Some studies have not shown cost savings Capitation for top Potentially fragmented care (Carve 20% (cont.) outs) May require administrative/actuarial assessment & modifications (for Risk adjustment) Financial & administrative burden (for Performance bonus) Long Term Effective & efficient use of services – Elective inductions N/A Put stop” to $0.85M $0.32M Pros: N/A Implementation Timeline: “hard to 39 weeks elective inductions Reduced C-section rate 3-6 mo. prior to 39 weeks Better outcomes Savings Realization Timeline: gestation Shorter labors 6-12 mo. Changes: Systems Cons: Challenge on how to implement Communication: Providers Document: SPA Radiology Benefits (PA requirements link from Implement $2.5M $0.9M Pros for RMB: May overlap with Implementation Timeline: Manager (RBM) MaineCare manual broken) Radiology Benefits More effective management of CMO and MCO 18-24 mo. Manager Require radiology services models, and Savings Realization Timeline: PA Reduce incidence of medically PA 2-4 years Utilize clinical unnecessary services Changes: Systems decision support Cost savings from prevented services Communication: Providers, (CDS) no PA Cons for RBM: Members – Implement Costs shifted to providers Document for RBM: RFP online Administrative burden on providers process, Contract interactive PA for PAs development Document for CDS and Pros for CDS: Reduce incidence of medically online interactive PA: unnecessary services Develop criteria, (If vendor)
Capitation for top 20% (cont.) Some studies have not shown cost savings Potentially fragmented care (Carve outs) May require administrative/actuarial assessment & modifications (for Risk adjustment) Financial & administrative burden (for Performance bonus) Long Term – Effective & efficient use of services Elective inductions to 39 weeks N/A Put “hard stop” to elective inductions prior to 39 weeks gestation $0.85M $0.32M Pros: Reduced C-section rate Better outcomes Shorter labors Cons: Challenge on how to implement N/A Implementation Timeline: 3-6 mo. Savings Realization Timeline: 6-12 mo. Changes: Systems Communication: Providers Document: SPA Radiology Benefits Manager (RBM) (PA requirements link from MaineCare manual broken) Implement Radiology Benefits Manager Require PA Utilize clinical decision support (CDS) – no PA Implement online interactive PA $2.5M $0.9M Pros for RMB: More effective management of radiology services Reduce incidence of medically unnecessary services Cost savings from prevented services Cons for RBM: Costs shifted to providers Administrative burden on providers for PAs Pros for CDS: Reduce incidence of medically unnecessary services May overlap with CMO and MCO models, and PA Implementation Timeline: 18-24 mo. Savings Realization Timeline: 2-4 years Changes: Systems Communication: Providers, Members Document for RBM: RFP process, Contract development Document for CDS and online interactive PA: Develop criteria, (If vendor)
recommendation-report12-15-2012.docx