The Criterion Health 3-D
From Design to Development to Delivery
Creating a Prepaid Health Plan
opportunity to organize a benefits managing entity is one that allows
providers a rare chance to conceptualize their operations from the
perspective of a benefits purchaser. The changes and skills required are
very significant. Criterion Health, Inc. has experience and brings an
organized process to the situation. This Briefing outlines an approach that
has been utilized successfully in several situations.
the timeline is best developed by working backwards from “go-live” back to
“now,” the process must proceed with rigorous adherence to timeframes that
accommodate the “3 D’s” (Design, Development, and Delivery) in that order.
Here is a brief outline of how it works
“design” part is between the Board/Council, the designated staff Project
Manager and the Criterion “General Contractor” (GC) Consultants (with other
special inputs as needed).
“development” phases are delivered by a special “Development Team” composed
of the Project Manager, the GC Consulting group and a special subset of
individuals detailed to work on the project. Other inputs will be solicited
to address specific issues as they are evolved.
“delivery” phase is the actual start-up and initial operations of the
dedicated staff entity that will perform the benefits management for
The Partners identify
themselves and form/sponsor the optimal legal/structural entity (With or
without GC Consulting support).
new entity establishes it’s “Governance Board/Directors’ Council.”
Board assigns a “Project Manager,” usually a leading candidate for a
significant executive position in the new venture (often CEO or COO, but not
necessarily); and provides him/her with access to a small (3 or 4 person)
but critically important ground team and a designated location for meeting.
addition to the Project Manager, the “ground team” expertise needs to
include individuals with a systemic perspective in the following areas:
Clinical expertise and the ability to connect to the care delivery system,
especially the medical leaders;
Someone with sufficient financial experience – including familiarity with
contract development and information technology – inputs, processes,
reports – that are critical; and
Someone who is very purchaser/plan member oriented and committed to the
idea that “preferred providers” need to become plan members’ providers of
Board arranges for its Criterion “General Contractor” consultant team.
Governance Board is guided in a prioritized “forced march” through a series
of critical Policy and Design issues and decisions that will determine
everything that follows:
Briefings for the Board needs to address accountability from all four
perspectives: (1) the plan member recipient of services, (2) the in-panel
provider, (3) the purchaser, and (4) other stakeholders requiring
accountability, including the Board’s own demands for proof of
Briefings need to solicit and be responsive to the Board’s idiosyncratic
issues/needs in addition to the standard, critical list of “benefits
management development” issues;
Board’s Policies and Procedural decisions must form the foundation of all
the development and deliver work that follows. The Board is determining
critical decisions about directions of the entity and it’s accountability
Board policy decision is immediately transformed into a list of needed
follow-up deliverables (a discrete list of concrete policies, plans,
procedures, manuals, formats, reports, contracts, etc.) to be jointly
developed by the Development (joint Consultant/Ground team) Team for the
Project Manager and returned with recommendations to the Board/Council for
Triaged and assigned to the appropriate member of either the “Ground Team”
(if requiring primarily local, generic, or established procedural
expertise) or the “Consultant Team” (if requiring national best practices
or locally unfamiliar expertise).
The 1st draft of each deliverable should approach a useable
document that also reflects research of “best practices,” and should be
targeted for completion within 3 weeks;
In a provider-sponsored, “CO-OP” model,
PHP, a copy of these initial “drafts” are also delivered to the
senior-level liaison designated by each of the regional
“provider-partners,” whose task it is to determine if there are any
significant “provider-partner alert” concerns or issues implicated by
the document that need to be addressed from the provider-owner
perspective -- either during the on-site work session identified below,
or later by the PHP Board of Governance.
One-week is allotted for edit by the “opposite” team then returned to the
originator on a specific date.
is a focused, 2 day on-site work session of the Ground Team and GC scheduled
monthly (on the days immediately preceding the Board Meeting) for review,
discussion, resolution, and consensus. The on-site work session typically
½ day presenting prepared materials to
the whole Ground/Consultant team;
1 day preparing for next issues/work load
from the Board or as follow up – assignment overview, etc.;
½ day for work completion / changed
(The consulting team will remain on-site
for the third day to service the needs of the CEO and/or the Board of
Two weeks are allotted to
finalize changes, followed with 2 weeks for edits
adjustments/coordination on site for CEO and presentation to the
Board/Council in final form.
The process from “Assignment
by Board” to “Approval by Board” is targeted at 8 weeks. The
targeted “work load” of each Ground Team/Consultant Team member
is the production of between three and four “procedural/operational” drafts
per month to assure that the “implementation schedule” remains “on-schedule.
The approved “development”
deliverables are the groundwork for hiring, operationalizing, and delivering
actual, go-live, benefits management services.
The Consultant Team assures
operational follow up and competency through initial
implementation/operational phase, until Board and CEO are confident all is
well; and remains available to consult “as needed” thereafter.
Obviously this approach has been presented in a form structured to show
practical timelines and roles. Certain tasks, such as establishment of a
MIS system and responding to critical inputs that vary the model, will cause
significant deviations from the general approach.
William Ullrich, J.D. Principal
Robert Dyer, Ph.D.