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Payment and Delivery Reform

Payment and Delivery Reform. Virginia Health Care Conference June 6, 2013. Shift to Value B ased Outcomes. Currently a perverse incentive based on FFS (volume driven) Shift to value-based reimbursement Quality and Cost (efficiency)

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Payment and Delivery Reform

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  1. Payment and Delivery Reform Virginia Health Care Conference June 6, 2013

  2. Shift to Value Based Outcomes • Currently a perverse incentive based on FFS (volume driven) • Shift to value-based reimbursement • Quality and Cost (efficiency) • Alignment between payers and providers of resources and information around populations • Address the entire continuum of care vs episodic care “Better health, better care and reduced cost” Triple Aim

  3. Health Plan Market Forces • Medical Loss (expenses) Ratio (MLR) Regulation • Federal Premium Rate Review • ACA coverage expansion • Pre-X exclusion • Marketplace (exchange) • Large Employer/ CMS/ Quality Agencies focused on quality based outcomes (volume to value) • Clinically Integrated Networks (CINs)/ Accountable Care Organizations (AC0s)

  4. Population ManagementCollaboration Payer Delivery System Shared decision making tools Clinical Performance Measurement System (CPMS) Patient registries Clinical data (Electronic Medical Record) Cost/ Quality transparency tools Quality improvement performance measurement Advanced Care Coordination Care plans High Cost/ High Utilizers Evidence based protocols Preventive care Health coaching Gaps in care Proactive personalized engagement • Cost data • Utilization data • Medical • Pharmaceutical • Limited clinical • Wellness • Health Risk Assessments • Engagement strategies • Incentives/ plan designs • Patient satisfaction tool

  5. Network Strategy • Select Network • Incentive: Premium (contribution) differential • Choice: Time of Enrollment • Tiered Network • Incentive: Co-pay differential • Choice: Time of service

  6. Why Optima Health • Understanding of all stakeholders’ needs • Diverse client portfolio • Appreciation of the delivery system • Part of an Integrated Health Care System • Health care is regional • Currently operational • Collaborative/ nimble

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