Mutual and CCNC: What s the Difference?

Transcription

1 Mutual and CCNC: What s the Difference?

2 Objectives Review the history and current status of the CMMI grant Discuss the transition from CCNC to CPESN and how Mutual fits in Discuss how local networks (Mutual CPESN) engage with national efforts (CPESN USA) Review current opportunities for participating pharmacies Review mechanics of CPESN USA and Mutual CPESN Participation

3 CMMI Year 4 Update September 1, 2017 to August 31, 2018 (but funds for payments to pharmacies may run out sooner) 232 pharmacies in year 4 Focus on sustainability mode Pharmacist ecare Plan instead of PHARMACeHOME Alternative payment model that accounts for both risk level of the patient and pharmacy performance

4 CCNC Practice Relationships Pre & Post Medicaid Reform CCNC CCNC CA-II Primary Care Practices (CCNC- Enrolled) CPESN Pharmacies Community Care Physicians Network (CCPN) Mutual CPESN (1 of 37+ CPESN networks nationally) Clinically Integrated Networks of Providers

5 NC Medicaid Reform References to CPESN Networks MARCH 2016 NC DHHS INITIAL WAIVER DRAFT North Carolina has launched several initiatives funded by CMS that focus on improving specialty care and integration. DHHS views this Demonstration as a clear opportunity to continue promoting CMS priorities while enhancing the medical home delivery model. These grants include: Community Pharmacy Enhanced Services Network. A CMMI grant to CCNC to develop a network of pharmacies that provide enhanced services, such as synchronization of a patient s chronic medication fill dates, adherence monitoring and coaching, compliance packaging, and home delivery. AUGUST 2017 NC DHHS WHITE PAPER ON REFORM EFFORTS Community Pharmacy Programs. DHHS is exploring opportunities to leverage pharmacists and technicians to help screen, identify, and link to care individuals with, or at risk of developing substance use disorders. DHHS will consult with the Community Pharmacy Enhanced Services Network (CPESN) when developing strategies that AMH care teams can implement to prevent opioid abuse. PHPs shall develop clinical programs to support pharmacy quality measures and that are consistent with the Community Pharmacy Enhanced Services Network and other DHHS and PCCM pharmacy program initiatives when developing pharmacy clinical programs.

6 The Evolution of CPESN from CCNC to MPSC to CPESN USA Voluntary NC CPESN Established at Request of CCNC PCPs Multi-State Pharmacy Collaborative Catalyze expansion of high-performing networks across America Provide a venue to connect pharmacists to share best practices CPESN USA Network of Networks to support local networks with expertise in network development, QA/QI/Practice transformation, and marketing

7 CPESN USA: 1400 Pharmacies in 38 Networks across 35 States CPESN USA is a Limited Liability Corporation with two member- owners: Community Care of North Carolina or CCNC with 50% ownership and the National Community Pharmacists Association or NCPA with 50% ownership. CPESN USA was established to develop and sustain local networks of community-based, high performing pharmacies that provide enhanced services for their patients. CPESN USA will empower its local networks, not compete with them. CPESN USA is governed by a Board of Managers from their local networks. Currently, there are 38 local networks across 35 states.

8 CPESN USA is a Clinically Integrated Network of Pharmacies High quality, high integrity, high performing pharmacies currently have no way of organizing to express their value and clinical contribution to the rest of the care team Concern that the providers themselves (the pharmacies) do not play an active role in engagement of payers and payer contracting Concern that clinical programs of the future will involve other care team members that are clinically integrated Simply put: no clinical integration means no exploration or negotiation of new payment models or improvements on existing payment models. Prospective and Retrospective Quality Data

9 Introducing Mutual CPESN Mutual CPESN (Community Pharmacy Enhanced Services Network) will function as a network of high performing community pharmacies offering enhanced services Mutual CPESN will operate as an independent subsidiary of Mutual Drug The Mutual Drug Board of Directors has approved a start-up loan for one year of operating costs for Mutual CPESN, which will be paid back in full over time

10 What will Mutual CPESN Do? Build on the momentum generated by the CCNC Grant Program in North Carolina Aggregate pharmacies offering enhanced services to generate opportunities for the network through two key channels: 1. Payment 2. Referrals Support pharmacies in implementation of enhanced services, maintaining quality, and developing best practices

11 How does Mutual CPESN Operate? Mutual Drug Board of Directors Mutual CPESN Oversight Committee Mutual CPESN Luminaries CEO Executive Director Wholesaler Operations Mutual CPESN Working Groups Network Operations QA/QI Service Sets Payer and Partner Relations

12 How does Mutual CPESN Operate? Mutual CPESN Oversight Committee: - Dave Marley - Mike Griffin - Whit Moose - Neal O Neal Mutual CPESN Luminaries: - Lori Altman - Tiffany Barber - Joe Moose - Rakesh Patel - Tim White (Lead) Mutual CPESN Executive Director: Patrick Brown Mutual CPESN Working Groups: - Network Operations: How does the Network Operate? - Service Sets: What do the pharmacies offer? - Quality Assurance and Quality Improvement: How do we maintain quality? - Payer and Partner Relations: Who should we be working with?

13 Meeting/Oversight Schedule Network Operations Every Monday, 8:00 AM Service Sets Second Friday, 9:00 AM Payer/Partner Relations Third Wednesday, 8:00 AM QA and QI Third Friday, 8:00 AM Oversight Committee Last Thursday, 8:00 AM Luminary Board Last Wednesday, 8:00 AM Mutual CPESN Newsletter Monthly (last week of the month)

14 Payer and Partner Channels Medicaid MCOs Accountable Care Organizations/Physician Networks Medicare Advantage Plans Commercial Insurance Self-Insured Employers Health Systems

15 Payer and Partner Engagements Medicaid Bridge 225 Pharmacist Signatures delivered to Secretary Cohen MCOs Engaged with three MCOs pursuing bids Signed one letter of intent (Aetna) Commercial Payers Two engagements Independent PBMs Three groups interested in pursuing self-insured business Transparent PBM model+ disease management Health Systems Two referral engagements (transitions of care) ACOs Pursuing regional referral program

16 The Network Adequacy Imperative Network Adequacy Metrics Population Adequacy Geographic Adequacy <30,000 Excellent >95% Excellent 30,000-40,000 Good 90-95% Good 40,000-50,000 Fair 85-80% Fair >50,000 Insufficient <85% Insufficient

17 The Network Adequacy Imperative 342 Pharmacies 256 Pharmacies 205 Pharmacies Network Adequacy Metrics Population Adequacy Geographic Adequacy <30,000 Excellent >95% Excellent 30,000-40,000 Good 90-95% Good 40,000-50,000 Fair 85-80% Fair >50,000 Insufficient <85% Insufficient

18 What do I need to do to Participate?

19 What do I need to do to Participate? 1. Sign the CPESN USA Pharmacy Participation Agreement CPESN USA began assessing an $85 per pharmacy per month participation fee on 4/1/18 Fees will be collected through ACH Bank Drafts this paperwork is included in the participation agreement and can be filled out separately for pharmacies who have already signed a USA agreement

20 What do I need to do to Participate? 1. Sign the CPESN USA Pharmacy Participation Agreement CPESN USA began assessing an $85 per pharmacy per month participation fee on 4/1/18 Fees are collected through ACH Bank Drafts this paperwork is included in the participation agreement and can be filled out separately for pharmacies who have already signed a USA agreement 2. Sign the Mutual CPESN Pharmacy Participation Agreement No fees right away Participation fees are likely to ensure financial independence of the organization, will be announced with 90 days notice

21 What do I need to do to Participate? 1. Sign the CPESN USA Pharmacy Participation Agreement CPESN USA began assessing an $85 per pharmacy per month participation fee on 4/1/18 Fees are collected through ACH Bank Drafts this paperwork is included in the participation agreement and can be filled out separately for pharmacies who have already signed a USA agreement 2. Sign the Mutual CPESN Pharmacy Participation Agreement No fees right away Participation fees are likely to ensure financial independence of the organization, will be announced with 90 days notice 3. Engage with a Pharmacy ecare Plan Vendor Pioneer, QS1, Creative Pharmacist, PrescribeWellness, etc

22 CPESN USA Fees Why are Participation Fees Necessary? Fund Operations Shared Investment in Quality Assurance and Reporting a requirement for Clinical Integration Clinical Integration allows for: Collective Marketing of all Participants Direct Negotiation with Payers Partnerships and Risk-Bearing Arrangement with Other Providers

23 CPESN USA Fees What are Participation Fees Used For? Facilitating Network Collaboration & Providing Support Services for Local Networks Offering Subject Matter Expertise & Network Consultation Services Driving Quality Improvement, Quality Assurance, & Practice Transformation Initiatives Providing Marketing Services & Promotional Materials for Local Networks Offering Insights & General Guidance

24 CPESN USA Fees Who Determines the Participation Fee Amount? CPESN USA is Governed by Board Managers from the Local CPESN Networks Budgeting process starts in March and Approved by Board in May of each year Based on: Number of Participating Pharmacies Required Operations and Capacity as Directed by Managers Can be Reset or Changed by Managers each year higher or lower Operates much like Homeowners Association Dues

25 CPESN USA Fees How do I Pay my Participation Fees? Fees are based on a per roof top model (again, much like an HOA) and are applied based on the number of pharmacies listed in the most current version of each executed Participation Agreement CPESN USA uses ACH drafting to collect Participation Fees

26 CPESN USA Fees As a participating pharmacy, what do I get? You are making an investment in your local CPESN network

27 What about the Local Fees? Three key revenue streams for financial sustainability of Mutual CPESN 1. Local Pharmacy Participation Fees 2. Administrative Fees on Central Reimbursements 3. CPESN USA Financial Support While the network will be open to all willing and able pharmacies, Mutual Drug members will receive discounted participation fees

28 The Bottom Line Mutual CPESN is committed to creativity, efficiency, and transparency, to ensure maximum value to participating pharmacies Setting up an independent business entity is necessary for a network supported by Mutual to be successful Skin in the Game through participation fees is a critical element to maintain Clinical Integration and allow contracting opportunities We need a solid network of pharmacies ( across North Carolina) to generate opportunities for pharmacies AND for this organization to be sustainable

29 Next Steps Complete agreements via DocuSign Engage an ecare Plan Vendor Consider participating in a Mutual CPESN Working Group Let us know of pharmacies that we should be recruiting Let us know if you know of potential payers and partners

30 Questions? Patrick Brown Tim White Joe Moose Tiffany Barber Rakesh Patel Lori Altman