Take Your Corners – Hospital Health Plan Negotiation Strategies

Hospital managed care teams need to understand their markets are much more expansive than other hospital competition, advises, a senior exec with a company that provides a range of services to providers.

“Essentially, there are three basic ways of dealing with negotiation differences: Continue reading

New: Medicare Pioneer ACO: Case Study on Atrius Health’s Focus on the Triple Aim

By applying an “ACO magnifying glass” to high-risk patients and high-cost events, and using an organizational background in rapid cycle improvement, Atrius Health has developed focused interventions to
hit Triple Aim goals within their Medicare’s Pioneer ACO model. Continue reading

Just Released: Guide to Embedded Case Management

Guide to Embedded Case Management

 Care coordination is at the core of value-based healthcare delivery models like the patient-centered medical home and the accountable care organization (ACO).

Healthcare case managers embedded within the physician delivery system help to put a face on care coordination while reducing readmissions and improving quality of care for high-risk populations such as dual eligibles. Continue reading

Just Released: Guide to Embedded Case Management

Guide to Embedded Case Management

 Care coordination is at the core of value-based healthcare delivery models like the patient-centered medical home and the accountable care organization (ACO).

Healthcare case managers embedded within the physician delivery system help to put a face on care coordination while reducing readmissions and improving quality of care for high-risk populations such as dual eligibles. Continue reading

Health Systems Seen Needing New Strategies to Reorganize Delivery Models

To succeed in this new post-health reform arena, Health systems should prioritize information technology infrastructure development, information sharing, and timely distribution of information to ensure outstanding patient care, prepare for a patient-centered medical home and bundled payment system, and move toward best practice levels of care coordination, according to Health Strategies & Solutions, a Philadelphia-based consulting firm.

“The Supreme Court decision to uphold the major provisions of the ACA launches a new era in health care in the United States. Development of a robust foundation of primary care services must move to the forefront of strategic priorities for all health care providers,” the firm, with offices in a number of states, says in a white paper.

According to the firm’s white paper “Primary Care In An Era of Healthcare Reform” health care organizations that  Continue reading

Bundled Payments May Be Another Developing Trend to Watch: Anthem Adopts Bundled Payment Agreements For Two Providers

Anthem BCBS has entered into “bundled payment” arrangements for select surgical procedures at the Orthopedic & Sports Institute of the Fox Valley in Appleton, Wis. and at Manitowoc Surgery Center in Manitowoc, Wis.

A “bundled payment” groups and coordinates all of the charges associated with a surgery and recovery together for one pre-negotiated price. This means an individual can quickly and easily understand their potential out-of-pocket costs before surgery and results in greatly reduced paperwork for all involved.

“Think of a bundled payment like a restaurant offering a complete meal for $20 deal,” said John Foley, regional Continue reading

How One Health Plan Looked to How Disney Does It To Upgrade Its Call Center

When Kim Suarez and her team at Priority Health set out to renovate the insurer’s call center, they looked to Disney as their model.

“We recognize that the world of healthcare is changing rapidly – and dramatically,” said Suarez, VP of Medical Operations and the Consumer Experience  for the Michigan-based health insurance provider.

“It’s no longer enough just to provide great service, we need to deliver a great experience.  That means we need to fundamentally think differently about how we do business,” she said.

And that started with a trip to the Disney Institute for 20 Priority “champions” to experience a hands-on approach to creating strong teams, developing brand loyalty and consistently surpassing consumer expectations.  After the week-long experience, the team  returned to channel their passion into transforming the call center physically – and philosophically.

The team started with a number of challenges, including the need to condense calls centers in four buildings on the Grand Rapids campus into a single, cohesive location.

The nearly 150 employees answered upwards of 5,000 calls each day – or, to look at it the Disney way, provided 5,000 solutions and a great experience in the process.

Suarez  said  a two-day design charette with architects Progressive AE, was held that led them to explore how they worked together,  how they wanted to work together and how the space should be configured to facilitate such a team approach.

The transformation took about six months, Suarez explained,  but when it was finished, Priority’s new call center featured:

  • Interdisciplinary four-person pods that gathered an entire team –from customer care specialists to pharmacy to clinical care managers– in close physical proximity.  The idea, Suarez explained, was to be able to provide a solution to the caller without having to transfer him or her throughout the organization.  “In keeping with Priority’s philosophy, this new approach gave us greater ownership over each call – and ultimately increased customer satisfaction,” she noted.
  • Ergonomic office furniture, including desks that raise and lower with the touch of a button.  West Michigan office makers Haworth and Herman Miller provided the furniture, which also included wall systems and chairs.
  • Organic elements, such as sand, water, leaves, soothing colors and natural woods.  The branding wall, which is prominent when you enter the call center, features photos of Priority Health customers and serves as a backdrop for one of many collaborative spaces on the floor.  Think hip coffee bar, complete with high-top tables and cool chairs encourage conversation.Natural lighting.  The outer office is ringed by windows, providing natural sunlight to  100 percent of all call center employees.
  • Conference rooms utilize clear windows, which provide privacy simultaneously with an open feeling.  Suarez said the result is a tremendous sense of openness throughout the center.
  • Great visibility, greater technology.  Unlike traditional call centers – and indeed, many large office suites – everyone at his/her workspace has tremendous visibility throughout the room.  Central to the action is a call center stat board, which tracks the number of calls waiting, how long they have been waiting and other pertinent details.
  • Calls go from green to yellow to red, depending on how long they have been in the queue.  In lean management principles, the practice is called providing visual cues that all employees can recognize and respond to.
  • Rewards & Recognition.  Equally as prominent to the entire call center is the new Reward & Recognition board, which prominently displays compliments that employees receive from customers.  Suarez said Priority adapted the concept from Zingerman’s, which uses similar “code green” to share good news.
  • Business continuity planning.  Priority Health also invested in laptops and IP headsets in the event that call center operations are disrupted and employees need to work from home or another remote location.

“We have had tremendous response from our employees and our customers over the new call center,” Suarez said.

“But we did diverge from Disney philosophy on one key point:  Disney invests all of its funds for ‘on-stage’ areas, meaning that had an incredibly unattractive call center. ”

Even though Priority’s call center is “back stage,” it is really the backbone of our operation, Suarez observed.  “We invested significantly to create one of the most attractive and functional spaces as our call center – and it shows.”

Source: Priority Health

Lessons From Florida – The Patient-Centered Medical Home: Statewide Rollout

A primary care focused pay-for-performance program at Florida Blue has been transitioned this year into a statewide patient-centered medical home initiative.

While the Recognizing Physician Excellence program (RPE) program had moved the bar on quality metric performance, the move to the PCMH provides a look at both the quality and efficiency factors of a patient’s care.

An under-the-hood look into the details of this successful new program will be presented during The Patient-Centered Medical Home: Lessons from a Statewide Rollout, a 45-minute webinar on May 10th at 1:30 pm Eastern, Barbara Haasis, R.N., CCRN, senior clinical lead, quality reward and recognition programs at Florida Blue, will share how the health plan transitioned from the RPE program into a medical home model.
She will share:

  •     Lessons learned from the first year of a PCMH pilot program and how this shaped the statewide rollout;
  •     The criteria for which physician practices were selected to participate in the program;
  •     The shared savings approach through which practices will be reimbursed;
  •     The role of a nurse educator in helping the practices transform;
  •     Reporting practice results to drive further improvement;
  •     Results in total cost of care from physicians originally enrolled in the pay-for-performance program, now in the first quarter of the PCMH.

For more information or to register, please contact call 800-516-4343 or click on this link now: http://store.hin.com/product.asp?itemid=4401

Are MCOs adequately addressing member satisfaction needs?

Related to the member communication initiatives of MCOs is meeting member\patient satisfaction.

So are health plans addressing patient satisfaction as a top priority?

This is question, from our Managed Care Leadership Survey, stirs strong opinions from providers, payers and others.

For instance: “No. Major carriers are doing just enough to maintain their satisfaction levels. They are also building their own satisfaction surveys to give the impression that they are top notch. A better way would to use a consistent measure like CAHPS to monitor.”

“Yes. New rules and bonus payments”

“No. Too little in the way of real tools, peer to peer assistance”

“No. Growing limits on provider access and increased carveouts are creating growing member dissatisfaction.”

“Yes. Adequately, yes. Meeting expectations, probably not. All depends on the benchmarks one is willing to use to measure member satisfaction.”

Source: Managed Care Information Center

Evaluating Oncology Management Programs: Trends in Payer Oncology Management and What You Need to Know for Success

MANASQUAN, NJ — Payers and providers across the country are grappling with choices for programs regarding oncology management and potential collaboration to control costs while also increasing the effectiveness of care.

There is a lot of discussion and many models being proposed for management of oncology costs. Both physicians and payers are seeking information to help in separating the wheat from the chaff and looking for help in choosing the best model for their needs especially in this challenging climate.

Evaluating Oncology Management Programs:Trends in Payer Oncology Management and What You Need to Know for Success is a 60-minute audio webcast scheduled for December 2, 2010, at 1:30 p.m. EST.

This program identifies the issues of concern in oncology management, outlines the current seven models under discussion/implementation, and reviews the players, pros and issues with each model.

Participants will learn how to:

  • Evaluate the results of two oncology trend reports while learning key perspectives on oncology policy and management from both payers and physicians as well as implications of the study results
  • Review the details of oncology management and collaborative models in play across the country, including drug pricing, guidelines and pathways
  • Understand how to evaluate the current models and what questions to ask in choosing a best fit for your organization
  • Develop strategies regarding oncology management and take away steps for implementation and collaboration with oncology providers

The session also includes:

  • Live Open Line question and answer session

The presenter for the program is Dawn G. Holcombe, president of
DGH Consulting and is sponsored by The Managed Care Information Center.

For complete details, please visit: