An Introduction Illinois Health Practice Alliance

CBHA 46th Annual Winter ConferenceDecember 10, 2018

Hyatt Regency Woodfield

IHPA Legal Structure

2

Providers

ProviderCo LLC

Centene

Illinois Health Practice Alliance

50%50%

Illinois Health Practice Alliance Goals

• Align providers and allow opportunity to invest in shared infrastructure

• Leverage scale and efficiencies – more safely able to take on risk

• Work together to transform practices and provide supports necessary to be successful

• Develop formal structure to drive quality and efficiency• Develop strategies to become a vehicle for Integrated Health

Homes (IHH)• Over time, include FQHCs and primary care providers in

implementation of IHH

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IHPA is a state-wide Behavioral Health IPAleveraging expertise of providers and Centene Corporation

IHPA Governance

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IHPA Board

ProviderCo CBHA Centene

• 50% vote• 4 members

• 50% vote• 9 members

• Non-voting• Ex-officio

Committees Management team

• Executive• Clinical Operations• Finance• Ad hoc

• CEO Started July ‘18• Senior Director of Finance Started

December ‘18• CCO – Offer Pending• Analyst, Admin – Offer Pending

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IHPA Value Proposition

MCO Contracting• Complex: multiple contracts require

need to manage provider engagement, credentialing and other administrative activities with each organization

• Efficient: Single contract with minimal administrative overhead: IHPA supports MCOs in provider enrollment

Payment Models• Outdated: FFS based only;

unpredictable cash flow; onerous reconciliation

• Value-Based: FFS + incentives; MCOs and providers benefit from enhanced quality and aligned incentives

Compliance• Transactional: MCO monitors and

responds to multiple providers and organization with varying clinical sophistication and infrastructure

• Self-directed: IHPA is sole interface with MCOs creating consistent rules with all IHPA BH organizations

Technology/Data• Siloed: Systems not integrated with

MCO or other providers; data limited to individual provider services

• Accessible: Claims and performance data; care management platform; real time updates; predictive risk stratification modeling; BH/physical health visibility enabled

Care Management• MCO Centralized: Often reliant

on telephonic outreach to members; limited coordination with providers; screening, assessment, and care plan duplication between plan and providers

• Provider Engaged: Embedded care managers; shared assessment and care plan capability; leverage expertise of plan and providers

Current IHPA

Catalyst to enable Integrated Health Homes and enable Value Based Care

IHPA Network Overview • Statewide network provides services both in

the community and in clinics

• 74 Community Behavioral Health Provider Organizations in network with 40% being owners

• Network Includes Required Professionals Under Integrated Health Home Guidelines

• Primary Care, BHS Specialists, SUD Specialists, Social Services, Nurse Care Manager, Clinical Coordinator

• Management Services Organization (MSO) Capable of Processing Claims and Providing Required Case Management Infrastructure and Supports

• Implementing Integrated Information Systems to Support Effective Care Coordination

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IHPA Network Capabilities• Outpatient counseling and therapy• Group and Family Therapy• Comprehensive Substance Abuse Treatment and Rehabilitation • Crisis Intervention Services• Comprehensive Community Treatment• Assertive Community Treatment• Residential Services for Behavioral Health and Substance Abuse • Member find and engagement services• Case Management Services• Support for Social Determinants of Need• Primary Health Care Services

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IHPA Financial Structure

8

MCO BIlliniCareContract

PMPM plus quality and total cost of care incentives

IHPA

ProviderCo members

(2 options)

90-95% FFS plus enhanced

performance incentives

PMPM plus highest performance

incentives

Contracted Providers

(3 options)

100% FFS plus performance

incentives

90-95% FFS plus enhanced

performance incentives

PMPM plus highest performance

incentives

MCO C

Outpatient BH

MSO Contract

CBHA Contract

CBHA (Community Behavioral Healthcare Association of IL) supports:+ Provider recruitment+ Provider technical

assistance+ Practice management

support

MSO (Management Services Organization) supports:+ Access to data+ Population health analytics+ Provider level and IHPA

performance measures+ Provider education+ Claims processing+ Provider call center

IHPA Operating Structure

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Illinois Health Practice Alliance

Contracted Providers

(BH Network)

MCO DContract

MCO CContract

MCO BContract

IlliniCare Contract

CBHA

Centralized MSO

Local MSO Staff

IHPAStaff

Confidential and Proprietary

IHPA ImplementationTimeline

Mar‘18

Apr‘18

May‘18

Jun‘18

Jul‘18

Aug‘18

Sept‘18

Oct‘18

Nov‘18

Dec‘18

Jan‘19

Feb‘19

Mar‘19

ProviderCo Joins IHPA, LLC

IHPA Leadership CEOHired

CFO/Analyst Hired

CCO Hired

Outreach and Engagement

ContractSigned

Find and Engage Pilot

Value Based Payment (VBP)

AssessmentComplete

AssessmentsMSO Agreement

Executed

IHPA Contract with MCOs

InNegotiations

VBP Amendments and Metrics

Integrated Health HomesBi-directional

PortalPopulation

HealthPlatform

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IHPA Is Uniquely Positioned for IHH SuccessIHPA’s mission and model is designed to improve the care and linkages between behavioral health and physical health…which fits the IHH Model

IHPA’s providers have long-standing collaborative relationships with local PCPs, FQHCs and other IHH stakeholders

IHPA is supported by an experienced, Illinois-based MSO that complements the network’s capabilities to deliver results for Managed Care Organizations

IHPA leverages a state-of-the-art population health and care management platform that drives accountability and performance insights

Managed Care Organization contracts with an IHH network aligned with its goals and objectives from Day 1

Managed Care Organization reduces its own administrative contract burden while maintaining a comprehensive, state-wide network for IHH

Managed Care Organization can be confident that services are delivered as contracted with a focus on improved outcomes and TCOC

Managed Care Organization benefits from high-quality data analytics and reporting that connects claim and EMR data for the IHH attributed member population

Benefits to the MCOsThe IHPA Difference

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IHPA IHHFinancial Structure

Managed Care Organizations (MCOs)

Provider A (Sub-Contractor)

Provider B (Sub-Contractor)

State of Illinois

Provider C(Collaborating BH Provider)

Collaborating BH provider

Collaborating PCP provider

Collaborating BH provider

Collaborating PCP provider

Collaborating PCP provider

IHPA(IHH)

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IHPA Contract/IHH Quality Metrics

Service Agreements• HRA Completion• Annual PCP Visit• 7 Day F/U After Inpt MH• 30 Day F/U After Inpt MH• MH ED Visit F/U • Initiation of AOD Treatment• Engagement of AOD Treatment• AOD ED Visit F/U• Total Cost of Care: Attribution Only

ED Visits per 1000IP Admissions per 1000Readmission Rate

Integrated Health Homes • Initiation/Engagement of AOD

Treatment• Screening/Care Plan for Depression• Chronic Condition for Admits• Adult BMI Assessment• Inpatient Discharge F/U• ED Visits per 1000• Immunization Combo 3• Breast Cancer Screening• Diabetes Management• Antidepressant Medication

Management

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Why IHPA? IHH Statewide Coverage • Adams

• Bond

• Carroll

• Clinton

• Cook

• DuPage

• Fayette

• Gallatin

• Hamilton

• Henderson

• Henry

• Jackson

• Kane

• Kendall

• Knox

• Lake

• Lee

• Macon

• Madison

• Marion

• Monroe

• Morgan

• Ogle

• Peoria

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• Randolph

• Saline

• Sangamon

• St. Clair

• Warren

• Washington

• Wayne

• White

• Whiteside

• Will

• Winnebago

Find and Engage Pilot Results• Pilot Objective:

• Find and Engage High Risk/High Cost Members in Outpatient Behavioral Health Services

• Pilot Results:• Total Pilot Population: 3,275 Cook County Members• Total Annual Cost Over $60M• Completed Over 18,000 Outreach Activities• Found 59% of the Eligible Members• Members Found = 17% Higher Risk Score and 32% Higher Cost

Than Members Not Found• 18% of Eligible Members Engaged in Services• Completed Over 200 Linkages/Referrals to Housing, Food, Other

Social or Health Needs, Primary Care, or Plan Utilization Management Team

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Management Services OrganizationApproach and Services

© 2018 Envolve. 16

MSO Overview

• Envolve brings together the capabilities of Centene and other partners to serve IHPA

• Leverages scale and maturity of Centene to deliver value to clients• Currently contracted to serve ~500K Medicaid lives nationally in

various markets• IHPA has engaged Envolve as its MSO partner to perform a range of

services on behalf of the IPA.– Full suite of managed services to enable IHPA to contract with

MCOs in delegated and other arrangements.• IHPA and Envolve MSO will initially focus on IlliniCare contract in 2018

with goal to expand to other payers in future months/years.• Target go-live is 2/1/19• MSO Location: Chicago, IL

17Confidential & Proprietary © 2017 Envolve, Inc.

High Level MSO Scope of Services

18Confidential & Proprietary © 2017 Envolve, Inc.

Provider Relations,

Contracting and Education

Data Analytics & Reporting

Eligibility & Enrollment

Provider Performance Management

Finance & AccountingIT Infrastructure

Claims

Provider Data Management

IHPA Human Resources

IHPA Facilities

IHPA Compliance

Compliance

IHPA IT Support

Admin Service

MSO Scope

Population Health Technology

Coming Soon

Integrated Health Homes

Enrollment and EligibilityAttribution and Assignment

• Initial attribution logic was based on attributing existing “known” IHPA clients

• MSO receives file from MCO monthly based on pre-defined IHPA/MCO methodology

• MSO processes Provider Assignment based on rules established by IHPA’s Clinical Operations Committee

• Envolve systems cascade this information to enable accurate claims processes

19Confidential & Proprietary © 2018 Envolve, Inc.

Claims RoutingStructured to minimize erroneous payments while maximizing flexibility for IHPA Claims setup will minimize the changes needed by IHPA providers at go-live

20Confidential & Proprietary © 2018 Envolve, Inc.

IHPA Provider

Not IHPA Provider

IHPA Pays

Claim

Illinicare Pays

Claim

Member Attributed to IHPA

Member Not Attributed

Outpatient Community-based BH Service

Not Community-based BH Service

Member Attributed to IHPA

Community-based BH Service

Not Community-based BH Service

Community-based BH Service

IHPA Provider Member Not Attributed Not Community-based BH Service

Community-based BH Service

IHPA Provider Member Attributed Not Community-based BH Service

Provider (and Member) Services • MSO will assume responsibility for Provider calls and related functions• IHPA is unique for Centene since the MSO will have accountability for a portion

of some processes while Illinicare maintains responsibility for other portions– Objective: Enhance provider experience while maintaining an efficient and

effective operation• Collaboration with Illinicare to establish process flows and warm hand-offs has

been very productive• The MSO will coordinate the following areas on behalf of IHPA Providers:

– Claim inquiries/disputes and member eligibility calls – Appeals and Grievances– Prior Authorizations– Provider Relations

21Confidential & Proprietary © 2018 Envolve, Inc.

22Confidential & Proprietary © 2018 Envolve, Inc.

Find a Provider IHPA Public Website

Provider Portal

Provider Manual and Data Management

Provider Manual• MSO is setting up companion

provider manual for IHPA• Collaborating with Illinicare

team on any changes to Illinicare’s manual

• Will reflect significant process changes and instructions on IHPA claim submissions, A&G processes etc

PDM• MSO will handle all provider

network updates beginning 2/1/19

• Providers will be able to make changes with Call Center or through the Portal

23Confidential & Proprietary © 2018 Envolve, Inc.

Provider Performance Support• MSO will create a new function to collaborate with healthcare providers to help

them achieve high performance with regard to their value-based contracts.– Own relationship with assigned provider group(s).– Assist in identification, development, and establishment of key performance metrics

to measure performance of providers related to their value based contracts– Collaborate with provider staff to develop and implement operational/clinical

process improvements to help providers achieve higher performance– Discuss KPI reports periodically with providers to identify improvement

opportunities and support providers with the development of actionable plans– Promote collaboration across provider groups to enable sharing of best practices

and performance improvement opportunities– Develop and provide training and support to provider staff to assist them in

understanding performance metrics and implement operational/clinical improvements

• Education/Experience:– Blend of experience on the team– clinical, primary care, behavioral health, quality,

process/performance management

Confidential & Proprietary © 2018 Envolve, Inc. 24

Data Analytics and Reporting• Objective: to enable visibility and

analysis of IHPA’s member population and support reporting requirements

• Reports at Provider and IHPA levels:

– Top 100 Members by Cost– ER and Inpatient Conversion– Medication Fill Rates and Labs– First Episode Psychosis – Pay for Performance/HEDIS

• Operational Reports at the IHPA Level:

– Cost of Care– Membership– Call Center Metrics– Claims– Encounters

25Confidential & Proprietary © 2018 Envolve, Inc.

Report Type: WeeklyThis Period: 1/6/19 - 1/12/19Last Period: 1/1/19 - 1/5/19Last Modified: August 22, 2018

MonthlyMembership Target 1/1/19 - 1/5/19 1/6/19 - 1/12/19 Jan Feb Mar Apr May Jun Jul YTD

Attributed Membership 30,000Member Assignment TBDMember Assignment TAT (after attribution) < = 3 Calendar days

Provider Services Target 1/1/19 - 1/5/19 1/6/19 - 1/12/19 Jan Feb Mar Apr May Jun Jul YTDCalls Offered ###Daily Average Volume ###Service Level ≥ 80.00%ASA ≤ 30 SecAbandonment Rate ≤ 5%Quality Audit ≥ 80.00%

Web/MobileProvider Portal RegistrationsMobile App Downloads

Claims Target 1/1/19 - 1/5/19 1/6/19 - 1/12/19 Jan Feb Mar Apr May Jun Jul YTDReceiptsPend Volume % ≤ 15%

Pended Inventory at Last Day of PeriodAA Rate ≥ 85.00%Reject Rate (% rejects of receipts) ~ 5.00%EDI Rate ~ 96.00%Payspan Registration Rate ≥ 80.00%Avg Age of Pending Claims < 15 DaysPay TAT (Avg days from receipt to paid) ≥ 95%Denial Rate ≤ 10%Interest $ PaidInterest % of Paid Amount ≤ 0.03%Payment Accuracy 97.00%Financial Accuracy 97.00%Claims Paid ($)

Encounters Target 1/1/19 - 1/5/19 1/6/19 - 1/12/19 Jan Feb Mar Apr May Jun Jul YTD% Accepted ≥ 95.0%% Pending% Rejected# of Not Yet Submitted

Provider Data Management Target 1/1/19 - 1/5/19 1/6/19 - 1/12/19 Jan Feb Mar Apr May Jun Jul YTDProvider Batch File TAT ≤ 30 daysPDM Update TAT ≥ 95%PDM Update Pending InventoryPDM Update Pends Avg Age ≤ 15 days

Illinois Health Practice AllianceMSO Operations - Executive Dashboard

Monthly

≤ 5.00%

End of QuarterEnd of Quarter

For Illustration Only

Sample Report – Medication Fill Frequency

26© 2016 Envolve.

Amisys # Age RangeMost Recent Fill

Date

99999999999 49-64 2018/10/01

99999999999 34-48 2018/10/25

99999999999 34-48 2018/10/15

99999999999 49-64 2018/10/06

99999999999 19-33 2018/03/22

99999999999 19-33 2018/03/20

99999999999 19-33 2018/01/19

99999999999 19-33 2018/03/12

99999999999 19-33 2018/01/19

Member Fill Frequency & Assigned

Provider TINAssigned Provider

Name Medicaid # Member Name

Fill Frequency & Metabolic Lab Report Tracking fill frequency for the following drug theraphy classes:

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSANTIANXIETY AGENTS

ANTIDEPRESSANTSANTIPSYCHOTICS/ANTIMANIC AGENTS

HYPNOTICSPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS -

MISC.

Nov 2017 - Oct 2018

999999999 - IHPA PROVIDER

57100010000315 Alprazolam Tab 1 MG999999999 IHPA PROVIDER 999999999 Rivers EVELYN 1977/11/05

Date of Birth GPI Number Generic Drug Name

999999999 IHPA PROVIDER 999999999 Rubble BETTY 1956/09/11 58180090107020 Venlafaxine HCl Cap ER 24HR 37.5 MG (Base Equivalent)

57100040000315 Diazepam Tab 10 MG

999999999 IHPA PROVIDER 999999999 Gravel, GABRIEL 1991/03/25 57100040000310 Diazepam Tab 5 MG

999999999 IHPA PROVIDER 999999999 Morehouse, ROGER 1963/10/01

999999999 IHPA PROVIDER 999999999 Nader, NADINE 1983/08/01 57100010000315 Alprazolam Tab 1 MG

58120080100310 Trazodone HCl Tab 100 MG

999999999 IHPA PROVIDER 999999999 Gravel, GABRIEL 1991/03/25 59153070100330 Quetiapine Fumarate Tab 200 MG

999999999 IHPA PROVIDER 999999999 Gravel, GABRIEL 1991/03/25

57100040000315 Diazepam Tab 10 MG

999999999 IHPA PROVIDER 999999999 Gravel, GABRIEL 1991/03/25 57200005100330 Buspirone HCl Tab 15 MG

999999999 IHPA PROVIDER 999999999 Gravel, GABRIEL 1991/03/25

Sample Report – Top 100 Members by Cost

© 2016 Envolve. 27

Population Health Technology

28Confidential & Proprietary © 2018 Envolve, Inc.

Advanced Systems IntegrationEnsures access, translation, normalization and aggregation

of data, regardless of system, care setting, source, or format

Rapid Implementation Typical go-live timelines of 6 to 8 weeks with a shortened contract time given existing agreement with Envolve.

Advanced AnalyticsConnect claims, clinical, and quality data and deliver

real-time, point-of-care insights. Clinicians are empowered to make patient-centric decisions quickly and confidently.

Adaptable Care ManagementAllows IHPA to initiate, track, and/or automate member outreach, patient assessments, care plans, intervention

scheduling, and document uploading and storage.

Revenue Cycle FunctionalityAllows IHPA to expand its own care management function

should it decide to hire its own care management team requiring it to submit claims to MCOs.

Envolve will leverage the Health EC platform for IHPA

Organization Key Performance Indicator (KPI)

Quality Measurement Monitoring

Inpatient Utilization Reports

Population Risk StratificationJohns Hopkins ACG Risk Model

Questions?

(I know you have them)

Michael Fierro-RandazzoSenior Director, OperationsO: 312-619-3038 mfierrorandazzo@envolvehealth.comlinkedin.com/in/mfierrorandazzo