The Partners For Kids Journey

Transcription

1 The Partners For Kids Journey OSU HSMP Management Institute October 28, 2016

2 Presentation Objectives What is Partners For Kids? Why was Partners For Kids created? What are Partners For Kids goals? How is Partners For Kids structured? How does funds flow work? What have we learned?

3 What is Partners For Kids? Physician-Hospital Organization Accountable Care Organization (with a twist) Member lives attributed to PFK based on the member s: Participation in a managed Medicaid plan Age County of residency Physician s contract status with PFK is not a factor

4 Network By The Numbers 100 NCH-employed and 200 community PCP s 700 NCH-employed and 50 community specialists 1 hospital (Nationwide Children s Hospital) Members 330,000 children

5 Health Plans By The Numbers 5 managed Medicaid plans in Ohio (full-risk capitation, delegated credentialing, delegated care coordination) 9 commercial plans (fee-for-service, delegated credentialing) Service area 34 counties

6 By The Numbers

7 Why Was Partners For Kids Managed Medicaid Created?

8 Why Was Partners For Kids Created? Thousands of Members Contracting Strategy Patient Membership Managed Care Strategy Accountable Care Org. (Population Health)

9 Value is Driving New Business Models and Partnership Strategies Quality Delivery Safety Value Cost

10 Value is Driving New Business Models and Partnership Strategies COM FFS Incentive based FFS FFS P4P Shared Savings / ACO PFK

11 What Are Partners For Kids Primary: Goals? Improving the health of children through high-quality, efficient and innovative care and community partnerships Secondary: Demonstrate that a pediatric ACO is viable model

12 PFK Population vs. Total Population County PFK Members within County Population PFK Members Ages 0-17* Total 0-17 Population ** % of Total Population = PFK VINTON 1,764 2, % MEIGS 2,791 4, % PIKE 3,625 6, % SCIOTO 10,195 17, % FAYETTE 3,534 6, % MARION 7,643 13, % JACKSON 3,987 7, % HOCKING 3,382 6, % JEFFERSON 7,213 13, % LAWRENCE 7,338 13, % MORGAN 1,471 2, % MUSKINGUM 10,957 20, % GALLIA 3,843 7, % ROSS 8,633 16, % CRAWFORD 4,760 9, % COSHOCTON 3,735 7, % PERRY 4,496 9, % FRANKLIN 143, , % GUERNSEY 4,266 9, % ATHENS 5,372 11, % NOBLE 904 1, % MONROE 1,310 2, % HARRISON 1,430 3, % WASHINGTON 5,449 12, % BELMONT 5,598 12, % MORROW 2,703 6, % PICKAWAY 4,584 11, % LICKING 13,277 35, % KNOX 5,036 13, % LOGAN 4,185 11, % FAIRFIELD 11,380 32, % MADISON 3,649 11, % UNION 2,746 10, % DELAWARE 5,888 51, % PFK Counties 310, , %

13 How Is Partners For Kids Structured? Formed as a joint venture (PHO) between Nationwide Children s Hospital, NCH- employed physicians and contracted, community physicians in (c)(3) as of January 2016 The Ohio Department of Insurance considers PFK to be an intermediary organization accepts financial risk, but not a health plan; required to maintain reserves and stop loss coverage

14 Governance Board of Directors comprised of 17 individuals 9 appointed by Nationwide Children s Hospital (including 1 parent of a child enrolled in Medicaid) 8 elected from PFK provider network (3 primary care at least one from a community practice; 2 medical specialists, 2 surgical specialist, 1 hospital-based specialty)

15 Provider Network and Member Access Out of Network Providers Providers Directly Contracted with Payors PFK Member Community Physicians NCH and NCH- Employed Physicians

16 Division of Responsibilities * Delegated for 3 of 5 health plans

17 Partners For Kids Departments Care Navigation Community Wellness Data Resource Center Office of the Medical Director Operations and Network Development Payor Relations

18 Flow of Funds PFK receives capitated payments for each child in the program and pays for their medical costs across the care spectrum

19 Pay for Performance Top to Bottom Alignment ODM State targets measures Health Plans PFK Health Plans incentivized PFK engaged in performance based contract Doctors Physician incentives on HEDIS and Quality

20 Provider Incentive Plan Summary Metrics adjusted annually by Incentive Committee (includes provider representation) Incentives paid quarterly Continues to shift to outcomes-based measures

21 Provider Incentive Sample Quality Health Supervision Visits Members = years old For patients who were eligible and were non-complaint in the prior year preceding the qualifying visit Quality Health Supervision Visits Members = 15 months old Members = 3-6 years old Pharmacy Shared Savings For practices which meet or exceed the established benchmark, receive a portion of the dollars saved through improvements in prescribing patterns Meeting with Provider Relations Rep to review current year incentive plan by April 30 $ per successful patient $47.86 per successful patient 25% (paid semiannually; paid per practice) Must complete to be eligible for any incentive payouts

22 What Have We Learned? There are advantages in being a providerbased ACO.

23 What Have We Learned? PFK Leadership NCH Leadership Director of Care Coordination PFK Care Coordination NCH Global Care Coordination NCH Inpatient Care Coordination

24 Quality Initiatives in the NICU Conservative PDA Management and Decreased Ligations Prevention of necrotizing enterocolitis Decrease utilization of inhaled nitric oxide Decreased LOS for Gastroschisis Patients IPAC initiative Decreased LOS for NAS Patients Parent engagement, Feeding enhancement, and readmissions

25 Complex Care Cohort Utilization Census Patient Days per 100 Feeding Tube Patients

26 Preventing Antibiotic Resistance

27 What Have We Learned? Accurate, timely and reliable data is essential.

28 Data Acquisition and Use

29 Comparative Analysis Ophthalmic Antihistamines Medication Relative Cost Plan 1 Utilization Plan 2 Utilization Plan 3 Utilization Ketotifen and its forms Patanol and its forms $9-11 6% 3% 81% $ % 97% 19% Identification: PFK identified variation in drug utilization by plan Intervention Working with plans to focus on NCH developed guidelines

30 What Have We Learned? The organization must be prepared to invest in infrastructure some of which may not have an immediate ROI.

31 On-Site QI Training

32 PROJECT SELECTION AMONG PRACTICES PARTICIPATING IN THE PFK QI/PRACTICE FACILITATION PROGRAM Practice Program Start Date* Asthma Immunizations Health Supervision Visits Practice A 8/14/2014 X X Practice B 8/19/2014 X Practice C 9/5/2014 X X Practice D 9/17/2014 X X Antibiotic Stewardship Practice E 11/12/2014 X X Practice F 12/11/2014 X X Fluoride Varnish Practice G 12/11/2014 X ED Avoidance Practice H 2/16/2015 X X Practice I 3/12/2015 X X Practice J 4/21/2015 X X Practice K 5/7/2015 X X Practice L 6/2/2015 X X Practice M 6/4/2015 X X Depression Screening Practice N 9/9/2015 X X Practice O 10/23/2015 X X Practice P 10/28/2015 X X Practice Q 1/27/2016 X X *Date of Feedback Meeting

33 What Have We Learned? We can effectively manage expenses and lower the rate of expense growth.

34 What Have We Learned?

35 What Have We Learned? There are value propositions for all stakeholders.

36 What Have We Learned?

37 Questions? Visit us at