Revenue and
Reimbursement
under Outcome-based
Payment Models
NACVA Healthcare Valuation Webinar
December 3, 2014
Speaker Bio
• David R. Crais, CMPE PMP
o Certified Medical Practice Executive (MGMA)
o Project Management Certification
o ...
Speaker Bio
• David R. Crais CMPE PMP
o Former Chairman, LA Imports & Exports Trust
Authority, Bond-issuing agency.
o Chai...
Outcome-based Payment
• Outcome-based Payment
o What is it?
o How is it different from the present FFS
(Fee-For-Service)
o...
Quality Measurement
Tools
• HEDIS – Primarily physician practice. Top
score of ‘5’.
• HCC – Risk Score for Population Heal...
Market Drivers under
VBP
Outcome-based Payment
History of OBP and VBP
- DRG (Diagnostic Related Group)
- 1980’s for inpatients
- Medical Necessity ...
Wholesale to Retail Shift
Value-based Payment
• Attaches quality to capitation and payment
structure.
• Metrics being developed to measure quality
•...
Value-based Economics
New Payment Models
• Bundled Payments
• Global Budgets
• Prospective payments
• Bonuses (ACO, PCMH)
• Direct Pay
• Concier...
Value Based Economics
Risk Spread with
Accountable Care
New Business Models
• ACO – Accountable Care
Organization
o CMS Shared Savings Program
o Commercial
o Physicians led
o Pay...
Aetna ACO Network
Finance and Ops Risk
under VBP
Value Based Economics
New Business Models
• Patient Centered Medical Home
o PCP
o Coordination
o Requires Certification
• Advanced Medical Pract...
Revenue Contracting FFS
to VBP
Accountable Care
Organizations
• Enabled by ACA (ObamaCare)
• Regulations issued Nov 2012
• Revised regs issued Monday, De...
ACO Services (Expenses)
Accountable Care
Organizations
• Payments based on 3 years prior data
• Baseline established
• Performance improvement bon...
Accountable Care
Organizations
• Structure:
• Minimum 5000 patients
• Can be urban or rural
• Requires lab, imaging, pharm...
Population Health
ACO Market Impacts
Accountable Care
Organizations
• Governance usually requires central
procurement
• Centralized IT with network-wide EMR
• ...
Accountable Care
Organizations
• If ACO providers constitute over 30% of
market, requires Justice Dept review.
• If ACO pr...
Variables of Provider Risk
Clinically Integrated
Network
• CIN’s are a mid-step between an IDN
(Integrated Delivery Network) and an ACO.
• CIN’s have...
Facets of ACO Network
Patient Centered Medical
Homes
• PCMH’s (Patient Centered Medical Home)
are primary care led medical practices
focused on ...
Patient Centered Medical
Homes
• Requirements:
o Extended Hours
o Saturday Hours
o Emailing patients
o Multi-generational ...
Patient Centered Medical
Homes
• Bonus paid for performance metrics
• Follows Wagner Chronic Disease
Model
• Expense ratio...
Dynamics of VBP
Practices
Advanced Medical
Practice
• Primary Care Focus
• Not formally certified
• Evolved from Clayton Christianson’s
“Solution Sh...
Advanced Medical
Practice
• Staff practices at the “Top of Their License”
• Workflow automation
• Higher value services pe...
Revenue Calculation with
VBP
Value Based Finance
Public and Private
Exchanges
Market Partnership
Strategies
Capital Investment Needs
FY2018
Contract Implications of Exchanges
Value-based Payors
Value-based Contracting
Resources
• “The Creative Destruction of Medicine”, Dr. Eric
Topol
• “Where Does It Hurt?”, Jonathan Bush
• “The Familiar ...
Helpful Links
• www.MGMA.org - Medical Group Management
Association
• www.ACHE.org - American College of Healthcare
Execut...
Questions
• Contact Info:
o David R. Crais CMPE PMP
• 773.398.4143
• davidcrais@hotmail.com
• david@carealytics.com
• Care...
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NACVA Revenue and Reimbursment preso

Published on: Mar 3, 2016
Source: www.slideshare.net


Transcripts - NACVA Revenue and Reimbursment preso

  • 1. Revenue and Reimbursement under Outcome-based Payment Models NACVA Healthcare Valuation Webinar December 3, 2014
  • 2. Speaker Bio • David R. Crais, CMPE PMP o Certified Medical Practice Executive (MGMA) o Project Management Certification o Series 7 & 66 Licensed o 25 years in healthcare and medical industry o Health Insurance Licensed o Served as CEO of 6 medical technology companies and medical provider organizations
  • 3. Speaker Bio • David R. Crais CMPE PMP o Former Chairman, LA Imports & Exports Trust Authority, Bond-issuing agency. o Chair, Opal Events 2014 ACO Summit o Chair, American College of Healthcare Executives Accountable Care Conference, 2014 o Chair, Louisiana Hospital Association Accountable Care Conference, 2014 o Medical IPO in 1999, American Stock Exchange
  • 4. Outcome-based Payment • Outcome-based Payment o What is it? o How is it different from the present FFS (Fee-For-Service) o What are the origins? o The ACA o Volume to Value
  • 5. Quality Measurement Tools • HEDIS – Primarily physician practice. Top score of ‘5’. • HCC – Risk Score for Population Health • Star Ratings – Payor Ratings • NCQA – Performance and Quality Metrics • Some Healthcare orgs have over 180 quality metrics they are reporting. This is not just for compliance, but ADDITIONAL REVENUE.
  • 6. Market Drivers under VBP
  • 7. Outcome-based Payment History of OBP and VBP - DRG (Diagnostic Related Group) - 1980’s for inpatients - Medical Necessity Regs - 1998 - Pay for Performance - Early 2000’s
  • 8. Wholesale to Retail Shift
  • 9. Value-based Payment • Attaches quality to capitation and payment structure. • Metrics being developed to measure quality • Baseline based on prior years and and performance metrics (biomarkers and population). • Data lag is an issue. Currently no real-time feedback with claims metrics. • Dashboards from registry data for analytics
  • 10. Value-based Economics
  • 11. New Payment Models • Bundled Payments • Global Budgets • Prospective payments • Bonuses (ACO, PCMH) • Direct Pay • Concierge Medicine
  • 12. Value Based Economics
  • 13. Risk Spread with Accountable Care
  • 14. New Business Models • ACO – Accountable Care Organization o CMS Shared Savings Program o Commercial o Physicians led o Payer led • MSO – Management Services Organization • CIN – Clinically Integrated Network
  • 15. Aetna ACO Network
  • 16. Finance and Ops Risk under VBP
  • 17. Value Based Economics
  • 18. New Business Models • Patient Centered Medical Home o PCP o Coordination o Requires Certification • Advanced Medical Practice o PCP with specialists and/or traditionally specialist services
  • 19. Revenue Contracting FFS to VBP
  • 20. Accountable Care Organizations • Enabled by ACA (ObamaCare) • Regulations issued Nov 2012 • Revised regs issued Monday, Dec 1, 2014 • Pioneer program o 32 started, 9 dropped out after 1 year. o Goes to 2016 • MSSP Shared Savings Program o Bonus potential, no assumption of risk…yet.
  • 21. ACO Services (Expenses)
  • 22. Accountable Care Organizations • Payments based on 3 years prior data • Baseline established • Performance improvement bonus • CMS started with 33 metrics, weighted to diabetes. • Multi-disciplinary, multi-provider network
  • 23. Accountable Care Organizations • Structure: • Minimum 5000 patients • Can be urban or rural • Requires lab, imaging, pharmacy, and acute partners • Requires FTC Anti-trust waiver • Single tax ID
  • 24. Population Health
  • 25. ACO Market Impacts
  • 26. Accountable Care Organizations • Governance usually requires central procurement • Centralized IT with network-wide EMR • Centralized disease registries • Measurement amongst all providers and allied health • Reimbursement and bonus heavily dependent on Quality Review Teams
  • 27. Accountable Care Organizations • If ACO providers constitute over 30% of market, requires Justice Dept review. • If ACO providers constitute over 60% of market, requires Justice Dept approval. • Practices that are part of ACO fall stringently under ACO governance. Practice is like a ‘franchise’ of the ACO.
  • 28. Variables of Provider Risk
  • 29. Clinically Integrated Network • CIN’s are a mid-step between an IDN (Integrated Delivery Network) and an ACO. • CIN’s have centralized governance like an ACO • CIN’s have an interoperable system-wide EMR • CIN’s have performance metrics MD’s follow • CIN’s MAY have centralized procurement • CIN”s DO NOT bundle payments or have global budgets. They exclude finance.
  • 30. Facets of ACO Network
  • 31. Patient Centered Medical Homes • PCMH’s (Patient Centered Medical Home) are primary care led medical practices focused on coordinated care and quality outcomes. • PCMH’s are certified entities by several certification bodies, the most popular being NCQA, URAC and The Joint Commission. • TriCare, US Military, and Indian Health Service will soon only reimburse PCMH practices.
  • 32. Patient Centered Medical Homes • Requirements: o Extended Hours o Saturday Hours o Emailing patients o Multi-generational patient engagement o Care Coordinator staff person • Clerical • Clinical
  • 33. Patient Centered Medical Homes • Bonus paid for performance metrics • Follows Wagner Chronic Disease Model • Expense ratio is high due to: o Staffing requirements o Extended Hours o Patient Engagement demands o Possible language and communication costs o Technology requirements
  • 34. Dynamics of VBP Practices
  • 35. Advanced Medical Practice • Primary Care Focus • Not formally certified • Evolved from Clayton Christianson’s “Solution Shop” model in book “The Innovators Prescription” • Utilizes Diagnostic and Therapeutic technology usually at the specialist level
  • 36. Advanced Medical Practice • Staff practices at the “Top of Their License” • Workflow automation • Higher value services performed • Increased revenue opportunities • Physician extender regulations trending nationally. • Tele-consult and Tele-diagnostics employed.
  • 37. Revenue Calculation with VBP
  • 38. Value Based Finance
  • 39. Public and Private Exchanges
  • 40. Market Partnership Strategies
  • 41. Capital Investment Needs
  • 42. FY2018
  • 43. Contract Implications of Exchanges
  • 44. Value-based Payors
  • 45. Value-based Contracting
  • 46. Resources • “The Creative Destruction of Medicine”, Dr. Eric Topol • “Where Does It Hurt?”, Jonathan Bush • “The Familiar Physician”, Dr. Peter Anderson • “The Checklist Manifesto”, Dr. Atul Guwande • “Hacking Healthcare”, Fred Trotter • “Patient Centered Medical Home”, Dr. Paul Grundy • “The Innovator’s Prescription”, Clayton Christensen • “How Data Science Will Transform Medicine”, Tim O’Reilly
  • 47. Helpful Links • www.MGMA.org - Medical Group Management Association • www.ACHE.org - American College of Healthcare Executives • www.AAFP.org - American Academy of Family Physicians • www.CMS.gov - Center for Medicare Services • www.HealthData.gov - Offc of National Coordinator • www.PCPCC.org - Patient Centered Primary Care Collaborative
  • 48. Questions • Contact Info: o David R. Crais CMPE PMP • 773.398.4143 • davidcrais@hotmail.com • david@carealytics.com • Carealytics.com • CraisGroup.com • LinkedIn.com/in/DavidCrais • Twitter.com: @DavidCrais • Thank you!

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