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

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    jordyn1990
    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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    April 28 10:15AM - Managed Care by Carlos Olivares

    Uploaded by

    jordyn1990
    592 views14 pages
    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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    Managed Care by Carlos Olivares

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    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.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    592 views14 pages

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

    Uploaded by

    jordyn1990
    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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    You are on page 1of 14

    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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