Network Innovations and Medical Management Success

Network Innovations and Medical Management Success

Mary D Strasser & Mary Hughes

Our Network

How do we build our Network?

• Find the right provider partners

• Commit to evidence-based decisions and results

• Reduce variation

Northwest Success

• 4 health plans left the NW ETF market

• Through innovative Network strategies, we changed the story

• The result – MLR reduction of 18.3%

Better care, more value

• Keep members well

• When care is needed, it is appropriate

• Decrease variation in resource use

• Shared decision making with members

• Anticipate future care needs

Why Preauthorization?

• Safety of our members

• Only appropriate care provided

• Right setting

• Right price

Example: Sleep Studies

What yields better results for the member? Sleep Studies done in the home or in a sleep clinic?

Shared Decision Making

Low Back Pain Program

• Helps members to make an informed decision about their care

• Percent of low back pain sufferers that require surgery: 1%

Soap

Gauze

Knee Implant

Hospital Day

Physical Therapy

Orthopedic Surgeon

=Knee Bundle (One price for all services necessary)

Warrantee against complications for 90 days

Today, we too often pay for one item at a time – example: knee replacement

Bundling Innovation

Orthopedic & Sports Institute of the Fox Valley

• 40 procedures

• Bundled price includes all services related to the procedure

• A 90 Day warranty is included

Bundles – A Quality Difference

• Infection Rate 0.3%

• Re-admission Rate: 0.8% (National Average: 4%)

• Average cost of a complication: $100,000

Bundles – The Numbers

Procedure Potential Savings

Total Hip Replacement $22,029

Total Knee Replacement $35,417

Rotator Cuff Repair $8,406

$250 Visa debit card will be given to members to drive them toward bundled services.

Neighborhood Family Clinic

• Partnered with as a low-cost, high quality option for Trust members

• Trust members can access at no cost

• Shared mission of reclaiming healthcare

• Member-centric approach

• Anticipate future care needs

• Transition of Care

• Personal Touch

Our Nurses