Insight into Dr. Flores'
KNOWLEDGE, SKILLS, ABILITIES
For three decades Arthur has demonstrated the ability to lead many clinical and managed care organizations in a wide array of physician executive roles. He has helped advance and contribute to the success of multiple health care organizations by utilizing his healthcare and managed care knowledge, analytic and problem-solving skills, and his ability to optimize and manage clinical programs and healthcare organizations.
Interdepartmental Management and Collaboration
Knowledge: Management of interdepartmental and clinical programs requiring collaboration on shared and overlapping organizational initiatives and functions.
Problem: Anthem's Medical Management programs were struggling with impacting high Emergency Department Utilization, Inpatient Admissions, and Hospital Readmissions. I saw a need for targeted collaboration by all medical management programs to work together to close care gaps and improve access to healthcare resources by increasing member touches along the medical management continuum.
Intervention: While at Anthem, revised care management clinical rounds and created a new format of integrated care management rounds to include behavioral health nurse care mangers, pharmacists, utilization management nurses, disease management nurses, and medical directors. This process change in clinical workflow created collaboration across multiple departments and specialties and broke down silo's across the medical management programs. Analysis of health outcomes and management of whole person care was initiated.
Result: This program initiative resulted in a 5% reduction in Hospital Readmissions, improved the HEDIS Follow up Appointment after Hospitalization, and established cross-departmental involvement of members from hospital admission through discharge and follow up care.
Additionally, received a Values in Action Award from Anthem for my work in establishing multi-disciplinary integrated care management rounds.
Population Health Management Strategies
Knowledge: Management of Populations and Targeted Sub-populations.
While Senior Medical Director of WebMD Health Services, I provided clinical oversight of the United States Government Federal Employee Plan (FEP) twenty- four-hour Nurse Triage Line. A plan of approximately 3.5 million federal employees and dependents.
Problem: I analyzed the Emergency Department (ED) utilization of the FEP population due to rising medical spend and upward trajectory of ED utilization. I determined that the Nurse Triage line was ineffective at dispositioning members to appropriate levels of care which resulted in our inability lower utilization and bend the cost curve. I conducted an extensive review and retrospective analysis of the algorithms, scripting and documentation, and claims data of members calling in and utilizing the nurse line.
Intervention: Revised nurse scripting, reviewed clinical care guidelines and algorithms, and implemented a nurse triage urgent care referral protocol that identified in real time, the closet alternate urgent care center for non-emergent conditions calling in for medical guidance. Names and hours of operation, in addition to location were provided to members.
Result: This revision, reprogramming, and retraining of staff of The Twenty-Four Hour Nurse Line resulted in a 12% decrease in avoidale Emergency Department utilization and approximately an $11 Million dollar savings for the Federal Employee Plan.
Interorganizational Collaboration & Integration
Knowledge of interorganizational collaborations and clinical systems integration.
New Initiative & Clinical Program: While a National Accounts Medical Director at Anthem overseeing the Google Account, I was responsible for the clinical integration of Google's Onsite Health and Wellness Clinics with Anthem's Medical Management Platform through a health liaison. This newly created position would work closely with a dedicated medical management specialist and assist in the navigation of Google employees through the Utilization Management, Care Management, and Disease Management services at Anthem. New workflows and clinical processes had to be developed, in addition to facilitating the exchange of PHI and other necessary data between the two organizations.
Result: Google improved and facilitated access to benefits for its employees, in addition to examining new opportunities for them with the ability to flex or amend current employee benefits which would have a positive effect on employee and family health and wellbeing and ultimately a healthier and more productive workforce. Anthem was able to obtain valuable experience on providing customized Medical Management Services to its National Accounts to try to demonstrate the effective administration of health benefits and health services to its corporate clients.
Process Improvement
Knowledge of clinical workflows and assessing programmatic efficacy.
Problem: Schaller-Anderson, Aetna's State Medicaid Plan was not meeting state mandated health risk assessment completion rates. As a result, Schaller-Anderson - Aetna was losing significant revenue from its inability to satisfy a core metric. Care Managers were conducting outbound calls, but there was no ability to quantify the work they were doing other than tallying number of daily calls.
Intervention: I created an Access database real-time tracker for care management to monitor outbound calling for the HRA administration process. The database was added to the desktops of all care managers that tracked number of calls, time of call, duration of call, successful and unsuccessful contacts, administration and completion of assessment, and outcome of the encounter.
Result: Care Management was then able to utilize this data for reassessing current workflows and procedures. I was able to determine care management staff were spending extreme amounts of time trying to contact members, many of whom we had bad contact numbers. A third-party calling company was eventually hired to conduct calls, obtain member contact data, and with our health plan, improve the HRA completion rates to qualify for that metric-based reimbursement.
Regulatory, Compliance, and Accreditation Knowledge
Knowledge: Regulations, Accreditation and Compliance standards.
Key Issue: Healthcare organizations are required to achieve and maintain appropriate Accreditations to maintain business operations:
Intervention:
While at Adult & Child, led the organization with all clinical requirements for the pursuit of FQHC Accreditation. In addition led multiple ambulatory - outpatient networks in their initial and recertification of JCAHO.
While at WebMD, had direct oversight of the Quality Department and Quality Director, worked on and obtained successful URAC reaccreditation.
While at Trillium, represented physical health and collaborated with the Quality and Compliance Director to obtain Trillium's first NCQA accreditation as a full-fledged health plan.
While at Third Street Family Health Services, led the successful JCAHO reaccreditation process.
Result: Multiple organizations were able to obtain initial accreditation / certification, or obtain successful reaccreditation, remain in good standing as a health plan or healthcare delivery provider by their respective accrediting agency.
Data Analytics, Interpretation, &
Action
Knowledge: Analyzing data, projecting clinical performance, and adjusting clinical operations toward outcomes measurements.
Problem: The algorithm for determination of low, moderate and high risk Medicaid Beneficiaries was not accurately giving the the expected percentages of each level. This was a problem as it affected nursing and care management staffing and caused misallocation of resources to those members incorrectly stratified into the wrong risk level. Reimbursement was dependent on level of care management provided in addition to staff resource expenditure.
Intervention: I performed risk adjustments to the methodology used in the algorithms for risk stratification to obtain a more normal distribution consistent with what was seen in other Medicaid populations and in accordance with CMS data. Additionally, revision of our predictive analytics algorithm was coupled with historic claims data to better identified future utilization based on current chronic disease and past utilization patterns.
Result: A more even distribution of members was seen, and our risk stratification tool was able to be used to more appropriately allocate care management resources due to a more reliable risk stratification process. This positioned the health plan to have a greater opportunity to hit targeted outcomes and reimbursement incentives.