Risky Business: Crystal Run Health Plans. Michelle A. Koury, MD Jonathan Nasser, MD Crystal Run Healthcare
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1 Risky Business: Crystal Run Health Plans Michelle A. Koury, MD Jonathan Nasser, MD Crystal Run Healthcare
2 About Crystal Run Healthcare Physician owned MSG in NY State, founded 1996 >350 providers, >30 locations ASC, Urgent Care, Diagnostic Imaging, Sleep Center, High Complexity Lab, Pathology Early adopter EHR (NextGen ) 1999 Accredited by Joint Commission since 2006 (1st in NY State) Level 3 NCQA PCMH since 2009
3 Outline Why form a health plan Licensure Process Products Marketing and Sales Network and Contracting Medical Management
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5 Get To The Premium Line
6 Evolution to Risk EHR
7 Evolution to Risk Care Manager Program EHR
8 Evolution to Risk Joint Commission Care Manager Program EHR
9 Evolution to Risk PCMH Joint Commission Care Manager Program EHR
10 Evolution to Risk ACO PCMH Joint Commission Care Manager Program EHR
11 ACO Portfolio Single Entity ACO MSSP April 2012 NCQA ACO Accreditation 2012 (1st in NY) Multiple Commercial Risk Based Contracts 40,000 attributed patients TSO 2016
12 Evolution to Risk Health Plan ACO PCMH Joint Commission Care Manager Program EHR
13 Outline Why form a health plan Licensure Process Products Marketing and Sales Network and Contracting Medical Management
14
15
16 Acquiring a Health Plan License Assemble team Secure Political Support Meet Capital Requirement Hired lawyer, actuary, issued RFP for consultant; assembled lean internal team: Chief Legal Officer, Executive Director, VP of Operations, Data Analyst Met with Secretary of Health, outlined CR goals for developing health plan products, clarified lack of intention to compete with large national health plan players Raised capital in lease-buy back arrangement with REIT to: Meet state reserve requirement of 12.5% of 3rd-year premiums Cover start-up costs Submit Application Design plan benefits Develop Network Went live selling commercial small group, large group and individual products, off-exchange June 2015; selling Medicaid products off-exchange March 1, 2016 Studied benefit design of other successful plans in market; based plan design on popular products Crystal Run physicians make up majority of the network; contracted with other providers to fill gaps in services.
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18 Commercial vs. Medicaid Key Differences Licensure Process Regulatory Oversight Medicaid DFS High Commercial DOH Medium Sales: Brokers vs. Enrollers Enrollers Brokers Network Core Core & Extended
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20 Outline Why form a health plan Licensure Process Products Marketing and Sales Network and Contracting Medical Management
21 Crystal Run Health Plans Org. Chart Crystal Run Healthcare, LLP Crystal Run Health Group Finance Chair Donna McGregor VP Finance0. Crystal Run Health Plan Crystal Run Health Insurance Company
22 Crystal Run Health Plans Internal Leadership Network and Contracting Utilization Management, Quality Management Delegated Claims Pharmacy Benefit, Vision, Dental Behavioral Health
23 Products Exclusive Provider Network (EPO) Commercial 2 Tiers of networks: core and extended (no out of network coverage) Members encouraged to choose PCP, referrals not needed Preferred Provider Network (PPO) Commercial 3 Tiers: core, extended and out of network Members encouraged to choose PCP, referrals not needed Health Maintenance Organization (HMO) Commercial and Medicaid In network coverage only PCP selection required, referrals not needed
24 Products Crystal Run Health Plan Product Offerings Health Maintenance Organization (HMO) Exclusive Provider Organization (EPO) Preferred Provider Organization (PPO) Plan Description: Only cover care provided Within the Crystal Run Network, does not require PCP referral to see specialists Covers two tiers of out-of- Network providers; does not require PCP referral To see a specialist Covers two tiers of out-of- Network providers at a Higher out-of-pocket cost; Does not require PCP Referral to see specialist Target Market: Medicaid managed care Patients, individual offexchange Employer-insured Patients who are looking for lower-cost network Employer-insured Patients who are generally resistant to HMOs Premium Price Network Breadth
25 Outline Why form a health plan Licensure Process Products Marketing and Sales Network and Contracting Medical Management
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27 .many changes are pushing providers to adopt population health management strategies. One of the most potent is the emergence of PSHPs. These plans offer numerous benefits to providers including acquisition of PHM skills, understanding and management of insurance risk, and integration of medical operations with the end goals of improved quality at a lower cost.
28 The new venture could cause insurers to view CRH in a negative light according to Jim Bonnette, executive VP of consulting and management at the Advisory Board Company. An insurance company is not going to look favorably on new competition on the block, he notes.
29 Eligible Members Employers in Orange or Sullivan county Small businesses ( small group ) of employees Large businesses ( large group ) of >100 employees. Medicaid eligible 2016 Individuals
30 Marketing Message Different for Consumers, Employers Marketing Message Marketing Channels Enrollment estimates rounded to the nearest 10. Small group non-exchange enrollees make up majority of commercial HMO projected enrollees. Consumers Concierge medicine for all Print TV Radio Broker community Employers We deliver personalized service dedicated to meeting our members every healthcare need Broker community More than 50% of both consumer, employer-oriented marketing done through brokers Projected Enrollment by Year-End ,309 Commercial HMO members 2 3,363 Medicaid HMO members 2,798 Large group, small group EPO/PPO members 7,470 TOTAL MEMBERSHIP
31 Outline Why form a health plan Licensure Process Products Marketing and Sales Network and Contracting Medical Management
32 Statistically, 100% of the shots you don t take don t go in.
33 Network Core Network CRHC providers along and 6000 directly contracted providers in Orange and Sullivan counties Extended Network partnership with MagnaCare & First Health, provides statewide and national networks
34 Crystal Run Health Plans Network Current Service Area: Orange and Sullivan Crystal Run Health Plans (6,100 + providers) MagnaCare (68k + providers) First Health (540k + providers)
35 Network Contracting to Fill Holes, Meet Network Requirements Most Health Plan Members to Receive Care Exclusively from Crystal Run Physicians Members Expected to receive care Exclusively from Crystal Run physicians Crystal Run Contracts with Other Providers to Fill Gaps in Services Members Expected 90% to receive care 10% State-wide IPA Exclusively from Skilled nursing facility Non-Crystal Run Local hospitals physicians Dental providers Rehab centers Pharmacy benefits
36 Contracting Strategy Fee For Service Driving Volume to Favorable Rates Value Contracts Shared Savings Benchmark based on Actual vs Budgeted MLR Bonus Pool (60% PCP, 30% hospital, 10% specialists) 4 out of 6 quality measures to earn share of pool
37 Outline Why form a health plan Licensure Process Products Marketing and Sales Network and Contracting Medical Management
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39 CRHP Committee Structure Board of Directors Medical Management Compliance Quality Management Finance Behavioral Health Credentialing Contract Executive Review Clinical Policy Delegation Oversight Physician Advisory Consumer Advisory Appeals & Grievances
40 Medical Management Committee Charter (MMC) Provides oversight and direction for the UM, Case Management, reviews and approves criteria for medical necessity CRHC Capabilities: Case Management, Population Health, Community Partnerships, Analytics
41 Utilization Management Process Criteria Process Philosophy Examples
42 Clinical Policy Committee Charter: Oversight of clinical practice guidelines, utilization criteria, new medical technologies, and the therapeutic use of drugs CRHC Capabilities: Best Practice Council, Variation Reduction, MTM, Medication Management Committee
43 Quality Management Committee Charter: (QMC) Development, implementation and oversight of overall quality program CRHC Capabilities: Quality program, Service Council, JC, Provider Resources, Analytics
44 How CRHP benefits CRHC Contracting and Network Development Percent Premium contracts Facility Engagement Claims Expertise Payer Expertise
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46 Crystal Run Health Plans Membership and Leakage Commercial EPO/PPO Commercial HMO Medicaid HMO Total Membership % outpatient claims within CRHC
47 Top 10 Drugs
48 Crystal Run Health Plans Site of Service Differential Outpatient Procedure Crystal Run/ASC Typical Hospital Percent Differential Colonoscopy $659 $2,000-2, MRI Spine Lumbar W/O Contrast Fragmenting of Kidney Stone $213 $1,000 - $1, $2,311 $6,500 - $7,
49 Crystal Run Health Plans Site of Service Differential Outpatient Procedure Crystal Run/ASC Typical Hospital Percent Differential Colonoscopy $659 $2,000-2, MRI Spine Lumbar W/O Contrast Fragmenting of Kidney Stone $213 $1,000 - $1, $2,311 $6,500 - $7,
50 Crystal Run Health Plans Site of Service Differential OPS- Cardiac Catheterization IP Claims Hip Replacement Hospital A Hospital B WCMC General Medical Admission CHF
51 Crystal Run Health Plans Anecdotal Learnings DRG Impact All generics are not created equal Coding
52 Crystal Run Health: Working Together to Advance Value Integrated Case Management Cost Effective Prescribing Inpatient Care and Impact on Cost
53 Crystal Run Health: Working Together to Advance Value Accurate Risk Assessment and Reporting ER and Hospital Avoidance Site of Service Performance
54 Providers Role in Success of Plan Know Medical Necessity Criteria Don t Blame the Plan Know the Network Understand Impact on Members Provide Great Service
55
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