Should a PPS Set Up a Hybrid Care Management Organization (CMO)?

Samir D’Sa, Principal, NY DSRIP Services and Charles Baumgart, MD, Senior Medical Director, December 1, 2015

It is always prudent to have some risk mitigation when taking on large risks. It’s no surprise then, that health insurers have armies of actuaries (price risk) and care managers (health risk) leveraging sophisticated data, tools, and best practices to manage population risks.

PPS’ are uniquely positioned to become learning laboratories capable of creating homegrown care management solutionsThe NY DSRIP program is a step on the journey toward transferring outcomes risk for Medicaid (and the uninsured) to providers. While Performing Provider Systems (PPS) don’t become health insurers overnight, there is an unmistakable shift occurring in their risk profile. For example: PPS’ that don’t meet targets (e.g., A1c goals, care plans, ED and readmission reductions) will see smaller checks from the Department of Health starting in 2016. The magnitude of withholds linked to outcomes only increases with time. PPS’ are expected to engage in meaningful, value-based payments with managed care organizations – and we don’t mean upside only, quality-bonus contracts!

Emerging thinking at PPS’ on how to mitigate this risk takes a few forms:

  • Deferral – “P4P isn’t till year 2 or 3… why worry about it now?”
  • Delegation“Our role is to distribute the funds and hold partners accountable.”
  • Hybrid“Our PPS-staffed care team will augment existing care management resources in the county – not only will we share best practices, but we will also embed care managers in select partner sites.”
  • Centralization – The participative, cross-organizational nature of DSRIP doesn’t lend itself to a fully centralized care management approach.

 

Why Hybrid? Clear advantages emerge for hybrid CMOs:

  1. Local solutions, best practice foundation: PPS’ are uniquely positioned to become learning laboratories capable of creating homegrown care management solutions, which are sustainable in their local medical neighborhood (i.e., the PPS as a factory that churns out care management solutions with the participation and buy-in of the community, but all built on a foundation of best practices in care management design).
  2. Navigating obstacles: Given their mandate and shared incentives, PPS-led CMOs can better eliminate traditional provider obstacles – “who should follow up with the patient?”, “why should I be involved in DSRIP?” and “why share data with competitors?”
  3. Outcomes buffer: If some partners are falling short of targets, the PPS has the ability to redeploy its highly trained team of care managers to better address hotspot ZIP codes or focus on a particular DSRIP project or help a challenged, high-volume ED.

 

What’s involved? Here is an abridged checklist for a CMO blueprint design:

Staffing – team composition, staffing ratios, job descriptions, accountability

Training – motivational interviewing, chronic conditions, etc.

Embedding – protocols for deploying care managers in model practices, ED/hospitals

Monitoring – performance appraisals, feedback, remedial actions, etc.

Handoffs – patient transfers protocols across settings, care managers, and organizations

Care Pathways – for chronic conditions like COPD, CHF, CAD, asthma, etc.

Policies & Procedures – for transitions, medication reconciliation, elder abuse, etc.

Workflows – screening intake, patient referrals, assessments, enrollment, interventions, follow-ups and case closure

Provider Engagement – educational sessions on care management, care team integration, etc.

PPS’ are uniquely positioned to fill a CMO void on a regional basis with their own locally crafted solution – will the majority of them capitalize on this opportunity to be successful within the 5-year DSRIP program and help set the rules of the game beyond DSRIP year 5?

For more information about DSRIP, contact Andrew Blackmon at ablackmon@xghealth.com.



Rocky Edmondson RN, BSN, MBA, CCRN
Senior Director, Bundled Payments, Care Redesign and Management Advisors, xG Health Solutions

Rocky Edmondson is the Senior Director of Bundled Payments for Care Redesign and Management Advisors at xG Health Solutions. Rocky has been involved in workflow redesign, program implementation, and analytic evaluation of Bundled Payment Programs across the country, and he coaches Hospitals, Health Systems, Post-Acute Providers, and Physician Groups on how to successfully implement care redesign in the Bundled Payment for Care Improvement (BPCI) and CJR Programs.

Rocky’s passion is helping people to understand the intricacies of Bundled Payment Programs. He has a talent for teaching people how to cut through all the noise and just do the things that matter to be successful in these programs.

Rocky holds an Associate’s Degree in Nursing from the University of Hawaii Maui, and a Bachelor’s Degree in Nursing and a Master’s Degree in Business Administration (MBA) from Boise State University.

Prior to joining xG Health Solutions, Rocky was the Southeast Region Director of Clinical Operations for Remedy Partners, overseeing program design, implementation and analytic evaluations for Bundled Payment Programs. Prior to embarking on a career in Bundled Payments, Rocky was a Registered Nurse for 18 years, working in a number of positions within Critical Care. Before becoming a Nurse, Rocky was an Institutional Broker at Merrill Lynch and advised a number of healthcare systems and large corporations on cash management strategies. In addition, Rocky has started several businesses and provided consulting for small business startups. Rocky served in the U.S. Marine Corps as a Recon Marine.

Janet Comrey RN, BSN, MHSA
Director, Population Health Solutions, Geisinger Health System

Janet Comrey, RN, BSN, MHSA has over 30 years of diversified nursing and leadership experience at Geisinger Health system and currently serves as Director of a small department embedded within Population Health. One of her key roles is managing the Bundle Payment for Care Improvement (BPCI) program since January 2014 earning an overall positive net payment reconciliation to date. Janet also serves as the coordinator for Project Achieve at Geisinger which is a national PCORI funded study related to patient’s perceptions of transitions of care.

Janet received her nursing education through Geisinger’s diploma program, her BSN through Bloomsburg University, and later earned her graduate degree from Marywood University. During her tenure at Geisinger she taught quality improvement methodology and facilitated improvement teams the Geisinger Quality Institute. She is currently enrolled in the Institute for Healthcare Improvement Advisory program.

Professional memberships include Sigma Theta Tau, Phi Kappa Phi, American Society for Quality.

Andrew Blackmon, MBA, MHS
Chief Sales and Business Development Officer

Chief Sales and Business Development Officer Andrew Blackmon, MBA, MHS, has more than 18 years of experience in healthcare product sales, marketing, and strategy.

Before joining xG Health, Andrew was vice president of sales for population health and risk management solutions at McKesson. He came to McKesson through acquisition of MedVentive, an early population health vendor. Before MedVentive, he served as vice president of enterprise solutions development at MedAssets. He is a past president of the Georgia chapter of HIMSS, and he has held strategy and planning positions at PricewaterhouseCoopers and Orlando Health.

Andrew has an MBA and a Master’s of Health Science from the University of Florida Warrington, College of Business, and a Bachelor of Arts degree in Psychology from Rollins College.

Holly Barbella, RN, MBA

Risk Coordinator, Geisinger Health System

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Earl P. Steinberg, MD, MPP
Chief Executive Officer

Earl P. Steinberg, MD, MPP, is a nationally recognized expert in healthcare quality improvement and serves as xG Health’s chief executive officer. Earl also is an adjunct professor of Medicine and of Health Policy and Management at Johns Hopkins University and a member of Blue Cross/Blue Shield Association’s National Medical Advisory Panel.

Before joining xG Health, Earl was executive vice president of Innovation & Dissemination, and chief, Healthcare Solutions Enterprise at Geisinger Health System.

Before joining Geisinger, he was senior vice president for Clinical Strategy, Quality & Outcomes at WellPoint, Inc., the largest commercial health insurer by membership in the US, and president and CEO of Resolution Health Inc. (RHI), a leading healthcare data analysis company that provides innovative quality improvement and cost reduction services to health plans, employers, pharmacy benefit managers, and disease management companies.

Before joining RHI, Earl spent six years as vice president of Covance Health Economics and Outcomes Services Inc., director of its Quality Assessment and Improvement Systems Division, and co-director of its Outcomes Studies Group. He also spent 12 years on the full-time faculty at Johns Hopkins University, where he was professor of Medicine and of Health Policy and Management and director of the Johns Hopkins Program for Medical Technology and Practice Assessment, and four years on the Federal Physician Payment Review Commission. He co-chaired the Institute of Medicine’s panel on Standards for Development of Trustworthy Practice Guidelines.

Earl has received many awards, including the Henry J. Kaiser Family Foundation Faculty Scholar Award in General Internal Medicine (1984), the “Outstanding Young Investigator” Award from the Association for Health Services Research (1988), and a Special Presidential Visionary Award from the National Kidney Foundation (NFK) (2004) for his work as the scientific director of the NKF’s landmark Kidney Disease Outcomes and Quality Initiative, which produced more than 250 clinical practice guidelines for management of patients with end-stage renal disease. He also is a fellow of both the American College of Physicians and AcademyHealth, and he has published more than 125 articles in peer-reviewed journals.

Earl received his AB from Harvard College (summa cum laude), his medical degree from Harvard Medical School, and a Master of Public Policy from the Kennedy School of Government. He performed his residency training in internal medicine at Massachusetts General Hospital.