The Criterion Health 3-D Development Process

From Design to Development to Delivery
Creating a Prepaid Health Plan 

The 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. 

While 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

The “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).

The “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.

The “delivery” phase is the actual start-up and initial operations of the dedicated staff entity that will perform the benefits management for purchasers.

Process Outline:

1.  The Partners identify themselves and form/sponsor the optimal legal/structural entity (With or without GC Consulting support).

2.  The new entity establishes it’s “Governance Board/Directors’ Council.”

3.  The 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.

4.  In 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 choice.

5.  The Board arranges for its Criterion “General Contractor” consultant team.

6.  The 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 performance;

• 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 to stakeholders.

7.  Every 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 approval/redirection.

8.  Each “deliverable” is:

• 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 1^st 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.

9.  There 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 consists of

• 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 priorities.

• (The consulting team will remain on-site for the third day to service the needs of the CEO and/or the Board of Governance/Director’s Council.)

10. Two weeks are allotted to finalize changes, followed with 2 weeks for edits

11. Final adjustments/coordination on site for CEO and presentation to the Board/Council in final form.

12. 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.

13. The approved “development” deliverables are the groundwork for hiring, operationalizing, and delivering actual, go-live, benefits management services.

14. 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.

Prepared by: