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A Managed Care Organization for the Entire Family PPC to Advicare: Making the Transition Presented to: Office of Rural Health July 23, 2013.

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Presentation on theme: "A Managed Care Organization for the Entire Family PPC to Advicare: Making the Transition Presented to: Office of Rural Health July 23, 2013."— Presentation transcript:

1 A Managed Care Organization for the Entire Family PPC to Advicare: Making the Transition Presented to: Office of Rural Health July 23, 2013

2 Medicaid Update Company Structure

3 Cesar D. Martinez, MBA, MPA Executive Director, Advicare CEO, PPC Health Plan Management Gerald Harmon, MD Medical Director Mikki Barrett, BSN, RN Director, Care Management Bea Prashad, RN, BSN, MBA, CNOR Team Leader, Care Management 1.Donna Steele, LPN, 2.Rhonda Dowie, RN Case/Disease Management Deryl Macaulay, RN Utilization Management LaTasha Bomer, LMSW Social Work Open Quality Management Kisha Price Director, Claims and Provider Data Management 1.Sherrie Marrapode 2.Dilsa Bailey 3.Raquel Soto Provider Credentialing 1.Nikki Moore 2.Shanitha Robinson 3.Yvonne Bishop Claims Service Center Dell Jeter Director, Network Management Mary Wasden, MBA Manager/Team Leader, Provider Relations 1.Kelli Williamson 2.Joan Reeves 3.Jeanne Watson 4.Pam Boyd 5.Jodi Key 6.Wendy McCrea 7.Neshelle Miller 8.Pat Rubio Provider Relations Representatives Kisha Price Director, Customer Service Flavia Figueroa Team Leader, Customer Service 1.Karen Cantrell 2.Yesenia Perez 3.Ruto Soto 4.Charlene Carter Customer Service Representatives Open Appeals & Grievance Coordinator Tandi Card, JD Director, Compliance and Human Resources Joe Lowry, CPA VP, Finance, Administration Board of Directors Patrick Caster President Organizational Chart May/June, 2013 Ken Meinke CFO Kathryn Gailey, JD, MPH Compliance Officer Toni Hunter Manager, Training and Human Resources Open Associate Medical Director Clara Figueroa Administrative. Assistant Harold Moore CIO, Information Services 2

4 Medicaid Update DHHS / Medicaid Update

5 Medicaid Update Data Source: SCDHHS, July 2012 3

6 4 Medicaid Update 170,000 205,000 Eligible Under Current Medicaid Rules Will Enroll In Medicaid Managed Care Per Individual Mandate Data Source: SCDHHS and Milliam, July 2012 236,000 ACA Expansion Potential New Membership

7 5 Medicaid Update Data Source: SCDHHS, October 2012 SCDHHS meets promise to insure more poor children through ‘Express Lane’ eligibility Posted 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.

8 Company Update Company Overview and Update

9 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

10 8 Start-Up EQRO Audit 92% Approved in 46 th 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 20,225 Members Statewide July Effectives SCDOI: Approves HMO License

11 2 Service Area - Driven by Provider Network 20,225 Members Statewide Jul 1 Effectives

12 Hospital Contracting As of 07/09/2013 Phase 3 Phase 2 Phase 1 Tenet HCA 4 Phase 4

13 Innovation in Care Coordination: System Features and Sample Screen Shots of Web Based System Available to Providers and PPC Staff Innovation in Care Coordination

14 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 Customer Service Quality Management Medical Economics Use of Evidence-based Clinical Practice Guidelines and Protocols: National Guidelines Clearinghouse™ (NGC) System integrates Interqual Medical Guidelines 18 CLOUD SYSTEM 1. NCQA HEDIS & P4P Certified

15 Innovation in Care Coordination – 2012 PIPs 19 PIPs NCQA QI Format PIP Goal Results 1. Maternity Initiative (SBIRT)Improve Quality & 1. Decreased Costs in Lower Mater./NICU Cost‘12 by $3.50pmpm 2. Prenatal & Postpartum Care HEDIS ~ 90% percentile; State is < 25% 2. Child Immunizations 75 th Percentile of HEDISOver 4K Outreach - Led (EPSDT/Well-Child)~ 40% Improvement Over Baseline (CY 2011) 3. Pediatric AsthmaDecrease Asthma AdmitsAdmits / 1,000 dropped to 2.8 from 9.3 in ‘12 over ‘11 4. Member RecertificationAt or Better thanDisenrollment Rate 5% Disenrollmentdropped to 8% from 11%

16 Innovation in Care Coordination – Risk Profile Membership Profile - As of 1Q2012 20 Membership Profile - As of 1Q2013 Risk Level Improvement

17 Innovation in Care Coordination Provider Monthly Panel for Patients to PCPs with Risk Score 21 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.

18 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 22

19 “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 Staff Full 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 23

20 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 24

21 Innovation In Care By 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. 25 Advicare Risk Adjusts All Members and Performs Predictive Modeling

22 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)

23 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.

24 Website : A Medical Home Network for the Entire Family Home Page Goals of the MHN Career Contact Us Home Page Welcome 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 C ontact 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. 26 1.On-Line PCP Directory 2.Provider Manual 3.Clinical Guidelines 4.Clinical Action Plans 5.Drug Look-Up 6.Pharmacy Look-Up 7.Download Forms 8.Member Benefit Information 9.Member Enrollment 10.Receive News & Updates

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