2015 CAPG COLLOQUIUMACHIEVING SUCCESS IN RISK‐BASED COORDINATED
CAREOctober 6, 2015: Marriot Wardman Park –
Washington, DC
BREAKOUT 8 GETTING READY TO TAKE ON RISK…
HOW DID NORTH SHORE‐LIJ DO IT?
Richard Miller
Daniel
Jorgenson1
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NORTH SHORE‐LIJ KEY FACTS
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What is ValueWhat is Value‐‐Based Care?Based Care?
Defining Value....
“The health outcomes achieved that matter to patients
relative
to the cost
of achieving those outcomes.”
‐Thomas H. Lee, MD and
Michael E. Porter
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NSLIJ Health SystemNSLIJ Health System NetworkNetwork
MLTC
FIDA
Commercial Plans
Exchange Plans
North Shore‐LIJ Hospitals
NSLIJ Post Acute Care
Full Vertically Integrated
Continuum of Care
Core Laboratories Behavioral Health
Dental, Vision & Other
Specialty Providers
Community Based Providers
North Shore‐LIJ Medical Group
NSLIJ Population Health Management MSO Services
Three Distinct Pillars Three Distinct Pillars
How will the transformation from Volume to ValueHow will the transformation from Volume to Value‐‐Based Care Be Based Care Be
Achieved?Achieved?
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Source: News Release, U.S. Department of Health & Human Services, News Division, 1/26/2015
Alternative Payment Models Hospital Payments Through Value‐
Based Programs
Today: 20%
2016 Goal: 30%
2018 Goal: 50%
2016 Goal: 85%
2018 Goal: 90%
VBP VBP ––
The Latest from the FedsThe Latest from the Feds……
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Source: Becker’s Hospital Review, 1/28/2015
“The formation of the Task Force…responds to HHS announcement that half of Medicare reimbursement will shift to alternative
payment arrangements by 2018.”
Accelerating the ValueAccelerating the Value‐‐Based TransitionBased Transition
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NSLIJ Stakeholders / Participants
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What is NSLIJ Care Solutions?
Our health system’s care management organization
accountable for the
implementation and performance of our system’s risk‐based programs
Care Solutions
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What is the Goal of Care Management?
To achieve an optimal level of wellness & to improve coordination of care while providing
cost effective, non‐duplicative services
Source: Center for Health Care Strategies, Inc, adapted from Robert Mechanic, “Will Care
Management Improve the Value of U.S. Health Care?”
2004
Care Management
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Patient Identification, Analytics &
Risk Stratification
Outreach and
Engagement
Care
Coordination
Performance
Measurement Innovations
& Change Mgt
Care Management Competencies & Domains
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P4P Metric Taskforce
Statement of PurposeStatement of Purpose
Develop a platform of metrics that will form the foundation for all P4P and incentive‐based health
insurance contracts that will be utilized by the NSLIJ Health System. The taskforce will track and
modify its recommendations based on the overall utility of these
metrics when instituted.
The framework for these metrics will be built around the following principles:
• The metrics are easily measurable;
• The metrics are achievable;
• The metrics are synergistic with metrics that are already followed for regulatory entities such as
CMS;
• The metrics are synergistic with provider incentives;
• The metrics may be both process and outcomes based with the evolution to a majority being
outcomes based; and
• The metrics will establish the foundation for managing the health of a population
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Daniel JorgensonChief of Staff &
Vice President, Strategic Planning
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
Agenda
The Opportunity
Go to Market Strategy
Integrated Medical Management
Integrated Customer Service
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Conclusion
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.17
The Opportunity
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
Why a Health Insurance Company?
The insurance market has very high barriers to entry…
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Strong and established competition
Requires large investment of capital
Ability to sustain long-term ROI
Infrastructure for managing risk
Volume to the health system
Enterprise value
…But success will result in significant value to NSLIJ
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
The OpportunityA combination of factors made 2013 the right time for North Shore-LIJ Health System to enter into the insurance market.
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Changes to reimbursement models
Experienced gained by offering limited network to NSLIJ employees
Health care reform Is changing provider and insurance markets
Affordable Care Act and advent of the exchange creates opportunity
Belief that the New York market was sophisticated enough for a new model
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
A Fundamental Problem
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From the customer’s perspective, health care is extremely complicated – even bizarre.
COPAY DEDUCTIBLE IN/OUT OF NETWORKCOINSURANCE OUT-OF-POCKET MAX
COPAY
EMBEDDED DEDUCTIBLE
DEDUCTIBLE
SPLIT COPAY
COINSURANCE
PLACE OF SERVICE
IN NETWORK
OUT OF NETWORK
OUT-OF-POCKET MAX
EOB
EFT CASE MANAGEMENT
REFERRAL
AUTHORIZATION
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
The Current Experience
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CASE MANAGEMENT
HOSPITAL DOCTOR
MEDICAL RECORDS BILLING
EOBS
Customer
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
CareConnect’s Mission
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SIMPLIFY HEALTHCARE
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
The CareConnect Experience
CASE MANAGEMENT
CASE MANAGEMENT
HOSPITALSHOSPITALS DOCTORSDOCTORS
MEDICAL RECORDS MEDICAL RECORDS BILLINGBILLING
EOB’sEOB’s
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CustomerCustomer
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
Provider-Payer Integration
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CareConnect’s integrated relationship with North Shore-LIJ creates numerous synergies that go beyond the traditional payer/provider relationship
AppointmentBooking
BrandLeverage
Expert SecondOpinions & Centers of Excellence
High Level of Care
Coordination
MarketingCapabilities
Daily Feeds & EMR System
Access
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.25
Go to Market Strategy:Price & Network
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.26
NETWORKSIZE
MEMBERPREMIUM
CARE COORDINATION
MEMBER EXPERIENCE
TRADITIONAL MODEL Large High Low Self Service
MEDICAID MODEL Large Low Low Self Service
New Models: Added Consumer Choice
INTEGRATED MODEL Small Low High Concierge
NARROW NETWORK Small Low Medium Self Service
North Shore-LIJ CareConnect Insurance Company, Inc.
Forefront of Narrow Network Trend
Relationship with largest health care provider in NYS gives us unique positioning and stability in terms of pricing and network
Other carriers removing major hospitals and providers
Competitor Premium Increases:
– First time since prior approval has been in place that there has been an increase of 20-30%
– A result of the high cost of large, robust networks
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The world is moving toward narrow network products and CareConnect is at the forefront of that trend
North Shore-LIJ CareConnect Insurance Company, Inc.
A Value Network
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Fully integrated provider network
– Allows CareConnect to provide better care management with lower denial rates
Continuing to partner with like-minded, high quality facilities to fill network gaps
– Breadth vs. depth: striving for contiguous network of the highest quality
– CareConnect will always have an exclusive network
North Shore-LIJ CareConnect Insurance Company, Inc.
Top Network Providers
2014 2016 % increase
Hospitals 15 47 +213%
Providers 5,500 20,000+ +264%
North Shore-LIJ CareConnect Insurance Company, Inc.
2016 Small Group Rate Comparison
Westchester / NYC (Gold)
$590+17.7%
$666+32.9%
$724+44.5%
$751+49.9%
$755+50.7%
Long Island (Gold)
$590+12.6%
$724+38.1%
$751+43.3%
$755+44.1%
$757+44.4%
$501$524
Lowest priced small group plans with access to NSLIJ
North Shore-LIJ CareConnect Insurance Company, Inc.
2016 Individual Rate Comparison
Lowest priced individual plans with access to NSLIJ
Long Island (Gold)
$557+11.8%
$569+14.3%
$624+25.3%
$656+31.7%
Westchester / NYC (Gold)
$549+15.3%
$557+17.0%
$569+19.5%
$656+37.8%
$476$498
North Shore-LIJ CareConnect Insurance Company, Inc.
Predictable Pricing Trends
Small Group Gold Single Rate New York Region
Over the past 3 years, there has been significant disruption in the market for employers looking for value
Our model can offer a long- term, economical solution for their clients
– No need to switch carriers due to large year-to-year price swings
North Shore-LIJ CareConnect Insurance Company, Inc.
Co-Branding Marketing Strategy
Improving name recognition
Tread lightly between using NSLIJ and limiting CareConnect to NSLIJ
Alignment with individual geo-targeted hospitals by market
Focus on savings, especially in the small business community
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Use the strength of the NSLIJ/Northwell brand to establish CareConnect
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.35
Integrated Medical Management
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
Integrated Medical Management
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A collaborative relationship between CareConnect and its providers establishes the trust necessary for effective utilization management. To ensure that CareConnect’s providers can deliver the kind of care they believe in, CareConnect uses nationally accepted peer-reviewed evidence based guidelines in addition to North Shore-LIJ’s care practice manual as the basis of its clinical practice guidelines.
COLLABORATIVE RELATIONSHIP
EFFECTIVE UTILIZATION MANAGEMENT
EVIDENCE-BASED GUIDELINES +
NORTH SHORE-LIJCARE PRACTICE MANUAL
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
Physician Advisory Group
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Insurance Plan
Clinical Processes Cost of Care Policies &
Guidelines
Centers of Excellence
Provider Network Nominations
Pharmacy Guidelines
Recommendations on Benefits Coverage
Expert Second Opinions
New Technologies
Medicine
Rehabilitation
Surgery
Radiation Medicine
Otolaryngology
Neurosurgery
Hematology
Oncology
Psychiatry
Ophthalmology
Urology
Pathology
Emergency Medicine
Obstetrics & Gynecology
Orthopedics
Dermatology
Care Solutions
Authorization Clinical Practice Guidelines & Milliman
Approve
Experience
Review
PHYSICIAN ADVISORY GROUP
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
Population Health Management
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Provider-payer integration makes it possible to proactively deliver the most effective level of care before, during and after encounters with the health care system, and gradually move interventions toward earlier points in the care continuum.
UTILIZATION DATA
LAB DATA PHARMACY CLAIMS ED VISITSHOSPITAL
CHARGES
PreventionIntervention + =DECREASE
HEALTH CARE COSTS
Track Members
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
Telemedicine
Around-the-clock access to board-certified physicians by phone or video consultationsConvenient and affordable option for quality care when a member:– Wants care immediately for a
non-emergency issue– Is away from home– Needs a short-term prescription refillAffordable alternative to costly urgent care and ER visitsWill be offered as a free, value-added service for all new and existing CareConnect members
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North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.40
Integrated Customer Service
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
Customer Service Tools
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ENTERPRISE WORKFLOW
SELF-SERVICE INTERFACE
CUSTOMER SERVICE
CALL CENTER
CUSTOMER CARE
CENTER
PROVIDES AN INTEGRATED WAY TO ROUTE WORK BETWEEN BUSINESS UNITS;
TRACKS AND LOGS INTERACTIONS FOR METRICS AND MONITORING.
ALLOWS MEMBERS TO COMPLETE TRANSACTIONS INDEPENDENTLY;
PROVIDES ACCESS TO INFORMATION ABOUT THEIR ACCOUNTS.
PROVIDES AN INTEGRATED WAY TO ROUTE WORK BETWEEN BUSINESS UNITS;
TRACKS AND LOGS INTERACTIONS FOR METRICS, MONITORING AND MANAGEMENT
OF MEMBER ENGAGEMENT.
2 DEDICATED STAFF (CALL CENTER STAFF ROTATE IN AND OUT)
CAPS, CRM, WEB TOOLS, NYS EXCHANGE, PORTALS
45 FTE CALL CENTERCAPS, CRM, WEB TOOLS,
NYS EXCHANGE,PORTALS
North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
The CareConnect Solution
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CUSTOMERCARE CENTER
ONLINEACCOUNT
MANAGEMENT
PROVIDERAPPOINTMENTSCHEDULING
ONE CALLDOES IT ALL
ONE-CALLRESOLUTION
Keeps Members In-Network
In-Network Providers Are All Committed To CareConnect’s Medical Management Approach
Resolution Rate88%
In-Person Visits 5,000+
Providers 20,000+
Members 25,000+
NO IVRALL CALLS ANSWERED
Avg Speed to Ans< 10 seconds
North Shore-LIJ CareConnect Insurance Company, Inc.
Integrated Customer Experience
Customer Service Statistics– Speed-to-answer: Under 10 seconds
– Call resolution: 88% of calls resolved by the answering representative
– Ability to reach a live person 363 days/year
Improved member ID cards
New look EOBs
New enhanced website
New provider look-up tool
Online premium payments
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North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.
Conclusion
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North Shore-LIJ CareConnect Insurance Company, Inc.
Our Integrated Model is Working
Coordinated integration has led to significantly lower utilization denial rates – Industry average: 10-20%– CareConnect (thru July 2015): 5%
Product pricing consistently among the lowest in the region– Only 2-5% increases for 2016 vs. 2015
Currently enrolling the largest private employer in the State: North Shore-LIJ Health System
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QUALITY NETWORK
CUSTOMER SERVICE
AFFORDABILITY
The proof is in our results:
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