999CFBHN joins Florida Behavioral HealthHillsborough County Workforce Board contracts with CFBHN to implement a three-year grant for supportive employment services targeted to the most difficult to employ TANF recipients
6 CFBHN History 2000 2001 DCF regionalization pilot DCF expands contracts with CFBHN to include substance abuse services for heroin and cocaine abusers and family intervention servicesDCF contracts with CFBHN to provide services in collaboration with Hillsborough County children’s system of care development grantSarasota County substance abuse provider and Hillsborough/ Manatee Public schools join collaborative as vendors2001G. Pierce Wood Hospital closesSubstance abuse and mental health providers in Hillsborough County collaborate to address needs of substance abusing persons with serious mental illness
7 CFBHN History2002CFBHN Board membership expanded to include 19 substance abuse and mental health non-profit providers in 9 counties comprised of Suncoast Region and District 14Family intervention services expanded to Pinellas, Pasco and Sarasota countiesCFBHN contracts to operationalize COSIG Grant in Hillsborough CountyTANF-funded services expanded to Pasco CountyCFBHN contracts to provide substance abuse aftercare services in Suncoast Region
8 CFBHN History2003CFBHN contracts for TANF-funded services throughout Suncoast Region and District 14 (Polk, Highlands and Hardee counties)DCF contracts with CFBHN to provide TANF oversight functions in Suncoast Region and District 14Family intervention services expanded to District 14SAMH Program Office contracts with CFBHN to provide services targeted to persons with co-occurring disorders and operationalize COSIG Grant in Hillsborough CountyCBC contracts with CFBHN to provide children’s mental health services in Hillsborough, Manatee and Sarasota countiesCFBHN awarded ASO development pilot for District 8 (Charlotte, Lee, Collier, Hendry and Glades counties)
9 CFBHN History2004DCF Suncoast Region contracts with CFBHN to provide substance abuse prevention for adultsDCF District 14 contracts with CFBHN to develop service strategies for persons with co-occurring disordersCFBHN identified to operationalize Robert Wood Johnson Resources for Recovery Grant throughout Suncoast RegionCFBHN operationalizes substance abuse elder care pilotCFBHN implements diversion services for CBCDistrict 8 DCF initiates start up contract for SB1258 ASO pilot
10 CFBHN History Current FY2004-2005 Contract DCF Suncoast contracts with CFBHN to manage all substance abuse treatment services and fundingDCF initiates single contract with CFBHN for contract administration, management and oversight functions for substance abuse treatment throughout Suncoast Region
11 Regional Substance Abuse Director The Purchaser’s RoleBob HolmRegional Substance Abuse DirectorSuncoast Region DCF
12 DCF’s Strategy What the Purchaser Wants Evaluate, integrate and re-engineer system of care into a seamless and easily navigated systemAbility to achieve uniform clinical policies and best practice throughout NetworkUniform data collection used to drive quality improvement initiativesResource maximization and cost effectivenessIncreased access to careSimplification and non-duplication of contracting and oversight functions to allow for effective use of limited staff
13 The Purchaser’s Role Moving the System Forward State and District SAMH plan developmentNeeds assessmentDefining population eligibilityUtilization standardsService allocation projectionFinancing strategiesASO and service system designContract developmentASO contract performance and oversightRegulation and licensingReview and approval of quality and systems improvement initiatives and plansTechnical assistance to managing entityReview and approval of contracts with network providers
14 Reengineering Substance Abuse Treatment RWJ Resources for Recovery Grant Suncoast Region and CFBHN named as a pilot in GrantMedicaid Maximization: Contract requires 10% increase in Medicaid revenues earned for substance abuse treatment throughout CFBHN providersTesting of Flexible Payment Methodologies: Grant funds moved to CFBHN to allow greater flexibility for services to more adequately meet consumer needs and to test strategies for case rates and other prospective payment methodologiesIncreased Access to Care: Contract requires reduction of wait lists for residential services and increased access to detoxification services
15 Contracting with Networks Currently using a hybrid performancecontracting mechanism designed to increase and move towards flexibility and accountability.Contract used to define ASO functions and Network requirements and is defined differently by local districts/regionAdministrative Services Organization: “An independent operating entity organized for the purpose of managing and assessing a network of human service providers and provider agencies, to include but not limited to, quality improvement, clinical management, network management, data management, revenue maximization and integration of systems.” (As described in District 8 ASO contract)
16 Suncoast-Specific Terms Managing Entity - An entity that manages the delivery of behavioral health servicesNetwork Provider - An entity that contracts with the Managing Entity to provide services to clients that are funded through the contract with the department (subcontractor)System of Care - Behavioral health services developed into an integrated network to provide services to substance abuse and mental health clients
17 Contract Requirements The ASO…Is responsible for the administration and provision of servicesMust ensure that network providers will provide services as specified in the system of care plans identified for each county in the Network Operational PlanMust ensure services described are provided throughout the contract period
18 Contract Requirements The ASO…Must ensure that the number of persons served, as required by contract, are served with outcomesMust establish a client grievance procedure that assures that all grievances not resolved at the provider level are referred to the managing entity
19 Contract Requirements The ASO is responsible for…All mandated outcomes,electronic data submissions and performance improvement initiativesIncident reportingAssuring emergency preparedness ofits providersProvider financial and audit requirementsBilling and invoice validation
20 ASO Contract Responsibilities Unique to Suncoast Region The ASO is responsible for…Management of wait lists for all substance abuse servicesReduction of wait list for residential treatment servicesEvaluation of Region’s detoxification systemIncrease of Medicaid billing and reimbursement for substance abuse treatment services by 10%Implementation of substance abuse services to the elder care pilotImplementation of co-occurring service capability throughout provider network
21 Lessons Learned from Purchaser Communication is Key!! Need to clearly define what is being purchasedNeed to understand and articulate the role of the purchaserRequires partnership of all stakeholdersRequires commitment of local SAMH Program Office and state SAMH Program OfficeRequires transfer of administrative responsibilities, dollars and staffNeed to identify barriers and work toward resolving issuesRequires ability to assess readiness of Network to assume responsibilities
22 Building the Network Governance Structure Richard BrownChief Operating OfficerThe Agency for Community Treatment ServicesactsThe Agency for Community Treatment Services
24 Governance StructureAll corporate generated documents need to reflect succinctly….”who you are and what you are to do”
25 CFBHN Descriptors Not-for-profit Provider sponsored network Administrative Service OrganizationAspiring to become:Single Managing Entity
26 Corporate Documents Articles of Incorporation Bylaws Business Plan Board PoliciesMember AgreementsVendor AgreementsEtc.
27 Policy Content Increased accessibility Continuous care approaches Reflect commitment to community driven, consumer centered care:Increased accessibilityContinuous care approachesIntegration with other systems
30 “Lines of Business” Membership Most congruent structure for a Provider Sponsored Network would reflect major providers of the anticipated“Lines of Business”
31 Single Managing Entity Substance AbuseMental HealthInsuranceSingleManagingEntity
32 Eligibility (Factors for Membership Decisions) AccreditationFinancial Buy-in to MembershipCurrent Contractor for Anticipated“Lines of Business”Medicaid ProviderDemonstrated ethics & conformance with requirements of Member / Vendor AgreementsIn good standing with current funders
34 Governance Decisions Claims Management Human Resources / Personnel Build & BuyClaims ManagementHuman Resources / PersonnelCall CenterInformation System & MIS ManagementAuditing / MonitoringEtc.
35 Governance Decisions Targeted Reserve Fund Development Capital EquipmentResearch & DevelopmentFinancial SecurityRisk ManagementInsurance LicensureInnovations
36 Governance Sticking Points Large vs. Small AgenciesMental Health vs. Substance AbuseComprehensive Providers vs. Niche ProvidersLocal vs. Remote HeadquartersInclusiveness: Members, Vendors, Purchasers, Stakeholders & ConsumersRight of First RefusalMarket Share Protections
37 Sticking Points – cont.Non-compete vs. Notification of IntentionsASO vs. Provider Status
38 TOOLS Towards Focus of Effort & the Attainment of Inclusiveness Business PlanningSystem of Care PlanningAh Right…It’s time for extreme makeover!!
39 “We will know that we have arrived when the ASO readily matches consumers benefit to provider payments & providers are free to focus on matching consumer needs to services consistent with their progress in recovery”
40 Building Administrative Capacity Linda McKinnonChief Executive OfficerCentral Florida Behavioral Health Network
41 Building Administrative Capacity The Role of the ASO Provider network development and managementPlanningCustomer serviceQuality managementUtilization managementInformation managementFinancial managementTraining and education; best practice developmentSystems integrationResource development
42 Current Organizational Structure Defined by Functional Roles August 16, 2004Collaborating for Excellence in Behavioral Health ServicesLinda McKinnonChief Executive OfficerSue WebberDirectorFinanceTBHManagerInformation Systems(On Hold)Lisa MainFiscal SupervisorLisa ThomasFiscal AssistantIS TechnicianIoan FernandezData SpecialistYenny HernandezMary HerkertNetwork OperationsJan BurtonContractsAccountantKathy WayLaura GrossAdministrativeAssistantRebekah BicklingExecutive Assistant/Admin Supervisor/HR LiaisonAdmin AssistantBrandi MasonJimmie Adams Admin Assistant/ReceptionistPaula Pressler-TashQuality Management/Utilization ManagementIbelice RiveraQuality SpecialistLaura CronkQuality Manager/Data Operations AnalystMarcia MonroeProvider ServicesKay DoughtySpecialty ServicesAdult ServicesChildren’s ServicesTampa Office
43 Current Organizational Structure Defined by Functional Roles District 8 OfficeLinda McKinnonChief Executive OfficerNancy RossbackReceptionist/Admin AsstBrian MogoskyDirectorRick SanefskiQI ManagerJennifer FormicaData SpecialistSusan LangConsumer AffairsManagerCollaborating for Excellence in Behavioral Health ServicesAugust 16, 2004
44 Building Administrative Capacity Quality Management Performance ImprovementProgram Evaluation – Specialized reports, outcomes improvement, best practice identification, outlier review, customer satisfactionPerformance Compliance - Corporate service validation, regulatory compliance and oversight, clinical pathway complianceUtilization Management - Clinical UM development and oversightOutcome/Data Management - Data and outcome validation, tracking and reportingTechnical Assistance and TrainingAccreditation
45 Building Administrative Capacity Provider Services Credentialing and profilingClinical systems developmentBest practice implementationTechnical assistanceProduct developmentService developmentProvider information and orientationManagement of training resourcesConsumer, stakeholder, purchaser and provider satisfactionComplaints and grievance
46 Building Administrative Capacity Financial Management Financial reporting and forecasting requires tracking, analysis and reporting of the following:Rate Setting and development methodologiesProvider allocationsCost accounting systemRevenue maximization strategies/ internal resource managementFunding utilization and cash flow analysisAgency reconciliationAccounts payable and receivableBudget development and managementInsuranceBoard communication
47 Building Administrative Capacity Administrative Services Information systems and data managementInformation system development and technical assistanceManagement reporting supportContract development, negotiation on and complianceRevenue maximizationProvider resource managementMedicaid maximizationGrant developmentRisk mangmentFacility management
48 Building Administrative Capacity IS Capabilities - Lessons Learned Identify information system needs early on and be willing to invest in them!!Requires identification of software functional needs for:- Network management functions- Claims processing functions- GL linkage and financial functions- Member services functions- Care access functions- Care management and utilization management
49 Building Administrative Capacity Executive Services Board developmentRegional council developmentPurchaser relationsAdvocacyLegalMarketingHuman resourcesOversight of all Network and ASO operations
50 Building Administrative Capacity Lessons Learned Identify potential conflicts of interest (an ASO is not a provider)Be prepared to perform once you have got what you asked for – greater flexibility has its own set of requirementsDon’t over-commitBe prepared to act on opportunism quicklyUnderstand the implications on providersDevelop a strong relationship with the BoardThis is a partnership with all stakeholders and requires open communication and trustASOs are not “one size fits all”
51 Chief Executive Officer Nancy HamiltonChief Executive OfficerOperation PAR
52 Provider/Member’s View PARProvider/Member’s ViewTwo-Hatters in Provider Sponsored NetworksCFBHN
53 “We have met the enemy & he is us” Pogo Keep this in mind…..ALWAYS!!
54 Holy Cow…What will become of us…will we survive??? FeelingsHoly Cow…What will become of us…will we survive???I’m so confused…what to do…get on the bus…or find my self hitchhiking later??
55 Contracting thru The ASO OpportunitiesFlexibilitySharing expertiseSustainabilityGiving up control to gain some control over the unpredictability of politicsRespond to the needs of the communityImprove quality of servicesChallengesOur invoices will now be matched to the information in the data warehouse. The network is not going to hold up invoices for the first couple of months (good) but could be problematic in the futureInvesting in the network meant reduction in revenues – invest today for potential higher returns later – scary, hard to explain to Board & staff
56 Testimony – the CFORenegotiating contract – reduced tedious financial reports required in the past.At negotiation, all reimbursement rates were increased to the model rate, less the admin. rate, which resulted in increased rates for most of our servicesContract was restructured to allow us more flexibility to spend dollars among cost centers. Don’t have to go through contract amendments to move dollars aroundEnd of the year, the network was able to re-allocate funds due to lapse dollars. Since PAR was over-producing units in some of the cost centers, we were able to share in this reallocation – Next year who knows
57 Testimony – VP of ISASO must have an excellent data system & provide “value added” or this is just an extra expense to providers/partners within the ASO. I don’t think I can emphasize this enough. The data system MUST be easy to use & not place additional demands on the providers; one thing providers do NOT need is additional demands or requirements.Offer an IS system for those smaller agencies & providers that do not have any IS system at all. This could be just client services & state reporting or it could be for other functions as well like HR, etc.IS should be involved strategically (like at CFBHN) & involved in the process assuming there is the appropriate staff to do so. This will produce better IS systems and processes & since ASOs move great amounts of data, it is so important that we have IS systems that minimize paper movement & increase automation.
58 Re-engineering (infrastructure, conceptually, & philosophically) BudgetingData ManagementQ.I.HR / CredentialingBilling / ReportingBusiness / Strategic PlanningSystem of Care Planning
59 ASO ExpectationReflect commitment to community driven, consumer centered care:Increased accessibilityContinuous care approachesIntegration with other systems
61 Sticking Points Large vs. Small Agencies Mental Health vs. Substance AbuseComprehensive Providers vs. Niche ProvidersLocal vs. Remote HeadquartersInclusiveness: Members, Vendors, Purchasers, Stakeholders & ConsumersRight of First RefusalMarket Share Protections
62 Eligibility (Factors for Membership Decisions) AccreditationFinancial Buy-in to MembershipCurrent Contractor for Anticipated“Lines of Business”Medicaid ProviderDemonstrated ethics & conformance with requirements of Member / Vendor AgreementsIn good standing with current funders
63 One Big Happy Family??? Young & Old – Big & Small Naive & Jaded Quiet & NoisyUnique PersonalitiesConflict / ResolutionsIn it for the long haul / RecommitmentAgree to DisagreeSafety in numbers / One for all – all for oneSometimes the needs of the many outweigh the needs of the few or the one…other times? Mr. Spock
64 Thank you for your attendance and participation!! For more information…Contact:Richard BrownThe Agency for Community Treatment Services4612 North 56th StreetTampa, FLphone <> faxNancy HamiltonOperation PARth Street NorthPinellas Park, FL 33782phone <> faxBob HolmDepartment of Children and FamiliesSAMH Program Office11351 Ulmerton Road, Suite 329Largo, FLphone <> faxLinda McKinnon719 US Highway 301 SouthTampa, FLphone <> fax <> cellThank you for your attendance and participation!!