Post-Acute Care Preferred Provider Networks are they beginning to resemble the development of Pharmacy benefit formularies and preferred tiered positioning? Are Health Systems equipped to establish/develop, implement and manage PAC Preferred Provider Networks or will we see a new advent of Provider Network Management organizations? As Healthplans began learning to work on cost containment and control, they turned over management of their formularies to Pharmacy Benefit Managers (PBM's). What is next for effectively establishing and managing PAC Preferred Provider Networks?
|Posted on September 28, 2016 at 5:50 PM||comments (0)|
The development, implementation and management of Post-Acute Care Preferred Provider Networks is beginning to resemble contracting in the Pharmacy benefit world working for the Status of Preferred or Tier 2. It was always the goal as a prior Managed Care Director to get our products covered in that coveted position of "preferred".
Narrow networks or formularies are one way that Plan Providers can help to contain and control costs, maintain a level of quality to meet their required outcomes and metrics and offer incentives related to rebates based on market share percentages. Several different Pharmacy Benefit designs, dependent on the positioning, tier, step edit with a PBM and/or MCO can become very complicated and overwhelming in calculating rebates based off of Wholesale Acquisition Costs.
Where are we headed with the narrowed networks of Post Acute Care Preferred Providers and will we eventually get to a place that in order to participate in this network, Health systems may involve additional models for increasing revenue by market share percentages? Will someone manage that for them? Similar to the gain in power of PBM's within the Healthplan world, who offer not only the ability to provide tighter network control but also analytics back to the plan related to the Pharmacy benefit. There will be incentives down the road related to the providers in the network for gain sharing, however is there opportunity for the Health Systems to explore getting more creative?
Out of change and challenge, comes opportunity for new companies, programs or organizations to help systems unaccustomed to managing network providers with an outsourced solution. Help them get the job done within an Alternate Payment Model including avoiding costly penalties. Analyzing data, predicting risk and predicting patient response related to care transitions associated with Bundled Payments is not yet the expertise of many large Health Systems. CMS is serious with an aggressive timeline, rolling out Cardiac Bundling Demonstrations in 2017, their timelines march on. Large systems are just beginning to get their arms around their own assets including bridging gaps with their internal processes and departments. Who will show up as the Knight in shining armor to help get them successfully to the finish line and take this large burden off?
Large Health Systems are notorious for silos, not oversight and connection between departments and integration of post-acute care providers. Is this a challenge we need to be concerned about, yes however it is a reality that everyone in the business of Healthcare today must do a deep soul search and recognize what they do well and where they need help. Transparency is more critical than ever before as well as knowing who and what you need to fill in those gaps, make you successful and transition you to the next phase of Healthcare reform. All Board retreats really should include an outside strategist that helps the system and/or provider "get real" as they say, so you can identify where you are today, where you need to be tomorrow and how you plan to get there.
|Posted on July 6, 2015 at 12:30 AM||comments (0)|
Trends, trends and more trends. Experts discussing which way things will go but this is what I know for sure, we are moving more and more to the model of Population Health Management. That is the buzz word of today and what will it take for Healthcare Providers to win the war of Population Health Management?
CMS continues it's march on "Compare" websites, the next to be added is the Physician Compare in 2016. We will see how the behaviors of physicians will impact their future Medicare Payments. CMS Star ratings are also another entity any organization should concern themselves with, knowing what is measured and what effect it will have on the future with reimbursement and value based purchasing. Are you or your organization concerned with Patient Satisfaction, Quality and achieving outcomes? You should be as this is taking precedence in the Healthcare Market place.
What about that Continuum of Care and the integration of all providers to produce a positive outcome? Health Systems and Physicians must now integrate and align with organizations that will enhance or positively influence their outcomes and of course, overall satisfaction which means an alignment of philosophies. Are you a provider that can measure your value and what you bring to the table to enhance the patient experience while reducing Hospital Readmissions, Hospital bed days and Medicare spending? Do you have data and is your data integratable?
Gone are the days of paper folks, you need to be much more sophisticated than that if you plan on playing in the Healthcare Environment of today and tomorrow. What can you measure, what can you prove, what can you query to produce your evidence on what you have to offer whether in a bundled payment system, an ACO or a risk sharing methodology. What are your costs and how can you improve upon those costs? If you are unable to get your arms around your costs and show efficiencies there, how can you improve the costs of another organization? Technology is a huge investment however technology offers much of the answers to streamlining processes, data collection, efficiencies and accessibility. Remember Healthcare Reform is about 3 things when you boil it down: Cost, Quality and Access.
Embracing technology is not as easy as it seems in Healthcare, however so necessary.
I cannot repeat that above sentence enough, embrace technology as it relates to your staff, your daily functions and also measuring what you offer. Take the time to assess, do I have the right people in place to lead and move your organization forward knowing what is needed is: Technology, Data, Contracting models that offer both solutions and compliance, Operational efficiencies that require a "think outside of the box" approach.
So if your organization embraces the following you will position yourself as a thought leader and provider of services that support Population Health Management and you will be one of the winners! Upgrade your technology as data integration is the key along with data collection to support key quality indicators and your impact on costs and outcomes. Are you open to new models of contracting and reimbursement that allow you to embrace risk sharing opportunties, new models of delivering care to engage the patient/member frequently and are you aligned with organizations where you share similar philosophies and are integrated securely in the continuum of care? Do you have the right leadership in place for Healthcare evolution or does your organization require the assistance of an outside agency or consulting firm to help get you there for the future?
Whenever we are called in to "advise" one of the first questions is: What is your 3-5 year plan and where do you see yourself in the future of Healthcare Delivery? That 3-5 year plan must be fluid but must have a basic outline that will get you there and if you do not have it, then this may be the time to consider some help on getting you there.
The train has left the station, is your organization a freight car, a passenger car, a high speed train or a locomotive? Now is the time to take a realistic assessment of where you are currently and where you want to be.
We wish you the best at Ahearn Advisement Partners!
|Posted on September 30, 2014 at 3:45 PM||comments (0)|
"In that direction," the Cat said waving it's right paw round, "lives a Hatter: and in that direction waving the other paw, "lives a March Hare. Visit either you like: their both mad." (Wonderland 6.52)
"But I don't want to go among mad people" Alice remarked.
"Oh you can't help that," said the Cat: "we're all mad here. I'm mad, Your mad".
"How do you know I'm mad?" said Alice
"You must be," said the Cat, "or you wouldn't have come here." (Wonderland 6.53-56)
I find the story of Alice in Wonderland a very good analogy at times for training new people entering the world of Managed Care Contracting. It takes a unique individual to enter this field, or perhaps someone that is mad as described in the above passage from Alice in Wonderland.
Managed Care Contracting is not one of those specialties that just happens to a person overnight, it is a long arduous process of relationship building, seeking out new territory, understanding healthcare and healthcare reform, reimbursement and multiple reimbursement models and staying ahead of the curve often before most within your organization. How often have you been met with question after question on contracting and the only answer you can give is "it depends?" Sales people and others within the organization look at us as if we are mad because our best answer is "it depends" when honestly that is the only answer you can give. If only it were simple, but really you can go in this direction or that direction as you try to assess what your customer needs, who is carrying financial risk and then provide a solution and there is never just one solution as you seek the optimal solution to get that contract.
I have spent the last 25 years in Managed Care Contracting both Nationally and also within the Country of Calif. as I often hear my home State referred to. Slow but sure my portfolio of Contacts is rich and that does not happen overnight. That comes through years of listening, analyzing and delivering what the customer needs on top of understanding the landscape that we function in. A Managed Care Contractor is usually doing a sales job not only to the customer but also to their company saying "we need to do this in order to close the business" only to be met with comments of "boy are they a high maintenance customer". Ugh, am I right? How many times have you heard that too?
When I go in to consult or train I always say, look for that key relationship that you can prove yourself to that will be the "rabbit hole" or jumping off point to get you to the next customer (organization) and the next and the next because truly, it is the relationships that gets you through the door. And that is just a start, that relationship is critical to get you through the door, however it does not stop there. Then the selling begins, especially in todays Healthcare market where cost, quality and access are the primary outcomes of Healthcare reform. How are you the Managed Care Contractor going to best partner, assist and help that organization get to the next level with your products or your services?
I often get asked, can we hire someone without experience and right out of school, train them and be successful? And as I tell my clients, in Managed Care you get what you pay for. Managed Care is relationship selling and not all companies understand that. Many times I have picked up business for a company simply because another organization chose to lay off their Managed Care people not realizing how important that relationship was to their customer. We are like wolves in waiting for those moments to happen and when they do we pounce on the opportunity taking advantage of another companies failure to realize how critical that relationship was to their business. This makes me wonder, is it really the Managed Care Contractor that is mad or a continued lack of understanding on what we do and what we bring to an organization?
More and more I also continue to find companies looking for the "perfect" Managed Care Contractor to fill their needs. To the point that they become paralyzed in the hiring process and allow the window of opportunity to pass. And in Managed Care, there are windows of opportunity and you must move before they close, or you will wait another 3 years. A Managed Care Contractor should bring to your organization relationships, vision, how to postion you against the competition and a working network of individuals that keeps them in the "know". I am beginning to realize that just perhaps that perfect Managed Care Contractor does not exist and it might actually be better as an outsourced function to energize and get things going until you can find a fit for your organization versus remaining paralyzed and letting opportunities pass.
So are we the Managed Care Contractor mad, curious or just love the challenge? Speaking for myself, I cherish my relationships and love Business Development, helping to grow a worthwhile organization and providing optimal solutions so that everyone wins! I try not to think of myself as too mad but having fun in my own way working through those challenges!