PrimeWest Health System Countybased Purchasing

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PrimeWest Health SystemCounty-based Purchasing

• Applying rural sensibilities to
• Rural Health Care Delivery

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What every rural person knows

• whats missing in this picture?

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(No Transcript)
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Todays Health Care Delivery System
If theres no barn, then whats in those silos?
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more silos
and whats inside all these silos
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Four Elements of Delivery
PRIVATE SERVICES
FINANCING
COUNTY SERVICES
CONSUMER
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Financing
MA/GAMC
EW
Disability Health
COUNTY
GRANTS
CTC
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County Services
Human Services
Public Health
Transportation
Public Safety
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Private Sector Services
Alternative Care
Mental Health
Pharmacy
Niche Providers
Medical Clinics
LTC
Hospital
Home Health
Allied Medical
Dental
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Financing feeds and seeds the system
But in farming
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you reap what you sow.financings impact on
integration/coordinated delivery.
PRIVATE SERVICES
PMAP MCO
PMAP MCO
COUNTY FINANCING
COUNTY SERVICES
CONSUMER
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History of County-based Purchasing (CBP)

• 1985 -- PMAP pilots in 4 counties one rural
• 1995 -- DHS begins rolling out PMAP statewide
• 1996 -- Rural counties move to stop roll out
• Suspicious of proprietary, urban-based HMOs
  administering PMAP benefits to their rural
  residents
• Cost shifting
• Limited provider networks, excluding local
  providers, limiting resident access/choice,
  hurting provider viability, economic threat
• Applying urban-based managed care practices to
  rural
• 1996 Gov. Carlson vetoes first CBP law
• 1997 Compromise CBP law passed, but compromises
  cost CBP independent identity. CBP law
  does not have its own rules, HMO law rules
  serve as default set.
• 2000 First CBP financially fails in final
  stages of development
• 2001 DHS conducts competitive procurement for
  PMAP in SCHA counties
• considered by some a fundamental defeat to CBP
• Two bidders
• SCHA awarded sole-source contract for PMAP in 9
  counties
• 2001 -- SCHA begins operations
• 2003 3 fully operating CBPs IMCare, SCHA,
  PrimeWest.
• 2004 PMAP for Seniors initiative generating
  interest in other counties about pursuing
  CBP.

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CBP Counties
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CBP Basics

• State selects contractor from eligible bidders to
  administer PMAP CBP compete with MCOs for
  contract
• Eligible bidders must satisfy all State and Fed
  HMO laws
• PrimeWest paid a set PMPM by State and Fed for
  administering Medicaid, Medicare Advantage,
  MnCare and Elderly Waiver services
• Eligible residents enrolled into PrimeWest
  through county social services

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FFS, Traditional PMAP CB-PMAP
State Fed Payor
State Fed Payor
State Fed Payor
MCO Payor
MCOPayor
CBP Payor
Private Services
County Services
Enrollee
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History of PrimeWest CBP

• 1997 Pipestone, Renville, McLeod and Meeker
  Counties form Joint Powers PRIM CBP
• 1997 Douglas, Grant, Big Stone, Stevens,
  Traverse and Pope Counties form West Central
  CBP
• 1998 The Joint Powers CBPs merge to form
  PrimeWest Health System and full development
  process begins
• 1998-2003 Developing organization to satisfy
  two agencies (DHS, MDH) separate but highly
  redundant approval processes
• March 2003 PW awarded PMAP contract only
  bidder
• July 2003 PrimeWest CBP begins operations
• 2005 Expanded to Elderly Waiver and Medicare
  Advantage dual eligible populations

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PrimeWest Today

• 95 million annual budget
• For providing full Medicare Advantage, Medicaid,
  MnCare benefit sets to over 10,000 enrollees in
  10 counties
• Provided by over 2,000 contracted providers
• NACo best in category award - 2006

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PrimeWest Expenses by Category
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PrimeWest and CBP

• Overarching Goal/Expectation
• To cost-effectively deliver a comprehensive set
  of health and human services through an
  integrated and coordinated system of care.

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Tearing down some silos

• and building barns

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Integrated State resources
Silo 1
MSHO
Other FFS
GRANTS
MDHO
MHCP
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Integrated County State-to-County resources
Silo 2
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before State Integration Traditional PMAP
PRIVATE SERVICES
PMAP MCO
PMAP MCO
COUNTY FINANCING
COUNTY SERVICES
CONSUMER
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After Resource Integration Traditional PMAP
Integration and Coordination Potential
PMAP PAYOR
PRIVATE SERVICES
State
PMAP PAYOR
County Financing
County Services
CONSUMER
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Building One barns for One Silo
PRIVATE SERVICES
County Services
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Traditional PMAP Managed Care Form and Function
influences on Integration/Coordination

• Programmatic Function
• Case Management
• UM SA
• Limiting network size
• Contractual provisions
• Risk-sharing

• Structure Form
• Non-locally based
• Privately sponsored
• Non-profit
• large, geographically dispersed urban and rural
  population
• Other products
• Non-sole source

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before Resource Integration CBP
PRIVATE SERVICES
COUNTY FINANCING
COUNTY SERVICES
CONSUMER
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after Resource Integration PrimeWest
CBPIntegration/Coordination of Services
Potential
State
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PrimeWest -- CBP Form and Function influences on
Integration/Coordination

• Function
• Care Coordination
• Provider stakeholders (community reinvestment)
• Network based on local provider referral patterns
• Open Access
• Local community standard Provider administrative
  PPs

• Form
• County government- sponsored
• Locally based
• Locally governed
• Provider committees
• Limited geographic area
• Comparatively small enrollee population
• All rural enrollee base
• Single product
• Sole source payor

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CBP and Traditional PMAPForm and Function
Influences

• Function
• Traditional PMAP payors are conducting or have
  the capacity to conduct the same programmatic
  strategies as CBP.

• Form
• However, the degree of influence that such
  strategies can have on integrated, coordinated
  care delivery, is largely dependent on structural
  variables.

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Form and Function Function Conducting Care
Coordination

• Form
• County government- sponsored
• Locally based
• Locally governed
• Provider committees QCCC, CRC, PAC
• Limited geographic area
• Comparatively small enrollee population
• All rural enrollee base
• Single product
• Sole source payor

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PrimeWest CBPFunction Creating Provider
Stakeholders

• Form
• County government- sponsored
• Locally based
• Locally governed
• Provider committees QCCC, CRC, PAC
• Limited geographic area
• Comparatively small enrollee population
• All rural enrollee base
• Single product
• Sole source payor

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Cost-effective Health Care Delivery

• Capitation and Community Reinvestment

PrimeWest

Community Reinvestment
Providers
Recycling a finite resource
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Designing the Barn

• PrimeWest Counties Goals
• Maximum access to and choice of providers
• Preservation of the local health care
  infrastructure
• Local provider inclusion in network
• Local economy preservation
• Prevent cost-shifting onto county
• Improve financing and service efficiencies by
  integrating Federal, State and local health care
  resources
• Retain health care financing surpluses locally
• Create a system of care that better addresses the
  specific health care needs of the community

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Keys to Success for PrimeWest-CBP

• Integration of State and Fed resources MSHO,
  MDHO, PMAP for Seniors, etc., coordinating grant
  initiatives with programs
• Counties maximizing payer role and ability to
  integrate county resources
• Member focus integrating resources around
  health and psycho-social needs
• County-PrimeWest cooperation/resource integration
• Sound Business Management
• Supporting Local Providers referral
  relationships
• County inter-departmental cooperation
• Inter-county cooperation/resource integration
• Private Sector-Public Sector cooperation
• Instilling Community Ownership/Confidence