Provider-Sponsored Networks “Building Partnerships” Presented by… Linda McKinnon, Chief...
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Transcript of Provider-Sponsored Networks “Building Partnerships” Presented by… Linda McKinnon, Chief...
Provider-Sponsored Networks
“Building Partnerships”
Presented by…
Linda McKinnon, Chief Executive Officer, Central Florida Behavioral Health NetworkBob Holm, Regional Substance Abuse Director, Suncoast Region DCFRichard Brown, Chief Operating Officer, The Agency for Community Treatment ServicesNancy Hamilton, Chief Executive Officer, Operation PAR
Central Florida Behavioral Health Network is a not-for-profit organization of community providers incorporated to ensure and enhance an array of behavioral health and other human services needs for the citizens of our communities.
CFBHN Mission
CFBHN History
Linda McKinnon
Chief Executive Officer
Central Florida Behavioral Health Network
CFBHN History“Not an overnight sensation!”1995 No collaboration among providers or between disciplines
1996 Collaboration among mental health providers in Hillsborough and
Manatee counties related to pre-paid Medicaid pilot
1997 Collaboration between ADM and substance abuse providers in
Hillsborough and Manatee counties to create CFBHN No collaboration between mental health and substance abuse
providers DCF contracts with CFBHN to manage funds targeted at SSD and
SSI dis-enrolled and intervention services
CFBHN History1998 Hillsborough County mental health providers join collaboration as
vendors DCF contracts with CFBHN for TANF-funded services and children’s
substance abuse services CFBHN assumes additional administrative responsibilities for
outcomes and quality oversight for contracted services
1999 CFBHN joins Florida Behavioral Health Hillsborough County Workforce Board contracts with CFBHN to
implement a three-year grant for supportive employment services targeted to the most difficult to employ TANF recipients
CFBHN History2000 DCF regionalization pilot DCF expands contracts with CFBHN to include substance abuse
services for heroin and cocaine abusers and family intervention services
DCF contracts with CFBHN to provide services in collaboration with Hillsborough County children’s system of care development grant
Sarasota County substance abuse provider and Hillsborough/ Manatee Public schools join collaborative as vendors
2001 G. Pierce Wood Hospital closes Substance abuse and mental health providers in Hillsborough
County collaborate to address needs of substance abusing persons with serious mental illness
CFBHN History
2002 CFBHN Board membership expanded to include 19 substance
abuse and mental health non-profit providers in 9 counties comprised of Suncoast Region and District 14
Family intervention services expanded to Pinellas, Pasco and Sarasota counties
CFBHN contracts to operationalize COSIG Grant in Hillsborough County
TANF-funded services expanded to Pasco County CFBHN contracts to provide substance abuse aftercare services in
Suncoast Region
CFBHN History2003 CFBHN contracts for TANF-funded services throughout Suncoast
Region and District 14 (Polk, Highlands and Hardee counties) DCF contracts with CFBHN to provide TANF oversight functions in
Suncoast Region and District 14 Family intervention services expanded to District 14 SAMH Program Office contracts with CFBHN to provide services
targeted to persons with co-occurring disorders and operationalize COSIG Grant in Hillsborough County
CBC contracts with CFBHN to provide children’s mental health services in Hillsborough, Manatee and Sarasota counties
CFBHN awarded ASO development pilot for District 8 (Charlotte, Lee, Collier, Hendry and Glades counties)
CFBHN History
2004 DCF Suncoast Region contracts with CFBHN to provide substance
abuse prevention for adults DCF District 14 contracts with CFBHN to develop service strategies
for persons with co-occurring disorders CFBHN identified to operationalize Robert Wood Johnson
Resources for Recovery Grant throughout Suncoast Region CFBHN operationalizes substance abuse elder care pilot CFBHN implements diversion services for CBC District 8 DCF initiates start up contract for SB1258 ASO pilot
CFBHN History
Current FY2004-2005 Contract DCF Suncoast contracts with CFBHN to manage all substance
abuse treatment services and funding
DCF initiates single contract with CFBHN for contract administration, management and oversight functions for substance abuse treatment throughout Suncoast Region
The Purchaser’s Role
Bob Holm
Regional Substance Abuse Director
Suncoast Region DCF
DCF’s StrategyWhat the Purchaser Wants
Evaluate, integrate and re-engineer system of care into a seamless and easily navigated system
Ability to achieve uniform clinical policies and best practice throughout Network
Uniform data collection used to drive quality improvement initiatives
Resource maximization and cost effectiveness Increased access to care Simplification and non-duplication of contracting and oversight
functions to allow for effective use of limited staff
The Purchaser’s RoleMoving the System Forward State and District SAMH plan development
Needs assessment Defining population eligibility Utilization standards Service allocation projection
Financing strategies ASO and service system design Contract development ASO contract performance and oversight Regulation and licensing Review and approval of quality and systems improvement initiatives and
plans Technical assistance to managing entity Review and approval of contracts with network providers
Reengineering Substance Abuse TreatmentRWJ Resources for Recovery Grant
Suncoast Region and CFBHN named as a pilot in Grant
Medicaid Maximization: Contract requires 10% increase in Medicaid revenues earned for substance abuse treatment throughout CFBHN providers
Testing of Flexible Payment Methodologies: Grant funds moved to CFBHN to allow greater flexibility for services to more adequately meet consumer needs and to test strategies for case rates and other prospective payment methodologies
Increased Access to Care: Contract requires reduction of wait lists for residential services and increased access to detoxification services
Contracting with Networks
Currently using a hybrid performance
contracting mechanism designed to increase and move towards flexibility and accountability.
Contract used to define ASO functions and Network requirements and is defined differently by local districts/region
Administrative Services Organization: “An independent operating entity organized for the purpose of managing and assessing a network of human service providers and provider agencies, to include but not limited to, quality improvement, clinical management, network management, data management, revenue maximization and integration of systems.” (As described in District 8 ASO contract)
Suncoast-Specific Terms
Managing Entity - An entity that manages the delivery of behavioral health services
Network Provider - An entity that contracts with the Managing Entity to provide services to clients that are funded through the contract with the department (subcontractor)
System of Care - Behavioral health services developed into an integrated network to provide services to substance abuse and mental health clients
Contract Requirements
The ASO… Is responsible for the administration and provision of
services
Must ensure that network providers will provide services as specified in the system of care plans identified for each county in the Network Operational Plan
Must ensure services described are provided throughout the contract period
Contract Requirements
The ASO… Must ensure that the number of persons served, as
required by contract, are served with outcomes
Must establish a client grievance procedure that assures that all grievances not resolved at the provider level are referred to the managing entity
Contract Requirements
The ASO is responsible for…
All mandated outcomes,electronic data submissions and performance improvement initiatives
Incident reporting
Assuring emergency preparedness ofits providers
Provider financial and audit requirements
Billing and invoice validation
ASO Contract ResponsibilitiesUnique to Suncoast Region
The ASO is responsible for… Management of wait lists for all substance abuse services Reduction of wait list for residential treatment services Evaluation of Region’s detoxification system Increase of Medicaid billing and reimbursement for
substance abuse treatment services by 10% Implementation of substance abuse services to the elder
care pilot Implementation of co-occurring service capability
throughout provider network
Lessons Learned from Purchaser Communication is Key!!
Need to clearly define what is being purchased Need to understand and articulate the role of the purchaser Requires partnership of all stakeholders Requires commitment of local SAMH Program Office and
state SAMH Program Office Requires transfer of administrative responsibilities, dollars
and staff Need to identify barriers and work toward resolving issues Requires ability to assess readiness of Network to assume
responsibilities
Building the NetworkGovernance Structure
Richard Brown
Chief Operating Officer
The Agency for Community Treatment Services
actsThe Agency for Community Treatment Services
CFBHNCFBHN
Suncoast & District XIV 9 counties 19 members (providers) 4 Regional Councils
District VIII 5 counties 8 members
5 providers 1 CBC 2 consumer representatives
Governance StructureGovernance Structure
All corporate generated documents need to reflect succinctly….
”who you are and what you are to do”
CFBHN DescriptorsCFBHN Descriptors
Not-for-profitProvider sponsored networkAdministrative Service OrganizationAspiring to become:
Single Managing Entity
Corporate DocumentsCorporate Documents
Articles of Incorporation Bylaws Business Plan Board Policies Member Agreements Vendor Agreements Etc.
Policy ContentPolicy Content
Reflect commitment to community driven, consumer centered care:Increased accessibilityContinuous care approachesIntegration with other systems
Scope of Fund AdministrationScope of Fund Administration
Select substance abuse funds All substance abuse funds Select substance abuse & select mental
health All substance abuse & select mental health All substance abuse & mental health Other (or) “Lines of Business”
Purchase RelationshipsPurchase Relationships
ADM Substance Abuse ADM Mental Health AHCA Community Care Provider(s) Local / Governmental Community Care Provider(s)
MembershipMembership
Most congruent structure for a Provider Sponsored Network
would reflect major providers of the anticipated
“Lines of Business”
Substance Abuse Mental Health Insurance
Single
Managing
Entity
Eligibility(Factors for Membership Decisions)Eligibility(Factors for Membership Decisions)
Accreditation Financial Buy-in to Membership Current Contractor for Anticipated
“Lines of Business” Medicaid Provider Demonstrated ethics & conformance with
requirements of Member / Vendor Agreements In good standing with current funders
Governance DecisionsGovernance Decisions
Financing ASO InfrastructureEarn & BuildStaffing Grants (OPS)FCO GrantsMembership Fee(s)Member / Vendor Dues
Governance DecisionsGovernance Decisions
Build & BuyClaims ManagementHuman Resources / PersonnelCall CenterInformation System & MIS ManagementAuditing / MonitoringEtc.
Governance DecisionsGovernance Decisions
Targeted Reserve Fund Development
A. Capital Equipment
B. Research & Development
C. Financial Security
D. Risk Management
E. Insurance Licensure
F. Innovations
Governance Sticking PointsGovernance Sticking Points Large vs. Small Agencies Mental Health vs. Substance Abuse Comprehensive Providers vs. Niche Providers Local vs. Remote Headquarters Inclusiveness: Members, Vendors, Purchasers,
Stakeholders & Consumers Right of First Refusal Market Share Protections
Sticking Points – cont.Sticking Points – cont.
Non-compete vs. Notification of Intentions
ASO vs. Provider Status
TOOLS Towards Focus of Effort & the Attainment of InclusivenessTOOLS Towards Focus of Effort & the Attainment of Inclusiveness
Business PlanningSystem of Care Planning
Ah Right…It’s time for extreme
makeover!!
“We will know that we have arrived when the ASO readily matches consumers benefit to provider payments & providers are free to focus on matching consumer needs to services consistent with their progress in recovery”
Building Administrative Capacity
Linda McKinnon
Chief Executive Officer
Central Florida Behavioral Health Network
Building Administrative CapacityThe Role of the ASO
Provider network development and management Planning Customer service Quality management Utilization management Information management Financial management Training and education; best practice development Systems integration Resource development
Current Organizational Structure Defined by Functional Roles
August 16, 2004Collaborating for Excellence in Behavioral Health Services
Linda McKinnonChief Executive Officer
Sue WebberDirectorFinance
TBHManager
Information Systems(On Hold)
Lisa MainFiscal Supervisor
Lisa ThomasFiscal Assistant
TBHIS Technician
(On Hold)
Ioan FernandezData Specialist
Yenny HernandezData Specialist
Mary HerkertDirector
Network Operations
Jan BurtonManagerContracts
TBHAccountant
Kathy WayManagerContracts
Laura GrossAdministrative
Assistant
Rebekah BicklingExecutive Assistant/Admin Supervisor/
HR Liaison
TBHAdmin Assistant
(On Hold)
Brandi MasonAdministrative
Assistant
Jimmie Adams Admin Assistant/
Receptionist
Paula Pressler-TashDirector
Quality Management/Utilization Management
Ibelice RiveraQuality Specialist
TBHQuality Specialist
TBHQuality Specialist
Laura CronkQuality Manager/
Data Operations Analyst
Marcia MonroeDirector
Provider Services
Kay DoughtyManager
Specialty Services
TBHManager
Adult Services
TBHManager
Children’s Services(On Hold)
Tampa Office
Current Organizational Structure Defined by Functional Roles
August 16, 2004
Collaborating for Excellence in Behavioral Health Services
Linda McKinnonChief Executive Officer
Nancy RossbackReceptionist/Admin Asst
Rick SanefskiQI Manager
Brian MogoskyDirector
Jennifer FormicaData Specialist
Susan LangConsumer Affairs
Manager
District 8 Office
Building Administrative CapacityQuality Management
Performance Improvement Program Evaluation – Specialized reports, outcomes
improvement, best practice identification, outlier review, customer satisfaction
Performance Compliance - Corporate service validation, regulatory compliance and oversight, clinical pathway compliance
Utilization Management - Clinical UM development and oversight
Outcome/Data Management - Data and outcome validation, tracking and reporting
Technical Assistance and Training Accreditation
Building Administrative CapacityProvider Services
Credentialing and profiling Clinical systems development Best practice implementation Technical assistance Product development Service development Provider information and orientation Management of training resources Consumer, stakeholder, purchaser and provider satisfaction Complaints and grievance
Building Administrative CapacityFinancial Management
Financial reporting and forecasting requires tracking, analysis and reporting of the following:
Rate Setting and development methodologies Provider allocations Cost accounting system Revenue maximization strategies/ internal resource management Funding utilization and cash flow analysis Agency reconciliation Accounts payable and receivable Budget development and management Insurance Board communication
Building Administrative CapacityAdministrative Services
Information systems and data management
Information system development and technical assistance
Management reporting support
Contract development, negotiation on and compliance
Revenue maximization
Provider resource management
Medicaid maximization
Grant development
Risk mangment
Facility management
Building Administrative Capacity IS Capabilities - Lessons Learned
Identify information system needs early on and be willing to invest in them!!
Requires identification of software functional needs for: - Network management functions - Claims processing functions - GL linkage and financial functions - Member services functions - Care access functions
- Care management and utilization management
Building Administrative Capacity Executive Services
Board development
Regional council development
Purchaser relations
Advocacy
Legal
Marketing
Human resources
Oversight of all Network and ASO operations
Building Administrative Capacity Lessons Learned Identify potential conflicts of interest (an ASO is not a
provider) Be prepared to perform once you have got what you asked
for – greater flexibility has its own set of requirements Don’t over-commit Be prepared to act on opportunism quickly Understand the implications on providers Develop a strong relationship with the Board This is a partnership with all stakeholders and requires open
communication and trust ASOs are not “one size fits all”
Nancy Hamilton
Chief Executive Officer
Operation PAR
Provider/Member’s ViewProvider/Member’s ViewTwo-Hatters in Provider Two-Hatters in Provider
Sponsored NetworksSponsored Networks
PAR
CFBHN
““We have met the enemy & he is us” We have met the enemy & he is us” PogoPogo
Keep this in Keep this in mindmind…..ALWAYS!!…..ALWAYS!!
Holy Cow…What will become of us…will we
survive???I’m so confused…what
to do…get on the bus…or find my self hitchhiking later??
Contracting thru The ASOContracting thru The ASOOpportunitiesOpportunities FlexibilityFlexibility Sharing expertiseSharing expertise SustainabilitySustainability Giving up control to gain Giving up control to gain
some control over the some control over the unpredictability of politicsunpredictability of politics
Respond to the needs of Respond to the needs of the communitythe community
Improve quality of servicesImprove quality of services
ChallengesChallenges Our invoices will now be Our invoices will now be
matched to the information in matched to the information in the data warehouse. The the data warehouse. The network is not going to hold network is not going to hold up invoices for the first up invoices for the first couple of months (good) but couple of months (good) but could be problematic in the could be problematic in the futurefuture
Investing in the network Investing in the network meant reduction in revenues meant reduction in revenues – invest today for potential – invest today for potential higher returns later – scary, higher returns later – scary, hard to explain to Board & hard to explain to Board & staffstaff
Testimony – the CFOTestimony – the CFO Renegotiating contract – reduced tedious Renegotiating contract – reduced tedious
financial reports required in the past. financial reports required in the past. At negotiation, all reimbursement rates were At negotiation, all reimbursement rates were
increased to the model rate, less the admin. increased to the model rate, less the admin. rate, which resulted in increased rates for rate, which resulted in increased rates for most of our services most of our services
Contract was restructured to allow us more Contract was restructured to allow us more flexibility to spend dollars among cost flexibility to spend dollars among cost centers. Don’t have to go through contract centers. Don’t have to go through contract amendments to move dollars around amendments to move dollars around
End of the year, the network was able to re-End of the year, the network was able to re-allocate funds due to lapse dollars. Since allocate funds due to lapse dollars. Since PAR was over-producing units in some of PAR was over-producing units in some of the cost centers, we were able to share in the cost centers, we were able to share in this reallocation – Next year who knowsthis reallocation – Next year who knows
ASO must have an excellent data system & provide ASO must have an excellent data system & provide “value “value added”added” or this is just an extra expense to providers/partners or this is just an extra expense to providers/partners within the ASO. I don’t think I can emphasize this enough. within the ASO. I don’t think I can emphasize this enough. The The data system MUST be easy to use & not place additional data system MUST be easy to use & not place additional demands on the providers; one thing providers do NOT need demands on the providers; one thing providers do NOT need is additional demands or requirements.is additional demands or requirements.
Offer an IS system for those smaller agencies & providers that Offer an IS system for those smaller agencies & providers that do not have any IS system at all. do not have any IS system at all. This could be just client This could be just client services & state reporting or it could be for other functions as services & state reporting or it could be for other functions as well like HR, etc.well like HR, etc.
IS should be involved strategically (like at CFBHN) & involved IS should be involved strategically (like at CFBHN) & involved in the process assuming there is the appropriate staff to do in the process assuming there is the appropriate staff to do so. so. This will produce better IS systems and processes & since This will produce better IS systems and processes & since ASOs move great amounts of data, it is so important that we ASOs move great amounts of data, it is so important that we have IS systems that minimize paper movement & increase have IS systems that minimize paper movement & increase automationautomation. .
Testimony – VP of ISTestimony – VP of IS
Re-engineering Re-engineering (infrastructure, conceptually, & philosophically)(infrastructure, conceptually, & philosophically)
BudgetingBudgeting Data ManagementData Management Q.I.Q.I. HR / CredentialingHR / Credentialing Billing / ReportingBilling / Reporting Business / Strategic PlanningBusiness / Strategic Planning System of Care PlanningSystem of Care Planning
ASO ExpectationASO Expectation
Reflect commitment to community Reflect commitment to community driven, consumer centered care:driven, consumer centered care: Increased accessibilityIncreased accessibility Continuous care approachesContinuous care approaches Integration with other systemsIntegration with other systems
ClinicalClinical Client Centered - Assessment & TreatmentClient Centered - Assessment & Treatment Consumer SatisfactionConsumer Satisfaction Matching & Prioritization Matching & Prioritization Waiting List Management Waiting List Management
Sticking PointsSticking PointsSticking PointsSticking Points
Large vs. Small AgenciesLarge vs. Small Agencies Mental Health vs. Substance AbuseMental Health vs. Substance Abuse Comprehensive Providers vs. Niche Comprehensive Providers vs. Niche
ProvidersProviders Local vs. Remote HeadquartersLocal vs. Remote Headquarters Inclusiveness: Members, Vendors, Inclusiveness: Members, Vendors,
Purchasers, Stakeholders & ConsumersPurchasers, Stakeholders & Consumers Right of First RefusalRight of First Refusal Market Share ProtectionsMarket Share Protections
EligibilityEligibility(Factors for Membership Decisions)(Factors for Membership Decisions)
AccreditationAccreditation Financial Buy-in to MembershipFinancial Buy-in to Membership Current Contractor for Anticipated Current Contractor for Anticipated
““Lines of Business”Lines of Business” Medicaid ProviderMedicaid Provider Demonstrated ethics & conformance with Demonstrated ethics & conformance with
requirements of Member / Vendor Agreementsrequirements of Member / Vendor Agreements In good standing with current fundersIn good standing with current funders
One Big Happy Family???One Big Happy Family???• Young & Old – Big & SmallYoung & Old – Big & Small
• Naive & JadedNaive & Jaded
• Quiet & NoisyQuiet & Noisy
• Unique PersonalitiesUnique Personalities
• Conflict / ResolutionsConflict / Resolutions
• In it for the long haul / RecommitmentIn it for the long haul / Recommitment
• Agree to DisagreeAgree to Disagree
• Safety in numbers / One for all – all for oneSafety in numbers / One for all – all for one
Sometimes the needs of the many outweigh the needs Sometimes the needs of the many outweigh the needs of the few or the one…other times? of the few or the one…other times? Mr. SpockMr. Spock
For more information…
Contact:
Richard BrownThe Agency for Community Treatment Services4612 North 56th StreetTampa, FL 33610813-246-4899 phone <> 813-621-6899 [email protected]
Nancy HamiltonOperation PAR6655 66th Street NorthPinellas Park, FL 33782727-545-7564 phone <> 727-545-7584 [email protected]
Bob HolmDepartment of Children and FamiliesSAMH Program Office11351 Ulmerton Road, Suite 329Largo, FL 33778727-518-3271 phone <> 727-588-3618 [email protected]
Linda McKinnon719 US Highway 301 SouthTampa, FL 33619813-740-4811 phone <> 813-740-4824 fax <> 813-389-8179 [email protected]
Thank you for your attendance and participation!!