see how far impact can reach. · 2015-11-02 · attributed pop. r rk subspec. for chronic care...

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SEE HOW FAR IMPACT CAN REACH. SOLUTIONS THAT CREATE HIGH-PERFORMING HEALTHCARE ORGANIZATIONS

Preparing For Next Generation Payment Models

HANYS NYS PAYMENT INNOVATION SYMPOSIUM - ANALYTICS AND DECISION SUPPORT

November 2, 2015


WHAT ARE WE TRYING TO TRANSFORM?

How will we pay for care and whom assumes

what type of financial risk(s) at our “organization”

and across our ACO/CIN/PHM network?

How will we collaborate to deliver

care, in what settings, under what

specific clinical protocols?

How will we organize our

respective operating models to

achieve a Triple Aim goal?

What is our Enterprise Strategy to select

a strategic operating model, revenue

model & partnership framework?

What conclusions have we agreed upon

with respect to our current and future

state strategic operating model? CIN?

Potential alliances?

How do we transition to a

new clinical care and

operating model

framework with a go to

market win strategy...

without blowing up our

revenue model?

HANYS NYS Payment Innovation Symposium - Analytics and Decision Support


Facility claims data

Professional claims

Employee claims data Payer Claims Data

Public, Subscription and Priority Database to evaluate and identify

performance opportunities

Truven Analytics (quantify PMPM

performance across a selection across 385

MSAs)

HCRIS-to evaluate drivers of cost of care

and cost trend

AHA, Definitive Healthcare, Truven

Market Scanner, Action OI, MedPar Claims Data

Total Cost of Care &

Operational

Accelerators to

Identify Cost TO Care

OUR PRIMARY SOURCES OF DATA TO ASSESS? HANYS NYS Payment Innovation Symposium - Analytics and Decision Support


1. Improving care coordination, navigation and access to medically necessary services

2. Implementing a care delivery model organized around center of excellence

continuums of care... with care delivered on campus, in the community & at the home

3. Helping patients to stay healthy and improve their patient care experience.

We will move towards our CIN-PHM-

ACO vision by…

POPULATION MANAGEMENT ACROSS CARE CONTINUUM

CIN DISTRIBUTED

NETWORK MODEL

WELLNESS/ PREVENTION/

CHRONIC CARE MANAGEMENT

CIN REGIONAL INTEGRATION

By delivering on our short-

term priorities…

AGING IN PLACE

To deliver integrated

services across service line & CIN care continuums

for…

Which meet defined CIN & Service Line population

health and payer needs for…

IMPROVED ACCESS ACROSS REGION

AMBULATORY SERVICES

» Safe/appropriate » Improve access/navigation » Re-tasking/new services » Equity in access & outcomes » Advanced access/demand

matching » Technology enablers

ON & OFF CAMPUS / IN COMMUNITY CARE FOR

ADULTS & PEDS

FPP & COMMUNITY PHYSICIAN ALIGNMENT

INFRASTRUCTURE, TME COST-EFFECTIVENESS AND

MIX OF FFS-VBC 3RD PARTY PAYER REIMBURSEMENT

SERVICES INTEGRATION

» CIN-system-wide alignment » Health promotion/illness

prevention across served populations

» Alliances for CIN » Seamless care navigation » Care and revenue model

integration

CLINICAL & SERVICE IMPROVEMENT

» Standards of care & quality » Reduce clinical variation » Innovation in care delivery » Incentives/infrastructure » Customer focused services » Leadership/operational

excellence

WHAT ARE WE DESIGNING AND ANALYTICS NEEDED? HANYS NYS Payment Innovation Symposium - Analytics and Decision Support


Cat

ego

ry

Medicare

Managed Care Value-Based Contracts

Bundled

Payments

Shared

Savings

Budgeted

Capitation

Shared /

Dir. Risk

Capitation/

Global Pay.

Str

ateg

y D

escr

ipti

on

• Value Based

Purchasing

• Bundled Payment for

Care Improvement

• Medicare Shared

Savings Program

• Next Gen ACO 2.0

• Oncology Care Model

• Comprehensive Care

for Joint Replacement

• New Pilots 2016 – 2020

• Sustainable G.R.

• Global episodic

payment

• Retrospective –

Access payer

par network, no

downside

• Prospective -

Network & at

risk payment

• Shared

savings

from

reduced

TME

• Upside

Only

• Upside &

Downside

• TME +

attributed

population

• Limited

downside

risk... billing

stays same

as FFS

• A mix of

FFS and

partial

upside/

downside

payment

risk

•Capitation - A

global amount for

each member in

a discrete

population

•Global – Similar

to BCBS MA

AQC... moves to

a product specific

global payment,

not linked to an

attributed pop.

Pro

vid

er

Net

wo

rk

PCPs, PAC; Specialist &

Subspec. for Chronic Care

Patients; CIN/ACO network

All applicable

providers within an

episode of care

Full

continuum of

providers

Full continuum of

providers

Full

continuum of

providers

Full continuum of

providers

Source: Navigant Analysis

Note: Baseline, accurate patient level claims/utilization data for attributed populations across a network of providers used is critical for almost all risk sharing VBC payment arrangements.


HOW WILL WE BE PAID AND ANALYTICS NEEDED?

NYS DSRIP and Performing Provider Systems


UNDERSTANDING YOUR 3RD PARTY PAYER REVENUE PYRAMID

Medicaid FFS (NYS/Oth)

($XXX M net in CY 20XX)

NYS

Medicaid

Reform,

DSRIP, Other

Initiatives

CT and NJ

Medicaid

Reform

Pilot

opportunities?

Managed Care ($XXX M net in CY 20XX)

Commercial

Group

Medicaid,

CHIP, Duals Medicare

Advantage &

SNPs

Medicare FFS ($XXX M net in CY 20XX)

Trad. Medicare FFS & Value-

Based Purchasing

BPCI Med &

Surg, OCM

Cancer &

Other value-

based pilots

MSSP ACO

and Next Gen

ACO

Overall 3rd Party Payer

Enterprise Strategy

Key Revenue

Line Strategies

& Tactics

Revenue

Category

Options:

Strategies

& Tactics

Your 3rd party payer revenue strategy

for FFS and VBC Payment Models:

Impact on Operating Model

FFS & VBC

»What are our revenue risks?

»What are our revenue opportunities?

Operating

Model

Support

w/Revenue

Ceilings

Commercial

HIX

Pilot

Opportunities? Other?

What is our market positioning strategy by

revenue source?

FFS & VBC

»Risks?

»Opps?

FFS & VBC

»Risks?

»Opps?

FFS & VBC

»Risks?

»Opps?

FFS & VBC

»Risks?

»Opps?

FFS & VBC

»Risks?

»Opps?

FFS & VBC

»Risks?

»Opps?

CY 2016 – 2020: FFS & VBC Development Initiatives/Activities

»CIN-Population Health Network / Horizontal-Vertical Growth / Other

To Be Decided



Middle case scenario

assumptions result in

these “XYZ” revenue risks

and revenue

opportunities?

How will your transition

from FFS to VBCs impact

your long-term financial

and capital plan?

Key Revenue Drivers

1. Utilization (U)

2. Price (P)

3. Payer Mix (PM)

$TBD M

Total Revenue Reduction Risk

CY 20XX

(1) Volume and Dollars will shift and accelerate 2018 – 2020 with corporate exchanges active in market

GME, IME, DSH Impact = $XXX M ?

Aggregate (by

Revenue

Source)... U, P,

PM, Impact =

??? $XXX M (1)


3RD PARTY PAYER REVENUE MODEL RISKS & OPPORTUNITIES



3RD PARTY PAYER TRANSITIONAL PAYMENT REVENUE MODEL


TODAY’S PRESENTER

Christopher J. Kalkhof, MHA, FACHE

Chris is a Director with Navigant with 30 years experience and has lead/co-led numerous provider and

payer engagements addressing acute, physician and post-acute verticals. He has also served as an

executive at both provider and payer organizations, including as a managed care SVP at a nine hospital

system.

More recently, Mr. Kalkhof has worked on varied strategic initiatives associated with provider and payer

next generation care delivery and payment models, standardizing best practices contract language,

hospital/physician alignment models, provider-direct employer contracting, provider-payer and payer-

payer strategic alliances, contract negotiations tactics/strategies and 3rd party payer revenue-operating

model enterprise strategies.

Over the span of Mr. Kalkhof’ s career, he has negotiated over 300 payer contracts and advised clients

on over 1,000 additional contracts across 22 states.

Contact: 716.912.0309 (mobile) / [email protected]


see how far impact can reach. · 2015-11-02 · attributed pop. r rk subspec. for chronic care...

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