1© 2018. All Rights Reserved.
www.openminds.com15 Lincoln Square, Gettysburg, Pennsylvania 17325
Phone: 717-334-1329 - Email: [email protected]
#OMInnovation
The 2018 OPEN MINDS Strategy & Innovation InstituteJune 6, 2018 | 9:45-11:00 am
Steven E. Ramsland, Ed.D., Advisory Board, OPEN MINDS
William G. Wood, MD, Former National Medical Director, Medical Management, Behavioral Health, Government Business Division, Anthem, Inc.
New Contract Development: Marketing to Payers & Other Stakeholders
2© 2018. All Rights Reserved.
I. Why Marketing To Managed Care Matters
II. Best Practices In Managed Care Marketing
III. Thought Leader Discussion with Dr. William Wood
IV. Questions & Discussion
Agenda
Why Marketing To Managed Care Matters
4© 2018. All Rights Reserved.
Health Plan Roles Are Shifting
• Shift from carve-out by
specialty to carve-out by
consumer type – the
vertical HMO
• Moving care coordination
and population
management role to
provider organizations –
often with ‘gain sharing’
relationship that shifts
many traditional system
roles
• Acquiring care delivery
capacity
• Population health
management
• Medical necessity and
clinical appropriateness
criteria with preferred
treatment protocols
• Decision on specific
service provider and
professionals in system
• Professional and provider
organization performance
standards
• Payment models and rates
for services, drugs, and
devices
Tra
dit
ion
al
Syst
em
Ro
les
Exp
an
din
g S
yste
m R
ole
s
5© 2018. All Rights Reserved.
5% of U.S.
population
account for half
(49%) of health
care spending1
50% of U.S.
population
account for
only 3% of
health care
spending1
Payers Focused On “Superutilizer” Care Coordination For Individuals With Complex & Comorbid Conditions
$43,212
average expenditure per
person per year1
$253
average expenditure
per person per year1
“Superutilizers”
Shorthand term for
people with complex
physical health,
behavioral health,
and social issues who
have high rates of
utilization of
emergency room and
hospital services2
6© 2018. All Rights Reserved.
The Effect Of Mental Illness On Health Care Spending
ConditionNo Behavioral
Health Disorder
With Mental
Illness
With Mental
Illness &
Addiction
Asthma/COPD $8,000 $14,081 $24,598
Congestive Heart
Failure$9,488 $15,257 $24,927
Coronary Heart
Disease$8,788 $15,430 $24,443
Diabetes $9,498 $16,267 $36,730
Hypertension $15,691 $24,693 $35,840
For Consumers with Co-Occurring Mental Illness & Chronic Health
Conditions, Annual Medicaid Costs Increase By 200%+
7© 2018. All Rights Reserved.
Strategic Implications For Health Plans
Margin squeeze due to medical loss ratio requirements
Increased integration
Repositioning as marketing, technology, and analytics organizations
Search for value
Shift from “providers as vendors” to “providers as partners”
– The “narrow network” phenomenon
8© 2018. All Rights Reserved.
• Assuming care
coordination and
population
management role –
often with ‘gain
sharing’ relationship
• Addition of many
population
management
functions
traditionally provided
by health plans
• Acquisition by health
plans
Provider Roles Are Shifting
Delivery of consumer
treatment
Tra
dit
ion
al
Syst
em
Ro
les
Ex
pan
din
g S
yste
m R
ole
s
9© 2018. All Rights Reserved.
Strategic Implications For Service Provider Organizations
Payers are developing more value-based contracts with provider
organizations and creating ‘narrow networks’
Technology requirements (of P4P, of compliance, of consumer
preference) increases need for economies of scale for investment
Role of marketing increasing
Best Practices In Managed Care Marketing
11© 2018. All Rights Reserved.
Building Successful Partnerships With Managed Care – Improving Your Positioning
Gaining ‘exclusivity’ within a payer system
Being ‘preferred’ within a payer network
The fee-for-service payer network contract
12© 2018. All Rights Reserved.
The Fee-For-Service Payer Network Contract
Most fundamental of all business relationships for provider organizations in health and
human services
Often need to begin with privileging professionals individually, rather than being
privileged at the organization level
Difficult market position but often necessary
No assurance of volume and no likelihood of referrals
Often ‘commodity’ positioning
13© 2018. All Rights Reserved.
The Goal: Preferred Or Exclusive
Being ‘Preferred’ Within A Payer Network
Having preferential referrals due
to some market differentiation
Need a demonstrable value
proposition – almost always
involving P4P or value-based
payment
Gaining ‘Exclusivity’ Within A Payer System
Having a financial relationship
(most often with significant
financial risk) that gives you
exclusivity by geography and/or
consumer type
Your organization is the ‘narrow
network’
14© 2018. All Rights Reserved.
Steps To Building Successful Partnerships With Managed Care Organizations
1. Market mapping
2. Solution-focused
sales and payer
strategy
development
3. Developing a
service with the
payer value
proposition in mind
15© 2018. All Rights Reserved.
XXXXXXXXXX Payer Market MapPayer Profiles
Last updated: April 1, 2013
Government Insurers Total Enrollment (CA) Enrollment, San Diego Enrollment, Imperial Enrollment, OrangeEnrollment, San
Bernardino Enrollment, Riverside Headquarters Street Address City
Medicare 5,000,198 178,583 2,466 189,292 123,223 152,359
MediCal 7,339,984 453,494 55,519 469,970 484,988 410,9321501 Capitol Ave., MS 4400 Sacramento
Tri-Care/Military
(UnitedHealthcare beginning
April 1,2013) 290,219 1,823 20,586 49,946 43,653425 Market St., 27th Fl. San Francisco
Blue Shading indicates plan with enrollment ≥ 1000 - threshold to complete demographic research for this plan
Note: Medicare Advantage Enrollment data does not include numbers <10 in each county according to Health Plan
Some Medicare Advantage plans are under same plan name/entity but have a different contract number with CMS, therefore under separate columns (Plan ID included in the last column)
Medicare Advantage Total Enrollment (CA) Enrollment, San Diego Enrollment, Imperial Enrollment, OrangeEnrollment, San
Bernadino Enrollment, Riverside Headquarters Street Address City
Aetna Health Of California, Inc. 25,452 1,844 2,410 5,837 6,813P.O. Box 10169 Van Nuys
Anthem Blue Cross Life And Health Ins Company 37,375 4,668 294 7,457 116 2,08050 Beale Street San Francisco
Blue Cross Of California 12,251 1,746 16 945 1,420 2,46350 Beale Street San Francisco
California Physicians' Service 66,727 569 118 18,124 4,422 2,52250 Beale Street San Francisco
Care1st Health Plan 30,369 7,288 1,075 445 219601 Potrero Grande Drive Montery Park
Caremore Health Plan 51,262 27 8,321 3,835 12900 Park Plaza Drive, Suite 150 Cerritos
Central Health Plan Of California, Inc. 12,211 748 1,320 311540 Bridgegate Drive Diamond Bar
Citizens Choice Healthplan 14,388 1,113 1,543 3,27117315 Studebaker Road, Suite 200 Cerritos
Community Health Group 1,221 1,221 740 Bay Blvd Chula vista
Easy Choice Health Pla Inc. 53,767 1,643 593 7,569 3,220 7,634180 East Ocean Boulevard, Suite 700 Long Beach
Health Net Of California 138,335 12,390 31 12,320 10,884 14,73021281 Burbank Boulevard, B3 Woodland Hills
Humana Health Plan Of California, Inc. 20,961 2,329 1,439 1,449 3,4915421 Avenida Encinas, Suite N Carlsbad
IEHP Health Access 9,452 5,034 4,397303 East Vanderbilt Way, Suite 400 San Bernardino
Inter Valley Health Plan, Inc. 20,191 17 6,859 8,230300 South Park Avenue, Suite 300 Pomona
Kaiser Foundation HP, Inc. 881,902 70,539 102 47,975 41,118 40,828300 Lakeside Drive, 13th Floor Oakland
Molina Healthcare Of California 7,469 1,344 16 1,357 706200 Oceangate, Suite 100 Long Beach
Orange County Health Authority 14,646 14,624 505 City Parkway West Orange
Sample Data
1. Payer Market Mapping – Payers, Consumers, Competitors
16© 2018. All Rights Reserved.
2. Solution-Focused Sales & Payer Strategy Development
Solution-focused sales is focused on understanding the needs of the
customer – and developing a solution (rather than ‘selling’ the services
currently offered)
Meeting with payers to identify problems and concerns
Developing ‘services’ that address those payer problems
17© 2018. All Rights Reserved.
3. Developing A Service With The Payer Value Proposition In Mind
Concept development
– Service description
– Cost/benefit or ROI analysis
Proposal development
Contracting
Implementation
Expansion
1.
Concept
2.
Build
3.
Test
4.
Feedback
5.
Revisions Concept
Development
Cycle
18© 2018. All Rights Reserved.
Partnering With MCOs: Get It Right
Deliver Rapid
Access
Demonstrate
Outcomes
• Clinical
Effectiveness
• Process Efficiency
• Reduced Inpatient
Utilization
• HEDIS & Other
National Measures
Follow Through
On Contractual
And Clinical
Expectations
Demonstrate
Operational
Excellence Via
National
Accreditation,
Licensing & MCO
Site Visits
Provider organizations must
19© 2018. All Rights Reserved.
Partnering With MCOs: Innovate
Be creative - conduct pilots and share what you learn
Integrate with medical and behavioral partners
Evidence-based practices
Peer and/or family support models
Centers of excellence
Telepsychiatry
Web-based member engagement and social networking options
EMR and data management
Submit claims electronically and promptly
20© 2018. All Rights Reserved.
The Golden Rule Of Managed Care Contracting
Treat the
MCO like a
partner – not
an adversary
• Communicate
• Develop relationships with clinical and network
staff
• Participate in periodic meetings with MCO clinical
staff
• Learn about their needs and plans, and how you
can help them
• Keep them informed about you
• Track your outcomes, share your data, talk about
your accomplishments
Thought Leader Discussion
William G. Wood, MD, Former National Medical
Director, Medical Management, Behavioral Health,
Government Business Unit, Anthem, Inc.
Questions & Discussion
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