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April 28 10:15AM - Managed Care by Carlos Olivares

The document summarizes a presentation by Carlos Olivares on managed care. It outlines YVFWC's 20 years of experience in risk contracts, starting with 14,643 members and growing to 70,000 members with $168M in premiums currently. It discusses administrative infrastructure like contract management and utilization review. It also covers management reports on quality measures, enrollment gaps, and medical loss ratio. The presentation explains why YVFWC participates in managed care for enrollment growth and pool distributions totaling $128M from 1995-2013. Fundamental principles of managed care and current Washington state contracts are also addressed.

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jordyn1990
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616 views14 pages

April 28 10:15AM - Managed Care by Carlos Olivares

The document summarizes a presentation by Carlos Olivares on managed care. It outlines YVFWC's 20 years of experience in risk contracts, starting with 14,643 members and growing to 70,000 members with $168M in premiums currently. It discusses administrative infrastructure like contract management and utilization review. It also covers management reports on quality measures, enrollment gaps, and medical loss ratio. The presentation explains why YVFWC participates in managed care for enrollment growth and pool distributions totaling $128M from 1995-2013. Fundamental principles of managed care and current Washington state contracts are also addressed.

Uploaded by

jordyn1990
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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MANAGED CARE

Presented by: Carlos Olivares YVFWC CEO

AGENDA
1. YVFWC Managed Care Experience 2. Fundamental Managed Care Principles 3. Current Washington State Managed Care Contracts 4. Structuring Risk Contracts 5. Managed Care and PPS/FQHC Payment Structure

EXPERIENCE
20 Years under risk contracts Started with 14, 643 HO Members and 423 BHP Members and today we have 70,000 lives, with a total premium of $168M.

ADMINISTRATIVE INFRASTRUCTURE
Contract Management Customer Service Referral Management Utilization Review Enrollment Monitoring

MANAGEMENT REPORTS
Quality Measures Reports Patient/Member Misalignment Report Enrollment Gaps & Recertification Report Premium Accuracy Reconciliation Report Quality Bonus Performance/Trending Report Medical Loss Ratio (MLR) Report Pool Balances & Trending Report

WHY ARE WE IN MANAGED CARE


ENROLLMENT
Year
1995 1996-2005 2006-2010 2011 2012 2013 2014

Healthy Options
14,643 14,600 Average 23,500 Average 30,262 35,838 35,035 49,725 423

BHP

Oregon Medicaid

Total Managed Care Enrollment


15,066 28,200 Average 37,100 Average

13,822 Average 13,600 Average 4,452 3,865 2,436 0 14,428 14,053 13,969 20,007

49,142 53,756 51,440 69,732

WHY ARE WE IN MANAGED CARE


POOL DISTRIBUTIONS
Year
1995 1996-2005 2006-2010 2011 2012 2013

Healthy Options
$3,068,053 $2.2M Average

BHP
$225,395 $6.3M Average

Total
$3,293,448 8.5M Average 7.2M Average ($1,332,588) $3,530,687 $1,951,630

($315,782) Average $7.5M Average Loss ($2,729,625) $2,391,470 $1,301,556 $1,397,037 $1,139,117 $650,074

Total pool distribution from 1995 to 2013 = $128,206,917 Total premium for 2014 = 70,000 X 200 = $168,000,000

FUNDAMENTALS

FUNDAMENTALS

FUNDAMENTALS

FUNDAMENTALS

FUNDAMENTALS

TYPES OF RISK

QUESTIONS?

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