Applying A New Approach to Managing Health Care Benefit Costs

1. Applying A New Approach to Managing Health Care Benefit Costs

2. Community Health Networks • California Nonprofit Mutual Benefit Corporation • “Owned” by Member employers • Aligned interests with employer community • No provider, insurer, or MCO affiliation • No “ulterior” motives

3. Community Health Networks • Patient Centered Medical Home (PCMH) • Adherence to Evidence Based Protocols • Early intervention and screening • Culturally compatible outreach services • On-site pharmacies • Community based provider networks

4. Community Health Networks • Patient Centered Medical Home (PCMH) • Unique population health and utilization patterns • Unmanaged utilization patterns • 35% of acute care physician visits occur through hospital outpatient and emergency departments1 • Clear need for a Primary Care patient system or structure to provide early intervention and care management services 1 Source: Health Affairs, September 7, 2010

5. Community Health Networks Adherence to Evidence Based Quality Criteria Source: Rand Corporation, New England Journal of Medicine

6. Community Health Networks • Patient Centered Medical Home (PCMH) • Identifiable physician or clinic relationship • Greater focus on prevention • Early identification and management of health problems • Compliance with Evidence Base Care Guidelines • Care management infrastructure and resources • Nurse Practitioners, Physician Assistants

7. Community Health Networks • Patient Centered Medical Home (PCMH) • PCMHs have quality improvement and quality assurance components and monitor the quality of medical care they provide • PCMHs significantly reduce emergency room visits and hospitalizations • PCMHs are extremely effective at managing patients with chronic conditions

8. Community Health Networks Source: University of California at San Francisco, Center for Excellence in Primary Care, August, 2009

9. Community Health Networks Source: University of California at San Francisco, Center for Excellence in Primary Care, August, 2009

10. Community Health Networks • Patient Centered Medical Home (PCMH) • “Quality of care, patient experiences, care coordination, and access are demonstrably better. • Investments to strengthen primary care result within a relatively short period of time in reductions in emergency visits and inpatient hospitalizations that produce savings in total costs.”1 1 Source: University of California at San Francisco, Center for Excellence in Primary Care, August, 2009

11. Community Health Networks • Patient Centered Medical Home (PCMH) • Value Based Purchasing: • “Increasing access to preventive and primary care, and promoting better coordinated care and care [delivered] in the right settings drives higher quality care.”1 1 Source: Kathleen Sebelius, Secretary of Health and Human Services

12. Community Health Networks • Patient Centered Medical Home (PCMH) • Community Health Networks has partnered with several community health organizations to provide access to integrated primary care and preventive services • National Health Services • Clinica Sierra Vista • Adventist Rural Health

13. Community Health Networks • Patient Centered Medical Home (PCMH) • National Health Services • Programs to provide a full range of primary and preventive care services to serve rural hourly worker population • 10 clinics located throughout Kern County

14. Community Health Networks • Patient Centered Medical Home (PCMH) • Clinica Sierra Vista • Primary Care and Specialty programs including child obesity, behavioral health, cancer detection, and diabetes • 14 clinics located throughout Kern County

15. Community Health Networks • Patient Centered Medical Home (PCMH) • Adventist Rural Health • Facilities provide primary care and specialty medical services • 17 clinic locations primarily in Northern parts of the Central Valley.

16. Community Health Networks • Patient Centered Medical Home (PCMH) • Other Rural Health Clinic Partners • Delano Regional Medical Center • Kern Medical Center • Tulare District Hospital

17. Community Health Networks Over 50 Clinic Locations Throughout Southern and Central California

18. Community Health Networks • Adherence to Evidence Based Protocols • Prevalence of “gaps in care” • Only 45% of diabetic patients receive care that complies with evidence-based protocols1 • Only 54% of asthma patients receive care that complies with evidence-based protocols1 1Source: Rand Corporation, New England Journal of Medicine

19. Community Health Networks • Adherence to Evidence Based Protocols • Community Health Networks programs identify these gaps in care through clinical programs and data analytics • On-site preventive health screenings • Medical claims data • Prescription drug data • Eligibility files

20. Community Health Networks • Adherence to Evidence Based Protocols • Closing “gaps in care” • Gaps are closed through coordinated effort with our Patient Centered Medical Home Programs • Outreach through face-to-face patient advocacy programs • Disease-specific education programs sponsored by health clinics

21. Community Health Networks • Adherence to Evidence Based Protocols • Care Gap Analysis and Clinical Intervention can be implemented using: • CHN Network and PBM Program, or • Your current Network and PBM Program

22. Community Health Networks • Early intervention and screening programs • Current system and structures fail to adequately address screening and early intervention • Only 55% of patients receive evidence-based preventive care services1 • Only 66% of patients receive appropriate immunizations1 • Only 18% of patients receive appropriate counseling and education1 1Source: Rand Corporation, New England Journal of Medicine

23. Community Health Networks • Early intervention and screening programs • Critical role of early identification and health screening in managing population health and health plan costs • Analysis of claims and population demographic data, and • Work-site health screening through partnerships with community stakeholders identify opportunities for focused intervention

24. Community Health Networks • Culturally Compatible Outreach Services • Unique population characteristics give rise to unique challenges • Perception regarding the role of health care • Lack of understanding of the health care system • Health care literacy deficit • Language barriers • Transportation issues

25. Community Health Networks • Culturally compatible outreach services • Outreach programs tailored to address challenges • On-site health screenings and care gap analysis • Face-to-face Patient Advocacy • Transportation services • Targeted health care education programs • Multi-lingual services

26. Community Health Networks • On-Site Pharmacies • Key challenge to managing population health is non-compliance with prescribed medication regimes • Results in complications to chronic disease states • Manageable chronic conditions become acute episodes of care

27. Community Health Networks • On-Site Pharmacies • Community Health Networks on-site pharmacy program includes pharmacy services through a Federal program known as “340B” • Patients may fill and refill prescriptions at the time and place of visit at qualifying clinics and community pharmacies • Pricing for prescriptions drugs dispensed through 340B pharmacies is 25% to 35% lower than that available through most pharmacy benefit manager programs

28. Community Health Networks • Community Based Provider Networks • Provider network tailored to meet the needs of rural employers and their members • Focus on access to primary care services • Integration of specialty, ancillary and hospital services with primary care • Core service area includes Kern, Tulare and Kings counties • Full complement of facilities and services

29. Community Health Networks • Community Based Provider Networks • Provider network tailored to meet the needs of rural employers and their members • 25% to 35% greater Provider Network savings compared to statewide plans1 • Network access fees typically 50% lower compared to statewide plans 1Based upon repricing of $40 million in 2009-2010 paid claims

30. Community Health Networks Available as an overlay to your current health care programs or in conjunction with Community Health Provider Network

31. Community Health Networks Available in conjunction with Patient Centered Medical Home

32. Community Health Networks • Next Steps • Needs Assessment and Review meeting with Employer, Broker/Consultant and CHN • Typical follow-up items • Identification of disease state management opportunities • High level care gap analysis • Matching of CHN Programs with population needs • Claim network savings evaluation

33. Community Health Networks • For more information • Contact your Broker or Consultant • Contact Community Health Networks • Derek Tefft, Director of Operations • 877-830-7470 or dtefft@centralcaliforniaehc.org