Repackaging your managed care strategy
Our family had just gotten back from a weekend at a Renaissance Fair and our six year old couldn’t wait to tell his friends about his adventures while at school Monday. That evening he told us that he shared stories about the knights jousting, shooting a bulls-eye with an arrow and being knighted Sir Chris by the King. But he lamented that “no one bows down to me”.
Despite all of our regal qualities, taking fragile patients home early from the hospital, providing educational or follow-up visits without reimbursement; it seems we don’t get much respect from payors.
Many of us remember the Roaring 80s and 90s when we heroically introduced health plans to the concept of home infusion therapy, we negotiated great rates, patients went home early and had great outcomes, health plans saved millions compared to hospital charges…everyone won.
That was then. The health plan now relegates us to the overwhelmed ancillary provider department who also contracts for sleep clinics, MRI centers, home health, DME, anything else that is not physician or hospital based. How do we break through the trend of shrinking reimbursement and commodious Par contracts?
We need to repackage our managed care strategy and our reimbursement. Why? Executives at health plans tell me that they view the current infusion therapy industry model as built around utilization. Incremental visits mean more nursing costs, more drugs, and more money from their premium dollars. All of the risk falls on the payor, whether they are the patient, employer and/or health plan. Due to recent high expenses, Health plans will now sit down with us if we present risk sharing agreements. Case rate, Cap Rate and Pay for Performance proposals are ideal if you are efficient and expert in your market for high-cost niches. Deals like this are common place outside of ancillary lines and health plans are receptive to these types of more exclusive partnerships.
Consider the following managed care strategies as you develop your proposals and meet with managed care executives:
1. Build your Case Rate proposal around your company's greatest clinical strengths. For example, acute & chronic pediatric programs in the home brings outstanding outcomes when administered by experienced pediatric nurses. Here is some insider information: Children Hospital Per Diems are the highest that Health Plans pay, show them how to take these patients home early and you will win a preferred contract and a new partner.
2. Connect with the CFO at your local acute care facility that has an Emergency Room. Hospital ERs are huge money loosers for facilities and a major concern for payors. Most ER patients have low acuity. Build a triage process with the ER Department that makes after hour admissions seamless. The partnership that will bring you hydration patients will also bring you all of the TPN patients.
3. Health Plans are becoming more assertive in some urban areas in developing alternatives to the physician's oncology suite. Infusion Suite programs that include Hematopoietic Growth Factor Injectables (HGF) are very timely discussions. Many oncologists are now realizing that when these lower margin products aren't tying up their infusion clinic and A/R then sicker patients with more rofitable therapies can be seen more timely.
4. Pay for Performance contracting is common place with acute and rehab facilities. Health Plans are eager for ancillary arrangements that will help reduce administrative costs such as maintaining a large network. Consider guaranteeing 100% admission on appropriate patients in certain counties in return for exclustivity.
5. Health Plans push to increase sales just as your organization does. Meet with the plan's Sales Executives to partner on their key prospects. Insurance company underwriters rate and price based on the risk of each employer. Health Plans routinely work with acute care facilities to drive down risk that allows the plan to give a more competitive rate. Your Transplant and Inotropic programs could be the risk reducers that help the plan land their next big contract. Since you are tied into to the risk equation, they will not call any one else.
You have the programs, facilities and the people that bring strengths that differentiate you from the competition. By repackaging and presenting these benefits to payors you will avoid network termination, develop greater exclustivity and sell your services at a premium; all while sharing a WIN with the patient, the physician and the payor.
These proposals can be a bit intimidating if your managed care team doesn’t have much experience in developing these programs.
2020 ConsultRx is experienced at developing winning proposals and helping you implement them profitably. We can even assist you in getting the high level audience that you need at the payor level. Give me a call and let’s discuss how we can build your business today.