1. Changing Nature of Managed Care Organization-Provider Relationships
WAMSS Conference
April 28, 2017
Andrew Nelson, Vice President, Provider Network Management
Molina Healthcare of Washington

2. Company History
Founded in 1980 by Dr. C. David Molina with a single clinic
Provide quality healthcare to those most in need and least able to afford it
Serves more than 775,000 members in Washington State
Serves more than 4.2M Medicaid, Medicare, Duals and Marketplace members
16 states and two territories
Molina Medical Group Clinics in states
Hospital Providers 101
PCPs 5,470
Specialists 12,780

3. HCA’s “Value-Based Purchasing” goals
In 2021, at least 90% of state-financed health care payments and 50% of commercial health care payments are linked to quality and value through Alternative Payment Mechanisms (APM) (Categories 2c-4b)
Washington’s annual health care cost growth will be below the national health expenditure trend.
2021
90%
state-financed
50%
commercial
Tools to accelerate VBP and health care transformation:
2014 Legislation directing HCA to implement VBP strategies
State Innovation Model (SIM) Round 2 grant,
DSRIP Medicaid Transformation Demonstration Project,

4. What is “Paying for Value?”
What is “Value”?
What is “Paying for Value?”
Patient experience
HEDIS
Avoidable emergency room visits or readmissions
Medical cost ratio
Per member per month

5. Provider relationships focus on value
Emerging focus on specific populations
Share, not shed, risk with providers who manage populations with complex needs, AH Blind Disabled and Medicare (DSNP)
Evolution from volume to value-based relationships
Focus on long-term relationships, not just ‘contracts’
Path-to-Value
Gain-sharing and risk-sharing on population –based outcomes performance. We have capitation arrangements with some integrated delivery systems
Not all providers are ready
Meet providers where they are at and start there
Increasing transparency into Provider Performance
Quality outcomes, cost, member satisfaction
Member self-direction & choice of provider and health plan
Aggregation of groups combine forces to create scale

6. Molina’s Value-Based Care “Path to Value” Approach
Shared Savings and Quality
Savings shared relative to a medical pmpm or medical cost ratio target
Savings tied to achievement of 4-6 HEDIS targets
Shared Risk and Quality
Greater shared savings potential in exchange for shared downside risk
Global Risk and Quality
Provider takes global risk as percent of premium
A portion of premium is tied to achievement of 4-6 HEDIS targets
Delegated functions such as UM, CM and claims

7. Challenges and opportunities in achieving a successful Value-Based Care relationship

8. An Aligned Culture of Quality
Know and Engage the Patient
Sharing Information & Resources
Promote Best Practice
Leverage Technology
Managed Care Organization
Share lists of non-engaged members
Shared outreach
Provider
Patient outreach and engagement
Provide appointment access
Managed Care Organization
Timely access to actionable data
Missing HEDIS services
HEDIS reporting
Align to provider workflow
Case Management
Provider
Share EMR Access
Member Satisfaction
Managed Care Organization
Align Prior authorizations and Utilization Management functions to reduce barriers and
promote consistent
quality of care
Provider
Clinical pathways
Managed Care Organization
Molina Virtual Care
24 /7 access
Shared documentation
CM referrals
My Molina – PHR
Care Team Integration
PreManage (EDIE)
Provider
ClinicalData Repository

9. VBC HEDIS Provider Performance Reporting

10. VBC HEDIS Provider Performance Reporting

11. EMR Chart Retrieval Analysis: HEDIS 2016
The rainbow colored column represents “compliance rate” by methodology
“Full” remote access benefits both providers and MCOs

12. VBC Medical Cost Provider Performance Reporting
Key Data Categories
Member Months
Premium
Capitation Amounts
Care Coordination Costs
Inpatient Hospital
Outpatient Hospital
Professional Services Rx
Incurred But Not Reported Claims
Medical Cost Ratio

13. Future of Strong MCO-Provider Relationships
Open communication on common goals - Quadruple Aim
Quality focused approach
Establishing trust and credibility
Focus on the relationship not just the contract

14. Contact information Andrew Nelson Molina Healthcare of Washington

15. Questions?