Marketing to Payers: A Guide to Building Relationships & Finding New Opportunities with Health Plans & ACOs

Transcription

1 Marketing to Payers: A Guide to Building Relationships & Finding New Opportunities with Health Plans & ACOs The 2017 OPEN MINDS Management Best Practices Institute August 17, :00pm 5:00 pm Steve Ramsland, Ed.D., Senior Associate, OPEN MINDS York Street, Gettysburg, Pennsylvania Phone: info@openminds.com

2 Agenda I. A Marketing Framework For Behavioral Health Organizations II. III. IV. Marketing To Managed Care Plans: The Basics A Six-Part Plan For New Contract Development Questions & Discussion 2

3 A Marketing Framework For Behavioral Health Organizations

4 Peter Drucker, On Marketing The business enterprise has two and only two basic functions: marketing and innovation. Marketing and innovation produce results; all the rest are costs. Peter Drucker, The Practice of Management,

5 Drucker s Five Questions The Five Most Important Questions You Will Ever Ask About Your Nonprofit Organization*: What is our mission? Who is our customer? What does our customer value? What are our results? What is our plan? These Five Questions provide the framework for your Payer Contracting Plan Drucker, Peter F

6 Developing A Plan For New Payer Contracts Provider organizations can optimize their business development budget by adopting a 6-part plan for developing new payer contracts: External Market Analysis Internal Marketing Analysis Payer-Focused Service Line Development Contract Development Performance Management Payer Relationship Management 6

7 Marketing To Managed Care Plans The Basics

8 The Changing World Of Health Plans Medical loss ratio limitations Smaller subsidies for plans on health exchanges Downward pressure on rates and increased competition (from each other and from ACOs) Focus on human service coordination for consumers with complex needs Consolidation to gain scale in operating costs Backward integration via acquisitions and gainsharing reimbursement arrangements with providers Large investments in technological substitution 8

9 Building Successful Partnerships With Managed Care Improving Your Positioning The fee for service payer network contract Being preferred within a payer network Gaining exclusivity within a payer system 9

10 The Fee-For-Service Payer Network Contract Most fundamental of all business relationships for provider organizations in health and human services Often need to begin with privileging professionals individually, rather than being privileged at the organization level Difficult market position but often necessary No assurance of volume and no likelihood of referrals Often commodity positioning 10

11 The Goal: Preferred & Exclusive Being Preferred Within A Payer Network Having preferential referrals due to some market differentiation Need a demonstrable value proposition almost always involving P4P or value-based payment Gaining Exclusivity Within A Payer System Having a financial relationship (most often with significant financial risk) that gives you exclusivity by geography and/or consumer type Your organization is the narrow network 11

12 External Market Analysis Part 1 of the 6-Part Plan for New Contracts

13 External Market Analysis: 4 Steps 1. National Market Trend Analysis 2. Local Payer Market Mapping 3. Payer Contracting Analysis 4. Competitor Analysis 13

14 1. National Market Trend Analysis 1. Expansion Of Managed Care Models 2. Focus On Reduction Of Health Care Costs & Integrated Care Models 3. Transition From Volume To Value Payments For Provider Organizations 4. Blurring Of The Role Of Payer & Provider 5. Increased Competition & Consolidation Of Provider Organizations 6. Technology Changing The Nature Of Service & Competition 14

15 Strategic Implications Of National Trends Preference for risk-based contracts with provider organizations creating narrow networks Technology requirements (of P4P, of compliance, of consumer preference) increases need for economies of scale for investment Health plans have already begun using technological substitution for services and expect contracted providers to work with them and the tools they have developed Health plans expect providers to be partners in population health management including sharing data and financial risk Health plans will purchase or partner with larger providers if they do not believe your services will be responsive Role of provider marketing increasing 15

16 2. Local Payer Market Mapping: Who Are The Payers In Your Market? XXXXXXXXXX Payer Market Map Payer Profiles Last updated: April 1, 2013 Government Insurers Total Enrollment (CA) Enrollment, San Diego Enrollment, Imperial Enrollment, Orange Enrollment, San Bernardino Enrollment, Riverside Headquarters Street Address City Medicare 5,000, ,583 2, , , ,359 MediCal 7,339, ,494 55, , , , Capitol Ave., MS 4400 Sacramento Tri-Care/Military (UnitedHealthcare beginning April 1,2013) 290,219 1,823 20,586 49,946 43, Market St., 27th Fl. San Francisco Blue Shading indicates plan with enrollment threshold to complete demographic research for this plan Note: Medicare Advantage Enrollment data does not include numbers <10 in each county according to Health Plan Sample Data Some Medicare Advantage plans are under same plan name/entity but have a different contract number with CMS, therefore under separate columns (Plan ID included in the last column) Medicare Advantage Total Enrollment (CA) Enrollment, San Diego Enrollment, Imperial Enrollment, Orange Enrollment, San Bernadino Enrollment, Riverside Headquarters Street Address City Aetna Health Of California, Inc. 25,452 1,844 2,410 5,837 6,813 P.O. Box Van Nuys Anthem Blue Cross Life And Health Ins Company 37,375 4, , , Beale Street San Francisco Blue Cross Of California 12,251 1, ,420 2, Beale Street San Francisco California Physicians' Service 66, ,124 4,422 2, Beale Street San Francisco Care1st Health Plan 30,369 7,288 1, Potrero Grande Drive Montery Park Caremore Health Plan 51, ,321 3, Park Plaza Drive, Suite 150 Cerritos Central Health Plan Of California, Inc. 12, , Bridgegate Drive Diamond Bar Citizens Choice Healthplan 14,388 1,113 1,543 3, Studebaker Road, Suite 200 Cerritos Community Health Group 1,221 1, Bay Blvd Chula vista Easy Choice Health Pla Inc. 53,767 1, ,569 3,220 7, East Ocean Boulevard, Suite 700 Long Beach Health Net Of California 138,335 12, ,320 10,884 14, Burbank Boulevard, B3 Woodland Hills Humana Health Plan Of California, Inc. 20,961 2,329 1,439 1,449 3, Avenida Encinas, Suite N Carlsbad IEHP Health Access 9,452 5,034 4, East Vanderbilt Way, Suite 400 San Bernardino Inter Valley Health Plan, Inc. 20, ,859 8, South Park Avenue, Suite 300 Pomona Kaiser Foundation HP, Inc. 881,902 70, ,975 41,118 40, Lakeside Drive, 13th Floor Oakland Molina Healthcare Of California 7,469 1, , Oceangate, Suite 100 Long Beach 16 Orange County Health Authority 14,646 14, City Parkway West Orange

17 Local Market Insurance Coverage (Example) 10% 4% 39% Commercial* Medicaid** Medicare** Dual-Eligibles 34% * Commercial enrollment includes employer-sponsored and administrative-services-only members ** Without dual-eligibles 17

18 Local Market Health Plan Enrollment (Example) 0 50, , , ,000 Market Share 50, ,000 17% 33% 100,000 50% MCO3 MCO2 MCO1 18 * Includes all commercial, Medicaid, Medicare and TRICARE enrollment ** Projected

19 Local Market Commercial Insurance Enrollment (Example) Self- Insured* 13% Ratio Enrollment 1,623,230 1,505, , ,854 Fully Insured 399, ,000 1,000,000 1,500,000 2,000,000 *Includes TRICARE MCO1 MCO2 MCO3 MCO4 MCO5 ** 19

20 Major Employers in Region (Example) 0 20,000 40,000 60,000 80, , , , ,000 Local County 150,000 Local Unified School District 110,000 City U.S. Government 90,000 85,000 State Of CA 65,000 Company A Company B Company C 30,000 28,000 25,000 20

21 Managed Medicaid (Example) Managed Medicaid Enrollment Total Beneficiaries Local State 4,221,599 12,697,685 1,764,514, 60% 961,390, 33% Percent Of Population 39% 33% MCO-Managed Title 19 Medicaid 2,928,273 9,742,931 MCP 1 MCP 2 MCP 3 192,684, 7% MCO-Managed CHIP MCO-Managed Medicaid Total-MCO Managed Medicaid % 77% 21

22 Managed Medicare (Example) 90,000, 24% Managed Medicare Enrollment 70,000, 18% Total Beneficiaries Percent Of Population Local State 1,469,395 5,539,335 13% 14% 200,000, 53% mco1 mco2 mco3 Other 20000, 5% Medicare HMO 380,000 2,113,311 Medicare PPO 6,418 39,403 Medicare PFFS 0 4,272 MCO-Managed Medicare Percentage 26% 39% 22

23 Commercial ACOs (Example) Commercial ACO Market Share 20% 7% 53% ACO-like models for Medi-Cal (Whole Person Care Pilots, Health Home Program) are currently In development 20% mco1 mco2 mco3 mco4 23

24 3. Payer Contracting Analysis Review market mapping data and prioritize health plans for contracting outreach Based on factors such as covered lives, populations served, behavioral health management model Call/meet with health plans to learn more about their: Local market network needs/gaps, and priorities Populations and geographies covered Plans for network growth to meet new contract needs General contracting requirements Preferred Provider models and requirements Value-Based Purchasing initiatives Clinical, administrative & technical resource sharing with network providers Interest in, and process for developing new service lines to meet payer needs Develop Payer Strategy Playbook 24

25 Payer Strategy Playbook Example Sample Data 25

26 4. Competitor Analysis Create a list of your main competitors in your geographic service area or expansion area Create a list of other possible competitors in your state and national competitors entering your market Conduct market research regarding their programs and market share Analyze your data to gain a knowledge of who are competitors and who are not competitors 26

27 Competitor X Behavioral Health Services 1. Website: 2. Primary Organization Function: Behavioral health professional medical corporation 3. Primary Markets: 27 Children & Family Services Annual Revenue: $ Profit/Loss: $ Profit Margin: $ Behavioral Health Services Programs/Services Offered: 1. Outpatient psychiatric & psychological services 2. In-home psychological services 3. Specialty psychiatric evaluations 4. Skilled nursing and med/surg psychiatric consultations 5. Inpatient utilization review 6. Outpatient psychiatric and psychological utilization review 7. Psychiatric stabilization 8. ECT 9. Behavioral risk assessments 10.Crisis Assessment Stabilization Team

28 Pay Attention to Potential Competition From Consolidator Companies More RFPs & Competition For Contracts At All Levels In The System Consolidator Companies Have Increasing Market Clout 28

29 Meet The Provider Consolidators Universal Health Services, Inc. FY2016 $9.77Billion Boys Town F FY2014 $194 Million ResCare FY2013 $1.6 Billion Resources For Human Development F FY2016 $262.5 Million Pathways By Molina FY FY2014 $1.7 Billion Centerstone F FY2013 $310 Million Acadia Healthcare FY2015 $1.8 Billion KidsPeace F FY2015 $126 Million NHS Human Services FY2016 $523.3 Million Vinfen F FY2015 $125 Million 29

30 Strategic Implications Of Increased Competition & Consolidation Of Provider Organizations Increased competition for payers and consumers due to geographical expansion by large health systems Increased competition in less populated geographical service areas due to online health assessments and remote clinical visits Opportunities to collaborate or merge with large consolidated organizations Development of preferred networks by ACOs with expectation that majority of healthcare services are in network 30

31 Group Exercise #1: External Market Analysis Form small groups and consider the following: What MCOs & ACOs are in your market? What needs do you suspect that MCOs & ACOs may have in your market that you can help them meet? What experience have you had in developing solutions to MCO/ACO needs like these? Who are your main competitors? Share: Your insights with the group 31

32 Internal Marketing Analysis Part 2 of the 6-Part Plan for New Contracts

33 Internal Marketing Analysis There are 3 key components to an Internal Marketing Analysis the starting point of a focused plan for winning new contracts: 1. Organizational Strategy Review 2. Managed Care Capabilities Review 3. Population Health Management Capabilities Review 33

34 Internal Marketing Analysis: Organizational Strategy An essential component of a focused play for payer contracts is to review, understand, and (if necessary) revise your: Organizational Purpose Services Primary Customers Target Populations Value Proposition 34

35 Common Strategic Questions For BH Providers What are we hoping to achieve? How do we leverage our capabilities to deliver managed care-ready services to our market? What are the gaps between our current competencies and the competencies we need to succeed? What services, populations, and customer-types do we need to focus on? What is our value proposition? 35

36 Internal Marketing Analysis: Managed Care Capabilities Before seeking managed care contracts, it is important to assess your organization s managed care capabilities in 3 broad areas: 1. Administrative Capabilities 2. Clinical Capabilities 3. Technology Capabilities 36

37 Administrative Capabilities For Managed Care Contracting Success Marketing and contracting functions payer contracting, referral development, and consumer choice Systems to facilitate administrative processes of FFS managed care and value based purchasing preauthorization, clinical criteria, documentation Revenue cycle management billing and collections for both payer and consumer Development of services that are customer preferred in terms of value both payer and consumer 37

38 Clinical Capabilities Valued By Managed Care Payers Rapid access Integration with medical and behavioral partners Evidence-based practices aligned with payer needs Peer and/or family support models Centers of excellence Telepsychiatry y Web-based member engagement and social networking options Data management that informs service delivery ED/Hospital diversion & care transitions 38

39 Health IT Tools To Succeed In Managed Care Population Health Analytics Health Information Exchange Risk Stratification & Predictive Clinical Analytics Remote Monitoring Web-Based Consumer Self- Management Telehealth Patient Portal Automated Outreach Referral Tracking Electronic Health Record 39

40 OPEN MINDS Managed Care Readiness Assessment The OPEN MINDS Managed Care Readiness Assessment was designed to help provider organizations to identify the operational and clinical elements necessary to succeed in managed care contracting and the degree to which the organization is ready - or must become ready - in each functional area in order to expand its business opportunities in both fee-for-service and value-based managed care contracting 40

41 Survey Design The Managed Care Readiness Assessment Survey focuses on twelve performance domains: Managed Care Clinical Operations Client Access Marketing Managed Care Marketing Technology Metrics Management Quality Management Compliance Management Margin Management Revenue Cycle Management: Admissions Revenue Cycle Management: Billing Revenue Cycle Management: Collections 41

42 Survey Rating Scale Respondents rate each sub-topic measure on a Likert Scale from 1-3. Respondents also have the option to answer Unsure for any measure for which they feel they do not have enough information to score on the 3 point Likert Scale. For Measures Related To Organizational Leadership (Included in the Leadership Performance Domain) Respondents scored their organizational leadership on a 3-point Likert Scale, where a score of 1. 1 = the measure was perceived as a characteristic not attributable to organizational leadership 2. 2 = the measure was perceived as a characteristic somewhat attributable to organizational leadership 3. 3 = the measure was perceived as a characteristic that was attributable to organizational leadership For All Other Measures Respondents scored the remaining measures on a 3- point Likert Scale for each sub-topic question, where a score of 1. 1 = the managed care capability is currently not in place 2. 2 = the managed care capability is currently not in place, but implementation was in process 3. 3 = the managed care capability is currently available 42

43 Average Of Likert Scale Ratings Survey Example: Overall Average Readiness Score By Respondent Average For All Respondents:

44 Survey Example: Overall Average Score (By Performance Domain)

45 Survey Example: Domain I, Managed Care Marketing (Readiness Results by Question) Question Average Score Ready? 1. You have a centralized managed care marketing capability responsible for a. Developing and maintaining mutually beneficial relationships with managed care organizations b. Understanding MCO priorities and communicating those priorities throughout the organization 1.55 NO 1.62 NO c. Negotiating contracts with MCOs 1.80 NO d. Working with clinical, financial, and operational leadership to align internal practices with MCO expectations and contract requirements 1.82 NO e. Assessing your compliance with MCO contract requirements 1.56 NO f. Understanding MCO reporting and data exchange requirements 1.56 NO g. Maintaining phone numbers and for key MCO provider relations staff 2.30 IN PROCESS 2. You currently have one or more contracts in place with managed care organizations (MCOs) 2.91 YES 3. Your managed care contracts are profitable 3.00 YES 45 Managed Care Marketing

46 Group Exercise #2: Internal Analysis Form small groups and consider the following questions: What are your organization s key strategic strengths for managed care contracting? What challenges/gaps do you anticipate facing in a managed care marketing strategy? What is your value proposition? Share: Your insights with the group 46

47 Payer-Focused Service Line Development Part 3 of the 6-Part Plan for New Contracts

48 Payer-Focused Service Line Development Strategy Focus on understanding the needs of the customer and developing a solution (rather than selling the services currently offered) Meet with payers to identify problems and concerns Develop services that address those payer problems 48

49 3. Developing A Service With The Payer Value Proposition In Mind Concept development Service description Cost/benefit or ROI analysis 1. Concept Proposal development Contracting Implementation 5. Revisions Concept Development Cycle 2. Build Expansion 4. Feedback 3. Test 49

50 Find The Service Line Sweet Spot What s important to your customers? What do you do best? What can you do that no one else can? 50

51 Opportunities for Specialist Organizations Are Many Behavioral health service system sub-capitation Specialty care coordination for consumers with behavioral disorders Specialty center of excellence programs for acute conditions Behavioral health consultation in officebased service locations live or via telehealth Management of specific acute episodes or chronic conditions via case rate or episodic/bundled payment Management of shortterm inpatient psychiatric and addiction treatment programs Psychiatric consultation live or via telehealth in hospital emergency rooms Behavioral health consultation program for inpatient programs live or via telehealth Hospital diversion programs Specialty behavioral health ER/crisis stabilization Hospital readmission prevention programs Community-based/mobile crisis response Home-based service delivery Specialty primary care 51

52 Key Considerations When designing your MCO offering, ask yourself: What s in it for them (MCO)? How does your service offering enhance their business goals? Does your model deliver what the MCO wants, and nothing more to distract from the value? What is the most advantageous pricing structure/model for them and for you? Can you design a better value proposition than your competitors? 52

53 Contract Development Part 4 of the 6-Part Plan for New Contracts

54 Contracting Process 1. Solicitation 2. Application and contract review (includes credentialing process by the payer) 3. Rate negotiations 4. Rate and contract language finalization (signatures) 5. Implementation (operationalfacility/clinician) 54

55 Contracting Process: Solicitation Identify major payers and health plans operating in your geographical area and research covered lives, major clients, employers served, etc. Become familiar with all on-line contracting and credentialing processes, forms, and requirements Initiate contact with personnel responsible for contracting (provider relations, facility contracting) Send introductory information regarding services your organization offers 55

56 Contracting Process: Application & Contract Review Health plans interested in contracting with facility providers utilize a facility application to credential the facility (JCAHO, State License, malpractice insurance requirements, program descriptions) Health plans interested in contracting with individual professionals mainly use the CAQH web site for their credentialing and have standardized take it or leave it contracts for individuals and/or groups 56

57 Contracting Process: Application & Contract Review A sample contract is sent to the prospective provider organization for their legal review (usually the most time consuming art of the process for facility contracts) Facility fill out the application, attach the appropriate licenses, accreditations, malpractice insurance, and program descriptions to the health plan Some health plans may require on-site review of your organization 57

58 Contracting Process: Rate Negotiations Rate negotiations take place between the health plan and the provider organization For individual services delivered by individual clinicians, most payers only offer fixed fee schedule For programmatic services, health plans have a limited range of acceptable rates (most rates are per diem) Areas of contention created in what is included in the per diem (physician fees, drug screens, aftercare sessions, assessments) 58

59 Contracting Process: Rates/Contract Language Finalized Provider organizations make proposed language changes for the contract and sends them to the health plan for review and modification and/or acceptance of language changes [NOTE: this is not the case with individual professional services] The health plan sends counter proposed language changes to facility Once language is settled, rates are confirmed via letter to the respective organizations 59

60 Contracting Process: Implementation Communication to the appropriate departments regarding the provisions of the contract is initiated The signed, executed agreement is sent to the person responsible for contract management Conduct training in-services to review the health plan s administrative and clinical policies Develop administrative and clinical tools to assist line staff in effective management of the contract 60

61 Performance Management Part 5 of the 6-Part Plan for New Contracts

62 Performance Management: Delivering On Your Promises Demonstrate outcomes Clinical effectiveness Client access Process efficiency Reduced inpatient utilization HEDIS and other national measures Follow through on contractual and clinical expectations Demonstrate operational excellence via national accreditation, licensing and MCO site visits 62

63 63 63

64 Performance-Management For Value-Based Payments Increased transparency of performance Increases pressure for improvement Facilitates consumer-directed care Reimbursement linked to desired performance Improved access to care Increased care integration and coordination Focusing on controlling costs of care Financial incentives to help consumers become and remain healthy for longer periods of time Increased lower-cost interventions for not yet seriously ill population Reduced unnecessary use of high-cost services 64

65 Performance & The Pay-For-Value Continuum Small % Of Financial Risk Moderate % Of Financial Risk Large % Of Financial Risk Fee-forservice Performanc e-based Contracting Bundled & Episodic Payments Shared Savings Shared Risk Capitation Capitation + Performanc e-based Contracting No Financial Accountability Moderate Financial Accountability Full Financial Accountability Management Via 100% Case By Case External Review Internal Ownership Of Performance Using Internal Data Management Passive Involvement Provider Engaged Provider Active In Management Providers Assumes Accountability 65

66 Payer Relationship Management Part 6 of the 6-Part Plan for New Contracts

67 Essentials Of Payer Relationship Management Treat the MCO like a partner not an adversary Communicate Develop relationships with clinical and network staff Participate in periodic meetings with MCO clinical staff Learn about their needs and plans, and how you can help them Keep them informed about you Track your outcomes, share your data, talk about your accomplishments 67

68 Partnering With MCOs: Innovate Be creative - conduct pilots and share what you learn Integrate with medical and behavioral partners Evidence-based practices Peer and/or family support models Centers of excellence Telepsychiatr y Web-based member engagement and social networking options EMR and data management Submit claims electronically and promptly 68

69 Group Exercise #3: Putting It All Together Form small groups and: Design a New Service for an MCO s commercial membership. Include the following components: Program Description Core Services Delivered Staffing Outcome Measures Contract Reimbursement Model Share: Present your initial sketch of the new program design to the group 69

70 A Closing Thought The aim of marketing is to know and understand the customer so well that the product or service fits him and sells itself. -Peter Drucker 70

71 Questions & Discussion

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