Health Plan Utilization Management Summit

Health Plan Utilization Management Summit
Held:March 20-21, 2017 in Orlando, FL

The Health Plan Utilization Management Summit provides guidance and strategies for health plans to ensure their benefits are administered properly, control costs for members, promote adherence to standards of care, reduce avoidable readmissions, and enhance collaboration between hospitals and plans, all with the goal of improving quality outcomes.

View Original Brochure Agenda (PDF)

8 available session presentation slide decks (PDFs) included with purchase.

Session Topics Include:
Monday, March 20, 2017

Concurrent Workshops

8:30 am -
11:45 am

Examine the Physician Advisor Role and Opportunities for Advancement

(Part 1: 1 hr 33 min 55 sec)
(Part 2: 1 hr 30 min 16 sec)

For those individuals new to the role (and even those who have been in the role for a considerable amount of time), it can be challenging to identify and define the appropriate duties and regular tasks associated with the position, as every hospital and health system is different. This interactive workshop provides an explanation and clarification of the traditional role and responsibilities of Physician Advisors, and how the role is evolving in the current health care landscape.

Identify the Essential Components of the Physician Advisor Role
  • Clarify the duties and responsibilities within the areas of case management, transitions of care, readmissions, clinical documentation, and medical necessity review
  • Review current best practices in addressing compliance issues, focusing on Code 44s and Code 72s
  • Discuss effective communication and engagement strategies for physicians
Define the Relationship of the Physician Advisor and Hospital Leadership
  • ­ Engage the leadership team
  • Communicate the value and impact of the Physician Advisor Program, highlighting key data metrics and demonstrating ROI
    • Discuss how data metrics can best be utilized to improve performance and build a foundation for the corporate strategy
    • Identify the audience for specified metrics
    • Apply data insights to inform peer-to-peer reviews and denials improvement
    Discuss the Resources Available to Support Physician Advisors in their Daily Activities and Stay Up-to-Date with Pertinent Regulations and Industry Changes
    • Leverage IT tools and analytics
      • Learn how to measure performance improvement and set up an EMR to generate dashboards
      • Navigate the path from process metrics to outcome metrics, and documentation to data generation
    • ­ Understand the importance of creating and gathering relevant metrics for reporting
    • Review trusted sources for timely and accurate updates relating to Medicare
    Act on Opportunities to Advance the Role and Effectiveness of the Physician Advisor
    • Explore new responsibilities or functional areas for physician advisors and how to initiate or become involved in them, such as participating in utilization review and increasing audit involvement
    • Identify the most desirable and effective personality types and behaviors for the role, and how individual Physician Advisors can improve in these areas
    • Set and track appropriate goals and benchmarks to drive success in the position
Workshop Facilitators:
  Kalyana C. Kanaparthy, MD, FHM
Medical Director, Physician Advisor Program, Director, MAT Unity
Rochester General Hospital
  Matt Phillips, MBA
Director, Physician Advisor Program
Rochester General Hospital
  Balazs Zsenits, MD, SFHM, FACP
Associate Chief Medical Officer, Utilization and Medical Informatics
Rochester Regional Health
8:30 am -
11:45 am
Achieve Cost Savings By Efficiently Managing Your UM Program

(Part 1: 1 hr 30 min 16 sec)
(Part 2: 48 min 08 sec)

Effectively optimizing resources is an essential component to a successful UM program; whether it’s re-visiting staffing considerations for the UM team and building consistency and continuity internally, or knowing the right focus areas externally, it’s necessary to constantly evaluate areas for improvement. Learn how payer organizations have structured their UM committees, and collaborate with peers to determine strategies that can have a financial impact both within your organization and for your members.

Internal Focus: Assemble a Cohesive UM Team

  • Discuss how pharmacy, UM, and case management teams interact within your health plan
    • Evaluate how pharmacy, UM, and case management can better collaborate
    • Assess which metrics to evaluate to understand where responsibilities may intersect, as well as areas to improve efficiency
  • Outline strategies to effectively break down silos
    • Evaluate the impact of a cohesive, collaborative team
    • Propose how to get administrative buy-in for changes in UM
    • Discuss the financial impact of an integrated team
External Focus: Refine Focus Areas for Population Health Management

By evaluating and identifying which members utilize the most resources and then creating a strategy to engage with them, plans can better allocate human and manage populations that need them. In this segment, discuss with peers how to manage finances for populations that have the most need, and understand how this focus can result in significant cost savings.

  • Find innovative ways to engage hard-to-reach members
  • Balance resources dedicated to populations like Medicaid that have significant need
  • Outline financial savings and ROI gained from a focused strategy
  Shelean Sweet, RN
Director, Utilization Management Pre-Service Review
United Healthcare of Nevada
  R. June Young, RN, BA, CCM
Director, Medical and Clinical Management, Nevada Market

1:00 pm

Chairperson’s Welcome and Opening Remarks

(12 min 12 sec)

  Chandrakala Gowda, MD, MBA
Vice President, Executive Medical Director
Highmark Inc.

Identify Strategies to Maintain Compliance with Regulatory and Quality Standards

1:15 pm
Assess Key Focus Areas to Gain or Maintain NCQA Accreditation and Improve Quality and Outcomes

(38 min 26 sec)

As the focus on quality outcomes becomes a point of emphasis in health care, it is increasingly important for health plans to adhere to standards set by NCQA. In this session, review the key aspects of UM that NCQA targets for accreditation, and discuss focus areas for your organization to ensure an emphasis on quality improvement and outcomes.
  • Review overall UM program structure and identify areas of improvement
  • Operationalize a strategy to improve quality outcomes and achieve accreditation
  • Discuss how this strategy and requirements may change from state to state
  • Navigate the distinction between medical necessity denials and administrative denials
  Shelean Sweet, RN
Director, Utilization Management Pre-Service Review
United Healthcare of Nevada
2:15 pm
CASE STUDY: Utilize Alternative Providers to Impact the Health of Patients with Complex Chronic Conditions in Medicare Advantage

(53 min 23 sec)

Effective partnerships between health plans and medical providers are increasingly recognized as a necessary strategy to maximize customer health in Medicare Advantage. Primary and secondary prevention rates have historically shown marked improvement as a result of quality programs designed to coordinate these partnerships. In an effort to extend the impact of effective partnerships into the tertiary prevention space, Cigna-HealthSpring is currently developing and implementing disease management strategies with alternative providers – such as Aspire Health and Alana Healthcare - to better address the health needs of customers with complex chronic conditions. Early analysis of programmatic results reveals that – through the provision of in-home, face to face, highly personalized care – these alternative providers are having a positive impact on customer health and, concomitantly, a positive fiduciary impact on the health plan.
  • Evaluate provider outcome performance in volume vs. value based ambulatory care models
  • Develop partnerships that improve primary and secondary prevention outcomes
  • Assess the need for alternative strategies of care for complex chronic illness
  • Create and implement disease management programs in partnership with alternative providers to impact tertiary prevention outcomes in complex chronic illness
  • Discuss the Comprehensive Respiratory Outcomes Management (CROMTM) Program and its impact on the health of COPD customers in Cigna-HealthSpring
  • Consider the future role of alternative providers in volume and value based ambulatory care systems
  Bob Coxe, MD
Senior Medical Director, GA Market
Cigna-Healthspring, Inc.

3:00 pm

GROUP DISCUSSION: Build Programs to Address Complex Chronic Illness

(17 min 41 sec)

  Bob Coxe, MD
Senior Medical Director, GA Market
Cigna-Healthspring, Inc.

4:00 pm

Assess the Impact of Unplanned Care — Explore How to Avoid Inpatient and ED Utilization

(43 min 13 sec)

With the scrutiny around admissions and readmissions, learn ways in which Utilization Management and Case Management can collaborate to focus on the right members at the right time through cost-saving medical management innovative strategies.
  • Identify strategies to reduce unplanned care through care coordination
  • Understand the value of Utilization Management and Case Management integrated processes
  • Optimize care collaboration with providers to reduce ED utilization
  • Augment Case Management activities to reduce readmissions
  Karen DePasquale, LSW, ACSW
Senior Director, Health Management
UPMC Health Plan

4:45 pm

Predict Future Changes in the Utilization Management Landscape

(39 min 19 sec)

As the structure and participants involved in UM evolve, and providers take on a bigger role — including more risk — it is essential to evaluate the impact on insurers and how this may impact a future UM structure. Discuss impending changes and focus areas in UM, and assess the future outlook for how personal, critical decision making within the scope of Case Management and Utilization Management may be impacted by technology.
  • Address how risk sharing with providers changes the UM landscape
  • Evaluate further provider education needed around medical necessity criteria and Interqual standards
  • Consider a potential demise in the structure of UM — How long may UM services be necessary?
  Jennifer McPeek, BSN, MBOE, SSGB
Director, Care Access Management-Utilization Management
Molina HealthCare Ohio
Tuesday, March 21, 2017

8:30 am

Chairperson’s Welcome and Review of Day One

(12 min 06 sec)

  Chandrakala Gowda, MD, MBA
Vice President, Executive Medical Director
Highmark Inc.

8:45 am

Drive Effective Collaboration Between Payers and Providers

(1 hr 28 min 44 sec)

Identifying correct patient status designation and aligning with CMS and commercial payers can be tricky, especially when there may be multiple people who are part of the care management team making decisions. Further coordinating and communicating efforts between payers and providers around appeals and managing denials calls for more candid and open, multi-stakeholder discussion and collaboration. During this panel discussion, first hear from providers and payers on strategies to improve patient status determination. Then, participate in a dialogue on how to effectively navigate appeals and denials between payers and providers in order to promote a more collaborative relationship that can improve efficiency and maximize resource utilization.

Part I: Examine Observation Status and Ethical Considerations for Case Managers

  • Discuss how to support and clarify the Case Manager’s priorities and role as patient advocate while balancing the need for efficiency and resource management
  • Summarize the appropriate designation of patients under observation status versus inpatient admission in the hospital
  • Explore the extent to which commercial payers align with CMS regulations in relation to status designation
  • Examine the variance in patient status order designation across payers – Medicaid Managed Care, Medicare Advantage, and Medicare – and consider potential financial implications
Part II : Establish a Common Ground for Appropriate Levels of Care to Decrease UR Burden
  • Discuss the regulatory challenges and pressures experienced by hospitals and insurance companies, and how collaboration can effectively address these issues
  • Identify the behaviors and tactics that yield successful appeals, careful negotiations, and effective Physician Advisors
  • Align payer and provider incentives in managed care relationships and commercial contracts so that both parties can perform efficiently and collaboratively
  • Identify how to utilize criteria to streamline communication between payers and providers
  • Consider how to coordinate efforts in MOON implementation, focusing on the shift to retrospective, versus concurrent, denials
  Zulma Berrios, MD, MBA, CPE
Physician Liaison
Baptist Health South Florida
  Peter Dehnel, MD
Medical Director, Integrated Health Management
Blue Cross Blue Shield of Minnesota
  Jessica L. Gustafson, Esq.
Founding Shareholder
The Health Law Partners, P.C.

Improve Pharmacy Utilization and Drug Management

10:45 am

Analyze the Increased Focus on Pharmacy in Utilization Management

(44 min 46 sec)

As drug costs continue to rise, plans must figure out ways to best manage high-cost medications, particularly in specialty pharmacy. In this session, discuss key focus areas for pharmacy management and how to incorporate a case management and medication adherence approach.
  • Hear strategies for managing drugs that replace traditional services amidst a reduction in medical benefit coverage
  • Understand how to best manage risk associated with compliance and adherence
  • Discuss key groups with which to focus on medication reconciliation
  •   Peter Dehnel, MD
    Medical Director, Integrated Health Management
    Blue Cross Blue Shield of Minnesota

    11:30 am

    CASE STUDY: Assess the Impact of Pharmacy Case Management on Health Care Costs

    (31 min 42 sec)

    In 2013, Kern Health Systems’ managed Medicaid health plan partnered with Komoto Healthcare to provide post-discharge comprehensive medication management (CMM) for its members who were either at risk for high utilization, had a certain number of prescription claims, or had been hospitalized within the past 45 days. Hear how this partnership created opportunities for medical cost savings, and how it can serve as a model for future health plan and pharmacy case management collaborations.
    • Explore opportunities for health plan/pharmacy partnerships to provide comprehensive medication management
    • Review a model of post-discharge CMM and how it can impact readmissions
    • Consider how a comprehensive program can result in cost savings for health plans
      Danielle Colayco, PharmD, MS
    Director, Health Outcomes and Value Strategy
    Komoto Healthcare
      Chandrakala Gowda, MD, MBA
    Vice President, Executive Medical Director
    Highmark Inc.

    1:30 pm

    IN-SUMMIT WORKSHOP: Explore Available Tools to Improve Utilization Management, Care Management, and Clinical Documentation Improvement

    (1 hr 27 min 10 sec)

    Physician Advisors sometimes struggle to align the medical staff with the hospital’s goals. Often times, the tools required to obtain and measure meaningful changes in the behavior of the medical staff are readily available. Explore how existing resources and time can be leveraged to drive remarkable success in the key operational areas of UM, Care Management, and CDI. I. Implement and Measure a Successful Care Management Huddle
    • Identify who should be present at CM huddles
    • Set appropriate goals for CM huddles
    • Discuss the expected Physician Advisor time allocation
    • Review sample schedules for incorporating CM huddles into the Physician Advisor’s workflow
    • Measure the effectiveness of CM huddles, using objective and subjective measures
    II. Utilize the UM Committee as a Change Agent in the Organization
    • Review who should be incorporated in the UM Committee and responsible for the clarification of goals
    • Define the role of the Physician Advisor in the UM Committee
    • Examine the function of metrics and UR Case Review in the committee
    • Consider how the UM Committee can serve as a tool to align physician behavior
    III. Implement Effective Clinical Documentation Rounds to Achieve Strategic Goals
    • List who should be present in CDI Rounds
    • Coordinate physician schedules to ensure that rounds are effective and efficient
    • Discuss the expected Physician Advisor time allocation
    • Establish clear goals and measure the effectiveness of CDI Rounds
      Yasser Said, MD
    Physician Advisor; Director, Care Management
    Advocate Medical Group