Question and Answer Session Regarding the Successful Use of the Milliman Care Guidelines

MMM Healthcare and PMC Medicare Choice follow the Milliman Care Guidelines (now known as MCG), the evidence-based guidelines that help providers and payors drive effective care through globally sourced, clinically validated best practices that support clinical decision-making. The guidelines help drive effective care for a majority of Americans, resulting in better outcomes and contained costs.

The following is a Question & Answer session with InnovaCare leadership regarding the company’s success in applying the MCG formula.

Q: How does MMM Healthcare and PMC Medicare Choice utilize MCG overall?

A: We are the leading Medicare HMO in Puerto Rico serving members in all 78 counties.As the first Medicare Advantage plan in Puerto Rico, our community medical management is uniquely positioned to meet the healthcare delivery needs of seniors in Puerto Rico. We offer multiple plans including a Medicare Special Needs Plan for the Chronically Ill and a Medicare Special Needs Plan for Dual Eligible Beneficiaries.

In 2007, our company became the first organization in Puerto Rico to adopt the Milliman Care Guidelines to aid in areas of clinical decision making, coding of ICD-9 and other Health Services programs.

As a company, we found that the Milliman Guidelines were better suited for inpatient care and care management than our previous system because they provide evidence-based clinical guidelines and are regularly updated by experts in the industry. The comprehensive care guidelines have worked well with our care management program that provides care plans and workflows for management as well. Milliman is able to link quality parameters and HEDIS.

As a health plan provider, adopting the Milliman Guidelines was a major change for the company and our company was met with significant resistance from area hospitals and physicians. However, our company was persistent in making sure the change happened.

Today, the Milliman Guidelines have spread across Puerto Rico, replacing the previously used Interqual. We give yearly presentations to each hospital in which the Milliman Care Guidelines are outlined. These presentations help keep the hospitals up-to-date on the guidelines and any changes, facilitating the service and treatment each patient receives, based on proven medical evidence. Our initiative also makes sure each CRN has a clear understanding of the guidelines as a way to validate a patient’s studies and treatment. We provide updates to our guidelines each year in order to stay on the forefront of the healthcare industry.

The care we have seen for members of our health plan has become significantly more streamlined and efficient since making the Milliman Guidelines part of our protocol. By using the Milliman Care Guidelines in our plan, we have been able to use this valuable and diverse tool to gain information about the care and treatment given in the hospital, the home, rehabilitation, and other settings.

Today, other health plans have followed our lead by adopting the Milliman Guidelines as well. We paved the way for Humana in Puerto Rico and others, as well as opening the market for several IPA’s. We have also served as the intermediary between hospitals and Milliman, bringing the care guidelines to a significantly larger portion of Puerto Rican healthcare providers.

Q: Utilizing the Milliman Care Guidelines, how does MMM and PMC help drive effective care.

A: By adopting the Milliman Care Guidelines, we have been able to position ourselves as pioneers in our market. It has encouraged the use of best practices and streamlined medical care in order to provide the best outcomes for the members we serve.

The guidelines provide our members with a clinical basis to strive for better health. We are able to provide physicians and CRNs with the appropriate guidelines so that they are consistently practicing medicine and making clear and defined clinical decisions for their patients and are accountable to the continuum of care they are offering patients.

The guidelines have provided us with a consistent and proven method for providing health care to members who have been diagnosed with a chronic illness or disease. By utilizing the Milliman Care Guidelines, we are now able to encourage members by reducing their healthcare costs and improving their outcomes, leading to increased satisfaction.

The implementation of the guidelines has allowed us to track variances in medical practices, identify best medical practices, and identify and reduce unnecessary or ineffective treatment methods or procedures and diagnostic tests. The care our members receive has increased substantially since we began using the Guidelines. We are better able to keep providers accountable, while reducing cost to the members and increasing satisfaction.

Q: How does the initiative impact all areas of the organization?

A: Our company was the first provider in Puerto Rico to adopt the Milliman Care Guidelines. The guidelines have influenced the way we do our work by effectively managing inpatient admission and length of care required for conditions. We find the chronic care management particularly useful for patients with chronic conditions because it allows us to use their care plan tools and workflows to effectively track and manage care as well as make further recommendations for care.

Since implementing the guidelines in 2007, the rest of our parent company’s subsidiaries have been able to see the increase in quality and cost savings for patients served by what our company has done.

Today, all the subsidiaries underneath our parent company have adopted the Milliman Care Guidelines and are benefiting from the consistency the guidelines provide to physicians, hospitals, and health plans.

In 2010, a few years after we began using the Milliman Guidelines, an independent surveying company completed an assessment of all health plans in Puerto Rico. As a result of the survey, we were identified as a top performer in their service area. We believe that part of the positive response we have seen from hospitals and physicians in the past few years are based on the partnership we have established with Milliman. Physicians and hospitals, alike, have begun to take notice of the positive impact the Milliman Guidelines have on quality patient care and cost savings.

Q: What has the impact been on MMM and PMC – from before you adopted the guidelines to today?

A: Since adopting the Milliman Care Guidelines, our company has solidified its place as the leading health plan in Puerto Rico and is considered a pioneer in our field. Since adopting the guidelines, we have also paved the way for other healthcare providers to begin utilization of the guidelines, encouraging consistency in the care of the people of Puerto Rico. This ultimately increased the awareness of our company and bolstered our reputation in the market, making us the most recognized Medicare Advantage health plan in Puerto Rico.

Adopting the Milliman guidelines also helped us achieve NCQA accreditation and it continues to help us remain focused on being a high-quality provider.

Since implementing the guidelines in 2007, we have seen a 71-day reduction in the number of bed days per thousand. This presents a significant cost savings for patients and providers both.

Our company has experienced significant quality changes in staff efficiencies, productivity, and satisfaction since implementing the Milliman Guidelines. The guidelines have allowed our staff to better serve the members of our health plan, providing the best and most efficient care possible. By providing comprehensive guidelines, our staff has found that they are better equipped to handle the cases they receive, and we have seen as reduction of 40% in the number of pending case reviews.

Today, many other healthcare providers are continuing to switch to the Milliman Guidelines, because they recognize that Milliman is the way of the future.

Q: Describe how your senior leadership supported this initiative.

A: The leadership of our organization has been incredibly supportive of the Milliman Care Guidelines initiative of our company. The proven effectiveness of the guidelines speaks for itself and our leadership has challenged our organization with providing the best possible care for our members.

By implementing these guidelines and using them in our strategy, we have improved the quality of care we are showing to all of our patients, especially those with a chronic illness. The leadership of this organization has supported our use of the guidelines to inform us and increase our knowledge of new issues that are arising, enabling us to remain industry leaders.

Senior leadership from the CEO down has provided extensive support in the implementation and promotion of the guidelines. After seeing the success of the guidelines, there was a company-wide mandate that the guidelines be used within the health plan and the provider community. The initiative received executive level sponsorship for the overall implementation of the guidelines as well as the follow-up support. Sufficient financial, management, supervision, and technical support and training were provided throughout the process.

Without the support of the senior leadership, we would not have been able to move this effort forward because of the resistance we encountered from the other providers in the area. Senior leadership supported this effort 100%, remaining fully committed to this day in and day out and supporting all of our transition efforts.

Q: How has the impact of the initiative helped on quality improvement, patient satisfaction, staff productivity, and other metrics?

A: Since implementing the Milliman Care Guidelines, we have experienced increased quality of care in almost all areas of service. We have been able to maintain the same number of employees in areas such as inpatient and pre-authorizations during the last three years, while membership has increased more than 15% for the same period.

Quality improvement has been shown through the Interrater Reliability (IRR) audits that occur in our staff cases. IRR’s are performed on a quarterly basis on all staff. The recent IRR results have yielded results of over 90% surpassing the internal goal of 80%.

Since the implementation of Milliman guidelines, staff efficiencies, productivity, and satisfaction have improved significantly. Staff efficiency has increased by 10% because of access to the readily available guidelines when processing authorization requests and inpatient care notification. The turnover of cases and the amount of cases we see has increased by 20% per staff. We have also experienced a 40% decrease in the pending case reviews because with the Milliman Guidelines cases are able to be reviewed with a decision almost immediately because all information is provided.

We have seen the significant impact of this initiative in all other areas of our care, as well. The improvement in patient safety and quality of care has spread to cost savings and member satisfaction. We have become the most profitable and successful heath plan in Puerto Rico and finding the right partner was crucial to that success – Milliman has made a huge difference.

Internal provider satisfaction and communication has been positively impacted since the implementation of the guidelines. The shift to a more satisfied provider community was assisted by the implementation of Milliman, which was able to provide information and documentation about the development of the guidelines, as well as documented organizations endorsing their usage of the system.

At our company, we are driven by physicians and clinically oriented people. We’re not accountants and because of this, we have been able to see the difference the adoption of these guidelines has made for our members. We are continuously implementing new medical initiatives, many of which are driven by the guidelines. Providers and members in the area have recognized us as the best health plan and we are confident it was the Milliman Guidelines that helped us get to that reputation.