MCR Project Highlights

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Practical, workable solutions to business challenges come from hands-on experience. Through its work with a diverse range of business interests within managed care, MCR is able to identify common ground and interdependent influences, and so can best achieve a client's goals.

MCR works with both public and private sector entities, including hospitals, physicians groups, academic medical centers, Federally qualified health centers, and other health care organizations.

The following engagements illustrate the wide range of competencies that MCR has displayed to its clients over the past two years:

Managed Care Organization Engagements

• Worked with a national HMO and a private behavioral health organization to assist in taking the HMO's behavioral health division private. Redeveloped its behavioral health delivery system, making it the most cost-effective such system in a major metropolitan market. Built on a substantial existing revenue base to generate substantial revenue from new customers who use its extensive provider network and its access center programs. Further, it plans to:
  • Redevelop the HMO's behavioral health division by increasingly contracting for outpatient services rather than using employees to deliver them

  • Streamline former staff model operations to improve productivity and efficiency, integrating mental health and addictions medicine programs

  • Maintain the integration with primary care providers that has distinguished behavioral health division operations.

• Performed a detailed readiness assessment, and prepared application materials for one of the largest integrated health systems in the U.S., as it sought state approval to serve prepaid Medicaid recipients. Designed utilization management programs, working with organization's medical management committees, and then implemented those UM programs.

• Conducted a pre-operational readiness assessment for a new HMO, organized to serve a Medicaid membership of over 35,000 members on a capitated basis. A children's hospital and a major public hospital co-sponsored the HMO.

• Conducted an operational assessment for a 90,000 member HMO to determine the success of the current management group, and to recommend alternate solutions to managing the organization.

Hospital Engagements

• Organized a joint venture between a hospital-based home care agency and hospital-based and national home care providers of high tech infusion care. Secured a geographically exclusive capitated agreement for 100,000 lives. Served as intermediary to finalize joint venture agreement, developed the organization's operational systems and procedures; prepared a comprehensive operations manual; and developed a detailed business plan.

• Performed an assessment of hospital-based behavioral health services, and identified strategies for securing additional managed care arrangements.

• Served as the primary managed care consultant to a metropolitan hospital in a major urban area, working with the medical staff to prepare them for participation in managed care programs. Formed an organization which consolidated the hospital and its physicians into a Management Services Organization (MSO), facilitating negotiation with key MCOs, and developing/implementing an IDS strategy key to its future success.

• Designed and implemented a medical management program for a hospital and its affiliated IPA and MSO. The program was designed to meet payer and regulatory requirements, accreditation standards, and changes in risk structures. The project included the development and implementation of the operational policies, procedures and protocols, and resulted in the reorganization of the hospital's departments, elimination of duplicate functions, and the adoption of a unified set of utilization management goals by the hospital and its affiliated organizations. The implementation of this program was a critical step toward meeting the hospital's overall objective of becoming a fully integrated delivery system.

• Assisted a state hospital association in developing its strategy for providing support services to their member hospitals as they confront the challenges of the evolving managed care environment. Also analyzed key regulatory and legislative documents for the association, to assess the potential impact of pending legislation on member hospitals.

• Conducted claims recovery program for a hospital and its affiliated IPA, including (1) the identification and elimination of payments for unbundled services, or improper billing practices by participating physicians, and (2) auditing managed care payments to assure that the hospital was being paid according to the contractual agreements.

• Worked with one of the largest public hospitals in the U.S. to develop relations with major area HMOs. This included the negotiation of rates for both the hospital and its professional staff. The contracts were the first for the institution.

Physician Group Engagements

• Created and implemented a plan for an ophthalmology network of 35 physicians, to secure capitated contracts with an area IPA and a large HMO. Created a customized administrative and operating system; developed contracts, negotiated risk-based subspecialty/procedure arrangements; and assisted in the organization of the network so that it could provide cost-effective care to over 100,000 capitated lives.

• Developed a single specialty IPA, and conducted capitation contract negotiations with a 65,000 member Managed Care Contracting Organization (MCCO). The IPA was awarded an exclusive arrangement with the MCCO.

• Assisted a radiology group in negotiating more favorable capitation rates with its 75,000 member MCCO, based on an analysis of data provided by the MCCO.

• Redesigned and assisted in the implementation of the organizational and operational structure for an IPA which is associated with an inner-city hospital, so that the hospital would be able to accept capitated contracts for both commercial and Medicaid populations.

• Worked with an obstetrics and gynecology group to develop a proposal to assume the responsibility for the overall management of the Ob/Gyn function of a staff model HMO. This proposal, which was accepted by the HMO, covers 100,000 members.

• Worked with a large multi-specialty group to renegotiate their contract with a major HMO, and assisted them in selling an existing facility.

Other Engagements

• Worked with an investor group to develop the concept and create the overall strategy for the development of freestanding primary care networks that could be formed in mature managed care markets. Developed a complete Operations Manual specifically designed for these networks, which included the PCP contract and PCP manual, as well as detailed functional manuals for utilization management, quality management, provider relations, and member services.

• Assisted a major foreign company to develop a relationship with a major retail pharmaceutical company, to create the first pharmacy benefits management (PMB) company in that country.

• Provided in-depth management consulting support to a Federally qualified community health center to effect the organizational, clinical, and administrative changes (including development of medical management programs) required to meet the demands of managed care as it becomes increasingly dominant in public sector programs.

• Worked with a national vision care company to establish a risk-based arrangement with managed care companies, to provide care to over 400,000 lives.

• Developed a case management system for a Federally qualified health center (FQHC), that integrated a publicly funded external case management system with the FQHC's internal systems for both fee-for-service and capitated patients.

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