community-based organization engagement with a managed ......the managed care perspective why...

Community-Based Organization Engagement with a Managed Care OrganizationSept. 20, 2018

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PCA-1-012081-08272018_08312018 © 2018 United HealthCare Services, Inc.

The Managed Care Perspective

Why collaborate with a Community-Based Organization (CBO)?

• Regulatory compliance

• Public/member health initiatives

• Community partnership

• Medical cost and utilization controls

• Alignment with similar initiatives (health homes)

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Regulatory Requirements: The New York Medicaid Landscape

Delivery System Reform Incentive Payment Program (DSRIP) and

Value- Based Contracting (VBC) fundamentally changed the Medicaid

business.

• As of Jan. 2018, value-based payment (VBP) contractors in a Level 2 or 3

arrangement must contract with at least one Tier 1 CBO.

• Language describing this standard must be included in the contract

submission to count as an “on-menu” VBP arrangement.

• This doesn’t prevent VBP contractors from including Tier 2 and 3 CBOs in

an arrangement to address one or more social determinants of health – in

fact, this is actually encouraged.

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Value-Based Contracting: Where to start?

How is my CBO classified?

• Tier 1: Non-profit, non-Medicaid billing, community-based social and

human service organizations

• Tier 2: Non-profit, Medicaid billing, non-clinical service providers

• Tier 3: Non-profit, Medicaid billing, clinical and clinical support service

providers. Licensed by the New York State Department of Health, New

York State Office of Mental Health, New York State Office for Persons with

Developmental Disabilities, or New York State Office of Alcoholism and

Substance Abuse Services

Is my organization in the Department of Health Directory?

• Take the survey on the Department of Health website:

https://www.surveymonkey.com/r/SDH-CBO

• The survey allows you to indicate your CBO’s service area and services

provided.

o MCOs use the CBO list when planning for CBO inclusion in VBC.

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https://www.surveymonkey.com/r/SDH-CBO



Value-Based Contracting: Where to start?

Know your Value Proposition

• What unique skills or strong relationships can my organization bring to

the table?

• What social determinants of health does my organization address?

• How does the population that we serve align with the MCO’s population?

• What geography do we serve?

• Is the CBO prepared to accept and share data? (performance data,

member health data, etc.)

• Does your organization have the ability to take additional referrals?

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Considerations

• MCO Strategy: What is driving the MCO/CBO collaboration?

• MCO Size: Does the MCO operate on a smaller, local scale; or larger global

scale?

• MCO Footprint/Market Share: What presence does the MCO have in a

particular geography?

• MCO/Provider Collaboration/Contracts in Place: Can the CBO

collaborate with care providers who already have key relationships with the

MCO?

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Case Study: Care Provider Collaboration

UnitedHealthcare Level II contract with large primary care health

system in New York City:

• The health system contracted with the CBO.

• The health system/CBO contract was incorporated formally in to the

MCO/health system VBC arrangement.

• The following components were called out in the contract:

- Health system strategy

- Social determinants to be addressed and CBO’s assistance with them

- Target patient population

- Service delivery

- Project scope

- Geographic location

- Needs assessment

- Targeting and evaluation

- Implementation and timeline

- Project funding

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Direct MCO Engagement with a CBO

Our existing relationships with CBOs:

• Collaborations to ensure continuity of coverage

• Collaborations to provide health education and engagement opportunities

such as health fairs

• Collaborations to share limited data to allow the health plan to locate

members who may be homeless and/or lost to care

• Expansions of existing relationships to provide direct interventions

addressing a social determinant of health.

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Going Forward

• Expanding the conversation around the MCO/care provider/CBO

collaboration

• Thinking outside the box

• Sustaining beyond Delivery System Reform Incentive Payment

(DSRIP)

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Questions?

Thank you!

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S E P T E M B E R 2 0 , 2 0 1 8

D O R E L L A W A L T E R S

D I R E C T O R O F E X T E R N A L P R O G R A M A F F A I R S

CBOs: Key Considerations on

Relationships with Managed Care

Organizations

G O D ’ S L O V E W E D E L I V E R

01 Mission in Action

02 Value Based Payment Opportunity

03 Partnerships are key

04 Contracting

05 Lessons Learned

.

Contents

1 2

Mission in ActionA b o u t G o d ’ s L o v e W e D e l i v e r


Our Mission

3

• God’s Love We Deliver, a nonsectarian organization, is the New York

metropolitan area’s leading provider of life-sustaining meals and nutritional

counseling for people living with severe illnesses

• We prepare and deliver nutritious, high-quality meals to people who, because

of their illness, are unable to shop or cook meals for themselves

• We provide illness-specific nutrition education and counseling to our clients,

and all meals are individually tailored for each client by one of our Registered

Dietician Nutritionists

Clients 7,000+ served annually including clients, children and caregivers

Bronx Westchester

CountyHudson

County, NJQueens

Manhattan

Brooklyn

Staten IslandNassau

County

Long Island


Our medically tailored meals are cooked in our state of the art commercial

kitchen in SoHo (NYC).

All meals are low-sodium and are freshly cooked with no preservatives,

starters or fillers, and are flash frozen to optimize nutritional value and

quality.

We customize meals by addressing a combination of restrictions, resulting

in almost infinite meal variety for members.

Meal restrictions include:

• Pork, Beef, Fish and Vegetarian

• Sugar, Fat and Dairy

• Renal, Minced and Pureed

• Acid/Bland and Fiber/Gas

Our Meals

1 5


What We Do What Members Do

1 6

Value Based Payment Opportunity


• Paying for VALUE over VOLUME of healthcare services

• Different levels for this type of arrangement, called Tiers

• NYSDOH Goal: 80% of all Mainstream Medicaid payment in VBP by 2020

• Requirement from NYSDOH: As of January 1, any Tier 2 or higher VBP arrangement must involve:

• One Tier One Community Based Organization

• One Social Determinants of Health project

God’s Love fulfills both requirements

1 8 8 8

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Value Based Payment Contracting Requirement

New York State Department of Health (NYSDOH)

Managed Long Term Care Growth

3,081

9,397

24,76751,780

57,871

66,80194,131

121,767

150,901

201,506

231,359

263,121

312,543

366,467

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

Mea

ls p

er F

Y


1. Leverage your history in the community

2. Speak to your core competencies

3. Know the research in your field

4. Leverage client and provider feedback

5. Have your data and report on your

historical impact

6. Anticipate the MCO’s goals/concerns

and then ask them to clarify

7. Know the metrics/goals the other party

needs to meet

8. Know the research in your field

9. Craft a convincing narrative about how

your services will help accomplish

these metrics

10. After your SWOT analysis, present your

“Return on Investment” for the MCO

2 0

Community Based Organizations

You’re Fabulous, Say So!

Partnerships are key


1. Be clear on the intention of your partnership

2. Establish clear parameters and expectations

3. Make sure to clarify decision points

• Agree on acronyms

• Be clear on how each organization works

• Confirm how members will be referred and

enrolled

• Establish clear communication lines

4. Determine key stakeholders early on

5. Establish communication structure and

timelines

6. Screening for SDOH

• Track what the patient needs and report on

it!

• Share findings with each other, consistently

• Make sure the MCO can keep track of what

you do and what you’ve reported

7. Billing and reimbursement timelines

8. Refine, review, implement and then do it again

2 2

Partnership considerations


• DSRIP Performing Provider Systems

• Hospitals

• Managed Care Organizations

• Integrated Primary Care

• Independent Practice Association

• Accountable Care Organizations

• And more!

2 3

Partnerships

What’s Possible?

If Managed Care

Organizations haven’t

reached out, you need to

pursue them!


• Anticipate the

MCO needing

help

completing

the template

• Consider your

target

populations

• Consider

evaluation

methods

2 4

Plan for the submission

SDOH


1. What preconceived notions the

MCO/contractor may have about your services?

2. What services will you offer and what’s the

price point?

3. How will you serve the MCO’s members?

4. What will be the members experience? Is

there a time limit on services?

5. How would you have to change your program to

meet contract requirements?

6. What are the pros and cons of flexibility?

7. How would you manage the new flexibility?

8. Who on your staff is involved in making

flexibility a success?

2 5

CBO Operations Considerations

Consider…

Contracting


• Which populations will you serve?

• Ask the MCO who they need help with!

• Diagnoses: HARP, Cancer, Asthma, etc

• What metric (s) do you want to influence?

• Re-hospitalizations

• New Admissions

• Potentially Preventable Emergency Room Visits

(PPVs),

• Prevention Quality Indicators– Adult (PQIs),

• Prevention Quality Indicators– Pediatric (PDIs).

• What services will you provide?

2 7

Populations and Services


1. Know what you can do going in:

• Are you looking for a smaller project with

option to grow? Or can you handle a bigger

scale?

• Do you have the ability to invest in new staff,

technology, data collection, etc.?

• Do you have the ability to deliver on ALL

aspects of contract? (reporting, health

screening, MIAs, and so much more)

2. Hire appropriate legal counsel

3. Start the conversation – formal or informal –

and then follow up

4. Be beyond responsive!

5. Are you willing to use other funding streams

to supplement the contracting arrangement

or do you expect direct payment through a

contract for services?

6. Even with direct contracting, do you have the

resources to cover your costs if there is a lag

in payment?

7. Know how much of your cost you are willing to

absorb should payment be predicated on

outcomes

8. What determines walking away?

2 8

Contracting Negotiations


• Communication is key!

• Build “buy in” constantly

• Responsiveness and timeliness

• Keep the MCO informed of engagement

opportunities

• Branding, volunteering, etc.

• Stay connected and engaged

• Meet in person, email updates, etc..

2 9

The room where it happens!


1. What data do you have/need to deliver

service?

2. What data do you have/need to show

outcomes?

3. What data does the healthcare entity

have/need?

4. How will you exchange this data adhering to

patient privacy laws?

5. How will you get outcomes data back?

6. Are there pro bono resources that can help

you add capacity?

3 0

Data and IT

Ask Yourself…


• Added/Changed Program Services

• Nutrition modification

• Allow health plan to authorize 1 – 21 meals a week

• New Delivery Options

• Aligned with Home Health Aide hours

• Flexibility in delivery days

• Expanded geography (to cover 2 very large suburban counties)

• Enhanced Customer Service

• Streamlined Authorization Process

• Ongoing education sessions for referral staff

• Open Houses/webinars

• Daily notification of MIAs

• Collaboration on providing care

3 1

Flexibility Example:

Community Partners Program

Lessons Learned


• Stay up to date on healthcare and its affect on

your patients

• Consider how you tell your story to a new

person, and make them fall in love with your

CBO

• Assess your data protections and strengthen

accordingly

• Get comfortable asking for what you need

• Consider collaborations to have an impact

3 3

Think Differently


1. Consider cultures and language

2. Make sure to clarify decision points

• Be clear on how each organization works

• Establish clear communication lines

3. Determine key stakeholders

4. Get buy in from champions

5. Track your discussions

6. Confirm contacts for contracting and

implementation

7. Engaged leadership in both organizations

will move the work faster!

8. Discuss and consider priorities in advance

9. Get clear on how the project will be done

3 4

Lessons Learned


TRACKING

SERVICES

Confirm populations to be

served and services to be

reported on, consider data

sharing

COLLABORATION

Make sure that both

decision makers and line

staff are all on the same

page for both

organizations

REPORTING

Establish reporting needs:

Medicaid Numbers, etc.

BRANDING

Establish early on how you

will showcase the

partnership

RESEARCH

Stay tuned to research

and work with the MCO on

quality and impact

reporting and publishing

COMMUNICATION

Stay in contact with each other,

lots of check-ins and emails.

Confirm a meeting structure to

modify accordingly

PAYMENT & B ILL ING

Determine how you will bill

and get reimbursed

M EDICAL INSIGHTS

Stay in touch on any

health discoveries with the

patient

3 5

Checklist

Keep this in mind

Questions?


God’s Love We Deliver

166 Avenue of the Americas

New York, NY 10013

Godslovewedeliver.org

Dorella Walters

Senior Director of External Program Affairs

[email protected]

212.294.8123

Alissa Wassung

Director of Policy & Planning

[email protected]

212.294.8171

Contacts

9 / 2 1 / 2 0 1

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P R E S E N T A T I O N T I T L E 3 7

http://godslovewedeliver.org/

mailto:[email protected]

mailto:[email protected]

Thank You

community-based organization engagement with a managed ......the managed care perspective why...

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