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Medicare risk revenue management 11 jun12 washington dc
The document discusses best practices in care management and data capture for Medicare risk revenue management, emphasizing the importance of collaboration among healthcare teams to improve patient outcomes. It highlights the Santa Clara County Individual Practice Association's (SCCIPA) approach to integrating data-driven decision-making and patient-centered care. Key strategies include leveraging technology for communication, enhancing data access for patients, and aligning incentives for healthcare providers.
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Medicare risk revenue management 11 jun12 washington dc
- 1. Leveraging the EntireCare Team to Improve Care Management and Data Capture Wayne Pan, MD, MBA Chief Medical Officer Pacific Partners Management Services, Inc. Medicare Risk Revenue Management - Best Practice Operation Strategies • Washington, DC • June 11, 2012
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- 12. goals goals
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- 21. it’s also about whom your DATA serving data to
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- 23. not current errorprone MPASTEE no comparator
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- 29. zen: one withthe universe
- 30. the new way of doing things... ...feels just like the old way
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- 33. ? who what where when why how
- 34. Who is ?
- 35. Individual Practice Association Medical Group of Santa Clara County
- 36. Individual Practice Association Medical Group of Santa Clara County
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- 38. largest IPA inSanta Clara County
- 39. Santa Clara County size1,304.01 sqmiles pop 1,781,642 (2010) medianincome $74,335
- 40. THE Apr 21,2012 Price 75 FB C REDITS VIEW FROM THE VALLEY EUROPE ENGLAND RUSSIA ATLANTIC OCEAN NEW YORK CITY FLORIDA M DA EX NA IC C A CLEVELAND APPALACHIA O ILLINOIS the Mississippi River INFINITE LOOP SAND HILL ROAD
- 41. 5 PCP 80Specialists 173 PCP 343 Specialists 57 PCP 104 Specialists 11 PCP 30 Specialists SCCIPA founded in 1986 physician-owned, physician-governed 800+ physicians - 240+ PCPs, 550+ specialists all 9 hospitals - including a tertiary care center 9 health plans (Commercial and Medicare Advantage) Anthem Commercial ACO pilot (2011)
- 42. urban/ suburban rural SCCIPA founded in 1986 physician-owned, physician-governed 800+ physicians - 240+ PCPs, 550+ specialists all 9 hospitals - including a tertiary care center 9 health plans (Commercial and Medicare Advantage) Anthem Commercial ACO pilot (2011)
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- 46. no original Medicare, Medi-Cal, CHIP, uninsured
- 49. = managementservicesorganization medicalmanagement casemanagement networkmanagement providercontracting qualityimprovement credentialing memberservices claims&encounterprocessing clinicaldataanalytics&reporting marketingoutreach grievance&appeals compliance&auditing ITservices finance&riskmanagement
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- 61. roughroad 4x4 healthcare
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- 66. Case Managers Patients PCPs Specialists coordination
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- 72. retrospective retrospective
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- 75. + behavioral
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- 85. peopleprocesses hospitalists available 24/7 evaluation ofpatients for possible redirection to SNF aggressive use of observation status annual coding/documentation training for risk adjustment notification of PCP of admission/discharge discharge summary faxed to PCP
- 86. peopleprocesses hospitalists available 24/7 evaluation ofpatients for possible redirection to SNF aggressive use of observation status annual coding/documentation training for risk adjustment notification of PCP of admission/discharge discharge summary faxed to PCP
- 87. peopleprocesses SNFists ongoing evaluation ofpatients to reduce rehospitalization notification of PCP of admission/discharge discharge summary faxed to PCP
- 88. peopleprocesses onsite case managers dailyreview of patients based on Milliman guidelines actively involved with discharge planning all discharge needs authorized/arranged prior to discharge post-discharge follow-up on all patients with DME/HHC needs
- 89. peopleprocesses complex case managers warmhand-off between onsite and ccm use of clinical and non-clinical staff to assist patient and family caregivers with care coordination insure follow-up with PCP/specialist within 2 weeks
- 90. peopleprocesses utilization review staff allauthorizations/referrals reviewed using Milliman guidelines working closely with PCPs/specialists/ccm to facilitate care coordination compliance with regulatory guidelines generate member/provider letters regarding medical necessity decisions physician performance and quality reporting identification of potential quality issues continuous process improvement
- 91. people:physicians/staff primary care physicians specialists ancillaryproviders community pharmacists
- 92. people:physicians/staff primary care physicians specialists ancillaryproviders community pharmacists front office staff
- 93. people:plan staff case managers diseasemanagers member outreach benefit design
- 94. peopleprocessesplatform communicate collaborate coordinate anticipate
- 95. peopleprocessesplatform common web-based communicationplatform facilitates administrative functions rules-based management of processes intuitive user-interface embed quality reminders into office/provider workflow provider feedback
- 96. peopleprocessesplatform common web-based communicationplatform facilitates administrative functions rules-based management of processes intuitive user-interface embed quality reminders into office/provider workflow provider feedback provide actionable clinical data at point of care allow patients to access their own data
- 97. peopleprocessesplatform common web-based communicationplatform facilitates administrative functions rules-based management of processes intuitive user-interface embed quality reminders into office/provider workflow provider feedback provide actionable clinical data at point of care allow patients to access their own data allow patients to provide feedback/enter their own data
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- 99. “put hot triggers in thepath of motivated people” BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
- 102. Are incentives alignedproperly? How can I increase their motivation?
- 104. Have I madeit easy for people to act? How can I make it even simpler?
- 106. Are people beingtriggered at the most appropriate time and in their workflow (path)?
- 111. putting it alltogether: how does it work?
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- 114. patient front desk staff
- 115. patient analog to digital front desk staff converter
- 116. AMERICAN HEALTH PLAN 112 MARY SMITH 1/1/2011 1234567890 $5.00 $10.00 $25.00 analog to digital analog to digital eligibility check converter converter
- 117. Quality Access Express TM Management Click here to register for a password or request more information Powered by Access ExpressQ-v5.0.#.0.1 Build 2011.04.04.00
- 118. ACCESSEXPRESS Q New Eligibility Response New Message (3)
- 119. ACCESSEXPRESS Q New Eligibility Response New Message (3) AMERICAN HEALTH PLAN
- 120. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 POP-UP 1234567890 MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
- 121. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 1234567890 MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD CLICK HERE
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- 124. ACCESSEXPRESS Q New Eligibility Response New Message (3) ENABLING SMITH, MARY 8/15/1945 1234567890 FRONT OFFICE MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, STAFF GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
- 125. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 SIMPLE 1234567890 CARE PLAN MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
- 126. ACCESSEXPRESS Q New Eligibility Response New Message (3) SMITH, MARY 8/15/1945 1234567890 MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD
- 127. ACCESSEXPRESS Q New Eligibility Response New Message (3)
- 128. ACCESSEXPRESS Q New Eligibility Response New Message (3)
- 129. ACCESSEXPRESS Q New Eligibility Response New Message (3)
- 130. ACCESSEXPRESS Q New Eligibility Response New Message (3)
- 131. ACCESSEXPRESS Q New Eligibility Response New Message (3)
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- 135. ACCESSEXPRESS Q New Eligibility Response New Message (3) TH PA AMERICAN HEALTH PLAN E TH IN
- 136. ACCESSEXPRESS Q New Eligibility Response New Message (3) ER SMITH, MARY 8/15/1945 G 1234567890 IG MAMMOGRAPHY, CRC, CARDIO CARE, BLUE SHIELD OF CA DIABETES CARE, HYPERTENSION, TR GLAUCOMA, MED MONITOR, FLU VAC, PNEUMO VAC, DEXA, OSTEOPOROSIS, RHEUM, COPD T O H
- 137. ACCESSEXPRESS Q New Eligibility Response New Message (3) N O TI VA TI O M
- 138. Capability for physician office entry Y IT IL AB
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- 141. on average, there isa pharmacy within 2.5 miles of every US resident Source: National Association of Chain Drug Stores
- 142. Source: Gallop, November28, 2011-December 1, 2011
- 144. get out ofthe rut?
- 147. from: Jeanne Liedtkaand Tim Ogilvie, Designing for Growth (2011)
- 148. IPA hosspital onsite discharge case planner manager hospitalist patient discharge planning thepatientjourney
- 149. hospitalist Rx patient discharge medication planning reconciliation thepatientjourney
- 150. hospitalist discharge instructions patient outpatient discharge medication physician planning reconciliation follow-up thepatientjourney
- 151. Rx discharge instructions family patient outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
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- 154. hosspital discharge IPA onsite hospitalist hospitalist Rx discharge instructions case planner manager hospitalist Rx discharge instructions family patient patient patient patient outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
- 155. hosspital discharge IPA onsite hospitalist hospitalist Rx discharge instructions case planner manager hospitalist Rx discharge instructions family patient patient patient patient outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
- 156. from: Jeanne Liedtkaand Tim Ogilvie, Designing for Growth (2011)
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- 159. hosspital discharge IPA onsite hospitalist hospitalist Rx discharge instructions case planner manager hospitalist Rx discharge instructions family patient patient patient patient outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
- 160. hosspital discharge IPA onsite pharmacist hospitalist Rx discharge instructions case planner manager hospitalist Rx discharge instructions family patient patient patient patient outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
- 161. “put hot triggers in thepath of motivated people” BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
- 165. Santa Clara CountyIPA (SCCIPA) Medication Reconciliation Pilot Project How to find the medication list for patients using AccessExpress 1. Go to the PPMSI AccessExpress provider portal (http://ppmsi.com/accessexpress.html): 2. Select Santa Clara County IPA: 3. Enter USER NAME and PASSWORD, click on “SUBMIT”:
- 167. Your SCCIPA doctor wants to help you with your medications, after you leave the hospital. Michael Lam, RPh pharmacist Samaritan Medical Center Pharmacy 2505 Samaritan Drive San Jose, CA (408) 356-7111 Please visit the Samaritan Medical Center Pharmacy to pick up your new prescriptions and have a pharmacist review your medications with you. SCCIPA A Pacific Partners Medical Group
- 168. from: Jeanne Liedtkaand Tim Ogilvie, Designing for Growth (2011)
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- 173. 80 Milliman - Loosely-Managed 70 Milliman - Moderately-Managed 60 Milliman - Well-Managed 50 SCCIPA 40 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > commercial admits/1000
- 174. 275 Milliman - Loosely-Managed 250 225 Milliman - Moderately-Managed 200 SCCIPA 175 Milliman - Well-Managed 150 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > commercial bed days/1000
- 175. 4.5 4.0 Milliman - Loosely-Managed 3.5 Milliman - Moderately-Managed SCCIPA 3.0 Milliman - Well-Managed 2.5 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > commercial average length of stay
- 176. 400 Milliman - Loosely-Managed 350 Milliman - Moderately-Managed 300 Milliman - Well-Managed SCCIPA 250 200 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > medicare admits/1000
- 177. 2,200 2,000 Milliman - Loosely-Managed 1,800 1,600 Milliman - Moderately-Managed 1,400 SCCIPA 1,200 Milliman - Well-Managed 1,000 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > medicare bed days/1000
- 178. 6.0 5.5 Milliman - Loosely-Managed 5.0 Milliman - Moderately-Managed 4.5 SCCIPA Milliman - Well-Managed 4.0 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > medicare average length of stay
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- 198. feel just likethe oldway
- 199. 1 trackingauths > using thesame auth system, have providers enter in tracking auths for aco patients
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- 201. 2 providerselectiontool > when selecting“referred to” providers, these providers are listed in descending order of quality, efficiency, satisfaction
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- 205. 3 rewardaccountability > referring physicianscan be tracked to incentivize use of provider network
- 206. 4 checkinbutton > allows forreal-time patient tracking, provides opportunity for care coodination efforts
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- 211. 5 qualityreminders > @every encounterwith the healthcare delivery system, quality is reinforced
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- 214. air trafffic control for patients
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- 227. Thank you! [email protected] slideshare.net/bonedoc97 WWW.SNOOPY.COM