Overview of Steps Needed to Develop Partnerships

Timothy P. McNeill, RN, MPHACL/AoA Consultant

Development of Partnerships

• Health Reform is impacting all sectors of healthcare and home and community based services

• Managed Long-Term Services and Supports is shifting traditional waiver services into Managed care

• Successful managed care contracting can occur using a collaborative approach

Market Analysis

• Market Analysis is a critical component to partnership development and sustainability

• Identify the Payer landscape• Market Penetration of payers• State climate for reform• State level initiatives

Partnership

• Partnerships can support Medicare contracting and managed care– One program can have more than one partner

• Relationship must be mutually beneficial• If the negotiations are difficult in the beginning,

they will likely remain difficult for the duration of the relationship

• Both organizations must have a process to track and monitor services

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Types of Partners

• Aging/Disability Networks• Hospitals• Health Departments• Patient-Centered Medical Homes• Private Practice Doctors or Group Practices• FQHCs• Rural Health Clinics

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EB Program Contracting Example

• ACL/AoA has embraced the adoption of evidence-based (EB) programs– Medicare Reimbursement– Managed Care Contracting

• ARRA and Older Americans Act funding supported expansion of EB programs

• Funding supports expansion of EB programs and support the growing demand for these services

History of DSMT Benefit

• The Centers for Medicare & Medicaid Services (CMS) provides reimbursement for DSMT

• Benefit began in 2002• Benefit provides compensation for up to ten

(10) hrs of DSMT per 12 month period• All recognized Medicare providers can submit

for reimbursement• Medicare coverage

– 80% Payment– 20% Co-insurance required

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Stanford DSMP Program site analysis

• Initially conducted an analysis of each DSMP program site– Infrastructure– Staffing mix– Delivery model– Target population– Integration with the health care delivery

system

Recommendation

• Developed a hypothetical model – Anywhere AAA– Partner DSMP program with Medicare

provider partner– Supplement infrastructure to meet National

Accreditation and Medicare billing guidelines– Develop break-even analysis– Provide revenue projection model

Initiative Status

• Eleven (11) programs fully accredited by the American Association of Diabetes Educators and recognized by Medicare – There are other programs that have sought

and achieved accreditation. This slide represents the programs that I have supported under the ACL/AoA consulting contract

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Business Acumen TA Initiative

• May 2013, ACL launched a learning collaborative to provide expanded TA to networks of community-based aging and disability organizations (CBOs) to improve their Business Acumen

Business Acumen Learning Collaborative

• Collaborative is supported by a team of ACL staff, contractors, and grantees

• 9 networks of CBOs selected across the U.S.• Goal is that each Network secure at least one

contract with an Integrative Health Organization– Medicare/Medicare Advantage– MLTSS– Managed Care– Accountable Care Organizations

Managed Care landscape

Important to understand the market forces for managed care:• Medical Loss Ratio• PMPM (Per Member Per Month) Premium

Payments• NCQA Credentialing Standards

Strategy Development

• Identify the local market drivers• Assess the landscape of health reform initiatives• Understand the political landscape• Develop a strategy• Implement the strategy• Assess current partners

Strategy Dev. (cont.)

• Identify organizational strengths• Complete a gap analysis for your organization

and partners• Identify additional partners that will be needed• Understand the cost drivers and price points• Establish contract capture plan

CBO support of Managed Care Contracting

• Meeting with MCOs have presented the following challenges for CBOs– Capacity to deliver services on a large scale with

uniform quality metrics– HealthIT systems compatible with health care– Quality assurance metrics that align with HEDIS

measures– Alignment of services with Health risk of the

consumer– Potential replication of services currently available

to consumers

Network Contracting Opportunities

• Networks of organizations are exploring contracting as a group

• A Network contracting method can provide greater coverage of defined market area and provide a single contracting point for managed care

• Economies of Scale can be achieved

Network Contracting Issues

• Funding to establish the Network• Antitrust Violation Potential• Legal Structure of the Network• Sustainability of the Network Structure• Shared Governance• Management Services Organization (MSO)

Option

Traditional MSO Services

• Electronic medical record access • Health IT consulting • Contract negotiation • Group purchasing power • General management support • Financial

Summary

• Health Reform is changing the healthcare landscape

• Payers and Providers are reacting to these changes

• Partnerships can provide strength in contracting in the face of change

• Know your strengths, weaknesses and understand the potential of local alliances

Questions

• Questions can be submitted in this open forum or by e-mail:

• tmcneill@me.com

Timothy P. McNeill, RN, MPH

Consultant

Direct: (202) 344-5465

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