Our Client, a large managed care organization (MCO), launched a transformational effort to redesign the plan’s operating structure into a comprehensive data, performance, and accountability driven model to transition from an underperforming, enterprise loss-leader into a profit-generating plan. After engaging Trexin to help develop a series of initiatives that reduced spend associated with high-cost members and resulted in $100M+ in savings, the plan President & CEO re-engaged Trexin to optimize its provider network, improve care provided to members, and reduce plan expenditures on what was suspected to be a subset of low-performing providers driving a high percentage of cost.
Trexin led three workstreams focused on areas judged to have the highest inefficiencies: primary care physicians (PCP), value-based contracting (VBC), and nursing home (NH) services.
PCP: Speaking with over 200 providers during the project, Trexin assessed and ranked the provider network based on quality and cost metrics, identified low-performing providers, and contacted the first 600+ identified lower-tier physicians that were candidates for remediation. To drive continual improvement, Trexin created a technology and communication infrastructure that sent useful, actionable information customized for each provider, including a provider handbook, a cost and utilization dashboard, a quality dashboard, a member outreach list, and a daily census. To gage provider receptiveness to the remediation efforts, performance was tracked via key metrics. Trexin also developed a member outreach list that targeted 10,000 individuals.
VBC: Trexin facilitated contract discussions between our Client and large provider groups, prioritizing them based on membership, previous performance, and prior plan engagement. Discussions also revealed underlying trust and communication issues to be resolved.
NH: Trexin designed and implemented a nursing home optimization program model to reduce hospital admissions and improve quality of care. This initiative involved assessing nursing homes, embedding care coordinators in low-performing facilities, maximizing the Medical Director role of supporting registered nurse care coordinators (RNCC), and developing standard tools to train and educate RNCCs.
Trexin’s work was institutionalized as a new provider strategy department and immediately produced the following results:
- PCP visits increased 5% for outreached members without a visit within 12 months
- Members seeing multiple PCPs decreased 2%
- IP admissions from members assigned to engaged PCPs decreased 10%
- 14 large provider groups representing 20% of membership adopted new value-based contracts