2015 CAPG COLLOQUIUMACHIEVING SUCCESS IN RISK‐BASED COORDINATED 

CAREOctober 6, 2015: Marriot Wardman Park –

Washington, DC

BREAKOUT 8 GETTING READY TO TAKE ON RISK…

HOW DID NORTH SHORE‐LIJ DO IT?

Richard Miller

Daniel 

Jorgenson1

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NORTH SHORE‐LIJ KEY FACTS

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What is ValueWhat is Value‐‐Based Care?Based Care?

Defining Value....

“The health outcomes achieved                        that matter to patients

relative 

to the cost

of achieving those  outcomes.”

‐Thomas H. Lee, MD and

Michael E. Porter

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NSLIJ Health SystemNSLIJ Health System NetworkNetwork

MLTC

FIDA

Commercial Plans

Exchange Plans

North Shore‐LIJ Hospitals

NSLIJ Post Acute Care 

Full Vertically Integrated 

Continuum of Care

Core Laboratories  Behavioral Health 

Dental, Vision & Other 

Specialty Providers

Community Based Providers

North Shore‐LIJ Medical Group

NSLIJ Population Health Management MSO Services

Three Distinct Pillars Three Distinct Pillars 

How will the transformation from Volume to ValueHow will the transformation from Volume to Value‐‐Based Care Be Based Care Be 

Achieved?Achieved?

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Source: News Release, U.S. Department of Health & Human Services, News Division, 1/26/2015

Alternative Payment Models Hospital Payments Through Value‐

Based Programs

Today: 20%

2016 Goal: 30%

2018 Goal: 50%

2016 Goal: 85%

2018 Goal: 90%

VBP VBP ––

The Latest from the FedsThe Latest from the Feds……

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Source: Becker’s Hospital Review, 1/28/2015

“The formation of the Task Force…responds  to HHS announcement that half of Medicare  reimbursement will shift to alternative 

payment arrangements by 2018.”

Accelerating the ValueAccelerating the Value‐‐Based TransitionBased Transition

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NSLIJ Stakeholders / Participants

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What is NSLIJ Care Solutions?

Our health system’s care management  organization

accountable for the 

implementation and performance of our  system’s risk‐based programs

Care Solutions

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What is the Goal of Care Management?

To achieve an optimal level of wellness &                to improve coordination of care while providing 

cost effective, non‐duplicative services

Source: Center for Health Care Strategies, Inc, adapted from Robert Mechanic, “Will Care 

Management Improve the Value of U.S. Health Care?”

2004

Care Management

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Patient Identification, Analytics &

Risk Stratification

Outreach and 

Engagement

Care 

Coordination

Performance 

Measurement Innovations

& Change Mgt

Care Management Competencies & Domains

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P4P Metric Taskforce

Statement of PurposeStatement of Purpose

Develop a platform of metrics that will form the foundation for all P4P and incentive‐based health 

insurance contracts that will be utilized by the NSLIJ Health System. The taskforce will track and 

modify its recommendations based on the overall utility of these

metrics when instituted.

The framework for these metrics will be built around the following principles:

• The metrics are easily measurable;

• The metrics are achievable;

• The metrics are synergistic with metrics that are already followed for regulatory entities such as 

CMS;

• The metrics are synergistic with  provider incentives;

• The metrics may be both process and outcomes based with the evolution to a majority being 

outcomes based; and 

• The metrics will establish the foundation for managing the health of a population

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Daniel JorgensonChief of Staff &

Vice President, Strategic Planning

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

Agenda

The Opportunity

Go to Market Strategy

Integrated Medical Management

Integrated Customer Service

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Conclusion

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.17

The Opportunity

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

Why a Health Insurance Company?

The insurance market has very high barriers to entry…

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Strong and established competition

Requires large investment of capital

Ability to sustain long-term ROI

Infrastructure for managing risk

Volume to the health system

Enterprise value

…But success will result in significant value to NSLIJ

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

The OpportunityA combination of factors made 2013 the right time for North Shore-LIJ Health System to enter into the insurance market.

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Changes to reimbursement models

Experienced gained by offering limited network to NSLIJ employees

Health care reform Is changing provider and insurance markets

Affordable Care Act and advent of the exchange creates opportunity

Belief that the New York market was sophisticated enough for a new model

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

A Fundamental Problem

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From the customer’s perspective, health care is extremely complicated – even bizarre.

COPAY DEDUCTIBLE IN/OUT OF NETWORKCOINSURANCE OUT-OF-POCKET MAX

COPAY

EMBEDDED DEDUCTIBLE

DEDUCTIBLE

SPLIT COPAY

COINSURANCE

PLACE OF SERVICE

IN NETWORK

OUT OF NETWORK

OUT-OF-POCKET MAX

EOB

EFT CASE MANAGEMENT

REFERRAL

AUTHORIZATION

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

The Current Experience

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CASE MANAGEMENT

HOSPITAL DOCTOR

MEDICAL RECORDS BILLING

EOBS

Customer

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

CareConnect’s Mission

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SIMPLIFY HEALTHCARE

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

The CareConnect Experience

CASE MANAGEMENT

CASE MANAGEMENT

HOSPITALSHOSPITALS DOCTORSDOCTORS

MEDICAL RECORDS MEDICAL RECORDS BILLINGBILLING

EOB’sEOB’s

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CustomerCustomer

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

Provider-Payer Integration

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CareConnect’s integrated relationship with North Shore-LIJ creates numerous synergies that go beyond the traditional payer/provider relationship

AppointmentBooking

BrandLeverage

Expert SecondOpinions & Centers of Excellence

High Level of Care

Coordination

MarketingCapabilities

Daily Feeds & EMR System

Access

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.25

Go to Market Strategy:Price & Network

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.26

NETWORKSIZE

MEMBERPREMIUM

CARE COORDINATION

MEMBER EXPERIENCE

TRADITIONAL MODEL Large High Low Self Service

MEDICAID MODEL Large Low Low Self Service

New Models: Added Consumer Choice

INTEGRATED MODEL Small Low High Concierge

NARROW NETWORK Small Low Medium Self Service

North Shore-LIJ CareConnect Insurance Company, Inc.

Forefront of Narrow Network Trend

Relationship with largest health care provider in NYS gives us unique positioning and stability in terms of pricing and network

Other carriers removing major hospitals and providers

Competitor Premium Increases:

– First time since prior approval has been in place that there has been an increase of 20-30%

– A result of the high cost of large, robust networks

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The world is moving toward narrow network products and CareConnect is at the forefront of that trend

North Shore-LIJ CareConnect Insurance Company, Inc.

A Value Network

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Fully integrated provider network

– Allows CareConnect to provide better care management with lower denial rates

Continuing to partner with like-minded, high quality facilities to fill network gaps

– Breadth vs. depth: striving for contiguous network of the highest quality

– CareConnect will always have an exclusive network

North Shore-LIJ CareConnect Insurance Company, Inc.

Top Network Providers

2014 2016 % increase

Hospitals 15 47 +213%

Providers 5,500 20,000+ +264%

North Shore-LIJ CareConnect Insurance Company, Inc.

2016 Small Group Rate Comparison

Westchester / NYC (Gold)

$590+17.7%

$666+32.9%

$724+44.5%

$751+49.9%

$755+50.7%

Long Island (Gold)

$590+12.6%

$724+38.1%

$751+43.3%

$755+44.1%

$757+44.4%

$501$524

Lowest priced small group plans with access to NSLIJ

North Shore-LIJ CareConnect Insurance Company, Inc.

2016 Individual Rate Comparison

Lowest priced individual plans with access to NSLIJ

Long Island (Gold)

$557+11.8%

$569+14.3%

$624+25.3%

$656+31.7%

Westchester / NYC (Gold)

$549+15.3%

$557+17.0%

$569+19.5%

$656+37.8%

$476$498

North Shore-LIJ CareConnect Insurance Company, Inc.

Predictable Pricing Trends

Small Group Gold Single Rate New York Region

Over the past 3 years, there has been significant disruption in the market for employers looking for value

Our model can offer a long- term, economical solution for their clients

– No need to switch carriers due to large year-to-year price swings

North Shore-LIJ CareConnect Insurance Company, Inc.

Co-Branding Marketing Strategy

Improving name recognition

Tread lightly between using NSLIJ and limiting CareConnect to NSLIJ

Alignment with individual geo-targeted hospitals by market

Focus on savings, especially in the small business community

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Use the strength of the NSLIJ/Northwell brand to establish CareConnect

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.35

Integrated Medical Management

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

Integrated Medical Management

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A collaborative relationship between CareConnect and its providers establishes the trust necessary for effective utilization management. To ensure that CareConnect’s providers can deliver the kind of care they believe in, CareConnect uses nationally accepted peer-reviewed evidence based guidelines in addition to North Shore-LIJ’s care practice manual as the basis of its clinical practice guidelines.

COLLABORATIVE RELATIONSHIP

EFFECTIVE UTILIZATION MANAGEMENT

EVIDENCE-BASED GUIDELINES +

NORTH SHORE-LIJCARE PRACTICE MANUAL

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

Physician Advisory Group

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Insurance Plan

Clinical Processes Cost of Care Policies &

Guidelines

Centers of Excellence

Provider Network Nominations

Pharmacy Guidelines

Recommendations on Benefits Coverage

Expert Second Opinions

New Technologies

Medicine

Rehabilitation

Surgery

Radiation Medicine

Otolaryngology

Neurosurgery

Hematology

Oncology

Psychiatry

Ophthalmology

Urology

Pathology

Emergency Medicine

Obstetrics & Gynecology

Orthopedics

Dermatology

Care Solutions

Authorization Clinical Practice Guidelines & Milliman

Approve

Experience

Review

PHYSICIAN ADVISORY GROUP

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

Population Health Management

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Provider-payer integration makes it possible to proactively deliver the most effective level of care before, during and after encounters with the health care system, and gradually move interventions toward earlier points in the care continuum.

UTILIZATION DATA

LAB DATA PHARMACY CLAIMS ED VISITSHOSPITAL

CHARGES

PreventionIntervention + =DECREASE

HEALTH CARE COSTS

Track Members

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

Telemedicine

Around-the-clock access to board-certified physicians by phone or video consultationsConvenient and affordable option for quality care when a member:– Wants care immediately for a

non-emergency issue– Is away from home– Needs a short-term prescription refillAffordable alternative to costly urgent care and ER visitsWill be offered as a free, value-added service for all new and existing CareConnect members

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North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.40

Integrated Customer Service

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

Customer Service Tools

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ENTERPRISE WORKFLOW

SELF-SERVICE INTERFACE

CUSTOMER SERVICE

CALL CENTER

CUSTOMER CARE

CENTER

PROVIDES AN INTEGRATED WAY TO ROUTE WORK BETWEEN BUSINESS UNITS;

TRACKS AND LOGS INTERACTIONS FOR METRICS AND MONITORING.

ALLOWS MEMBERS TO COMPLETE TRANSACTIONS INDEPENDENTLY;

PROVIDES ACCESS TO INFORMATION ABOUT THEIR ACCOUNTS.

PROVIDES AN INTEGRATED WAY TO ROUTE WORK BETWEEN BUSINESS UNITS;

TRACKS AND LOGS INTERACTIONS FOR METRICS, MONITORING AND MANAGEMENT

OF MEMBER ENGAGEMENT.

2 DEDICATED STAFF (CALL CENTER STAFF ROTATE IN AND OUT)

CAPS, CRM, WEB TOOLS, NYS EXCHANGE, PORTALS

45 FTE CALL CENTERCAPS, CRM, WEB TOOLS,

NYS EXCHANGE,PORTALS

North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

The CareConnect Solution

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CUSTOMERCARE CENTER

ONLINEACCOUNT

MANAGEMENT

PROVIDERAPPOINTMENTSCHEDULING

ONE CALLDOES IT ALL

ONE-CALLRESOLUTION

Keeps Members In-Network

In-Network Providers Are All Committed To CareConnect’s Medical Management Approach

Resolution Rate88%

In-Person Visits 5,000+

Providers 20,000+

Members 25,000+

NO IVRALL CALLS ANSWERED

Avg Speed to Ans< 10 seconds

North Shore-LIJ CareConnect Insurance Company, Inc.

Integrated Customer Experience

Customer Service Statistics– Speed-to-answer: Under 10 seconds

– Call resolution: 88% of calls resolved by the answering representative

– Ability to reach a live person 363 days/year

Improved member ID cards

New look EOBs

New enhanced website

New provider look-up tool

Online premium payments

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North Shore-LIJ CareConnect Insurance Company, Inc.North Shore-LIJ CareConnect Insurance Company, Inc.

Conclusion

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North Shore-LIJ CareConnect Insurance Company, Inc.

Our Integrated Model is Working

Coordinated integration has led to significantly lower utilization denial rates – Industry average: 10-20%– CareConnect (thru July 2015): 5%

Product pricing consistently among the lowest in the region– Only 2-5% increases for 2016 vs. 2015

Currently enrolling the largest private employer in the State: North Shore-LIJ Health System

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QUALITY NETWORK

CUSTOMER SERVICE

AFFORDABILITY

The proof is in our results:

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